Baseline Characteristics and 3-Year Outcome of Nonvalvular Atrial Fibrillation Patients Treated with the Four Direct Oral Anticoagulants (DOACs)

Direct oral anticoagulants (DOACs) represent the cornerstone therapy for cardioembolic events prevention in patients with nonvalvular atrial fibrillation (NVAF). In practice, the choice of one DOAC over another is guided by the decision-making process of the physician, which considers specific patient and drug characteristics. This study aimed to evaluate the clinical features and long-term outcomes of a real-world population treated with DOACs, where the use of the 4 different DOACs is quite equal. We conducted a retrospective observational, single-center, multidisciplinary study enrolling consecutive NVAF patients treated with one of the 4 DOACs. From an initial number of 753 patients, we excluded 72 patients because of loss to follow-up, at the end we enrolled 681:174 (23%) treated with dabigatran, 175 (23%) with apixaban, 190 (25%) with rivaroxaban, and 214 (29%) with edoxaban. Patients treated with apixaban were significantly older, more women represented (p <0.001), and with a higher cardioembolic and bleeding risk (p <0.001). Dabigatran was preferred in patients with liver failure (p = 0.008), whereas Apixaban and Edoxaban were chosen in chronic kidney disease (p = 0.002). At 3-year follow-up, 20 patients (2.7%) experienced a systemic thromboembolic event without significant differences in the 4 DOACs. In the same period, an International Society of Thrombosis and Hemostasis classification major bleeding event occurred in 26 patients (3.6%), more statistically correlated to edoxaban (6.1%) (p = 0.038). Thromboembolic events or major bleeding were higher in the edoxaban group (10%) compared with the others (p = 0.014). In our single-center real-world experience, the choice of the DOAC for a patient with NVAF was tailored to specific clinical features and drug pharmacokinetics of the patient. As a result, a small number of adverse events were observed.

Direct oral anticoagulants versus percutaneous left atrial appendage occlusion in atrial fibrillation: 5-year outcomes

BACKGROUND

LAAO is an emerging option for thromboembolic event prevention in patients with NVAF. We previously reported data on comparison between LAAO and DOAC at two-year follow-up in NVAF patients at HBR (HAS-BLED ≥3).

AIMS

Limited data are available on long term follow-up. We aimed to evaluate the efficacy and safety of DOACs versus LAAO indication after 5 years.

METHODS

We enrolled 193 HBR treated with LAAO and 189 HBR patients with DOACs. At baseline, LAAO group had higher HAS-BLED (4.2 vs 3.3, p < 0.001) and lower CHADS-VASc (4.3 vs. 4.7, p = 0.005). After 1:1 PSM, 192 patients were included (LAAO n = 96; DOACs n = 96).

RESULTS

At 5-year follow-up the rate of the combined safety and effectiveness endpoint (ISTH major bleeding and thromboembolic events) was significantly higher in LAAO group (p = 0.042), driven by a higher number of thromboembolic events (p = 0.047). The rate of ISTH-major bleeding events was similar (p = 0.221). After PSM no significant difference in the primary effectiveness (LAAO 13.3% vs DOACs 9.5%, p = 0.357) and safety endpoint (LAAO 7.5% vs DOACs 7.5%; p = 0.918) were evident. Overall bleeding rate was significantly higher in DOACs group (25.0% vs 13.7%, p = 0.048), while a non-significant higher number of TIA was reported in LAAO group (5.4% vs 1.1%, p = 0.098). All-cause and cardiovascular mortality were higher in LAAO group at both unmatched and matched analysis.

CONCLUSION

We confirmed safety and effectiveness of both DOAC and LAAO in NVAF patients at HBR, with no significant differences in thromboembolic events or major bleeding were at 5-year follow-up. The observed increased mortality after LAAO warrants further investigations in RCTs.

Kinetic Generation of Whistler Waves in the Turbulent Magnetosheath

The Earth's magnetosheath (MSH) is governed by numerous physical processes which shape the particle velocity distributions and contribute to the heating of the plasma. Among them are whistler waves which can interact with electrons. We investigate whistler waves detected in the quasi-parallel MSH by NASA's Magnetospheric Multiscale mission. We find that the whistler waves occur even in regions that are predicted stable to wave growth by electron temperature anisotropy. Whistlers are observed in ion-scale magnetic minima and are associated with electrons having butterfly-shaped pitch-angle distributions. We investigate in detail one example and, with the support of modeling by the linear numerical dispersion solver Waves in Homogeneous, Anisotropic, Multicomponent Plasmas, we demonstrate that the butterfly distribution is unstable to the observed whistler waves. We conclude that the observed waves are generated locally. The result emphasizes the importance of considering complete 3D particle distribution functions, and not only the temperature anisotropy, when studying plasma wave instabilities.

Electron Signatures of Reconnection in a Global eVlasiator Simulation

Geospace plasma simulations have progressed toward more realistic descriptions of the solar wind-magnetosphere interaction from magnetohydrodynamic to hybrid ion-kinetic, such as the state-of-the-art Vlasiator model. Despite computational advances, electron scales have been out of reach in a global setting. eVlasiator, a novel Vlasiator submodule, shows for the first time how electromagnetic fields driven by global hybrid-ion kinetics influence electrons, resulting in kinetic signatures. We analyze simulated electron distributions associated with reconnection sites and compare them with Magnetospheric Multiscale (MMS) spacecraft observations. Comparison with MMS shows that key electron features, such as reconnection inflows, heated outflows, flat-top distributions, and bidirectional streaming, are in remarkable agreement. Thus, we show that many reconnection-related features can be reproduced despite strongly truncated electron physics and an ion-scale spatial resolution. Ion-scale dynamics and ion-driven magnetic fields are shown to be significantly responsible for the environment that produces electron dynamics observed by spacecraft in near-Earth plasmas.

Structure of a Perturbed Magnetic Reconnection Electron Diffusion Region in the Earth's Magnetotail

We report in situ observations of an electron diffusion region (EDR) and adjacent separatrix region in the Earth's magnetotail. We observe significant magnetic field oscillations near the lower hybrid frequency which propagate perpendicularly to the reconnection plane. We also find that the strong electron-scale gradients close to the EDR exhibit significant oscillations at a similar frequency. Such oscillations are not expected for a crossing of a steady 2D EDR, and can be explained by a complex motion of the reconnection plane induced by current sheet kinking propagating in the out-of-reconnection-plane direction. Thus, all three spatial dimensions have to be taken into account to explain the observed perturbed EDR crossing. These results shed light on the interplay between magnetic reconnection and current sheet drift instabilities in electron-scale current sheets and highlight the need for adopting a 3D description of the EDR, going beyond the two-dimensional and steady-state conception of reconnection.

Extraoral traction and class III treatment

True Class III malocclusions are difficult to treat because they reflect basal bone discrepancies and there are many limitations to conventional treatment mechanisms. For example, Class III elastics may adversely affect the inclination of the occlusal plane and bite depth. On the other hand, extraoral appliances can be used advantageously. One important application is to move a retrognathically positioned maxilla forward orthopedically by means of the facial mask of Delaire. In addition, extraoral appliances placed against the lower incisor segment can also be used to retract the mandibular incisors and control bite depth during the retraction procedure.

In vivo effect of oral environment on etched enamel: a scanning electron microscopic study

After etching the enamel in teeth of young children with 50% buffered phosphoric acid and allowing the teeth to remain in the oral environment for a few months, an irregular enamel surface similar to the morphology of recently etched enamel was noted by means of scanning electron microscopy. In addition, the enamel surfaces were covered with plaque. Accordingly, observations by other authors, that etched human enamel takes on a normal appearance after short exposure in the oral cavity, could not be confirmed. However, when the surface of the etched enamel was pumiced, the enamel reacquired both the shine and appearance of non-etched enamel.