Hypoxemia in healthy subjects at moderate altitude.

BACKGROUND: Healthy individuals are known to have significantly reduced oxygen saturations at rest when acutely exposed to moderate altitudes, such as during commercial flight. There is a paucity of data on the response of healthy individuals to exercise at these altitudes. The aim of this study was to establish the normal response to exercise during acute, moderate altitude exposure with regard to oxygen saturations. Secondary aims were to establish if this response can be predicted from pulmonary function measurements at sea level. METHODS: At sea level, 20 subjects performed pulmonary function tests, including submaximal steady state exercise, followed by replication of submaximal steady state exercise during acute altitude exposure at 6844 ft (2086 m). RESULTS: Mean resting oxygen saturation at 6844 ft (2086 m) was 96%, a significant reduction from the sea level value of 99%. Mean nadir oxygen saturation during steady state exercise at moderate altitude was 89%. There was a weak negative correlation between aerobic capacity and end exercise oxygen saturation at altitude. Modified BORG dyspnea scores were unchanged at rest at 6844 ft (2086 m) and higher post-exercise at 6844 ft (2086 m) when compared to sea level, although absolute values were low. DISCUSSION: Healthy individuals desaturate at rest and upon exercise during acute altitude exposure at 6844 ft (2086 m). A quarter of participants experienced SpO2 < or = 85% upon exercise at altitude, although this had no correlation with dyspnea scores or baseline pulmonary function measurements. The weak negative correlation between aerobic capacity and end exercise oxygen saturation is unexplained and merits further research.

A pilot study evaluating multiple risk factor interventions by community pharmacists to prevent cardiovascular disease: the PAART CVD pilot project.

BACKGROUND: There is insufficient evidence for the efficacy of comprehensive multiple risk factor interventions by pharmacists in the primary prevention of cardiovascular disease (CVD). Given the proven benefits of pharmacist interventions for individual risk factors, it is essential that evidence for a comprehensive approach to care be generated so that pharmacists remain key members of the health care team for individuals at risk of initial onset of CVD. OBJECTIVE: To establish the feasibility of an intervention delivered by community pharmacists to reduce the risk of primary onset of CVD. METHODS: A single-cohort intervention study was undertaken in 2008-2009. Twelve community pharmacists from 10 pharmacies who were trained to provide lifestyle and medicine management support to reduce CVD risk recruited 70 at-risk participants aged 50-74 years who were free from diabetes or CVD. Participants received a baseline assessment to establish CVD risk and health behaviors. An assessment report provided to patients and pharmacists was used to collaboratively establish treatment goals and, over 5 sessions, implement treatment strategies. Follow-up assessment at 6 months measured changes in baseline parameters. The primary outcome was the average change to overall 5-year risk of CVD onset. RESULTS: Sixty-seven participants were included in the analysis. The mean participant age was 60 years and 73% were female. We observed a 25% (95% CI 17 to 33) proportional risk reduction in overall CVD risk. Significant reductions also occurred in mean blood pressure (-11/-5 mm Hg) and waist circumference (-1.3 cm), with trends toward improvement for most other observed risk factors. CONCLUSIONS: Findings support previous evidence of positive cardiovascular health outcomes following pharmacist intervention in other patient groups; we recommend generating randomized controlled trial evidence for a primary prevention population.

Evaluation of rapid DNA using ANDE™ in a technical exploitation Level 2 laboratory workflow.

A trial of rapid DNA (rDNA), a fully automated DNA profiling system, within a technical exploitation (TE) workflow is an important endeavor. In the 2019 Ardent Defender (AD) exercise, the Deployable Technical Analysis Laboratory (DTAL), of the Canadian Department of National Defence (DND), evaluated the use of rDNA using ANDE™. Sixteen samples were processed during a pre-exercise "controlled" setting, 44 samples were from an "uncontrolled" environment during the exercise, and 22 samples were buccal swabs. The proportion of profiles suitable for upload to ANDE™ was 95.5% of buccal samples (21/22), 66.7% controlled samples, and 15.9% for uncontrolled samples. A considerable difference was observed in the proportions of complete DNA profiles obtained from all exploited items between the controlled (58.3%) and uncontrolled (15.9%) trials and in the proportions of samples where no DNA was detected (16.7% controlled trial vs. 56.8% uncontrolled trial). Overall, the trials highlighted the potential to gain identity intelligence using rDNA within a TE workflow and revealed the impact of operational constraints and the need to improve certain TE practices to gain the most benefit from rDNA. It also demonstrated the benefit of including an uncontrolled component for a more realistic indication of rDNA effectiveness in operational settings and highlighted operational practices impacting rDNA success. Mixture deconvolution was difficult as current guidelines do not consider some of the stochastic effects produced by the rDNA analysis; however, overall, the study demonstrated that rDNA using the ANDE™ instrument could be successfully incorporated into a TE workflow within a deployable laboratory.

Evaluation of a community pharmacy-based intervention for improving patient adherence to antihypertensives: a randomised controlled trial.

BACKGROUND: The majority of patients using antihypertensive medications fail to achieve their recommended target blood pressure. Poor daily adherence with medication regimens and a lack of persistence with medication use are two of the major reasons for failure to reach target blood pressure. There is no single intervention to improve adherence with antihypertensives that is consistently effective. Community pharmacists are in an ideal position to promote adherence to chronic medications. This study aims to test a specific intervention package that could be integrated into the community pharmacy workflow to enable pharmacists to improve patient adherence and/or persistence with antihypertensive medications--Hypertension Adherence Program in Pharmacy (HAPPY). METHODS/DESIGN: The HAPPY trial is a multi-centre prospective randomised controlled trial. Fifty-six pharmacies have been recruited from three Australian states. To identify potential patients, a software application (MedeMine CVD) extracted data from a community pharmacy dispensing software system (FRED Dispense). The pharmacies have been randomised to either 'Pharmacist Care Group' (PCG) or 'Usual Care Group' (UCG). To check for 'Hawthorne effect' in the UCG, a third group of patients 'Hidden Control Group' (HCG) will be identified in the UCG pharmacies, which will be made known to the pharmacists at the end of six months. Each study group requires 182 patients. Data will be collected at baseline, three and six months in the PCG and at baseline and six months in the UCG. Changes in patient adherence and persistence at the end of six months will be measured using the self-reported Morisky score, the Tool for Adherence Behaviour Screening and medication refill data. DISCUSSION: To our knowledge, this is the first research testing a comprehensive package of evidence-based interventions that could be integrated into the community pharmacy workflow to enable pharmacists to improve patient adherence and/or persistence with antihypertensive medications. The unique features of the HAPPY trial include the use of MedeMine CVD to identify patients who could potentially benefit from the service, control for the 'Hawthorne effect' in the UCG and the offer of the intervention package at the end of six months to patients in the UCG, a strategy that is expected to improve retention. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12609000705280.

Prevalence, Safety, and Effectiveness of Oral Anticoagulant Use in People with and without Dementia or Cognitive Impairment: A Systematic Review and Meta-Analysis.

BACKGROUND: Differences in management and outcomes of oral anticoagulant (OAC) use may exist for people with and without dementia or cognitive impairment (CI). OBJECTIVE: To systematically review the prevalence and safety and effectiveness outcomes of OAC use in people with and without dementia or CI. METHODS: MEDLINE, EMBASE, and CINAHL were searched for studies reporting prevalence or safety and effectiveness outcomes of OAC use for people with and without dementia, published between 2000 to September 2017. Study selection, data extraction, and quality assessment were performed by two reviewers. RESULTS: studies met pre-specified inclusion criteria (21 prevalence studies, 6 outcomes studies). People with dementia had 52% lower odds of receiving OAC compared to people without dementia. Mean OAC prevalence was 32% for people with dementia, compared to 48% without dementia. There was no difference in the composite outcome of embolic events, myocardial infarction, and all-cause death between dementia and non-dementia groups (adjusted hazard ratio (HR) 0.72, 95% CI, 0.45-1.14, p = 0.155). Bleeding rate was lower for people without dementia (HR 0.56, 95% CI, 0.37-0.85). Adverse warfarin events were more common for residents of long-term care with dementia (adjusted incidence rate ratio 1.48, 95% CI, 1.20-1.82). Community-dwelling people with dementia treated with warfarin had poorer anticoagulation control than those without dementia (mean time in therapeutic range (TTR) % ±SD, 38±26 (dementia), 61±27 (no dementia), p < 0.0001). CONCLUSION: A lower proportion of people with dementia received oral anticoagulation compared with people without dementia. People with dementia had higher bleeding risk and poorer anticoagulation control when treated with warfarin.

Early carotid endarterectomy after ischemic stroke improves diffusion/perfusion mismatch on magnetic resonance imaging: report of two cases.

OBJECTIVE AND IMPORTANCE: The functional magnetic resonance imaging techniques of diffusion-weighted imaging and perfusion-weighted imaging allow for ultra-early detection of brain infarction and concomitant identification of blood flow abnormalities in surrounding regions, which may represent brain "at risk." CLINICAL PRESENTATION: We report two patients with acute ischemic stroke associated with ipsilateral high-grade carotid stenosis. The first patient, a 64-year-old woman with a remote history of ischemic stroke and a vertebral artery aneurysm, presented with worsening of her preexisting right hemiparesis. The second patient, another 64-year-old woman with known multiple intracranial aneurysms and bilateral high-grade internal carotid artery stenosis, was admitted for the elective microsurgical clipping of an enlarging giant left carotid-ophthalmic artery aneurysm. Postoperatively, she developed right hemiparesis and mild aphasia. Both patients showed progressive worsening of their neurological deficits in the setting of small or undetected diffusion-weighted imaging abnormalities and large perfusion-weighted imaging defects. INTERVENTION: After prompt carotid endarterectomy, symptoms in both patients resolved or improved. Follow-up magnetic resonance imaging scans demonstrated resolution or significant improvement in the perfusion abnormalities in both patients. CONCLUSION: Carotid endarterectomy in the setting of diffusion-weighted/perfusion-weighted imaging mismatch can lead to improvement in cerebral perfusion as evidenced by resolution of the perfusion-weighted imaging lesion. Diffusion/perfusion magnetic resonance imaging may be useful in identifying patients with severe neurological deficits but without large territories of infarction who may safely undergo early surgical revascularization.