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Patients with well-controlled anticoagulation intensity on VKA therapy (TTR >70%) have a low risk of thromboembolism and bleeding. 46 48 An average TTR of >70% for individual patients is recommended in a position statement from the ESC Working Group on Thrombosis Anticoagulation Task Force. 49 Where TTR using the linear interpolation method of Rosendaal is not always available, other measures of quality of anticoagulation control, such as proportion of time in therapeutic INR range, may be used. In the randomized trials, the effect size of NOAC compared with warfarin for stroke and bleeding was maintained irrespective of centre-based TTR quartile, and the clear relative risk reduction of NOACs for intracranial haemorrhage compared with VKA persisted, although the difference in absolute rates was small. A high TTR can also easily be altered by acute events, such as infection (requiring antibiotics), hospitalization, decompensated heart failure, and deterioration of renal or hepatic function.

A meta-analysis of the NOAC trials found a greater reduction in major bleeding with the NOACs when centre-based TTR was <66% than when it was ≥66% (relative risk 0.69, 95% CI 0.59–0.81 vs. 0.93, 0.76–1.13; interaction P = 0.022). 34 In a longitudinal follow-up of AF patients on a VKA with initial baseline TTR of 100%, the SAMe-TT 2 R 2 score [Sex, Age <60 years, Medical history (at least two of the following: hypertension, diabetes, CAD/myocardial infarction, PAD, heart failure, previous stroke, pulmonary disease, hepatic, or renal disease), Treatment (interacting drugs, e.g. amiodarone for rhythm control), current Tobacco use (two points), Race (non-Caucasian, two points)] identified anticoagulated AF patients who were likely to remain event free on VKA therapy (SAMe-TT 2 R 2 score 0–2, with TTR >70%). 50 52 This difference is attributable to adverse events such as thromboembolism and bleeding when the TTR is low or labile. 51 The SAMe-TT 2 R 2 score may help to guide the selection of an NOAC or VKA treatment without a trial of warfarin that could expose patients to an increased risk of thromboembolism or intracranial haemorrhage.

Ultimately, patient values and preferences should be considered, 53 particularly for patients with TTR of >70% for whom routine anticoagulation INR monitoring is challenging, self-monitoring is unsuitable, or adherence to the dietary, drug, or alcohol restrictions required for safe VKA use is difficult. Substitution of an NOAC may be appropriate for such patients but, as always, associated comorbidities should be considered in choosing one NOAC over another.

Patients with a single additional stroke risk factor have an increased risk of AF-related stroke. The stroke risk is lower than in patients with multiple vascular risk factors. 54 , 55 Reported ischaemic stroke and thromboembolism rates vary widely, but in some studies the annual risk was 0.5–3.0%. 56 , 57 Different individual single stroke risk factors occurring in isolation to yield a CHA 2 DS 2 -VASc [Congestive heart failure (or left ventricular systolic dysfunction), Hypertension, Age ≥75 years (2 points), Diabetes mellitus, prior Stroke or TIA or thromboembolism (2 points), Vascular disease (e.g. PAD, myocardial infarction, and aortic plaque), Age 65–74 years, Sex category (i.e. female sex)] score of 1 in males and 2 in females are not associated with equal stroke risk: the highest risk is associated with hypertension and age 65–74 years followed by diabetes. 44 , 58

The CDC currently recommends that contact precautions be continued for the duration of the illness [ 222 ]. The UK guidelines recommend continuing contact precautions for at least 48 hours after diarrhea resolves [ 223 ]. Clostridium difficile was suppressed to undetectable levels in stool samples from most patients by the time diarrhea resolved (mean, 4.2 days) in a prospective study of 52 patients [ 95 ]. However, at the time of resolution of diarrhea, skin and environmental contamination was high at 60% and 37%, respectively. In addition, stool detection of C. difficile was 56% at 1–4 weeks posttreatment. Continue contact precautions for at least 48 hours after diarrhea has ceased. There are no studies that demonstrate further extending contact precautions results in reductions in CDI incidence. Prolonging contact precautions until discharge remains a special control measure if CDI rates remain high despite implementation of standard infection control measures against CDI [ 222 ].

Transmission of C. difficile strains commonly occurs via the hands of healthcare personnel. After caring for patients with CDI, the proportion of healthcare personnel with hand contamination when gloves are not worn ranges from 14% to 59% [ 74 , 87 , 216 , 224 ]. Hand hygiene is considered to be one of the cornerstones of prevention of transmission of C. difficile , as it is for most other healthcare-associated infections. Many studies have documented low rates of handwashing by healthcare personnel, particularly when sinks are not readily accessible [ 225–228 ]. The introduction of alcohol-based hand antiseptics has been considered transformative for increasing hand hygiene compliance. Hand hygiene guidelines recommend the use of alcohol-based products, unless the hands have come into contact with body fluids or are visibly soiled, in which case handwashing with soap and water is recommended. These alcohol-based antiseptics are popular because of their ease of use at the point of care and their effectiveness in rapid killing of most vegetative bacteria and many viruses that contaminate hands. However, C. difficile spores are highly resistant to killing by alcohol. Indeed, the addition of ethanol to stool samples in the laboratory facilitates the culture of C. difficile from these specimens [ 229 ]. Therefore, healthcare personnel who do not wear gloves or whose hands become contaminated when doffing gloves may be merely redistributing spores over the hand surface when using alcohol-based products. This could potentially increase the risk of transferring C. difficile to patients under their care, but numerous studies have not shown an association between the use of alcohol-based hand hygiene products and an increased incidence of CDI. The impact of using an alcohol-based hand hygiene product on rates of infection with MRSA, VRE, and CDI 3 years before and after its implementation was studied [ 230 ]. After implementation, the rates of MRSA and VRE infections decreased by 21% and 41%, respectively, whereas the incidence of CDI was unchanged. This finding is consistent and has been reproduced in other studies [ 231–234 ]. A large prospective, ecological interrupted time series study was conducted from July 2004 to June 2008 in England and Wales to evaluate the impact of the “cleanyourhands” campaign on the rates of hospital procurement of alcohol hand rub and soap and to investigate the association between the rates of MRSA bacteremia and CDI [ 235 ]. Procurement of these products was used as a proxy for hand hygiene compliance. This study demonstrated that increased soap procurement was significantly associated with a decline in CDI rates whereas increased alcohol hand rub procurement was significantly associated with a reduction in MRSA bacteremia rates.

826 Valencia’s Exploring Words Summer Camp is a five-week program for third- through fifth-graders, many of whom have been working with us throughout the school year in our after-school programs. Thesestudents explore creative writing and science through reading, writing, and hands-on activities that strengthen the STEM curriculum (Science, Technology, Engineering, Math). Throughout the camp, students conduct science experiments, craft original stories, and write with the one-on-one support of tutors. At the end of the five weeks, students will have developed a portfolio of their work, and we publish a chapbook of their selected writing.

In 2013, we brought our model of after-school writing table to Buena Vista Horace Mann, a bilingual K–8 school in San Francisco’s Mission District. A Taco Ice Cream World is our recent publication to come out of the program aimed at 3rd-, 4th-, and 5th-grade English Learners and students reading and writing below grade level. Each semester this program culminates with a polished and brightly-colored collection of short fiction, poetry, and personal narrative. The students write on different weekly prompts, tackling topics such as perseverance, responsibility, strength, and bravery, and work with tutors to learn to stretch their imaginations, invent characters, and offer explanations for the world around them.

The Straight-up News is written by the students of Everett Middle School with the help of 826 Valencia’s volunteers. The school is currently in its eleventh year of hosting learning about investigative journalism, feature writing, comics, and engaging interviews. Previous issues have featured interviews with ghost hunter Jim Fassbinder, Pixar animator Gabriel Slumberger, the Giants’ Jason Ellison and Jose Vizcaino, as well as Q A’s with comedians Eddie Griffin and George Lopez. Written in Everett Middle School’s Writers’ Room as one of the cornerstone projects of our In-Schools Programming .

The Courage to Climb , Fall 2017A brave group of seventh-graders at Everett Middle School were asked to select vivid personal memories and transform them into realistic fiction stories. Alongside tutors from 826 Valencia, they embarked on a journey to retell their stories with gripping description and imagination. This is a collection of excerpts from their stories.

The Courage to Climb

The foundational project of the Writers’ Room at Mission High, which opened in the fall of 2014, Mission Magazine is written by a different group of students each year, and is dedicated to social justice issues and subjects the student authors are passionate about. Read more about our satellite Writers’ Rooms .

The Valencia Bay-farer

Our in-house newspaper,, is the product of a six-week evening workshop held once per season for journalists between the ages of eight and thirteen. The students are joined by volunteers who help them research, interview, write, fact-check, edit, and ultimately polish their articles. Topics covered range from serious to silly, with students reporting on everything from the political issues of the day, to reviews of local playgrounds,to speculation about skateboards of the future (hoverboards, of course!). The paper is produced and printed in-house, and the publication is celebrated with a reading and release party where journalists read their pieces aloud to family and friends.

Writing and Publishing Apprentices brings together students aged 13–18 and writing professionals for a semester-long workshop designed to develop a creative writing project of the student’s choice. The workshop gives young writers an opportunity to learn a variety of skills from professional writers and editors and to get college writing-workshop style feedback from peers and from tutors. The group meets weekly to write, polish, and eventually publish their work. wide range of sale online cheap sale prices Asics Mens GelTech Walker Neo 4 Walking Shoe White 7 UK Black/Black/Silver prices sale online kBamIvPr5

The term ‘real-life data’ covers a wide range of research methodologies, which include, but are not limited to (classified in order of complexity) 9 :

○ Case series

○ Cross-sectional studies or surveys

○ Case–control studies

○ Retrospective cohort studies

○ Prospective cohort studies (longitudinal studies)

Data sources 10

○ Patient registries

○ Existing electronic health records

○ Routinely collected administrative data

○ Primary patient-level data collection (prospective or retrospective)

○ Population health surveys

Real-life studies have higher external validity than RCTs owing to their potentially large size, and the ability to include a patient sample that is representative of the average patient population. 3 They may also provide evidence of effectiveness of new therapies in the general population, and insights into the care and outcomes of patients who are under-represented in RCTs. Owing to the differences between RCTs and routine clinical practice, increased toxicity may be observed when approaches that were previously successful in RCTs are applied to everyday care. Real-life studies can therefore provide information about potential toxicity associated with treatment in routine practice. Despite compelling evidence from RCTs and available treatment guidelines, physicians may be reluctant to adopt new medical therapies in the absence of real-life data. Following the publication of pivotal RCTs, real-life studies can be utilized to determine the translatability of the results observed, allowing policy-makers an evaluation of how to improve outcomes and care in the general population.

Real-life studies do have some drawbacks that must be assessed when considering treatment benefit. 3 , 11 They have limited internal validity or, in other words, it may be difficult to separate the effects of a new treatment from other factors. They should not be used to assess the efficacy of a therapy, and identification of comparative benefit in these studies is prone to multiple biases, including confounding by indication for a given treatment and/or concurrent changes in practice and/or disease biology. There is also little or no control on the quality of data collection. 11 It is clear that the intention of performing real-life studies must be clear from the outset. Many important clinical questions cannot be addressed in the context of an RCT and therefore clinicians may need to rely on information provided by real-life studies. 3

One important source of real-life data is national registries and databases. The Clinical Practice Research Datalink (formerly known as the General Practice Research Database [GPRD]) is the largest validated and most utilized primary care database in the UK. 12 , 13 As of March 2011, it contained data from >12 million patients and >800 research papers have been published using this resource. 12 , 13 In Denmark, all permanent residents have a unique personal identification number assigned (CPR number) that is used universally for registration of data. From this, it is possible to link data from one or more registers or from other sources with register-based information at an individual level. 14 In Canada, linked patient-level drug and healthcare data are presently accessible to pharmaceutical industry but with restrictions, e.g. some data may only be used by academics, or may only be available on particular subsets of patients, depending on the region. 15 The Canadian Institutes of Health Research established the Drug and Safety Effectiveness Network (DSEN) in collaboration with Health Canada and other stakeholders, in an effort to increase evidence on drug safety and effectiveness and to increase capacity to undertake high-quality post-market research. 16 In the USA, the Kaiser Permanente Healthcare programme is a large, multi-ethnic healthcare plan that has been used to link patient records to other sources, e.g. census information, to augment socioeconomic data—providing valuable information on age-specific prevalence, incidence, and mortality rates in the US population. 17

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Joe Garofoli is the San Francisco Chronicle’s senior political writer, covering national and state politics. He has worked at The Chronicle since 2000 and in Bay Area journalism since 1992, when he left the Milwaukee Journal. He is the host of “It’s All Political,” The Chronicle’s political podcast. Catch it here: .

He has won numerous awards and covered everything from fashion to the Jeffrey Dahmer serial killings to two Olympic Games to his own vasectomy — which he discussed on NPR’s “Talk of the Nation” after being told he couldn’t say the word “balls” on the air. He regularly appears on Bay Area radio and TV talking politics and is available to entertain at bar mitzvahs and First Communions. He is a graduate of Northwestern University and a proud native of Pittsburgh. Go Steelers!

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