Educational Impact on Apixaban Adherence in Atrial Fibrillation (the AEGEAN STUDY): A Randomized Clinical Trial

Adherence to non-vitamin-K oral anticoagulants (NOACs) may be lower than to vitamin K antagonists because NOACs do not require routine monitoring. We assessed the impact of an educational program on adherence and persistence with apixaban in patients with non-valvular atrial fibrillation (NVAF). Patients with NVAF eligible for NOACs with one or more stroke risk factor (prior stroke/transient ischemic attack, age ≥ 75 years, hypertension, diabetes, or symptomatic heart failure) were randomized (1:1) to standard of care (SOC) or SOC with additional educational (information booklet, reminder tools, virtual clinic access). The primary outcome was adherence to apixaban (2.5 or 5 mg twice daily) at 24 weeks. Patients receiving the educational program were re-randomized (1:1) to continue the program for 24 further weeks or to switch to secondary SOC. Implementation adherence and persistence were reassessed at 48 weeks. In total, 1162 patients were randomized (SOC, 583; educational program, 579). Mean implementation adherence ± standard deviation (SD) at 24 weeks was 91.6% ± 17.1 for SOC and 91.9% ± 16.1 for the educational program arm; results did not differ significantly between groups at any time-point. At 48 weeks, implementation adherence was 90.4% ± 18.0, 90.1% ± 18.6, and 89.3% ± 18.1 for continued educational program, SOC, and secondary SOC, respectively; and corresponding persistence was 86.1% (95% confidence interval [CI] 81.3–89.7), 85.2% (95% CI 81.5–88.2), and 87.8% (95% CI 83.4–91.1). Serious adverse events were similar across groups. High implementation adherence and persistence with apixaban were observed in patients with NVAF receiving apixaban. The educational program did not show additional benefits. This study is registered at ClinicalTrials.gov [NCT01884350].     

Retrograde Inversion Stripping as a Complication of the Clarivein? Mechanochemical Venous Ablation Procedure

The endovenous revolution has accelerated the development of new techniques and devices for the treatment of varicose veins. The ClariVein^® mechanochemical ablation device offers tumescentless treatment with a rotating ablation tip that can theoretically become stuck in tissue. We present the first report of retrograde stripping of the small saphenous vein without anaesthesia following attempted use of the ClariVein^® device, without adverse sequelae.     

Impaired Cotranslational Processing as a Mechanism for Type I Antithrombin Deficiency

Most secretory proteins, including antithrombin (AT), aresynthesized with a signal peptide, which is cleaved before the mature protein is exported from the cell. The signal peptide is important inthe process whereby nascent protein is recognized as requiring subsequent modification within the endoplasmic reticulum (ER). We haveidentified a novel mutation, 2436TC L(-10)P, which affects the central hydrophobic domain of the AT signal peptide, in a probandpresenting with venous thrombotic disease and type I AT deficiency. Weinvestigated the basis of the phenotype by examining expression inmammalian cells of a range of variant AT cDNAs with mutations affectingthe -10 residue. Glycosylated AT was secreted from COS-7 cellstransfected with wild-type AT, -10L deletion, -10V or -10M variants,but not variants with P, T, R, or G at -10. Cell-free expression ofwild-type and variant AT cDNAs was then performed in the presence ofcanine pancreatic microsomes, as a substitute for ER. Variant ATproteins with P, T, R, or G at residue -10 did not undergoposttranslational glycosylation, and their susceptibility to trypsindigestion suggested they had not been translocated into microsomes. Ourresults suggest that the ability of AT signal peptide to direct theprotein to ER for cotranslational processing events appears to becritically dependent on maintaining the hydrophobic nature of theregion including residue -10. The investigations have defined impairedcotranslational processing as a hitherto unrecognized cause ofhereditary AT deficiency.     

Eosinophils stimulate fibroblast DNA synthesis

Fibrosis complicates a number of chronic inflammatory diseases and occurs in some conditions following chronic hypereosinophilic syndromes. We assessed whether eosinophils might be a source of fibrogenic factors. Extracts of human and guinea pig cell populations enriched for eosinophils contained substances that stimulated tritiated thymidine incorporation by human fibroblasts. Supernatants derived from resting eosinophils and extracts prepared from eosinophil granules also contained fibrogenic factors. Our findings demonstrate a new potential role for eosinophils and suggest a causal relationship between tissue eosinophilia and scar formation in certain parasitic conditions.