Impact of 4 + 1 Block Scheduling on Patient Care Continuity in Resident Clinic

BACKGROUND

Leaders in medical education have called for redesign of internal medicine training to improve ambulatory care training. 4?+?1 block scheduling is one innovative approach to enhance ambulatory education.

AIM

To determine the impact of 4?+?1 scheduling on resident clinic continuity.

SETTING

Resident continuity clinic in traditional scheduling in which clinics are scheduled intermittently one-half day per week, compared to 4?+?1 in which residents alternate 1 week of clinic with 4 weeks of an inpatient rotation or elective.

PARTICIPANTS

First-year internal medicine residents.

PROGRAM DESCRIPTION

We measured patient–provider visit continuity, phone triage encounter continuity, and lab follow-up continuity.

PROGRAM EVALUATION

In traditional scheduling as opposed to 4?+?1 scheduling, patients saw their primary resident provider a greater percentage; 71.7 % vs. 63.0 % (p?=?0.008). In the 4?+?1 model, residents saw their own patients a greater percentage; 52.1 % vs. 37.1 % (p?=?0.0001). Residents addressed their own labs more often in 4?+?1 model; 90.7 % vs. 75.6 % (p?=?0.001). There was no significant difference in handling of triage encounters; 42.3 % vs. 35.8 % (p?=?0.12).

DISCUSSION

4?+?1 schedule improves visit continuity from a resident perspective, and may compromise visit continuity from the patient perspective, but allows for improved laboratory follow-up, which we pose should be part of an emerging modern definition of continuity.     

An Evaluation of Internal Medicine Residency Continuity Clinic Redesign to a 50/50 Outpatient–Inpatient Model

BACKGROUND

There have been recent calls for improved internal medicine outpatient training, yet assessment of clinical and educational variables within existing models is lacking.

OBJECTIVE

To assess the impact of clinic redesign from a traditional weekly clinic model to a 50/50 outpatient–inpatient model on clinical and educational outcomes.

DESIGN

Pre-intervention and post-intervention study intervals, comparing the 2009–2010 and 2010–2011 academic years.

PARTICIPANTS

Ninety-six residents in a Primary Care Internal Medicine site of a large academic internal medicine residency program who provide care for > 13,000 patients.

INTERVENTION

Continuity clinic redesign from a traditional weekly clinic model to a 50/50 model characterized by 50 % outpatient and 50 % inpatient experiences scheduled in alternating 1 month blocks, with twice weekly continuity clinic during outpatient months and no clinic during inpatient months.

MAIN MEASURES

1) Clinical outcomes (panel size, patient visits, adherence with chronic disease and preventive service guidelines, continuity of care, patient satisfaction, and perceived safety/teamwork in clinic); 2) Educational outcomes (attendance at teaching conference, resident and faculty satisfaction, faculty assessment of resident clinic performance, and residents’ perceived preparedness for outpatient management).

RESULTS

Redesign was associated with increased mean panel size (120 vs. 137.6; p?≤ 0.001), decreased continuity of care (63 % vs. 48 % from provider perspective; 61 % vs. 51 % from patient perspective; p ≤ ?0.001 for both; team continuity was preserved), decreased missed appointments (12.5 % vs. 10.9 %; p ≤ ?0.01), improved perceived safety and teamwork (3.6 vs. 4.1 on 5-point scale; p ≤ ?0.001), improved mean teaching conference attendance (57.1 vs. 64.4; p ≤ ?0.001), improved resident clinic performance (3.6 vs. 3.9 on 5-point scale; p ≤ ?0.001), and little change in other outcomes.

CONCLUSION

Although this model requires further study in other settings, these results suggest that a 50/50 model may allow residents to manage more patients while enhancing the climate of teamwork and safety in the continuity clinic, compared to traditional models. Future work should explore ways to preserve continuity of care within this model.     

Craniocervical decompression in patients with mucopolysaccharidosis VI: development of a scoring system to determine indication and outcome of surgery

Objective

To analyse diagnostic value of somato-sensory evoked potentials (SEP), magnetic resonance imaging (MRI), and clinical neurological examination in the decision for decompression surgery in mucopolysaccharidosis (MPS) VI patients with craniocervical cord compression (CCJ).

Methods

We retrospectively analysed neurological examination, SEP of the median nerve and MRI outcomes from 31 MPS VI patients. Individual scores for each test (based on severity of findings) and a sum of scores of all three procedures (CCJ score) were evaluated for their potential to measure the need for and improvement after surgery. Differences between rapidly and slowly progressive patients were also evaluated.

Results

Fourteen patients (45 %) aged 4–34 years underwent decompression surgery. Median age at first operation was lower in rapidly than in slowly progressive patients (12 vs. 24 years; P?=?0.008). Neurological and SEP findings but not MRI results differed significantly between non-operated and operated patients (P?<?0.001, P?=?0.003 and P?=?0.08, respectively). A significant relationship was found between MRI and clinical neurological examination (P?<?0.001) and between SEP and clinical neurological examination (P?=?0.01) but not between MRI and SEP (P?=?0.06). The CCJ score discriminated between operated and non-operated patients (4–9 points vs. 0–3 points; P?<?0.001) and decreased in 61.5 % of patients after surgery.

Conclusions

CCJ is common in rapidly and slowly progressive MPS VI patients. The CCJ score is an objective and transparent tool for assessing pathology of the CCJ, the need for surgery, and improvement after surgery.     

Do young patients have different clinical presentation of colorectal cancer causing delay in diagnosis?

Purpose

The incidence of colorectal cancer is increasing among young patients. In these patients, colorectal cancer is believed to have a poorer prognosis because it is more aggressive and diagnosed at later stages; however, the behavior of these tumors in young patients remains to be elucidated. We investigated the impact of time interval between onset of symptoms and diagnosis (TISD) at the pathologic stage of colorectal cancer in young patients.

Methods

The medical records of 215 patients with colorectal adenocarcinoma were reviewed. Patients were divided into two groups according to age. The young group (age?<?50 years) consisted of 66 patients, and the older group (age?≥?50 years) of 149 patients. Clinical variables, TISD, pathologic stage, operative mortality, and oncologic outcomes were compared between groups.

Results

The older group had less abdominal pain (74.0 vs. 56.0 %, p?=?0.0129). In multivariate analysis, the following variables were independently associated with tumor pathologic stage: personal history of inflammatory bowel disease (p?<?0.0001), family history of familial adenomatous polyposis (p?=?0.00100), and smoking (p?=?0.0070). Both groups had similar rates regarding pathologic stage (I, 15 vs. 22 %; II, 22 vs. 24 %; III, 27 vs. 16 %; IV, 37 vs. 38 %, p?=?0.3380). There was no difference in overall survival [45 (69 %) vs. 84 (61 %), p?=?0.2482] and cancer-free survival [36 (63 %) vs. 83 (62 %), p?=?0.9218] between groups.

Conclusions

Young patients with colorectal cancer had clinical and pathological presentation similar to that of older patients.     

Primary Care Utilization and Mental Health Diagnoses Among Adult Patients Requiring Interpreters: a Retrospective Cohort Study

BACKGROUND

Patients requiring interpreters may utilize the health care system differently or more frequently than patients not requiring interpreters; those with mental health issues may be particularly difficult to diagnose.

OBJECTIVE

To determine whether adult patients requiring interpreters exhibit different health care utilization patterns and rates of mental health diagnoses than their counterparts.

Design

Retrospective cohort study examining patient visits to primary care (PC), express care (EC), or the emergency department (ED) of a large group practice within 1 year.

PATIENTS

Adult outpatients (n?=?63,525) with at least one visit within the study interval and information regarding interpreter need.

MAIN MEASURES

Mean visit counts, counts of mental disorders, and somatic symptom diagnoses between patients requiring interpreters (IS patients) and not requiring interpreters (non-IS patients).

KEY RESULTS

IS patients (n?=?1,566) had a higher mean number of visits overall (3.10 vs. 2.52), in PC (2.54 vs. 1.95), and in ED (0.53 vs. 0.44) than non-IS patients (all p?<?0.01). IS patients had a lower mean number of visits in EC than non-IS patients (0.03 vs. 0.13; p?<?0.01). Interpreter need remained a significant predictor of visit count in multivariate analyses including age, sex, insurance, and clinical complexity. A greater proportion of IS patients were high utilizers (10+ visits) than non-IS patients (3.6 % vs. 1.7 %; p?<?0.01). IS patients had a lower frequency of mental health diagnoses (13.9 % vs. 16.7 %), but a higher frequency of diagnoses recognized as potential somatic symptoms including diseases of the nervous (29.3 % vs. 24.2 %), digestive (22.6 % vs. 14.5 %), and musculoskeletal systems (43.2 % vs. 34.5 %), and ill-defined conditions (61 % vs. 49.9 %), all p?<?0.01.

CONCLUSIONS

IS patients visited PC more often than their counterparts and were more often high utilizers of care. Two sources of high utilization, mental health diagnoses and somatic symptoms, differed appreciably between our populations and may be contributing factors.     

Dabigatran in the peri-procedural period for radiofrequency ablation of atrial fibrillation: efficacy, safety, and impact on duration of hospital stay

Purpose

Dabigatran is effective for both the prevention of stroke and bleeding in patients with atrial fibrillation (AF). However, the safety and efficacy of the use of dabigatran in the peri-procedural period for radiofrequency catheter ablation (RFCA) of AF is unknown. Therefore, the purpose of this study was to evaluate the safety and efficacy of dabigatran in the peri-procedural period for RFCA of AF and the duration of hospital stay.

Methods

Consecutive patients (n?=?227) who underwent RFCA for AF were prospectively analyzed. Peri-procedural anticoagulant therapy with dabigatran (n?=?101, D group) was compared with warfarin and heparin bridging (n?=?126, W group). Dabigatran was discontinued 12–24 h before and restarted 3 h after the procedure. Warfarin was stopped 3 days before the procedure and unfractionated heparin was administered.

Results

Ischemic stroke occurred in one patient of the D group (0.8 %). There was no significant difference between the two groups in the incidence of major bleeding (three cases of cardiac tamponade in each group and one case of intracranial bleeding in the W group, p?=?0.93) or minor bleeding (five cases in the D group vs. five in the W group, p?=?0.54). The duration of hospital stay was significantly shorter in the D group than in the W group (7.2 vs. 10.3 days, p?=?0.0001).

Conclusions

Peri-procedural anticoagulation therapy with dabigatran for RFCA of AF was equally safe and effective compared with warfarin and heparin bridging. The use of dabigatran for RFCA of AF shortened the duration of hospital stay.     

Continuous warfarin versus periprocedural dabigatran to reduce stroke and systemic embolism in patients undergoing catheter ablation for atrial fibrillation or left atrial flutter

Purpose

Left atrial catheter ablation for patients with atrial fibrillation (AF) requires periprocedural anticoagulation to minimize thromboembolic complications. High rates of major bleeding complications using dabigatran etexilate for periprocedural anticoagulation have been reported, raising concerns regarding its safety during left atrial catheter ablation. We sought to evaluate the safety and efficacy of a dabigatran use strategy versus warfarin, at a single high-volume AF ablation center.

Methods

We performed a retrospective analysis on consecutive patients undergoing left atrial ablation at Vanderbilt Medical Center from January 2011 through August 2012 with a minimum follow-up of 3 months. Patient cohorts were divided into two groups, those utilizing dabigatran etexilate pre- and post-ablation and those undergoing ablation on dose-adjusted warfarin, with or without low-molecular-weight heparin bridging. Dabigatran was held 24–30 h pre-procedure and restarted 4–6 h after hemostasis was achieved. We evaluated all thromboembolic and bleeding complications at 3 months post-ablation.

Results

A total of 254 patients underwent left atrial catheter ablation for atrial fibrillation or left atrial flutter. Periprocedural anticoagulation utilized dabigatran in 122 patients and warfarin in 135 patients. Three late thromboembolic complications occurred in the dabigatran group (2.5 %), compared with one (0.7 %) in the warfarin group (p?=?0.28). The dabigatran group had similar minor bleeding (2.5 vs. 7.4 %, p?=?0.07), major bleeding (1.6 vs. 0.7 %, p?=?0.51), and composite of bleeding and thromboembolic complications (6.6 vs. 8.9 %, p?=?0.49) when compared to warfarin. There were no acute thromboembolic complications in either group (<24 h post-ablation).

Conclusions

In patients undergoing left atrial catheter ablation for AF or left atrial flutter, use of periprocedural dabigatran etexilate provides a safe and effective anticoagulation strategy compared to warfarin. A prospective randomized study is warranted.     

Factors associated with fluoroscopy exposure during pediatric catheter ablation utilizing electroanatomical mapping

Purpose

Exposure to ionizing radiation during electrophysiologic procedures in children is believed to increase the risk of future malignancy. Electroanatomical navigation can reduce exposure, but the cohort of children who derive the greatest benefit from this approach is incompletely defined. We sought to determine factors associated with fluoroscopy exposure with conventional catheter ablation versus electroanatomical navigation.

Methods

A retrospective review of all ablation procedures over a 5-year period during the transition to electroanatomical navigation performed by a single electrophysiologist was performed. Fluoroscopy time >20 min was considered “prolonged.” Statistical analysis was performed to determine differences among groups.

Results

Two hundred thirty-four subjects underwent catheter ablation during the study period (conventional, n?=?127; navigation, n?=?107). Mean fluoroscopy decreased from 11.1 to 3.5 min with electroanatomical navigation (p?<?0.0001). Overall 53/107 subjects (50 %) undergoing catheter ablation using electroanatomical navigation required no fluoroscopy, of which atrioventricular nodal reentry tachycardia (AVNRT) (n?=?23) and right-sided accessory pathways (n?=?22) were most common (p?=?0.001). Prolonged fluoroscopic exposure was observed for 22/127 (17 %) subjects undergoing conventional fluoroscopy versus 3/107 (3 %) subjects with electroanatomical navigation (p?=?0.001) and was not observed after increased experience. Flouroscopy time decreased significantly after the first 20 procedures (p?=?0.04). There was no difference in success, complication, or recurrence rate between groups.

Conclusions

Electroanatomical navigation significantly reduced fluoroscopic exposure without compromising safety, efficacy, or recurrence. Subjects with AVNRT and right-sided accessory pathways derived the greatest benefit as did those requiring prolonged fluoroscopy by the conventional approach.     

The timing of surgery after preoperative short-course S-1 chemoradiotherapy with delayed surgery for T3 lower rectal cancer

Purpose

The purpose of this study was to analyze the influence of variations in clinical practice regarding the timing of surgery with short-course chemoradiotherapy with delayed surgery (SCRT-delay) for lower rectal cancer.

Methods

A total of 171 patients with T3 N0-2 lower rectal cancer treated with SCRT-delay (25 Gy/10 fractions/5 days (S-1); days 1–10) were retrospectively evaluated. The median waiting period of 30 days was used as a discriminator (group A: waiting period, ≤30 days; group B: waiting period, ≥31 days). Preoperative treatment responses and oncological outcomes were analyzed.

Results

The mean waiting periods for groups A and B were 24.4?±?5.3 and 41.4?±?12.3 days, respectively. There were no statistically significant differences between the two groups in any of the clinical variables. The clinicopathological outcomes were as follows: T downstaging (43.5 vs 37.2 %; p?=?0.400), negative yp N (67.1 vs 75.6 %; p?=?0.218), pCR (7.1 vs 1.2 %; p?=?0.119). The 5-year local recurrence-free survival (89.3 vs 87.6 %; p?=?0.956), the recurrence-free survival (82.2 vs 78.8 %; p?=?0.662), and the overall survival (88.5 vs 84.4 %; p?=?0.741), all of which were similar between the two groups.

Conclusions

The longer waiting period did not increase the tumor downstaging and not improve the oncological outcomes for T3 lower rectal cancer treated with SCRT-delay. In addition, considering that the impaired leukocyte response occurred during the sub-acute period, any time after the sub-acute period (day 12) up to 30 days after radiotherapy would be a suitable waiting period.     

Inner lumen mapping catheter-facilitated big cryoballoon treatment for atrial fibrillation shortens procedural duration and fluoroscopic exposure with comparable mid-term efficacy

Purpose

This study aims to investigate whether the use of a novel inner lumen circular mapping catheter (IMC) can shorten the procedural duration and fluoroscopic exposure of the single transseptal big cryoballoon (CB) pulmonary vein isolation (PVI) procedures in patients with atrial fibrillation (AF).

Methods

This is a prospective non-randomized case–control study. Forty-two patients (28 men, mean age 55.7?±?12.1) with drug-refractory paroxysmal or persistent AF and underwent CB PVI procedures were divided into Group A (conventional single transseptal big CB approach, n?=?21) and Group B (IMC-facilitated approach, n?=?21). They were compared in the co-primary endpoints: (1) procedural duration and (2) fluoroscopic exposure and secondary endpoints: (1) 6-month AF-free survival and (2) number of cryo-applications.

Results

Both the procedural duration (162?±?26 vs. 215?±?25 min; p?<?0.001) and fluoroscopic exposure (44.1?±?10.4 vs. 56.8?±?11.7 min; p?=?0.001) were significantly shorter in Group B than Group A patients. With multivariate stepwise regression, only the use of IMC was an independent predictor for procedural duration (β?=??59; 95 % CI, ?84.1 to ?33.8; p?<?0.001) and fluoroscopic exposure (β?=??16.9; 95 % CI, ?28.4 to ?5.4; p?=?0.006). The number of cryo-applications was significantly fewer in Group B than Group A patients (median 8 vs. 11; p?=?0.001). There was no significant difference in the 6-month AF-free survival between the two approaches (57 % vs. 71 %; p?=?0.351).

Conclusions

Compared to conventional single transseptal big CB PVI procedures, the use of IMC may reduce procedural duration, fluoroscopic exposure and the number of cryo-applications with comparable mid-term efficacy.     

Heterogeneous Postprandial Lipoprotein Responses in the Metabolic Syndrome, and Response to Fenofibrate Therapy

Background

Hypertriglyceridemia subjects with metabolic syndrome exhibit variable postprandial triglyceride responses. We investigate the effects of fenofibrate therapy on postprandial triglyceride-containing lipoproteins in subjects with early (3.5 h) versus late (8 h) postprandial triglyceride responses.

Methods

Fifty-five subjects with fasting hypertriglyceridemia (≥1.7 mmol/L (150 mg/ dL) and <5.8 mmol/L (500 mg/dL)) and ≥2 Adult Treatment Panel III criteria of the metabolic syndrome were randomized to daily fenofibrate (160 mg/d) or placebo for 12 weeks in a double-blind controlled clinical trial. A standardized fat load (50 g/m²) was given orally after a 12 h fast. Blood specimens were obtained at 0 h (fasting), 3.5 h, and 8 h after the test meal. Analysis is confined to the 53 subjects with clearly identifiable early or late triglyceride peaks prior to therapy.

Results

Fenofibrate was more effective in late peakers (n?=?8) when compared to early peakers (n?=?15) with respect to reducing postprandial triglyceride concentrations (?67% vs. ?34%, p?=?0.0024) and large VLDL (?76% vs. ?31%, p?=?0.0016), and increasing total HDL particles (20% vs. 11%, p?=?0.008) and large HDL particles (185% vs. 88%, p?=?0.003). On fenofibrate therapy, 100% of those initially designated as late peakers were reclassified as early peakers; 47% of late peakers assigned to placebo were reclassified as early peakers.

Conclusions

Late postprandial triglyceride responders have attenuated clearance of large VLDL particles, but they were more responsive to fenofibrate.     

Insulin pump use in pregnancy is associated with lower HbA1c without increasing the rate of severe hypoglycaemia or diabetic ketoacidosis in women with type 1 diabetes

Aims/hypothesis

The aim of this study was to compare glycaemic control and maternal–fetal outcomes in women with type 1 diabetes managed on insulin pumps compared with multiple daily injections of insulin (MDI).

Methods

In a retrospective study, glycaemic control and outcomes of 387 consecutive pregnancies in women with type 1 diabetes who attended specialised clinics at three centres 2006–2010 were assessed.

Results

Women using insulin pumps (129/387) were older and had a longer duration of diabetes, more retinopathy, smoked less in pregnancy, and had more preconception care (p?<?0.01 for each). Among 113 pregnancies >20 weeks’ gestation in women on insulin pumps and 218 in women on MDI, there was a significant difference in HbA_1c in the first trimester (mean HbA_1c 6.90?±?0.71% (52?±?7.8 mmol/mol) vs 7.60?±?1.38% (60?±?15.1 mmol/mol), p?<?0.001), which persisted until the third trimester (mean HbA_1c 6.49?±?0.52% (47?±?5.7 mmol/mol) vs 6.81?±?0.85% (51?±?9.3 mmol/mol), p?=?0.002). Rates of diabetic ketoacidosis were similar in women on insulin pumps vs MDI (1.8% vs 3.0%, p?=?0.72). Despite lower HbA_1c, women on insulin pumps did not have an increased incidence of severe hypoglycaemia (8.0% vs 7.6%, p?=?0.90) or more weight gain (16.3?±?8.7 vs 15.2?±?6.2 kg, p?=?0.18). More large-for-gestational-age infants in the pump group (55.0% vs 39.2%, p?=?0.007) may have resulted from confounding by parity.

Conclusions/interpretation

In this large multicentre study, women using insulin pumps in pregnancy had lower HbA_1c without increased risk of severe hypoglycaemia or diabetic ketoacidosis but no improvement in other pregnancy outcomes. This information can help inform care providers and patients about the glycaemic effectiveness and safety of insulin pumps in pregnancy.     

Colectomy without mechanical bowel preparation in the private practice setting

Background

Despite randomized trials and meta-analyses demonstrating the safety of omitting mechanical bowel preparation (MBP) before colorectal surgery, private practice surgeons may hesitate to eliminate MBP for fear of being outside community standards. This study evaluated the safety of eliminating MBP before colectomy in a private practice setting.

Methods

This prospective observational study included elective abdominal colorectal operations from one surgeon’s practice from October 2008 to June 2011. MBP was not routinely utilized after November 2009. Postoperative 30-day complication rates and length of hospital stay were compared in patients with and without MBP. Multivariable regression models were developed to compare outcomes among study groups, adjusting for demographics, diagnoses, procedures, and year.

Results

A total of 165 patients were analyzed. Demographics were similar between groups. Laparoscopic procedures were more common in patients without MBP due to increased laparoscopy over time (43 vs. 61 %, p = 0.03). As regards complications, infection rates were similar between groups (MBP 10.5 % vs. no MBP(NMBP) 11.4 %, adj p = 0.57). Patients without MBP had a shorter length of hospital stay (median: 6 vs. 5 days, p = 0.01), but those differences were not statistically significant after adjustment (p = 0.14).

Conclusions

Private practice surgeons should embrace evidence-based practice changes and make efforts to quantitatively evaluate the safety of those changes. Omission of MBP for most elective colectomy procedures appears to be safe with no significant increase in complications or length of hospital stay. Because MBP has substantial drawbacks, there is little justification for its routine use in the majority of elective abdominal colorectal procedures.     

Primary Care Careers Among Recent Graduates of Research-Intensive Private and Public Medical Schools

BACKGROUND

Despite a growing need for primary care physicians in the United States, the proportion of medical school graduates pursuing primary care careers has declined over the past decade.

OBJECTIVE

To assess the association of medical school research funding with graduates matching in family medicine residencies and practicing primary care.

DESIGN

Observational study of United States medical schools.

PARTICIPANTS

One hundred twenty-one allopathic medical schools.

MAIN MEASURES

The primary outcomes included the proportion of each school’s graduates from 1999 to 2001 who were primary care physicians in 2008, and the proportion of each school’s graduates who entered family medicine residencies during 2007 through 2009. The 25 medical schools with the highest levels of research funding from the National Institutes of Health in 2010 were designated as “research-intensive.”

KEY RESULTS

Among research-intensive medical schools, the 16 private medical schools produced significantly fewer practicing primary care physicians (median 24.1 % vs. 33.4 %, p?<?0.001) and fewer recent graduates matching in family medicine residencies (median 2.4 % vs. 6.2 %, p?<?0.001) than the other 30 private schools. In contrast, the nine research-intensive public medical schools produced comparable proportions of graduates pursuing primary care careers (median 36.1 % vs. 36.3 %, p?=?0.87) and matching in family medicine residencies (median 7.4 % vs. 10.0 %, p?=?0.37) relative to the other 66 public medical schools.

CONCLUSIONS

To meet the health care needs of the US population, research-intensive private medical schools should play a more active role in promoting primary care careers for their students and graduates.     

Brain magnetic resonance imaging findings in patients with mucopolysaccharidosis VI

Introduction

Mucopolysaccharidosis type VI (MPS VI) is a rare lysosomal storage disorder caused by the deficient activity of N-acetylgalactosamine 4-sulfatase. MPS VI is usually considered as not being associated with mental retardation.

Aims/methods

The main objective of the present study was to describe brain magnetic resonance imaging (MRI) findings and their correlation with clinical and biochemical findings in MPS VI patients. The study was conducted at Hospital de Clínicas de Porto Alegre, Brazil with 25 MPS VI patients. All patients were evaluated through clinical evaluation, IQ tests, urinary glycosaminoglycans (GAG) analysis, and brain MRI.

Results

Mean age at evaluation was 10.6?±?4.52 years. Five of 16 patients presented total IQ below the normal range. Brain MRI was abnormal in the majority of patients (n?=?19/21), and the most frequent abnormalities found were the presence of dilated perivascular spaces and white matter lesions. Correlations were found between age and normalized white matter lesion load (NLL) (r?=?0.46; p?=?0.04) and normalized cerebral volume (NCV) (r?=??0.56; p?=?0.01), between NLL and height deficit (r?=?0.48; p?=?0.04), and between NCV and weight deficit (r?=??0.58; p?=?0.01) and height deficit (r?=??0.55; p?=?0.01). A correlation between urinary GAG levels and quantitative brain MRI findings was not found, neither between qualitative and quantitative brain MRI findings and IQ scores.

Conclusions

MPS VI patients may present abnormal IQ scores without correlation with brain abnormalities on the MRI, a finding which was found to be very frequent in MPS VI. Additional studies are required to confirm our findings.     

The prevalence and risk factors for atrioesophageal fistula after percutaneous radiofrequency catheter ablation for atrial fibrillation: the Canadian experience

Purpose

Atrioesophageal fistula (AEF) is an infrequent complication of radiofrequency (RF) ablation for atrial fibrillation (AF). The aim of this study was to determine the prevalence and operator-dependent factors associated with AEF using a nationwide survey of electrophysiologists (EP).

Methods

Thirty-eight EPs performing AF ablation between 2008 and 2012 were invited to complete a web-based questionnaire assessing the prevalence and factors associated with AEF.

Results

Responses were obtained from 25 EPs (68 %) accounting for 7,016 AF ablations. Five cases of proven AEF (0.07 %) were reported. Operators who reported AEF [AEF (+)] more often used general anesthesia (GA) [90 % AEF (+) vs. 44 % AEF (?), p?=?0.046]. AEF (+) operators were also more likely to be users of the non-brushing technique in the posterior wall of the LA [5 (100 %) AEF (+) vs. 5 (25 %) AEF (?), p?=?0.005]. The combined usage of GA and non-brushing technique during LA posterior wall ablation had a strong association with AEF (+) operators [4 (80 %) AEF (+) vs. 2 (10 %) AEF (?), p?=?0.002]. There was a trend towards higher maximal RF energy setting in the posterior wall [47.4 + 7.6 AEF (+) vs. 40.2 + 8 AEF (?), p?=?0.09]. Other procedure parameters were similar.

Conclusions

The reported prevalence of AEF among Canadian AF ablators is 0.07 %. AEF was associated with high mortality. The use of GA and non-brushing movements during posterior wall ablation were two factors associated with AEF.     

Safety of new oral anticoagulants for patients undergoing atrial fibrillation ablation

Background

The new oral anticoagulants (NOAC), dabigatran and rivaroxaban, have been demonstrated to be at least equivalent to warfarin for preventing cardiac thromboembolism (TE) in patients with atrial fibrillation (AF). However, there is limited data regarding use around catheter ablation (CA) procedures.

Objective

We evaluated the risk of bleeding and TE complications associated with NOAC use during AF ablation.

Methods

Consecutive patients undergoing AF ablation between January 2011 and 6 September 2013 were grouped based on peri-procedural anticoagulation regimen: (1) uninterrupted warfarin with therapeutic INR (WARF), n?=?114, (2) dabigatran, n?=?89, or (3) rivaroxaban, n?=?98. NOACs were held for 24 h (dabigatran) or 36 h (rivaroxaban) prior to the procedure. Heparin infusion was initiated 6 h post-procedure for the NOAC groups; NOACs were resumed the morning after the procedure. Antral PVI was performed with activated clotting time (ACT) maintained >300 s. TE or bleeding complications during ablation and through 30 days were compared.

Results

Three hundred and one patients underwent ablation for paroxysmal (71 %) or persistent (29 %) AF. International Normalization Ratio (INR) for the WARF group was 2.0?±?0.5. Baseline characteristics were similar among the groups. There were two TE events (asymptomatic cerebral emboli and TIA), and there were 17 bleeding events (large hematoma n?=?4; pericardial effusion n?=?6; persistent hematuria n?=?1; pseudoaneurism/AV fistula n?=?6). Of the six pericardial effusions, three required drainage. There was no significant difference in combined TE/bleeding risk among the groups (WARF vs. dabigatran vs. rivaroxaban; 6.2 % vs. 6.7 % vs. 6.0 %; p?=?0.82)

Conclusions

In this group of AF patients undergoing CA, use of peri-procedure dabigatran or rivaroxaban compared to uninterrupted warfarin did not lead to an increase in bleeding or TE complications.