Clinical versus fixed warfarin dosing and the impact on quality of anticoagulation (The ClinFix trial).

Different dosing strategies exist to initiate warfarin, most commonly fixed warfarin dosing (FWD), clinical warfarin dosing (CWD), and genetic-guided warfarin dosing (GWD). Landmark trials have shown GWD to be superior when compared to FWD in the EU-PACT trial or CWD in the GIFT trial. COAG trial did not show differences between GWD and CWD. We aim to compare the anticoagulation quality outcomes of CWD and FWD. This is a prospective cohort study with a retrospective comparator. Recruited subjects in the CWD (prospective) arm were initiated on warfarin according to the clinical dosing component of the algorithm published in www.warfarindosing.org. The primary efficacy outcome was the percentage time in the therapeutic range (PTTR) from day 3 to 6 till day 28 to 35. The study enrolled 122 and 123 patients in the CWD and FWD, respectively. The PTTR did not differ statistically between CWD and FWD (62.2 ± 26.2% vs. 58 ± 25.4%, p = 0.2). There was also no difference between both arms in the percentage of visits with extreme subtherapeutic international normalized ratio (INR) (<1.5; 15 ± 18.3% vs. 16.8 ± 19.1%, p = 0.44) or extreme supratherapeutic INR (>4; 7.7 ± 14.7% vs. 7.5 ± 12.4%, p = 0.92). We conclude that CWD did not improve the anticoagulation quality parameters compared to the FWD method.

Metronidazole associated optic neuritis-induced irreversible vision loss: A case report and literature review.

Optic neuritis is an inflammatory condition involving the optic nerve causing vision abnormalities ranging from decreased to complete vision loss. We present a 30 years old lady who suffered acute gradual reduced vision, which progressed to complete vision loss in her right eye the next day after receiving one dose of intravenous Metronidazole.

Claustrum sparing sign in seronegative limbic encephalitis.

Background: Limbic encephalitis (LE) is a rare variant of autoimmune encephalitis. It often manifests with subacute neuropsychiatric symptoms of agitation, delusions, variable seizure semiology, and short-term memory loss. Seronegative limbic encephalitis can pose a diagnostic conundrum owing to its inadequately understood pathophysiology. Case presentation: We report a rare case of a young male with subacute neuropsychiatric manifestations of delusions, agitations and seizures. He was diagnosed with seronegative limbic encephalitis (SNLE). Brain MRI demonstrated bilateral Claustrum sparing sign. An EEG showed continuous left-sided epileptiform discharges in periodic to predominantly left middle temporal. Patient condition gradually improved with pulsed methylprednisolone, intravenous immunoglobulins and anti-seizure medications. Conclusion: Claustrum remains one of the least understood neuroanatomical structures. Claustrum sign has been reported in febrile infection-related epilepsy syndrome (FIRES), LE, and autoimmune refractory epilepsy. To the best of our knowledge, we report the first case in literature with Claustrum sparing sign in seronegative Limbic Encephalitis. Further experimental models and researches are warranted to better understand the unique function of the claustrum and unravel possible other attributable auto-antibodies, which could alter treatment and prognosis.

Hyponatremia and SARS-CoV-2 infection: A narrative review.

A novel rapid spreading and changing virus called SARS-CoV-2 appeared in Wuhan city in December 2019. It was announced by the World Health Organization (WHO) as a pandemic disease in March 2020. It commonly presents with respiratory symptoms; however, it may be asymptomatic. Electrolyte abnormalities are not uncommon features of SARS-CoV-2 infection. Hyponatremia is one of these electrolyte disturbances among SARS-CoV-2 patients, and it may produce symptoms such as weakness and seizure as the initial presenting symptoms. The underlying mechanism(s) of hyponatremia due to SARS-CoV-2 infection is (are) not established. The aim of this review is to evaluate the possible mechanism of hyponatremia in patients with COVID-19. Understanding and categorizing the hyponatremia in these patients will lead to better treatment and correction of the hyponatremia. A review of the literature between December 2019 and March 2022 was conducted searching for the possible reported mechanism(s) of hyponatremia in SARS-CoV-2. Although SIADH is the commonly reported cause of hyponatremia in SARS-CoV-2 infection, other causes such as diarrhea, vomiting, and kidney salt loss must be considered before SIADH.

The experience of Hamad General Hospital collaborative anticoagulation clinic in Qatar during the COVID-19 pandemic.

Hamad General Hospital Anticoagulation Clinic is one of the largest collaborative-practice clinics of its type in Qatar. The patients being followed at this clinic are typically complex and vulnerable. During the coronavirus disease 2019 pandemic, measures were implemented at the clinic to minimize the exposure of patients and healthcare providers to the acute respiratory syndrome coronavirus-2 and to promote social distancing. These measures included extending INR-recall period, transitioning to direct oral anticoagulant drugs whenever feasible, home visits to elderly and immunocompromised patients for INR testing, establishing an anticoagulation hotline, and relocation of warfarin dispensing from the main pharmacy to the anticoagulation clinic. In addition, the clinic shifted its multidisciplinary team meetings onto an online platform using Microsoft Teams. Telehealth consultations were extensively utilized to closely follow up with the patients and ensure that anticoagulation efficacy and safety remained optimal. The aim of this paper is to share our experience and describe the measures adopted by the clinic as part of the Hamad Medical Corporation response to the emerging situation.

Evaluation of the Validity of SAMe-TT2R2 Score in a Cohort of Venous Thromboembolism Patients Treated With Warfarin.

Low SAMe-TT2R2 score of <2 was validated as a predictor of optimum anticoagulation control, reflected by mean time in therapeutic range (TTR) above 65% to 70%, among warfarin-treated atrial fibrillation patients. This study aimed to validate the ability of SAMe-TT2R2 score and its individual components in predicting anticoagulation control (mean TTR and clinical events) among a cohort of venous thromboembolism (VTE) patients in Qatar. A total of 295 patients were retrospectively evaluated. There was a trend toward statistical significance in mean TTR between low (<2) and high (≥ 2) SAMe-TT2R2 score groups (P = .05), a difference that was not sustained when a cutoff of 3 was used (ie, a score of 3 or more). Patients with poor INR control (TTR <70%) were numerically less likely to have SAMe-TT2R2 score of <2 compared with those with good INR control, though the difference was not statistically significant (16.7% vs 83.3%, respectively, P = .4). No thromboembolic events were reported, and no association was found between the score and risk of bleeding. Non-Caucasian origin was the only significant predictor of good anticoagulation in the studied cohort. In conclusion, SAMe-TT2R2 score could not predict quality of anticoagulation control in a cohort of VTE patients treated with warfarin in Qatar. Contribution of other clinical factors and whether a different scoring may yield better prediction of anticoagulation control remains to be tested.

Inhaled Tranexamic Acid for Non-Massive Haemoptysis in a Rivaroxaban-Receiving Patient Not Responding to the Oral Form.

Haemoptysis is the expectoration of blood originating from the respiratory tract and occurs secondary to infection, malignancy, bronchiectasis or vascular disease. Its severity varies from minimal blood-streaked sputum to life-threatening haemorrhage. Therefore, prompt evaluation of the cause of the haemoptysis and its severity, and timely management are crucial. Although there is still no effective therapy for haemoptysis apart from treating the cause, inhaled tranexamic acid (TXA) might have a potential role in controlling non-massive haemoptysis. Here, we present a case of non-massive haemoptysis in a COPD patient with bronchiectasis on rivaroxaban for atrial fibrillation who responded to inhaled TXA following a failed trial of the oral formulation. LEARNING POINTS: Haemoptysis is the expectoration of blood and has several causes including bronchitis, bronchiectasis and bronchial neoplasms; severity ranges from simple blood-streaking of sputum to massive blood without sputum.Early recognition of haemoptysis, identification of the cause, and controlling it are crucial, especially in patients on anti-coagulation medicine.Inhaled tranexamic acid has shown benefit in controlling bleeding in patients with non-massive haemoptysis.

The effect of genetic and nongenetic factors on warfarin dose variability in Qatari population.

The objective of this study is to estimate the prevalence of VKORC1, CYP2C9, and CYP4F2 genetic variants and their contribution to warfarin dose variability in Qataris. One hundred and fifty warfarin-treated Qatari patients on a stable dose and with a therapeutic INR for at least three consecutive clinic visits were recruited. Saliva samples were collected using Oragene DNA self-collection kit, followed by DNA purification and genotyping via TaqMan Real-Time-PCR assay. The population was stratified into derivation and validation cohorts for the dosing model. The minor allele frequency (MAF) of VKORC1 (-1639G>A) was A (0.47), while the MAF's for the CYP2C9*2 and *3 and CYP4F2*3 were T (0.12), C (0.04) and T (0.43), respectively. Carriers of at least one CYP2C9 decreased function allele (*2 or *3) required lower median (IQR) warfarin doses compared to noncarriers [24.5 (14.5) mg/week vs. 35 (21) mg/week, p < 0.001]. Similarly, carriers of each additional copy of (A) variant in VKORC1 (-1639G>A) led to reduction in warfarin dose requirement compared to noncarriers [21(7.5) vs. 31.5(18.7) vs. 43.7(15), p < 0.0001]. CYP4F2*3 polymorphism on the other hand was not associated with warfarin dose. Multivariate analysis on the derivation cohort (n = 104) showed that a dosing model consisting of hypertension (HTN), heart failure (HF), VKORC1 (-1639G>A), CYP2C9*2 & *3, and smoking could explain 39.2% of warfarin dose variability in Qataris (P < 0.001). In the validation cohort (n = 45), correlation between predicted and actual warfarin doses was moderate (Spearman's rho correlation coefficient = 0.711, p < 0.001). This study concluded that VKORC1 (-1639G>A), CYP2C9*2 & *3 are the most significant predictors of warfarin dose along with HTN, HF and smoking.

Hepatitis B and C status among health care workers in the five main hospitals in eastern Libya.

The aim of the present study was to determine the frequency of hepatitis B and C transmission to health care workers (HCWs) in five major hospitals in eastern Libya and to analyze how the risk of these infections are affected by the type of occupation, hospital work place and working period. From July 2008 to June 2009, 601 HCWs (mean age: 32.90 ± 8.85 years) were tested for HBV and HCV markers using ELISA techniques. Polymerase chain reaction (PCR) was performed on all positive samples of HBsAg and Anti-HCV antibody to determine the level of HBV-DNA and HCV-RNA viremia, respectively. The overall frequency of HBsAg positivity was 1.8%. Anti-HBc, HBeAg and Anti-HBe antibodies were found in 8.5%, 0.7% and 8.0% of samples, respectively. The HBV-DNA level was positive in 55% of all HBsAg-positive samples. Approximately half of the HCWs (51.4%) were Anti-HBs antibody positive. The overall positivity rate of Anti-HCV antibodies was 2.0%, and HCV-RNA was positive in 33.3% of these samples. Overall, 52% of HCWs reported receiving full vaccination doses (three doses) against HBV infection. Among them, anti-HBs positivity was approximately 98.0%. 3.9% of those who never received any HBV vaccination dose were HBsAg positive, compared to 1.3% HBsAg positive in those HCWs who had received one or two doses of hepatitis B vaccine (p=0.01 for all comparisons). Nurses and nurse-aides had the highest rates of both HBsAg and Anti-HCV among the studied HCWs (HBsAg: 2.1% and 3.2%; Anti-HCV: 3.2% and 4.9%, respectively). It is noteworthy that doctors also had a relatively high prevalence rate of Anti-HCV (2.2%). Obstetric wards, isolation room, dialysis units and dentist work places had higher frequencies of HBV. HCV was found to be higher in the medical and surgical wards (the prevalence varied between 3% and 5.6%). There was no significant difference between HBsAg status and the work period of HCWs. In conclusion, universal precautions should be applied for the care of all patients by all HCWs. Further, HBV vaccines should be more readily available for Libyan HCWs by reinforcing current vaccination programs.