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Biomedical subjects

B J Hunt

Publications and source records attributed to B J Hunt.

At least 19 recordsLinked to original sources
PubMed2006

Gout Assessment Questionnaire: Initial results of reliability, validity and responsiveness.

We evaluated the psychometric properties of a new gout-specific patient reported outcomes questionnaire. The Gout Assessment Questionnaire (GAQ) and the SF-36 were administered to 126 subjects in a multicenter Phase II program of febuxostat, an investigational treatment for hyperuricemia (serum uric acid >8.0 mg/dl) in patients with chronic gout. The questionnaire was administered at baseline and 1, 6 and 12 months later. The majority of subjects, mean age 54 years, were male, Caucasian and had experienced a gout flare within the last year. Seven domains were identified, all met criteria for reliability and validity. Cronbach's alpha ranged from 0.78 to 0.97. Pearson correlations between GAQ and SF-36 scales were generally low to moderate, with the highest correlation between Gout Pain and Severity and SF-36 Bodily Pain, r = 0.45. Guyatt's statistic (measure of responsiveness) ranged from 0.24 to 1.00 at 12 months. Minimal clinically important differences ranged from 2 (Gout Concern) to 10 points (Productivity). The GAQ has acceptable psychometric properties. Further research is required to confirm results, which may provide more information to improve the GAQ for use in clinical trials.

Adult↗
PubMed2006

Treatment of menorrhagia associated with oral anticoagulation: efficacy and safety of the levonorgestrel releasing intrauterine device (Mirena coil).

Menorrhagia is common in women receiving oral anticoagulation. In healthy women, reductions of up to 90% of menstrual loss have been described with the levonorgestrel releasing intrauterine device (LNG-IUS). However there is no data about the use of LNG-IUS in women receiving oral anticoagulation and so we assessed the efficacy and safety of LNG-IUS in this setting. Patients with menorrhagia who used LNG-IUS and warfarin were contacted by post and asked to complete a questionnaire assessing the extent and duration of menstrual bleeding, quality of life and treatment satisfaction. The questionnaire was sent to 23 patients and returned by 17. The amount of bleeding was reduced with the LNG-IUS in 10 (58.8%) women; amenorrhea occurred in four (23.5%), no change in blood loss in one (5.9%) and greater blood loss in two (11.8%) patients. The number of sanitary pads used was less in 12 (70.6%) patients; same in one (5.9%) patient, more in two (11.8%) patients and two (11.8%) did not remember. Five patients (29.4%) had shorter duration of bleeding, four (23.5%) had amenorrhoea, four (23.5%) had longer periods and four (23.5%) had same duration by subjective assessment. Eight (47.1%) patients felt very satisfied, four (23.5%) felt satisfied, two (11.8%) felt dissatisfied with the treatment, one felt very dissatisfied (5.9%) and two (11.8%) did not respond to the question. This small study suggests LNG-IUS is effective in reducing the duration and amount of menstrual bleeding in women with menorrhagia associated with oral anticoagulation. We feel the use of LNG-IUS is a major advance in reducing menorrhagia in women on oral anticoagulation as the previous alternative--hysterectomy--is associated with an increased risk of thrombosis and bleeding.

Administration, Oral↗
PubMed2006

Anticoagulation via anti-Factor Xa inhibition.

Hospital-acquired deep vein thrombosis (DVT) affects 10-25% of medical patients and up to 60% of surgical patients. While thromboprophylaxis is without a doubt under utilized in the hospital setting, there is also a need for more efficacious agents. Fondaparinux, the first of a new class of agents Factor Xa inhibitiors, has recently come into clinical use. It is a synthetic pentasaccharide and indirect Factor Xa inhibitor with a predictable antithrombotic action. Being a synthetic product, there are no concerns about supply, nor viral or prion protein contamination. Initial large international trials in orthopaedic patients demonstrated its superior efficacy to standard thromboprophylaxis. Further trials confirmed its superior efficacy in venous thromboembolism (VTE) prevention, both in medical and surgical patient groups, as well as treatment of pulmonary embolism and DVT. Its use has also recently been evaluated in acute coronary syndromes and angioplasty. Fondaparinux currently has licenses in the UK for thromboprophylaxis and treatment of VTE and a license for the management of acute coronary syndrome is likely to be forthcoming. It has a favourable side effect profile and if the price is acceptable, is likely to take over from low molecular weight heparins in these indications as the drug of choice on the grounds of efficacy and safety.

Anticoagulants↗
PubMed2005

The placental bed in pregnancies complicated by primary antiphospholipid syndrome.

UNLABELLED: Pregnancy in women with primary antiphospholipid syndrome (APS) is frequently associated with placental insufficiency leading to intrauterine growth restriction (IUGR)+/-fetal death, pre-eclampsia, placental abruption, premature delivery or thrombosis. The aim of this study was to investigate the placental bed in APS pregnancies for evidence of impaired trophoblast invasion, endothelial cell activation (ECA) and macrophage infiltration. METHODS: Biopsies from the presumed site of the placental bed were obtained from 12 women with treated primary APS and 16 controls. Immunohistochemical methods were employed to investigate expression of cytokeratin (trophoblasts), alpha-actin (smooth muscle), CD68 (macrophages) and VCAM-1 (as marker of ECA). Fibrinoid and elastin distribution and expression were determined by periodic acid/Schiff and orcein stain, respectively. RESULTS: Three APS pregnancies developed IUGR, one with concurrent pre-eclampsia. Eight of 12 APS biopsies were confirmed to be from the placental bed; one patient failed to meet APS criteria and was excluded from analysis; six included spiral arteries in the biopsy; 11 of 16 controls' biopsies were from the placental bed. APS biopsies had a higher concentration of inflammatory cells (p=0.0001), particularly macrophages (p=0.014). Three APS biopsies showed necrosis with hyperplastic vessels; one demonstrated arterial thromboses, but none had profound vasculopathy/atherosis or ECA. CONCLUSION: Inflammatory mechanisms in the placental bed may contribute to APS pregnancy complications.

Antiphospholipid Syndrome↗
PubMed2004

Venous thromboembolism after acute ischemic stroke: a prospective study using magnetic resonance direct thrombus imaging.

BACKGROUND AND PURPOSE: We prospectively evaluated the prevalence and clinical risk factors for venous thromboembolism (VTE) after acute ischemic stroke using magnetic resonance direct thrombus imaging, a highly accurate noninvasive technique that directly visualizes thrombus.Method-102 unselected patients with AIS receiving standard prophylaxis with aspirin and graded compression stockings (GCS) were sequentially recruited, underwent regular clinical assessments, and were screened for VTE. RESULTS: The prevalence of all VTE, proximal deep vein thrombosis (PDVT), and pulmonary embolism (PE) after 21 days were 40%, 18%, and 12%, increasing to 63%, 30%, and 20% in patients with Barthel indices (BI) of < or =9 2 days after stroke (BI-2< or =9). Clinical deep vein thrombosis and PE occurred in 3% and 5% overall; half these events were overlooked by the attending team. The true incidence of clinical events is probably higher because the natural history of subclinical PDVT was modified by screening and anticoagulation. BI-2< or =9 or nonambulatory status 2 days after stroke were the clinical factors most strongly associated with subsequent VTE on univariate analysis. Odds ratios for any VTE and PDVT for BI-2< or =9 versus >9 were 8.3 (95% CI, 2.7 to 25.2) and 8.1 (95% CI, 1.7 to 38.3) on multivariable analysis. CONCLUSIONS: BI < or =9 or nonambulatory status around the time of admission identifies a subgroup of acute ischemic stroke patients at very high risk for VTE in whom the current strategy of thromboprophylaxis may be inadequate. Future thromboprophylactic studies should focus on the patients at high risk defined in this study.

Aged↗
PubMed2004

Comparison of structured use of routine laboratory tests or near-patient assessment with clinical judgement in the management of bleeding after cardiac surgery.

BACKGROUND: Using algorithms based on point of care coagulation tests can decrease blood loss and blood component transfusion after cardiac surgery. We wished to test the hypothesis that a management algorithm based on near-patient tests would reduce blood loss and blood component use after routine coronary artery surgery with cardiopulmonary bypass when compared with an algorithm based on routine laboratory assays or with clinical judgement. METHODS: Patients (n=102) undergoing elective coronary artery surgery with cardiac bypass were randomized into two groups. In the point of care group, the management algorithm was based on information provided by three devices, the Hepcon, thromboelastography and the PFA-100 platelet function analyser. Management in the laboratory test group depended on rapidly available laboratory clotting tests and transfusion of haemostatic blood components only if specific criteria were met. Blood loss and transfusion was compared between these two groups and with a retrospective case-control group (n=108), in which management of bleeding had been according to the clinician's discretion. RESULTS: All three groups had similar median blood losses. The transfusion of packed red blood cells (PRBCs) and blood components was greater in the clinician discretion group (P<0.05) but there was no difference in the transfusion of PRBCs and blood components between the two algorithm-guided groups. CONCLUSION: Following algorithms based on point of care tests or on structured clinical practice with standard laboratory tests does not decrease blood loss, but reduces the transfusion of PRBCs and blood components after routine cardiac surgery, when compared with clinician discretion. Cardiac surgery services should use transfusion guidelines based on laboratory-guided algorithms, and the possible benefits of point of care testing should be tested against this standard.

Aged↗
PubMed2004

Dehydration and venous thromboembolism after acute stroke.

BACKGROUND: Although it is widely assumed that dehydration predisposes to venous thromboembolism (VTE), there are no clinical studies to support this. AIM: To evaluate the relationship between biochemical indices of dehydration and VTE after acute ischaemic stroke (AIS). DESIGN: Prospective observational study. METHODS: Unselected AIS patients (n = 102) receiving standard thromboprophylaxis with aspirin and graded compression stockings, underwent serial measurements of serum urea, creatinine and osmolality, and were screened for VTE using magnetic resonance direct thrombus imaging. RESULTS: Serum osmolality of >297 mOsm/kg, urea >7.5 mmol/l and urea:creatinine ratio (mmol:mmol) >80 a few days post-AIS were associated with odds ratios for VTE of, respectively, 4.7, 2.8 and 3.4 (p = 0.02, 0.05, 0.02) on multivariable analysis. DISCUSSION: Dehydration after AIS is strongly independently associated with VTE, reinforcing the importance of maintaining adequate hydration in these patients.

Aged↗
PubMed2004

Screening for proximal deep vein thrombosis after acute ischemic stroke: a prospective study using clinical factors and plasma D-dimers.

Deep vein thrombosis (DVT) remains common in patients with acute ischemic stroke (AIS) receiving aspirin and graded compression stockings (considered standard thromboprophylaxis in the UK), most events occurring in patients with Barthel indices (BI) of <9 ('severe stroke') around the time of admission. In the absence of data indicating improved clinical outcomes with use of low-dose anticoagulant thromboprophylaxis, we evaluated the hypothesis that plasma D-dimers (D-d) might be a valuable initial screening test for proximal DVT (PDVT), facilitating selective use of imaging. One hundred and two unselected AIS-patients receiving aspirin/graded compression stockings thromboprophylaxis were screened for DVT using magnetic resonance direct thrombus imaging, a highly accurate non-invasive technique which directly visualizes thrombus. D-d (VIDAS and IL test D-d assays) were measured on recruitment and at weekly intervals. Median D-d were significantly higher throughout the study in patients with severe stroke who developed PDVT vs. those with severe stroke not developing PDVT, differences being most marked around day 9. Depending on the discriminatory threshold used, a single D-d measurement at this time in patients with severe-AIS allowed identification of a subgroup with ~50% prevalence of PDVT. Sensitivity of these strategies for PDVT was 67-83%, at a cost of imaging 22-30% of the entire cohort of patients. A single measurement of BI around the time of admission and D-d level at day 9 in AIS-patients receiving aspirin/graded compression stockings thromboprophylaxis allows identification of a subgroup containing a substantial proportion of all PDVTs who could be selectively imaged.

Age Factors↗
PubMed2003

Anticoagulation or inferior vena cava filter placement for patients with primary intracerebral hemorrhage developing venous thromboembolism?

BACKGROUND: Most patients with primary intracerebral hemorrhage developing clinically apparent proximal deep vein thrombosis (DVT) and/or pulmonary embolism (PE) require treatment with either anticoagulants or inferior vena cava filter insertion. Although the latter probably reduces the immediate risk of incident or recurrent PE and surmounts the undefined risk of recurrent intracranial bleeding with anticoagulation, the issue of preventing further thrombus propagation is not addressed, and there are associated short- and long-term risks, including a greater incidence of recurrent DVT. SUMMARY OF REVIEW: There are no data from randomized trials to clarify optimum treatment in these patients; indeed, the feasibility of such studies is questionable. Hence, treatment decisions continue to be made on an individualized basis and should include assimilation of information on key factors such as time elapsed post-stroke and lobar versus deep hemispheric location of the index event, natural history studies demonstrating a two-fold risk of recurrent intracerebral hemorrhage in the former subgroup. CONCLUSIONS: In patients selected for anticoagulation, data from nonstroke patients suggest that a 5- to 10-day course of full-dose low-molecular-weight heparin followed by 3 months of lower-dose low-molecular-weight heparin is at least as effective as warfarin and may be associated with fewer hemorrhagic complications.

Anticoagulants↗
PubMed2003

The utility of pretest probability assessment in patients with clinically suspected venous thromboembolism.

The assessment of pretest probability (PTP), with stratification into low-, intermediate- and high-risk groups is an essential initial step in the current diagnostic management of patients with suspected venous thromboembolism (VTE). In combination with additional information, it reduces the need for initial and supplementary imaging, and allows considerable refinement of the posterior probability of VTE following non-invasive imaging. PTP may be assessed either empirically or by using various decision rules or scoring systems, the best known of which are the simplified Wells scores for suspected deep vein thrombosis (DVT) and pulmonary embolism (PE), and the Geneva score for suspected PE. Each of these approaches shows similar directional and categorical accuracy, and has been validated as facilitating clinically useful classification of the PTP, although an overview of data suggests that fewer patients tend to be classified as low PTP when assessed empirically. This group is the most important to identify, as several outcome studies have shown that imaging and treatment are safely obviated in outpatients with suspected DVT or PE who have a low PTP in combination with negative d-dimer testing, a subgroup accounting for up to half of all patients studied. Hence, while probably not of critical importance, the explicit approach offered by scoring systems might be preferred over empirical assessment, particularly when used by more junior staff.

Bayes Theorem↗
PubMed2003

Is mild normobaric hypoxia a risk factor for venous thromboembolism?

BACKGROUND: Modern air travel entails a cabin altitude between 1520 and 2440 m (5000-8000 ft) and thus exposure to mild hypoxia. There is debate as to whether hypoxia is causally related to venous thromboembolism (VTE) occurring during or after travel. One study suggested that a short period of hypobaric hypoxia causes activation of coagulation. OBJECTIVES: To test the hypothesis that hypoxia alone (normobaric hypoxia) causes activation of coagulation, possibly through endothelial cell activation. METHODS: Six healthy male volunteers were exposed for 3 h, while seated, on two separate occasions to (i) dry air (control) and (ii) hypoxic gas mixture (12.8% O2 in N2, equivalent to breathing air at 3660 m [12000 ft]). RESULTS: There were no differences in hemostatic or endothelial markers between control and hypoxic groups, but platelet and leukocyte counts increased and were significantly higher in the hypoxic group. There were increases in fibrinogen and von Willebrand factor, as well as rheological changes, but these were not significantly different between control and hypoxic groups. CONCLUSIONS: This small study does not support the previous suggestion that hypoxia causes activation of coagulation, and suggests that immobility-induced rheological changes may be more significant in the etiology of VTE occurring during or after travel.

Adult↗