Implementation and Evaluation of a Standardized Non-Vitamin K Oral Anticoagulant (NOAC) Patient Safety Alert Card Across the Northern Region of England.

Many patients are prescribed anticoagulants. Newer non-vitamin K oral anticoagulants, NOACs, were launched in 2008 and are increasingly commonly used. However, they may still be unfamiliar to patients and health care professionals. It is mandated by the National Patient Safety Agency and European Society of Cardiology to provide written safety information for patients receiving anticoagulants. We developed a standard patient alert card with the support of the North of England Strategic Clinical network (NESCN) to clearly provide key safety information for patients and health care professionals. This is the only card in the United Kingdom that is used over such a wide geographical area. We recognized that this would avoid duplication of work devising a similar card across all the sites in primary and secondary care. Given that staff and patients commonly move about the region it would also lead to better ease of recognition. The NESCN card was developed with input from all the key stakeholders, including cardiology, stroke, hematology, acute medicine, primary care, and patient groups. It was launched in 2015 across the Northern region, which includes over 3 million people. It was distributed to general practitioners (GPs), primary and secondary care pharmacists. Electronic and face-to-face education was carried out alongside to pharmacists, GPs, and hospital physicians. We gathered patient and clinical staff feedback regarding the card and found the alert card was widely embedded within practice across the region and patient feedback was good. The evaluation shows a simple and inexpensive intervention delivered with no formal funding can address this patient safety concern. We have engaged with Clinical Commissioning Groups and secondary care trusts in the region to ensure the legacy of the project. In response to requests from other regions and organizations, the card has been widely shared and implemented across many areas of the United Kingdom.

Haemoptysis in an intravenous drug user: injection needle impacted in the left main bronchus.

We report a case of a 35-year-old man who presented with 4-week history of haemoptysis, with a history of intravenous drug use. There was no other significant medical or surgical history and no recollection of any foreign body aspiration. Chest X-ray and CT scan showed 40 mm long needle in left main bronchus, partly lying outside the bronchus into the mediastinum. Flexible and rigid bronchoscopes proved to be unsuccessful in retrieving the needle. We proceeded with left posterolateral thoracotomy and the left main bronchus was explored to take out this 21-gauge (green) injection needle. The distal half of the needle with the sharp end was lying in the mediastinum piercing through the bronchial wall. Surgery was uneventful with good postoperative recovery and the patient was discharged 4 days later.

Extensive genomic and functional polymorphism of the complement control proteins.

Using combinations of genomic markers, we describe more than 20 distinct ancestral haplotypes (AH) of complement control proteins (CCPs), located within the regulators of complement activation (RCA) alpha block at 1q32. This extensive polymorphism, including functional sites, is important because CCPs are involved in the regulation of complement activation whilst also serving as self and viral receptors. To identify haplotypes, we used the genomic matching technique (GMT) based on the pragmatic observation that extreme nucleotide polymorphism is packaged with duplicated sequences as polymorphic frozen blocks (PFB). At each PFB, there are many alternative sequences (haplotypes) which are inherited faithfully from very remote ancestors. We have compared frequencies of RCA haplotypes and report differences in recurrent spontaneous abortion (RSA) and psoriasis vulgaris (PV).

Do oxidized fatty acids activate coagulation factor VII during post-prandial lipemia in women?

Factor VII is activated to VIIa within hours after dietary fat, irrespective of its fatty acid composition. Edible oils contain oxidized material (hydroxy fatty acids, HOFA). Twenty-five fasting women, aged 38 (10) years, consumed 30 g walnut oil containing 26 (6) mg HOFA. Blood was collected 2-hourly to measure plasma triglycerides and plasma lipid HOFA by gas chromatography/mass spectrometry. VII and sTF-dependent VIIa were quantified at 0, 6 and 24 h. Increased plasma triglycerides and HOFA (areas under the curve 0-8 h, AUC) were related r = 0.83, p < 0.001. VIIa increased from 2.6 (1.4) to 4.2 (1.9) ng/mL at 6 h (p < 0.001). Plasma VII remained constant. VIIa (6 h) was related to plasma triglycerides- and HOFA-AUC: r = 0.38 and 0.53, respectively (both p < 0.05). Plasma VIIa was also related to body weight, fasting triglycerides, HOFA and VII. Only HOFA-AUC and body weight related to VIIa (6 h) in stepwise regression analysis (p = 0.007 and 0.038, respectively). Oxidized, not normal, fat activates VII and could increase coronary risk in humans.

Dietary hydroxy fatty acids are absorbed in humans: implications for the measurement of 'oxidative stress' in vivo.

Lipid peroxidation products formed in vivo or originating from the diet may lead to atherosclerosis. However, little is known about the absorption of these products in man. We studied the absorption of fat (30 g) containing 14-15 mg [U-13C]-labeled hydroxy or dihydroxy triglycerides in two groups of six apparently healthy women aged 40 +/- 2 years. Post-prandial 13C-labeled hydroxy fatty acid concentration increased in a pattern somewhat different from that of plasma triglycerides, with peak levels being reached between 4 and 6 h. However, the amount of 13C-labeled oxidized fat absorbed (area under the curve of plasma concentrations from 0 to 8 h) was related to that of plasma triglycerides: 13C hydroxy vs TG (r = 0.88, p <.02), and 13C dihydroxy vs TG (r = 0.85, p <.05). 13C monohydroxy triglycerides appeared to be absorbed to a greater extent than those of 13C dihydroxy triglycerides. Although low levels of 13C hydroxy lipids could be detected in fasting plasma after 24 h, concentrations were very low. Dietary lipid oxidation products are absorbed. The measurement of hydroxy fatty acids in plasma total lipids may not be a valid marker of lipid peroxidation in vivo when subjects are not fasting.