Reducing unnecessary vitamin testing in general practice: barriers and facilitators according to general practitioners and patients.

OBJECTIVE: There has been an increase in testing of vitamins in patients in general practice, often based on irrational indications or for non-specific symptoms, causing increasing healthcare expenditures and medicalisation of patients. So far, there is little evidence of effective strategies to reduce this overtesting in general practice. Therefore, the aim of this qualitative study was to explore the barriers and facilitators for reducing the number of (unnecessary) vitamin D and B12 laboratory tests ordered. DESIGN AND SETTING: This qualitative study, based on a grounded theory design, used semistructured interviews among general practitioners (GPs) and patients from two primary care networks (147 GPs, 195 000 patients). These networks participated in the Reducing Vitamin Testing in Primary Care Practice (REVERT) study, a clustered randomized trial comparing two de-implementation strategies to reduce test ordering in primary care in the Netherlands. PARTICIPANTS: Twenty-one GPs, with a maximum of 1 GP per practice who took part in the REVERT study, and 22 patients (who were invited by their GP during vitamin-related consultations) were recruited, from which 20 GPs and 19 patients agreed to participate in this study. RESULTS: The most important factor hampering vitamin-test reduction programmes is the mismatch between patients and medical professionals regarding the presumed appropriate indications for testing for vitamin D and B12. In contrast, the most important facilitator for vitamin-test reduction may be updating GPs' knowledge about test indications and their awareness of their own testing behaviour. CONCLUSION: To achieve a sustainable reduction in vitamin testing, guidelines with clear and uniform recommendations on evidence-based indications for vitamin testing, combined with regular (individual) feedback on test-ordering behaviour, are needed. Moreover, the general public needs access to clear and reliable information on vitamin testing. Further research is required to measure the effect of these strategies on the number of vitamin test requests. TRIAL REGISTRATION NUMBER: WAG/mb/16/039555.

Periprocedural anticoagulation in atrial fibrillation: Update on electrical cardioversion and ablation.

In this manuscript, we discuss the most important changes in the field of anticoagulant treatment in patients with atrial fibrillation in the setting of electrical cardioversion or catheter ablation. Moreover, we provide practical guidance as well as information on daily practice.

Real-life use of Rivaroxaban in the Netherlands: data from the Xarelto for Prevention of Stroke in Patients with Atrial Fibrillation (XANTUS) registry.

BACKGROUND: The Xarelto for Prevention of Stroke in Patients with Atrial Fibrillation (XANTUS) registry investigated the safety and efficacy of the factor Xa inhibitor rivaroxaban. We studied the Dutch XANTUS cohort to a ssess drug safety and prescription patterns in the Netherlands. METHODS: The XANTUS registry was designed as a European prospective, observational study among patients with non-valvular atrial fibrillation. Major bleeding and all-cause mortality were assessed every three months during a 1-year follow-up period. In this Dutch sub-cohort we were also specifically interested in dosing regimens and the incidence and reasons for temporary or permanent discontinuation. RESULTS: Patients (n = 899) had a mean age of 69 (SD ± 9) years and 64.8% were male. The median CHA2DS2-VASc score was 2 (IQR 2-4) and the median HAS-BLED score was 2 (IQR 1-2). Major bleeding occurred in 19 patients (2.4 per 100 patient-years) and 8 patients (1.0 per 100 patient-years) died during the 1­year follow-up period. According to renal function, label-discordant dosing was observed in 48 (8.3%) patients. Finally, 124 patients (13.8%) reported a temporary interruption of rivaroxaban treatment and 11.8% switched to another oral anticoagulant therapy after permanent discontinuation of rivaroxaban. CONCLUSION: In the Dutch subset of the XANTUS registry, we observed low rates of major bleeding and label-discordant dosing and high persistence rates during one year of follow-up in patients receiving rivaroxaban in routine clinical practice. However, documenting the motivation of novel oral anticoagulant (NOAC) type and dose is essential to study label-discordant prescription, a potential safety paradox and identify patient characteristics to optimise NOAC use and adherence.

Cerebellar Cathodal Transcranial Direct Stimulation and Performance on a Verb Generation Task: A Replication Study.

The role of the cerebellum in cognitive processing is increasingly recognized but still poorly understood. A recent study in this field applied cerebellar Transcranial Direct Current Stimulation (c-tDCS) to the right cerebellum to investigate the role of prefrontal-cerebellar loops in language aspects of cognition. Results showed that the improvement in participants' verbal response times on a verb generation task was facilitated immediately after cathodal c-tDCS, compared to anodal or sham c-tDCS. The primary aim of the present study is to replicate these findings and additionally to investigate possible longer term effects. A crossover within-subject design was used, comparing cathodal and sham c-tDCS. The experiment consisted of two visits with an interval of one week. Our results show no direct contribution of cathodal c-tDCS over the cerebellum to language task performance. However, one week later, the group receiving cathodal c-tDCS in the first visit show less improvement and increased variability in their verbal response times during the second visit, compared to the group receiving sham c-tDCS in the first visit. These findings suggest a potential negative effect of c-tDCS and warrant further investigation into long term effects of c-tDCS before undertaking clinical studies with poststroke patients with aphasia.

Low performance of bleeding risk models in the very elderly with atrial fibrillation using vitamin K antagonists.

UNLABELLED: Essentials Under-treatment of oral anticoagulation in the elderly with atrial fibrillation is common. As bleeding prediction is challenging, we compared HAS-BLED, ATRIA and HEMORR2 HAGES. All three were associated with major bleeding in the elderly, but with poor predictive abilities. Future studies with focus on elderly-specific risk factors for bleeding are warranted. SUMMARY: Background Anticipated bleeding complications contribute to underuse of oral anticoagulants, especially in elderly patients with atrial fibrillation (AF). Bleeding risk models could provide guidance; however, these were developed in the general AF population. Objective To study and compare the performance of the HAS-BLED, ATRIA and HEMORR2 HAGES for major bleeding in very elderly AF patients. Methods Subjects were a random sample (N = 1157) of AF patients ≥ 80 years using a vitamin-K antagonist with prospective clinical follow-up from 2011 to 2014. The primary outcome was major bleeding (International Society on Thrombosis and Haemostasis criteria). Results Patients aged 84 years (median; 25th-75th 82-87) were classified as low risk by HAS-BLED (25.2%), ATRIA (59.6%) and HEMORR2 HAGES (23.3%). Three-year rates of major, clinically relevant and any bleeding were 6.7%, 28.3% and 42.3%, respectively. We observed a statistically significant association for all models with major bleeding, but discriminatory abilities were rather poor (C-statistics < 0.60) without clear superiority for any of the three. Only two (anemia and antiplatelet therapy) of the various classical risk factors were associated with bleeding. An estimated risk-benefit profile indicated a favorable trade-off for oral anticoagulation in this specific cohort (number needed to treat, 22; number needed to harm, 91). Conclusions In this large prospective cohort of very elderly AF patients, the currently used bleeding risk scores were all associated with major bleeding, but with poor predictive abilities. Use of the ATRIA model may inadvertently result in less attention being paid to modifiable risk factors in this particular population. In light of the issues of under-treatment and the suggested favorable risk-benefit profile, future models with incorporation of elderly-specific risk factors may provide more guidance in this growing population of AF patients.

Predicting benign course and prolonged illness in lower respiratory tract infections: a 13 European country study.

BACKGROUND: Clinicians and patients are often uncertain about the likely clinical course of community-acquired lower respiratory tract infection (LRTI) in individual patients. We therefore set out to develop a prediction rule to identify patients at risk of prolonged illness and those with a benign course. METHODS: We determined which signs and symptoms predicted prolonged illness (moderately bad symptoms lasting >3 weeks after consultation) in 2690 adults presenting in primary care with LRTI in 13 European countries by using multilevel modelling. RESULTS: 212 (8.1%) patients experienced prolonged illness. Illness that had lasted >5 days at the time of presentation, >1 episode of cough in the preceding year, chronic use of inhaled pulmonary medication and diarrhoea independently predicted prolonged illness. Applying a rule based on these four variables, 3% of the patients with ≤ 1 variable present (n = 955, 37%) had prolonged illness. Patients with all four variables present had a 30% chance of prolonged illness (n = 71, 3%). CONCLUSIONS: Most patients with acute cough (>90%) recover within 3 weeks. A prediction rule containing four clinical items had predictive value for the risk of prolonged illness, but given its imprecision, appeared to have little clinical utility. Patients should be reassured that they are most likely to recover within three weeks and advised to re-consult if their symptoms persist beyond that period.

[Liver abscess following navel piercing]. / Leverabces na navelpiercing.

In an 18-year-old woman with abdominal complaints of unknown origin, ultrasonography and CT showed a large abnormal structure in the left half of the liver. Biopsy showed this to be an abscess. Because Staphylococcus aureus was cultured and the patient had suffered from a navel infection after navel piercing several months earlier, it was concluded that the infection had spread through the ligamentum teres hepatis to cause the liver abscess. The abscess was drained and the patient was treated successfully with antibiotics.

Emergency cricothyrotomy: a randomised crossover trial comparing the wire-guided and catheter-over-needle techniques.

In a randomised crossover trial, we compared a wire-guided cricothyrotomy technique (Minitrach) with a catheter-over-needle technique (Quicktrach). Performance time, ease of method, accuracy in placement and complication rate were compared. Ten anaesthesiology and 10 ENT residents performed cricothyrotomies with both techniques on prepared pig larynxes. The catheter-over-needle technique was faster than the wire-guided (48 compared to 150 s, p < 0.001) and subjectively easier to perform (VAS-score 2.1 vs. 5.6, p < 0.001). Correct positioning of the cannula could be achieved in 95% and 85%, respectively (NS). There was one complication in the catheter-over-needle group compared to five in the wire-guided group. We conclude that the wire-guided minitracheotomy kit is unsuitable for emergency cricothyrotomies performed by inexperienced practitioners. On the other hand, the catheter-over-needle technique appears to be quick, safe and reliable.

Postexercise macronutrient oxidation: a factor dependent on postexercise macronutrient intake.

BACKGROUND: It has been widely shown that exercise increases postexercise fat oxidation and energy expenditure. OBJECTIVE: The aim of this study was to investigate the effect of exercise on postexercise substrate oxidation and energy expenditure when the exercise-induced expenditure of energy and macronutrients oxidized is compensated by an equivalent intake immediately after exercise. DESIGN: Twenty-four-hour energy expenditure (24EE) and macronutrient oxidation of 8 young men were measured in a whole-body indirect calorimeter under the 2 following, randomly assigned conditions: 1) a control session of sedentary activities in the calorimeter for 61 h and 2) a similar session preceded by 60 min of exercise at 50% of maximal oxygen consumption. Immediately after exercising, subjects ingested a milk shake containing the same amount of energy (above resting metabolic rate) expended during exercise and with a food quotient corresponding to the mean exercise respiratory quotient. 24EE and substrate oxidation were compared between conditions on a day-to-day basis (days 1, 2, and 3) and for the 61-h observation period. RESULTS: There was no difference in 24EE between the 2 conditions. Moreover, the composition of the postexercise fuel mix oxidized, as reflected by the respiratory quotient, was strictly the same under the 2 conditions. CONCLUSION: Voluntary postexercise compensations in energy and macronutrient intakes play a major role in the ability of exercise to alter postexercise substrate utilization.