Canada-wide mixed methods analysis evaluating the reasons for inappropriate emergency department presentation in patients with a history of atrial fibrillation: the multicentre AF-ED trial

ObjectivesThe primary objective of this study was to ascertain the reasons for emergency department (ED) attendance among patients with a history of atrial fibrillation (AF).DesignAppropriate ED attendance was defined by the requirement for an electrical or chemical cardioversion and/or an attendance resulting in hospitalisation or administration of intravenous medications for ventricular rate control. Quantitative and qualitative responses were recorded and analysed using descriptive statistics and content analysis, respectively. Random effects logistic regression was performed to estimate the OR of inappropriate ED attendance based on clinically relevant patient characteristics.ParticipantsParticipants ≥18 years with a documented history of AF were approached in one of eight centres partaking in the study across Canada (Ontario, Nova Scotia, Alberta and British Columbia).ResultsOf the 356 patients enrolled (67±13, 45% female), the majority (271/356, 76%) had inappropriate reasons for presentation and did not require urgent ED treatment. Approximately 50% of patients(172/356, 48%) were driven to the ED due to symptoms, while the remainder presented on the basis of general fear or anxiety (67/356, 19%) or prior medical advice (117/356, 33%). Random effects logistic regression analysis showed that patients with a history of congestive heart failure were significantly more likely to seek urgent care for appropriate reasons (p=0.03). Likewise, symptom-related concerns for ED presentation were significantly less likely to result in inappropriate visitation (p=0.02). When patients were surveyed on alternatives to ED care, the highest proportion of responses among both groups was in favour of specialised rapid assessment outpatient clinics (186/356, 52%). Qualitative content analysis confirmed these results.ConclusionsImproved education focused on symptom management and alleviating disease-related anxiety as well as the institution of rapid access arrhythmias clinics may reduce the need for unnecessary healthcare utilisation in the ED and subsequent hospitalisation.Trial registration numberNCT03127085

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Red Blood Cell Transfusion in the Emergency Department: An Observational Cross-Sectional Multicenter Study

Journal of Clinical Medicine ◽

10.3390/jcm10112475 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2475

Author(s):

Olivier Peyrony ◽

Danaé Gamelon ◽

Romain Brune ◽

Anthony Chauvin ◽

Daniel Aiham Ghazali ◽

...

Keyword(s):

Emergency Department ◽

Logistic Regression ◽

Blood Cell ◽

Red Blood Cell ◽

Cross Sectional Study ◽

Red Blood Cell Transfusion ◽

Cross Sectional ◽

Acute Bleeding ◽

History Of ◽

Rbc Transfusion

Background: We aimed to describe red blood cell (RBC) transfusions in the emergency department (ED) with a particular focus on the hemoglobin (Hb) level thresholds that are used in this setting. Methods: This was a cross-sectional study of 12 EDs including all adult patients that received RBC transfusion in January and February 2018. Descriptive statistics were reported. Logistic regression was performed to assess variables that were independently associated with a pre-transfusion Hb level ≥ 8 g/dL. Results: During the study period, 529 patients received RBC transfusion. The median age was 74 (59–85) years. The patients had a history of cancer or hematological disease in 185 (35.2%) cases. Acute bleeding was observed in the ED for 242 (44.7%) patients, among which 145 (59.9%) were gastrointestinal. Anemia was chronic in 191 (40.2%) cases, mostly due to vitamin or iron deficiency or to malignancy with transfusion support. Pre-transfusion Hb level was 6.9 (6.0–7.8) g/dL. The transfusion motive was not notified in the medical chart in 206 (38.9%) cases. In the multivariable logistic regression, variables that were associated with a higher pre-transfusion Hb level (≥8 g/dL) were a history of coronary artery disease (OR: 2.09; 95% CI: 1.29–3.41), the presence of acute bleeding (OR: 2.44; 95% CI: 1.53–3.94), and older age (OR: 1.02/year; 95% CI: 1.01–1.04). Conclusion: RBC transfusion in the ED was an everyday concern and involved patients with heterogeneous medical situations and severity. Pre-transfusion Hb level was rather restrictive. Almost half of transfusions were provided because of acute bleeding which was associated with a higher Hb threshold.

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P029: Requesting prescriptions in the emergency department: the patient, the request and the response

CJEM ◽

10.1017/cem.2020.236 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S74-S75

Author(s):

L. Shepherd ◽

M. Mucciaccio ◽

K. VanAarsen

Keyword(s):

Emergency Department ◽

Family Doctor ◽

Wait Time ◽

Primary Objective ◽

Urgent Care ◽

Care Centre ◽

Medication Prescription ◽

Physician Decision Making ◽

Service Gap ◽

Urgent Care Centre

Introduction: Patients presenting to the Emergency Department (ED) for the sole purpose of requesting prescriptions are problematic. Problematic for the patient, who may have a long wait to be seen and may leave dissatisfied. Problematic for the ED physician, who is in the business of episodic not comprehensive care and is diligently trying to avoid the misappropriation of medications. The primary objective of this study was to determine the characteristics of patients who present to the ED or Urgent Care Centre (UCC) requesting a prescription, the nature of these requests and the resulting action by the attending physician. The secondary objective was to determine the proportion of medication requests and responses that have potential street value. With this knowledge we may be better positioned to serve these patients and support physician decision-making. Methods: This was a single-centre, retrospective electronic chart review looking at all adult patients with a presenting complaint of medication request who attended a two-site tertiary ED or an Urgent Care Centre (UCC) in London, Ontario between April 1, 2014 and June 30, 2017. Data was tested for normality and analyzed using descriptive statistics. Results: A total of 1923 cases met the inclusion criteria. Cases were removed (n = 421) if it was unclear which prescription was requested or if a non-medication prescription or injection was requested. The patient median (IQR) age was 44 (32-54) with 58% being male and 55% having a family doctor. There were a total of 2261 prescriptions requested by 1502 patients. The top 3 most commonly requested classes of medications were opioids 433/1502 (28.8%), antidepressants/antipsychotics 371/1502 (24.7%) and benzodiazepines 252/1502 (16.8%). The median (IQR) wait time was 73 minutes (35-128). 298/1502 (19.8%) of patients received their requested prescription (opioids 12.7%; antidepressant/antipsychotic 55.3% and benzodiazepines 16.3%). 740/1502 (49.3%) of patients requested a medication that had street value. Of those, 118/740 (15.9%) received the requested medication. Conclusion: There is no “one size fits all” solution for the patient who presents to the ED requesting a prescription. The large number of requests for psychiatric medications suggests a service gap for mental health patients in the community. This data supports the need for comprehensive electronic medication records to guide physicians’ decisions.

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Anaesthetic Management of Pheochromocytoma with Atrial Fibrillation - A Case Report

Journal of Evidence Based Medicine and Healthcare ◽

10.18410/jebmh/2020/590 ◽

2020 ◽

Vol 7 (48) ◽

pp. 2885-2887

Author(s):

Anjali Chandrasekharan ◽

Thasreefa Vettuvanthodi ◽

Priya Jayasree ◽

Suvarna Kaniyil ◽

Nanda Lakshmi Anitha

Keyword(s):

Atrial Fibrillation ◽

Bladder Carcinoma ◽

Lateral Wall ◽

Anaesthetic Management ◽

Ventricular Rate ◽

Vanillylmandelic Acid ◽

Normal Limits ◽

Left Lateral Wall ◽

History Of ◽

Enhanced Computed Tomography

An elderly female aged 65 years weighing 69 Kgs presented to the Pre-Anaesthetic Clinic (PAC) for transurethral resection of bladder carcinoma. As part of the evaluation of bladder carcinoma, Contrast Enhanced Computed Tomography (CECT) abdomen done showed a left adrenal lesion. She was a known case of hypertension since the last 10 years and was on telmisartan tablets 40 mg once daily (OD) since then. She had a history of palpitations 3 years back, which when evaluated was diagnosed as atrial fibrillation. She was started on metoprolol tablets 25 mg OD and warfarin 2 mg OD. In view of her history and positive findings on CECT abdomen, it was decided in the PAC to screen her for pheochromocytoma. There was no definite history of classic triad of headache, palpitation and sweating. No history of headache, weight loss, fatigue, syncopal attacks, hypo / hyperthyroidism were reported. Physical examination showed Heart Rate (HR) of 96 beats per minute (bpm), irregular in rhythm, Respiratory Rate (RR) of 16 breaths per minute and Blood Pressures (BP) of 146 / 98 mmHg and 140 / 90 mmHg in the supine and sitting positions respectively. Biochemical test results showed 24-hour urine metanephrine 0.452 mg / l which is 1.45 mg / 24 hrs. (normally < 1 mg / 24 hrs.) and urine vanillylmandelic acid 8.1 mg / gm creatinine (2 – 7 mg / gm). Electrocardiography (ECG) showed right bundle branch block and AF (Atrial Fibrillation) with controlled ventricular rate. Echocardiography showed mild aortic stenosis, aortic regurgitation and ejection fraction of 68 % with no evidence of clots / thrombus. In terms of clinical imaging, the CECT showed a well-defined lesion in the left adrenal measuring 19 x 12 mm with a relative washout of 21 % and a faint subtle hyperdense lesion in the base of left lateral wall of the urinary bladder measuring approximately 20 x 19 mm. Other blood investigations like Hb, haematocrit, urea, creatinine and blood sugars were within normal limits.

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Qualität des Antikoagulationsmanagements bei ambulanten Patienten mit Vorhofflimmern

Praxis ◽

10.1024/0369-8394.92.21.991 ◽

2003 ◽

Vol 92 (21) ◽

pp. 991-995 ◽

Cited By ~ 1

Author(s):

Gubler ◽

Martina ◽

Arpagaus ◽

Dieterle

Keyword(s):

Atrial Fibrillation ◽

Emergency Department ◽

Oral Anticoagulation ◽

Medical Emergency ◽

Psychiatric Disease ◽

Recurrent Falls ◽

History Of ◽

Acute Condition

Many patients with atrial fibrillation do not receive anticoagulation due to accepted contraindications but also due to considerable underuse. We screened 2215 consecutive patients when they entered the Medical Emergency Department for any acute condition. The decision on correct use or underuse of oral anticoagulation was made from the charts by consensus of two experienced physicians. The prevalence of atrial fibrillation was 3.7%. 43 of 83 patients with atrial fibrillation had oral anticoagulation (52%, mean age 76 years). 32 patients were treated with Aspirin only (38%, mean age 79 years). 29 patients (35%) did not receive anticoagulation because of accepted contraindications, i.e., dementia and risk for recurrent falls (n = 16), history of bleeding (n = 6), drug malcompliance due to forgetfulness (n = 4) and psychiatric disease (n = 1). Underuse of anticoagulation occurred only in three patients (4%, unclear reasons in two patients, patient's unwillingness in one patient). Conclusion: We did not observe substantial underuse of anticoagulation in patients with atrial fibrillation.

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Patient involvement in consultation for atrial fibrillation – the cardiologists’ perspective

International Journal of Health Care Quality Assurance ◽

10.1108/ijhcqa-10-2017-0194 ◽

2019 ◽

Vol 32 (4) ◽

pp. 765-776 ◽

Cited By ~ 1

Author(s):

Ulla Hellström Muhli ◽

Jan Trost ◽

Eleni Siouta

Keyword(s):

Atrial Fibrillation ◽

Decision Making ◽

Content Analysis ◽

Shared Decision Making ◽

Patient Involvement ◽

Qualitative Content Analysis ◽

Medical Consultation ◽

Shared Decision ◽

Consultation Process ◽

Content Type

Purpose The purpose of this paper is to analyse the accounts of Swedish cardiologists concerning patient involvement in consultations for atrial fibrillation (AF). The questions were: how cardiologists handle and provide scope for patient involvement in medical consultations regarding AF treatment and how cardiologists describe their familiarity with shared decision-making. Design/methodology/approach A descriptive study was designed. Ten interviews with cardiologists at four Swedish hospitals were held, and a qualitative content analysis was performed on the collected data. Findings The analysis shows cardiologists’ accounts of persuasive practice, protective practice, professional role and medical craftsmanship when it comes to patient involvement and shared decision-making. The term “shared decision-making” implies a concept of not only making one decision but also ensuring that it is finalised with a satisfactory agreement between both parties involved, the patient as well as the cardiologist. In order for the idea of patient involvement to be fulfilled, the two parties involved must have equal power, which can never actually be guaranteed. Research limitations/implications Methodologically, this paper reflects the special contribution that can be made by the research design of descriptive qualitative content analysis (Krippendorff, 2004) to reveal and understand cardiologists’ perspectives on patient involvement and participation in medical consultation and shared decision-making. The utility of this kind of analysis is to find what cardiologists said and how they arrived at their understanding about patient involvement. Accordingly, there is no quantification in this type of research. Practical implications Cardiologists should prioritise patient involvement and participation in decision-making regarding AF treatment decisions in consultations when trying to meet the request of patient involvement. Originality/value Theoretically, the authors have learned that the patient involvement and shared decision-making requires the ability to see patients as active participants in the medical consultation process.

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Anterior Mediastinal Mass Causing Intermittent Atrial Fibrillation

Military Medicine ◽

10.1093/milmed/usab057 ◽

2021 ◽

Author(s):

Adam M Spanier ◽

Garrett R Evans ◽

Hugh M Hiller

Keyword(s):

Atrial Fibrillation ◽

Emergency Department ◽

Mediastinal Mass ◽

Mass Effect ◽

Metabolic Effects ◽

Anterior Mediastinal Mass ◽

Chest Discomfort ◽

Rare Finding ◽

Ventricular Response ◽

History Of

ABSTRACT Mediastinal masses are a rare finding in the emergency department and typically present with vague chest complaints such as chest discomfort, chest pain, or dyspnea. Rarely do these tumors present with dysrhythmias, and when dysrhythmias are present, they typically arise secondary to endocrine or metabolic effects exerted by the tumor. Here we report a case of a patient who presented to the emergency department with atrial fibrillation with rapid ventricular response, concomitant with a history of recurrent palpitations that were previously aborted with self-induced vagal maneuvers. Upon further investigation, the patient had an anterior mediastinal mass, diagnosed as a thymoma, suspected to be contributing to his presenting dysrhythmia through mass effect.

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Thyroid Storm Treated With Nonconventional Therapy

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1967 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A962-A962

Author(s):

Caroline Tashdjian ◽

Paul Shiu ◽

Tarandeep Kaur

Keyword(s):

Atrial Fibrillation ◽

Critically Ill ◽

Liver Enzymes ◽

Normal Liver ◽

Ventricular Rate ◽

Thyroid Storm ◽

Free T4 ◽

History Of ◽

Chest X Ray ◽

Iodine Treatment

Abstract Background: Thyroid storm is a rare sequela of thyrotoxicosis with mortality rate of 10-30%. Management of thyroid storm is heavily dependent on thionamides. Cholestyramine and potassium iodide (SSKI) are used as adjunctive therapy and not as the sole treatment for storm. We present a case of thyroid storm treated with cholestyramine and SSKI. Clinical Case: A 45 year old male with past medical history of atrial fibrillation, congestive heart failure, hypertension, substance abuse and grave’s disease presented to the emergency department (ED) for diarrhea. During the course of ED, patient went into atrial fibrillation with rapid ventricular rate. Chest X-ray showed pulmonary edema. Labs were: TSH <0.0025 mIU/L (0.35-4.94 mIU/L) and free T4 3.52 ng/dl (0.7-1.40 ng/dl). Patient was noncompliant with methimazole. Upon admit, ACLS was initiated due to hypoxia and transferred to ICU for ventilator and pressor support. Wartofsky score was 60, suggestive of thyroid storm. Management included methimazole 20mg every 4hours, hydrocortisone 100mg every 8 hours, cholestyramine 4mg every 6 hours, and SSKI 250mg every 6 hours for thyrotoxicosis and amiodarone infusion for afib. Despite normal liver enzymes on admit, day 3 AST increased to 2740 U/L (5-34) and ALT 2684 U/L (0-55). Methimazole was stopped due to potential hepatotoxicity. Day 3 free T4 remained high at 4.16 ng/dl and patient remained critically ill. Plasmapheresis was offered as methimazole was stopped and patient was hemodynamically unstable to undergo surgery. However, family declined this intervention; SSKI and cholestyramine were continued. Free T4 was monitored over the course of treatment; by day 5 free T4 trended down to 1.93 ng/dl. SSKI was eventually stopped on day 8 of treatment as free T4 had normalized and cholestyramine reduced to 4mg twice daily. By day 15, free T4 was 0.8 ng/dl, so cholestyramine was stopped. Due to clinical improvement, patient was weaned off the ventilator and pressor support along with hydrocortisone. Liver enzymes normalized by Day 17. Patient was restarted on methimazole 5mg daily before discharge. Discussion: Thyroid storm is associated with varying degree of liver dysfunction, which can pose a challenge to treatment. In our case, acute fulminant liver failure was multifactorial in the setting of shock, thyroid storm and potential drug toxicity. Thus, thionamides were contraindicated. Radioactive iodine treatment was contraindicated due to use of amiodarone. Plasmapheresis and emergent thyroidectomy could not be done. Thus, nonconventional therapy was used and patient responded well to treatment. This case emphasizes the use of cholestyramine along with SSKI as an effective treatment in patients who are critically ill the setting of a thyroid storm, especially when thionamides are contraindicated and other avenues of treatment are limited.

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Qualitative exploration of the factors influencing the use of dietary supplements in Iranian women: introduction to areas of focus for developing interventions

10.21203/rs.3.rs-96331/v1 ◽

2020 ◽

Author(s):

Akramsadat Hoseini ◽

Tahereh Dehdari ◽

Mahnaz Solhi ◽

Seyedeh Tayebeh Rahideh ◽

Leila Janani

Keyword(s):

Content Analysis ◽

Dietary Supplements ◽

Qualitative Content Analysis ◽

Personal Factors ◽

Iranian Women ◽

Factors Influencing ◽

Effective Interventions ◽

Data Saturation ◽

History Of ◽

Qualitative Exploration

Abstract Background: Literature shows that the consumption of Dietary Supplements (DS) is more common in Iran. This study aimed to explore the experiences of a sample of Iranian women regarding the factors influencing the use of DS.Methods: This qualitative content analysis study was conducted in Qods city, Tehran province, Iran from January to March 2020. Forty-two semi-structured in-depth interviews were performed with women. The participants were asked about their experiences about the determinants of the consumption of DS. After the first round of the interviews was done, we performed content analysis of the data and continued up to data saturation.Results: Two main themes including personal factors (with 5 subthemes including sociodemographic characteristics, perceived benefits of DS, history of illness, physiological conditions, and lifestyle factors) and socio-economic factors (with 3 subthemes including subjective norms, the price of food and commercial considerations of the sectors involved in the production and sale of DS) emerged as the experiences of the participants as to the intake of DS.Conclusions: These variables may suggest areas which need to be focused on for performing more effective interventions to affect appropriate consumption of DS in Iran.

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Cultural memory in Lithuanian periodical press during World War II

Lietuvos istorijos studijos ◽

10.15388/lis.2020.45.8 ◽

2020 ◽

Vol 45 ◽

pp. 95-114

Author(s):

Titas Krutulys

Keyword(s):

Content Analysis ◽

World War Ii ◽

Soviet Union ◽

Cultural Memory ◽

Qualitative Content Analysis ◽

Periodical Press ◽

World War ◽

Soviet Occupation ◽

History Of ◽

Historical Periods

During World War II Lithuania was ruled by three completely different political regimes. In the first year Lithuania was authoritarian state ruled by group of nationalists, in 1940 Lithuania was occupied by Soviet Union and in 1941 State was occupied by Nazi Germany. All these political powers was undemocratic and propagated their ideologies. One of the most important aspect of every ideology is to suggest new concept of time. This change of perception of time could be seen in the change of cultural memory. Article try to analyze this change using the most popular Lithuanian periodical press of the period. This research analyzed main historical periods and the most popular themes represented in the main newspapers. Using theories of Anthony D. Smith and Raoul Girardet research showed what historical periods was seen positively and what negatively, what was main historical heroes and enemies; also how foreign history was represented in the periodical press. The quantitative content analysis showed that while representations of history in the so called independent Lithuania and in Lithuania occupied by Nazis was quite similar, historical representations during first Soviet occupation was unique. Qualitative content analysis showed that there was three very different paradigms of cultural memories, represented in periodical press. Lithuanian nationalist mostly tried to promote Lithuanian medieval times and especially Lithuanian dukes and historical capital Vilnius, also they tried to justify their politics creating myth of great welfare during their rule. They praised Soviet history, criticized Poland and poles, but wrote about most of the countries quite neutral. During Soviet occupation all Lithuanian history was harshly criticized and showed as negative times, this regime promoted only few Lithuanian heroes who died young or was known for their left wing politics. Main historical past represented in the newspapers was history of Soviet Union, other countries was ignored. Main enemies of Soviets was Lithuanian gentry, and Lithuanian rulers of the past. During Nazi occupation there was more Lithuanian national history than German history, but the main appreciable historical periods was Lithuanian prehistory and the 19th Century. Regime promoted history of Lithuanian culture and language, but tried to ignore Lithuanian state. Foreign history was mostly binary – propaganda criticized Soviet Union as well as Tsarist Russia, USA and United Kingdom, but appreciated history of Italy, Japan, Finland, Turkey, Spain etc. Main historical enemies were of course Bolsheviks and Jews.

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Atrial fibrillation following low voltage electrical injury

BMJ Case Reports ◽

10.1136/bcr-2020-239306 ◽

2021 ◽

Vol 14 (1) ◽

pp. e239306

Author(s):

Shrestha Ghosh ◽

Atanu Chandra ◽

Sourav Sen ◽

Sukanta Dutta

Keyword(s):

Atrial Fibrillation ◽

Cardiac Involvement ◽

Low Voltage ◽

Ventricular Rate ◽

Prior History ◽

Electrical Injury ◽

Bundle Branch Block ◽

History Of ◽

Premature Beats ◽

Irregular Pulse

Electrical injuries can have myriad presentations, including significant cardiac involvement. Arrhythmias are the most frequently experienced cardiac affliction, of which sinus tachycardia or bradycardia, ventricular fibrillation, atrial or ventricular premature beats and bundle branch block are most commonly reported. A 50-year-old man, with no prior history of cardiac disease, presented with palpitations following low voltage electrical injury. On examination, he was tachycardic with an irregularly irregular pulse. An ECG confirmed atrial fibrillation with rapid ventricular rate. Chemical cardioversion was attempted successfully, following which the patient reverted to sinus rhythm. Atrial fibrillation following electrical injury has been rarely described in the literature, and is rarer so without associated high voltage electrical exposure or pre-existing cardiac ailment.

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