Homocysteine-lowering vitamins and cardiovascular mortality: are they really effective?

In the light of current data obtained from prospective outcome studies, we believe that it is premature to support the use of homocysteine-lowering vitamins including folic acid in patients with established coronary artery disease in order to improve cardiovascular outcomes. We think that future large-scale epidemiological trials with very long-term follow-up periods will probably solve this dilemma.     

Clinical laboratory assays for measuring anti-dsDNA antibodies. Where are we now?

It is over 40 years since anti-dsDNA antibodies were first described in patients with lupus. A wide variety of methods for detecting these immunoglobulins have been established. In this review, we consider the utility and practical problems that the main assays present. The clinical correlations between anti-dsDNA antibodies and clinical activity in patients with lupus is discussed.     

Shared Clinical Decision-Making Recommendations for Adult Immunization: What Do Physicians Think?

BackgroundIn 2019, the Advisory Committee on Immunization Practices (ACIP) incorporated the terminology “shared clinical decision-making” (SDM) into recommendations for two adult vaccines.ObjectiveTo assess among general internal medicine physicians (GIMs) and family physicians (FPs) nationally (1) attitudes about and experience with ACIP SDM recommendations, (2) knowledge of insurance reimbursement for vaccines with SDM recommendations, (3) how SDM recommendations are incorporated into vaccine forecasting software, and (4) physician and practice characteristics associated with not knowing how to implement SDM.DesignSurvey conducted in October 2019–January 2020 by mail or internet based on preference.ParticipantsNetworks of GIMs and FPs recruited from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) who practice ≥ 50% in primary care. Post-stratification quota sampling performed to ensure networks similar to ACP and AAFP memberships.Main MeasuresResponses on 4-point Likert scales (attitudes/experiences), true/false options (knowledge), and categorical response options (forecasting). Multivariable modeling with outcome of “not knowing how to implement SDM” conducted.Key ResultsResponse rate was 64% (617/968). Most physicians strongly/somewhat agreed SDM requires more time than routine recommendations (90%FP; 95%GIM, p = 0.02) and that they need specific talking points to guide SDM discussions (79%FP; 84%GIM, p = NS). There was both support for SDM recommendations for certain vaccines (81%FP; 75%GIM, p = 0.06) and agreement that SDM creates confusion (64%FP; 76%GIM, p = 0.001). Only 41%FP and 43%GIM knew vaccines recommended for SDM would be covered by most health insurance. Overall, 38% reported SDM recommendations are displayed as “recommended” and 23% that they did not result in any recommendation in forecasting software. In adjusted multivariable models, GIMs [risk ratio 1.44 (1.15–1.81)] and females [1.28 (1.02–1.60)] were significantly associated with not knowing how to implement SDM recommendationsConclusionsTo be successful in a primary care setting, SDM for adult vaccination will require thoughtful implementation with decision-making support for patients and physicians.KEY WORDS: shared decision-making, vaccination, ACIP     

What are the anticoagulation options for intermittent hemodialysis?

Prevention of clotting in the extracorporeal circuit was one of the major hurdles that had to be overcome to enable the expansion of routine outpatient hemodialysis to free-standing satellite centers and the home. Unfractionated heparin, the anticoagulant of choice for many years, is now being replaced by low-molecular-weight heparins (LMWHs) in an expanding number of countries. This trend is attributable to the ease and convenience of the administration of LMWHs coupled with their reliability and predictability of dosing. However, the choice of which LMWH to use depends on the duration and frequency of the dialysis sessions. For patients who are allergic to heparin or have heparin-induced thrombocytopenia, alternative anticoagulants--the direct thrombin inhibitors and heparinoids--are now available. These agents either have short half-lives (and therefore need to be delivered by infusions), or prolonged half-lives, which allows simple bolus administration, but increases the risk of drug accumulation, overdosage and hemorrhage. In patients at risk of bleeding, regional anticoagulants enable anticoagulation to be limited to the extracorporeal circuit. Prostanoids and nafamostat mesilate are expensive regional anticoagulants, and citrate infusions add complexity to the procedure. A citrate-based dialyzate has now been introduced that might enable heparin-free dialysis or reduce systemic anticoagulant requirements.