Direct Oral Anticoagulants for Thromboprophylaxis in Patients with Antiphospholipid Syndrome.

The current mainstay of the treatment and secondary thromboprophylaxis of thrombotic antiphospholipid syndrome (APS) is anticoagulation with warfarin or other vitamin K antagonists (VKAs). In addition to their well-known limitations, VKAs are often problematic in APS patients because of the variable sensitivity of thromboplastins to lupus anticoagulant. As a result, the international normalized ratio may not accurately reflect the intensity of anticoagulation. Direct oral anticoagulants (DOACs) are established as therapeutic alternatives to VKAs for a wide range of indications, including the treatment and secondary prevention of venous thromboembolism. Definition of the role of DOACs in the treatment of thrombotic APS is emerging with the results of recent and ongoing clinical studies. This review focuses on the current situation with regard to DOACs for secondary thromboprophylaxis in APS and issues pertinent to DOAC use in APS patients, as well as potential future directions.

How we manage patients with heparin induced thrombocytopenia.

Heparin induced thrombocytopenia (HIT) remains a rare, but significant, condition related to mortality and morbidity. The incidence has decreased with reduced use of unfractionated heparin, with the exception of cardiac surgery. Due to the high risk of thrombosis, a switch to a non-heparin anticoagulant is required, until platelet counts normalize. Within the acute setting, argatroban, fondaparinux and direct acting oral anticoagulants (DOACS) are therapeutic options. In patients with HIT-associated thrombosis or who require long-term anticoagulation, warfarin remains the preference, but DOACs are attractive alternatives.

Venous thromboembolism associated with medically assisted reproduction (MAR): British fertility society policy and practice guidance for assessment and prevention.

The association between Medically Assisted Reproduction (MAR) and thromboembolic complications has been reported widely in multiple published studies. Although venous thromboembolism (VTE) is not thought to be a common complication of MAR, it is associated with high morbidity and is often preventable. Since VTE usually occurs after completion of MAR treatment and is often managed outside of the treating fertility unit, these complications are likely to be underreported and there may be limited awareness of the risks among clinicians. As we continue to see a rise in the total number of MAR treatment cycles, particularly in women over 40 years of age, along with a steady increase in the number of fertility preservation cycles for both medical and social indications, it is likely that we will see an increase in absolute numbers of VTE complications. Currently, there is a lack of management guidance and reporting of VTE events associated with assisted conception treatment. The aim of this guidance is to provide clinicians with information on VTE risk factors, guidance on assessing VTE risk and the best practice recommendations on risk reducing strategies for individuals at risk of VTE undergoing ovarian stimulation and embryo transfer cycles.

Rivaroxaban for stroke patients with antiphospholipid syndrome (RISAPS): protocol for a randomized controlled, phase IIb proof-of-principle trial.

Background: Optimal secondary prevention antithrombotic therapy for patients with antiphospholipid syndrome (APS)-associated ischemic stroke, transient ischemic attack, or other ischemic brain injury is undefined. The standard of care, warfarin or other vitamin K antagonists at standard or high intensity (international normalized ratio (INR) target range 2.0-3.0/3.0-4.0, respectively), has well-recognized limitations. Direct oral anticoagulants have several advantages over warfarin, and the potential role of high-dose direct oral anticoagulants vs high-intensity warfarin in this setting merits investigation. Objectives: The Rivaroxaban for Stroke patients with APS trial (RISAPS) seeks to determine whether high-dose rivaroxaban could represent a safe and effective alternative to high-intensity warfarin in adult patients with APS and previous ischemic stroke, transient ischemic attack, or other ischemic brain manifestations. Methods: This phase IIb prospective, randomized, controlled, noninferiority, open-label, proof-of-principle trial compares rivaroxaban 15 mg twice daily vs warfarin, target INR range 3.0-4.0. The sample size target is 40 participants. Triple antiphospholipid antibody-positive patients are excluded. The primary efficacy outcome is the rate of change in brain white matter hyperintensity volume on magnetic resonance imaging, a surrogate marker of presumed ischemic damage, between baseline and 24 months follow-up. Secondary outcomes include additional neuroradiological and clinical measures of efficacy and safety. Exploratory outcomes include high-dose rivaroxaban pharmacokinetic modeling. Conclusion: Should RISAPS demonstrate noninferior efficacy and safety of high-dose rivaroxaban in this APS subgroup, it could justify larger prospective randomized controlled trials.

Diabetes knowledge in predominantly Latino patients and family caregivers in an urban emergency department.

PURPOSE: To describe the baseline level of disease-specific knowledge in predominantly Latino patients with diabetes and in their family caregivers at an urban emergency department, and to elucidate characteristics which are associated with increased diabetes knowledge. METHODS: The 24-item Diabetes Knowledge Questionnaire (DKQ) was administered to a convenience sample of 291 primarily Latino adults in the emergency department who either had diabetes or who identified themselves as a caregiver for an immediate family member with diabetes. Participants with diabetes provided additional information on specific characteristics hypothesized to be associated with level of diabetes knowledge. RESULTS: Patients with diabetes received higher scores on the DKQ than their family caregivers (13.9 vs 12.3, P < .01). On univariate analysis self-monitoring of blood glucose, English language preference, longer time since diagnosis, and education at the high school level or above were associated with higher scores. However, on multivariate analysis only years since diagnosis and education reached statistical significance. The most frequently missed questions involved diet, signs of high/low blood sugar, organ function, and wound care. CONCLUSIONS: Diabetes-specific knowledge was poor in both patients and primary family caregivers in our largely Latino urban emergency department patient population, highlighting the need for increased education in non-traditional settings. Based on our findings, this education should focus on areas of severe knowledge deficit including diet, symptoms of hyper- and hypoglycemia, and wound care. This study provides the foundation and justification for constructing effective and focused emergency department-based educational materials, thereby improving the knowledge and health of our patients.

A profile of physiotherapy clinical education.

The purpose of the study was to examine clinical education placement data to generate a profile of providers and examine the students' exposure to health care and educational factors during clinical education. A retrospective audit of clinical placement rosters was undertaken for 3 calendar years (2001-2003). Data were analysed overall and by clinical school for sites and placements, public or private sector and type of placement. Over the 3-year period, 209 sites provided 3475 clinical placements, with the number of placements increasing from 1066 placements in 2001 to 1133 in 2002 and to 1276 in 2003. Overall, 72.2% of placements were located in metropolitan Sydney. The proportion from regional providers increased over the 3 years from 11.8% to 15.1%. Overall 85.8% of placements were delivered by public providers. The profile indicated that a considerable number of clinical sites were utilised with an emphasis on large public hospitals. The challenge for curriculum development is to reduce the clinical education demands on current providers while ensuring graduates meet entry-level standards of physiotherapy.

Profile of the physiotherapy profession in New South Wales (1975-2002).

This was the first study known to the authors exploring workforce data from the New South Wales Physiotherapists Registration Board over several decades. Labour force statistics were examined from various data sources over the years 1975 to 2002. The results indicate that the demographics and working patterns of physiotherapists in New South Wales have remained remarkably stable over time. The workforce continues to grow, however the growth rate has decreased markedly with only a 2.3% increase from 2001 to 2002. The proportion of men within the profession is steadily increasing; in 1975 men accounted for 5.2% of physiotherapists, in 2000 23.5% of physiotherapists were male. While the male workforce increases, the female workforce is ageing. The modal age for female physiotherapists has steadily increased from 25-29 years in 1975 to 40-44 years in 2001. Importantly, in relation to attrition, the degree of workforce participation has not undergone significant change since 1987. Although labour force analysis has demonstrated that the workforce is in shortage, attrition does not appear to be the major contributor to this situation. The proportion of the profession who are inactive has remained relatively stable since 1987. More pertinent to the current shortage is the slowing of the growth rate of the profession while demand for physiotherapy services continues to rise.