1. Novel metrics suggests that electronic consultations are an appropriate and useful alternative to face-to-face medical appointments
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Using novel metrics, researchers found that 70 percent of electronic consultations, or e-consults, were appropriate based on their proposed criteria and 81 percent were associated with avoided face-to-face visits. Study authors say these metrics provide meaningful insight into practice and may provide a rubric for comparison in future studies. Findings from a cohort study were published in Annals of Internal Medicine.
E-consults can improve patient access to specialists, minimize travel, and reduce unnecessary in-person visits. However, metrics to enable study of e-consults and their effect on processes and patient care are lacking.
Researchers from Brigham and Women's Hospital and Massachusetts General Hospital reviewed a random sample of 150 medical records from each of five specialties with a high volume of e-consult requests - psychiatry, hematology, dermatology, infectious diseases, and rheumatology - to assess novel metrics of e-consult appropriateness and utility. The appropriateness of each e-consult was measured by the following criteria: could not be answered by reference to society guidelines or a point-of-care resource, were not requesting logistical information, were not urgent, and were considered complex. Utility was measured by rate of avoided face-to-face visits within 120 days of the e-consult. The authors found 70 percent of e-consults to be appropriate based on their criteria, ranging from 61 percent in rheumatology to 78 percent in psychiatry. Nearly all questions were of appropriate urgency, but some were deemed too simple or too complex. Across all specialties, 81 percent of e-consults were associated with avoided visits, ranging from 62 percent in dermatology to 93 percent in psychiatry.
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2. Levetiracetam may reduce anticoagulation effect of rivaroxaban
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Levetiracetam, a commonly used medication to prevent seizures, may reduce the anticoagulation effect of oral rivaroxaban in humans. As such, clinicians should measure direct oral anticoagulant plasma levels during treatment. A case report is published in Annals of Internal Medicine.
Clinical guidelines recommend the use of levetiracetam with oral anticoagulants because animal studies suggest that the anti-convulsant acts as a P-glycoprotein inducer to reduce rivaroxaban plasma levels. However, not everyone is convinced that levetiracetam should be avoided in patients receiving rivaroxaban because there is little or no published evidence describing this interaction in humans.
Researchers from the University of Prugia, Perugia, Italy, report the case of a 69-year-old man who was taking rivaroxaban for atrial fibrillation and started to experience seizures in his right frontal lobe, for which he was prescribed levetiracetam. Several months later, he was clinically diagnosed with recurrent transient ischemic attacks. The clinicians measured his rivaroxaban plasma levels to determine if low levels would explain the transient ischemic attacks and then changed levetiracetam with lacosamide, an anticonvulsive not interfering with P-glycoprotein. Repeated measurement of rivaroxaban plasma levels showed a clinically relevant interaction between levetiracetam and rivaroxaban, where the drug reduced plasma levels, with a particularly strong and long-lasting effect on trough levels. The clinicians believe that this interaction is clinically important but caution that their study was limited and they did not measure P-glycoprotein activity in the patient.
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Annals of Internal Medicine