Resident Physicians Choices of Anticoagulation for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation.

Atrial fibrillation (AF) is a common cardiac arrhythmia and is associated with an increased risk of ischemic stroke. The aim of this study was to identify practice patterns of Canadian resident physicians pertaining to stroke prevention in nonvalvular AF according to the Canadian Cardiovascular Society guidelines. A Web-based survey consisting of 16 multiple-choice questions was distributed to 11 academic centres. Questions involved identification of risks of stroke, bleeding, and selection of appropriate therapy in clinical scenarios that involve a patient with AF with a Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) score of 3 and no absolute contraindications to anticoagulation. There were 1014 total respondents, of whom 570 were internal, 247 family, 137 emergency medicine, and 60 adult cardiology residents. For a patient with a new diagnosis of AF, warfarin was chosen by 80.3%, novel oral anticoagulants (NOACs) by 60.3%, and acetylsalicylic acid (ASA) by 7.2% of residents. To a patient with a history of gastrointestinal bleed during ASA treatment, warfarin was recommended by 75.1%, NOACs by 36.1%, ASA by 12.1%, and 4% were unsure. For a patient with a history of an intracranial bleed, warfarin was recommended by 38.8%, NOACs by 23%, ASA by 24.8%, and 18.2% were unsure. For a patient taking warfarin who had a labile international normalized ratio, 89% would switch to a NOAC and 29.5% would continue warfarin. This study revealed that, across a wide sampling of disciplines and centres, resident physician choices of anticoagulation in nonvalvular AF differ significantly from contemporary Canadian Cardiovascular Society guidelines.

Can the Blaylock Risk Assessment Screening Score (BRASS) predict length of hospital stay and need for comprehensive discharge planning for patients following hip and knee replacement surgery? Predicting arthroplasty planning and stay using the BRASS.

BACKGROUND: Knee and hip arthroplasty constitutes a large percentage of hospital elective surgical procedures. The Blaylock Risk Assessment Screening Score (BRASS) was designed to identify patients in need of discharge planning. The purpose of this study was to evaluate whether the BRASS was associated with length of stay (LOS) in hospital following elective arthroplasty. METHODS: We retrospectively reviewed the charts of individuals undergoing primary elective arthroplasty for knee or hip osteoarthritis who had a documented BRASS score. RESULTS: In our study cohort of 241, both BRASS (p < 0.001) and replacement type (hip v. knee; p = 0.048) were predictive of LOS. Higher BRASS was associated with older patients (p < 0.001), higher American Society of Anesthesiologists score (p < 0.001) and longer LOS (p < 0.001). We found a specificity of 83% for a BRASS greater than 8 and a hospital stay longer than 5 days and a specificity of 92% for a BRASS greater than 10. CONCLUSION: The BRASS represents a novel and significant predictor of LOS following elective arthroplasty. Patients with higher BRASS are more likely to stay in hospital 5 days or more and should receive pre-emptive social work consultations to facilitate timely discharge planning and hospital resources.

CONTEXTE: Les arthroplasties du genou et de la hanche représentent un fort pourcentage des interventions chirurgicales non urgentes pratiquées dans les hôpitaux. Le score BRASS (Blaylock Risk Assessment Screening Score) a été conçu pour reconnaître les patients dont il faut planifier le congé de l'hôpital. Le but de la présente étude était de vérifier s'il y a un lien entre le score BRASS et la durée du séjour hospitalier (DSH) après une arthroplastie non urgente. MÉTHODES: Nous avons analysé rétrospectivement les dossiers de patients soumis à une arthroplastie primaire non urgente du genou ou de la hanche dont le score BRASS avait été documenté. RÉSULTATS: Dans la cohorte de 241 patients de notre étude, le score BRASS (p < 0,001) et le type d'arthroplastie (hanche c. genou, p = 0,048) ont été des facteurs prédicteurs de la DSH. Un score BRASS plus élevé était associé à un âge plus avancé des patients (p < 0,001), à un score plus élevé à l'échelle de l'American Society of Anesthesiologists (p < 0,001) et à une DSH plus longue (p < 0,001). Nous avons observé une spécificité de 83 % pour un score BRASS supérieur à 8 et un séjour hospitalier de plus de 5 jours, et une spécificité de 92 % pour un score BRASS supérieur à 10. CONCLUSION: Le score BRASS constitue un nouveau prédicteur important de la DSH après une arthroplastie non urgente. Les patients dont le score BRASS est plus élevé, risquent davantage de séjourner plus de 5 jours à l'hôpital et devraient bénéficier de consultations préventives auprès du personnel des Services sociaux afin de faciliter la planification des congés en temps opportun et d'assurer l'utilisation efficace des ressources hospitalières.

The peri-procedural use of dabigatran in patients undergoing left atrial ablation for atrial fibrillation.

INTRODUCTION: Pulmonary vein isolation is an effective strategy in patients with atrial fibrillation (AF). The peri-procedural use of anticoagulation is routinely employed to reduce thromboembolic risk. AIMS/METHODS: The aim of this study was to compare the use of Dabigatran to the other 2 strategies involving the use of Warfarin. Single centre observational study comparing 3 anticoagulation strategies: Group 1 consisted of patients maintained on Warfarin (5.15 ± 2.52 mg) with a therapeutic INR of 2-3. Group 2 comprised patients initially treated with Warfarin (6.98 ± 3.17 mg), which was discontinued 1 week prior to LA ablation, during which time patients were bridged with a therapeutic dose of Dalteparin. Group 3 included patients anticoagulated with Dabigatran (40 patients received 150 mg BID, 3 patients received 110 mg BID), which was discontinued 24-30 h prior to the procedure. RESULTS: A total of 207 patients were included in the study. There were no significant differences in age, sex, LA volume, CHADS2 score or proportion of patients with persistent AF. There were no significant differences in the number of patients with intra-cardiac thrombus found at TOE (Group 1: 2.3% vs. Group 2: 1.5% vs. Group 3: 0%; P = 0.37). Furthermore, there were no differences in the rate of groin hematoma (2.2% vs. 1.5% vs. 2.3%; P = 0.8) or the development of pericardial effusion (5.4% vs. 8.8% vs. 2.3%; P = 0.54). No thromboembolic events were seen. CONCLUSION: Peri-procedural use of Dabigatran during AF ablation procedures is safe, with no significant difference when compared to conventional anticoagulation with either Warfarin bridged with Dalteparin or uninterrupted Warfarin.

A long delay from the first symptom to definite diagnosis of pulmonary tuberculosis.

BACKGROUND: Despite the recent advances in medicine, still many people suffer from long-standing tuberculosis. Delay in the diagnosis may result in further mortality and morbidity. Because of the importance of delay in the diagnosis, we decided to study and evaluate the patient delay and physician delay. METHODS: A descriptive analytical study was done on 97 patients referred to the National Research Institute of Tuberculosis and Lung Disease in Tehran from September 2002 through March 2003. Those individuals who fulfilled the inclusion criteria underwent a face to face interview. The questionnaires were filled out. The interval between the first appearance of the clinical manifestation and the first visit to the physician was calculated (patient delay). Also, the period between the patient's first visit to the physician and the final diagnosis was worked out. RESULTS: The mean patient delay time was 15 +/- 13 days with a median of 13 days. The mean physician delay time was 93 +/- 72 days with a median of 75 days. The mean total delay time was 108 +/- 71 days with a median of 96 days. CONCLUSION: The patient delay in our country is at an acceptable level compared with other countries, but our physician delay time has not been shortened during the last eight years. Improving and upgrading the mycobacteriological courses for general physicians and specialists during their academic years should be accompanied by short-term teaching courses after the graduation.