Assessment of the quality of anticoagulation management with warfarin in a tertiary care center

Objectives:To evaluate the quality of an anticoagulation clinic in a tertiary hospital and identified factors affecting the time in the therapeutic range (TTR) and its relation to different complications.Methods:This single-center retrospective study conducted between March 2015 and June 2016 included 1914 patients receiving warfarin therapy. They were divided into 4 warfarin indication groups: non-valvular atrial fibrillation (AF) (n=403), valvular AF (n=227), prosthetic valves (n=700), and venous or pulmonary embolism (n=584).Results:The median age was 56 (25th, 75th percentiles: [45, 67]) years, and 53.2% were female. The median TTR was 0.52 (0.28, 0.76). Low hemoglobin (0.007) and high alkaline phosphatase (0.020) levels negatively affected the TTR. Venous thromboembolism (VTE) was associated with low TTRs. Minor bleeding occurred in 64 (3.35%), gastrointestinal bleeding in 14 (0.7%), and stroke in 41 (2.2%) patients, with no inter-group differences. The TTR was not associated with minor bleeding (odds ratio [OR]=0.49; p=0.09), gastrointestinal bleeding (OR=0.29; p=0.18), or stroke (OR=1.15; p=0.79).Conclusion:Reflecting the real-life experience of anticoagulation control, our patients spend less than half the TTR within the INR. The low target TTR mandates the need to improve service quality and control factors affecting the TTR, including hemoglobin levels and regular visits for patients with VTE.     

Individualized Intervention to Support Mental Health Recovery Through Implementation of Digital Tools into Clinical Care: Feasibility Study

Myriad digital tools exist to support mental health but there are multiple barriers to using these tools in routine care. This study aimed to assess the feasibility of an intervention incorporating a support role to help the clinical team identify and use technology to promote recovery. The technology specialist intervention is 3 months in duration and comprises four stages: goal setting, researching and evaluating tools, demonstrating and selecting tools, and ongoing support. We implemented the intervention in a community mental health center and a dual diagnosis treatment program, working with eight clients and their case managers. Clients and case managers willingly engaged with the technology specialist and found the intervention beneficial. Integration and collaboration with the care team facilitated implementation of the technology specialist in these real-world settings. Clients reported that the intervention made it easy to try a digital tool. Six of the eight participants stated that they made substantial progress toward their goals. The technology specialist is a promising new role for mental health care delivery to augment traditional services and enhance individualized recovery.

     

National disparities in laparoscopic colorectal procedures for colon cancer

Introduction

Racial disparity in the treatment of colorectal cancer (CRC) has been cited as a potential cause for differences in mortality. This study compares the rates of laparoscopy according to race, insurance status, geographic location, and hospital size.

Methods

The 2009 Healthcare Cost and Utilization Project: Nationwide Inpatient Sample (HCUP-NIS) database was queried to identify patients with the diagnosis of CRC by the International Classification of Diseases, Ninth Revision (ICD-9) codes. Multivariate logistic regression was performed to look at age, gender, insurance coverage, academic versus nonacademic affiliated institutions, rural versus urban settings, location, and proportional differences in laparoscopic procedures according to race.

Results

A total of 14,502 patients were identified; 4,691 (32.35 %) underwent laparoscopic colorectal procedures and 9,811 (67.65 %) underwent open procedures. The proportion of laparoscopic procedures did not differ significantly by race: Caucasian 32.4 %, African-American 30.04 %, Hispanic 33.99 %, and Asian-Pacific Islander 35.12 (P = 0.08). Among Caucasian and African-American patients, those covered by private insurers were more likely to undergo laparoscopic procedures compared to other insurance types (P ≤ 0.001). The odds of receiving laparoscopic procedure at teaching hospitals was 1.39 times greater than in nonteaching hospitals (95 % confidence interval [CI] 1.29–1.48) and did not differ across race groups. Patients in urban hospitals demonstrated higher odds of laparoscopic surgery (2.24, 95 % CI 1.96–2.56) than in rural hospitals; this relationship was consistent within races. The odds of undergoing laparoscopic surgeries was lowest in the Midwest region (0.89, 95 % CI 0.81–0.97) but higher in the Southern region (1.14, 95 % CI 1.06–1.22) compared with the other regions.

Conclusions

Nearly one-third of all CRC surgeries are laparoscopic. Race does not appear to play a significant role in the selection of a laparoscopic CRC operation. However, there are significant differences in the selection of laparoscopy for CRC patients based on insurance status, geographic location, and hospital type.     

Stent thrombosis is a major concern in clinical practice: A single Saudi center experience

BackgroundDrug-eluting stents (DES) are used in the majority of patients who undergo percutaneous coronary intervention (PCI), and have reduced the rate of in-stent restenosis and repeated revascularization in comparison to bare metal stents. However, stent thrombosis (ST) is an uncommon but serious complication of coronary artery stents that is mostly fatal or presents as a large non-fatal myocardial infarction (MI), usually with ST elevation.ObjectiveTo study the incidence of stent thrombosis in Middle Eastern Saudi patients who underwent PCI using both drug-eluting stents (DES) and bare metal stents (BMS). ST can occur acutely (within 24 h), sub acutely (within 30 days), or as late as one year (late) or even more than one year (very late).MethodsIn an observational, single center study in catheterization (cath) lab a total of 1386 patients underwent PCI between January 2008 and September 2010. The study included all patients in that period who had acute coronary syndrome and stable coronary artery disease (CAD).ResultsA total of 1386 patients had PCI and stent deployments; 19 (1.3%) patients had stent thrombosis, four patients (21%) received BMS and 15 patients (79%) received DES. Four patients had acute ST; five had subacute ST; eight patients had late ST; while two patients had very late ST. Nine patients (47%) had DM and eight patients (42%) had hypertension.ConclusionThe incidence of ST in Saudi patients who received DES at our center is similar to internationally reported numbers. Almost half of ST patients are diabetics and there is increasing concern that the risk for late stent thrombosis is slightly higher with DES than BMS.     

Controlling of systemic absorption of gliclazide through incorporation into alginate beads

This work investigates preparation of biodegradable beads with alginate polymer by ionotropic gelation method to take the advantages of the swelling and mucoadhesive properties of alginate beads for improving the oral delivery of the antidiabetic agent gliclazide. It demonstrates that the ionic gelation of alginate molecules offers a flexible and easily controllable process for manipulating the characteristics of the beads which are important in controlling the release rate and consequently the absorption of gliclazide from the gastrointestinal tract. Variations in polymer concentration, stirring speed, internal phase volume and the type of surfactant in the external phase were examined systemically for their effects on the particle size, incorporation efficiency and flow properties of the beads. The swelling behavior was strongly dependent on the polymer concentration in the formulations and the pH of the medium. The in vitro release experiments revealed that the swelling is the main parameter controlling the release rate of gliclazide from the beads. In vivo studies on diabetic rabbits showed that the hypoglycemic effect induced by the gliclazide loaded alginate beads was significantly greater and more prolonged than that induced by the marketed conventional gliclazide tablet (Gliclazide). The results clearly demonstrated the ability of the system to maintain tight blood glucose level and improved the patient compliance by enhancing, controlling and prolonging the systemic absorption of gliclazide.