Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial).

BACKGROUND: Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS: We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION: We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION: ClinicalTrials.gov NCT05009225 .  Registered on 17 August 2021.

Nomifensine alters sex differences in striatal dopaminergic function.

A series of three experiments are presented in which the acute effects of the catecholamine reuptake inhibitor, nomifensine, upon striatal dopaminergic function are compared in female and male mice. In Experiment 1, treatment with nomifensine (5 mg kg⁻¹), at 30 min prior to injection of methamphetamine (40 mg kg⁻¹) significantly decreased the amount of striatal dopamine depletion in male, but not female, mice, thereby abolishing the sex difference in methamphetamine-induced neurotoxicity (males > females). In Experiment 2, the methamphetamine-evoked sex differences in dopamine and DOPAC output from superfused striatal tissue (males > females) were abolished in mice treated with nomifensine at 30 min prior to tissue removal. In Experiment 3, the potassium chloride-evoked sex differences in dopamine and DOPAC output from superfused striatal tissue (females > males) were reversed in mice treated with nomifensine at 30 min prior to tissue removal. Taken together these results demonstrate the critical role played by catecholamine transporters in sex differences of dopaminergic function and suggest that this may involve the dopamine transporter, due to its high concentrations within the striatum. Such findings highlight the need for gender-specific considerations in use of treatments that target reuptake transporters function.