Comparative effectiveness and safety of direct acting oral anticoagulants in nonvalvular atrial fibrillation for stroke prevention: a systematic review and meta-analysis

European Journal of Epidemiology - Purpose:To systematically review available evidence of indirect comparisons from RCTs and direct comparisons from observational studies regarding the comparative...     

基于机器学习模型缺血性脑卒中1年死亡预测效果评价

  目的  对机器学习在医疗和公共卫生研究中的应用方向进行梳理,为制定相应政策和策略提供科学依据。  方法  通过Citespace科研文献可视化工具对Web of Science数据库有关机器学习在医疗和公共卫生中应用的2 014篇文献进行聚类,找到当今的研究热点。  结果  机器学习在医疗和公共卫生中的应用主要为辅助诊疗、监测和预防疾病、机器人辅助手术、药物警戒和研发以及医疗体系质量管理5个方向。  结论  机器学习在医疗和公共卫生相关研究中具有较强的适用性和十分广阔的应用前景,在机器学习模型的帮助下根据医学相关数据做出的诊断和决策,不仅能够为个人带来健康,更有助于国家战略的实现。未来在打破医疗数据孤岛以及机器学习的医学伦理等方向可进一步加强探索。     

Economic evidence in stroke: a review

The European Journal of Health Economics -     

Preventing stroke in people with atrial fibrillation: a cross-sectional study

BACKGROUND: The annual stroke rate in atrial fibrillation is around 5 per cent with increased risk in those with hypertension, diabetes, left ventricular dysfunction and other cardiovascular risk factors. This study set out to identify the patients with atrial fibrillation and modifiable risk factors for stroke. METHOD: Analysis of practice computer data taken from eight general practices (81 811 patients) in the south of England. 944 patients with a diagnosis of atrial fibrillation, of whom 782 (82.8 percent) were aged 65 years and over. RESULTS: The age standardised prevalence of diagnosed atrial fibrillation was 1.23 per cent (1.28 percent for men and 1.18 percent for women). It was much more prevalent in the older population, 8.28 percent and 6.66 percent for males and females over 65, respectively. Cardiovascular co-morbidities were more frequent with increasing age. Blood pressure (BP) was recorded in over 95 per cent of patients with atrial fibrillation though there was scope for improving control; 25 per cent of men and 31 per cent women had a BP over 150/90. Inconsistent recording of ECG and echocardiography made it hard to identify patients with left ventricular dysfunction. Forty six percent of men and 37 percent of women were either being prescribed Warfarin, or had contraindications to its use; of those on Warfarin 75.9 percent have an international normalized ratio in range. Forty four per cent were treated with aspirin. People at high risk of stroke were no more likely to be treated with Warfarin or aspirin than those at moderate risk. CONCLUSIONS: The rate of use of Warfarin remains low, and there is scope for better recording and management of risk factors particularly BP.     

Common flaws exist in published cost-effectiveness models of pharmacologic stroke prevention in atrial fibrillation

ObjectivesDecision makers use models to assist in evaluating the cost-effectiveness of pharmacologic stroke prevention in atrial fibrillation (SPAF).Study Design and SettingWe performed a search of databases through October 3, 2012 to identify pharmacologic SPAF cost-effectiveness models.ResultsOf 30 identified models, 28 included warfarin, but only 60% assessed the impact of warfarin control on conclusions. Aspirin, dual antiplatelet, and newer anticoagulants were included in 41%, 10%, and 63% of models, respectively. Models used similar structures but included varying health states and made varying assumptions. They rarely reported performing a literature search to identify anticoagulant-specific inputs and used similar and older sources. Sixteen models used a lone randomized trial to reflect the efficacy and safety of main comparisons. One-third of models claimed a societal perspective; however, none included indirect costs. Patients typically initiated anticoagulation in the sixth or seventh decade of life and are followed for their lifetimes. Almost 70% of incremental cost-effectiveness ratios were below reported willingness-to-pay thresholds. All used deterministic sensitivity analyses and 77% conducted Monte Carlo simulation. Less than half of the models were rated “high quality,” yet were frequently published in high-impact journals.ConclusionPharmacologic SPAF cost-effectiveness models have been extensively reported, but many may have flaws giving reason for decision makers to use caution. We provide 10 recommendations to avoid common flaws in SPAF cost-effectiveness models.     

华法林与阿司匹林预防老年心房颤动患者缺血性卒中的临床比较及成本-效果分析

目的 研究华法林与阿司匹林预防老年心房颤动患者缺血性卒中的临床效果,并对二者进行成本-效果分析.方法 随访2007年1月至2009年12月确诊为心房颤动住院患者53例,按随机数字表法将所有患者分为华法林组和阿司匹林组.华法林组采用华法林治疗,阿司匹林组给予阿司匹林治疗.比较两组缺血性卒中发病情况、药物不良反应及成本效果比.结果 49例完成随访,失访率为7.5％(4/53),其中华法林组完成随访28例,阿司匹林组完成随访21例.华法林组缺血性卒中发病1例,发病率为3.6％(1/28),阿司匹林组发病6例,发病率为28.6％(6/21),两组缺血性卒中发病率比较差异有统计学意义(x2=4.28,P＜ 0.05);两组不良反应发生率比较差异无统计学意义(x2=0.07,P＞ 0.05);成本效果比华法林组每1个单位的有效率需花费16.3元,阿司匹林组每1个单位的有效率需花费10.4元,阿司匹林组花费低于华法林组,差异有统计学意义(P＜0.05).结论 华法林预防老年心房颤动患者缺血性卒中发病效果更好,但成本较高;而阿司匹林成本较低,但预防效果不佳.     

An external cardiac pacemaker for prevention of atrial fibrillation

The paper presents an account of and the technical data of a new external pacemaker to be used to prevent atrial fibrillations. It shows it expedient to design such devices and presents their characteristics.     

The WATCHMAN device for stroke prophylaxis in atrial fibrillation: an evolving niche

Atrial fibrillation is associated with a markedly increased risk of thromboembolic stroke. At present, lifelong antithrombotic therapy with warfarin or a novel oral anticoagulant is indicated for prophylaxis in the majority of patients. Left atrial appendage occlusion devices have been developed as an alternative to these agents, aiming to avoid issues around consistency of anticoagulation, bleeding risk, and drug-related side effects. The best evidence is available for Boston Scientific’s WATCHMAN device. The safety and efficacy of WATCHMAN and other similar devices have been questioned, although the increasing body of evidence supports a role in selected settings. A recently updated randomized controlled trial of WATCHMAN (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation [PROTECT-AF]) demonstrates its noninferiority to warfarin and suggests an advantage in terms of functional outcome for patients, with superior net clinical benefit 6 to 9 months after starting treatment. The procedural risk associated with device implantation remains substantial, although improving device design and increasing operator experience means that this should decrease in the future. As the body of data and overall experience around WATCHMAN grow, it may come to be recognized as the best option in selected patients.     

Flavonoids and cancer prevention: a review of the evidence

The objective of this work is to review data from epidemiological and preclinical studies addressing the potential benefits of diets based on flavonoids for cancer prevention. Flavonoids are subdivided into subclasses including flavonols, flavones, flavanones, flavan-3-ols, anthocyanidins, and isoflavones. Epidemiological studies suggest dietary intake of flavonoids may reduce the risk of tumors of the breast, colon, lung, prostate, and pancreas. However, some studies have reported inconclusive or even harmful associations. A major challenge in the interpretation of epidemiological studies is that most of the data originate from case-control studies and retrospective acquisition of flavonoid intake. Differences in agricultural, sociodemographics, and lifestyle factors contribute to the heterogeneity in the intake of flavonoids among populations residing in the United States, Europe, and Asia. Dose and timing of exposure may influence the anticancer response to flavonoid-rich diets. A limited number of intervention trials of flavonoids have documented cancer preventative effects. Proposed anticancer mechanisms for flavonoids are inhibition of proliferation, inflammation, invasion, metastasis, and activation of apoptosis. Prospective studies with larger sample sizes are needed to develop biomarkers of flavonoid intake and effect. Mechanistic studies are needed to ascertain how flavonoid-rich diets influence gene regulation for cancer prevention.     

Rationale and design of a randomized clinical trial on prevention of stroke in isolated systolic hypertension

Isolated systolic hypertension (ISH)-ix. high systolic pressure with nonhypertensive (< 90 mmHg) diastolic pressure—is a recognized risk factor for cardiovascular disease among individuals in the age group 60 years and above. This observation suggests that antihypertensive treatment might be beneficial. Results of the Systolic Hypertension in the Elderly Program Pilot Study (SHEP-PS) indicated the feasibility of a full-scale clinical trial on the efficacy of drug treatment of ISH.

The Systolic Hypertension in the Elderly Program (SHEP) is a randomized, double-blind, placebo-controlled clinical trial with the primary objective of assessing the effect of drug treatment of ISH—systolic pressure 160–219 mmHg and diastolic pressure <90—on occurrence of fatal and nonfatal stroke. This multicenter clinical trial has a sample size of 4736 participants, with high statistical power to detect a reduction of 32% or more in the study's primary end point during the 4–6 year period of treatment and follow-up. Low dosage chlorthalidone is the main study drug. Further features of the design of SHEP and the trial's organization are described.     

The link between atrial fibrillation and stroke in women

Atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia. The most serious complication of AF is thromboembolic stroke. The individual risk of stroke in the setting of AF varies. Several clinical factors have been identified as independent predictors of stroke in AF, including prior stroke, age, hypertension and diabetes. The bulk of available data identifies female gender as another independent predictor of stroke risk in AF. In this article, we review the link between AF and an elevated stroke risk in women, explore the potential pathophysiologic basis for this association and examine the data regarding the effectiveness of anticoagulation in reducing this risk.     

筛查和防治心房颤动 预防缺血性脑卒中

心房颤动（房颤）是常见的心律失常之一,缺血性脑卒中的病因中20%~30%是由与房颤相关,房颤相关的卒中具有高发病率、高死亡率、高致残率、高复发率、高经济负担等特点。常规检查不能有效发现房颤。移动医疗技术极速发展为房颤的筛查提供了很多支持手段,有助于在房颤危险因素人群中筛查房颤。依据指南和循证证据管理房颤,预防房颤相关脑...