Warfarin has had a thin margin of benefit over risk for the prevention of stroke and systemic embolism in patients with ESRD because of higher bleeding risks and complications of therapy. The successful use of warfarin has been dependent on the selection of patients with nonvalvular atrial fibrillation at relatively high risk of stroke and systemic embolism and lower risks of bleeding over the course of therapy. Without such selection strategies, broad use of warfarin has not proven to be beneficial to the broad population of patients with ESRD and nonvalvular atrial fibrillation. In a recent meta-analysis of use of warfarin in patients with nonvalvular atrial fibrillation and ESRD, warfarin had no effect on the risks of stroke (hazard ratio, 1.12; 95% confidence interval, 0.69 to 1.82; P=0.65) or mortality (hazard ratio, 0.96; 95% confidence interval, 0.81 to 1.13; P=0.60) but was associated with increased risk of major bleeding (hazard ratio, 1.30; 95% confidence interval, 1.08 to 1.56; P<0.01). In pivotal trials, novel oral anticoagulants were generally at least equal to warfarin for efficacy and safety in nonvalvular atrial fibrillation and mild to moderate renal impairment. Clinical data for ESRD are limited, because pivotal trials excluded such patients. Given the very high risk of stroke and systemic embolism and the early evidence of acceptable safety profiles of novel oral anticoagulants, we think that patients with ESRD should be considered for treatment with chronic anticoagulation provided that there is an acceptable bleeding profile. Apixaban is currently indicated in ESRD for this application and may be preferable to warfarin given the body of evidence for warfarin and its difficulty of use and attendant adverse events.

Acute kidney injury (AKI) is a common medical problem, especially in patients undergoing cardiovascular procedures. The risk of kidney damage has multiple determinants and is often related to or exacerbated by intravenous or intra-arterial iodinated contrast. Contrast-induced AKI (CI-AKI) has been associated with an increased risk of subsequent myocardial infarction, stroke, the development of heart failure, rehospitalization, progression of chronic kidney disease, end-stage renal disease, and death. Statins have been studied extensively in the setting of chronic kidney disease and they have been shown to reduce albuminuria, but they have had no effect on the progressive reduction of glomerular filtration or the need for renal replacement therapy. Several meta-analyses have shown a protective effect of short-term statin administration on CI-AKI and led to two large randomized controlled trials evaluating the role of rosuvastatin in the prevention of CI-AKI in high-risk patients with acute coronary syndrome and diabetes mellitus. Both trials showed a benefit of rosuvastatin prior to contrast administration in a statin-naive patient population. In aggregate, these studies support the short-term use of statins specifically for the prevention of CI-AKI in patients undergoing coronary angiography with or without percutaneous coronary intervention.

We report a patient with hypoxia secondary to a right-to-left shunt through a patent foramen ovale, following aortic root, valve, and arch replacement due to an aortic dissection in the setting of the Marfan syndrome. Following the operation, he failed extubation twice due to hypoxia. An extensive workup revealed a right-to-left shunt previously not seen. The patent foramen ovale was closed using a percutaneous closure device. Following closure, our patient was extubated without difficulty and has done well postoperatively.A pproximately 25% of the general population is estimated to have a patent foramen ovale (PFO). Th ese small atrial septal defects, present from birth, are usually asymptomatic and found incidentally by echocardiogram or at autopsy (1). We describe the benefi t of closure of a PFO for postoperative hypoxia. CASE DESCRIPTIONA 23-year-old Hispanic man with the Marfan syndrome presented with acute chest pain that radiated to his back. Th e diagnosis of a dilated aortic root and a type B aortic dissection was made quickly by computed tomography scan with contrast. He underwent surgical repair using a two-staged "elephant trunk" procedure. Th e initial stage of the procedure consists of an aortic valve, root, and arch replacement, including leaving an elephant trunk portion of the graft that hangs down into the descending aorta. Finally the descending thoracic aorta is wrapped at that level of the diaphragm. Th e second stage of the procedure uses a stent graft, via an endovascular approach, to connect the elephant trunk with the wrapped portion of the aorta. Following the fi rst stage, his postoperative course was complicated by recurrent hypoxia. He underwent two attempted extubations on postoperative days 1 and 7, but the hypoxia persisted. A PFO with a signifi cant right-to-left shunt was found on transesophageal echocardiogram with bubble study (Figure 1).On postoperative day 9, a percutaneous closure procedure was performed via the right femoral vein. A #25 Amplatzer Cribriform Septal Occluder (AGA Medical Corp., Plymouth, MN) was deployed in the PFO, and placement was confi rmed with intracardiac echocardiography and fl uoroscopy (Figure 2). A negative echocardiographic bubble study at the conclusion of the procedure confi rmed resolution of the right-to-left shunt. On day 10, extubation was successful and normal oxygen saturation was maintained. Th e patient was discharged from the hospital on postoperative day 22. Five weeks later, he underwent stage 2 of the "elephant trunk" procedure without postoperative respiratory complications. He continues to do well 5 months following the second stage of the procedure. DISCUSSIONDespite the severity of potential consequences of a PFO, hypothesized benefi ts of closing PFOs, specifi cally for migraine headaches and strokes, have not resulted in clinical benefi t over standard medical management. Th ree large randomized controlled trials, RESPECT (2), CLOSURE I (3), and PC Trial (4), failed to show a benefi t of PFO closure over medical management fo...

Background Neutropenic fever is a medical emergency, which poses a significant morbidity and mortality risk to cancer patients receiving chemotherapy. National guidelines recommend that patients presenting with suspected neutropenic fever receive appropriate intravenous antibiotics within 60 min of admission. Aim We aimed to investigate the management of neutropenic fever in a large private oncology centre. Methods A retrospective audit of all patients who presented to St John of God Hospital, Subiaco, in the 2017 calendar year, with a known solid organ malignancy and a recorded diagnosis of neutropenic fever was conducted. Patients were identified through the hospitals Patient Administration System and ICD‐10 codes. Information was collected from the hospital medical records using a standardised data collection tool. Results There were 98 admissions relating to 88 patients with neutropenic fever during the study period. The median age was 64 years (range: 23–85 years) with 57 (65%) females. Antibiotic selections consistent with the Australian guidelines were made in 88 (89%) admissions. The mean time to antibiotic administration was 279 min, with a median of 135 min (range: 15–5160 min). Antibiotics were administered within the recommended time frame in only eight (11%) admissions. Conclusion Clinicians prescribed antibiotics in accordance with national guidelines; however, there were systemic inefficiencies which resulted in delayed antibiotic initiation. This has resulted in implementation of strategies to minimise delay.