Due to its unique triacylglycerol composition, palm oil has the particularity of being semi-solid at room temperature. Major fatty acids are palmitic (P) and oleic (O) types, tripalmitin (P3), oleo-dipalmitin (P2O) and palmito-diolein (PO2) being the most abundant tri-saturated, mono-unsaturated and di-unsaturated triacylglycerols. Palm oil is also the most fractionated oil worldwide, mostly in multi-step operations. Dry fractionation is a process that combines crystallization and separation of partially crystallized oil; in the case of palm oil, the main triacylglycerols involved are obviously P3, P2O and PO2. Crude palm oil is made up of symmetrical and asymmetric isomers and, more particularly, contains POP and OPP in a fixed ratio. This ratio may sometimes be modified during the refining process. Adverse effects of excessive OPP content affect the dry fractionation process and are also reflected in the crystallization properties of the produced solid and liquid fractions. It is therefore fundamental to understand at a molecular level the interactions involved. This paper details and compares the binary phase diagrams of several systems: PPP-POP, PPP-OPP; PPP-POO, POP-POO, OPP-POO and POP-OPP, obtained by combining differential scanning calorimetry and variable temperature powder X-ray diffraction. Co-crystallization properties are analyzed in dynamic mode (heating after quenching) and after tempering (few months stabilization at room temperature). The ternary phase diagrams PPP/POP/POO and PPP/OPP/POO give a complementary representation in terms of isothermal melting lines. Better understanding of these molecular interactions is critical for perspicacious carrying out of the palm oil dry fractionation process.
Chlamydia psittaci is an intracellular organism causing psittacosis which is found in psittacine birds and can be transmitted to humans by inhalation or direct contact. Here we present a case of human psittacosis mimicing acute monocytic leukemia which demonstrates an extraordinary clinical presentation of psittacosis.
What is precision medicine? No standard definition is found. Sometimes described as High Definition Medicine which is: “the dynamic assessment , management, and understanding of an individual’s health measured at (or near) its most basic units.” The impetus for this venture was advanced and stimulated by biogenetics, the study of how genes and their products affect health but also contribute to disease or resistance to cure. Medicine is an epistemology: a way of knowing, perceiving, remembering, finding out, proving, inferring, wondering, reflecting, a conceptual knowing relying upon observations fitted to disease concepts.
Background: The corona virus disease 2019 (COVID-19) outbreak originating in Wuhan, Hubei province, China, coincided with chunyun, the period of mass migration for the annual Spring Festival. To contain its spread, China adopted unprecedented nationwide interventions on January 23 2020. These policies included large-scale quarantine, strict controls on travel and extensive monitoring of suspected cases. However, it is unknown whether these policies have had an impact on the epidemic. We sought to show how these control measures impacted the containment of the epidemic. Methods: Web of Science database was searched on February 26, 2020 for Corona virus (COVID-19) publications published between 1997 to 2020. It was performed on the same day in order to avoid the possible bias came from update on the database because the metrics are changing over time. All publication types were considered; however publications as errata were excluded. Analysis parameters include year of publication, publication type, patterns of international collaboration, research institutions, journals, impact factor, h-index, language, and times cited. Results: A total of 12612Corona virus (COVID-19) research publications were published across the world. The Corona virus (COVID-19) associated publications were originated from 25 countries/territories, indicating the international spread of Corona virus (COVID-19) research. The USA was the largest contributor, with 4524 articles published over 32 years, followed by Peoples R China(2667 articles). The total number of citations for these publications has already achieved 8,015, with an average of 9.01 citations per each publication. The h-index for Corona virus (COVID-19) -associated publications was 48. The USA also have the highest h-index (32), followed by KSA (26) and UK (22). Netherland produced the greatest proportion of publications with international research collaboration (72.7 %) followed by the UK (71 %) and Germany (69.1 %) out of the total number of publications for each country.
Background: Prostate cancer early detection (PCa-ED) trough prostatic specific antigen (PSA) and digital rectal examination (DRE) has proved to lower mortality rates and should be carry out by primary care physicians (PCP). In Mexico, 80% of prostate cancers are detected in advanced-stages but PCP trends on PCa-ED remain unknown. Aim: To assess PCP knowledge and skills regarding PCaED. Materials and Methods: A self-administrating survey about the knowledge and skills of PCa-ED was created and delivered to PCP. Logistic regression analysis was conducted for the propensity of PCP to test prostatic specific antigen (PSA) on asymptomatic men. Results: The survey was completed by 170 PCP. The 13.5% answered being “not-well trained”. Score on risk factors knowledge was 51.5±15.7% but a score above the mean was not associated with testing PSA on asymptomatic men (p=0.674). The 40.6% answered having an institutional program on PCa-ED and 86% having access to PSA testing. Testing PSA on asymptomatic men was found in 40%. Moreover, 61.2% do not perform any digital rectal examination for PCa-ED, and this was not associated with preventing factors like lack of space, time, and assistance (p>0.05). Fewer years in practice and being a family medicine resident was associated with a less likelihood of testing PSA in asymptomatic men whereas having access to PSA testing and an institutional program on PCa-ED, increased the probability. The only significantly associated factor in the multivariable model was to have access to PSA testing [OR: 3.36 (CI 95% 1.54-7.30) p=0.002]. Conclusions: A low proportion of PCP in southeast Mexico performs PCa-ED and uses concepts outside evidence-based recommendations. A national program on PCa-ED and continuing medical education for PCP is a promising strategy to improve PCa-ED.
Recent efforts to determine the high-resolution crystal structures for the adenosine receptors (A1R and A2AR) have utilized modifications to the native receptors in order to facilitate receptor crystallization and structure determination. One common modification is a truncation of the unstructured C-terminus, which has been utilized for all the adenosine crystal structures obtained to date. However, the C-terminus has been identified as a location for protein-protein interactions that may be critical for physiological function of these important drug targets. Here, we determine whether the presence of the full-length C-terminus affected downstream signaling using a yeast MAPK response-based fluorescence assay. Upon ligand binding, the A1Δ291R or A2AΔ316R variants were unable to couple to human-yeast chimeric G-protein chimeras to generate a downstream signal in yeast, though full-length receptors showed native-like G-protein coupling. Further, constructs transfected into mammalian cells (HEK-293) showed similar behavior – i.e. the variants with C-terminal truncations lacked cAMP-linked signaling compared to the full-length receptors. Although the C-terminus was essential for Gα protein- associated signaling, chimeras of A1R with a C-terminus of A2AR coupled to the A1R-specific Gα (i.e. Gαi1 versus Gαs). This surprising result suggests that the C-terminus is important in signaling, but not specificity, for the interaction with Gα protein. This result has further implications in drug discovery both in enabling the experimental use of chimeras for ligand design, and in cautious interpretation of structure-based drug design based on truncated receptors.
Widespread dispersal of progeny is expected to result in enough gene flow to maintain genetic homogeneity over large areas. Surveys of genetic markers in species with planktonic larvae have mostly confirmed this expectation. However, genetic structure has occasionally been found at small spatiotemporal scales and interpreted as evidence of restricted dispersal, natal homing, sweepstakes reproductive success, or natural selection. We investigated genetic population structure in blue crabs from the Atlantic and Gulf of Mexico coasts of North America. Sampling was most intensive from five estuaries along the coast of Louisiana, with megalopae, juveniles and adults sampled from 2010 to 2016. 1446 individuals were genotyped at 2486 SNPs in 1363 putative protein-coding loci. Levels of differentiation between locations were consistently low, but significant differentiation was found among locations and among years. No evidence was found for chaotic genetic patchiness or sweepstakes reproductive success: no genetic differentiation was detected among collections of megalopae and none of the sampled individuals were closely related. Our results indicate that gene flow in blue crabs maintains near genetic homogeneity from the northern Gulf of Mexico through the Atlantic coast of North America.
Background and purpose: Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome- Coronavirus 2 (SARS-CoV2) is a highly contagious disease that has infected more than 200,000 patients and led to more than 10000 deaths in 166 countries in less than four months. New medications are needed to combat this disease. Since the process of discovery, development and approval of new drugs is long, old drugs can be repurposed for treatment of COVID-19. Oseltamivir is used for management of COVID-19 and Influenza A. Rimantadine is an alternative drug to oseltamivir for management of influenza A. Therefore, it is possible that rimantadine can be used for management of COVID-19 as an alternative to oseltamivir. The purpose of the study is to verify the potential of rimantadine as a drug for COVID-19 Methods: The SARS-CoV2 nucleocapsid was downloaded from the Protein databank and the chemical structure of rimantadine downloaded from Pubchem. Molecular docking of the nucleocapsid as the receptor and rimantadine as the ligand was done using avogadro and chimera software. Prediction of pharmacokinetic properties was done using SWISSADME website while the toxicity properties predicted using the ProTox server. Results: The interactions between rimantadine and the SARS-CoV2 nucleocapsid involved conventional hydrogen bonding with threonine & asparagine; attractive charge interaction with aspartate and Pi-alkyl interaction with tryptophan. Rimantadine has high gastrointestinal activity, very few drug-drug interactions and is relatively safe. Conclusion: Rimantadine binds to the SARS-CoV2 nucleocapsid and can thus be used for management of COVID-19. Keywords: Rimantadine, COVID-19, SARS-CoV2, Oseltamivir
Abstract: In this paper the feeding index (FI), Gastro somatic index (GaSI) and Food Prevalence Index (FPI) of freshwater prawn M. assamense peninsulare were evaluated to assess the quantity and kind of food which this prawn consumes in the Rawasan stream. A total of 401 prawns were collected for an interval of two years form five selected site in Rawasan stream of Garhwal in Central Himalaya, India from August 2013 to July 2015. Collected prawn was in the size range of 20-75 mm in male and 24-65 mm in female in total length during the study period. The stomach contents of 10 collected specimens were examined monthly and observed that 35% of the stomach was full or semi-full and 15% stomach were empty. Highest Gastro somatic value (Mean±SE) was obtained 2.95±0.80 during June in the male and 3.25±0.44 during May in the female. After that, it gradually decreased in both the sex and this repeated in cyclic pattern each year. More or less a similar trend was reported in the feeding index value during the study indicate a significant relationship between feeding intensity and Gastro somatic index. Highest Food Prevalence Index (FPI) was seen in fragment of animals in both sex, which was (88.48) in male and (58.26) in female prawn and lowest FPI value in sand debris 7.9 and 5.7 in male & female prawn respectively. Main food items were fragment of plants & animal, diatoms, algae, and sand. In overall, the results show that this prawn is selectively abstemious
Abstract Rationale, aims and objectives: Sri Lanka has a well-established government-funded universal health coverage which provides free health care to all citizens. The aim of this qualitative study was to examine the out-of-pocket expenses incurred by patients with cirrhosis during admission to a tertiary care government hospital in Sri Lanka, and the impact such expenses might have on equity of care and patient outcome. Methods This is a qualitative study conducted among patients with cirrhosis admitted to a tertiary-care hospital, their caregivers and physicians. Quota sampling was used until data saturation was achieved. Data was collected through individual interviews and small group discussions using directed and open-ended questions. Thematic framework method was used to analyze data. Out-of-pocket expenses incurred by patients, its impact on equity of patient care and outcome were investigated. Results Costs for laboratory investigations, drugs purchased from the private sector and hired caretakers for hospitalized patients were reported as direct expenses. Loss of work and other sources of income were the primary indirect expenses. The impact of such expenses was higher in patients and families from lower socioeconomic categories, especially among those who were dependent on a daily income. Health care workers actively tried to minimize these out-of-pocket expenses, resulting in choice on investigations, drugs and other interventions often being made by the clinician and occasionally not being discussed with the patient, resulting in poor patient satisfaction. Conclusion This study reveals a substantial direct and indirect economic impact on patients despite being cared for in a government hospital with universal health coverage. The impact was more in patients from lower socioeconomic strata, potentially resulting in inequity in the care provided as well as the health outcomes.
Title:Ondansetron in pregnancy revisited: Assessment and pregnancy labelling by the European Medicines Agency (EMA) & Pharmacovigilance Risk Assessment Committee (PRAC).Running title:Ondansetron in pregnancyPer DamkierMD, PhDDepartment of Clinical Biochemistry & Pharmacology Odense University Hospital, DenmarkDepartment of Clinical research University of Southern Denmark, DenmarkMail:firstname.lastname@example.orgPhone: +45 65 50 37 90Ondansetron is an effective antiemetic that is being widely used as a second-line treatment option for severe Nausea and Vomiting of Pregnancy (NVP) in accordance with clinical guidelines (1–4).In July 2019, the European Medicines Agency (EMA) Pharmacovigilance Risk Assessment Committee (PRAC) released updated comprehensive assessment report on the use of ondansetron in first trimester (5). This report is a detailed assessment of the available published data on the subject, including responses to supplementary questions posed to the Marking Authorization Holder (MAH), and the authors to the two central publications discussed below. The ensuing Summary of product Characteristics (SmPC) was updated in November 2019 with important changes to section 4.6 “Fertility, pregnancy and lactation” (6), which now state that ondansetron should not be used in first trimester of pregnancy.We acknowledge that the EMA SmPC in principal only frames the way that the MAH are legally allowed to market their product within the EU. It does not bind the physician as such; they must act and adhere with reference to the legal framework of their respective countries. We also acknowledge that EMA operates within a given formalized set of options on SmPC phrasings. In everyday practice however, the wording of the SmPC has consequences for treatment options and decision support beyond those formal to the legal ramifications of the SmPC.We applaud the EMA for the following nuanced phrasings in the SmPC:Based on human experience from epidemiological studies, ondansetron is suspected to cause orofacial malformations when administered during the first trimester of pregnancy.In one cohort study including 1.8 million pregnancies, first trimester ondansetron use was associated with an increased risk of oral clefts (3 additional cases per 10 000 women treated; adjusted relative risk, 1.24, (95% CI 1.03-1.48)).The available epidemiological studies on cardiac malformations show conflicting results. We believe that data from animal studies are of less relevance in these and analogue situations with an abundance of human data available:“Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity.”We do not believe that the most important sentence therein is appropriately substantiated or justified:“Ondansetron should not be used during the first trimester of pregnancy.”The latter statement comes with very clear and immediate consequences to clinical practice and pregnant women suffering from NVP. Previous somewhat contradictory data notwithstanding (7), the core of the discussion is down to the interpretation of two extraordinarily large sets of data. These are recent publications each comprising 80.000+ first-trimester exposed liveborn children. Previous studies with somewhat contradictory results comprise cumulated first trimester exposures less than 10% of these new data.Huybrechts et al., a well-established research group within studies of adverse pregnancy outcome following drug exposure during pregnancy with an elite publication track-record, published their large study in December 2018 (8). In this meticulously designed, conducted and reported study comprising 88.000 liveborn children exposed to ondansetron in first trimester, they reported no increased overall risk of malformations and null associations for any or cardiac malformations and a small increased risk for oral cleft. Compared to 1,727.000 unexposed liveborn, propensity score adjusted relative risks were 1.01 (95% CI 0.98-1.05), 0.99 (95% CI 0.93-1.06) and 1.24 (95% CI 1.03-1.48) for any, cardiac and oral cleft malformations, respectively. The increased risk of oral clefts corresponds to about 3 additional cases for every 10.000-liveborn children exposed to ondansetron in first trimester.Zambelli-Weiner et al. published their findings from a large study in January 2019 (9). This triggered controversy and extensive discussions among clinicians and researchers within the field.They reported data on 82.000 liveborn children exposed to ondansetron in first trimester. Compared to about 780.000 unexposed liveborn, their overall analysis identified a weak but no clinically meaningful association with cardiac effects, aOR 1.04 (95% CI 1.00-1.08) and a weak association to orofacial clefts, aOR 1.12 (95% CI: 0.95-1.33). Ade facto subgroup analysis – defined by the authors as “primary analysis” - restricted exposure to 5.500 women who were administered ondansetron in hospitals (“medical administration”). The inferential analysis substantially reinforced the overall weak signal for cardiac effects (aOR 1.43; 95% CI 1.28-1.61) but not orofacial clefts, (aOR 1.30; 95% CI: 0.75-2.25). The technical analysis appears suboptimal as adjustments were made as by a crude approach; i.e. the selection of confounder variables was based on these resulting in at least 10% change in effect estimates rather than simply including all selected confounders in the model.It appears plausible that this subpopulation of pregnant women in whom hospital treatment was deemed necessary, suffered from a more severe presentation of NVP, a confounder that they did not accounted for. The sensitivity analysis performed in patients assigned a diagnosis of NVP or hyperemesis gravidarum does not satisfactorily account for this. In almost all exposed cases, the exposure comprised a single intravenous dose of ondansetron. It is biologically counterintuitive that a causal relation to cardiac malformations be present based on such exposure. The paper reports extraordinarily high rates of congenital cardiac malformations be it among unexposed (3.7%) or exposed (5.5 and 4.1% for intravenous and any exposure, respectively) liveborn children. These observations are incompatible with all other reported data on the rate of congenital cardiac malformations. The external validity of the study findings is therefore less convincing and compromises comparisons to other findings.The authors did not provide satisfactory responses to additional questions poses by PRAC during the assessment process. Five specific questions were posed, and the authors did not address any of these. They provided a short narrative statement that did not serve to clarify or advance understanding of their findings (5). Not least, this paper is severely compromised by an initially undisclosed serious conflict of interest. The formal COI disclosure in the paper state: ”As an organization, TTi reports receiving funds from plaintiff law firms involved in ondansetron litigation…” The extent of this COI was only revealed during a litigation process. The specific study received substantial funding ($ 210.000) from plaintiffs’ representation who was pursuing litigative damage by claiming malformations from ondansetron use in pregnancy (10). It is the position of the undersigned and ENTIS Scientific Committee that this study is methodologically and ethically compromised to an extent that the results thereof cannot be considered when assessing the totality of evidence on the safety of ondansetron in pregnancy.Since the PRAC recommendation two additional studies have been published that should be considered in the overall assessment of the risk during pregnancy.In January 2020, Huybrechts et al. published an additional study on intravenous administration of ondansetron in early pregnancy and risk of congenital malformations (11). In this study, the authors revisited the study population from their original paper, but restricted their analysis to those women who received intravenous ondansetron in first trimester (8). The resulting propensity-score adjusted inferential analysis of about 24.000 pregnancies exposed to intravenous ondansetron did not result in increased risk of cardiac malformations (RR 0.97; 95% CI 0.86-1.10), oral clefts (RR 0.95; 95% CI 0.63-1.43), or any congenital malformation(RR 1.02; 95% CI 0.96-1.08). Unadjusted analyses suggested a small increased risk for cardiac and any malformation (11). These data strongly mitigate the previous data on intravenous ondansetron (9).Lemon and colleagues reported a small increased risk of ventricular septal defect (VSD) following first trimester exposure to intravenous or oral ondansetron in first trimester among 3700 pregnancies (12). Across various methodological approaches the adjusted risk ratio varied between 1.7 and 2.1 with 95% CI ranging between 1.0 and 4.0. In an overall analysis though there was no increased risk for any birth defect or any heart defect, illustrating the dilemma of splitting versus lumping in such analyses (13). In this study, there may be an issue of ascertainment bias. Women exposed to ondansetron likely suffered from more severe NVP and thus may have been be subject to more attention and their newborn babies to a greater extent are subject to an echocardiograph evaluation. VSDs may be clinically asymptomatic and ”Up to 80% of small, muscular VSDs and 30%-50% of perimembranous defects will close spontaneously” (14).In summary, we believe that the abundance of most methodologically convincing data on cardiovascular malformations is reasonably reassuring. Even if a small excess risk may still be present, ondansetron in first trimester should remain an option for pregnant women with severe NVP.It is the opinion of ENTIS that the EMA decision to explicitly discourage first trimester treatment with ondansetron puts pregnant women with severe NVP, physicians and health care professionals between a rock and a hard place. We do not agree that the specific wording against the use of ondansetron in first trimester is justified and we do not support the conclusion of EMA/PRAC assessment report and this section of the SmPC.We urge the EMA/PRAC to carefully consider everyday clinical consequences of formal regulatory decisions. In cases with likely widespread clinical consequences, we suggest that EMA/PRAC consult liberally with relevant patient organizations, clinicians and health care professionals before final adoption of a recommendation.
1. Gummosis on Acacia decurrens, an invasive tree species, that got established in Merapi Volcano National Park (MVNP) after the eruption of Mount Merapi in 2010 was studied to i) identify the causal organism of the disease, ii) analyze disease symptoms, iii) understand the spatio-temporal distribution of gummosis in the tree population and iv) examine how the disease affects the anatomy of tree wood. 2. Pathological, morphological and molecular studies were used in this studies. 3. Ceratocystis fimbriata was proved to be the causal organism of the disease. The disease spread was probably aided by the ambrosia beetle (Euwallacea sp.) which bores holes on the stem. 4. The disease is noted to spread from the base of the trees, where the ambrosia beetle bores holes first, to the upper part. 5. The number of parenchyma cells in the infected stem was significantly more than in the healthy stem which apparently facilitated water and nutrition transport within the tree helping it to grow normally despite serious gummosis. 6. The management of invasion by A. decurrens in the MVNP area poses a serious challenge due its success as an invader in the volcano impacted area and the threat of the gummosis pathogen spreading to other species both of which will affect the regeneration and establishment of native species and recuperation of the ecosystem.
We have recently developed a computational methodology to separate the effects of size, composition, symmetry and fluxionality in explaining the experimental photoelectron spectra of mixed-metal clusters. This methodology was successfully applied first in explaining the observed differences between the spectra of Al13- and Al12Ni- and more recently to explain the measured spectra of AlnMo-, n=3-5,7 clusters. The combination of our approach and new synthesis techniques can be used to prepare cluster based materials with tunable properties. In this work we use the methodology to predict the spectrum of Al6Mo-. This system was chosen because its neutral counterpart is a perfect octahedron and it is distorted to a D3d symmetry and was not observed in the recent experiments. This high symmetry cluster bridges the less symmetric Al5Mo- and Al7Mo-structures. The measured spectra of Al5Mo- has well defined peaks, while that of Al7Mo-does not. This can be explained by the fluxionality of Al7Mo-, as at least 6 different structures lie within the range that can be reached by thermal effects. We predict that Al6Mo- has well defined peaks, but some broadening is expected as there are two low-lying isomers, one of D3d and the second of D3h symmetry that are only 0.052 eV apart.
Due to low working temperature, high energy density and low pollution, proton exchange fuel cells have been investigated under different operating conditions in different applications. Using platinum catalysts in methanol fuel cells leads to increasing the cost of this kind of fuel cell which is considered as a barrier to the commercialism of this technology. For this reason, a lot of efforts have been made to reduce the loading of the catalyst required on different supports. In this study, carbon black (CB) and carbon nanotubes (CNT) have been used as catalyst supports of the fuel cell as well as using the double-metal combination of platinum-ruthenium (PtRu) as anode electrode catalyst and platinum (Pt) as cathode electrode catalyst. The performance of these two types of electro-catalyst in the oxidation reaction of methanol has been compared based on electrochemical tests. Results showed that the carbon nanotubes increase the performance of the micro-fuel cell by 37% at maximum power density, compared to the carbon black.Based on thee-electrode tests of chronoamperometry and voltammetry, it was found that the oxidation onset potential of methanol for CNT has been around 20% less than CB, leading to the kinetic improvement of the oxidation reaction.The current density of methanol oxidation reaction increased up to 62% in CNT sample compared to CB supported one, therefore the active electrochemical surface area of the catalyst has been increased up to 90% by using CNT compared to CB which shows the significant rise of the electrocatalytic activity in CNT supported catalyst.
Machine learning techniques have been successfully used to simulate and optimise bioprocesses. This study explores the feasibility to apply Gradient Boosting, an emerging Ensemble Learning algorithm, which combines weak learners to generate better predictions for bioprocess dynamic modelling and prediction. A thorough procedure was presented for Gradient Boosting based data-driven model construction. Different case studies were employed including fermentation and algal photo-production processes. Given that generating a large size of experimental data for model training is time consuming and challenging to many bioprocesses, this work launched a first investigation on the data efficiency of Gradient Boosting by comparing its predictive capability against the predominantly used artificial neural networks. By carrying out a series of experimental verifications over a broad spectrum of process operating conditions, this study concluded that Gradient Boosting may have several advantages in small experimental datasets and can outperform artificial neural networks for bioprocess predictive modelling, indicating its potential for future bioprocess digitalisation and optimisation.
Anticoagulants are used in the treatment and prevention of thromboembolism. The most common indications for long-term anticoagulation with warfarin are atrial fibrillation, mechanical heart valves and venous thromboembolism. A number of anticoagulants are available, including unfractioned heparin, low molecular weight heparin, and the vitamin K antagonists; warfarin, acenocoumarol and phenindione. These anticoagulants have been used for many years, and at present most people who require an anticoagulant are prescribed warfarin.However, recent national guidelines have recommended the use of New oral anticoagulants(NOAC) in certain circumstances. The new oral anticoagulants; rivaroxaban, dabigatran and apixaban have all completed phase III clinical trials for stroke prevention in patients with atrial fibrillation, and many countries, including the United Kingdom, have approved the use of the new oral anticoagulants for the prevention of cerebrovascular accidents and systemic embolism in patients with atrial fibrillation and the treatment and prevention of deep vein thrombosis and pulmonary embolism.This report aims to look at the peri-operative management of patient using the NOACs.