Mayank Mittal

Assessment of email communication skills of rheumatology fellows: a pilot study

Physician-patient email communication is gaining popularity. However, a formal assessment of physicians email communication skills has not been described. We hypothesized that the email communication skills of rheumatology fellows can be measured in an objective structured clinical examination (OSCE) setting using a novel email content analysis instrument which has 18 items. During an OSCE, we asked 50 rheumatology fellows to respond to a simulated patient email. The content of the responses was assessed using our instrument. The majority of rheumatology fellows wrote appropriate responses scoring a mean (±SD) of 10.6 (±2.6) points (maximum score 18), with high inter-rater reliability (0.86). Most fellows were concise (74%) and courteous (68%) but not formal (22%). Ninety-two percent of fellows acknowledged that the patients condition required urgent medical attention, but only 30% took active measures to contact the patient. No one encrypted their messages. The objective assessment of email communication skills is possible using simulated emails in an OSCE setting. The variable email communication scores and incidental patient safety gaps identified, suggest a need for further training and defined proficiency standards for physicians email communication skills.

Comparison of left ventricular ejection fraction values obtained using invasive contrast left ventriculography, two-dimensional echocardiography, and gated single-photon emission computed tomography:

Objectives: Left ventricular ejection fraction can be measured by a variety of invasive and non-invasive cardiac techniques. This study assesses the relation of three diagnostic modalities to each other in the measurement of left ventricular ejection fraction: invasive contrast left ventriculography, two-dimensional echocardiography, and quantitative gated single-photon emission computed tomography. Methods: Retrospective chart review was conducted on 58 patients hospitalized with chest pain, who underwent left ventricular ejection fraction evaluation using each of the aforementioned modalities within a 3-month period not interrupted by myocardial infarction or revascularization. Results: The mean left ventricular ejection fraction values were as follows: invasive contrast left ventriculography (0.44±0.15), two-dimensional echocardiography (0.46±0.13), and gated single-photon emission computed tomography (0.37±0.10). Correlations coefficients and associated p values were as follows: invasive contrast left ventriculography versus two-dimensional echocardiography (r=0.69, p<0.001), invasive contrast left ventriculography versus gated single-photon emission computed tomography (r=0.80, p<0.0001), and gated single-photon emission computed tomography versus two-dimensional echocardiography (r=0.69, p<0.001). Conclusion: Our results indicate that strong positive correlations exist among the three techniques studied.

Antithrombotics in atrial fibrillation and coronary disease.

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and approximately 18–45% of AF patients have concomitant coronary artery disease (CAD). Several studies have demonstrated that oral anticoagulation is the mainstay of therapy for stroke prevention in AF. Similarly, antiplatelet therapy including aspirin and P2Y12 inhibitor is recommended in the management of acute coronary syndrome and stable CAD. Despite the high prevalence of CAD with AF, practice guidelines are scarce on the appropriate antithrombotic regimen due to lack of large-scale randomized clinical trials. The use of direct thrombin and factor Xa inhibitors for stroke prevention in AF has also complicated the possible combinations of antithrombotic therapies. This review aims to discuss the available evidence regarding aspirin as an antithrombotic strategy, the role of novel anticoagulants and the specific clinical situations where aspirin may be beneficial in patients with AF and CAD.

TCT-216 Bivalrudin vs. Argatroban for treatment of Heparin-induced Thrombocytopenia: A Meta-analysis.

RESULTS A total of 8,044 patients from 5 trials were included. The incidence of major bleeding was 1.8% in the bivalirudin group versus 2.2% in the unfractionated heparin group (RR 0.72, 95% CI 0.44-1.17, p1⁄40.18). Subgroup analysis showed benefit with bivalirudin when compared with unfractionated heparin plus planned or provisional glycoprotein IIb/IIIa inhibitors, but not when compared with unfractionated heparin plus provisional glycoprotein IIb/IIIa inhibitors (Pinteraction1⁄40.03). Meta-regression analysis demonstrated that the risk of major bleeding was lower with bivalirudin when higher doses of unfractionated heparin were used in the control arm (p1⁄40.02). There were no significant differences in the incidence of major adverse cardiac events, all-cause mortality, and net adverse clinical events between both groups (RR 1.15, 95% CI 0.81-1.64, p1⁄40.44; RR 0.98, 95% CI 0.70-1.36, p1⁄40.89; and RR 0.79, 95% CI 0.62-1.03, p1⁄40.08; respectively).

Role of isolated ultrafiltration in the management of chronic refractory and acute decompensated heart failure

Chronic congestive heart failure (CHF) and acute decompensated heart failure (ADHF) refractory to medical therapy represent therapeutic challenges. In such patients, attempts to reduce pulmonary and systemic congestion frequently produce deterioration of renal function. In studies of patients with chronic severe CHF refractory to medical therapy (including loop diuretics), isolated ultrafiltration was frequently able to relieve congestive symptoms by precise removal of extracellular water and sodium, and in some cases was able to restore responsiveness to loop diuretics. Randomized controlled trials comparing isolated ultrafiltration and medical therapy (mainly loop diuretics) in patients with ADHF failed to demonstrate the superiority of isolated ultrafiltration over diuretic therapy with respect to renal function and mortality. Isolated ultrafiltration reduced length of hospital stay in several studies. At this time, there is insufficient evidence to support the use of isolated ultrafiltration as initial therapy of ADHF.

RARE CASE OF R TO L SHUNTING THROUGH PATENT FORAMEN OVALE AFTER MITRAL VALVE REPLACEMENT

Patent foramen ovale (PFO) is a common condition present in about 20% of patients undergoing cardiac surgery as identified by intraoperative trans-esophageal echocardiography (TEE). Management of a coincidental diagnosis of PFO during cardiac surgery is variable.nnA 44-year-old female with end-stage

Does pharmacotherapy improve cardiovascular outcomes in hemodialysis patients

Cardiovascular disease (CVD) occurs commonly in patients with chronic kidney disease (CKD) including those treated with hemodialysis (HD), and is associated with poor outcomes in this population. Pharmacologic management of hypertension, dyslipidemia, acute and chronic coronary artery disease, and atrial fibrillation in the general population is supported by the results of high‐quality, randomized, controlled clinical trials. Pharmacotherapy of these disorders in the general population is effective in improving clinical outcomes. In contrast, information concerning the effect of pharmacotherapy on mortality and cardiovascular outcomes in patients with CKD, and particularly in HD patients, is limited. Available data suggest that, in general, pharmacotherapy of hypertension and dyslipidemia, anti‐platelet therapy of CVD, and anticoagulant therapy in patients with atrial fibrillation are less effective in HD patients than in the general population or even in patients with early stage of CKD.