Burden of oral anticoagulation in embolic stroke of undetermined source without atrial fibrillation.

OBJECTIVE: Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies. METHODS: CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective. RESULTS: Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient's lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953-£7018 per patient (UK), €6683-€7368 (Netherlands), €4933-€9378 (Spain), AUD$5353-6539 (Australia) and $26,768-$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468-$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years). CONCLUSIONS: Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients.

Underwater Acoustic Impulsive Noise Monitoring in Port Facilities: Case Study of the Port of Cartagena.

Recording underwater impulsive noise data is an important aspect of mitigating its environmental impact and improving maritime environmental management systems. This paper describes the method used and results of the spatial monitoring of both the baseline noise level and the impulsive noise sources in the Port of Cartagena. An autonomous vessel was equipped with a smart digital hydrophone with a working frequency range between 10 and 200 kHz and a received voltage response (RVR) of, approximately, -170 dB re 1V/µPa. A GIS map was drawn up with the spatiotemporal distribution of the basal sound pressure levels by coupling the acoustic data with the vessel's GPS positions to identify the sources of the impulsive noise of interest and their temporal characteristics. The loading of cargo containers was identified as the main source of impulse noise. This study is the first of a series designed to obtain accurate information on underwater noise pollution and its potential impact on biodiversity in the Port of Cartagena.

Direct health costs and clinical outcomes of open surgery in patients with abdominal aortic aneurysm in Spain. The RECAPTA study.

OBJECTIVE: Abdominal aortic aneurysm (AAA) is a chronic, progressive disease that often requires surgical repair. This study aimed to assess the healthcare costs and clinical outcomes of open AAA repair in Spain. METHOD: Observational, retrospective, multicenter study with a one-year follow-up. Healthcare resource use and costs related to the surgical procedure, hospital stay, and follow-up period were assessed. RESULTS: Ninety patients with asymptomatic AAA who underwent open repair were recruited between 2003 and 2009 at three Spanish hospitals. Four patients (4.44%) died in the first 30 postoperative days. Mean [standard deviation] procedure time was 292.83 [72.10] minutes and mean hospital length of stay was 11.44 days [5.42]. Thirty two patients (35.56%) presented in-hospital complications and three patients (3.45%) underwent re-intervention during follow-up. The mean overall cost per patient during the study period was €21,622.59, of which 42.40% (€9,168.19), 52.08% (€11,261.74), and 5.52% (€1,192.66) corresponded to the surgical procedure, the inpatient stay, and the study follow-up period, respectively. CONCLUSIONS: Given the economic burden imposed by the treatment of patients admitted with AAA on the Spanish health system, additional efforts comparing the cost of open repair with endovascular treatments are needed to ensure greater efficiency.

Effects of intramammary antibiotic therapy during the dry period on the performance of Lacaune dairy sheep under intensive management.

Often the only way to ensure profitability of Lacaune dairy sheep is intensive management, which requires appropriate dry-period treatment to ensure animal productivity and health. The present study aimed to investigate the effects of intramammary antibiotic dry therapy on the performance and health of Lacaune sheep under intensive management. We recorded data for 5981 complete lactation periods that followed a dry period. A total of 2402 lactation periods were preceded by a dry period involving intramammary administration of 300 mg of cephapirin benzathine (antibiotic group) and 3579 lactation periods were preceded by dry periods with no treatment (control group). The following on-farm yield data were collected for individual lactation periods: length of the subsequent lactation period; total milk yield per lactation period; daily milk yield and length of the subsequent dry period. Data on confounding factors that might affect productivity were also recorded, including the individual ewe, number of lactation periods and length of the previous dry period. Milk quality was assessed using data on somatic cell count (SCC) and content of protein and fat taken from the Spanish National Official Milk Yield Recording System. Antibiotic dry therapy significantly improved total yield per lactation period, which was 429±151·1 l in the antibiotic group and 412±165·5 l in the control group, as well as the daily milk yield, which was 1986±497·0 and 1851±543·2 ml/d, respectively (both P<0·0001). The initial dry period was significantly longer in the antibiotic group than in the control group, and dry period length correlated inversely with yield variables such us total yield per lactation period (r=-0·055; P<0·0001) and yield per day in milk (r=-0·039; P<0·0001). As a result, milk yield records systematically underestimated the positive effects of antibiotic dry therapy. Antibiotic dry therapy also significantly improved milk quality. Milk from the antibiotic group showed 50% lower SCC (573±1326 vs. 1022±2126 cells/ml; P<0·0001) and slightly higher content in fat (7·33±0·91 vs. 7·15±0·87%) and protein (5·63±0·44 vs. 5·44±0·4%). The results of this study suggest that cephalosporin dry therapy of Lacaune dairy sheep increases milk production and improves milk quality during subsequent lactation periods.