Background Hepatitis B vaccine provides a model for improving uptake and completion of multi-dose vaccinations in the drug-using community. Methods DASH project conducted randomized controlled trial among not-in-treatment current drug users in two urban neighborhoods. Neighborhoods were cluster-randomized to receive a standard (HIV information) or enhanced (HBV vaccine acceptance/adherence) behavioral intervention; participants within clusters were randomized to a standard (0, 1, 6 mo) or accelerated (0, 1, 2 mo) vaccination schedule. Outcomes were completion of three-dose vaccine and HBV seroprotection. Results Of those screening negative for HIV/HBV, 77% accepted HB vaccination and 75% of those received all 3 doses. Injecting drug users (IDUs) on the accelerated schedule were significantly more likely to receive 3 doses (76%) than those on the standard schedule (66%, p=.04), although for drug users as a whole the adherence was 77% and 73%. No difference in adherence was observed between behavioral intervention groups. Predictors of adherence were older age, African American race, stable housing, and alcohol use. Cumulative HBV seroprotection (≥10 mIU/mL) was gained by 12 months by 65% of those completing. Seroprotection at 6 months was greater for the accelerated schedule group. Conclusions The accelerated vaccine schedule improves hepatitis B vaccination adherence among IDU.

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Background There are a variety of periprocedural anticoagulation strategies for atrial fibrillation (AF) ablation, including the use of dabigatran. It is unclear which strategy is superior. Objective To compare the safety and efficacy of anticoagulation with uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing ablation of AF at four experienced centers. Methods and Results In this retrospective analysis, 882 patients (mean age: 61 ± 11 years) underwent ablation of AF using uninterrupted warfarin (n = 276), dabigatran (n = 374), or warfarin with heparin bridging (n = 232) for periprocedural anticoagulation. The rate of total complications was 23/276 (8.3%) in the uninterrupted warfarin group, 30/374 (8.0%) in the dabigatran group, and 29/232 (12.5%) in the bridged group (P = 0.15). Major complications were more frequent in the uninterrupted warfarin group 12/276 (4.3%) compared with 3/374 (0.8%) in dabigatran and 6/232 (2.6%) in the bridged group (P = 0.01). The most common major complication was the need for transfusion or occurrence of major bleeding. Minor complications did not differ among the three groups. On multivariate analysis, female gender (odds ratio [OR] 1.93, confidence interval [CI] 1.16–3.19, P = 0.011), bridging heparin (OR 2.13, CI 1.100–3.941, P = 0.016), use of triple antithrombotic therapy (OR 1.77, CI 1.05–2.98, P = 0.033), and prior myocardial infarction (OR 2.40, CI 1.01–5.67, P = 0.046) independently predicted total complications. Conclusions When comparing the use of uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing catheter ablation of AF, dabigatran was not associated with increased risk, major complications were more common in the uninterrupted warfarin group, and after adjustment, warfarin with bridging increased total complications.

A variety of fluid solutions can be used as intravascular replacement for surgical volume loss, and to avoid or delay blood transfusions. Crystalloid solutions, such as Ringer lactate, are typically administered at a rate of 3 or 4 times the volume of blood loss caused by continuous rapid extravasations. Approximately 20% of the volume initially administered remains in the intravascular space hours later. Therefore, rapid infusion of large amounts of crystalloid solutions can cause problems in elderly patients with limited cardiovascular reserve, and can lead to pulmonary and systemic edema. Alternatively, a commonly used synthetic colloid, hydroxyethyl starch (HES), readily allows for a 1:1 replacement ratio of intravascular volume to shed blood, and remains in the intravascular space longer compared with crystalloid solutions. However, HES can induce coagulopathy during prolonged surgical procedures because of the reduced release of factor VIII, von Willebrand Factor (vWF), and impaired platelet function.There are many types of HES according to molecular weight (MW) and degree of substitution (DS). In general, HES with a low MW and low DS is preferred because HES solutions with a high MW and high DS are harder to metabolize and eliminate from the intravascular space. This prolonged stay results in extended adverse effects on coagulation. Six percent HES with a MW of 130 kDa and a DS of 0.4 in a saline medium (Voluven, Fresenius Kabi, Germany) has the lowest MW/DS ratio among other HES on the market and therefore is purported to induce less coagulation impairment. This review of crystalloid and colloid fluid replacement alternatives explores recently published evidence of the clinical utility of Voluven.

Despite the high immunogenicity of the hepatitis B vaccine, evidence suggests that immunological response in drug users is impaired compared to the general population. A sample of not-in-treatment adult drug users from two communities in Houston, Texas, USA, susceptible to hepatitis B virus (HBV), was sampled via outreach workers and referral methodology. Participants were randomized to either the standard multi-dose hepatitis B vaccine schedule (0, 1, 6 month) or to an accelerated (0, 1, 2 month) schedule. The participants were followed for one year. Antibody levels were measured at 2, 6 and 12 months after enrollment in order to determine the immune responses. At 12 months, cumulative adequate protective response was achieved in 65% of the HBV susceptible subgroup using both the standard and accelerated schedules. The standard group had a higher mean antibody titer (184.6 vs 57.6 mIU/mL). But at six months, seroconversion at the adequate protective response was reached by a higher proportion of participants and the mean antibody titer was also higher in the accelerated schedule group (104.8 vs. 64.3 mIU/mL). Multivariate analyses indicated a 63% increased risk of non-response for participants 40 years or older (p=0.046). Injecting drugs more than once a day was also highly associated with the risk of non-response (p=0.016). Conclusions from this research will guide the development of future vaccination programs that anticipate other prevalent chronic conditions, susceptibilities, and risk-taking behaviors of hard-to-reach populations.