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Managing AF: A Look at Treating Specialty

Managing AF: A Look at Treating Specialty

About 2.3 million Americans are affected by atrial fibrillation and atrial flutter (AF), a condition that causes 15% of the 700,000 strokes that occur annually in the United States. Anticoagulants like warfarin can help prevent stroke in AF patients, but these therapies can also cause bleeding in some cases. “Prediction tools, such as the CHADS2 score, have been developed to estimate stroke risk and are now recommended by clinical guideline statements,” says Mintu P. Turakhia, MD, MAS. “These guidelines, however, vary considerably in describing how stroke and bleeding risk should be evaluated and integrated into clinical decision making.” Assessing Potential Variations in Warfarin Use It has been suspected that use of warfarin in AF may vary by specialty and over time. In the American Heart Journal, Dr. Turakhia and colleagues had a study published that evaluated differences and trends in warfarin prescription by treating specialty for new AF cases. Using VA data from the TREAT-AF study, the investigators reviewed more than 141,000 participants with newly diagnosed AF in which patients had at least one internal medicine, primary care, or cardiology encounter within 90 days of their diagnosis. The primary outcome was prescription of warfarin. According to results, care of patients with new AF from cardiologists appeared to be associated with a greater likelihood of warfarin prescription when compared with care only from primary care physicians (Table 1), even after adjusting for covariates and a propensity for cardiology care. The observation was also consistent across subgroups of patients, including those who were at lowest risk for bleeding. Furthermore, warfarin prescriptions were more frequently provided to those at highest risk for stroke,...
Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Patients with a trauma-induced coagulopathy account for more than half of hemorrhagic deaths in the United States. About 25% of severely injured patients are already coagulopathic and thrombocytopenic upon arrival to trauma centers. Mortality rates have been shown to decrease in these patients when they receive higher ratios of plasma and platelets. “Early transfusion of red blood cells (RBCs) has been established as a core element of trauma resuscitation,” says Bryan A. Cotton, MD, MPH. “Most trauma centers store RBCs in their EDs, but few store plasma in their EDs. This makes it challenging to achieve high plasma-RBC ratios early during care, which in turn can worsen coagulopathy and increase patient mortality.” Expediting Plasma Delivery Over the past several years, more and more trauma centers have implemented massive transfusion (MT) protocols to ensure that severely injured patients receive higher plasma-RBC ratios early. “This was shown to markedly reduce the time to release of plasma, but the time to transfusion was still excessively long,” Dr. Cotton says. In an effort to expedite the delivery of plasma for patients requiring MT, some medical centers began keeping thawed plasma (TP) in their blood banks (BBs).   MT protocols vary throughout trauma centers in the U.S., but those reporting the most marked changes in survival are the ones that have implemented concurrent TP programs. Furthermore, trauma centers that develop TP programs concurrent with MT protocols have shown that they can reduce the time to first plasma transfusion and the overall number of blood components transfused. Testing a New Thawed Plasma Protocol In 2006, Dr. Cotton and colleagues began a TP program in their...
Wide Variation in Blood Transfusion Use

Wide Variation in Blood Transfusion Use

Current clinical guidelines from three medical societies suggest that the hemoglobin threshold for blood transfusions during surgery should be 7 g/dl or 8 g/dl. These guidelines also note that patients don’t need a transfusion when hemoglobin levels are above 10 g/dl. However, when hemoglobin levels fall between these thresholds, there is little consensus on the best course of action. Although four landmark studies published over the past 5 years suggest that it’s safe to wait until hemoglobin levels fall to 7 g/dl or 8 g/dl before transfusing, wide variation and excessive use of blood transfusions have been reported. Advances in viral testing in recent years have made blood transfusion safer, but risks still exist for these patients, including lung injury, immune suppression, and viral transmission. Blood is also in scarce supply and expensive. Wide Variation of Hemoglobin Thresholds In an issue of Anesthesiology, my colleagues and I had a study published that sought to confirm the wide range of hemoglobin thresholds used by surgeons and anesthesiologists. Over 18 months, we collected data on more than 48,000 surgical patients at Johns Hopkins Hospital. Within the institution, there was a variation of up to 3 g/dl in hemoglobin thresholds among surgeons and anesthesiologists, when compared with their peers. Virtually all providers used thresholds above the ones recommended in guidelines, and none used thresholds below the recommended range. Surprisingly, sicker patients—generally those under-going cardiac surgeries—had the lowest hemoglobin thresholds, whereas those undergoing surgery for pancreatic cancer, orthopedic issues, and aortic aneurysms received blood transfusions at higher thresholds. The amount of blood transfused did not correlate with how sick the patients were or...

Cerebral Aneurysms: Analyzing the Treatment Shift

Ruptures of cerebral aneurysms lead to subarachnoid hemorrhage (SAH) and are associated with substantial mortality and morbidity. Previous research has indicated that the rupture rates of aneurysms vary with size, location, and morphological characteristics, as well as patients’ personal and family medical history. “These variables have historically been used to help guide the clinical management of cerebral aneurysms,” explains Robert M. Friedlander, MD. “For clinicians who treat these patients, microsurgical clipping and endovascular coiling have emerged as the two primary interventions for cerebral aneurysms that require intervention.” In 2002, outcomes for patients with ruptured cerebral aneurysms were reported in the International Subarachnoid Aneurysm Trial (ISAT). The trial compared mortality and clinical outcomes of patients with aneurysmal SAH who were treated with either surgical clipping or endovascular coiling. The study found that patients who underwent coiling had lower mortality and better outcomes at 1 year than those who had open surgery. As a result of the ISAT findings, it was assumed that more clinicians in the United States would begin treating ruptured aneurysms with endovascular approaches. “Sufficient time has now passed since the publication of the ISAT results to allow for a formal examination of treatment patterns for cerebral aneurysms—both ruptured and unruptured—within the U.S.,” says Dr. Friedlander. “It’s important to analyze trends on the use of endovascular coiling because patterns may be different in demographic subgroups and in hospitals located in different geographic areas.” Recent Trends in Cerebral Aneurysm Treatment In the May 2012 Journal of Neurointerventional Surgery, Dr. Friedlander, Ning Lin, MD, and colleagues published an analysis describing patterns of use and in-hospital mortality associated with surgical and...
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