Experiences of a low-intensity anticoagulation regimen for extended secondary prevention of venous thromboembolism

Extended treatment with vitamin K antagonists for more than 6 months is often used for secondary prevention of venous thromboembolism (VTE) in patients at high or moderate risk for recurrent events. The intensity of anticoagulant therapy is usually maintained at an International Normalized Ratio (INR) of 2-3. An INR of 1.5-2 might also prevent thromboembolic events with less complications of bleeding, but results from randomized trials are not yet available. In a non-prospective, uncontrolled study 40 patients with a history of VTE and an estimated high risk for recurrent events due to several previous events and/or thrombophilic defects were, after a median of 11.5 months on regular intensity anticoagulation (INR 2-3), switched to a low intensity regimen (INR 1.5-2). In six of the patients an estimated high risk for complications of bleeding contributed to this decision. After a median follow-up of 36 months (140 patient-years) recurrent events, complications of bleeding and some basic quality of life measurements regarding the new treatment were registered. No recurrent events, four minor bleedings and no major bleedings were registered. Twenty-six patients preferred an INR of 1.5-2 compared to 2-3. The main reasons for that preference were a lower risk for bleeding (13 patients) and less frequent monitoring of the INR (18 patients). No patient preferred full-dose anticoagulation at INR 2-3. In patients at a high risk for recurrence of VTE an initial period of regular intensity anticoagulation, followed by a low-intensity regimen, may provide effective and safe secondary prophylaxis.     

The changing risk and burden of wildfire in the United States

Recent dramatic and deadly increases in global wildfire activity have increased attention on the causes of wildfires, their consequences, and how risk from wildfire might be mitigated. Here we bring together data on the changing risk and societal burden of wildfire in the United States. We estimate that nearly 50 million homes are currently in the wildland–urban interface in the United States, a number increasing by 1 million houses every 3 y. To illustrate how changes in wildfire activity might affect air pollution and related health outcomes, and how these linkages might guide future science and policy, we develop a statistical model that relates satellite-based fire and smoke data to information from pollution monitoring stations. Using the model, we estimate that wildfires have accounted for up to 25% of PM_2.5 (particulate matter with diameter <2.5 μm) in recent years across the United States, and up to half in some Western regions, with spatial patterns in ambient smoke exposure that do not follow traditional socioeconomic pollution exposure gradients. We combine the model with stylized scenarios to show that fuel management interventions could have large health benefits and that future health impacts from climate-change–induced wildfire smoke could approach projected overall increases in temperature-related mortality from climate change—but that both estimates remain uncertain. We use model results to highlight important areas for future research and to draw lessons for policy.     

The decline of butterflies in Europe: Problems,significance, and possible solutions

We review changes in the status of butterflies in Europe, focusing on long-running population data available for the United Kingdom, the Netherlands, and Belgium, based on standardized monitoring transects. In the United Kingdom, 8% of resident species have become extinct, and since 1976 overall numbers declined by around 50%. In the Netherlands, 20% of species have become extinct, and since 1990 overall numbers in the country declined by 50%. Distribution trends showed that butterfly distributions began decreasing long ago, and between 1890 and 1940, distributions declined by 80%. In Flanders (Belgium), 20 butterflies have become extinct (29%), and between 1992 and 2007 overall numbers declined by around 30%. A European Grassland Butterfly Indicator from 16 European countries shows there has been a 39% decline of grassland butterflies since 1990. The 2010 Red List of European butterflies listed 38 of the 482 European species (8%) as threatened and 44 species (10%) as near threatened (note that 47 species were not assessed). A country level analysis indicates that the average Red List rating is highest in central and mid-Western Europe and lowest in the far north of Europe and around the Mediterranean. The causes of the decline of butterflies are thought to be similar in most countries, mainly habitat loss and degradation and chemical pollution. Climate change is allowing many species to spread northward while bringing new threats to susceptible species. We describe examples of possible conservation solutions and a summary of policy changes needed to conserve butterflies and other insects.     

Lymphocytic myocarditis in an overlap syndrome of systemic sclerosis and polymyositis

Clinical Rheumatology -     

Gender differences in clinical features and outcomes of a Portuguese systemic sclerosis cohort

Clinical Rheumatology - Evidence for the role of sex in the clinical manifestations of systemic sclerosis (SSc) patients is emerging. Some multicenter cohorts have shown that male SSc patients have...     

Effects of exercise training on bone mineral density and some health-related outcomes in HIV conditions: A randomized controlled trial

Introduction:Human Immunodeficiency Virus (HIV) infection remains prevalent co-morbidity, and among fracture patients. Few studies have investigated the role of exercise interventions in preventing bone demineralization in people who have fractures and HIV. If exercise exposed, HIV-infected individuals may experience improved bone health outcomes (BMD), function, quality of life (QoL). The study will aim to assess the impact of home based exercises on bone mineral density, functional capacity, QoL, and some serological markers of health in HIV infection among Nigerians and South Africans.Methods and design:The study is an assessor-blinded randomized controlled trial. Patients managed with internal and external fixation for femoral shaft fracture at the study sites will be recruited to participate in the study. The participants will be recruited 2 weeks post-discharge at the follow-up clinic with the orthopaedic surgeon. The study population will consist of all persons with femoral fracture and HIV-positive and negative (HIV-positive medically confirmed) aged 18 to 60 years attending the above-named health facilities. For the HIV-positive participants, a documented positive HIV result, as well as a history of being followed-up at the HIV treatment and care center. A developed home based exercise programme will be implemented in the experimental group while the control group continues with the usual rehabilitation programme. The primary outcome measures will be function, gait, bone mineral density, physical activity, and QoL.Discussion:The proposed trial will compare the effect of a home-based physical exercise-training programme in the management of femoral fracture to the usual physiotherapy management programmes with specific outcomes of bone mineral density, function, and inflammatory markers.Trial registration:The study was prospectively registered with the Pan African Clinical Trials Registry (Reference number – PACTR201910562118957) on October 21, 2019. (https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9425).