The Effects of Warfarin and Direct Oral Anticoagulants on Systemic Vascular Calcification: A Review.

Warfarin has been utilized for decades as an effective anticoagulant in patients with a history of strong risk factors for venous thromboembolism (VTE). Established adverse effects include bleeding, skin necrosis, teratogenicity during pregnancy, cholesterol embolization, and nephropathy. One of the lesser-known long-term side effects of warfarin is an increase in systemic arterial calcification. This is significant due to the association between vascular calcification and cardiovascular morbidity and mortality. Direct oral anticoagulants (DOACs) have gained prominence in recent years, as they require less frequent monitoring and have a superior side effect profile to warfarin, specifically in relation to major bleeding. The cost and lack of data for DOACs in some disease processes have precluded universal use. Within the last four years, retrospective cohort studies, observational studies, and randomized trials have shown, through different imaging modalities, that multiple DOACs are associated with slower progression of vascular calcification than warfarin. This review highlights the pathophysiology and mechanisms behind vascular calcification due to warfarin and compares the effect of warfarin and DOACs on systemic vasculature.

The Impact of Diabetes Mellitus in Patients with Chronic Obstructive Pulmonary Disease (COPD) Hospitalization.

(1) Background: Chronic obstructive pulmonary disease (COPD) is the leading cause of morbidity and mortality worldwide. Diabetes mellitus (DM) has been shown to have adverse inflammatory effects on lung anatomy and physiology. We investigated the impact of DM on COPD patient outcomes during inpatient hospitalization. (2) Methods: We conducted a retrospective analysis using the Nationwide Inpatient Sample (NIS) over the years 2002-2014. Three groups, COPD without diabetes, COPD with diabetes but no complication, and COPD with DM and complication, were analyzed. (3) Results: A total of 7,498,577 were COPD hospitalization; of those, 1,799,637 had DM without complications, and 483,467 had DM with complications. After adjusting for clinical, demographic, and comorbidities, the odds of increased LOS in the COPD/DM with complication were 1.37 (confidence interval (CI): 1.326-1.368), and those of DM without complication were 1.061 (1.052-1.070) when compared with COPD alone. The odds of pneumonia, respiratory failure, stroke, and acute kidney injury were also higher in COPD hospitalizations with DM. Both DM with complication (odds ratio (OR): 0.751 (CI 0.727-0.777)) and DM without complication (OR: 0.635 (CI: 0.596-0.675)) have lesser odds of mortality during hospitalization than with COPD alone. (4) Conclusions: There is a considerable inpatient burden among COPD patients with DM in the United States.

Extramedullary hematopoiesis presented as cytopenia and massive paraspinal masses leading to cord compression in a patient with hereditary persistence of fetal hemoglobin.

BACKGROUND: Extramedullary hematopoeisis (EMH) can occur in various physiological and pathologic states. The spleen is the most common site of EMH. CASE PRESENTATION: We report a case with hereditary persistence of fetal hemoglobin with extramedullary hematopoiesis presented as cord compression and cytopenia secondary to multi-paraspinal masses. CONCLUSION: Treatment can be a challenge. Relapse is a possibility.

Electronic Capture of Written Handoff Information: What Are the Next Steps?

Communication lapses during patient care transitions are reported to be frequent and may result in patient harm. The primary objective of our study was to assess the completeness, accuracy, and usefulness of our electronic handoff system to guide future software changes and educational interventions. We randomly selected and reviewed 707 of 2840 available handoff records generated on the medicine service of an academic medical center between August 1, 2012 and December 31, 2012. We used both quantitative and qualitative analytical techniques to characterize sign-outs in the following dimensions: completeness, usefulness and accuracy of information content, handoff task category, logic, internal consistency and appropriateness of assigned tasks, and composition and complexity of assigned tasks. The degree of completeness of information varied considerably across domains. Completeness was highest for entry of assigned tasks (99.9%), nearly as high for hospital course/presenting illness (95%), and relatively high (87%-98%) for entry of provider name and contact information, principal diagnosis, allergies, current clinical condition, mental status, and code status. Eighty-eight percent written handoffs described clinical condition and hospital course and whether there were tasks to complete. In 58% of suitable records, all problems listed in the electronic health record (EHR) were also present in the history of present illness. The accuracy of entered information also displayed wide variation. Only 80% of cardiovascular medications matched the contemporaneous EHR pharmacy record. Birth dates and allergies were identical in the handoff system and EHR in 95% and 86% of respective records. Of assigned tasks, 8% contained at least 1 unnecessary component or illogical/internally inconsistent element. Use of a handoff system, which organizes information entry through a standard template, promotes completeness of written handoff information. Inaccuracies in handoff data are associated with manual entry and should be discouraged. Programs should be encouraged to develop robust interfaces between the EHR and handoff platforms to promote entry of complete and accurate data and to enhance provider workflow.