Left Atrial Thrombosis Despite Dabigatran Therapy.

Dabigatran is a novel anticoagulation which has been approved as an alternative to warfarin therapy for non-valvular atrial fibrillation. Use of Dabigatran for approved indications as well as off label use has dramatically increased after Federal Drug Administration (FDA) approval. Our patient had left atrial thrombosis even after being on Dabigatran for more than one month which raises question about safety and efficacy of use of dabigatran around cardioversion and ablation.

Training in clinical ethics: launching the clinical ethics immersion course at the Center for Ethics at the Washington Hospital Center.

In May 2011, the clinical ethics group of the Center for Ethics at Washington Hospital Center launched a 40-hour, three and one-half day Clinical Ethics Immersion Course. Created to address gaps in training in the practice of clinical ethics, the course is for those who now practice clinical ethics and for those who teach bioethics but who do not, or who rarely, have the opportunity to be in a clinical setting. "Immersion" refers to a high-intensity clinical ethics experience in a busy, urban, acute care hospital. During the Immersion Course, participants join clinical ethicists on working rounds in intensive care units and trauma service. Participants engage in a videotaped role-play conversation with an actor. Each simulated session reflects a practical, realistic clinical ethics case consultation scenario. Participants also review patients' charts, and have small group discussions on selected clinical ethics topics. As ethics consultation requests come into the center, Immersion Course participants accompany clinical ethicists on consultations. Specific to this pilot, because participants' evaluations and course faculty impressions were positive, the Center for Ethics will conduct the course twice each year. We look forward to improving the pilot and establishing the Immersion Course as one step towards addressing the gap in training opportunities in clinical ethics.

Hiring a hospital staff clinical ethicist: creating a formalized behavioral interview model.

This paper presents the behavioral interview model that we developed to formalize our hiring practices when we, most recently, needed to hire a new clinical ethicist to join our staff at the Center for Ethics at Washington Hospital Center.

Curbside consultation re-imagined: Borrowing from the conflict management toolkit.

Curbside ethics consultations occur when an ethics consultant provides guidance to a party who seeks assistance over ethical concerns in a case, without the consultant involving other stakeholders, conducting his or her own comprehensive review of the case, or writing a chart note. Some have argued that curbside consultation is problematic because the consultant, in focusing on a single narrative offered by the party seeking advice, necessarily fails to account for the full range of moral perspectives. Their concern is that any guidance offered by the ethics consultant will privilege and empower one party's viewpoint over-and to the exclusion of-other stakeholders. This could lead to serious harms, such as the ethicist being reduced to a means to an end for a clinician seeking to achieve his or her own preferred outcome, the ethicist denying the broader array of stakeholders input in the process, or the ethicist providing wrongheaded or biased advice, posing dangers to the ethical quality of decision-making. Although these concerns are important and must be addressed, we suggest that they are manageable. This paper proposes using conflict coaching, a practice developed within the discipline of conflict management, to mitigate the risks posed by curbside consultation, and thereby create new "spaces" for moral discourse in the care of patients. Thinking of curbside consultations as an opportunity for "clinical ethics conflict coaching" can more fully integrate ethics committee members into the daily ethics of patient care and reduce the frequency of ethically harmful outcomes.

Esophageal overtube facilitation of transesophageal echocardiography in patients with previously difficult esophageal intubation.

BACKGROUND: In upper endoscopy, overtubes protect the hypopharynx and esophagus in patients requiring multiple esophageal intubations. Transesophageal echocardiography (TEE) is frequently used in general cardiology practice to provide high-resolution, real-time images of cardiac structures that are often not visualized by transthoracic imaging alone. Patients with a history of esophageal disorders or difficult esophageal intubations may have increased risk for complications from the echoprobe. An esophageal overtube may facilitate TEE in such patients. OBJECTIVE: We sought to evaluate the usefulness of upper endoscopy with placement of an esophageal overtube to facilitate TEE in patients with prior difficult esophageal intubations. METHODS: We performed upper endoscopy, followed by placement of an esophageal overtube, in 4 patients who had an unsuccessful intubation with the TEE probe. The endoscopic procedures were successfully completed, thus, allowing for uneventful subsequent TEE. CONCLUSIONS: Upper endoscopy with placement of an esophageal overtube may allow for safe successful completion of TEE in patients with previously unsuccessful blind esophageal intubation.

Contrast echocardiography: experience in a clinical echocardiography laboratory.

Although 2-dimensional echocardiography with adjunct intravenous contrast media improves endocardial visualization and enhances quality of spectral Doppler signals, widespread use of contrast agents has not occurred for various reasons. Results from this study indicate that discretionary use of contrast media will enhance endocardial and Doppler signal visualization scores without an impact on total procedure duration, lending credence to an argument for a lower threshold for discretionary use of contrast media.

Interactions between genetic and reproductive factors in breast cancer risk in a population-based sample of African-American families.

Incidence of breast cancer (BC) varies among ethnic groups, with higher rates in white than in African-American women. Until now, most epidemiological and genetic studies have been carried out in white women. To investigate whether interactions between genetic and reproductive risk factors may explain part of the ethnic disparity in BC incidence, a genetic epidemiology study was conducted, between 1989 and 1994, at the Howard University Cancer Center (Washington, DC), which led to the recruitment of 245 African-American families. Segregation analysis of BC was performed by use of the class D regressive logistic model that allows for censored data to account for a variable age of onset of disease, as implemented in the REGRESS program. Segregation analysis of BC was consistent with a putative dominant gene effect (P < 0.000001) and residual sister-dependence (P < 0.0001). This putative gene was found to interact significantly with age at menarche (P = 0.048), and an interaction with a history of spontaneous abortions was suggested (P = 0.08). A late age at menarche increased BC risk in gene carriers but had a protective effect in non-gene carriers. A history of spontaneous abortions had a protective effect in gene carriers and increased BC risk in non-gene carriers. Our findings agree partially with a similar analysis of French families showing a significant gene x parity interaction and a suggestive gene x age at menarche interaction. Investigating gene x risk factor interactions in different populations may have important implications for further biological investigations and for BC risk assessment.

Vapor-Liquid Equilibrium of Carbon Dioxide With Isobutane and n-Butane: Modified Leung-Griffiths Correlation and Data Evaluation.

The Leung-Griffiths model as modified by Moldover and Rainwater is used to correlate high-pressure vapor-liquid equilibria of mixtures of carbon dioxide with n-butane and isobutane. Model correlations are compared against 10 independent experimental sources for these mixtures. Agreement is generally very good and comparable to mutual experimental discrepancies. The utility of the model as a data evaluation technique is demonstrated in that small suspect regions have been identified in certain data sets and the model predictions have been confirmed by subsequent measurements that agree with the model better than the earlier data.