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An increasing number of patients are being prescribed direct oral anticoagulants (DOACs), while the patients who remain on warfarin are becoming more complex. There is currently a lack of a standardised anticoagulation review for patients in primary care, resulting in potentially preventable harm events. Our aim was to implement a new service, where a standardised review is carried out by a specialist multidisciplinary secondary care anticoagulation team. Overall, the implementation of a standardised review resulted in better optimisation of anticoagulation management for patients taking either a DOAC or a warfarin. Of the 172 eligible patients prescribed warfarin, 47 (27%) chose to switch a DOAC. The average time in therapeutic range for patients on warfarin before and after the pilot increased from 73.5% to 75%. Of 482 patients taking a DOAC, 35 (7%) were found to be on incorrect dose. In 32 (91%) of 35 patients, the dose was amended after notifying the patient’s general practitioner. We also found a significant number of patients inappropriately prescribed concomitant medication such as antiplatelet or non-steroidal anti-inflammatory drugs, potentially putting the patients at an elevated risk of bleeding. While further research is needed; we believe the results of this pilot can be used to help build a case to influence the commissioning of anticoagulation services. Secondary care anticoagulation teams, like our own, may be well-placed to provide or support such services, by working across the primary care and secondary care interface to support our primary care colleagues.
It is well documented that problematic sleep patterns in children are related to maternal mental health issues, such as stress, depression and anxiety. Although it is not clear whether it is the sleep patterns that predict maternal mental health or vice versa. Studies have called for the use of transactional models to allow for the contextual representation of the complexities of the interaction between mother and child. The current paper examines the potential bi-directional relationship between infant sleep patterns and maternal negative affect. Maternal negative affect was measured using the Edinburgh Postnatal Depression Scale and the Depression Anxiety Stress Scales. Infant sleep was measured using the Brief Infant Sleep Questionnaire (BISQ) and maternal ratings of infant sleep.
Structural equation modeling suggests relationships are bi-directional but appear to weaken after 8 weeks, although there is some re-emergence of the relationship again at 9-12 months. Moreover, the results indicate poor maternal negative affect during pregnancy predicts poorer infant sleep at birth to eight weeks and two to six months, and poor infant sleep at birth to eight weeks predicts poorer maternal negative affect at 8 weeks old.
The results indicate the relationship between maternal negative affect and infant sleep is bi-directional. Clinically, this has important implications for assessment and treatment, advocating the need for both constructs to be considered in the context of each other. They also highlight the importance of screening and treatment for maternal mental health during pregnancy and potential intervention for infant sleep problems in the early postnatal period.