Anticoagulation for newly diagnosed atrial fibrillation and 90-day rates of stroke and bleeding.

BACKGROUND: Atrial fibrillation increases the risk of stroke, which can be mitigated by anticoagulant prescription. We evaluated local emergency physician anticoagulation practice for patients discharged from the emergency department with atrial fibrillation, along with 90-day incidence of stroke and major bleeding. METHODS: This was a health record review of patients diagnosed with new onset atrial fibrillation in two emergency departments between 2014 and 2017. We collected data on CHADS65 scores, contraindications to direct oral anticoagulant (DOAC) prescription and initiation of anticoagulation in the ED. Patient charts were reviewed for the diagnosis of stroke, transient ischemic attack (TIA), systemic embolism or major bleeding within 90 days. RESULTS: We identified 399 patients, median age 68 (IQR 57-79), 213 (53%) male. Only 299/399 patients had an indication for anticoagulation (CHADS65-positive). Of these 299, 27 had a contraindication to or were already prescribed anticoagulation. 45/272 (17%, 95% confidence interval 12-22%) patients eligible for initiation of anticoagulation left the emergency department with a prescription for anticoagulation. During 90-day follow-up, seven patients had stroke or TIA. Four stroke/TIA patients had been eligible to start an anticoagulant but were not started, two left the emergency department with prescriptions for an anticoagulant and one patient had a contraindication to initiating anticoagulation in the emergency department. There were no major bleeding episodes. CONCLUSION: Few eligible patients were prescribed anticoagulation and the 90-day stroke rate was high. Physicians should become familiar with the CAEP Acute AF Best Practices Checklist AF which offers guidance on anticoagulation prescription.

RéSUMé: CONTEXTE: La fibrillation auriculaire augmente le risque d'accident vasculaire cérébral, qui peut être atténué par la prescription d'anticoagulants. Nous avons évalué la pratique d'anticoagulation des médecins d'urgence locaux pour les patients sortis du service d'urgence avec la fibrillation auriculaire, ainsi que l'incidence sur 90 jours d'AVC et des saignements majeurss. MéTHODES: Il s'agissait d'un examen du dossier de santé des patients diagnostiqués avec une nouvelle apparition de la fibrillation auriculaire dans deux services d'urgence entre 2014 et 2017. Nous avons recueilli des données sur les scores CHADS65, les contre-indications à la prescription d'anticoagulants oraux directs (AOD) et l'initiation de l'anticoagulation au service des urgences. Les fiches des patients ont été revues pour le diagnostic d'AVC, d'accident ischémique transitoire (AIT), d'embolie systémique d'hémorragie majeure dans les 90 jours. RéSULTATS: Nous avons identifié 399 patients, d'âge médian 68 (IQR 57-79), 213 (53 %) hommes. Seuls 299/399 patients avaient une indication d'anticoagulation (CHADS65 positif). Sur ces 299, 27 présentaient une contre-indication ou se voyaient déjà prescrire une anticoagulation. 45/272 (17 %, 95 % intervalle de confiance de 12 % à 22 %) patients éligibles pour l'initiation de l'anticoagulation ont quitté avec une prescription d'anticoagulation. Au cours du suivi de 90 jours, sept patients ont eu un accident vasculaire cérébral ou un AIT. Quatre patients ayant subi un AVC / AIT étaient éligibles pour commencer un anticoagulant mais qui n'ont pas été commencés, deux ont quitté le service des urgences avec des ordonnances d'un anticoagulant et un patient avait une contre-indication à l'initiation de l'anticoagulation au service des urgences. Il n'y a pas eu d'épisodes d'hémorragie majeure. CONCLUSION: Peu de patients éligibles se sont vu prescrire une anticoagulation et le taux d'AVC durant les 90 jours était élevé. Les médecins doivent se familiariser avec la liste de contrôle des meilleures pratiques pour la CAEP FA aiguë qui offre des conseils sur la prescription des anticoagulations.

Professional Medical Interpreters Influence the Quality of Acute Ischemic Stroke Care for Patients Who Speak Languages Other than English.

BACKGROUND: The inability to communicate effectively in a common language can jeopardize clinicians' efforts to provide quality patient care. Professional medical interpreters (PMIs) can help provide linguistically appropriate health care, in particular for the >25 million Americans who identify speaking English less than very well. We aimed to evaluate the relationship between use of PMIs and quality of acute ischemic stroke care received by patients who preferred to have their medical care in languages other than English. METHODS AND RESULTS: We analyzed data from 259 non-English-preferring acute ischemic stroke patients who participated in the American Heart Association Get With The Guidelines-Stroke program at our hospital from January 1, 2003, to April 30, 2014. We used descriptive statistics and logistic regression models to examine associations between involvement of PMIs and patients' receipt of defect-free stroke care. A total of 147 of 259 (57%) non-English-preferring patients received PMI services during their hospital stays. Multivariable analyses adjusting for other socioeconomic factors showed that acute ischemic stroke patients who did not receive PMIs had lower odds of receiving defect-free stroke care (odds ratio: 0.52; P=0.04). CONCLUSIONS: Our findings suggest that PMIs may influence the quality of acute ischemic stroke care.

Using drug probes to monitor hepatic drug metabolism in critically ill patients: midazolam, a flawed but useful tool for clinical investigation of CYP3A activity?

IMPORTANCE OF THE FIELD: In the UK, acute kidney injury (AKI) occurs in 25% of patients admitted to intensive care. Outcome is worsened in the presence of AKI for reasons not easily explained. AKI unpredictably affects the pharmacokinetics and pharmacodynamics of drugs and dosing in patients with AKI is largely based on data from chronic kidney disease patients, but how appropriately is unknown. AREAS COVERED IN THIS REVIEW: Midazolam as a drug probe of CYP3A activity is reviewed, with discussion of its limitations and alternatives in critically ill patients. Pharmacogenetics of CYP3A enzymes and their significance are discussed and emerging evidence that AKI affects liver metabolism is reviewed. WHAT THE READER WILL GAIN: The aim is to give the reader insight into the complexities of in vivo research in critically ill patient with discussion of interaction between the kidney and liver. We explain the use of midazolam as a drug probe for the investigation of the effect of AKI on hepatic function. TAKE HOME MESSAGE: Critically ill patients are difficult to manage but methods are now available for investigation of complex interrelationships that complicate the care and management of these patients with the potential to improve safety, efficacy and outcome, particularly for drug administration.

A rare presentation of micro-angiopathic haemolytic anaemia in a critically ill patient: a case report.

A 36-year-old woman presents to hospital peri-arrest with hypertension, sustained loss of consciousness following a tonic clonic seizure and a micropathic haemolytic anaemia on blood film. After initial resuscitation, more specialised treatment was instigated as the diagnosis became clearer but all was not as it first seemed. This case demonstrates the importance of re-examination, especially in the critically ill, in conjunction with unusual laboratory tests in order to eventually reach a rare diagnosis of a rare presentation.

Rituximab is an effective treatment for lupus nephritis and allows a reduction in maintenance steroids.

BACKGROUND: Lupus nephritis is a life-threatening complication of SLE. Treatment regimes include steroids and cyclophosphamide, both associated with significant morbidity. Newer regimes include mycophenolate mofetil (MMF). We report our outcomes in a prospectively monitored cohort of patients receiving our new standard treatment protocol, comprising rituximab induction therapy and MMF maintenance in patients already taking maintenance immunosuppression for SLE who developed lupus nephritis. We then attempted steroid reduction/withdrawal. METHODS: Patients with class III/IV/V lupus nephritis were included. All patients were on steroids prior to the development of lupus nephritis. Eighteen patients have reached at least 1 year follow-up. These patients received rituximab induction therapy and MMF maintenance therapy. Steroid reduction/withdrawal was guided by clinical response. RESULTS: Fourteen of 18 (78%) patients achieved complete or partial remission with a sustained response of 12/18 (67%) at 1 year, with 2 patients having a relapse of proteinuria. Four patients did not respond. There was a significant decrease in proteinuria from a mean protein:creatinine ratio (PCR) of 325 mg/mmol at presentation to 132 mg/mmol at 1 year (P = 0.004). Serum albumin significantly increased from a mean of 29 g/L at presentation to 34 g/L at 1 year (P = 0.001). The complication rate was low with no severe infections. Following treatment with rituximab, 6 patients stopped prednisolone, 6 patients reduced their maintenance dose and 6 patients remained on the same dose (maximum 10 mg). CONCLUSION: This data demonstrates the efficacy of a rituximab and MMF based regime in the treatment of lupus nephritis, allowing a reduction or total withdrawal of corticosteroids.

Is there a role for intensive insulin therapy in patients with kidney disease?

There is increasing evidence for the benefit of intensive insulin therapy in maintaining near-normoglycemia in patients without diabetes with severe acute illness. Morbidity and mortality have both improved, with decreased episodes of sepsis, acute kidney injury, transfusion requirements, and post-intensive care complications. The metabolic mayhem of severe acute illness has many parallels with those induced by kidney failure itself, and patients with kidney failure are at increased risk from many of the complications potentially improved by insulin therapy. We reviewed the potential benefits of intensive insulin therapy and examined the published trials for data directly applicable to patients with kidney failure. There are no trials directly answering the question and no specific analysis of patients with kidney disease in published studies. We extracted pertinent data regarding patients with impaired renal function from the reported trials, identified parallels between patients with kidney injury and other severe illnesses, and suggest possible future studies. We hypothesize that intensive insulin therapy has a role outside the intensive care setting and, in particular, a role for patients with severe acute illness and kidney failure, whether acute or chronic.