Two male first cousins with mild haemophilia A had baseline factor VIII levels of 12-15% and experienced bleeding requiring coagulation factor infusion therapy with trauma and surgical procedures. Both the patients with haemophilia A also had electrocardiographically documented symptomatic paroxysmal atrial fibrillation (PAF) for several years that had become resistant to pharmacological suppression. Radiofrequency ablation was considered in both the cases but deferred considering refusal of consent by the patients to undergo the procedure. Remission of arrhythmias has been reported in patients with iron-overload syndromes. Body iron stores assessed by serum ferritin levels were elevated in both men but neither had the C282Y or H63D genes for haemochromatosis. Calibrated reduction of iron stores by serial phlebotomy, avoiding iron deficiency, was followed by remission of symptomatic PAF in both cases. Iron reduction may be an effective treatment for arrhythmias apart from the classic iron-overload syndromes and deserves further study particularly in patients with bleeding disorders who might be at risk for arrhythmias and other diseases of ageing.
IntroductionThe reporting of adverse effects is an integral aspect of a hospital quality improvement (QI) program with the goal of improving care for current and future patients. We report the results of our experience tracking patient hospitalizations, treatment breaks, and weight loss in patients receiving radiotherapy as part of a departmental QI program.MethodsIn 2014, the Center for Cancer Care at Exeter hospital developed a departmental quality initiative to track adverse outcomes in a population of patients receiving radiation therapy. Criteria for inclusion in this initiative included: treatment break ≥3 days, hospitalization either while on treatment of within 2 weeks of treatment, death within 2 weeks of treatment, or weight loss of ≥10%. Patients included on this registry were reviewed at regularly scheduled departmental QI meetings, where solutions for improvement were discussed.ResultsNinety-one patients were identified as having an event that meet the above-mentioned criteria. Forty-three patients were receiving concurrent chemotherapy (47.2%) Fifty-four (54.9%) patients had toxicity directly attributable to their treatment. Sixty-five patients (71.4%) were treated with curative intent. Nineteen patients (21.1%) died either during the course of radiotherapy, or within two weeks of completion of treatment. Advanced age was significantly associated with inferior overall and disease free survival in this analysis, HR 1.030 (1.006–1.054) p = 0.0125, and HR 1.034 (1.008–1.061) p = 0.010 respectively.ConclusionWe believe that this protocol to track events has been helpful in making practice changes in our department. Our results suggest that elderly patients who experience qualifying event are at increased risk of death, and providers should be cognizant of this finding. Future QI projects can seek to better understand how such changes have resulted in improvements in patient care.
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5100 Two male first cousins with mild hemophilia A had symptomatic electrocardiographically documented paroxysmal atrial fibrillation for several years that had become resistant to pharmacologic suppression. Both had baseline factor VIII levels of 12 to 15% and experienced bleeding requiring coagulation factor infusion therapy in response to trauma and surgical procedures. Radiofrequency ablation of ectopic electrical foci was considered in both cases but deferred because anticoagulation required to prevent thromboembolic complications of radiofrequency ablation carried an unacceptably high risk of bleeding. Iron accumulation with aging has been implicated in the pathogenesis of cardiovascular disease in general and arrhythmias in particular. Uncompensated iron-catalyzed oxygen free radical formation accounts for such toxicity. Remission of arrhythmias has been reported with iron reduction therapy in patients with iron overload disorders. Effects of iron reduction on arrhythmias in settings other than iron overload syndromes are unknown. Body iron stores as assessed by serum ferritin levels were elevated in both men (389 and 305 ng/ml respectively) but neither had the C282Y or H63D genes for hemochromatosis. Calibrated reduction of iron stores by serial phlebotomy, avoiding iron deficiency, was performed and was followed by sustained remission of PAF in both cases. These findings suggest that iron reduction with maintenance of ferritin levels below about 100 ng/ml may be effective treatment for arrhythmias apart from the classic iron overload syndromes. Effects of primary prevention of iron accumulation over time and reduction of existing elevated iron stores deserve further study in patients with bleeding disorders in whom standard treatment of diseases of aging may be costly and carry high risk. The efficacy, safety, simplicity and cost effectiveness of iron reduction therapy commends application of this investigational approach to disease prevention and treatment in the general population. Disclosures No relevant conflicts of interest to declare.
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