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Background There is significant practice variation in oral anticoagulation ( OAC ) use following catheter ablation for atrial fibrillation. It is not clear whether the risk of cardioembolism increases after discontinuation of OAC following catheter ablation. Methods and Results We identified 6886 patients within a large national administrative claims database who underwent catheter ablation for atrial fibrillation between January 1, 2005, and September 30, 2014. We assessed the effect of time off of OAC by CHA 2 DS 2 ‐ VAS c score (after adjusting for other comorbidities) on risk of cardioembolism, using Cox proportional hazards models. There was an increase in the use of non–vitamin K OAC after ablation from 0% in 2005 to 69.8% in 2014. OAC discontinuation was high, with only 60.5% and 31.3% of patients remaining on OAC at 3 and 12 months, respectively. The rate of discontinuation was higher in low‐risk patients (82% versus 62.5% at 12 months for CHA 2 DS 2 ‐ VAS c 0–1 versus ≥2, respectively; P <0.001). Stroke occurred in 1.4% of patients with CHA 2 DS 2 ‐ VAS c ≥2 and 0.3% of those with CHA 2 DS 2 ‐ VAS c 0 or 1 over the study follow‐up. The risk of cardioembolism in the first 3 months after ablation was increased among those with any time off OAC (hazard ratio 8.06 [95% CI 1.53–42.3], P <0.05). The risk of cardioembolism beyond 3 months was increased with OAC discontinuation among high‐risk patients (hazard ratio 2.48 [95% CI 1.11–5.52], P <0.05) but not low‐risk patients. Conclusion The overall risk of stroke in postablation patients is low; however, OAC discontinuation after ablation is common and is associated with increased risk of cardioembolism for all patients within the first 3 months and for high‐risk patients in the long term. Continuing OAC for at least 3 months in all patients and indefinitely in high‐risk patients appears to be the safest strategy.

Transbronchial cryobiopsy technique yields larger biopsies with enhanced quality. The benefits and safety of cryobiopsies have not been thoroughly studied in lung allografts.Context.— To compare size, quality, reproducibility of interpretation of rejection and complications of cryobiopsies with those of conventional biopsies from lung allografts.Objective.— All cryobiopsies (March 2014–January 2015) of lung allografts performed at Mayo Clinic, Rochester, and medical records were reviewed. For comparison, conventional biopsies from the same patient or, if unavailable, from a random patient, were selected. Two pathologists blinded to outcome reviewed all biopsies. Specimen volume, number of alveoli, small airways, and pulmonary vessels were counted and statistically compared.Design.— Fifty-four biopsies (27 cryobiopsies) from 18 patients (11 men) were reviewed. A median of 3 (range, 2–5) and 10 (range, 6–12) specimens were obtained with cryobiopsies and conventional biopsies, respectively. Cryobiopsies were larger and contained more alveoli (P &lt; .001, both) and small airways (P = .04). Conventional biopsies showed more fresh alveolar hemorrhage (procedural) and crush artifact/atelectasis (P &lt; .001, both). Cryobiopsies contained more pulmonary veins and venules (P &lt; .001). There was no significant difference between the types of biopsies with respect to the reviewers' agreement on grades of rejection. Complications were more frequent in the cryobiopsy group, though the difference was not statistically significant.Results.— Cryobiopsies of lung allografts are larger and have less artifact. However, complications occur and should be considered. Three cryobiopsy specimens appear sufficient for histopathologic evaluation of lung allografts.Conclusions.—

ObjectiveTo characterize the evolving management of vestibular schwannoma (VS) in the United States.Study DesignRetrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) database.SettingSEER database.Subjects and MethodsAll patients with a diagnosis of VS were analyzed. Data were described and compared using trend analyses and univariate and multivariable logistic regression.ResultsA total of 8330 patients (average age 54.7 years, 51.9% female) were analyzed. The mean incidence was approximately 1.1 per 100,000 per year and did not vary significantly across time; however, from 2004 to 2011, there was a statistically significant decrease in tumor size category at time of diagnosis (P <. 01). Overall, 3982 patients (48%) received primary microsurgery, 1978 (24%) radiation therapy alone, and 2370 (29%) observation. Within the microsurgical cohort, 732 (18%) underwent subtotal resection, and of those, 98 (13.4%) received postoperative radiation therapy. Multivariable regression revealed that surgical treatment was more common in younger patients and larger tumor size categories (P <. 05). Management trend analysis revealed that microsurgery was used less frequently over time (P <. 0001), observation was used more frequently (P <. 0001), and the pattern of radiation therapy remained unchanged. Linear regression was used to create an equation that was applied to predict future management practices. These data predict that by 2026, half of all cases of VS will be managed initially with observation.ConclusionWhile the incidence of VS has remained steady, tumor size at time of diagnosis has decreased over time. Within the United States there has been a clear, recent evolution in management toward observation.

ObjectiveAssess algorithms for linking patients across de‐identified databases without compromising confidentiality.Data Sources/Study SettingHospital discharges from 11 Mayo Clinic hospitals during January 2008–September 2012 (assessment and validation data). Minnesota death certificates and hospital discharges from 2009 to 2012 for entire state (application data).Study DesignCross‐sectional assessment of sensitivity and positive predictive value (PPV) for four linking algorithms tested by identifying readmissions and posthospital mortality on the assessment data with application to statewide data.Data Collection/Extraction MethodsDe‐identified claims included patient gender, birthdate, and zip code. Assessment records were matched with institutional sources containing unique identifiers and the last four digits of Social Security number (SSNL4).Principal FindingsGender, birthdate, and five‐digit zip code identified readmissions with a sensitivity of 98.0 percent and a PPV of 97.7 percent and identified postdischarge mortality with 84.4 percent sensitivity and 98.9 percent PPV. Inclusion of SSNL4 produced nearly perfect identification of readmissions and deaths. When applied statewide, regions bordering states with unavailable hospital discharge data had lower rates.ConclusionAddition of SSNL4 to administrative data, accompanied by appropriate data use and data release policies, can enable trusted repositories to link data with nearly perfect accuracy without compromising patient confidentiality. States maintaining centralized de‐identified databases should add SSNL4 to data specifications.

This article provides a brief summary of the relevant recommendations and references related to percutaneous mechanical circulatory support. The goal was to provide the clinician with concise, evidence‐based contemporary recommendations, and the supporting documentation to encourage their application. The full text includes disclosure of all relevant relationships with industry for each writing committee member. A fundamental aspect of all expert consensus statements is that these carefully developed, evidence‐based documents can neither encompass all clinical circumstances, nor replace the judgment of individual physicians in management of each patient. The science of medicine is rooted in evidence, and the art of medicine is based on the application of this evidence to the individual patient. This expert consensus statement has adhered to these principles for optimal management of patients requiring percutaneous mechanical circulatory support. © 2015 by The Society for Cardiovascular Angiography and Interventions, The American College of Cardiology Foundation, the Heart Failure Society of America, and The Society of Thoracic Surgeons.

Although historically the intra‐aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella®; left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high‐risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right‐sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines. © 2015 by The Society for Cardiovascular Angiography and Interventions, The American College of Cardiology Foundation, The Heart Failure Society of America, and The Society for Thoracic Surgery.

Background Surgical site infections (SSIs) result in significant patient morbidity following immediate tissue expander breast reconstruction (ITEBR). This study determined a single institution's 30-day SSI rate and benchmarked it against that among national institutions participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Methods Women who underwent ITEBR with/without acellular dermal matrix (ADM) were identified using the ACS-NSQIP database between 2005 and 2011. Patient characteristics associated with the 30-day SSI rate were determined, and differences in rates between our institution and the national database were assessed. Results 12,163 patients underwent ITEBR, including 263 at our institution. SSIs occurred in 416 (3.4%) patients nationwide excluding our institution, with lower rates observed at our institution (1.9%). Nationwide, SSIs were significantly more common in ITEBR patients with ADM (4.5%) compared to non-ADM patients (3.2%, P=0.005), and this trend was observed at our institution (2.1% vs. 1.6%, P=1.00). A multivariable analysis of all institutions identified age ≥50 years (odds ratio [OR], 1.4; confidence interval [CI], 1.1-1.7), body mass index ≥30 kg/m2 vs. <25 kg/m2 (OR, 3.4; CI, 2.6-4.5), and operative time >4.25 hours (OR, 1.9; CI, 1.5-2.4) as risk factors for SSIs. Our institutional SSI rate was lower than the nationwide rate (OR, 0.4; CI, 0.2-1.1), although this difference was not statistically significant (P=0.07). Conclusions The 30-day SSI rate at our institution in patients who underwent ITEBR was lower than the nation. SSIs occurred more frequently in procedures involving ADM both nationally and at our institution.

This study shows what employees in the Environment, Health and Safety (EHS) area within private Brazilian companies think about the relationship between ergonomic risks and Homogeneous Exposure Groups (HEG). Thirty-seven professionals from different market segments answered a questionnaire via Google Docs. The results show that 75.6% of the companies sampled use HEG in order to map occupational risks. Within those companies, 54% include ergonomic risks in their HEG, which has negative consequences to both employees and employers in these companies.

This discussion panel aims to identify ergonomic concerns, solutions and research needs, physical stresses, and outcomes related to clinical and surgical procedures. This session will begin with formal presentations to demonstrate current ergonomic concerns and research initiatives associated with clinical and surgical procedures to frame the panel discussion for the second part of the session. Discussion of different procedures will help to identify solutions and research needs that relate to a broad range of ergonomic problems. Questions will be collected from the attendees and speakers and organized so as to guide the panel discussion and to engage all of the speakers in the discussion to achieve the symposium aims.