Incorporation of a patient navigator into a secondary fracture prevention program identifies barriers to patient care.

INTRODUCTION: Patient navigation improves outcomes in various clinical contexts, but has not been evaluated in secondary fracture prevention. METHODS: We retrospectively reviewed charts of patients, age 50 + from April to October, 2016 hospitalized with fragility fracture contacted by a patient navigator. Patients were identified using an electronic tool extracting data from electronic medical records which alerted the patient navigator to contact patients by phone post-discharge to schedule appointments to "High-Risk Osteoporosis Clinic" (HiROC) and Dual-energy X-ray Absorptiometry (DXA) scan. Primary outcome was transition from hospital to HiROC. We also compared completion of DXA, five osteoporosis-associated in-hospital laboratory tests (calcium, 25-hydroxy vitamin D, complete blood count, renal, and liver function), osteoporosis medication prescription and adherence, and other patient characteristics to historical controls (2014-2015) without patient navigation. Comparisons were made using Chi-square, Fisher's Exact, two-sample t test or Wilcoxon Rank Sum test, as appropriate. RESULTS: The proportion of patients transitioning to HiROC with and without patient navigation was not different (53% vs. 48%, p = 0.483), but DXA scan completion was higher (90% vs. 67%, p = 0.006). No difference in medication initiation within 3 months post discharge (73% vs. 65%, p = 0.387) or adherence at 6 months (68% vs. 71%, p = 0.777) was found. Patients attending HiROC lived closer (11 vs. 43 miles, p < 0.001) and more likely to follow-up in surgery clinic (95% vs. 61%, p < 0.001). CONCLUSION: Patient navigation did not improve transition to HiROC. Longer travel distance may be a barrier-unaffected by patient navigation. Identifying barriers may inform best practices for Fracture Liaison Service programs.

Feasibility of concomitant vacuum-assisted removal of lead-related vegetations and cardiac implantable electronic device extraction.

BACKGROUND: Cardiac implantable electronic device (CIED) infections associated with large, mobile vegetation adds to the complexity of lead extraction and is associated with significant patient morbidity and mortality. OBJECTIVE: To show the feasibility of concomitant cardiovascular implantable electronic device extraction and vacuum-assisted removal of lead-related vegetations. METHODS: This is a single-center retrospective case series of consecutive patients with persistent bacteremia, sepsis, or endocarditis despite medical therapy who have vegetations >2 cm and subsequently underwent immediate CIED lead extraction after debulking with vacuum-assisted suction. RESULTS: Eight patients underwent successful removal of 17 leads immediately after debulking of vegetations with vacuum-assisted device suction. Debulking procedure was not successful in 1 patient due to inability to direct the vacuum suction device into proper position. There were no intraprocedure complications related to the vacuum-assisted debulking. One patient required open sternotomy for tear of the coronary sinus ostium related to extraction of a left ventricular pacing electrode. There was no mortality within 30 days of the procedure. CONCLUSIONS: Based upon these clinical results, it is feasible for patients with infected CIED systems that have large right-sided vegetations to undergo vacuum-assisted debulking then immediately followed by percutaneous CIED removal in whom surgical removal is considered high risk.

The effect of establishing pre-angiography thresholds on contrast utilization.

INTRODUCTION: Contrast induced nephropathy is linked to contrast utilization and strategies for minimizing renal injury are incorporated into many laboratories that perform coronary angiography. Contrast limits have been described, below which there is minimal incremental increase in the risk of renal injury. Whether a priori acknowledgement of these limits as part of a contrast "Time-Out" reduces contrast utilization has not been established. In this study, we investigate the effect of verbalizing pre-angiography and ½ time contrast thresholds on contrast utilization and associated clinical outcomes. METHODS: We retrospectively reviewed 5265 cases of coronary angiography (984 with contrast thresholds defined pre-procedure compared to 4281 without pre-defined contrast thresholds). There were two primary endpoints: (1) proportion of procedures that utilized an amount of contrast ≤ threshold, and (2) median difference between amount of contrast utilized and the contrast threshold. Secondary outcomes incorporated indices of renal function, and included changes in serum creatinine levels, eGFR, and CKD stage. RESULTS: Compared to pre-"Time-Out" group, the post-"Time-Out" group had a higher proportion of procedures with contrast ≤ stated contrast threshold (88% vs 84%, P < 0.002), and a lower amount of total contrast volume (88 mL [IQR 60-136] versus 78 mL [IQR 53-119]). The post-"Time-Out" group also had a lower incidence of any increase in post-procedure serum creatinine (45% vs 36%; P = 0.04), and a larger median decrease of pre- to post-procedure eGFR (P = 0.04). CONCLUSION: Acknowledgement of contrast threshold as part of a contrast "Time-Out" is associated with reduced overall contrast utilization, and likely minimizes risks of contrast-induced nephropathy.

Cancer immune checkpoint blockade therapy and its associated autoimmune cardiotoxicity.

The immune checkpoint molecules are emerged in the evolution to protect the host from self-attacks by activated T cells. However, cancer cells, as a strategy to survive and expand, can hijack these molecules and mechanisms to suppress T cell-mediated immune responses. Therefore, an idea of blocking the checkpoint molecules to enhance the anti-tumor activities of the host immune system has been developed and applied to the cancer therapy after discovery of the inhibitory T cell co-receptor, cytotoxic T-lymphocyte associated protein 4 (CTLA-4), and further enhanced on the identification of PD-1 and its ligands. Since 2010, several checkpoint inhibitors have been approved by FDA and many more are in clinical trials. In the treatment of advanced cancers, these inhibitors significantly increased response rates and survival benefits. However, accompanied with the striking results, immune-related adverse events (irAEs) that broadly occurred in many organs were observed and reported, some of which were fatal. Herein, we first review the recent progressions in the research of the immune checkpoint molecules and the application of their blocking antibodies in cancer treatment, and then discuss the cardiac toxicity induced by the therapy and the strategy to monitor, manage this adverse event when it occurs.

Beta-blocker use in patients with chronic obstructive pulmonary disease: A systematic review: A systematic review of ßB in COPD.

Beta-blockers (ßB) are a frequently used class of medications. Although ßB have many indications, those related to cardiovascular disease are among the most common and important. However, in patients with chronic obstructive pulmonary disease (COPD), ßB are used less often due to concerns about an unfavorable impact on respiratory morbidity and mortality. We performed a systematic review to assess the safety of ßB in patients with COPD. We included a total of 2 randomized controlled trials and 28 observational studies. The majority found statistically significant reductions in mortality. The two higher quality observational studies reported increased mortality with ßB. The risk of COPD exacerbations was reduced in about half of the studies. Nonetheless, there were significant biases that confounded the results. The highest quality RCT found a significant increase in severe and very severe COPD exacerbations with ßB use. In conclusion, data on the safety of ßB in patients with COPD are conflicting. However, given higher quality evidence showed harm with their use, ßB should be prescribed with caution in patients with COPD, including patients with cardiac indication for ßB.

Distal Radial and Ulnar Arteries: the Alternative Forearm Access.

PURPOSE OF REVIEW: Radial artery access for catheter-based procedures has demonstrated improved margins of safety and patient comfort without a loss of efficacy compared with femoral access. Unfortunately, radial access is not always available, so a review of the alternatives such as the ulnar artery and distal radial artery has been completed to understand alternative access sites that may preserve the benefits of distal forearm access without losing the efficacy of traditional transradial access. RECENT FINDINGS: Several different trials have demonstrated the utility of ulnar access as a possible workhorse access point. These suggest efficacy and safety, but inferior ease-of-access and more crossover than traditional radial access exists. Distal (dorsal) radial access has also been shown to have reasonable efficacy and offer some ergonomic advantages, but this comes at the price that 20-30% of all comers may not have a sufficiently large artery to use. Understanding the anatomy and techniques required to access the non-traditional, distal forearm arteries increases the skill set of operators. While neither the ulnar nor distal radial appears to substitute completely for radial access, both have potential applications that should be considered, and their utility should not be ignored.

Bleeding Complications Related to Right Heart Catheterization in the Setting of Elevated INR.

OBJECTIVES: Right heart catheterization (RHC) provides cardiovascular hemodynamic information in a variety of clinical settings. RHC performed in the setting of coagulopathy may have the potential to increase bleeding complications; however, data currently are limited. This study was undertaken to determine bleeding complications during RHC with an elevated international normalized ratio (INR) value. METHODS: A total of 312 patients who underwent RHC were retrospectively studied. Patients were divided into two groups: INR <1.8 (257 patients; median INR, 1.2; range, 0.8-1.7) and INR ≥1.8 (55 patients; median INR, 2.1; range, 1.8-4.0). There were 80 patients (31.1%) and 46 patients (83.6%) taking oral vitamin K antagonist (warfarin) in the INR <1.8 and ≥1.8 groups, respectively. RESULTS: Overall bleeding complications related to the procedure were extremely low, occurring in 2 patients (0.6%). All bleeding complications occurred in the INR <1.8 group, and both patients developed a small-sized hematoma requiring prolonged manual pressure without further intervention (0.8% vs 0.0% in the INR <1.8 vs INR ≥1.8 groups, respectively; P>.99). CONCLUSION: Bleeding complications associated with RHC were extremely low when performed by experienced operators in the cardiac catheterization laboratory. Furthermore, these complications were not related to an elevated INR, as bleeding occurred in patients with INR <1.8. Performing RHC in patients with an elevated INR in the therapeutic range did not increase bleeding compared to lower INR values.