D‐dimer levels and stroke progression in patients with acute ischemic stroke and atrial fibrillation

Krarup L‐H, Sandset EC, Sandset PM, Berge E. D‐dimer levels and stroke progression in patients with acute ischemic stroke and atrial fibrillation.
Acta Neurol Scand: 2011: 124: 40–44.
© 2010 John Wiley & Sons A/S. Background – Patients with acute ischemic stroke and atrial fibrillation are at increased risk of stroke progression and recurrence. We sought to assess whether D‐dimer and other markers of hemostatic activation could predict these adverse events in such patients. Method – Blood samples were obtained from patients included in the Heparin in Acute Embolic Stroke Trial. Stroke progression was defined as a ≥3‐point worsening on the Scandinavian Stroke Scale during the first 48 h after randomization. Blood samples were analyzed for D‐dimer, prothrombin fragment 1 + 2, soluble fibrin monomer, and C‐reactive protein. Results – A total of 382 patients were included in the analyses. Levels of D‐dimer and other markers of hemostatic activation were not significantly higher in patients with stroke progression than in other patients (D‐dimer median values: 1025 ng/ml vs 970 ng/ml, P = 0.73). The same was true for recurrent stroke (D‐dimer: 720 ng/ml vs 973 ng/ml, P = 0.96), and the combined endpoint of stroke progression, recurrent stroke, and death (D‐dimer: 991 ng/ml vs 970 ng/ml, P = 0.91). Multivariable analyses did not alter the results. Conclusion – D‐dimer and other markers of hemostatic activation were not associated with stroke progression, recurrent stroke, or death in patients with acute ischemic stroke and atrial fibrillation.     

Sport as a vehicle for health promotion – an analysis of Norwegian policy documents

In contemporary western society, there has been an increasing focus on physical activity as a vehicle for promoting health. How physical activity is promoted and organized varies across countries. This article focuses on the Norwegian system, which is characterized by voluntary sport being organized during leisure time, and all being federated under the Norwegian Olympic Committee and Confederation of Sports (NOC). Guided by the field concept of Bourdieu, historical works and contemporary sport policy documents are analyzed in order to explore how health is considered within the sport context. The conclusion is that health is both facilitated and constrained in the sport field. The voluntary dominance of the sport field makes it sustainable in relation to providing physical activity. However, the voluntary dominance of the sport field also makes it vulnerable and unpredictable in relation to implementing state sport and/or health policy. The state cannot in any way be assured to achieve its health objectives through the sport field.     

Release of netilmicin and vancomycin from cancellous bone

First, we studied the effect of the following variables used for netilmicin- and vancomycin-impregnation of cancellous bone: a) antibiotic concentration of the impregnation fluid, b) time used for impregnation, c) pH of the impregnation fluid, d) the degree of bone morselizing and e) antibiotic combination. An increase in the antibiotic concentration of the impregnation fluid increased the amount of antibiotics released from bone. In addition, the amount of vancomycin eluted was also dependent on the time used for impregnation. The fraction of the total amount of netilmicin and vancomycin released after 24 h was 80% and 30%, respectively. More netilmicin and vancomycin were eluted from bone impregnated with antibiotics at pH 7 than the amount eluted from bone impregnated at pH 3. More netilmicin was eluted from fine morselized bone than from coarse morselized bone. By combining netilmicin and vancomycin in the impregnation fluid, the release of vancomycin was reduced. Secondly, we analyzed if the release of antibiotics from bone was complete: 99.9% of the total amount of netilmicin adsorbed to the bone was released by elution during 6 weeks. Finally, after implantation of netilmicin-impregnated bone in rabbit femur condyle, we measured netilmicin and vancomycin in serum: peak serum values of netilmicin were 4.2 (3.7-4.7) mg/L 2-3 h postoperatively.     

Determinants of adherence to recommendations for depressed elderly patients in primary care: A multi-methods study

Objective. It is logical that tailoring implementation strategies to address identified determinants of adherence to clinical practice guidelines should improve adherence. This study aimed to identify and prioritize determinants of adherence to six recommendations for elderly patients with depression. Design and setting. Group and individual interviews and a survey were conducted in Norway. Method. Individual and group interviews with healthcare professionals and patients, and a mailed survey of healthcare professionals. A generic checklist of determinants of practice was used to categorize suggested determinants. Participants. Physicians and nurses from primary and specialist care, psychologists, researchers, and patients. Main outcome measures. Determinants of adherence to recommendations for depressed elderly patients in primary care. Results. A total of 352 determinants were identified, of which 99 were prioritized. The most frequently identified factors had to do with dissemination of guidelines, general practitioners’ time constraints, the low prioritization of elderly patients with depression, and the patients’ or relatives’ wish for medication. Approximately three-quarters of the determinants were from three of the seven domains in the generic checklist: individual healthcare professional factors, patient factors, and incentives and resources. The survey did not provide useful information due to a low response rate and a lack of responses to open-ended questions. Implications. The list of prioritized determinants can inform the design of interventions to implement recommendations for elderly patients with depression. The importance of the determinants that were identified may vary across communities, practices. and patients. Interventions that address important determinants are necessary to improve practice.Key Words: Depression, determinants of practice, elderly patients, general practice, Norway, primary care, tailored implementation

• Multiple factors might impede or facilitate general practitioners’ (GPs’) adherence to guidelines for the care of depressed elderly patients. Interviews and a survey were conducted to identify and prioritize such determinants of adherence.
• Factors related to dissemination of guidelines, GPs’ time constraints, and the lack of priority given to elderly patients with depression were the most frequently suggested barriers to adherence.
• Other determinants were individual healthcare professional factors (e.g. their knowledge and skills), patient factors (e.g. their beliefs and preferences), incentives, and the availability of necessary resources.

     

Adherence to clinical guidelines for Barrett’s esophagus

Abstract

Background and aim: Clinical guidelines recommend endoscopy surveillance at given intervals or endoscopic therapy for Barrett’s esophagus with low-grade dysplasia (LGD) and high-grade dysplasia (HGD). Whether these guidelines are followed in clinical practice is unknown and was assessed in this study.

Methods: This nationwide Swedish cohort study included patients with Barrett’s esophagus with histologically verified LGD or HGD from 50 centers in 2006–2013. These patients were followed up using nationwide registers. Adherence to clinical guidelines was explored. Eight potential risk factors for deviation from guidelines were assessed using multivariable logistic regression, providing adjusted odds ratios (OR) with 95% confidence intervals (95%CI).

Results: Among 211 patients with Barrett’s esophagus (mean age 67.0 years, standard deviation 9.7 years, 81% male), 71% had LGD and 29% had HGD. During median 3.9 years of follow-up, 84% underwent a follow-up endoscopy, 17% received endoscopic therapy and 8% underwent esophagectomy. The clinical management deviated from guidelines in 60% of all patients (69% in LGD and 39% in HGD), which was mainly due to under-surveillance (86%). Risk factors for deviation from guidelines were LGD compared to HGD (OR 3.4, 95%CI 1.7–6.8), longer Barrett’s segment length (OR 2.0, 95%CI 1.0–3.9, comparing ≥3?cm with <3?cm), and treatment at gastroenterology compared to surgery departments (OR 2.3, 95%CI 1.2–4.4). Age, sex, calendar period and university hospital status were not associated with deviation from surveillance guidelines.

Conclusions: Adherence to guidelines for dysplastic Barrett’s esophagus is poor, particularly for LGD. Efforts to implement clinical guideline recommendations are needed.     

High excretion of β-aminoisobutyric acid in patients with ketoacidosis

High concentrations of β-aminoisobutyric acid (BAIBA) were found to be present in the urine from patients with ketoacidosis. The R-form was always the dominating isomer of BAIBA. The finding is discussed, and it is suggested that the mechanism might be a derangement in the degradation of valine.