Poetic community Voyce, Stephen
Poetic community,
c2013, 20130617, 2017, 2013, 2013-06-17
eBook
Poetic Communitydemonstrates that the most important literary innovations of the post-war period were the results of intensive collaboration and social action opposing the Cold War's ideological ...enclosures.
IMPORTANCE: Atrial fibrillation (AF) is the most common cardiac arrhythmia, and multiple studies have reported increasing AF incidence rates over time, although the underlying explanations remain ...unclear. OBJECTIVES: To estimate AF incidence rates from 2006 to 2018 in a community-based setting and to investigate possible explanations for increasing AF by evaluating the changing features of incident AF cases and the pool of patients at risk for AF over time. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included 500 684 patients who received primary care and other health care services for more than 2 years through a single integrated health care delivery network in Pennsylvania. Data collection was conducted from January 2003 to December 2018. The base study population had no documentation of AF in the electronic medical record for at least 2 years prior to baseline. Data analysis was conducted from May to December 2019. MAIN OUTCOMES AND MEASURES: Incident AF cases were identified through diagnostic codes recorded at inpatient or outpatient encounters. Age- and sex-adjusted AF incidence rates were estimated by calendar year from 2006 to 2018 both overall and across subgroups, including according to diagnostic setting (inpatient vs outpatient) and priority (primary vs secondary diagnosis). RESULTS: Among 514 293 patients meeting criteria for the base study population, the mean (SD) age at baseline was 47 (18) years and 282 103 (54.9%) were women; 13 609 (2.6%) met AF diagnostic criteria on or prior to the baseline date and were excluded. Among 500 684 patients free of AF at baseline, standardized AF incidence rates from 2006 to 2018 increased from 4.74 (95% CI, 4.58-4.90) to 6.82 (95% CI, 6.65-7.00) cases per 1000 person-years, increasing significantly over time (P < .001). Incidence rates increased in all age and sex subgroups, although absolute rate increases were largest among those aged 85 years or older. The fraction of incident AF cases among individuals aged 85 years or older increased from 135 of 1075 (12.6%) in 2006 to 451 of 2427 (18.6%) in 2017. Patients with incident AF were more likely over time to have high body mass index (1351 of 3389 patients 39.9% in 2006-2008 vs 4504 of 9214 48.9% in 2015-2018; P < .001), hypertension (2764 81.6% in 2006-2008 vs 7937 86.1% in 2015-2018; P < .001), and ischemic stroke (328 9.7% in 2006-2008 vs 1455 15.8% in 2015-2018; P < .001), but less likely to have coronary artery disease (1533 45.2% in 2006-2008 vs 3810 41.4% in 2015-2018; P < .001). Among 22 077 new cases of AF, 9146 (41.4%) were diagnosed as inpatients and 5731 (26.0%) as the primary diagnosis. Incidence rates of AF increased significantly in all diagnostic setting and priority pairings (eg, inpatient, primary: rate ratio, 1.07; 95% CI, 1.06-1.08; P < .001). Among patients at risk for AF, high BMI and hypertension increased over time (BMI: 71 433 of 198 245 36.0% in 2007 to 130 218 of 282 270 46.1% in 2017; hypertension: 79 977 40.3% in 2007 to 134 404 47.6% in 2017). Documentation of short-term ECG increased over time (23 297 of 207 349 11.2% in 2008 to 45 027 16.0% in 2017); however, long-term ECG monitoring showed no change (1871 0.9% in 2007 to 4036 1.4% in 2017). CONCLUSIONS AND RELEVANCE: In this community-based study, AF incidence rates increased significantly during the study period. Concurrent increases were observed in AF risk factors in the at-risk population and short-term ECG use.
Guideline-directed medical therapies (GDMTs), initiated in-hospital and continued during the transition to outpatient care, are paramount to successful outcomes for patients with acute coronary ...syndrome (ACS). Incomplete discharge medication prescribing and delayed follow-up lead to worse cardiovascular outcomes.
We investigated a system of care using inpatient and outpatient clinical pharmacists to close GDMT gaps, ensure seamless transition to outpatient care, improve patient education, and optimize therapies.
We conducted a pre-post cohort analysis of patients with ACS pre- versus post-intervention to compare process metrics and key outcomes using electronic health record data.
There were 181 and 135 patients in the pre- and post-intervention cohorts, respectively. Patients post-intervention were significantly more likely to have appropriately-timed follow-up visits scheduled with cardiology (79% vs. 51%, P < 0.0001) and primary care (57% vs. 43%, P = 0.01), to be discharged with prescriptions for P2Y12 inhibitors (87% vs. 64%, P < 0.0001), high dose statins (86% vs. 70%, P = 0.001), and beta blockers (87% vs. 76%, P = 0.01), and significantly less likely to have 30-day all-cause hospital readmissions (4% vs. 12%, P = 0.02) and emergency department (ED) visits (10% vs. 18%, P = 0.04).
The integration of advanced practicing pharmacists into a cardiology team at transition and post-hospitalization resulted in improved rates of posthospital follow-up visits, optimization of GDMT medications, and significantly lower 30-day hospital readmission and ED utilization.
Several hospital-based studies have determined that physicians often inappropriately prescribe acid-suppressive medications for stress ulcer prevention in hospitalized patients and continue these ...drugs after discharge. We sought to determine the frequency of inappropriate proton pump inhibitor (PPI) use continued at discharge within our geographic region.
We undertook a retrospective review of the medical records and pharmacy prescription database of a large regional insurance carrier from January 2005 through December 2008 (total hospital admissions 96,669). The primary inclusion criterion was hospital-initiated PPI therapy and continuation on hospital discharge without an appropriate indication. Patients receiving a PPI at the time of admission were excluded from the analysis.
The number of patients per year discharged on a PPI decreased during the study period: 876 (2005), 763 (2006), 562 (2007), and 485 (2008). Of the patients discharged on a PPI, the number (%) of patients receiving PPIs inappropriately were 695 (79%; 2005); 627 (82%; 2006), 441 (78%; 2007), and 397 (82%; 2008). The annual number of PPI prescriptions and PPI doses dispensed decreased from 2015 to 1263 and from 60,608 to 38,742, respectively, during the study period. The estimated 4-year cost of inappropriate PPI use was $595,809, although cost savings from the absolute reduction in inappropriate PPI use over time was $65,598.
We report a significant decrease of 39% in the number of inappropriate discharge prescriptions for PPIs during the study period; however, the percentage of inappropriate use of PPIs remains high. There is room for improvement in cost-effective use of PPIs.
Cardiovascular disease surveillance involves quantifying the evolving population-level burden of cardiovascular outcomes and risk factors as a data-driven initial step followed by the implementation ...of interventional strategies designed to alleviate this burden in the target population. Despite widespread acknowledgement of its potential value, a national surveillance system dedicated specifically to cardiovascular disease does not currently exist in the United States. Routinely collected health care data such as from electronic health records (EHRs) are a possible means of achieving national surveillance. Accordingly, this article elaborates on some key strengths and limitations of using EHR data for establishing a national cardiovascular disease surveillance system. Key strengths discussed include the: (1) ubiquity of EHRs and consequent ability to create a more "national" surveillance system, (2) existence of a common data infrastructure underlying the health care enterprise with respect to data domains and the nomenclature by which these data are expressed, (3) longitudinal length and detail that define EHR data when individuals repeatedly patronize a health care organization, and (4) breadth of outcomes capable of being surveilled with EHRs. Key limitations discussed include the: (1) incomplete ascertainment of health information related to health care-seeking behavior and the disconnect of health care data generated at separate health care organizations, (2) suspect data quality resulting from the default information-gathering processes within the clinical enterprise, (3) questionable ability to surveil patients through EHRs in the absence of documented interactions, and (4) the challenge in interpreting temporal trends in health metrics, which can be obscured by changing clinical and administrative processes.
Interventional cardiologists have few data on which to base clinical decisions regarding optimal care for ST-segment-elevation myocardial infarction patients who are taking therapeutic chronic oral ...anticoagulation. We present what we believe to be the first reported case of emergency coronary angiography and primary percutaneous coronary intervention in an ST-segment-elevation myocardial infarction patient who was on a dabigatran regimen for atrial fibrillation. The patient tolerated the procedures well and had no observable bleeding sequelae. In addition to the patient's case, we discuss the current evidence regarding the periprocedural management of oral anticoagulation in patients who need coronary angiography and percutaneous coronary intervention.
Abstract only Introduction: Direct Oral anticoagulants (DOACs) have demonstrated superiority or non inferiority to vitamin K antagonists (VKAs) for stroke/embolic prevention in patients with ...nonvalvular atrial fibrillation (NVAF). However, clinical inertia may delay widespread adoption of newer therapies in medicine. Hypothesis: We evaluated whether uptake of DOACs into clinical medicine varied by physician specialty. Methods: We performed a retrospective review of patients with NVAF within the Geisinger Health System from 2011-2022. Longitudinal yearly trends for new/initial prescriptions (Rx) of DOAC vs VKA by cardiology or primary care (PCP) specialties Results: We identified patients with NVAF initiated on an oral anticoagulant from the years 2011 through 2023. Figures 1 and 2 demonstrate a statistically significant linear yearly increase in new Rx for DOACs for both cardiology and PCP specialties.By 2022, DOACs currently account for 96% of all new oral anticoagulant Rx by cardiologists and 90% of Rx by PCP. New Rx for DOAC by PCP lagged cardiology at all time points. Cardiology initial Rx >50% DOAC by 2015 while PCP did not achieve this mark until 2018. Conclusions: In this real-world setting, we observed a significant increase in DOAC use as the initial prescription for patients with NVAF by both cardiology and primary care specialties.Significant difference in the adoption of DOAC was noted between cardiology and primary care specialties.Primary care use of DOAC as first Rx for NVAF increased over time but lagged cardiology by 2-3 years.
A unique case of right ventricular myocardial infarction complicating an acute inferior-posterior myocardial infarction in a patient with a single left coronary artery is described. The clinical, ...electrocardiographic, and hemodynamic features of right ventricular myocardial infarction and the angiographic patterns of anomalous single coronary arteries are reviewed.
Abstract only Introduction: Direct Oral anticoagulants (DOACs) have demonstrated superiority or noninferiority to vitamin K antagonists (VKAs) for stroke prevention in patients with nonvalvular ...atrial fibrillation (NVAF). The uptake of DOACs into clinical medicine has been variable and may be influenced by many factors. Objective: To determine how the prescription (Rx) pattern for DOACs has evolved since their introduction and to evaluate the temporal effects of factors which may impact DOAC Rx. Methods: We performed a retrospective review of patients with NVAF within the Geisinger Health System from 2011-2020. We evaluated longitudinal yearly trends in anticoagulant use and new/initial Rx of DOAC vs VKA in NVAF. We examined subgroups based on clinical and demographic indices. Key points in the timeline regarding DOAC availability and medical society or institutional guidelines were incorporated to determine whether changes DOAC Rx were temporally associated with these events. Results: We identified 34, 936 patients with NVAF. The average age of the was 74.3 years, 48% were female and 98% white. The average CHA 2 DS 2 Vasc score was 2.5. There was a linear increase in overall and new Rx for DOACs with 77.7% of all new Rx for DOAC in 2020. The greatest increase in new DOAC Rx coincide with timepoints of DOAC incorporation into ACC/AHA Guidelines, approval of Xa reversal agent and institutional formulary change. Apixaban was the most common DOAC Rx since 2015 and now accounts for 70.9% of all new anticoagulation Rx and 91.3% of new DOAC Rx at our institution. Conclusions: There was a linear increase in DOACs use for NVAF over time and apixaban has become the most prescribed DOAC at our institution. Society guidelines, approval of reversal agents and institutional formulary changes appear to be temporally associated with increased Rx of DOACs for NVAF.
Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome or sudden cardiac death. SCAD has most frequently been described as presenting as an acute coronary ...syndrome in females during the peripartum period. It may also be associated with autoimmune and collagen vascular diseases, Marfan's syndrome, chest trauma, and intense physical exercise. The most common presentation of SCAD is the acute onset of severe chest pain associated with autonomic symptoms. This condition has a high mortality rate if not identified and treated promptly. Here, we present a case of SCAD presenting with stroke, followed by a brief review.
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