Impact of a Multidisciplinary Treatment Pathway for Atrial Fibrillation in the Emergency Department on Hospital Admissions and Length of Stay: Results of a Multi-Center Study.

Background Variability in the management of atrial fibrillation (AF) in the emergency department (ED) leads to avoidable hospital admissions and prolonged length of stay (LOS). In a retrospective single-center study, a multidisciplinary AF treatment pathway was associated with a reduced hospital admission rate and reduced LOS. To assess the applicability of the AF pathway across institutions, we conducted a 2-center study. Methods and Results We performed a prospective, 2-stage study at 2 tertiary care hospitals. During the first stage, AF patients in the ED received routine care. During the second stage, AF patients received care according to the AF pathway. The primary study outcome was hospital admission rate. Secondary outcomes included ED LOS and inpatient LOS. We enrolled 104 consecutive patients in each stage. Patients treated using the AF pathway were admitted to the hospital less frequently than patients who received routine care (15% versus 55%; P<0.001). For admitted patients, average hospital LOS was shorter in the AF pathway cohort than in the routine care cohort (64 versus 105 hours, respectively; P=0.01). There was no significant difference in the average ED LOS between AF pathway and routine care cohorts (14 versus 12 hours, respectively; P=0.32). Conclusions In this prospective 2-stage, 2-center study, utilization of a multidisciplinary AF treatment pathway resulted in a 3.7-fold reduction in admission rate and a 1.6-fold reduction in average hospital LOS for admitted patients. Utilization of the AF pathway was not associated with a significant change in ED LOS.

A comparison of postprocedural anticoagulation in high-risk patients undergoing WATCHMAN device implantation.

BACKGROUND: Left atrial appendage closure (LAAC) is an alternative to long-term anticoagulation for thromboembolic protection in patients with atrial fibrillation (AF) and high bleeding risk. Short-term Warfarin use following LAAC is well-studied, while data pertaining to novel oral anticoagulant (NOAC) use in this setting is less robust. Specifically, data regarding the safety and efficacy of postprocedural NOAC use in high-risk patients is lacking. OBJECTIVE: To compare the safety and efficacy of Warfarin and NOAC use in a high-risk patient population undergoing LAAC with the WATCHMAN device. METHODS: From November 2015 to October 2017, 97 patients underwent LAAC with the WATCHMAN device. All patients were discussed at a multidisciplinary meeting prior to device implantation. Longitudinal data were collected and analyzed for a composite endpoint of stroke and death at 8 months, and major bleeding at 3 and 6 months. RESULTS: Among the 90 patients included in the safety and efficacy analysis, 43 were prescribed Warfarin and 47 were prescribed NOACs. Baseline characteristics were comparable between study groups. There were no procedural complications and no significant differences in the incidence of death and stroke at 8 months or major bleeding at 3 and 6 months. CONCLUSION: For patients with AF at high risk of both thromboembolic and hemorrhagic events, NOACs as compared to Warfarin, seem to be safe and effective for short-term anticoagulation following LAAC with the WATCHMAN device. Further validation in large randomized controlled trials is required.

Persistent carry-over effects of planktonic exposure to ocean acidification in the Olympia oyster.

Predicting impacts of global environmental change is challenging due to the complex life cycles that characterize many terrestrial and aquatic taxa. Different life stages often interact with the physical environment in distinct ways, and a growing body of work suggests that stresses experienced during one life stage can "carry over" to influence subsequent stages. Assessments of population responses to environmental perturbation must therefore consider how effects might propagate across life-history transitions. We investigated consequences of ocean acidification (decreased pH and carbonate saturation) for early life stages of the Olympia oyster (Ostrea lurida), a foundation species in estuaries along the Pacific coast of North America. We reared oysters at three levels of seawater pH, including a control (8.0) and two additional levels (7.9 and 7.8). Oysters were cultured through their planktonic larval period to metamorphosis and into early juvenile life. Larvae reared under pH 7.8 exhibited a 15% decrease in larval shell growth rate, and a 7% decrease in shell area at settlement, compared to larvae reared under control conditions. Impacts were even more pronounced a week after settlement, with juveniles that had been reared as larvae under reduced pH exhibiting a 41% decrease in shell growth rate. Importantly, the latter effect arose regardless of the pH level the oysters experienced as juveniles, indicating a strong carry-over effect from the larval phase. Adverse impacts of early exposure to low pH persisted for at least 1.5 months after juveniles were transferred to a common environment. Overall, our results suggest that a stringent focus on a single phase of the life cycle (e.g., one perceived as the "weakest link") may neglect critical impacts that can be transferred across life stages in taxa with complex life histories.