Transitions in Atrial Fibrillation Care: A Systematic Review.

BACKGROUND: Patients with atrial fibrillation (AF) commonly transition between care settings and providers. These transitions are often points in the health care system where errors and clinical deterioration can occur. Anticoagulation interruption or discontinuation and sub-optimal follow-up post-emergency department (ED) discharge are considered major transitional issues. OBJECTIVE: The purpose of this study was to synthesise the evidence examining the impact of transitional care interventions on patient, provider, and health care utilisation outcomes. METHODS: This systematic mixed studies review examined citations from four databases Medline, CINAHL, EMBASE, and Cochrane Central Controlled Register of Trials (CENTRAL) using relevant search terms. Fourteen (14) moderate to high quality articles were selected. RESULTS: The available evidence reporting impacts of transitional interventions on health care utilisation, provider, and patient outcomes in AF patients is mixed and of variable quality. The stronger evidence revealed improvements in patient outcomes including knowledge, quality of life, and medication adherence and increased provider anticoagulant prescriptions resulting from transitional interventions. Hospital admissions and ED visits were not significantly affected by any interventions. CONCLUSIONS: Apps and educational toolkits improved patient knowledge. Pathways increased patient quality of life and provider prescription rates. There is a need for more research to determine the AF transition interventions which maximise patient, provider and health care outcomes.

It's All Due to the Thyroid: Lessons Learnt From a Patient's Perspective.

Symptoms associated with thyroid pathology can mimic and overlap with a myriad of other diagnostic possibilities. Based on the patient's educational status, underlying fear, anxiety, online medical search, the patient can erroneously attribute various symptoms to thyroid pathology. We present a case of a 79-year-old female with a history of Hashimoto's hypothyroidism, meningioma, who erroneously attributed many of her symptoms to hypothyroidism despite having normal thyroid labs. The patient had symptoms of fatigue, dysphagia, and proximal muscle weakness. Surprisingly the patient already had an existing diagnosis of dermatomyositis and Zenker's diverticulum which could clearly explain her above symptoms. Moreover, the patient did not follow up for whole body scan and other tests that were ordered for cancer screening, which is the standard practice for dermatomyositis. The patient helped us identify the deficiencies in the current health system regarding patient counseling. We identified factors that could act as communication barriers if not properly addressed which include: (1) patient's prior medical knowledge, (2) patient's own underlying fears about their health conditions, (3) use of effective patient education tools, (4) minimizing or avoiding use of medical jargon, (5) role switching to verify patient's understanding, (6) repetition of relevant information, and (7) involvement of the patient in shared decision making. It is important to recognize that thyroid gland dysfunction is the most commonly self-diagnosed condition by patients and the blame can be shifted to thyroid despite evidence to the contrary if effective patient education and counseling are lacking. Understanding the psychological state of the patient along with addressing the underlying fears, and effective patient education with repetition is the key for patient compliance and management.

News Article Portrayal of Virtual Care for Health Care Delivery in the First 7 Months of the COVID-19 Pandemic.

Objectives: The onset of the 2020 coronavirus pandemic resulted in rapid implementation of virtual care solutions at an unprecedented pace. The news media, as a trusted source for many Canadians, plays a vital role during emergencies by reporting on changes in health care protocols, policies, and technologies. This article presents the results of a qualitative analysis of Canadian news articles between February and August of 2020 to identify critical themes with respect to virtual care. Methods: A full-text search of the database Canadian Newsstream resulted in 1542 articles (708 duplicates), of which 294 articles were included in the final analysis. Inductive analysis was used to generate themes and identify voices, contradictions, and tensions in the articles. Results: Analysis generated four themes: coronavirus disease (COVID-19) as a catalyst for virtual care, safety and protection, economic impacts, and telehealth as a model of care. Media portrayals represented some voices (e.g., physicians) while limiting others (e.g., patients), reflected some contradictory messaging with respect to safety and protection, and raised key issues and concerns about virtual health care delivery during the first 7 months of COVID-19. Conclusions: Our findings of successful and rapid uptake, uses and concerns around funding, and privacy and virtual care adoption reported in the news media can be used to inform longer term implementation and sustainability. Policy makers could benefit from crafting messages that balance information and reassurance. Public/patient perspectives, which were largely missing from news media, are needed to gauge receptivity and sustainability.

Bexarotene: A Rare Cause of Misleading Thyroid Function Tests.

Bexarotene is a very rare cause of central hypothyroidism (CH) and its effects have been reported to be dose-dependent; however, the available data in the literature on dose-dependent effects are variable. The standard practice of monitoring thyroid function using thyroid-stimulating hormone (TSH) to adjust levothyroxine (LT4) dose does not apply to bexarotene since it causes CH. In CH, TSH is not reliable. Hence free tetraiodothyronine (fT4) level is used to monitor and adjust the LT4 dose. We report a case of an 81-year-old Caucasian male with cutaneous T-cell lymphoma (CTCL) who was treated with bexarotene. His pre-treatment TSH was normal at 1.6 µIU/mL (reference range: 0.46-4.68 µIU/mL). Post-bexarotene, the total tetraiodothyronine (T4) level was within the reference range, but a downward trend was noted. Eventually, total triiodothyronine (T3) dropped to a low level of 0.61 ng/mL (reference range: 0.97-1.69 ng/mL), and LT4 was initiated. Bexarotene dose was increased, but LT4 was not increased by the primary physician who relied on TSH level, which was low, and hence the existing LT4 dose was maintained. The patient had persistent symptoms of hypothyroidism and, eventually, a diagnosis of CH was made. The symptoms of hypothyroidism improved after normalizing fT4, with an increase in the LT4 dose. This case represents an example of missed CH due to bexarotene, -which led to suboptimal LT4 replacement impacting the quality of life for the patient.

The impact of nurse-led atrial fibrillation clinics on patient and healthcare outcomes: a systematic mixed studies review.

BACKGROUND: Atrial fibrillation, the most common arrhythmia worldwide, continues to increase as the population ages. Patients with atrial fibrillation, particularly those newly diagnosed or who have multiple comorbidities, have high healthcare utilisation rates. Nurse-led atrial fibrillation clinics have developed to improve care and guidance for atrial fibrillation patients, with the potential to reduce hospital presentations and healthcare utilisation. Atrial fibrillation clinics that provide specialised and patient-centred care have improved patient symptom management, quality of life and reduced healthcare utilisation and costs. AIMS: The aim of this study was to provide the first synthesis of evidence for the impact of nurse-led atrial fibrillation clinics on patient, healthcare utilisation, and quality of care outcomes. METHODS: This systematic mixed studies review examined citations from three databases: Medline, CINAHL and Embase, using the search terms 'atrial fibrillation' and 'clinic', and related concepts. Seventeen moderate to high quality articles were selected. RESULTS: Overall, atrial fibrillation clinics were more cost effective, had shorter wait times and reduced hospitalisation and emergency department visits. Symptoms and sinus rhythm restoration were comparable in the nurse-led compared to physician-led cardioversion clinics. Findings related to patient knowledge and patient satisfaction were mixed, while mortality rates were lower, and patient medication adherence was higher in nurse-led atrial fibrillation compared to usual care. Quality of life and guideline adherence was increased in patients receiving nurse-led atrial fibrillation care compared to usual care. CONCLUSION: Nurse-led clinics improved healthcare, patient and quality care outcomes. Future research might examine the role of technology in delivery of nurse-led clinics in rural/remote areas as well as patient experiences with nurse-led clinics.