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Aims There are scarce data evaluating the effectiveness and safety of rivaroxaban vs. warfarin in non-valvular atrial fibrillation (NVAF) patients with concomitant coronary artery disease (CAD) and/or peripheral artery disease (PAD) treated in routine practice. Methods and results Using MarketScan data from January 2012 to December 2017, we identified oral anticoagulant (OAC)-naïve NVAF patients receiving rivaroxaban (15–20 mg once daily) or warfarin, with comorbid CAD and/or PAD and ≥12 months of insurance coverage before OAC initiation. Differences in baseline covariates between cohorts were adjusted using inverse probability-of-treatment weights based on propensity scores (standardized differences Conclusion Among patients with NVAF and comorbid CAD and/or PAD, rivaroxaban use was associated with a reduced risk of MTVEs vs. warfarin, without significantly increasing major bleeding risk.

Aims To compare the effectiveness and safety of standard-dose rivaroxaban (20 mg o.d.) and warfarin in non-valvular atrial fibrillation (NVAF) patients with a non-sex-related CHA2DS2-VASc score of 1. Methods and results Analysis of United States Truven MarketScan claims from November 2011 to December 2016 for anticoagulant-naïve NVAF patients with a single non-sex-related stroke risk factor assigned 1-point in the CHA2DS2-VASc score and ≥12-months of continuous medical/prescription insurance coverage prior to the qualifying oral anticoagulant dispensing. Standard-dose rivaroxaban users were 1:1 propensity score-matched to warfarin users. Patients were followed until outcome occurrence, insurance disenrollment, or end of data availability. Primary outcomes included stroke or systemic embolism and major bleeding and were compared using Cox regression and reported as hazard ratios (HRs) with 95% confidence intervals (CIs). In all, 3319 rivaroxaban users were 1:1 propensity score-matched to 3319 warfarin users. Median (interquartile range) duration of follow-up was 1.6 (0.7, 2) years and the most common qualifying stroke risk factor was hypertension (n = 4532, 68.3%). Rivaroxaban was associated with a significant reduction in the 1-year stroke or systemic embolism vs. warfarin (HR 0.41, 95% CI 0.17–0.98), with no significant difference in overall major bleeding (HR 0.74, 95% CI 0.44–1.26) or major bleeding subtypes (HR ranging from 0.33 to 0.78, P > 0.05 for all). Similar results were seen after extending follow-up to 2 years. Conclusions Rivaroxaban may lower the rate of stroke or systemic embolism vs. warfarin in NVAF patients with a non-sex-related CHA2DS2-VASc score of 1 without impacting major bleeding.

As an author, there is no better feeling than to receive correspondence from a journal editor that your paper has been accepted for publication. However, that sense of elation can quickly turn to dread if the author has to respond to dozens, even hundreds, of comments from peer reviewers. We have

Peer review is a shared responsibility intended to enhance the quality of manuscripts published in biomedical journals. Under ideal circumstances, everyone—authors, reviewers, and editors—understands their role and responsibilities, approaching the process with deliberate thoughtfulness. In our

Publishing manuscripts in the peer-reviewed literature is essential for the advancement of both science and healthcare.[1][1] For those who work in academic environments, including residency or fellowship training programs, disseminating one’s work in peer-reviewed journals and other forums is

Purpose The effect of ascorbic acid on inflammatory markers after cardiothoracic surgery (CTS) was studied. Methods In this randomized, double-blind, placebo-controlled trial, patients undergoing cardiopulmonary bypass graft surgery or valve replacement surgery from April 2009 through March 2010 at Hartford Hospital were randomized to receive ascorbic acid (2-g loading dose followed by 500 mg every 12 hours) or matching placebo the evening before surgery and for four days postoperatively. Inflammatory mediators were measured preoperatively and on postoperative days 1–4. Intergroup comparisons were performed using two-tailed t tests and Fisher’s exact test. Multiple comparisons were conducted using repeated analyses of variance with Bonferroni tests. Results Of the 62 patients screened, 24 met the study inclusion criteria. Of these, 13 were assigned to receive ascorbic acid and 11 received placebo. Ascorbic acid did not affect the natural course of inflammatory marker rise for C-reactive protein (CRP) concentration, white blood cell (WBC) count, or fibrinogen concentration versus placebo at any evaluated time point ( p > 0.05 for all intergroup comparisons). Intragroup analyses demonstrated significant differences among baseline and postoperative measures of all inflammatory mediators ( p < 0.05). No significant differences were noted in inflammatory markers between patients undergoing cardiothoracic surgery with or without cardiopulmonary bypass, regardless of treatment group. Conclusion Ascorbic acid did not attenuate the rise in inflammatory markers after CTS when compared with placebo. The use of off-pump surgery did not significantly change the levels of CRP and fibrinogen or the WBC count postoperatively when compared with on-pump surgery with a biocompatible polymer coating.

Purpose Evidence regarding combination therapy for the management of hypertension is reviewed. Summary Numerous clinical trials have demonstrated the importance of early aggressive lowering of blood pressure, especially in patients at high cardiovascular risk. However, one of the difficulties with achieving these blood pressure goals quickly is that monotherapy is often insufficient. Many large randomized trials have shown that two or more antihypertensive agents are required for patients to reach their treatment goals. Recent data have suggested that the use of combination therapy in patients with hypertension may be beneficial in terms of improving blood-pressure-lowering efficacy, obtaining blood pressure goals earlier, and reducing major adverse cardiovascular events. Studies have found that therapy with a calcium channel blocker (CCB) combined with an angiotensin-converting-enzyme (ACE) inhibitor significantly reduces both blood pressure and major clinical events compared with an ACE inhibitor–diuretic combination. Combination ACE inhibitor–CCB therapy has also demonstrated superior blood-pressure-lowering efficacy and safety compared with either group used as monotherapy, including lower rates of peripheral edema compared with those achieved with increased doses of CCBs. The combination of an ACE inhibitor and an angiotensin II-receptor blocker has not been found to be superior to either group as monotherapy in patients with hypertension and should not be recommended at this time. Conclusion Combination drug therapy for the treatment of hypertension is supported by numerous randomized trials and clinical management guidelines. The addition of a diuretic or CCB to renin–angiotensin–aldosterone-system blocker therapy may provide an effective combination for reducing blood pressure and cardiovascular events.

Purpose The effect of i.v. chromium administration on glucose control in two patients receiving enteral nutrition is described. Summary Chromium supplementation has been hypothesized to potentiate the actions of insulin in facilitating cellular uptake of glucose. We report two cases—one involving a diabetic patient and the other a nondiabetic patient—in which chromium administration appeared to decrease insulin requirements. In case 1, a diabetic patient given a single course of chromic chloride appeared to have a probable response to the drug. Within the first day of chromic chloride administration, insulin requirements declined. When chromic chloride was discontinued, insulin requirements did not rise, suggesting efficacy and sustained effect. The patient’s glucose intake and blood glucose levels remained relatively stable, while there was a significant decline in insulin requirements. Serum chromium levels were not assessed, so it is uncertain if the patient experienced chromium deficiency or if it was adequately treated with chromium supplementation, and a dose–response relationship could not be ascertained because the patient received a continuous infusion of chromium. In case 2, the insulin requirements of a nondiabetic patient appeared to decrease in response to multiple courses of chromic chloride. Upon initial discontinuation of chromic chloride, the patient’s lower insulin requirements were sustained for a few days, but changes in clinical status and other medications precipitated elevated insulin requirements and the need for subsequent chromic chloride administration. Further research in more controlled settings is necessary to elucidate chromium’s effect on insulin requirements. Conclusion Infusion of chromic chloride appeared to reduce insulin requirements in one diabetic patient and one nondiabetic patient.

Purpose. The effect of study-level factors on the proportion of time spent with International Normalized Ratio (INR) values inside the therapeutic range in patients treated with warfarin in the United States was evaluated. Methods. Studies evaluated in a previous meta-analysis were screened for potential inclusion, in addition to a systematic literature search of databases from January 2005 through February 2008. Studies were included if they (1) contained at least one warfarin dosing group that enrolled >25 patients for whom INR control was monitored for at least three weeks, (2) included only patients treated in the United States, (3) used a patient–time approach to report outcomes, and (4) reported proportion of time spent in the therapeutic INR range. Analyses included determining how study-level factors, such as study setting, year of study publication, INR interpolation method, study design, and presence of self-management, affected outcomes. Results. Twenty-four studies, including a total of 43 unique warfarin groups, were included in the analysis. Overall, patients spent 57% of their time in the therapeutic range (95% confidence interval [CI], 55–59%). Compared with anticoagulation clinics, community management resulted in less time (−13%; 95% CI, −18% to −7.9%) and prospective studies resulted in more time (7.3%; 95% CI, 1.5–13.1%) spent in the therapeutic range than retrospective studies. When studies from both the United States and Canada were included, similar results to those in the base-case analysis were seen; however, study year and interpolation method were also found to be significant modifiers of INR control. Conclusion. Patients included in the meta-analysis maintained INR values within the therapeutic range 57% of the time, although the use of anticoagulation clinic services appeared to be superior to standard community care in this regard. However, patients treated in anticoagulation clinics had INR values within the therapeutic range less than two thirds of the time.

The Minnesota Heart Health Program is a 13-year research and demonstration project to reduce morbidity and mortality from coronary heart disease in whole communities in the upper Midwest. Six communities were selected for the study: three intervention and three comparison sites, matched to increase baseline comparability. After 2-4 years of baseline observations, a 5- to 6-year program of intensive intervention was introduced in the three intervention communities. Periodic cross-sectional and cohort surveys provided data on risk factors and related behaviors. Regression adjustments within and between communities reduced the confounding influences of important covariates and the variance inflation associated with the nesting of individuals within communities and surveys. Post hoc stratification allowed exploration of the main and strata-specific effects of the intervention program. Finally, the intervention effect was modeled as a departure from the trend line fit to the nonintervention city-year means. Together, these procedures explicitly acknowledged the component of variance associated with communities, and so avoided a major source of bias created in the usual analysis when that variation is ignored. They also increased the interpretability of the analyses and reduced the mean square errors used to assess the treatment effects.

In their publication in EP-Europace , Vrijens and Heidbuchel1 conclude twice-daily (BID) dosing of non-vitamin K antagonist (VKA) oral anticoagulants ‘may be more forgiving in patients with suboptimal adherence’ than once-daily (OD) dosing. The authors submit the above conclusion is ‘exemplified’ by the PLATO trial, which compared OD clopidogrel to BID ticagrelor in acute coronary syndrome patients; suggesting the reduced rate of cardiovascular events with BID ticagrelor was the result of a ‘greater degree of continuity of drug action’ in the presence of suboptimal adherence.1,2 This theory ignores potential differences in antiplatelet potency between agents, in …

Toluene interferes with the anthrone reaction for hexoses causing a decrease in the absorption maximum at 625 mµ and producing a second absorption band with a maximum at 475 mµ. Xylene, benzene, and cyclohexene also interfere, whereas cyclohexane, o-chlorobenzene, and benzoic acid do not.