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Patients with atrial fibrillation (AF) have a high risk of stroke and mortality, which can be considerably reduced by oral anticoagulants (OAC). Recently, four non-vitamin-K oral anticoagulants (NOACs) were compared with warfarin in large randomized trials for the prevention of stroke and systemic embolism. Today's clinician is faced with the difficult task of selecting a suitable OAC for a patient with a particular clinical profile or a particular pattern of risk factors and concomitant diseases. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. NOACs for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In the first of a two-part review, we discuss the choice of NOAC for stroke prevention in the following subgroups of patients with AF: (i) stable coronary artery disease or peripheral artery disease, including percutaneous coronary intervention with stenting and triple therapy; (ii) cardioversion, ablation and anti-arrhythmic drug therapy; (iii) mechanical valves and rheumatic valve disease, (iv) patients with time in therapeutic range of >70% on warfarin; (v) patients with a single stroke risk factor (CHA 2 DS 2 VASc score of 1 in males, 2 in females); and (vi) patients with a single first episode of paroxysmal AF. Although there are no major differences in terms of efficacy and safety between the NOACs for some clinical scenarios, in others we are able to suggest that particular drugs and/or doses be prioritized for anticoagulation.

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Introduction

Patients with atrial fibrillation (AF) have a high risk of stroke, which can be considerably reduced by oral anticoagulants (OACs). Large randomized phase III trials have compared five non-vitamin-K oral anticoagulants (NOACs) with warfarin for prevention of stroke and systemic embolism. 1 4 Dabigatran was evaluated at two different doses in the RE-LY trial. 1 Two NOACs were evaluated using one dose, with protocol-mandated dose adaptations: rivaroxaban in the ROCKET AF study 2 and apixaban in the ARISTOTLE trial. 3 Edoxaban was evaluated at two doses, each with dose adaptation, in the ENGAGE AF-TIMI 48 trial 4 ( Table 1 ). Apixaban has also been compared with aspirin in patients unable or unwilling to take a vitamin K antagonist (VKA). 5 The first agent to be studied, ximelagatran, was taken off the market due to hepatic toxicity. 6 8 No direct head-to-head comparisons have been reported for the four available NOACs, and it is therefore difficult for the practising physician to choose between different drugs and different doses.

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Lauren Kirchner, ProPublica -

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The algorithms that play increasingly central roles in our lives often emanate from Silicon Valley, but the effort to hold them accountable may have another epicenter: New York City. Last week, the New York City Council unanimously passed a bill to tackle algorithmic discrimination—the first measure of its kind in the country.

The algorithmic accountability bill , waiting to be signed into law by Mayor Bill de Blasio, establishes a task force that will study how city agencies use algorithms to make decisions that affect New Yorkers’ lives, and whether any of the systems appear to discriminate against people based on age, race, religion, gender, sexual orientation, or citizenship status. The task force’s report will also explore how to make these decision-making processes understandable to the public.

The bill’s sponsor, Council Member James Vacca, said he was inspired by ProPublica’s investigation into racially biased algorithms used to assess the criminal risk of defendants.

“My ambition here is transparency, as well as accountability,” Vacca said.

A previous, more sweeping version of the bill had mandated that city agencies publish the source code of all algorithms being used for “targeting services” or “imposing penalties upon persons or policing” and to make them available for “self-testing” by the public. At a hearing at City Hall in October, representatives from the mayor’s office expressed concerns that this mandate would threaten New Yorkers’ privacy and the government’s cybersecurity.

The bill was one of two moves the City Council made last week concerning algorithms. On Thursday, the committees on health and public safety held a hearing on the city’s forensic methods, including controversial tools that the chief medical examiner’s office crime lab has used for difficult-to-analyze samples of DNA.

As a ProPublica/ New York Times investigation detailed in September, an algorithm created by the lab for complex DNA samples has been called into question by scientific experts and former crime lab employees.

The software, called the Forensic Statistical Tool, or FST, has never been adopted by any other lab in the country.

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MetaTrader is aplatform thathas become increasingly popular, with MetaTrader4 long considered to be the best trading platform, recognized for its ease of use… that was before therelease of Admiral Markets’ MetaTrader 4 Supreme Edition (MTSE)plug-in that provides some key enhancements to the popular MetaTrader 4 platform.

Forthose who are notfamiliar with the platform –more commonly known as MT4 – MetaTrader 4 is an electronic trading platform that is used by Forex CFD traders online.

The trading platform provides live streaming of prices and charts, a portal to place orders and also functionality to manage exposures and accounts with the chosen broker.

Asfar asthe speculative traderis concerned, MT4’smost popular capability was giving the option to users to put together personalized trading scripts, with the use of robots to automate trading, supporting the increased popularity of algorithmic trading.

While MT4was released back in 2005, the release of MetaTrader 5 in 2010 proved to be less popular, with MT4 to continue as the platform of choice until the release of MT4 Special Edition plug-in.

MetaTrader Supreme Edition

MetaTrader 4 Supreme Edition was developed notto replace the key capabilities of the original MT4 platform, but to enhance the existing offerings, with features that are most certainly going togivethe SupremeEdition platform significant advantages, bringing Admiral Markets the prospects of more accolades in the Forex world.

The MT4 and MT5 Supreme Edition plug-ins were designed as stand-alone platforms, with traders being ableto entertwo types of orders – pendingand marketorders. While pending orders are only executed when prices reach a chosen target price, market orders offer four methods of execution.

Some of the key features of the MT4 platform that marry particularly well with the additional features of the MT4 Supreme Edition plug-in include:

Instant execution : Orderis executed at theprice indicated at the time of placing the order,instant execution ispopular because of the execution price being known at the time of placing the order. For instance, if you decide to purchase Bitcoin or Etheuem, you will an instant execution of the available price.

The use of alcohol-based products has been compared with other methods of hand hygiene in removal of C. difficile spores [ 236 , 237 ]. These studies evaluated the efficacy of different handwashing methods among volunteers for removal of spores of a nontoxigenic strain of C. difficile . Handwashing with soap and water, or with an antimicrobial soap and water, was found to be more effective at removing C. difficile spores than alcohol-based hand hygiene products. McFarland et al showed that chlorhexidine-containing antiseptic was more effective than plain soap for eliminating C. difficile from the hands of healthcare personnel [ 74 ]. Clostridium difficile was recovered from the hands of 88% of personnel (14 of 16) who had washed with plain soap. Washing with 4% chlorhexidine gluconate reduced the rate to 14% (1 of 7 personnel) [ 74 ]; in contrast, another study that conducted experimental hand seeding with C. difficile spores showed no difference between plain soap and chlorhexidine gluconate in removing C. difficile from hands [ 238 ].

In summary, there is a theoretical possibility for alcohol-based hand hygiene products to increase the incidence of CDI because of their inability to eliminate C. difficile spores from the hands. However, there have not been any clinical studies to support that the use of alcohol-based hand hygiene products results in an increased incidence of CDI. Therefore, before and after providing care for a patient with CDI, it is recommended to preferentially use soap and water over alcohol-based products alone for hand hygiene in CDI-hyperendemic (sustained high rates) or outbreak settings. It is important to confirm compliance with glove use and to use alcohol-based products in nonoutbreak or endemic settings.

The hands of patients can also become contaminated with C. difficile at a rate of 32% [ 239 ]. Potentially, these patients can transmit C. difficile to surfaces. In addition, this could be a factor in CDI recurrence when the spores are ingested from their contaminated hands. Patient bathing can also decrease skin contamination of C. difficile . Among 37 patients with CDI, showering was more effective than bed bathing in decreasing the rate of positive skin cultures [ 240 ]. Encouraging patients to wash hands and shower could be a useful strategy to reduce the burden of spores on the skin.

Single-use disposable equipment should be used to prevent CDI transmission. Nondisposable medical equipment should be dedicated to the patient’s room, and other equipment should be thoroughly cleaned after use in a patient with CDI. Environmental contamination has been associated with the spread of C. difficile via contaminated commodes, blood pressure cuffs, and oral and rectal electronic thermometers [ 74 , 241 , 242 ]. Replacement of electronic thermometers with single-use disposable thermometers has been associated with significant decreases in CDI incidence [ 243 ]. During simulated routine physical examinations on patients with CDI, stethoscopes were found to acquire and transfer C. difficile spores as often as gloved hands [ 244 ]. These results support the recommendation to use disposable patient equipment when possible and to ensure that reusable equipment is cleaned and disinfected with a US Environmental Protection Agency–registered, sporicidal disinfectant, when possible. It is important to ensure that the responsibility and methods for cleaning and disinfection are clearly defined in standard operating procedures.