Showing papers by "Deborah Grady published in 2015"

Criteria for waiver of informed consent for quality improvement research-reply.

Abstract: In Reply We thank Secades and colleagues for their interest in our case report.1 The diagnosis of left ventricular noncompaction (LVNC) carries with it significant consequences, especially for the competitive athlete of Afro-Caribbean descent.2 We agree that the current diagnostic criteria for LVNC are inadequate. Tizón-Marcos and colleagues3 recently showed that healthy young men demonstrate a variable amount of trabeculation and an incidence of noncompaction cardiomyopathy greater than anticipated when applying the current criteria. We also agree that there needs to be better risk stratification. Reversibility, diastolic myocardial thickness and electrocardiography may be emerging risk stratification criteria. In a recently published study, Gati and colleagues4 demonstrated that increased trabeculation occurring in pregnancy resolved during the postpartum period. They theorized that increased trabeculation was not due to noncompaction but rather to a temporary elevation in left ventricular (LV) loading. This observation may be especially important in low-risk individuals noted to only have increased trabeculation, ie, those without LV systolic dysfunction, arrhythmias, and/or cardioembolic events. Myocardial diastolic thickness has also been proposed as an important diagnostic factor. Supported by elegant mathematical modeling, MacIver5 postulated that inadequate compaction and subsequent reduced wall thickness predispose the heart to increased wall stress. It is this increased wall stress that results in elevated myocardial strain and subsequent decreased LV function. Lastly, Steffel et al6 used electrocardiographic variations to determine which abnormalities were associated with poor long-term outcomes in patients with LVNC. Soon, the 36th Bethesda Conference will be updated, and we hope that this important document will be less restrictive on athletes with hypertrabeculation but preserved LV function. Continued research, focusing on exercise induced LV loading as a potential cause for hypertrabeculation, should help improve risk assessment and limit over diagnosis of LVNC in athletes.

Abstract 11583: Length of Hospital Stay and All-Cause Mortality Among Adults With Atrial Fibrillation Hospitalized for Bleeding During Treatment With Warfarin, Dabigatran, or Rivaroxaban

Abstract: Introduction: Little is known about the relative outcomes of bleeding complications during warfarin therapy compared to bleeding complications during treatment with dabigatran or rivaroxaban. Hypothesis: Because warfarin is more easily reversible, bleeding complications during warfarin therapy may be associated with better outcomes. Methods: We performed a retrospective cohort study using a US commercial claims database of 38 million members from 11/1/10 to 3/31/14. Participants were adults with atrial fibrillation hospitalized for bleeding after starting warfarin, dabigatran, or rivaroxaban. The outcomes were length of hospital stay, ICU admission, length of ICU stay, and all-cause mortality. The analyses used propensity scores as covariates in a multivariable Poisson regression. Subgroup analyses examined patients with chronic kidney disease, heart failure, more than 7 comorbidities, hemorrhagic stroke, major gastrointestinal bleed, those over 75, those without ICU admission, and those restarting anticoagulation after discharge. Results: Admissions for bleeding included 2446 warfarin, 442 dabigatran, and 256 rivaroxaban users. Warfarin users were older than dabigatran or rivaroxaban users (74 vs 69 vs 68 years) and had more comorbidities. After adjustment, warfarin was associated with a 2.2 mean day increase in hospital stay (CI 2.0 - 2.5) compared to dabigatran and a 3.1 mean day increase (CI 2.8 - 3.4) compared to rivaroxaban. There were no significant differences in the proportions of ICU admissions among the 3 groups. Warfarin was associated with a mean ICU stay increase of 2.3 days (CI 0.94 - 3.6) compared to dabigatran. After 3.4 years follow up, there was a 17% adjusted mortality in the warfarin cohort, 13% in the dabigatran cohort, and 6% in the rivaroxaban cohort. Warfarin was associated with longer hospitalization in every subgroup. Conclusions: Despite warfarin’s reversibility, bleeding complications during warfarin therapy are associated with longer hospitalization and higher adjusted mortality. However, because patients treated with newer oral anticoagulants are younger and healthier, randomized trials are necessary to better understand these unexpected differences in bleeding-related outcomes.

A Simple Approach to Reducing Inappropriate Use of Central Venous Catheters.

Abstract: Editor's Note A Simple Approach to Reducing Inappropriate Use of Central Venous Catheters Central venous catheters are commonly used in hospitalized patients. Many are not indicated, evidence of benefit is scant, and all put patients at risk for thrombosis and infection. In this issue, McDonald and Lee1 describe a simple intervention— making inpatient teams aware that a patient has a central venous catheter and the probable indication for the catheter— that appears to have resulted in a major reduction in the prevalence of inappropriate use of central venous catheters. While we applaud this effort, additional evidence is needed, as this intervention took place at 1 hospital and there was no concurrent control group. But we hope the study will stimulate additional research, preferably randomized clinical trials, to document the efficacy of interventions to reduce the use of inappropriate central venous catheters.

How Much Vitamin D Is Enough

Abstract: 41. Roux C, Bischoff-Ferrari HA, Papapoulos SE, de Papp AE, West JA, Bouillon R. New insights into the role of vitamin D and calcium in osteoporosis management: an expert roundtable discussion. Curr Med Res Opin. 2008;24(5):1363-1370. 42. Need AG, O’Loughlin PD, Morris HA, Coates PS, Horowitz M, Nordin BE. Vitamin D metabolites and calcium absorption in severe vitamin D deficiency. J Bone Miner Res. 2008;23(11):1859-1863.