The effect of administering preprocedural VITamin K on the international normalized ratio in patients anticoagulated with ACEnocoumarol (VITKACE-study): a prospective cohort study.

BACKGROUND: The effect of the vitamin K antagonist acenocoumarol on coagulation needs to be reversed when patients undergo an invasive procedure with considerable bleeding risk. A strategy to achieve this is by administering oral vitamin K before a procedure while continuing acenocoumarol. OBJECTIVES: To assess the effect on periprocedural international normalized ratio (INR) values and safety using oral vitamin K as anticoagulant reversal method. METHODS: In this prospective cohort study, consecutive patients using acenocoumarol undergoing elective procedures between 2019 and 2022 were included. According to standard of care in our hospital, patients took 10 mg oral vitamin K 36 to 48 hours before the procedure while continuing their normal use of acenocoumarol. Effectiveness to lower INR to <1.8 preprocedural was assessed. Bleeding and thrombotic complications within 30 days after the procedure were assessed. Periprocedural course of INR was monitored by collecting additional blood samples. RESULTS: Seventy-four patients were included for analysis. On the day of the procedure, an adequate INR of <1.8 was achieved in 99% of patients. One clinically relevant nonmajor bleeding complication and no thrombotic complications were observed during the first 30 days after the procedure. INR gradually restored to therapeutic level during the days after the procedure. CONCLUSION: Using oral vitamin K while patients continue acenocoumarol intake is an effective way to adequately lower INR before an invasive procedure. Low amount of bleeding complications and absence of thromboembolic complications suggest that this is a safe strategy. The INR values returned gradually to therapeutic range after the procedure, probably contributing to the observed low bleeding rate.

Tailored anticoagulant treatment after a first venous thromboembolism: protocol of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study - cohort-based randomised controlled trial.

INTRODUCTION: Patients with a first venous thromboembolism (VTE) are at risk of recurrence. Recurrent VTE (rVTE) can be prevented by extended anticoagulant therapy, but this comes at the cost of an increased risk of bleeding. It is still uncertain whether patients with an intermediate recurrence risk or with a high recurrence and high bleeding risk will benefit from extended anticoagulant treatment, and whether a strategy where anticoagulant duration is tailored on the predicted risks of rVTE and bleeding can improve outcomes. The aim of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study is to evaluate the outcomes of tailored duration of long-term anticoagulant treatment based on individualised assessment of rVTE and major bleeding risks. METHODS AND ANALYSIS: The L-TRRiP study is a multicentre, open-label, cohort-based, randomised controlled trial, including patients with a first VTE. We classify the risk of rVTE and major bleeding using the L-TRRiP and VTE-BLEED scores, respectively. After 3 months of anticoagulant therapy, patients with a low rVTE risk will discontinue anticoagulant treatment, patients with a high rVTE and low bleeding risk will continue anticoagulant treatment, whereas all other patients will be randomised to continue or discontinue anticoagulant treatment. All patients will be followed up for at least 2 years. Inclusion will continue until the randomised group consists of 608 patients; we estimate to include 1600 patients in total. The primary outcome is the combined incidence of rVTE and major bleeding in the randomised group after 2 years of follow-up. Secondary outcomes include the incidence of rVTE and major bleeding, functional outcomes, quality of life and cost-effectiveness in all patients. ETHICS AND DISSEMINATION: The protocol was approved by the Medical Research Ethics Committee Leiden-Den Haag-Delft. Results are expected in 2028 and will be disseminated through peer-reviewed journals and during (inter)national conferences. TRIAL REGISTRATION NUMBER: NCT06087952.

[Interest of a biopsychosocial approach in the management of a patient with chronic pain : a narrative review]. / Intérêt d'une approche biopsychosociale dans la prise en charge d'un patient souffrant de douleurs chroniques : une revue narrative.

Pain is generally perceived as a sensory, emotional and cognitive aggression by the patient who suffers from it and as the enemy that must be defeated by the physician. It may become chronic, and the passage from the acute phase to the chronic phase cannot be explained in a single way. Indeed, multiple factors come into play: biological, psychological and socio-professional. The patient's quality of life then deteriorates and places him/her in a vicious cycle of pain. The assessment of the different components of pain (sensory, emotional, cognitive and behavioural) and its maintenance factors allow for the implementation of therapeutic strategies, both physical and psychological, adapted to every patient. Due to the complexity of chronic pain management, a multidisciplinary strategy is being developed, with a global approach according to the biopsychosocial perspective, including non-pharmacological approaches, with the objective of allowing the patient to be autonomous in the management of his/her symptoms.

La douleur est généralement perçue comme une agression sensorielle, émotionnelle et cognitive par le patient qui en souffre, et comme l'ennemi que le médecin doit vaincre. Elle peut se chroniciser, et le passage de la phase aiguë à la phase chronique ne peut s'expliquer d'une façon unique. En effet, de multiples facteurs biologiques, psychologiques et socio-professionnels entrent en jeu. La qualité de vie du patient se dégrade alors et le place dans un véritable cercle vicieux de la douleur. L'évaluation des différentes composantes de la douleur (sensorielle, émotionnelle, cognitive et comportementale) et de ses facteurs de maintien permet de mettre en place des stratégies thérapeutiques, aussi bien sur le plan physique que psychologique, adaptées à chaque patient. Du fait de la complexité de la prise en charge de la douleur chronique, se développe une méthode pluridisciplinaire, dans une perspective d'approche globale selon le modèle biopsychosocial, incluant également des approches non médicamenteuses avec comme objectif, notamment, de permettre au patient une autonomie dans la gestion de sa symptomatologie.

Clinical heterogeneity in monogenic chylomicronaemia.

Chylomicronaemia accompanies hypertriglyceridaemia, usually due to a polygenic predisposition in combination with secondary risk factors. Monogenic chylomicronaemia represents a small subgroup of patients with hypertriglyceridaemia. This article describes three patients and illustrates the heterogeneity in the presentation of monogenic chylomicronaemia. The first case is a man with mild hypertriglyceridaemia who is a compound heterozygote for two variants in the LMF1 gene, without relevant medical history. The second case is a woman who is a double heterozygote of variants in the LPL and APOA5 genes. She experienced pancreatitis. The third case is a man, with recurrent pancreatitis attributed to severe hypertriglyceridaemia and homozygous for a variant in the APOC2 gene. This article highlights that in patients with hypertriglyceridaemia, the absence of pancreatitis or the presence of mild hypertriglyceridaemia does not exclude monogenic chylomicronaemia. Genetic screening should be considered in patients with unexplained or severe hypertriglyceridaemia, to determine appropriate treatment and follow-up.

Smartphone Application-Assisted Home Blood Pressure Monitoring Compared With Office and Ambulatory Blood Pressure Monitoring in Patients With Hypertension: the AMUSE-BP Study.

BACKGROUND: The development of automated, smartphone application (app)-assisted home blood pressure monitoring (HBPM) allows for standardized measurement of blood pressure (BP) at home. The aim of this study was to evaluate the (diagnostic) agreement between app-assisted HBPM, automated office BP (OBP), and the reference standard 24-hour ambulatory BP monitoring (ABPM). METHODS: In this open randomized 5-way cross-over study, patients diagnosed with hypertension were randomized to one of 10 clusters, each containing 5 BP measurement methods (ABPM, HBPM, attended OBP, unattended OBP, and unattended 30-minute BP) in different order. RESULTS: In total, 113 patients were included. The average 24-hour ABPM was 126±11/73±8 mm Hg compared with 141±14/82±10 mm Hg with app-assisted HBPM, 134±13/80±9 mm Hg with unattended 30-minute BP, 137±16/81±11 mm Hg with attended OBP, and 135±15/81±10 mm Hg with unattended OBP monitoring. Diagnostic agreement between app-assisted HBPM and 24-hour ABPM for diagnosing sustained (OBP >140/90 mm Hg and ABPM ≥130/80 mm Hg or HBPM ≥135/85 mm Hg), white-coat (OBP ≥140/90 mm Hg and ABPM <130/80 mm Hg or HBPM <135/85 mm Hg), and masked hypertension (OBP <140/90 mm Hg and ABPM ≥130/80 mm Hg or HBPM ≥135/85 mm Hg) was fair-to-moderate (κ statistics ranging from 0.34 to 0.40). App-assisted HBPM had high sensitivities (78%-91%) and negative predictive values (90%-97%) for diagnosing sustained and masked hypertension. CONCLUSIONS: This study showed a considerable (diagnostic) disagreement between app-assisted HBPM and ABPM. App-assisted HBPM had high sensitivity in the diagnosis of sustained and masked hypertension and may therefore be used as complementary to, but not a replacement of, ABPM.

When LDL Cholesterol Is Not LDL Cholesterol: LpX, A Clinical Lesson.

LpX is a lipoprotein formed in cholestatic conditions and often erroneously reported as LDL-C. A low ApoB level can support the diagnosis of LpX. Treatment should not automatically focus on lowering serum lipid levels, but primarily on resolving the cause of cholestasis. (Level of Difficulty: Advanced.).

The use of a novel burn dressing out of bacterial nanocellulose compared to the French standard of care in paediatric 2nd degree burns - A retrospective analysis.

PURPOSE: Paediatric burn care is a delicate discipline which benefits from special attention. Despite being highly effective, the current standard of care for second degree burns in the largest paediatric burn center in France - exposure to infrared light - involves long hospital stays, straining economic and professional resources, especially in times of a pandemic. The present study investigated this standard of care and compared it to the use of a bacterial nanocellulose dressing. MATERIALS AND METHODS: A retrospective analysis of two groups has been performed: the control group assessed thirty consecutive children treated with the standard of care, and the intervention group assessed thirty consecutive children treated with the bacterial nanocellulose dressing. Parameters evaluated were: healed wounds, additional treatments, rate of infections, hospital length of stay, pain experience and overall satisfaction. RESULTS: The two groups did not differ significantly in terms of age and TBSA. A significant reduction in hospital length of stay (p < .001) and pain experience (p < .001) could be observed. In terms of healed wounds, additional treatments and infections, the two groups were equally matched (p > .05) with satisfactory results in both groups. Tendencies towards better results could be seen in the intervention group. CONCLUSION: The use of bacterial nanocellulose wound dressings is an important tool in the armamentarium of today's burn surgeons. Satisfying results were achieved, ameliorating burn care for children. Future studies are indicated to further support its value and assess the economic impact.

Ruling out Pulmonary Embolism in Patients with (Suspected) COVID-19-A Prospective Cohort Study.

Background Diagnostic strategies for suspected pulmonary embolism (PE) have not been prospectively evaluated in COVID-19 patients. Methods Prospective, multicenter, outcome study in 707 patients with both (suspected) COVID-19 and suspected PE in 14 hospitals. Patients on chronic anticoagulant therapy were excluded. Informed consent was obtained by opt-out approach. Patients were managed by validated diagnostic strategies for suspected PE. We evaluated the safety (3-month failure rate) and efficiency (number of computed tomography pulmonary angiographies [CTPAs] avoided) of the applied strategies. Results Overall PE prevalence was 28%. YEARS was applied in 36%, Wells rule in 4.2%, and "CTPA only" in 52%; 7.4% was not tested because of hemodynamic or respiratory instability. Within YEARS, PE was considered excluded without CTPA in 29%, of which one patient developed nonfatal PE during follow-up (failure rate 1.4%, 95% CI 0.04-7.8). One-hundred seventeen patients (46%) managed according to YEARS had a negative CTPA, of whom 10 were diagnosed with nonfatal venous thromboembolism (VTE) during follow-up (failure rate 8.8%, 95% CI 4.3-16). In patients managed by CTPA only, 66% had an initial negative CTPA, of whom eight patients were diagnosed with a nonfatal VTE during follow-up (failure rate 3.6%, 95% CI 1.6-7.0). Conclusion Our results underline the applicability of YEARS in (suspected) COVID-19 patients with suspected PE. CTPA could be avoided in 29% of patients managed by YEARS, with a low failure rate. The failure rate after a negative CTPA, used as a sole test or within YEARS, was non-negligible and reflects the high thrombotic risk in these patients, warranting ongoing vigilance.

Protein capture and SERS detection on multiwavelength rainbow-trapping width-graded nano-gratings.

Surface-enhanced Raman scattering (SERS) substrates with multiwavelength rainbow-trapping properties hold the potential for a one-size-fits-all platform for rapid and multiplexed disease detection. We present the first report on the utilization of rainbow-trapping width-graded nano-gratings, a new class of chirped metamaterials, to detect protein biomarkers. Using cytochrome c (Cc), a charged analyte with inherent difficulty in adsorbing onto sputtered silver films, we investigated methods of binding Cc on the silver nano-grating in order to improve the SERS signal strength at both 532 and 638 nm excitation. Cc was not detectable on the Ag nano-gratings without surface functionalization at 1µM concentration. Upon charge reversal functionalization of the Ag nano-gratings, 1µM Cc was detectable albeit not reliably. By further crosslinking 1µM Cc to the functionalized Ag nano-gratings, the analyte-capture detection scheme greatly improved the SERS signal strength and reliability at both excitation wavelengths and allowed for quantification of their coefficients of variation with values down to 27%.

Arterial grafts for proper palmar digital artery reconstruction: An anatomical study.

Digital ischemia due to arterial defects need urgent surgical management. The traditional treatment consists of vascular reconstruction using a reversed autologous venous graft as a bypass. Very few studies have described the use of arterial grafts for digital artery reconstruction. This cadaver study characterized the forearm perforator arteries to assess the potential feasibility of using them as donor grafts for digital artery reconstruction. Eleven forearms and twenty hands were dissected from freshly injected cadavers. All clinically significant perforators (>0.5 mm) derived from radial or ulnar arteries and digital arteries were evaluated. The digital palmar arteries were measured at three points: metacarpophalangeal (MCP) joint, proximal interphalangeal (PIP) joint, and distal interphalangeal (PIP) joint. In the 11 forearms analyzed, 5.5 ± 1.3 perforators from radial or ulnar arteries with a diameter of at least 0.5 mm were found per dissection. The mean diameters were 0.9 ± 0.18 mm proximally and 0.8 ± 0.15 mm distally; the mean length was 35.6 ± 11.35 mm. The mean diameters for the dominant and non-dominant arteries were 1.5 and 1.3 mm at the MCP, 1.3 and 1.0 mm at the PIP, 0.8 and 0.7 mm at the DIP, respectively. The forearms are good donor sites as they have large-diameter arteries of suitable length for arterial grafting. These new arterial grafts may be suitable for vascular reconstruction of digital arteries starting from the PIP joint.

[Medial femoral condyle free flap for reconstruction of carpometacarpal bone defect after giant cell tumour of tendon synovial sheath resection]. / Transfert osseux libre de condyle fémoral médial pour la reconstruction d'une perte de substance osseuse carpo-métacarpienne après résection d'une tumeur à cellule géante des gaines synoviale.

We report the case of a 23-year-old patient treated for a large giant cell tumour of the synovial sheaths of the ulnar edge of the hand and wrist invading the triquetrum, the hamatum, the ulnar part of the capitate as well as the bases of the 3rd, 4th and 5th metacarpals and the floor of the Guyon's canal and the carpal tunnel. A monobloc resection was performed in a healthy margin ; the loss of bone substance was 7×3.5cm. We performed a bone reconstruction using a cortico-cancellous medial femoral condyle free flap of 8×4cm. Postoperative follow-up was uneventful and bone consolidation was achieved at 2,5 months postoperatively. The cortico-cancellous medial femoral condyle free flap is an interesting option for treating small and medium size bone loss in the hand and wrist. Its use in its pure bone form or in its chimeric form with muscle, cartilage or skin opens up a wide range of choices for the reconstructive surgeon.

Volar fracture dislocation of the 2nd metacarpal base associated with acute carpal tunnel syndrome: A case report.

Posttraumatic acute carpal tunnel syndrome is a not a usual complication in traumatic hand injuries but requires more urgent and aggressive management. Compression of the median nerve should be systematically sought when there is a major and painful swelling of the hand, associated with one or several hand and wrist fractures. In rare case, a single metacarpal fracture or dislocation can be the only cause of median nerve compression and requires urgent diagnosis. If missed or neglected irreversible damage could occur to the median nerve. If surgery is perform in a timely manner outcomes are excellent, with complete recovery in most of the cases. We present the case of a 24-year-old man with an acute compression of the median nerve due to an intra-articular fracture of the 2nd metacarpal base. A bony fragment shifting from the base of 2nd metacarpal was found in the carpal tunnel participating, at least in part, in the compression of the median nerve.

[A woman with painful bruising of the fingers]. / Een vrouw met pijnlijke hematomen op de vingers.

We describe a 45-year-old woman with recurrent episodes of painful bruising of the fingers, caused by minimal, everyday traumata. We concluded this to be Achenbach's syndrome (acute idiopathic blue finger), a benign condition that does not require treatment or follow-up. The diagnosis can be made on clinical grounds.

Four ECG left ventricular hypertrophy criteria and the risk of cardiovascular events and mortality in patients with vascular disease.

OBJECTIVE: The relation between different electrocardiographic left ventricular hypertrophy (ECG-LVH) criteria and cardiovascular risk in patients with clinical manifest arterial disease is unclear. Therefore, we determined the association between four ECG-LVH criteria: Sokolow-Lyon, Cornell product, Cornell/strain index and Framingham criterion; and risk of cardiovascular events and mortality in this population. METHODS: Risk of cardiovascular events was estimated in 6913 adult patients with clinical manifest arterial disease originating from the Secondary Manifestations of ARTerial disease (SMART) cohort. Cox proportional regression analysis was used to estimate the risk of the four ECG-LVH criteria and the primary composite outcome: myocardial infarction (MI), stroke or cardiovascular death; and secondary outcomes: MI, stroke and all-cause mortality; adjusted for confounders. RESULTS: The highest prevalence of ECG-LVH was observed for Cornell product (10%) and Cornell/strain index (9%). All four ECG-LVH criteria were associated with an increased risk of the primary composite endpoint: Sokolow-Lyon (hazard ratio 1.37, 95% CI 1.13-1.66), Cornell product (hazard ratio 1.54, 95% CI 1.30-1.82), Cornell/strain index (hazard ratio 1.70, 95% CI 1.44-2.00) and Framingham criterion (hazard ratio 1.78, 95% CI 1.21-2.62). Cornell product, Cornell/strain index and Framingham criterion ECG-LVH were additionally associated with an elevated risk of secondary outcomes. Cardiovascular risk increased whenever two, or three or more ECG-LVH criteria were present concurrently. CONCLUSION: All four ECG-LVH criteria are associated with an increased risk of cardiovascular events. As Cornell/strain index is both highly prevalent and carries a high cardiovascular risk, this is likely the most relevant ECG-LVH criterion for clinical practice.

[A woman with ischemia of the eyes and the left arm]. / Een vrouw met ischemische klachten van ogen en arm.

We saw a 23-year-old women with orthostasis, visual disturbances and pale discoloration of fingers on the left hand. Arterial pulsations were absent on both carotid, radial and ulnar arteries. Inflammatory parameters were raised and on funduscopy there was retinal ischemia. On FDG-PET/CT the diagnosis of Takayasu arteritis was made.

The relation between resting heart rate and cancer incidence, cancer mortality and all-cause mortality in patients with manifest vascular disease.

BACKGROUND: Previous studies suggest that elevated resting heart rate (RHR) is related to an increased risk of cancer mortality. The aim of this study was to evaluate the relation between RHR and cancer incidence and mortality in patients with vascular disease. METHODS: Patients with manifest vascular disease (n=6007) were prospectively followed-up for cancer incidence and mortality. At baseline, RHR was obtained from an electrocardiogram. The relation between RHR and cancer incidence, cancer mortality and total mortality was assessed using competing risks models. RESULTS: During a median follow-up of 6.0 years (interquartile range: 3.1-9.3) 491 patients (8%) were diagnosed with cancer and 907 (15%) patients died, 248 (27%) died from cancer. After adjustment for potential confounders, the hazard ratio (HR) for incident cancer per 10 beats/min increase in RHR was 1.00 (95% confidence interval [CI]: 0.93-1.07). There was a trend toward an increased risk of colorectal cancer in patients with higher RHR (HR 1.15, 95% CI 0.97-1.36). The risk of all-cause mortality was increased in patients in the highest quartile of RHR compared to the lowest quartile (HR 1.86, 95% CI 1.53-2.27), but no effect of RHR on cancer mortality was observed (HR 1.01, 95% CI 0.70-1.46). CONCLUSIONS: In patients with manifest vascular disease, elevated RHR was related to a higher risk of premature all-cause mortality, but this was not due to increased cancer mortality. RHR was not related to risk of overall cancer incidence, although a relation between elevated RHR and incident colorectal cancer risk could not be ruled out.

[The resting heart rate]. / De hartfrequentie in rust.

Assessment of resting heart rate is frequently performed and is easy, reliable and inexpensive. Heart rate is used in many algorithms to assess the prognosis of acutely ill patients. Elevated resting heart rate is independently related to the development of type 2 diabetes, cardiovascular disease and premature all-cause mortality. Adding heart rate to cardiovascular prediction models does not lead to improved prediction of vascular events or mortality. Beta blockers and non-dihydropyridine calcium channel blockers decrease heart rate (and blood pressure) and lower the risk of premature mortality in patients with heart failure or recent myocardial infarction. In two recent randomised trials, ivabradine specifically decreased heart rate (but not blood pressure) and the risk of cardiovascular events in patients with heart failure or coronary artery disease, decreased left ventricular function and resting heart rate of ≥ 70 beats/minute. Selective heart rate reduction is a potential treatment option to decrease cardiovascular risk.

Structural and functional variation in soil fungal communities associated with litter bags containing maize leaf.

Soil fungi are key players in the degradation of recalcitrant organic matter in terrestrial ecosystems. To examine the organisms and genes responsible for complex organic matter degradation in soil, we tracked changes in fungal community composition and expressed genes in soil adjacent to mesh bags containing maize leaves undergoing decomposition. Using high-throughput sequencing approaches, changes in fungal community composition were determined by targeting 18S rRNA gene sequences, whereas community gene expression was examined via a metatranscriptomic approach. The majority of the 93 000 partial 18S rRNA gene sequences generated, were affiliated with the Ascomycota and Basidiomycota. Fungal diversity was at least 224 operational taxonomic units at the 97% similarity cutoff level. During litter degradation, the relative proportion of Basidiomycota increased, with a decrease in Ascomycota : Basidiomycota ratios over time. The most commonly detected decomposition-associated fungi included Agaricomycetes and Tremellales as well as unclassified Mucoromycotina. The majority of protein families found in the metatranscriptomic data were affiliated to fungal groups described to degrade plant-derived cellulose, such as Mucoraceae, Chaetomiaceae, Sordariaceae, Sebacinaceae, Tremellaceae, Psathyrellaceae and Schizophyllaceae. The combination of high-throughput rRNA gene-based and metatranscriptomic approaches provided perspectives into the organisms and genes involved in complex organic matter in soil.