Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy.

INTRODUCTION: The periprocedural management of patients with atrial fibrillation (AF) using a direct oral anticoagulant (DOAC) undergoing elective gastrointestinal (GI) endoscopic procedure remains uncertain. We investigated the safety of a standardized periprocedural DOAC management strategy. METHODS: The Periprocedural Anticoagulation Use for Surgery Evaluation cohort study enrolled adult patients receiving a DOAC (apixaban, rivaroxaban, or dabigatran) for AF scheduled for an elective procedure or surgery. This analysis addresses patients undergoing digestive endoscopy. Standardized periprocedural management consisted of DOAC interruption 1 day preendoscopy with resumption 1 day after procedure at low-moderate risk of bleeding or 2 days in case of a high bleeding risk. Thirty-day outcomes included GI bleeding, thromboembolic events, and mortality. RESULTS: Of 556 patients on a DOAC (mean [SD] age of 72.5 [8.6] years; 37.4% female; mean CHADS 2 score 1.7 [1.0]), 8.6% were also on American Society of Anesthesiology (ASA) and 0.7% on clopidogrel. Most of the patients underwent colonoscopies (63.3%) or gastroscopies (14.0%), with 18.9% having both on the same procedural day. The mean total duration of DOAC interruption was 3.9 ± 1.6 days. Four patients experienced an arterial thromboembolic event (0.7%, 0.3%-1.8%) within 24.2 ± 5.9 days of DOAC interruption. GI bleeding events occurred in 2.5% (1.4%-4.2%) within 11.1 ± 8.1 days (range: 0.6; 25.5 days) of endoscopy, with major GI bleeding in 0.9% (0.4%-2.1%). Three patients died (0.5%; 0.2%-1.6%) 15.6-22.3 days after the endoscopy. DISCUSSION: After a contemporary standardized periprocedural management strategy, patients with AF undergoing DOAC therapy interruption for elective digestive endoscopy experienced low rates of arterial thromboembolism and major bleeding.

A Case of Fat Embolism Syndrome with Cerebral Involvement in Sickle Cell Anemia.

Fat embolism syndrome (FES) is a rare condition that can occur as a complication of sickle cell disease. We describe a case of a patient with sickle cell disease (homozygous Hb S or HBB: c.20A>T) presenting with initial signs and symptoms consistent with a vaso-occlusive crisis (VOC). Within 24 hours, the patient developed evidence of coagulopathy, multi organ failure and a reduced level of consciousness (LOC) prompting intubation. A diagnosis of FES was made on the basis of the patient's clinical presentation, in conjunction with magnetic resonance imaging (MRI) of the brain revealing innumerable tiny foci of restricted diffusion, intracytoplasmic microvesicular fat on Sudan Red staining of bronchoalveolar lavage samples and evidence of a pulmonary shunt on echocardiogram bubble study. Red blood cell (RBC) exchange transfusion was initiated 3 days following initial presentation and no further exchange transfusions were needed on the basis of subsequent Hb S (HBB: c.20A>T) levels. The LOC gradually improved and the patient was extubated 12 days following presentation. Neurological improvement was slow, with mild cognitive impairment initially evident at 3 months and no cognitive or neurological deficits remaining within 6 months of admission. This case highlights the importance of understanding the pathophysiology and clinical presentation of FES, as early exchange transfusion may improve survival in patients with sickle cell disease and FES.

Venous thromboembolism prophylaxis in high-risk orthopedic and cancer surgery.

Orthopedic surgery and surgery for cancer are major risk factors for venous thromboembolism (VTE). Deep vein thrombosis (DVT) can occur in up to 50% of patients after major orthopedic surgery. The rate of VTE after cancer surgery varies according to the type of surgery, with rates as high as those after orthopedic surgery in certain settings. Use of thromboprophylaxis in these high-risk settings is well established and recent studies inform the type and duration of thromboprophylaxis. With major orthopedic surgery, there has been a shift from use of low molecular weight heparins (LMWHs) to direct oral anticoagulants (DOACs) along with renewed interest in aspirin as a thromboprophylaxis agent. Recent studies have also informed optimal thromboprophylaxis strategies after nonmajor orthopedic surgery. Use of thromboprophylaxis after major cancer surgery for cancer is established and recent evidence has focused on the potential benefits of extended-duration thromboprophylaxis. This review will summarize emerging evidence for thromboprophylaxis after orthopedic and cancer surgery with a view to providing clinicians with concise and actionable guidance for best practice.

Exploration of Barriers and Facilitators to Optimal Emergency Department Care of Sickle Cell Disease: Opportunities for Patient-Physician Partnerships to Improve Care.

Sickle cell disease patients commonly present to an emergency department (ED) due to acute vaso-occlusive pain episodes (VOEs), also known as vaso-occlusive crises (VOCs). Unsatisfactory patient care leads to preventable morbidity, mortality, and substantial financial costs. This study investigated the current use of sickle cell disease patient-directed physician education (PDPE) in the clinical setting and also explored opportunities for improvement. A qualitative phenomenologic design was used with semi-structured in-depth interviews. Open-ended questions were used to probe participant's experiences with EDs, the feasibility of a PDPE program as well as barriers and facilitators to PDPE. A total of nine patients and eight physicians participated in the study. Three major themes were identified: divergent challenges to patient recommendations, new targets for sickle cell disease education and triage process: not heard and not seen. Numerous challenges exist to the implementation and optimization of PDPE with sickle cell disease triage processes and nursing support identified as influential factors. Paramount to the process of improving PDPE is physicians perceiving patients as credible sources of information, especially as it relates to generalized concerns of opioid dosing. A patient provided written or digital education tool can be considered to facilitate PDPE to ease communication strain on patients while increasing communication efficiency.

Current Challenges in Diagnosis of Venous Thromboembolism.

In patients with suspected venous thromboembolism, the goal is to accurately and rapidly identify those with and without thrombosis. Failure to diagnose venous thromboembolism (VTE) can lead to fatal pulmonary embolism (PE), and unnecessary anticoagulation can cause avoidable bleeding. The adoption of a structured approach to VTE diagnosis, that includes clinical prediction rules, D-dimer testing and non-invasive imaging modalities, has enabled rapid, cost-effective and accurate VTE diagnosis, but problems still persist. First, with increased reliance on imaging and widespread use of sensitive multidetector computed tomography (CT) scanners, there is a potential for overdiagnosis of VTE. Second, the optimal strategy for diagnosing recurrent leg deep venous thrombosis remains unclear as is that for venous thrombosis at unusual sites. Third, the conventional diagnostic approach is inefficient in that it is unable to exclude VTE in high-risk patients. In this review, we outline pragmatic approaches for the clinician faced with difficult VTE diagnostic cases. In addition to discussing the principles of the current diagnostic framework, we explore the diagnostic approach to recurrent VTE, isolated distal deep-vein thrombosis (DVT), pregnancy associated VTE, subsegmental PE, and VTE diagnosis in complex medical patients (including those with impaired renal function).

Improvement in Hematology Interprofessional Care: Simulation With an Emphasis on Collaboration.

Introduction: For many training programs, including hematology, there are limited structured opportunities to practice collaboration as a competency. Training is often limited to ad hoc interactions during clinical rotations. Accordingly, there is further need for immersive and standardized collaboration educational programs. This pilot study explored simulation for developing and assessing collaboration competency among hematology residents. Methods: Two standardized simulation center scenarios were developed that required residents to work in interprofessional teams. The objectives were to develop collaboration competence and confidence through experiential learning and facilitated reflection. Team members included education and simulation experts as well as hematology nurses as embedded participants. Case 1 presented a 72-year-old male with stage 4 lymphoma experiencing shortness of breath during a rituximab infusion. Case 2 presented a 68-year-old male who suffered a provoked pulmonary embolism. Both cases utilized a simulated clinic space. Pre, post, and 3-month questionnaires (self-assessed collaboration competency and simulation evaluation) were completed. Each session included structured debriefing with facilitated reflection focused on collaboration. Results: Seven senior hematology subspecialty residents participated. Despite residents entering the simulation cases with confidence in collaboration, higher collaboration confidence ratings were observed on postsimulation questionnaires (8.2 vs. 7.6 on a 10-point Likert scale). Residents demonstrated awareness of appropriate collaboration skills, but at times failed to implement knowledge into action. Facilitated reflection during the debrief helped residents critique their collaboration performance and develop improvement plans. Discussion: Simulation is a promising tool for teaching and assessing collaboration within hematology training.

Heparin-induced thrombocytopenia: An international assessment of the quality of laboratory testing.

BACKGROUND: Accurate diagnosis of heparin-induced thrombocytopenia (HIT) is essential to ensure timely treatment and prevent complications. Current diagnostic assays include enzyme-linked immunosorbent assays (ELISAs) and rapid immunoassays (RIs). RIs offer fast turnaround times but were not significantly represented in previous external proficiency testing challenges. OBJECTIVES: To use external proficiency testing to assess qualitative concordance for heparin/PF4 antibody detection. METHODS: From 2013 to 2017, the External Quality Control for Assays and Tests (ECAT) Foundation distributed 10 samples internationally. RESULTS: In total, 437 laboratories submitted 3149 results. ELISAs accounted for 1484 (47%) responses with RIs accounting for 1665 (53%) responses. RI use increased over the 5-year period. ELISAs classified 96% of both consensus positive and consensus negative samples concordantly. The coefficient of variation (CV) for positive sample optical densities (ODs) ranged from 35% to 50% when combining ELISA assay methods together. Quantitative RIs classified 97% of consensus-positive and 98% of consensus-negative samples concordantly. Qualitative RIs had a higher proportion of discordant responses and classified 88% of consensus-positive samples and 73% of consensus-negative samples concordantly. Of RIs only latex immunoassays and IgG specific chemiluminescent assays identified > 95% of samples concordantly with consensus. CONCLUSION: Quantitative RIs and ELISAs classify > 95% of samples concordantly. The ODs from different ELISA methods vary considerably and are not interchangeable. Qualitative RI use is increasing despite a greater proportion of discordant classifications. This includes a higher than expected number of negative classifications for consensus-positive samples among many RIs, challenging their use as "rule out" tests.