A Direct Oral Anticoagulant as a Cost Effective Alternative to Warfarin for Treatment of Provoked Venous Thrombosis.

In Ireland, Warfarin is the primary anticoagulant prescribed in the secondary prevention of provoked DVT. We completed a comprehensive cost analysis of a trial group of 24 patients treated with Rivaroxaban (between November 2013 and December 2014), versus a control group treated with Warfarin (between January 2008 and November 2013). The groups were matched for gender (3/7 M/F ratio), DVT type (5 proximal, 19 distal DVTs), provoking factor (20 traumatic, 4 atraumatc), and age. We calculated the cost for each group based on drug administration and clinic costs (labour, sample analysis, and additional costs). Warfarin patients attended clinic 14.58 times; Rivaroxaban patients attended 2.92 times. Overall, the cost per patient on Rivaroxaban is €273.30 versus €260.68 with warfarin. This excludes patient costs which would further increase cost of Warfarin therapy.

Impact of flow path length and flow rate on phosphorus loss in simulated overland flow from a humic gleysol grassland soil.

In this overland flow simulation experiment, the relationships between flow path length, flow rate and the concentration of different P fractions were investigated. Overland flow was simulated using a 3 mx0.12 m laboratory flume. To remove the impact of rainfall on P lost in overland flow, simulated rainfall was not used during these experiments. Instead overland flow was generated by pumping water into the flume at the surface of the grass sod. The experimental setup allowed for the variation in flow path length and flow rate between and during experimental runs. The results demonstrated that an increase in flow path length caused an increase in Total Dissolved P (TDP), Dissolved Reactive P (DRP) and Total Reactive P (TRP) concentration in overland flow (p<0.01) while an increase in flow rate resulted in a decrease in the concentration of these P fractions in overland flow due to dilution (p<0.01). Total P (TP), Particulate P (PP) and Dissolved Organic P were not affected by the variables tested during this study. When flow path length was increased in conjunction with flow rate, there was an increase in TDP, DRP, and TRP concentrations despite the impact of greater dilution. The results indicate that variations in flow path length during a rainfall event may play a role in determining the concentration of dissolved P fractions in overland flow at field scale.

The activity of primate ventrolateral thalamic neurones during motor adaptation.

Three monkeys were trained to perform stereotyped wrist movements to track a target (phase 1). Changing the gain between the wrist movement and visual display required the monkey to adapt its wrist movement. This adaptation consisted of progressive reduction of movement amplitude over a number of trials (phase 2) until a stereotyped movement accommodating the new gain was learned (phase 3). The experiment's aim was to investigate whether cerebellar thalamic neuronal discharge (ND) changed during motor adaptation and whether this change was related to scaling of kinematic parameters or movement error. Extracellular single-cell recordings were made from "wrist-related" neurones in the cerebellar thalamus (59) and the nucleus ventro-posterior lateralis caudalis (VPLc) (37) of each monkey while they performed the movement paradigm. Neurones were selected for further analysis (37/59 cerebellar thalamic and 23/37 VPLc) if phase-1 movements were stereotyped and motor adaptation occurred in phase 2 (according to statistical definitions). When the gain initially changed, there were positional errors in the form of overshoot. Adaptation to the new gain was achieved by a variety of strategies, including modification of the amplitude of kinematic parameters and positional error in addition to reduction of time to peak velocity and movement time. During stereotyped movements, most cerebellar thalamic neurones fired before movement onset and before VPLc neurones. During adaptation, this order of onset of firing was reversed, and cerebellar thalamic neurones discharged after VPLc neurones and close to the onset of movement. During motor adaptation, the mean rate of phasic ND rose in a large proportion of cerebellar thalamic and VPLc neurones, and the proportion of cerebellar thalamic neurones that encoded a signal about positional error and movement amplitude also increased. In addition, there is set-related activity in the discharge of a majority of cerebellar thalamic and VPLc neurones. This does not appear to be specifically related to motor adaptation, but is related to the movement amplitude. We have discussed the role of the cerebello-thalamo-cortical pathway in error detection in the light of the similarities between discharge patterns of cerebellar thalamic and VPLc neurones. We speculate that, when learned movements are performed, the discharge of cerebellar thalamic neurones occurs before movement, perhaps representing an efference copy of the intended movement. During adaptation, this signal is gated out, and later-arriving peripheral afferent input dominates cerebellar thalamic discharge.

A randomized trial of perioperative hemodilution versus transfusion of preoperatively deposited autologous blood in elective surgery.

Hemodilution, one of several methods proposed to decrease homologous blood transfusion in elective surgery, has not been studied in a prospective controlled trial to determine if it is successful. A prospective, randomized controlled study was conducted to determine if hemodilution can serve as an alternative to preoperative autologous blood donation. Fifty patients were randomized to preoperatively deposit 3 units of autologous blood or to undergo hemodilution immediately before elective radical retropubic prostatectomy. All patients were treated under a standard protocol, including surgery performed by a single surgeon. The preoperative deposit groups received a mean of 2.44 +/- 1.0 units of blood; 2 of 25 patients required homologous blood transfusion for blood loss of 2600 mL and 1700 mL. The hemodilution group received a mean of 2.88 +/- 0.4 units of autologous blood: no hemodilution patient received homologous blood. At discharge, the mean hematocrit for the preoperative deposit group was 35.5 +/- 4.9 (0.35 +/- 0.05), and that for the hemodilution group was 31.8 +/- 4.7 (0.32 +/- 0.05) (p less than 0.001). There were no differences in perioperative morbidity in the treatment groups. The best predictor of discharge hematocrit was the initial hematocrit of the patient. It can be concluded that hemodilution can safely replace or at least augment preoperative autologous donations as a means of decreasing homologous blood transfusion in study patients. These results can be applied to any elective surgery procedure in which a 1000-mL blood loss is anticipated. Other advantages of hemodilution, including convenience, lower cost, and better preservation of all components of autologous blood, suggest that this practice deserves wider application.

General anesthesia for whole-body hyperthermia.

General anesthesia was used to facilitate 259 whole-body hyperthermia treatments in 90 patients. These patients fell into American Society of Anesthesiologists Classifications 3 (moderate to severe systemic disease) and 4 (severe systemic disease with life-threatening potential). Whole-body hyperthermia imposes severe stress on cardiopulmonary and renal function. In this series, elevation of temperature from 38 degrees to 41.5 degrees raised cardiac output to approximately 200% of control, while oxygen consumption rose 35%. General anesthesia provides conditions which allow for more precise control and support of vital signs, fluid requirements, and blood gases.