Research Spotlight

Flannery, B., C. Smith, R. J. Garten, M. Z. Levine, J. R. Chung, M. L. Jackson, L. A. Jackson, A. S. Monto, E. T. Martin, E. A. Belongia, H. Q. McLean, M. Gaglani, K. Murthy, R. Zimmerman, M. P. Nowalk, M. R. Griffin, H. Keipp Talbot, J. J. Treanor, D. E. Wentworth and A. M. Fry (2018). “Influence of Birth Cohort on Effectiveness of 2015-2016 Influenza Vaccine Against Medically Attended Illness Due to 2009 Pandemic Influenza A(H1N1) Virus in the United States.” J Infect Dis. Jan 18. [Epub ahead of print].

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Background: The effectiveness of influenza vaccine during 2015-2016 was reduced in some age groups as compared to that in previous 2009 pandemic influenza A(H1N1) virus (A[H1N1]pdm09 virus)-predominant seasons. We hypothesized that the age at first exposure to specific influenza A(H1N1) viruses could influence vaccine effectiveness (VE). Methods: We estimated the effectiveness of influenza vaccine against polymerase chain reaction-confirmed influenza A(H1N1)pdm09-associated medically attended illness from the 2010-2011 season through the 2015-2016 season, according to patient birth cohort using data from the Influenza Vaccine Effectiveness Network. Birth cohorts were defined a priori on the basis of likely immunologic priming with groups of influenza A(H1N1) viruses that circulated during 1918-2015. VE was calculated as 100 x [1 – adjusted odds ratio] from logistic regression models comparing the odds of vaccination among influenza virus-positive versus influenza test-negative patients. Results: A total of 2115 A(H1N1)pdm09 virus-positive and 14 696 influenza virus-negative patients aged >/=6 months were included. VE was 61% (95% confidence interval [CI], 56%-66%) against A(H1N1)pdm09-associated illness during the 2010-2011 through 2013-2014 seasons, compared with 47% (95% CI, 36%-56%) during 2015-2016. During 2015-2016, A(H1N1)pdm09-specific VE was 22% (95% CI, -7%-43%) among adults born during 1958-1979 versus 61% (95% CI, 54%-66%) for all other birth cohorts combined. Conclusion: Findings suggest an association between reduced VE against influenza A(H1N1)pdm09-related illness during 2015-2016 and early exposure to specific influenza A(H1N1) viruses.

Garrett, J. S., C. Berry, H. Wong, H. Qin and J. A. Kline (2018). “The effect of vertical split-flow patient management on emergency department throughput and efficiency.” Am J Emerg Med. Jan 11. [Epub ahead of print].

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BACKGROUND: To address emergency department overcrowding operational research seeks to identify efficient processes to optimize flow of patients through the emergency department. Vertical flow refers to the concept of utilizing and assigning patients virtual beds rather than to an actual physical space within the emergency department to care of low acuity patients. The aim of this study is to evaluate the impact of vertical flow upon emergency department efficiency and patient satisfaction. METHODS: Prospective pre/post-interventional cohort study of all intend-to-treat patients presenting to the emergency department during a two-year period before and after the implementation of a vertical flow model. RESULTS: In total 222,713 patient visits were included in the analysis with 107,217 patients presenting within the pre-intervention and 115,496 in the post-intervention groups. The results of the regression analysis demonstrate an improvement in throughput across the entire ED patient population, decreasing door to departure time by 17min (95% CI 15-18) despite an increase in patient volume. No statistically significant difference in patient satisfaction scores were found between the pre- and post-intervention. CONCLUSIONS: Initiation of a vertical split flow model was associated with improved ED efficiency.

Filardo, G., R. J. Damiano, Jr., G. Ailawadi, V. H. Thourani, B. D. Pollock, D. M. Sass, T. K. Phan, H. Nguyen and B. da Graca (2018). “Epidemiology of new-onset atrial fibrillation following coronary artery bypass graft surgery.” Heart. Jan 11. [Epub ahead of print].

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OBJECTIVES: Postoperative atrial fibrillation (AF) following coronary artery bypass graft surgery (CABG) is significantly associated with reduced survival, but poor characterisation and inconsistent definitions present barriers to developing effective prophylaxis and management. We sought to address this knowledge gap. METHODS: From 2002 to 2010, 11 239 consecutive patients without AF underwent isolated CABG at five sites. Clinical data collected for the Society of Thoracic Surgeons (STS) Database were augmented with details on AF detected via continuous in-hospital ECG/telemetry monitoring to assess new-onset post-CABG AF (adjusted for STS risk of mortality); time to first AF; durations of first and longest AF episodes; total in-hospital time in AF; number of in-hospital AF episodes; operative mortality; stroke; discharge in AF; and length of stay (LOS). RESULTS: Unadjusted incidence of new-onset post-CABG AF was 29.5%. Risk-adjusted incidence was 33.1% and varied little over time (P=0.139). Among 3312 patients with post-CABG AF, adjusted median time to first AF was 52 (IQR: 48-55) hours; mean (SD) duration of first and longest events were 7.2 (5.3,9.1) and 13.1 (10.4,15.9) hours, respectively, and adjusted median total time in AF was 22 (IQR: 18-26) hours. Adjusted rates of operative mortality, stroke and discharge in AF did not vary significantly over time (P=0.156, P=0.965 and P=0.347, respectively). LOS varied (P=0.035), but in no discernible pattern. CONCLUSIONS: Each year, ~800 000 people undergo CABG worldwide; >264 000 will develop post-CABG AF. Onset is typically 2-3 days post-CABG and episodes last, on average, several hours. Effective prophylaxis and management is urgently needed to reduce associated risks of adverse outcomes.

Farzad, A. and J. M. Schussler (2018). “Acute Myopericardial Syndromes.” Cardiol Clin 36(1): 103-114.

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Acute myopericardial syndromes are common but can be challenging to manage and potentially have life-threatening complications. Careful clinical history, physical examination, electrocardiogram interpretation, and application of diagnostic criteria are needed to make an accurate diagnosis, exclude concomitant disease, and properly treat patients. Therapy for acute pericarditis should be guided per the underlying cause. For the most common causes, nonsteroidal antiinflammatory drugs or aspirin with the addition of colchicine remains the mainstay of therapy. Patients with hemodynamic compromise who are resistant to therapy or display high-risk features should prompt hospitalization and initiation of more aggressive and/or invasive therapy.

“Erwin, J. P., 3rd and B. Iung (2018). “Current recommendations for anticoagulant therapy in patients with valvular heart disease and atrial fibrillation: the ACC/AHA and ESC/EACTS Guidelines in Harmony…but not Lockstep!” Heart. Jan 11. [Epub ahead of print].

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From the standpoint of the majority of clinical scenarios, there is great harmonisation between the AHA/ACC and ESC/EACTS valvular guidelines as it pertains to managing the patient with VHD and AF. Both guidelines also point out the importance of using a Valve Team/Heart Valve Centre. This team approach to care is paramount to bridge the areas where there are no guidelines or where the level of evidence (LOE) provides weak guidance in special patient populations. Both groups of authors contend that the term non-valvular atrial fibrillation (NVAF) is poorly defined and should be abandoned. Rather, the clinician should consider AF in the context of each type of specific valvular heart disease (VHD) and in context to specific patient variables.