Biomarkers of Coagulation and Inflammation in COVID-19-Associated Ischemic Stroke.

[Figure: see text].

Early Identification of Individuals with Poorly Controlled Diabetes Undergoing Elective Surgery: Improving A1C Testing in the Preoperative Period.

OBJECTIVE: To describe a process improvement strategy that increased the identification of individuals with poorly controlled diabetes (glycated hemoglobin [A1C] ≥8%) undergoing elective surgery at a major academic medical center and increased their access to specialist care. METHODS: An algorithm was developed to ensure A1C measurements were obtained as per the American Association of Clinical Endocrinologists/American Diabetes Association (AACE/ADA) guidelines. The diabetes management team worked collaboratively with anesthesiologists, surgeons, and preoperative nurse practitioners to improve the glycemic control of patients with an A1C ≥8%. RESULTS: Before implementing the program, A1C testing was recorded in 854 out of 2,335 (37%) patients with diabetes seen in the preoperative clinic from January 1, 2011 to December 31, 2012. The program was instituted in February 2013. From February 2013 to February 2014, A1C testing occurred in 1,236 out of 1,334 (93%) patients with diabetes. After excluding those scheduled for same day surgery, 228 patients were considered high risk with A1C ≥8%, and 175 were available for endocrine preoperative consultation. The program led to significant blood glucose level improvements on the day of surgery. CONCLUSION: A process improvement strategy to evaluate and treat diabetes in the preoperative period of elective surgery patients was implemented by a multidisciplinary team (endocrinologists, nurse practitioners, anesthesiologists, and surgeons) and resulted in a substantial improvements in obtaining A1C tests, access to specialist diabetes care, and glycemic control on the day of surgery. The impact of improved glycemic control on hospital and surgical outcomes needs further evaluation.

Factors Associated with Anticoagulation Initiation for New Atrial Fibrillation in an Urban Emergency Department.

Objective: To explore factors associated with anticoagulation (AC) initiation after atrial fibrillation (AF) diagnosis. Design: Retrospective cohort study. Setting: Urban medical center. Patients: Adults with emergency department (ED) diagnosis of new onset AF from 1/1/2017-1/1/2020 discharged home. Methods: We compared patients initiated on AC, our primary outcome, to those not initiated on AC. Stroke, major bleeding, and AC initiation within 1 year of visit were secondary outcomes. We hypothesized that minority race and non-English language preference are associated with failure to initiate AC. Results: Of 111 patients with AF, 88 met inclusion criteria. Mean age was 65 (SD 15); 47 (53%) were women. 49 (56%) patients were initiated on AC. Age (61 vs 68 years; P=.02), non-English language (28% vs 10%; P=.03), leaving ED against medical advice (AMA) (36% vs 14%; P=.04), and CHA2DS2-VASc score of 1 (41% vs 6%; P<=.001) were associated with no AC initiation. There were no associations between patient-reported race/ethnicity and AC. Cardiology consultation (83.67% vs 30.78%; P<.0001) and higher median CHA2DS2-VASc score (3[2-4]) vs. 2[1-4]; P=.047) were associated with AC. Of 73 patients with follow-up data at 1 year, 2 (8%) not initiated on AC had strokes, 2 (4%) initiated on AC had major bleeds, and 15 (62.5%) not initiated on AC in the ED subsequently were initiated on AC. Conclusion: More than half of ED patients with new AF eligible for AC were initiated on it. Work to improve AC utilization among patients with new AF who left AMA from ED and those who prefer to communicate in a non-English language may be warranted.

The effect of race on composite thrombotic events in patients with COVID-19.

COVID-19 associated coagulopathy and mortality related to thrombotic complications have been suggested as biological mediators in racial disparities related to COVID-19. We studied the adjusted prevalence of acute ischemic stroke, pulmonary embolism, myocardial infarction, and deep venous thrombosis stratified by race in hospitalized patients in one New York City borough during the local COVID-19 surge. The multi-racial cohort included 4299 patients hospitalized with COVID-19, 9% of whom were white, 40% black, 41% Hispanic and 10% Asian or other. We found a 6.1% prevalence of composite thrombotic events. There were no significant race-specific differences in thrombotic events when adjusting for basic demographics, socioeconomic factors, medical comorbidities or biomarkers using a stepwise regression model. We therefore found no evidence that the racial disparities related to COVID-19, and specifically thrombotic complications, are caused by biological differences in race.