Evaluation of Bleeding Events Requiring Hospitalization in Patients With Atrial Fibrillation Receiving Dabigatran, Warfarin, or Antiplatelet Therapy.

OBJECTIVE: To determine the incidence and severity of bleeding events requiring hospitalization among patients with atrial fibrillation (AF) receiving anticoagulants (dabigatran or warfarin) or antiplatelet agents (eg, aspirin and clopidogrel). METHODS: This was a single-center, retrospective cohort study involving 1494 patients with AF hospitalized from November 1, 2010, to November 1, 2011, with prior warfarin, dabigatran, or antiplatelet therapy. RESULTS: Overall bleeding events in the dabigatran group compared to the warfarin group were 24% and 12%, respectively ( P = .004). Of these events, individually, there were no significant differences in major (56% vs 58%, P = .88), life-threatening (25% vs 36%, P = .38), or minor bleeding (44% vs 42%, P = .06). Gastrointestinal (GI) bleeding occurred more in the dabigatran group compared to the warfarin group ( P = .02). Intracranial bleeding occurred in 15% of patients in the warfarin group and did not occur at all in the dabigatran group. Warfarin patients had significantly more overall bleeding events compared to antiplatelet therapy ( P < .001), with an increasing trend seen in major bleeding ( P = .06). GI bleeding, however, favored the warfarin group over the antiplatelet group (48% vs 73%, P = .04). CONCLUSION: Anticoagulation with dabigatran was associated with an overall increased occurrence of bleeding requiring hospital admission compared to warfarin. GI bleeding was more prevalent with dabigatran and antiplatelets than with warfarin. There were more intracranial hemorrhages seen in the warfarin group.

Role of agents for reversing the effects of target-specific oral anticoagulants.

PURPOSE: The available clinical data on target-specific oral anticoagulant (TSOAC) reversal agents that are currently in development or have been approved by the Food and Drug Administration (FDA) are reviewed. SUMMARY: The development of TSOACs such as dabigatran, rivaroxaban, edoxaban, and apixaban has presented benefits and new challenges. One of the main challenges associated with the use of TSOACs is the lack of suitable agent-specific reversal agents. Several treatment options for the management of life-threatening bleeding events associated with TSOAC use, such as fresh frozen plasma, prothrombin complex concentrates, and recombinant coagulation factor VIIa, have been used, with inconsistent results. Currently, two potential reversal agents for oral direct factor Xa inhibitors (andexanet alfa and ciraparantag) are at various stages of clinical development. Idarucizumab, a reversal agent for the oral direct thrombin inhibitor dabigatran, was approved by FDA in October 2015. Idarucizumab and andexanet alfa have been reported to produce anticoagulation reversal effects within minutes of administration. Ciraparantag was demonstrated to decrease whole blood clotting time to within 10% of baseline values in 10 minutes or less, with a return to baseline hemostasis in 10-30 minutes. TSOAC reversal agents have been generally well tolerated in clinical trials. CONCLUSION: Idarucizumab and other TSOAC reversal agents, such as andexanet alfa and ciraparantag, present the potential for consistent and effective treatment and management options when life-threatening or uncontrolled TSOAC-associated bleeding occurs or when emergency surgery is warranted in patients using TSOACs.

A comprehensive newborn exam: part I. General, head and neck, cardiopulmonary.

A comprehensive newborn examination involves a systematic inspection. A Ballard score uses physical and neurologic characteristics to assess gestational age. Craniosynostosis is caused by premature fusion of the sutures, and 20% of children with this condition have a genetic mutation or syndrome. The red reflex assessment is normal if there is symmetry in both eyes, without opacities, white spots, or dark spots. If the red reflex findings are abnormal or the patient has a family history of pertinent eye disorders, consultation with an ophthalmologist is warranted. Newborns with low-set ears should be evaluated for a genetic condition. Renal ultrasonography should be performed only in patients with isolated ear anomalies, such as preauricular pits or cup ears, if they are accompanied by other malformations or significant family history. If ankyloglossia is detected, a frenotomy may be considered if it impacts breastfeeding. The neck should be examined for full range of motion because uncorrected torticollis can lead to plagiocephaly and ear misalignment. Proper auscultation is crucial for evaluation of the bronchopulmonary circulation with close observation for signs of respiratory distress, including tachypnea, nasal flaring, grunting, retractions, and cyanosis. Benign murmurs are often present in the first hours of life. Pulse oximetry should be performed in a systematic fashion before discharge.

A comprehensive newborn exam: part II. Skin, trunk, extremities, neurologic.

Skin findings are common during the newborn examination. Although these findings are often benign, it is important to visualize the entire skin surface to distinguish these findings and appropriately reassure parents. The chest should be observed for symmetric movement, pectus excavatum, pectus carinatum, prominent xiphoid, or breast tissue. The infant should be as relaxed as possible so that the physician can more easily detect any abdominal masses, which are often renal in origin. A single umbilical artery may be associated with another congenital abnormality, especially renal anomalies, and intrauterine growth restriction and prematurity. Signs of ambiguous genitalia include clitoromegaly and fused labia in girls, and bilateral undescended testes, a micropenis, or a bifid scrotum in boys. Sacral dimples do not warrant further evaluation if they are less than 0.5 cm in diameter, are located within 2.5 cm of the anal verge, and are not associated with cutaneous markers; dimples that do not fit these criteria require ultrasonography to evaluate for spinal dysraphism. Brachial plexus injuries are most common in newborns who are large for gestational age, and physical therapy may be required to achieve normal function. Patients with abnormal findings on Ortolani and Barlow maneuvers should be evaluated further for hip dysplasia. It is also important to assess newborns for tone and confirm the presence of normal primitive reflexes.

Anti-Stokes Raman spectrometry with 1064-nm excitation: an effective instrumental approach for field detection of explosives.

Anti-Stokes Raman spectra of 28 explosive materials were obtained with 1064-nm excitation using fiber-optic sampling and a dispersive spectrograph equipped with a charge-coupled device (CCD) array detector. By using a silicon CCD detector, anti-Stokes features could clearly be observed for the majority of samples from -250 to -1650 cm(-1). Using the fiber-optic probe, spectra were routinely obtained from samples positioned up to twelve meters from the spectrograph within 240 s. The utility of an anti-Stokes correction routine is demonstrated, which routine allowed anti-Stokes spectra measured with 1064-nm excitation to be successfully searched and identified against libraries of Stokes spectra obtained using a Fourier transform (FT) Raman system equipped with a 1064-nm Nd:YAG laser.