Quality of anticoagulation with unfractionated heparin plus phenprocoumon for the prevention of thromboembolic complications in cardioversion for non-valvular atrial fibrillation. Sub-analysis from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial.

INTRODUCTION: Anticoagulation in cardioversion for atrial fibrillation is performed using unfractionated heparin and oral anticoagulants. TEE-guided cardioversion, after achievement of therapeutic anticoagulation (1-3 days), may be an alternative to the traditional procedure (3-week anticoagulation followed by cardioversion). The quality of anticoagulation in atrial fibrillation has not been investigated in a randomised trial with TEE-guided cardioversion. We analysed respective data from the ACE trial on the quality of conventional anticoagulation, where most participating centres chose the TEE-guided approach. MATERIALS AND METHODS: In a randomised, prospective, multicentre trial, we analysed the efficacy of unfractionated heparin plus phenprocoumon in 248 patients on an intention-to-treat basis. There were 2373 evaluable anticoagulation measurements (out of 2925 measurements) and 4 categories of anticoagulation quality (under-, target, over- and severe over-anticoagulation). Of patients with evaluable measurements, 88% received short-term anticoagulation (4 weeks) in TEE-guided cardioversion. RESULTS: The median time to achieve therapeutic anticoagulation (aPTT> or =60 and <80 s or INR> or =2 and <3) was 3 days. Anticoagulation values were out of therapeutic range in 69.5% of measurements during 4- or 7-week follow-up, and never within therapeutic range in 10% of patients. Of the 15 primary endpoints observed (death, thromboembolism and major bleeding complications), only 3 were in patients with anticoagulation measurements within therapeutic range. CONCLUSIONS: In this study setting, with predominance of 4 weeks anticoagulation in TEE-guided cardioversion for atrial fibrillation, therapeutic anticoagulation was reached within 3 days using conventional anticoagulation. Despite careful dose adjustments, anticoagulation was out of therapeutic range in almost 70% of total measurements and 80% of primary endpoints.

Institutions of the European Union: medical perspective.

The way through the institutions of the European Union (EU) is very difficult. The difficulties will increase with the expansion of EU to 25 member states, and even more so in the area of medical societies. Following the agenda of the EU, an efficient public health service is a responsibility of every member country. The possibilities of medical interest are pointed out in this paper

[The health service in the European Community. What can await in the future EU-members?]. / Lecznictwo w krajach Unii Europejskiej. Czego moga spodziewac sie przyszli czlonkowie UE?

The problems of national health system in the European Community member states and affiliating countries will be discussed. Particular attention will be paid to team doctor model, continuous medical education, social security system and disease management programme.

UV index forecasts and measurements of health-effective radiation.

While erythemal irradiance as a potentially damaging effect to the skin has been extensively studied and short-term forecasts have been issued to the public to reduce detrimental immediate and long-term effects such as sunburn and skin cancer by overexposure, beneficial effects to human health such as vitamin D(3) production by UV radiation and melatonin suppression by blue visible light have attained more and more attention, though both of them have not become part of forecasting yet. Using 4years of solar radiation data measured at the mid-latitude site Lindenberg (52°N), and forecast daily maximum UV index values, an overall good correspondence has been found. The data base of solar UV radiation and illuminance has also been used to analyze effects of clouds and aerosols on the effective irradiance. Optically thick clouds can strongly modify the ratios between erythemal and vitamin D(3) effective irradiance such that direct radiative transfer modeling of the latter in future UV forecasts should be preferably used. If parameterizations of vitamin D(3) effective irradiance from erythemal irradiance are used instead, the optical cloud depth would have to be taken into account to avoid an overestimation of vitamin D(3) with parameterizations neglecting cloud optical depth. Particular emphasis for the beneficial effects has been laid in our study on low exposure. Daily doses of solar irradiation for both vitamin D(3) and melatonin suppression do not reach minimum threshold doses even with clear sky and unobstructed horizon during the winter months.