Changes in Oral Anticoagulant Treatment Rates in Atrial Fibrillation before and after the Introduction of Direct Oral Anticoagulants.

BACKGROUND: Direct oral anticoagulants (DOACs) have the potential to improve stroke prevention among atrial fibrillation (AF) patients. We sought to determine if oral anticoagulation (OAC) treatment rates have increased since the approval of DOACs. METHODS: We identified 6,688 patients with AF at an academic medical center from January 2008 to June 2015. We examined OAC prescription rates over time and according to CHA2DS2VASc score using multivariable Poisson regression models, with an interaction term between risk score and year of AF diagnosis. RESULTS: Among 6,688 AF patients, 78% had CHA2DS2VASc scores ≥2, 51.6% of whom received an OAC prescription within 90 days of diagnosis. The OAC prescription rate was 47.8% in the pre-DOAC era and peaked at 56.4% in 2014. Relative to the pre-DOAC era, prescription rates increased in 2012 and leveled off thereafter. The prescription rate for the highest risk group was 58.5%, compared with 45.0% in patients with a CHA2DS2VASc score of 2 (p < 0.01). In the adjusted analysis, prescription rates were higher for the higher risk group (adjusted relative risk 1.24 for CHA2DS2VASc score 7-9 vs. 2, 95% CI 1.09-1.40). CONCLUSIONS: OAC treatment rates have increased since DOAC introduction, but substantial treatment gaps remain, specifically among the higher risk patients.

Clinical Outcomes of Orthopedic Surgery Comanagement by Internal Medicine Advanced Practice Clinicians: A Cohort Study.

OBJECTIVE: Compare clinical outcomes between advanced practice clinician-based comanagement and usual orthopedic care. BACKGROUND: Comanagement of orthopedic surgery patients by internal medicine hospitalists is associated with improvements in clinical outcomes including complications, length of stay, and cost. Clinical outcomes of orthopedic comanagement performed solely by internal medicine advanced practice clinicians have not been reported. METHODS: Retrospective cohort study in patients 18 years or older, hospitalized for orthopedic joint or spine surgery between May 1, 2014, and January 1, 2022. Outcomes assessed were length of stay, ICU transfer, return to operating room, inhospital and 30-day mortality, 30-day readmission, and total direct cost excluding surgical implants. Generalized boosted regression and propensity score weighting was used to compare clinical outcomes and healthcare cost between usual care and advanced practice clinician comanagement. RESULTS: Advanced practice clinician comanagement was associated with a 5% reduction in mean length of stay (RR=0.95, p=0.009), decreased odds of returning to the operating room (OR= 0.51, p=0.002), and a significant reduction in 30-day mortality (OR= 0.32, p=0.037) compared to usual orthopedic care in a weighted analysis. Need for ICU transfer was higher with advanced practice clinician comanagement (OR= 1.54, p=0.009), without significant differences in 30-day readmission or inhospital mortality. CONCLUSIONS: We observed reductions in length of stay, healthcare costs, return to the operating room, and 30-day mortality with advanced practice clinician comanagement compared to usual orthopedic care. Our findings suggest advanced practice clinician-based comanagement may represent a safe and cost-effective model for orthopedic comanagement.

Carcinoid Syndrome-Induced Ventricular Tachycardia.

Introduction. Carcinoid tumors are rare neuroendocrine malignancies that secrete multiple bioactive substances. These bioactive substances are responsible for the carcinoid syndrome characterized by diarrhea, flushing, syncope, and right-sided valvular heart disease. Previous case reports have described carcinoid syndrome associated with coronary vasospasm and the well-characterized carcinoid heart disease. Case. Our patient is a 73-year-old female with complex past medical history most notable for metastatic carcinoid tumors diagnosed in 2013-05. She initially presented in 2014-09 with syncope and dizziness associated with sinus pause on an event monitor. She received a pacemaker given normal left ventricular function and was discharged. However, she was readmitted with similar symptoms corresponding to multiple episodes of ventricular tachycardia. She was started on high-dose beta blockade and has had no recurrence of arrhythmia over a follow-up period of 12 months. Conclusion. We hypothesize that the patient's ventricular tachycardia was mediated by the multiple bioactive substances secreted by her carcinoid tumors. Her carcinoid tumor biomarkers were elevated and other explanations for arrhythmia were investigated and ruled out. To our knowledge, this is the first case of ventricular tachycardia mediated by carcinoid syndrome and suppressed by beta-blocker. Further investigation into this relationship is needed.