The effects of the COVID-19 pandemic on drug and poison-related deaths in Gold Coast, Australia.

INTRODUCTION: COVID-19 is postulated to impact drug- and poison-related deaths. America has reported an increased in drug-related deaths, whereas Australia has reported a decline. Regional studies are scant and may not mirror national data. Characterising drug and poison-related deaths during COVID-19 at a regional level would inform local interventions and policies on the current and future pandemics. METHODS: A 4-year retrospective study from January 1, 2018, to December 31, 2019 (pre-COVID-19 pandemic) and from January 1, 2020, to December 31, 2021 (COVID-19 pandemic) of all drug and poison-related deaths admitted to the Gold Coast University Hospital under Coronial investigation. RESULTS: Drug and poison-related deaths increased in both the proportion and absolute numbers before and during the COVID-19 pandemic. There was no statistical difference in age, sex, location of death, manner of death and classification of drugs and poison implicated. CONCLUSIONS: Although there is an increase in drug and poison-related deaths, the overall demographic and pattern have not changed. Further studies to account for the variation may enable implementation of targeted public health interventions to address the burden of related deaths in regional settings in the context of future pandemics.

Developing "MinDag" - an app to capture symptom variation and illness mechanisms in bipolar disorder.

Introduction: The illness course of bipolar disorder (BD) is highly heterogeneous with substantial variation between individuals with the same BD subtype and within individuals over time. This heterogeneity is not well-delineated and hampers the development of more targeted treatment. Furthermore, although lifestyle-related behaviors are believed to play a role in the illness course, such mechanisms are poorly understood. To address some of these knowledge gaps, we aimed to develop an app for collection of multi-dimensional longitudinal data on BD-relevant symptoms and lifestyle-related behaviors. Methods: An app named MinDag was developed at the Norwegian Center for Mental Disorders Research in Oslo, Norway. The app was designed to tap into selected areas: mood, sleep, functioning/activities (social, occupational, physical exercise, leisure), substance use, emotional reactivity, and psychotic experiences. Ethical, security and usability issues were highly prioritized throughout the development and for the final app solution. We conducted beta- and pilot testing to eliminate technical problems and enhance usability and acceptability. Results: The final version of MinDag comprises six modules; three which are presented for the user once daily (the Sleep module in the morning and the Mood and Functoning/Activities modules in the evening) and three which are presented once weekly (Substance Use, Emotional Reactivity, and Psychotic Experiences modules). In general, MinDag was well received in both in the beta-testing and the pilot study, and the participants provided valuable feedback that was taken into account in the final development. MinDag is now in use as part of the research protocol at the NORMENT center and in a specialized treatment unit for BD at Oslo University Hospital in Norway. Discussion: We believe that MinDag will generate unique longitudinal data well suited for capturing the heterogeneity of BD and clarifying important unresolved issues such as how life-style related behavior may influence BD symptoms. Also, the experiences and knowledge derived from the development of MinDag may contribute to improving the security, acceptability, and benefit of digital tools in mental health.

Impact of bleeding complications after transcatheter mitral valve repair.

BACKGROUND: Bleeding in the context of cardiac catheterization is frequent and negatively impacts on short- and long-term patient outcome. We evaluated the clinical impact of in-hospital bleeding events after transcatheter mitral valve repair (TMVr) in the long-term follow- up. METHODS: 586 consecutive patients treated with first-time TMVr were enrolled in this registry. In-hospital MVARC (Mitral Valve Academic Research Council) bleedings were assessed and patients were grouped according to the incidence of a bleeding event. Multivariate logistic regression was used to identify significant independent predictors of MVARC bleeding. This study received approval by local ethics committee. RESULTS: 78 patients (13.3%) suffered from an MVARC bleeding event (Access site-related bleedings: 46.2%; GI tract bleeding: 35.9%; Other bleedings: 17.9%). Among these bleeding subgroups, neither relevant differences in baseline characteristics nor in severity of bleeding events were observed. Despite not being an independent predictor for overall death in the multivariate Cox regression analysis, MVARC bleeding was associated with prolonged hospital stay. The ORBIT bleeding score was the best match to predictors of any MVARC bleeding found in our cohort (c-score overall cohort: 0.68; c-score GI bleeding cohort: 0.72). CONCLUSION: MVARC bleedings after TMVr are frequent findings but were only in half of the cases related to the access site. The ORBIT score could be useful for identification of patients at high risk for non-access site bleeding and especially GI bleeding.

Comparative effectiveness of rivaroxaban versus a vitamin K antagonist in patients with renal impairment treated for non-valvular atrial fibrillation in Germany - A retrospective cohort study.

BACKGROUND: The risk of thromboembolic events is increased in patients with non-valvular atrial fibrillation (NVAF) and renal impairment. The risk of bleeding events is increased if these patients are treated with anticoagulants and further increased in those with active cancer. METHODS: RELOAD, a retrospective database study, assessed the outcomes of patients with NVAF prescribed rivaroxaban versus phenprocoumon. Here, we present a subgroup analysis evaluating effectiveness and safety of rivaroxaban versus phenprocoumon in patients with NVAF and renal impairment. Analyses were additionally stratified by patients with and without evidence of cancer at baseline. RESULTS: When using the 'one tablet per day' definition of estimating drug exposure time, the incidence of the primary endpoint of ischaemic stroke was significantly lower in patients (without evidence of cancer at baseline) receiving rivaroxaban 15 mg or 20 mg once daily versus those receiving phenprocoumon (2.40 vs 3.51 events per 100 patient-years, respectively; hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.55-0.94, p = 0.015); with the incidence of the primary safety outcome of intracranial haemorrhage being numerically lower (0.57 vs 0.89 events per 100 patient-years, respectively; HR = 0.66, 95% CI 0.38-1.14, p = 0.14). Similar results were observed when using the 'empirical defined daily dose' definition to estimate drug exposure time and when including patients with evidence of cancer. CONCLUSION: The prescription of rivaroxaban in patients with NVAF and renal impairment was associated with a lower incidence of ischaemic stroke and intracranial haemorrhage versus phenprocoumon in patients without evidence of cancer.

Drug and alcohol use and treatment for Australian Indigenous and non-Indigenous prisoners: demand reduction strategies.

PURPOSE: The purpose of this paper is to compare the use of drugs and alcohol by Indigenous and non-Indigenous prisoners and examine relevant treatment in Australian prisons. DESIGN/METHODOLOGY/APPROACH: Prison authorities were surveyed about alcohol and drug use by prisoners prior to and during imprisonment and drug and alcohol treatment programs in prison. The literature was review for information on alcohol and drug use and treatment in Australian prisons. FINDINGS: In 2009, over 80 percent of Indigenous and non-Indigenous inmates smoked. Prior to imprisonment, many Indigenous and non-Indigenous inmates drank alcohol at risky levels (65 vs 47 percent) and used illicit drugs (over 70 percent for both groups). Reports of using heroin (15 vs 21 percent), ATS (21 vs 33 percent), cannabis (59 vs 50 percent) and injecting (61 vs 53 percent) were similarly high for both groups. Prison-based programs included detoxification, Opioid Substitution Treatment, counselling and drug free units, but access was limited especially among Indigenous prisoners. RESEARCH LIMITATIONS/IMPLICATIONS: Drug and alcohol use was a significant issue in Australian prisons. Prisoners were over five times more likely than the general population to have a substance use disorder. Imprisonment provides an important opportunity for rehabilitation for offenders. This opportunity is especially relevant to Indigenous prisoners who were more likely to use health services when in prison than in the community and given their vast over representations in prison populations. PRACTICAL IMPLICATIONS: Given the effectiveness of treatment in reducing re-offending rates, it is important to expand drug treatment and especially culturally appropriate treatment programs for Indigenous inmates. ORIGINALITY/VALUE: Very little is known about Indigenous specific drug and alcohol programs in Australian prisons.

Use of novel oral anticoagulants for patients with atrial fibrillation: systematic review and clinical implications.

Atrial fibrillation (AF), a common arrhythmia, increases the risk of ischemic stroke. Stroke and bleeding scores for patients with AF can help to stratify risk and determine the need for antithrombotic therapy, for which warfarin has been the gold standard. Although highly effective, warfarin has several limitations that can lead to its underuse. Data from randomized, Phase III clinical trials of the novel oral anticoagulants, dabigatran, a direct thrombin inhibitor, and rivaroxaban and apixaban, both factor Xa inhibitors, indicate these drugs are at least noninferior to warfarin for the prevention of stroke and systemic embolism. They are easier to administer, and have an equivalent or lower risk of bleeding versus warfarin. A better understanding of the risks and benefits of the novel oral anticoagulants, and their use in clinical practice, will prepare clinicians to anticipate and address educational and clinical needs of AF patients and their families, and promote evidence-based prescription of appropriate and safe anticoagulation therapy.

Pattern of atrial fibrillation and risk of outcomes: the Loire Valley Atrial Fibrillation Project.

BACKGROUND: Risk of stroke and thromboembolism (TE) in patients with non-valvular atrial fibrillation (NVAF) is categorised in stroke risk stratification scores. The role of pattern of NVAF in risk prediction is unclear in contemporary 'real world' cohorts. METHODS AND RESULTS: Patients with NVAF in a four-hospital-institution between 2000 and 2010 were included. Stroke/TE event rates were calculated according to pattern of AF, i.e. paroxysmal, persistent and permanent. Risk factors were investigated by Cox regression. Among 7156 NVAF patients, 4176 (58.4%) patients with paroxysmal, 376 (5.3%) with persistent and 2604 (36.3%) with permanent patterns of NVAF were included. In non-anticoagulated patients, overall stroke/TE event rate per 100 person-years was 1.29 (95% CI 1.13-1.47). Compared with paroxysmal NVAF, rates of stroke/TE, bleeding and all-cause mortality (p<0.001) were significantly higher in permanent NVAF patients but not in persistent NVAF patients. In multivariate analyses, previous stroke (hazard ratio, HR 2.58, 95% CI 2.08-3.21), vascular disease (HR 1.34, 1.12-1.61), heart failure (HR 1.20, 1.00-1.44), age ≥ 75 years (HR 2.75, 2.16-3.50) and age 65-74 years (HR 1.60, 1.22-2.09) independently increased stroke/TE risk, but not persistent (HR 1.13, 0.76-1.70) and permanent (HR 1.44, 0.96-2.16) NVAF patterns. CONCLUSION: In this large 'real world' NVAF cohort, rates of stroke, TE, death and bleeding differed significantly by patterns of NVAF. However, only previous stroke, age, heart failure and vascular disease (not pattern of NVAF) independently increased risk of adverse outcomes in multivariate analyses. Thus, stroke risk is similar across all patterns of NVAF and antithrombotic therapy should be based on clinical risk factors, not on arrhythmia pattern.

Prevalence of undiagnosed atrial fibrillation and of that not being treated with anticoagulant drugs: the AFABE study.

INTRODUCTION AND OBJECTIVES: Atrial fibrillation constitutes a serious public health problem because it can lead to complications. Thus, the management of this arrhythmia must include not only its treatment, but antithrombotic therapy as well. The main goal is to determine the proportion of cases of undiagnosed atrial fibrillation and the proportion of patients not being treated with oral anticoagulants. METHODS: A multicenter, population-based, retrospective, cross-sectional, observational study. In all, 1043 participants over 60 years of age were randomly selected to undergo an electrocardiogram in a prearranged appointment. Demographic data, CHA2DS2-VASc and HAS-BLED scores, international normalized ratio results, and reasons for not receiving oral anticoagulant therapy were recorded. RESULTS: The overall prevalence of atrial fibrillation was 10.9% (95% confidence interval, 9.1%-12.8%), 20.1% of which had not been diagnosed previously. In the group with known atrial fibrillation, 23.5% of those with CHA2DS2-VASc≥2 were not receiving oral anticoagulant therapy, and 47.9% had a HAS-BLED score≥3. The odds ratio for not being treated with oral anticoagulation was 2.04 (95% confidence interval, 1.11-3.77) for women, 1.10 (95% confidence interval, 1.05-1.15) for more advanced age at diagnosis, and 8.61 (95% confidence interval 2.38-31.0) for a CHA2DS2-VASc score<2. Cognitive impairment (15.2%) was the main reason for not receiving oral anticoagulant therapy. CONCLUSIONS: The prevalence of previously undiagnosed atrial fibrillation in individuals over 60 years of age is 20.1%, and 23.5% of those who have been diagnosed receive no treatment with oral anticoagulants.

The HAS-BLED score has better prediction accuracy for major bleeding than CHADS2 or CHA2DS2-VASc scores in anticoagulated patients with atrial fibrillation.

OBJECTIVES: The aim of this study was to test the hypothesis that a specific bleeding risk score, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), was better at predicting major bleeding compared with CHADS2 (congestive heart failure, hypertension, 75 years of age or older, diabetes mellitus, and previous stroke or transient ischemic attack) and CHA2DS2-VASc (congestive heart failure, hypertension, 75 years of age and older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, 65 to 74 years of age, female) in anticoagulated atrial fibrillation (AF) patients. BACKGROUND: The CHADS2 and CHA2DS2-VASc scores are well-validated stroke risk prediction scores for AF, but are also associated with increased bleeding and mortality. METHODS: We recruited 1,370 consecutive AF patients (49% male; median age, 76 years) receiving oral anticoagulation therapy from our outpatient anticoagulation clinic, all of whom were receiving acenocoumarol and had an international normalized ratio between 2.0 and 3.0 during the preceding 6 months. During follow-up, major bleeding events were identified by the 2005 International Society on Thrombosis and Haemostasis criteria. Model performance was evaluated by calculating the C-statistic, and the improvement in predictive accuracy was evaluated by calculating the net reclassification improvement and integrated discrimination improvement. RESULTS: After a median follow-up of 996 (range, 802 to 1,254) days, 114 patients (3.0%/year) presented with a major bleeding event; 31 of these events were intracranial hemorrhages (0.8%/year). Based on the C-statistic, HAS-BLED had a model performance superior to that of both CHADS2 and CHA2DS2-VASc (both p < 0.001). Both net reclassification improvement and integrated discrimination improvement analyses also show that HAS-BLED was more accurately associated with major bleeding compared with CHADS2 and CHA2DS2-VASc scores. CONCLUSIONS: In anticoagulated AF patients, a validated specific bleeding risk score, HAS-BLED, should be used for assessing major bleeding. The practice of using CHADS2 and CHA2DS2-VASc as a measure of high bleeding risk should be discouraged, given its inferior predictive performance compared with the HAS-BLED score.