Antithrombin restriction in extracorporeal membrane oxygenation support (ARES): A multidisciplinary approach.

Background: Antithrombin (AT) replacement is occasionally utilized in the setting of extracorporeal membrane oxygenation (ECMO)-associated heparin resistance. Although past studies emphasized the high costs and limited clinical benefit of AT supplementation,  guidance on strategies to prevent unnecessary use remain lacking.Methods: In this retrospective study, we evaluated the cost, efficacy, and safety outcomes three years pre- and post-implementation of an AT restriction protocol in adult ECMO patients. The primary endpoint was the cost spent on anticoagulation and AT normalized to ECMO duration. Secondary endpoints included thromboembolic and bleeding outcomes.Results: 175 patients were included for analysis (pre-restriction protocol n = 87; post-restriction protocol n = 88). Implementation of the restriction resulted in complete elimination of AT use and significantly reduced the primary cost endpoint from $1009.20 to $42.99 per ECMO day (p < .001). There was no significant change in occurrence of new Venous Thromboembolism (VTE) (p = .099). Those in the pre-implementation group had significantly higher rates of transfusions (p < .001) and ISTH major bleeding (p < .001). Outcomes remained significant after exclusion of patients with coronavirus infections.Conclusion: Results of this study exemplify how AT restriction can be successfully implemented to decrease anticoagulation-associated costs without jeopardizing the risk of bleeding and thrombosis in ECMO patients.

Levels of Albumin and Impact on Loop Diuretic and Albumin Co-administration in Heart Failure.

ABSTRACT: Management of heart failure (HF) requires the use of loop diuretics to relieve congestion and improve symptoms. When loop diuretics alone fail to induce adequate diuresis, albumin has been proposed to enhance loop diuretic delivery and promote redistribution of fluid for excretion by the kidneys. Despite the theoretical benefits of albumin, studies suggesting its benefit in HF are scarce and the co-administration of loop diuretics and albumin remains controversial. This retrospective, observational study evaluated patients with HF 18 years or older who received concomitant intravenous loop diuretic and albumin administration. The primary objective was to evaluate the association of serum albumin level with urine output (UOP) in hospitalized patients with HF who received concomitant albumin and loop diuretic therapy. Secondary endpoints included total weight loss after 72 hours, and ICU and hospital lengths of stay. In total, 276 patients were included for analysis. There was no association between initial serum albumin level and 72-hour UOP (coefficient -623.1, 95% confidence interval -1558.6 to 312.4; P = 0.191) or weight difference at 72 hours (coefficient -1.0, 95% confidence interval -2.4 to 0.3; P = 0.131). Lower albumin levels were associated with longer ICU ( P = 0.034) and hospital ( P = 0.039) lengths of stay. Concomitant thiazide diuretic use and increasing loop diuretic doses were associated with increased 72-hour UOP. The results of our study suggests that providers should avoid using baseline albumin levels as guidance for albumin dosing in HF. Given the lack of comparator groups, larger randomized controlled trials should be done to provide a definitive role for albumin to enhance diuresis in patients with HF on intravenous loop diuretics.

Apixaban for Treatment of Atrial Fibrillation and Venous Thromboembolism After Lung Transplantation.

INTRODUCTION: Guidelines recommend the use of direct oral anticoagulation therapy over warfarin for the treatment of venous thromboembolism and atrial fibrillation. However, there is uncertainty and a lack of data supporting the safety and efficacy of anticoagulation therapy in lung transplant recipients. Additionally, there are unique considerations for this population, such as labile renal function and drug interactions. PROJECT AIMS: The objective of this program evaluation was to evaluate the safety and efficacy of apixaban therapy for atrial fibrillation and venous thromboembolism in lung transplant recipients. DESIGN: Medical records of all adult lung transplant recipients who received apixaban for atrial fibrillation or venous thromboembolism treatment between January 1, 2018, and August 31, 2020 were retrospectively reviewed. Safety was evaluated by the incidence of bleeding. Efficacy was evaluated by the recurrence of blood clots or the incidence of stroke. RESULTS: A total of 134 recipients were included in the review. Thromboembolisms occurred in 14 recipients (10%), and none experienced a stroke. Bleeding occurred in 12 recipients (9%). CONCLUSIONS: The results of this evaluation were similar to those seen in smaller studies of the safety and efficacy of direct oral anticoagulation therapy for the treatment of atrial fibrillation or venous thromboembolism in lung transplant recipients, especially in recipients taking interacting azole antifungals. Prospective, comparative studies are needed to confirm these findings.

Intravenous to Oral Transition of Amiodarone (IOTA): Effect of Various Durations of Overlap on Atrial Fibrillation Recurrence After Cardiothoracic Surgery.

ABSTRACT: The use of amiodarone for postoperative atrial fibrillation (AF) is widespread; however, there is a paucity of data on the optimal duration of overlap when transitioning from intravenous (IV) to oral amiodarone. The objective of this study was to evaluate the safety and efficacy of varying durations of overlap when amiodarone IV infusion is transitioned to oral administration in cardiothoracic surgery patients. This retrospective, observational, single-center study included cardiothoracic surgery patients who were initiated on IV amiodarone for supraventricular arrhythmia and subsequently transitioned to oral amiodarone. The primary outcome was AF recurrence within 24 hours after IV amiodarone discontinuation. Safety outcomes include occurrence of bradycardia or hypotension while on amiodarone. A total of 184 patients were included for analysis. AF recurrence occurred in 24.5% of patients (n = 45). No significant association was found between various overlap durations and AF recurrence (odds ratio (OR) 1.00, 95% CI 1.00-1.01, P = 0.9). In addition, no significant association was found between duration of overlap and rates of bradycardia (OR 1.00, 95% confidence interval (CI) 0.99-1.00, P = 0.08) or hypotension (OR 1.00, 95% CI 0.99-1.00, P = 0.21), which occurred in 35.9% and 47.3% of patients, respectively. Our study suggests following conversion to normal sinus rhythm; cardiothoracic surgery patients can effectively and safely be transitioned from IV to oral amiodarone without the need for specific overlap duration or transition strategy.

Congenital blindness improves semantic and episodic memory.

Previous studies reported that congenitally blind people possess superior verb-generation skills. Here we tested the impact of blindness on capacity and the fidelity of semantic memory by using a false memory paradigm. In the Deese-Roediger-McDermott paradigm, participants study lists of words that are all semantically related to a lure that is not presented. Subsequently, participants frequently recall the missing lure. We found that congenitally blind participants have enhanced memory performance for recalling the presented words and reduced false memories for the lure. The dissociation of memory capacity and fidelity provides further evidence for enhanced verbal ability in the blind, supported by their broader structural and functional brain reorganisation.