Risk factors for MACE and bleeding in atrial fibrillation patients undergoing surgery: Insights from the bridge trial.

INTRODUCTION: Patients with atrial fibrillation (AF) undergoing elective procedures are at risk for Major Adverse Cardiovascular Events (MACE) and symptomatic bleeding. We aimed to identify risk factors to guide perioperative risk stratification. METHODS: We conducted a post-hoc analysis of the "Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery" randomized trial. The primary outcomes were MACE and symptomatic bleeding. Our statistical approach encompassed standard univariate analysis, logistic stepwise regression, and Cox regression models. Additional interaction analyses evaluated the interplay between low-molecular-weight heparin bridge therapy and other identified risk factors. RESULTS: Among a total of 1,813 participants (mean age 71.6 ± 8.8, 73.3 % male), MACE occurred in 25 (1.4 %) individuals, with pre-procedure clopidogrel use (adjusted hazard ratio [aHR] 7.73, 95 % CI 2.63-22.72, p < 0.001) and CHA2DS2-VASc score ≥ 5 (aHR 2.89, 95 % CI 1.26-6.63, p = 0.012) identified as risk factors. Symptomatic bleeding occurred in 57 (3.1 %) individuals, with bridge therapy (aHR 1.84, 95 % CI 1.07-3.19, p = 0.029), renal disease (aHR 2.50, 95 % CI 1.34-4.67, p = 0.004), post-procedure aspirin use (aHR 2.86, 95 % CI 1.66-4.91, p < 0.001), post-procedure nonsteroidal anti-inflammatory drug use excluding aspirin (aHR 3.40, 95 % CI 1.22-9.43, p = 0.019), and major surgery (aHR 3.94, 95 % CI 2.26-6.85, p < 0.001) identified as risk factors. The interactions between risk factors and bridging therapy on MACE and symptomatic bleeding outcomes were not significant (p > 0.05). CONCLUSION: We identified predictors for MACE and symptomatic bleeding in AF patients undergoing elective procedures. These insights may help guide perioperative decisions to reduce the risk of adverse outcomes.

Recurrence risk in symptomatic intracranial stenosis treated medically in the real world.

BACKGROUND: The risk of early recurrence in medically treated patients with intracranial atherosclerotic stenosis (ICAS) may differ in clinical trials versus real-world settings. Delayed enrollment may contribute to lower event rates in ICAS trials. We aim to determine the 30-day recurrence risk in a real-world setting of symptomatic ICAS. METHODS: We used a comprehensive stroke center stroke registry to identify hospitalized patients with acute ischemic stroke or TIA due to symptomatic 50-99% ICAS. The outcome was recurrent stroke within 30 days. We used adjusted Cox regression models to identify factors associated with increased recurrence risk. We also performed a comparison of 30-day recurrent stroke rates in real world cohorts and clinical trials. RESULTS: Among 131 hospitalizations with symptomatic 50-99% ICAS over 3 years, 80 hospitalizations of 74 patients (mean age 71.6 years, 55.41% men) met the inclusion criteria. Over 30 days, 20.6 % had recurrent stroke; 61.5% (8/13) occurred within first 7 days. The risk was higher in patients not receiving dual antiplatelet therapy (HR 3.92 95% CI 1.30-11.84, p = 0.015) and hypoperfusion mismatch volume >3.5 mL at a T max>6 s threshold (HR 6.55 95% CI 1.60-26.88, p < 0.001). The recurrence risk was similar to another real world ICAD cohort (20.2%), and higher than that seen in clinical trials (2.2%-5.7%), even in those treated with maximal medical treatment or meeting inclusion criteria for trials. CONCLUSIONS: In patients with symptomatic ICAS, the real-world recurrence of ischemic events is higher than that seen in clinical trials, even in subgroups receiving the same pharmacological treatment strategies.

Collaborative Care in Ambulatory Psychiatry: Content Analysis of Consultations to a Psychiatric Pharmacist.

OBJECTIVES: To determine the volume and nature (or topic) of consultations submitted to a psychiatric pharmacist embedded in an ambulatory psychiatry clinic, within a tertiary care academic medical center and to increase our understanding about the ways in which providers consult with an available psychiatric pharmacist. EXPERIMENTAL DESIGN: Authors analyze and describe the ambulatory psychiatric pharmacist consultation log at an academic ambulatory clinic. All consultation questions were submitted between July 2012 and October 2014. PRINCIPAL OBSERVATIONS: Psychiatry residents, attending physicians, and advanced practice nurse practitioners submitted 280 primary questions. The most common consultation questions from providers consulted were related to drug-drug interactions (n =70), drug formulations/dosing (n =48), adverse effects (n =43), and pharmacokinetics/lab monitoring/cross-tapering (n =36). CONCLUSIONS: This is a preliminary analysis that provides information about how psychiatry residents, attending physicians, and advanced practice nurse practitioners at our health system utilize a psychiatric pharmacist. This collaborative relationship may have implications for the future of psychiatric care delivery.

Guideline adherence for mentally ill reproductive-aged women on treatment with valproic acid: a retrospective chart review.

OBJECTIVE: Valproic acid (VPA) use during pregnancy increases fetal risk of major congenital malformations and cognitive impairment. Given these risks, several medical societies have put forth guidelines suggesting to either limit the use of VPA or take certain precautions, such as making sure effective contraception practices and/or appropriate folic acid supplementation are in place, when treating reproductive-aged women. Our study aimed to review and assess adherence to these guidelines. METHODS: Using electronic medical record (EMR) and administrative claims data over a 19-month period (January 1, 2013-July 31, 2014), a retrospective chart review was conducted of all reproductive-aged female patients at a major medical center in the Midwest who were prescribed VPA as treatment for their psychiatric illness (n = 190; aged from 15 to 49 years). Psychiatric diagnoses were determined via ICD-9 billing codes. We assessed 3 variables of interest as an index of adherence to guidelines: chart documentation of provider-patient discussion regarding potential teratogenicity associated with VPA use, prescription of contraceptives, and co-prescription of folic acid. RESULTS: EMR documentation of provider-patient discussions regarding possible teratogenicity of VPA was rare (13.2%), as was documentation of contraception use (30%) and co-prescription of folate (7.9%). Neither patient demographic characteristics nor diagnoses were associated with outcomes. Among those not receiving treatment in the inpatient setting, patients who were seen by outpatient psychiatry or neurology clinics (rather than other outpatient settings) were more likely to have documented discussions about teratogenicity (23% and 30%, respectively; P = .003), and patients receiving neurologic care were more likely to be prescribed folate than those seen by other providers (26%, P = .004). Women who had contact with inpatient psychiatric services were less likely to be taking contraception (n = 12 [20%], P = .041). Only 22% of women under 34 years of age were documented as using contraception (P = .03). CONCLUSIONS: Adherence to standard guidelines is low even at an academic tertiary care center. To the extent that there is any documentation or co-prescription of folate, it varies by provider specialty.

Automation Improves Schedule Quality and Increases Scheduling Efficiency for Residents.

BACKGROUND: Medical resident scheduling is difficult due to multiple rules, competing educational goals, and ever-evolving graduate medical education requirements. Despite this, schedules are typically created manually, consuming hours of work, producing schedules of varying quality, and yielding negative consequences for resident morale and learning. OBJECTIVE: To determine whether computerized decision support can improve the construction of residency schedules, saving time and improving schedule quality. METHODS: The Optimized Residency Scheduling Assistant was designed by a team from the University of Michigan Department of Industrial and Operations Engineering. It was implemented in the C.S. Mott Children's Hospital Pediatric Emergency Department in the 2012-2013 academic year. The 4 metrics of schedule quality that were compared between the 2010-2011 and 2012-2013 academic years were the incidence of challenging shift transitions, the incidence of shifts following continuity clinics, the total shift inequity, and the night shift inequity. RESULTS: All scheduling rules were successfully incorporated. Average schedule creation time fell from 22 to 28 hours to 4 to 6 hours per month, and 3 of 4 metrics of schedule quality significantly improved. For the implementation year, the incidence of challenging shift transitions decreased from 83 to 14 (P < .01); the incidence of postclinic shifts decreased from 72 to 32 (P < .01); and the SD of night shifts dropped by 55.6% (P < .01). CONCLUSIONS: This automated shift scheduling system improves the current manual scheduling process, reducing time spent and improving schedule quality. Embracing such automated tools can benefit residency programs with shift-based scheduling needs.

A case-control study evaluating RT-PCR/ESI-MS technology compared to direct fluorescent antibody and xTAG RVP PCR.

Waste nasopharyngeal swabs (N = 244) were evaluated by the reverse-transcriptase polymerase chain reaction/electrospray ionization mass spectrometry PLEX-ID Broad Respiratory Virus Surveillance Kit version 2.5 compared to direct fluorescent antibody and xTAG Respiratory Virus Panel for percent agreement, sensitivity, and specificity. Sensitivity and specificity were 91% (111/122) and 95.1% (116/122), respectively. Sensitivity by virus, except parainfluenza, was 92.9-100%, and specificity was 99-100%.

Independent deficits of visual word and motion processing in aging and early Alzheimer's disease.

We tested whether visual processing impairments in aging and Alzheimer's disease (AD) reflect uniform posterior cortical decline, or independent disorders of visual processing for reading and navigation. Young and older normal controls were compared to early AD patients using psychophysical measures of visual word and motion processing. We find elevated perceptual thresholds for letters and word discrimination from young normal controls, to older normal controls, to early AD patients. Across subject groups, visual motion processing showed a similar pattern of increasing thresholds, with the greatest impact on radial pattern motion perception. Combined analyses show that letter, word, and motion processing impairments are independent of each other. Aging and AD may be accompanied by independent impairments of visual processing for reading and navigation. This suggests separate underlying disorders and highlights the need for comprehensive evaluations to detect early deficits.