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The optimal dose of direct oral anticoagulants (DOACs) to prevent ischemic stroke (IS) and systemic thromboembolism (STE) in atrial fibrillation (AF) patients with a predisposing bleeding risk remains unclear. The purpose of this study was to compare the effectiveness and safety of different DOAC dosage regimens in AF patients with high bleeding risk but low thrombosis risk. This retrospective observational study was conducted with the National Health Insurance claims database in Taiwan to include AF patients aged 20 up to 75 years, under DOAC therapy, with CHA 2 DS 2 -VASc score of 1 for males and 2 for females and HAS-BLED score ≥3. Standard-dose regimen was defined as dabigatran 300 mg, rivaroxaban 20 mg, apixaban 10 mg, or edoxaban 60 mg per day. Any other lower-dose regimen were defined as the low-dose regimen. The primary outcomes were IS and major bleeding (MB). The secondary outcomes were STE, gastrointestinal bleeding, intracranial hemorrhage, and cardiovascular death. A total of 964 patients were included (52.1% standard-dose regimen). Median HAS-BLED score was 3 [interquartile range 3–3]. Compared with standard-dose group, patients in the low-dose group had a significantly increased risk of IS (adjusted hazard ratio [aHR] 5.13; 95% confidence interval 1.37–19.22) and STE (aHR 3.14 [1.05–9.37]) but similar risk of MB (aHR 0.45 [0.12–1.67]). The risks of other hemorrhage and cardiovascular death were similar between the 2 dose groups. Among patients with a predominant bleeding risk but relatively low thrombosis risk, the low-dose DOAC regimen is not a more appropriate selection than standard-dose regimen. [ABSTRACT FROM AUTHOR]

Background: The recommended target low-density lipoprotein cholesterol (LDL-C) level for coronary artery disease (CAD) patients has been lowered from 100 to 70 mg/dL in several clinical guidelines for secondary prevention. We aimed to assess whether initiating statin treatment in CAD patients with baseline LDL-C 70-100 mg/dL in Taiwan could be cost-effective.Methods: A Markov model was developed to simulate a hypothetical cohort of CAD patients with a baseline LDL-C level of 90 mg/dL. The incidence and recurrence of MI and stroke related to specific LDL-C levels as well as the statin effect, mortality rate, and health state utilities were obtained from the literature. The direct medical costs and rate of fatal events were derived from the national claims database. The incremental cost-effectiveness ratio (ICER) per quality-adjusted life years (QALYs) was calculated, and sensitivity analyses were performed.Results: Moderate-intensity statin use, a treatment regimen expected to achieve LDL <70 mg/dL in the base case, resulted in a net gain of 562 QALYs but with an additional expenditure of $11.4 million per 10,000 patients over ten years. The ICER was $20,288 per QALY gained. The probabilities of being cost-effective at willingness-to-pay thresholds of one and three gross domestic product per capita ($24,329 in 2017) per QALY were 51.1% and 94.2%, respectively. Annual drug cost was the most influential factor on the ICER.Conclusion: Lowering the target LDL-C level from 100 to 70 mg/dL among treatment-naïve CAD patients could be cost-effective given the health benefits of preventing cardiovascular events and deaths. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to determine the relationship between the on-treatment lipid profiles and the CV events in CKD and non-CKD population.Method: This study was a multi-center observational registry, the Taiwanese Secondary Prevention for patients with AtheRosCLErotic disease (T-SPARCLE) Registry. This study follows up patients with CV diseases in Taiwan who have secondary prevention therapies. The primary outcome is the time of first occurrence of a major adverse cardiac events (MACEs).Result: 5388 patients with ASCVD were included and 1478 (27.4%) had CKD without dialysis. CKD patients had higher TG and lower LDL-C levels. The incidence of recurrent MACEs per 1000 person-years in CKD patients was 19.5 (95% CI 15.5-24.9), compared with 9.1 (95% CI 7.4-11.1) in non-CKD patients. In patients with statin therapy, there were no differences in MACE risk between each level of on-treatment LDL-C, TG and HDL-C level. Higher on-treatment non-HDL-C level was a significant predictor for higher MACE risk in patients without CKD, and borderline significant in CKD patients under statin therapy. Heart failure history was also associated with higher MACE risk in both group. Lower body mass index (BMI < 23 kg/m2) was associated with higher MACE risk in CKD patients.Conclusion: In ASCVD patients, on-treatment LDL-C was not a good CV outcome predictor. Instead, on-treatment non-HDL-C was a better predictor. Heart failure history was also associated with higher MACE risk in both group of patients. Lower BMI (<23 kg/m2) was associated with higher recurrent MACE risk in CKD patients. [ABSTRACT FROM AUTHOR]

Background: Large series reporting outcomes for penetrating thoracic trauma have identified injury pattern and injury severity scoring as predictors of poor outcome. However, the impact of surgical expertise on patient outcomes has not been previously investigated. We sought to determine how often board-certified cardiothoracic surgeons are utilized for operative thoracic trauma and whether this has an effect on patient outcomes. Methods: A level I trauma center registry was queried between 2003 and 2011. Records of patients undergoing surgery as a result of penetrating thoracic trauma were retrospectively reviewed. Patient demographics, injuries, injury severity, utilization of a cardiothoracic surgical operative consult and outcomes were recorded. Patients operated on by cardiothoracic surgeons were compared with patients operated on by trauma surgeons using stepwise multivariate analyses to determine the factors associated with utilization of cardiothoracic surgeons for operative thoracic trauma and survival. Results: Cardiothoracic surgeons were used in 73.0% of cases (162 of 222) over the study period. The use of cardiothoracic surgeons increased incrementally both overall (38.5% to 73.9%), and for emergent/urgent cases (31.8% to 73.3%). When comparing patients undergoing operation on an emergent/urgent basis by cardiothoracic versus trauma surgeons, there was no significant difference with regard to demographics, mechanism of injury, injury severity scoring, or surgical morbidity. Stepwise logistic regression showed the presence of a cardiothoracic surgeon to be independently associated with survival (odds ratio 4.70; p = 0.019). Conclusions: Use of cardiothoracic surgeons for operative thoracic trauma increased over the study period. Outcomes for severely injured patients with elevated chest injury scores or decreased revised trauma scores may be improved with appropriate operative consultation with a board-certified cardiothoracic surgeon. [Copyright &y& Elsevier]

Background: Evidence for the association between prenatal antidepressant use and the development of hypertensive disorders of pregnancy is inconsistent. Previous studies have reported that antidepressant use during pregnancy increases the risk for gestational hypertension and preeclampsia, but the results of these studies are potentially confounded by important methodologic limitations. Furthermore, it remains unknown whether a higher cumulative dose of antidepressant increases the risk for hypertensive disorders of pregnancy.Objective: This study aimed to investigate the association between prenatal antidepressant use and the risk for hypertensive disorders of pregnancy and the potential effect of a higher cumulative antidepressant dose.Study Design: This retrospective cohort study used data from the Health and Welfare Database in Taiwan. Pregnant women with depression aged 18 to 49 years were enrolled as part of the study population. Prenatal antidepressant use was defined as at least 1 dispensing record of an antidepressant between the conception date and 20 weeks of gestation. Antidepressant users were further divided into groups according to the cumulative defined daily dose based on whether they took the defined daily dose for ≤10 weeks (low cumulative dose group ≤70 cumulative defined daily dose) or for >10 weeks (high cumulative dose group >70 cumulative defined daily dose). The primary outcome was hypertensive disorders of pregnancy defined as the diagnosis of either gestational hypertension or preeclampsia during the period from 20 weeks of gestation to delivery. Propensity score matching and stabilized inverse probability of treatment weighting were used to balance the confounders between the comparison groups. A robust Cox regression model was used to evaluate the association between exposure and outcome.Results: A total of 5664 pregnant women with depression were included in the study (2832 antidepressant users matched to 2832 antidepressant nonusers). Prenatal antidepressant use was not associated with an increased risk for hypertensive disorders of pregnancy (adjusted hazard ratio, 0.89; 95% confidence interval, 0.67-1.18). However, among antidepressant users, the risk for hypertensive disorders of pregnancy was higher among women with a higher cumulative defined daily dose than among women with a lower cumulative defined daily dose (adjusted hazard ratio, 2.46; 95% confidence interval, 1.05-5.74).Conclusion: No association was found between antidepressant use and the development of hypertensive disorders of pregnancy. However, women taking higher cumulative doses of antidepressants were at greater risk. More frequent or regular monitoring of blood pressure may be warranted in women on high cumulative doses of antidepressants. [ABSTRACT FROM AUTHOR]

Background: Chest computed tomography (CCT) is a method of screening for intrathoracic injuries in hemodynamically stable patients with penetrating thoracic trauma. The objective of this study was to examine the changes in utilization of CCT over time and evaluate its contribution to guiding therapeutic intervention. Methods: A level 1 trauma center registry was queried between 2006 and 2011. Patients undergoing CCT in the emergency department after penetrating thoracic trauma as well as patients undergoing thoracic operations for penetrating thoracic trauma were identified. Patient demographics, operative indications, use of CCT, injuries, and hospital admissions were analyzed. Results: In all, 617 patients had CCTs performed, of whom 61.1% (371 of 617) had a normal screening plain chest radiograph (CXR). In 14.0% (51 of 371) of these cases, the CCT revealed findings not detected on screening CXR. The majority of these injuries were occult pneumothoraces or hemothoraces (84.3%; 43 of 51), of which 27 (62.8%) underwent tube thoracostomy. In only 0.5% (2 of 371), did the results of CCT alone lead to an operative indication: exploration for hemopericardium. The use of CCT in our patients significantly increased overall (28.8% to 71.4%) as well as after a normal screening CXR (23.3% to 74.6%) over the study period. Conclusions: The use of CCT for penetrating thoracic trauma increased 3.5-fold during the study period with a concurrent increase in findings of uncertain clinical significance. Patients with a normal screening CXR should be triaged with 3-hour delayed CXR, serial physical examinations, and focused assessment with sonography for trauma; and CCT should only be used selectively as a diagnostic modality. [ABSTRACT FROM AUTHOR]

Abstract: Combination of atom transfer radical and conventional free radical polymerizations has been successfully used to prepare poly(hydroxyethyl methacrylate-b-vinyl pyrrolidone) (PHEMA-b-PVP) copolymers with controlled molecular weight and low polydispersity (<1.4). The thermal behavior and specific interaction of PHEMA-b-PVP diblock copolymers and their corresponding PHEMA/PVP blends were characterized. The result shows that glass transition temperatures of diblock copolymers analysed by differential scanning calorimetry (DSC) are higher than those of the blends. Infrared and solid-state NMR spectroscopic analyses show that hydrogen-bonding interaction of hydroxyl–carbonyl groups of diblock copolymers was also greater than that of the blends. Measurement of the proton spin–lattice relaxation time in the rotating frame, , reveals that all diblock copolymers and blends possess one composition-dependent , indicating that both diblock copolymers and blends are homogeneous, which is consistent with the DSC analysis. [Copyright &y& Elsevier]

Abstract: Introduction: The incidence of acute deep venous thrombosis as a result of penetrating proximity extremity trauma (PPET) to the thigh has been demonstrated to be 16% in a single report. The purpose of the current study is to demonstrate the incidence and clinical significance of venous injury as a result of proximity trauma to the thigh in a large cohort screened with colour flow duplex (CFD) ultrasound and to identify factors predictive of defining a wound in proximity to a major vascular structure. Patients and methods: A prospective observational study was conducted from January 1st, 2010 to January 1st, 2012 on all patients presenting with penetrating extremity trauma. Data on injury location, mechanism, associated extremity and non-extremity injuries, use and results of CFD, as well as the admitting trauma surgeon were recorded and analysed. Results: 220 thigh wounds with a normal physical examination were identified, of which 167 (75.9%) underwent CFD due to proximity. The incidence of acute venous injury was 4.8% (8/167). 37.5% (3/8) of these injuries resulted in morbidity. Injury mechanism and which attending physician was on call were predictive of a wound being defined as in proximity, whereas an injury with an associated fracture was a negative predictor. Conclusions: Occult venous injuries as a result of PPET occur in 4.8% of patients with thigh wounds in proximity to a major vascular structure. The designation of a wound as being in “proximity” was influenced by injury mechanism, associated fractures, and the judgement of the on-call attending. Colour flow duplex is a valuable tool with the ability to identify not only occult arterial injuries, but also venous injuries with the potential to cause significant morbidity as well. [Copyright &y& Elsevier]