Perceptions and knowledge gaps on CHA2DS2-VASc score components: a joint survey of Chinese clinicians and clinical pharmacists.

BACKGROUND: The CHA2DS2-VASc score is a guideline-recommended stroke risk stratification scheme for patients with atrial fibrillation (AF). Accurately calculating the CHA2DS2-VASc score and recognizing the stroke risk in AF patients is the foundation of optimal anticoagulation therapy. This survey aims to obtain a comprehensive understanding of perceptions and knowledge gaps on CHA2DS2-VASc scores among Chinese medical professionals for future education programs. METHODS: A cross-sectional survey was conducted among clinicians, including cardiologists, neurologists, emergency physicians (EPs), general practitioners (GPs) and clinical pharmacists (CPs) using a self-administered questionnaire on the Chinese mainland. The survey contained 21 questions in combination with single-choice questions, multiple-choice questions, and an open-ended question, which was distributed online via e-mail or social media. RESULTS: A total of 562 participants (40.9% cardiologists, 19.2% neurologists, 8.5% EPs, 10.3% GPs, and 21.0% CPs) completed the survey. Most respondents across all specialties reported skills requiring improvements in the CHA2DS2-VASc score. In general, cardiologists, neurologists, and CPs had a relatively better understanding than GPs and EPs about the application of CHA2DS2-VASc score. Considering 'H' and 'D' components, more than 90% of respondents chose the correct answer in single-choice questions, whereas the correctness rate declined concerning detailed scoring criteria. Regarding 'C,' 'A2,' 'S2,' and 'V' components, partly correct answers were commonly observed in most multiple-choice questions. The majority of cardiologists believed themselves to be very familiar or at least familiar with the score and its components, while around 70% of EPs and GPs felt relatively unfamiliar with the CHA2DS2-VASc score. Mobile apps, AF guidelines and notebooks/handbooks were popular referencing scoring tools for respondents. CONCLUSIONS: Chinese medical professionals, especially EPs and GPs, revealed a lack of knowledge and insufficient skills for CHA2DS2-VASc scores and their components. Improvements in the awareness of the CHA2DS2-VASc score and its detailed scoring criteria are urgently needed for Chinese medical professionals. Therefore, education programs concerning the introduction of stroke risk evaluation for AF patients and the development of referencing scoring tools are necessary.

Clinical effect of different maintenance doses of caffeine citrate in the treatment of preterm infants requiring assisted ventilation: a pilot multicenter study / 中国当代儿科杂志

OBJECTIVES@#To explore the optimal maintenance dose of caffeine citrate for preterm infants requiring assisted ventilation and caffeine citrate treatment.@*METHODS@#A retrospective analysis was performed on the medical data of 566 preterm infants (gestational age ≤34 weeks) who were treated and required assisted ventilation and caffeine citrate treatment in the neonatal intensive care unit of 30 tertiary hospitals in Jiangsu Province of China between January 1 and December 31, 2019. The 405 preterm infants receiving high-dose (10 mg/kg per day) caffeine citrate after a loading dose of 20 mg/kg within 24 hours after birth were enrolled as the high-dose group. The 161 preterm infants receiving low-dose (5 mg/kg per day) caffeine citrate were enrolled as the low-dose group.@*RESULTS@#Compared with the low-dose group, the high-dose group had significant reductions in the need for high-concentration oxygen during assisted ventilation (P=0.044), the duration of oxygen inhalation after weaning from noninvasive ventilation (P<0.01), total oxygen inhalation time during hospitalization (P<0.01), the proportion of preterm infants requiring noninvasive ventilation again (P<0.01), the rate of use of pulmonary surfactant and budesonide (P<0.05), and the incidence rates of apnea and bronchopulmonary dysplasia (P<0.01), but the high-dose group had a significantly increased incidence rate of feeding intolerance (P=0.032). There were no significant differences between the two groups in the body weight change, the incidence rates of retinopathy of prematurity, intraventricular hemorrhage or necrotizing enterocolitis, the mortality rate, and the duration of caffeine use (P>0.05).@*CONCLUSIONS@#This pilot multicenter study shows that the high maintenance dose (10 mg/kg per day) is generally beneficial to preterm infants in China and does not increase the incidence rate of common adverse reactions. For the risk of feeding intolerance, further research is needed to eliminate the interference of confounding factors as far as possible.

Rationale and design of a prospective, multicenter, cross-sectional study of appropriateness evaluation of the prescription of non-vitamin K antagonist oral anticoagulants for Chinese atrial fibrillation patients (Chi-NOACs-AF trial).

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs) are alternative to vitamin K antagonists (VKAs) for stroke prevention in patients with atrial fibrillation (AF). Along with their widespread clinical use in China, the off-label use of NOACs is commonly seen in real-world practice, which could result in adverse drug events and poor clinical outcomes. However, guideline adherence and label adherence for NOAC prescriptions have not been well evaluated in a real-world setting in China. METHODS: Between January 2021 and June 2021, a total of 1,750 outpatients or inpatients with AF will be consecutively enrolled at 26 canters in China. Data on patient demographics, clinical characteristics, treatment strategies, and prescribing information related to anticoagulation therapy for patients with AF will be collected. Clinical pharmacists will evaluate the rationality of the anticoagulation regimens and NOAC prescriptions based on the guideline recommendations and drug labels that are approved by the National Medical Products Administration. The primary outcomes will be the prevalence of irrational anticoagulation strategies and the inappropriate NOAC prescriptions, as well as potential risk factors associated with inappropriate prescriptions in patients with AF. DISCUSSION: This study will be the first national, multicenter, prospective study performed by pharmacists to explore real-world data on the appropriateness of NOAC prescription in Chinese patients with AF. TRIAL REGISTRATION: The Chi-NOACs-AF trial (Trial number: ChiCTR2000035908).

Net clinical benefit of non-vitamin K antagonist oral anticoagulants in atrial fibrillation and chronic kidney disease: a trade-off analysis from four phase III clinical trials.

BACKGROUND: Atrial fibrillation (AF) is quite prevalent in patient with chronic kidney disease (CKD). This study mainly investigated the net clinical benefit (NCB) property of non-vitamin K antagonist oral anticoagulants (NOACs) versus warfarin in patients with AF and CKD by a pooled-analysis. METHODS: A comprehensive search of Medline, Embase, Cochrane Library and Clinical Trials.gov Website was performed for eligible randomized controlled trials (RCTs) reporting the efficacy and safety outcomes according to renal function of NOACs. Pre-specified outcomes and their number of patients needed to treat (NNT), including stroke/systemic embolism (SSE), major bleeding, and all-cause death, were evaluated using a random-effects model. NCB that balanced SSE and major bleeding was calculated using Singer's method. RESULTS: Four phase III clinical trials including 70,952 patients were enrolled, 45,265 (64%) with CKD, and 25,687 (36%) without CKD; 41,942 (59%) taking NOACs and 29,010 (41%) taking warfarin. Risks of SSE [relative risk (RR): 0.80, 95% confidence interval (CI): 0.73-0.88, P<0.01], major bleeding (RR: 0.79, 95% CI: 0.66-0.96, P=0.017), and all-cause death (RR: 0.91, 95% CI: 0.84-0.99, P=0.031) were significantly lower in CKD patients with NOACs than those with warfarin, accompanying with a high absolute risk reduction (NNT: 182 for SSE; 122 for major bleeding; 196 for all-cause death). While NOACs were not superior to warfarin on SSE, major bleeding, and all-cause death in patients without CKD, the NCB of NOACs versus warfarin was progressively increased with the deterioration of renal function (NCB: 0.72 for no CKD, 1.59 for mild CKD, 2.74 for moderate CKD). Sensitivity analyses did not significantly affect the primacy results. CONCLUSIONS: NOACs, compared with warfarin, provide a better clinical profile on SSE, major bleeding, all-cause death, and NCB in CKD patients.

Decreased risk of renal impairment in atrial fibrillation patients receiving non-vitamin K antagonist oral anticoagulants: A pooled analysis of randomized controlled trials and real-world studies.

BACKGROUND: Patients with warfarin have a potential risk of warfarin-related nephropathy, which could result in the discontinuation of anticoagulation therapy. The question of whether non-vitamin K antagonist oral anticoagulants (NOACs) use is associated with increased risk of renal impairment in atrial fibrillation (AF) patients remains unanswered. METHODS: Studies were systematically searched through Medline, Embase, Cochrane Library databases, and ClinicalTrials.gov Website. Randomized controlled trials (RCTs) reporting renal impairment events and observational nationwide database studies presenting adjusted hazard ratio (HR) in AF patients with NOACs were identified. The Primacy outcome was renal impairment, defined as a composite of any renal disorder. The secondary outcomes were narrow definition of renal failure (including renal failure, acute renal failure, chronic renal failure, acute prerenal failure and postrenal failure) and individual renal impairment reported in involved studies. HR and 95% confidence intervals (95%CI) were calculated using fixed- or random-effects models according to the extent of heterogeneity. Subgroup analyses were conducted according to individual NOACs, study types and different controls. RESULTS: Totally, 189,483 patients from 11 RCTs and 3 observational database studies were included in the analysis (119,188 patients with NOACs and 70,295 patients with vitamin K Antagonists or acetylsalicylic acid). Overall results indicated a significantly lower risk of renal impairment in AF patients with NOACs versus VKAs/acetylsalicylic acid (HR: 0.67, 95%CI: 0.62-0.73). Results of narrow definition of renal impairment were accordant with the primacy outcome (HR: 0.65, 95%CI: 0.60-0.71). Compared with VKAs or acetylsalicylic acid, dabigatran (HR: 0.64, 95%CI: 0.56-0.72), rivaroxaban (HR: 0.66, 95%CI: 0.55-0.77) and apixaban (HR: 0.73, 95%CI: 0.59-0.87) were all associated with a significantly lower risk of renal impairment, with the exception of edoxaban (HR: 0.79, 95%CI: 0.30-1.27). CONCLUSIONS: Patients with NOACs might bring about a lower risk of renal impairment compared to VKA or acetylsalicylic acid. Further specialized designs of RCTs and real-world studies on evaluation of renal function are warranted to obtain a robust result on this issue.

Countermeasure research on strengthening electronic archives construction of digital medicine in medical industry / 中国医学装备

Objective:To explore the countermeasure of strengthening the electronic archives construction of digital medicine in medical industry so as to impel the establishment of electronic archives of digital medicine.Methods: The current situation and improvement of electronic files of digital medicine in medical industry are discussed and the countermeasure in the construction of electric archives of digital medicine was strengthened through analyzing the important role of medical electronic files in the development of hospitals and the existed insufficient in medically electronic file management.Results: The existed shortcomings in the management of medically electronic archives mainly included the lack of precise elaboration and accountability in the existed management system of medically electronic archives, the lack of professional electronic archivists and the hardware facilities should be improved in the management of electronic archives. The countermeasures of strengthening the construction of electronic archives of digital medicine in the medical industry mainly included that improving the management of electronic archives, improving the quality of managers, synchronizing the management of hospital electronic documents and paper documents, strengthening the technical maintenance for electronic archives, increasing the capital investment of electronic archives management and improving the storage of electronic files.Conclusion: Strengthening the construction of electronic files of digital medicine in medical industry is imperative. In order to improve the quality of electronic files, the existed problems in management measures should be clarified and corresponding countermeasures that aimed at problems should be formulated to solve the problems.

Effect and cost of perioperative use of antibiotics in coronary artery bypass grafting: a randomized controlled study.

BACKGROUND: Bacterial infections remain a serious complication following coronary artery bypass grafting (CABG). The objective of the study was to determine the effectiveness of a guideline for the appropriate use of antibiotics in CABG during the perioperative period. METHODS: Six hundred and fourteen hospitalized patients who had undergone CABG from January to June 2006 were randomly allocated to an intervention group and a control group. The data on the hospital stay, days of antibiotic used, types of prophylactic antibiotics used, surgical wound infection and pulmonary infection and antibiotic costs for the patients were compared. RESULTS: The postoperative hospitalization days of the intervention group were significantly fewer than that for the control group (P < 0.05). The time of antibiotic use and post-infection treatment time were also significantly less in the intervention group than in the control group (P < 0.05). The average hospital daily cost and total cost of antibiotics were less in the intervention group than in the control group (P < 0.05). Compared with the control group, prophylactic antibiotic use in the intervention group was more reasonable. CONCLUSIONS: The guideline for the appropriate use of antibiotics in CABG during the perioperative period is effective strategies for reducing antibiotic costs, the time of antibiotic use and post-infection treatment time without compromising the patients' clinical outcome.

[Changes of myocardial enzymes related to glycolysis and fatty acid metabolism in chronic myocardial ischemia: experiment with pigs].

OBJECTIVE: To investigate the changes myocardial enzymes related to glycolysis and fatty acid metabolism in chronic myocardial ischemia and to evaluate the relationship between the gene expression of glycolytic metabolism related enzymes and myocardial viability. METHODS: Fourteen Chinese experimental pigs underwent placement of arterial ring into the left anterior descending coronary artery so as to establish models of myocardial ischemia and infarction. (18)F-2-deoxy-2-fluoro-D-glucose single photon emission computed tomography was conducted to observe the viability of the myocardium. One week later the pigs were killed with their hearts taken out. Specimens of ischemic zone, infarction zone, and non-ischemic zone were obtained. RT-PCR was used to detect the mRNA expression of glucose transporter (GLUT) 1, GLUT4, medium-chain acyl-CoA dehydrogenase (MCAD), and heart-fatty acid binding protein (H-FABP). Immunohistochemistry was used to examine the protein expression of Glut1 and Glut4. Periodic Acid Schiff-hematoxylin staining was conducted to detect the glycogen. RESULTS: Pathological examination showed 5 pigs with myocardial infarction and 5 pigs with ischemia. In the pigs with ischemia, the mRNA expression levels of GLUT1 and GLUT4 in the ischemic zone were 9466 +/- 9033 and 60 398 +/- 64 699 respectively, both significantly higher than those in the control zone (5854 +/- 5287 and 34 188 +/- 44 714 respectively, P = 0.043, P = 0.043). the RNA expression of H-FABP in the ischemic zone was 18 123 +/- 15 925, significantly lower than that in the control zone (50 718 +/- 62 412, P = 0.043), and there was no significant difference in the mRNA expression level of MCAD. In the pigs with infarction the mRNA expression of level of H-FABP in the infarction zone was 21 919 +/- 15 224, significantly lower than that in the control zone (87 545 +/- 92 990, P = 0.043), and there were not significant differences in the mRNA expression levels of the GLUT1, GLUT4, and MCAD genes (all P > 0.05). The mRNA expression of GLUT1 in the myocardial segments with perfusion/metabolism mismatch was significantly higher than that in the myocardial segments with perfusion/metabolism match (19 794 20 454 vs 5134 + 6022, P = 0.046). The ischemic cardiac myocytes showed hypertrophy and positive staining of anti-GLUT1 polyclonal antibody. CONCLUSION: The changes of mRNA and protein expression of enzymes related to glycolysis and fatty acid metabolism after myocardial ischemia play an important role in glycolytic metabolism during myocardial ischemia.

[Glycolytic and fatty acid metabolic enzyme changes early after acute myocardial ischemia].

OBJECTIVE: To explore the changes of mRNA and protein expressions of glycolytic and fatty acid metabolic enzymes early after acute myocardial ischemia. METHODS: Twelve dogs were randomly divided into 3 groups (sham, 20 min ischemia and 40 min ischemia, n = 4 each). Myocardial samples from ischemic and nonischemic zone were obtained for histology examination, and the mRNA expressions for Phosphofructokinase (PFK), Glyceraldehyde-3-phosphate dehydrogenase (GAPDH), GLUT1, GLUT4, Medium-chain acyl-CoA dehydrogenase (MCAD) and Heart-fatty acid binding protein (H-FABP) were determined by Real Time PCR-SYBR Green RT-PCR. GLUT1 protein expression was determined by immunohistochemistry. The apoptotic cardiomyocytes was evaluated by TUNEL. RESULTS: Compared to sham hearts, H-FABP mRNA was decreased in nonischemic and ischemic zone (P < 0.05) while GLUT1 mRNA expression was significantly increased in nonischemic and ischemic zone (P < 0.05) in dogs underwent 20 and 40 min ischemia. PFK mRNA tended to be higher in ischemic myocardium (P = 0.065) and GAPDH, MCAD as well as GLUT4 remained unchanged post ischemia (all P > 0.05). Positive GLUT1 protein staining was visualized in ischemic myocardium of hearts underwent 20 and 40 min ischemia. The myocardial apoptosis cells was 6.4% +/- 0.9% in sham hearts, 28.0% +/- 3.7% in hearts underwent 20 min ischemia (P < 0.05 vs. sham) and 38.4% +/- 1.9% in hearts underwent 40 min ischemia (P < 0.05 vs. sham). CONCLUSIONS: Significant down and up-regulated glycolytic and fatty acid metabolic enzymes early after myocardial ischemia suggested that these enzymes might play an important role in acute myocardial ischemia.

[Experimental study of pharmaceutic stress myocardial perfusion imaging with higenamine].

OBJECTIVE: To evaluate the applicative value of higenamine used as a new agent for pharmaceutical stress test in detection of coronary artery disease by radionuclide myocardial perfusion imaging. METHODS: Thirteen pigs with chronic coronary artery stenosis by placement of the Ameroid constrictor in the middle section of left anterior descending artery were included in this study. Rest, higenamine and dobutamine stress radionuclide myocardial perfusion imaging was performed with Tc-99m-sestamibi. RESULTS: The sensitivity for detection of coronary artery disease by radionuclide myocardial perfusion imaging was 85% in both higenamine and dobutamine stress imaging. Imaging scores (9.9 +/- 8.5 vs. 9.4 +/- 8.6, P = NS) and defect severity (68% +/- 12% vs. 68% +/- 15%, P = NS) showed no significant difference between higenamine and dobutamine stress test. Agreement of imaging scores between higenamine and dobutamine stress imaging was good (kappa = 0.849, P < 0.0001). CONCLUSION: Our study demonstrates that detection of coronary artery stenosis and ischemic myocardium by myocardial perfusion imaging with higenamine is highly sensitive.