Extended International Normalized Ratio testing intervals for warfarin-treated patients.

Essentials Warfarin typically requires International Normalized Ratio (INR) testing at least every 4 weeks. We implemented extended INR testing for stable warfarin patients in six anticoagulation clinics. Use of extended INR testing increased from 41.8% to 69.3% over the 3 year study. Use of extended INR testing appeared safe and effective. SUMMARY: Background A previous single-center randomized trial suggested that patients with stable International Normalized Ratio (INR) values could safely receive INR testing as infrequently as every 12 weeks. Objective To test the success of implementation of an extended INR testing interval for stable warfarin patients in a practice-based, multicenter collaborative of anticoagulation clinics. Methods At six anticoagulation clinics, patients were identified as being eligible for extended INR testing on the basis of prior INR value stability and minimal warfarin dose changes between 2014 and 2016. We assessed the frequency with which anticoagulation clinic providers recommended an extended INR testing interval (> 5 weeks) to eligible patients. We also explored safety outcomes for eligible patients, including next INR values, bleeding events, and emergency department visits. Results At least one eligible period for extended INR testing was identified in 890 of 3362 (26.5%) warfarin-treated patients. Overall, the use of extended INR testing in eligible patients increased from 41.8% in the first quarter of 2014 to 69.3% in the fourth quarter of 2016. The number of subsequent out-of-range next INR values were similar between eligible patients who did and did not have an extended INR testing interval (27.3% versus 28.4%, respectively). The numbers of major bleeding events were not different between the two groups, but rates of clinically relevant non-major bleeding (0.02 per 100 patient-years versus 0.09 per 100 patient-years) and emergency department visits (0.07 per 100 patient-years versus 0.19 per 100 patient-years) were lower for eligible patients with extended INR testing intervals than for those with non-extended INR testing intervals. Conclusions Extended INR testing for stable warfarin patients can be successfully and safely implemented in diverse, practice-based anticoagulation clinic settings.

Early career professionals: the mission of a task force.

Early career researchers and clinicians face unique challenges in comparison with more senior colleagues, for instance connecting with expert leaders outside of their own institution to enhance their expertise. As the largest international thrombosis and hemostasis professional society, the ISTH can play a central role in supporting the development of early career professionals. The ISTH Early Career Task Force was formed to improve support for, and encourage collaboration between early career thrombosis and hemostasis researchers and clinicians. These activities include (1) maintaining an online forum for early career ISTH members to connect, promote clinical, research, funding and educational activities, and to generate a sense of community; (2) broaden ISTH's reach with early career professionals in the developing world through promotion of the Reach-the-World fellowships and translating ISTH websites into six languages; (3) encourage early career engagement with ISTH activities, such as guidelines and guidance document processing and online webinar series; and (4) establishing this early career forum series in this journal. The JTH Forum series will highlight the early career perspective on a wide range of issues relevant to this group, and all ISTH early career members are encouraged to contribute.

A major gene for resistance to white pine blister rust in Western white pine from the Western cascade range.

ABSTRACT A dominant gene for resistance to white pine blister was indicated by Mendelian segregation in full-sib families of western white pine parent trees selected for phenotypic resistance in six heavily infected stands in the Western Cascades of Oregon and Washington. Seedlings were artificially inoculated three times between 1959 and 1964 and observed for development of stem infection. Segregation at this locus (Cr2) occurred in only two of the six parent populations sampled: one a natural stand, Champion Mine (CM), and the other a plantation of unknown seed origin. At CM, reduced penetrance of this gene was expressed by altered Mendelian ratios (mostly less-than-expected resistant phenotypes) in families of specific combinations of certain parents, indicating the presence of modifier genes with effects that ranged from mild to almost complete suppression of Cr2. Between 1968 and 1994, an apparent shift in virulence at CM caused all of the resistant selections to become infected and die. Recent inoculations of many of the same or related families from these parents, made from grafted ramets in a seed orchard, showed that Cr2 conditions a classical hypersensitive reaction (HR) in needle tissues, the primary infection courts. In the latter tests, seedlings were challenged with wild-type and four other sources of inoculum at and near CM that were also suspected of having wider virulence than wild type. No seedlings segregating for HR that were inoculated with wild type subsequently developed stem symptoms, but the other inocula induced both susceptible and HR needle spots on Cr2- genotypes, and many of these seedlings did develop stem infections. This implied that spore genotypes with specific virulence to Cr2 are carried in these inocula.

A comparative study of the effects of ranitidine and cimetidine on carbohydrate tolerance, growth hormone secretion and the hypothalamic-pituitary-gonadal axis in man.

The effect of chronic oral administration of cimetidine (1 g per day) and ranitidine (300 mg per day) on plasma levels of prolactin (PRL), testosterone, dihydrotestosterone (DHT), luteinizing hormone (LH), follicle stimulating hormone (FSH), sex hormone binding globulin (SHBG) and human growth hormone was compared in 2 groups of male patients who presented with dyspeptic symptoms. Eight were treated with ranitidine and 9 with cimetidine for 4 weeks. The glucose and insulin response to a 100 g oral glucose load was also assessed. Cimetidine treatment resulted in a significant increase in plasma testosterone levels which was not found in the ranitidine group. No significant change occurred in PRL, LH, FSH, SHBG, DHT and growth hormone. There was no evidence of a significant alteration in carbohydrate metabolism.

Lack of effect of angiotensin on levels of cyclic AMP in isolated adrenal zona glomerulosa cells from the rat.

The effects of pure [Asp1,Val5]- and [Asn1,Val5]-angiotensin II and also [des-Asp1,Ile5]-angiotensin II (angiotensin III) on cyclic AMP and steroid outputs by dispersed rat capsular cells, comprising 95% zona glomerulosa and 5% zona fasciculata cells, have been studied. The results showed that [Asp1, Val5]-and [Asn1, VAl5]-angiotensin II, at doses between 2.5 X 10(-11) and 2 X 10(-4) mol/l, which produced typical increases in steroidogenesis, failed to increase output of cyclic AMP. This lack of effect was observed whether the nucleotide was measured by radioimmunoassay or by adrenal binding protein and under the same conditions in which 8.4 mM-K+ consistently increased the output of cyclic AMP. Instead the results showed a small but significant decrease in cyclic AMP output with angiotensin II. Similar results were obtained with incubations for 60 rather than 120 min and with medium containing a concentration of 5 or 40 g bovine serum albumin/l. Although the levels of cyclic AMP were generally higher in the presence of the phosphodiesterase inhibitor, 3-isobutyl-1-methylxanthine, the same decrease relative to basal outputs was observed with angiotensin II which increased steroidogenesis. Angiotensin III also failed to increase output of cyclic AMP at doses (2.5 X 10(-9) to 2.5 X 10(-6) mol/l) which produced increases in steroid output equivalent to those with angiotensin II. These results indicate that angiotensin II and III can act through a cyclic AMP-independent mechanism.

Effect of TRH and dopamine on cyclic AMP levels in enriched mammotroph and thyrotroph cells.

Populations of normal anterior pituitary cells enriched in thyrotrophs or mammotrophs prepared by velocity sedimentation were used to investigate the effect of modulators of TSH and prolactin secretion on cyclic AMP accumulation. In both thyrotroph-enriched and mammotroph-enriched fractions, IBMX increased cyclic AMP accumulation. In the presence of IBMX, TRH invoked an increase in cyclic AMP suggesting that TRH modulates cyclic AMP accumulation in both of these cell types from normal pituitary glands. In the mammotroph-rich fraction, dopamine inhibited the increase in cyclic AMP induced by TRH. In contrast however, in the thyrotroph-enriched fraction dopamine lowered neither cyclic AMP concentration nor TSH secretion. Thus the inhibiting effect of dopamine on cyclic AMP appears to be specific for prolactin-secreting cells.