Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation.

The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.

Guideline-based educational intervention to decrease the risk for readmission of newborns with severe hyperbilirubinemia.

INTRODUCTION: The purpose of this study was to determine if educational intervention with medical providers in combination with a management tool to facilitate clinical guideline usage would (a) increase quality of care, (b) increase compliance with published guidelines, and (c) decrease hospital readmissions as a result of hyperbilirubinemia in the first week of life. METHOD: A quality improvement initiative was undertaken with a preintervention/postintervention design. INTERVENTION: An educational intervention was offered to persons who provide medical care to newborns. The charts of newborns were reviewed before and after the intervention in three samples: a care quality sample (N = 244), a compliance sample (N = 240), and a readmission sample. RESULTS: In the quality care sample, documentation of three quality care indicators improved significantly and one worsened significantly. In the compliance sample, the percentage of infants who were given appropriate follow-up appointments in primary care based on their hyperbilirubinemia risk at discharge improved (p = .03), and the readmission rate of newborns within the first week of life as a result of hyperbilirubinemia decreased by 50%. DISCUSSION: An educational intervention with a clinical tool may help change provider practice. Longer follow-up is needed to determine if the impact is sustainable.

Triad of exophthalmos, pretibial myxedema, and acropachy in a patient with Graves' disease.

Graves' disease is an autoimmune disorder of the thyroid gland with characteristic peripheral manifestations. The most common clinical findings include ophthalmopathy in 30% of patients, dermopathy (pretibial myxedema) in 4% of patients, and thyroid acropachy in 1% of patients. The triad of exophthalmos, pretibial myxedema, and acropachy occurs in less than 1% of patients. We present a case of Graves' disease with the clinical triad of eye disease, dermopathy, and acropachy.