Chest
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Our objective was to determine stroke and thromboembolism event rates in patients with atrial fibrillation (AF) classified as "low risk" using the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) score and to ascertain event rates in this group in relation to the stroke risk assessment advocated in the 2012 European Society of Cardiology (ESC) guidelines (based on the CHA2DS2-VASc [congestive heart failure, hypertension, age ≥ 75 years, diabetes, previous stroke/transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score). We tested the hypothesis that the stroke risk assessment scheme advocated in the ESC guidelines would be able to further refine stroke risk stratification in the low-risk category defined by the ATRIA score. ⋯ Patients categorized as low risk using an ATRIA score 0 to 5 are not necessarily low risk, with 1-year event rates as high as 36.94 per 100 person-years. Thus, the stroke risk stratification scheme recommended in the ESC guidelines (based on the CHA2DS2-VASc score) would be best at identifying the "truly low risk" subjects with AF who do not need any antithrombotic therapy.
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Most physicians are unfamiliar with the details of the Resource-Based Relative Value Scale (RBRVS) and how changes in the RBRVS influence Medicare and private reimbursement rates. Physicians in a wide variety of settings may benefit from understanding the RBRVS, including physicians who are employees, because many organizations use relative value units as productivity measures. Despite the complexity of the RBRVS, its logic and ideal are simple: In theory, the resource usage (comprising physician work, practice expense, and liability insurance premium costs) for one service is relative to the resource usage of all others. ⋯ Critics have attributed various health-care system problems, including declining and growing gaps between primary care and specialist incomes, to the RUC's role in the RBRVS update process. There are persistent concerns regarding the quality of data used in the process and the potential for services to be overvalued. The Affordable Care Act addresses some of these concerns by increasing payments to primary care physicians, requiring reevaluation of the data underlying work relative value units, and reviewing misvalued codes.
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The appropriate justification for using a diagnostic or therapeutic intervention is that it provides benefit to patients, society, or both. For decades, indwelling arterial catheters have been used very commonly in patients in the ICU, despite a complete absence of data addressing whether they confer any such benefits. Both of the main uses of arterial catheters, BP monitoring and blood sampling for laboratory testing, can be done without these invasive devices. ⋯ Given the potential dangers, widespread use, and uncertainty about consequences of arterial catheter use in ICUs, equipoise exists and randomized trials are needed. Multiple studies in different, well-characterized, patient subgroups are needed to clarify whether arterial catheters influence outcomes. These studies should assess the range of relevant outcomes, including mortality, medical resource use, patient comfort, complications, and costs.
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Allergen-specific immunotherapy (AIT) was described as a therapeutic option for the treatment of allergies > 100 years ago. It is based on administration of allergen extracts and leads to the development of clinical allergen tolerance in selected patients. According to current knowledge, AIT results in the restoration of immune tolerance toward the allergen of interest. ⋯ The disease modification effect leads to decreased disease severity, less drug usage, prevention of future allergen sensitizations, and a long-term curative effect. Increasing safety while maintaining or even augmenting efficiency is the main goal of research for novel vaccine development and improvement of treatment schemes in AIT. This article reviews the principles of allergen-specific immune tolerance development and the effects of AIT in the clinical context.
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Multicenter Study
Long term outcomes following development of new-onset atrial fibrillation during sepsis.
New-onset atrial fibrillation (AF) is associated with adverse outcomes during a sepsis hospitalization; however, long-term outcomes following hospitalization with sepsis-associated new-onset AF are unclear. ⋯ Most sepsis survivors with new-onset AF during sepsis have AF occur after discharge from the sepsis hospitalization and have increased long-term risks of heart failure, ischemic stroke, and death. Our findings may have implications for posthospitalization surveillance of patients with new-onset AF during a sepsis hospitalization.