Primary care management for optimized antithrombotic treatment [PICANT]: study protocol for a cluster-randomized controlled trial

ABSTRACT: BACKGROUND: Antithrombotic treatment is a continuous therapy that is often performed in general practice and requires careful safety management. The aim of this study is to investigate whether a best practice model that applies major elements of case management, including patient education, can improve antithrombotic management in primary health care in terms of reducing major thromboembolic and bleeding events. METHODS: This 24-month cluster-randomized trial will be performed in 690 adult patients from 46 practices. The trial intervention will be a complex intervention involving general practitioners, health care assistants and patients with an indication for oral anticoagulation. To assess adherence to medication and symptoms in patients, as well as to detect complications early, health care assistants will be trained in case management and will use the Coagulation-Monitoring-List (Co-MoL) to regularly monitor patients. Patients will receive information (leaflets and a video), treatment monitoring via the Co-MoL and be motivated to perform self-management. Patients in the control group will continue to receive treatment-as-usual from their general practitioners. The primary endpoint is the combined endpoint of all thromboembolic events requiring hospitalization, and all major bleeding complications. Secondary endpoints are mortality, hospitalization, strokes, major bleeding and thromboembolic complications, severe treatment interactions, the number of adverse events, quality of anticoagulation, health-related quality of life and costs. Further secondary objectives will be investigated to explain the mechanism by which the intervention is effective: patients' assessment of chronic illness care, self-reported adherence to medication, general practitioners' and health care assistants' knowledge, patients' knowledge and satisfaction with shared decision making. Practice recruitment is expected to take place between July and December 2012. Recruitment of eligible patients will start in July 2012. Assessment will occur at three time points: baseline (T0), follow-up after 12 (T1) and after 24 months (T2). DISCUSSION: The efficacy and effectiveness of individual elements of the intervention, such as antithrombotic interventions, self-management concepts in orally anticoagulated patients and the methodological tool, case-management, have already been extensively demonstrated. This project foresees the combination of several proven instruments, as a result of which we expect to profit from a reduction in the major complications associated with antithrombotic treatment.     

The evolution of parental care in freshwater leeches

Summary The life-history strategies of a selection of the most common European freshwater leeches (Euhirudinea) are described. On the basis of this information and results from the literature, the probable phylogenetic development of parental care in the Euhirudinea is reconstructed. The jawless worm leeches (Erpobdellidae) secrete a protective cocoon, cement it to the substrate and sometimes ventilate it before they leave the egg capsules. This behaviour represents the most ancient state in leech evolution. Members of the jawed Hirudinidae deposit desiccation-resistant cocoons on land. All known Glossiphoniidae (leeches equipped with a proboscis) have evolved the habit of brooding the eggs and young. These unique parental care patterns within one family of extant freshwater leeches can be arranged schematically in a series of increasing complexity which may reflect the evolution of brooding behaviour. Glossiphoniid leeches of the genus Helobdella, which have a world-wide distribution, display the most highly developed parental care system: they not only protect but also feed the young they carry. This results in the young being much larger when they leave the parent and, presumably, in higher subsequent survival. Isolated cocoons of all aquatic leeches are rapidly destroyed by predators, primarily water snails. In erpobdellids (but not glossiphoniids, which protect the cocoons) a large portion of the cocoons are lost due to predatory attacks. We conclude that the major selective pressure driving the evolution of parental care in leeches may have been predation on eggs and juvenile stages. Dedicated to Professor Dr. G. Osche on the occasion of his 75th birthday     

Desulphation of heparin by mice and guinea pig leukocytes

Leukocytes from mice and guinea pigs were tested for their sulphate-splitting activity on heparin. Mouse macrophages showed the highest degrading activity while mouse neutrophils and lymphocytes were less active. In comparison, guinea pig spleen cells and leukocytes showed only a weak degrading activity. Mouse macrophages maintained in tissue culture were also found to degrade heparin, the amount of sulphate released increasing with time up to 96 h. Spleen extracts were found to neutralize the anticoagulatory activity of heparin.     

Tissue stresses in growing plant organs

Rapidly growing plant organs (e.g. coleopties, hypocotyls, or internodes) are composed of tissues that differ with respect to the thickness, structure, and extensibility of their cell walls. The thick, relatively inextensible outer wall of the epidermal cells contains both transverse and longitudinally oriented cellulose-microfibrils. The orientation of microfibrils of the thin, extensible walls of the parenchyma cells seems to be predominantly transverse. In many growing organs (i.e. leafstalks), the outer epidermal wall is supported by a thickened inner epidermal wall and by thick-walled subepidermal collenchyma tissue. Owing to the turgor pressure of the cells the peripheral walls are under tension, while the extensible inner tissue is under compression. As a corollary, the longitudinal tensile stress of the rigid peripheral wall is high whereas that of the internal walls is lowered. The physical stress between the tissues has been described by Sachs in 1865 as 'tissue tension'. The term 'tissue stress'. however, seems to be more appropriate since it comprises both tension and compression. Hitherto no method has been developed to measure tissue stresses directly as force per unit cross-sectional area. One can demonstrate the existence of tissue stresses by separation of the tissues (splitting, peeling) and determining the resulting strain of the isolated organ fragments. Based on such experiments it has been shown that rapid growth is always accompanied by the existence of longitudinal tissue stresses.     

Discovery of triazole aminopyrazines as a highly potent and selective series of PI3Kδ inhibitors

A novel class of potent PI3Kδ inhibitors with >1000-fold selectivity against other class I PI3K isoforms is described. Optimization of the substituents on a triazole aminopyrazine scaffold, emerging from an in-house PI3Kα program, turned moderately selective PI3Kδ compounds into highly potent and selective PI3Kδ inhibitors. These efforts resulted in a series of aminopyrazines with PI3Kδ IC₅₀ ? 1 nM in the enzyme assay, some of the most selective PI3Kδ inhibitors published to date, with a cell potency in a JeKo-cell assay of 20–120 nM.     

The specificity of delayed hypersensitivity to ABA-tyr-pulsed and ABA-coupled macrophages

Guinea pigs immunized with ABA-tyr in CFA respond well by skin test to ABA-tyr-pulsed macrophages but poorly to ABA-coupled macrophages and not at all to ABA-coupled red cells, thymocytes, or L₂C cells. On the other hand, guinea pigs immunized with ABA-coupled macrophages do not respond to ABA-insulin or ABA-tyr-pulsed macrophages but do respond to ABA-coupled macrophages. Similarly guinea pigs immunized with Ars-NCS-coupled macrophages respond only to the homologous antigen. The specificity of these reactions is determined by how ABA is associated with the Ia-positive accessory cell. The presence of Ia molecule is not a sufficient condition since neither Ia-positive L₂C cells nor spleen cells depleted of adherent macrophages are effective as immunogens or elicitors of response when coupled with ABA. These results suggest that the topography of the ABA and Ia complex formed on the accessory cell is the prime determinant of specificity for T-cells responses.     

Effects of penicillin and erythromycin on adherence of invasive and noninvasive isolates of Streptococcus pyogenes to laminin

This study investigated the possible relationship between the invasiveness of group A Streptococcus (GAS) strains and their abilities to adhere to laminin and assessed the effects of subinhibitory concentrations of penicillin and erythromycin on the ability of GAS to adhere to laminin. The adherence of noninvasive and highly invasive isolates of GAS to laminin was significantly higher than the adherence displayed by isolates of low invasiveness. Antibiotic treatment caused significant reductions in adherence to laminin in all three groups of strains. Penicillin was more successful in reducing the adherence abilities of the tested GAS strains than erythromycin.