Warfarin Therapy in the HIV Medical Home Model: Low Rates of Therapeutic Anticoagulation Despite Adherence and Differences in Dosing Based on Specific Antiretrovirals

Abstract To determine the indications for, rates of therapeutic anticoagulation during, and complications of warfarin therapy in HIV-infected individuals, in whom long-term anticoagulation is frequently indicated. To identify risk factors for nonoptimal anticoagulation and to determine if warfarin dosing is differentially affected by specific antiretroviral agents. Retrospective study of a dedicated anticoagulation program at one of the largest clinics for HIV-infected individuals in the United States. Seventy-three HIV-infected individuals on warfarin were followed for a total of 911 visits. The rate of therapeutic internation normalized ratio (INR) levels was 34.5% when including only visits at which patients were assessed to be adherent with warfarin. In multivariable analysis, injection drug use at baseline was an independent risk factor for subtherapeutic INR (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.3-4.7, p=0.01). Additionally, warfarin adherence was protective of both subtherapeutic (OR 0.4, 95% CI 0.2-0.6, p<0.0001) and supratherapeutic (OR 0.5, 95% CI 0.3-0.9, p=0.02) INR status. Efavirenz-based antiretroviral regimens were associated with lower weekly warfarin doses (46?mg) to maintain therapeutic INR compared to lopinavir/ritonavir-based regimens (68?mg; p=0.01) and atazanavir/ritonavir-based regimens (71?mg; p=0.007). Consistently therapeutic warfarin therapy is difficult to achieve in HIV-infected individuals, even with a dedicated anticoagulation program. Adherence to warfarin therapy is important but rates of therapeutic INR levels are nonetheless low. Lower warfarin dosing was required for efavirenz compared to two commonly used protease inhibitor-based regimens. Because of these factors, the emergence of new oral anticoagulants is an important development for HIV-infected individuals who require long term anticoagulation therapy.     

Norovirus disease surveillance using google internet query share data

Google Internet query share (IQS) data for gastroenteritis-related search terms correlated strongly with contemporaneous national (R(2)?=?0.70) and regional (R(2)?=?0.74) norovirus surveillance data in the United States. IQS data may facilitate rapid identification of norovirus season onset, elevated peak activity, and potential emergence of novel strains.     

Use of Internet search data to monitor impact of rotavirus vaccination in the United States

Google-based Internet query share (IQS) for rotavirus search terms correlated well with US rotavirus laboratory detections from 2004 to 2010 (r = 0.88; P < .001), capturing the reduction observed during postvaccine years (2008-2010). IQS analysis could become an inexpensive and reliable supplement for monitoring the impact of rotavirus vaccination in the United States.     

Pre-operative staging of rectal cancer: MRI or ultrasound?

Optimal management of rectal cancer depends on obtaining accurate and detailed staging information at the time of diagnosis. The majority of this comes from radiological staging investigations such as computed tomography (CT), magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS). Whilst there is little debate on the use of CT to assess distant spread of disease, there is still variation in the use of MRI or EAUS in the local staging of rectal cancer. Both techniques have their roles but MRI is better able to visualise the entire rectum and mesorectum as well as accurately identify the circumferential resection (CRM) margin in relation to the tumour edge. Breach of the CRM is one of the most important predictors of local recurrence and knowledge of its relationship to the tumour determines initial management. MRI has additional advantages in being able to identify other poor prognostic factors such as extramural venous invasion (EMVI) and mucin deposition, which further influence oncological treatment. It also provides the surgeon with accurate information on the relationship of the tumour to surrounding structures and the sphincter complex which is important for surgical planning. This review highlights the important determinants of local staging in rectal cancer and presents the evidence to answer the question as to which is a better imaging modality—MRI or EAUS?     

Spontaneous bilateral displaced femoral neck fractures in nutritional osteomalacia--a case report

Background and purpose?Incorporation of fresh-frozen allograft bone and safety aspects associated with this procedure can be improved by removing blood and lipids from the bone. We investigated in a quantitative manner how efficient pulse lavage might be for removal of adipose tissue from morselized allograft bone.

Methods?Depending on the study, the washing was performed with an average of 0.8 L or 1.6 L of sterile saline at room temperature. Fat content of the morselized bone samples was determined using hexane elution. The efficiency of pulse lavage alone was compared with that after an additional wash in 12 L of warm water (55°C). Unprocessed controls were also included for comparison.

Results?Pulse lavage with 0.8 L saline alone removed 80% of the fat from the bone, whereas 95% of the fat was removed when washing was performed with 1.6 L of saline. The cleansing efficacy was improved further when an additional wash with warm water was used.

Interpretation?Our results indicate that pulse-lavage washing alone at room temperature is an effective method for defatting of morselized allograft bone, but an additional wash with warm water improves the cleansing efficiency. Pulse lavage is easily available and simple to use in the operating theater.     

Outcome after decompressive craniectomy in patients with dominant middle cerebral artery infarction: A preliminary report

Introduction:

Life-threatening, space occupying, infarction develops in 10-15% of patients after middle cerebral artery infarction (MCAI). Though decompressive craniectomy (DC) is now standard of care in patients with non-dominant stroke, its role in dominant MCAI (DMCAI) is largely undefined. This may reflect the ethical dilemma of saving life of a patient who may then remain hemiplegic and dysphasic. This study specifically addresses this issue.

Materials and Methods:

This retrospective analysis studied patients with DMCAI undergoing DC. Patient records, operation notes, radiology, and out-patient files were scrutinized to collate data. Glasgow outcome scale (GOS), Barthel index (BI) and improvement in language and motor function were evaluated to determine functional outcome.

Results:

Eighteen patients between 22 years and 72 years of age were included. 6 week, 3 month, 6 month and overall survival rates were 66.6% (12/18), 64% (11/17), 62.5% (10/16) and 62.5% (10/16) respectively. Amongst ten surviving patients with long-term follow-up, 60% showed improvement in GOS, 70% achieved BI score >60 while 30% achieved full functional independence. In this group, motor power and language function improved in 9 and 8 patients respectively. At last follow-up, 8 of 10 surviving patients were ambulatory with (3/8) or without (5/8) support. Age <50 years corresponded with better functional outcome amongst survivors (P value –0.0068).

Conclusion:

Language and motor outcomes after DC in patients with DMCAI are not as dismal as commonly perceived. Perhaps young patients (<50 years) with DMCAI should be treated with the same aggressiveness that non-DMCAI is currently dealt with.Key Words: Craniectomy, dominant, middle cerebral artery, outcome, stroke