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Mohammed Majid Akhtar,1,2 Amit Bhan,2 Zhan Yun Lim,2 Mohammed Abid Akhtar,3 Neha Sekhri,2 Preeti Bharadwaj,4 Michael Mullen2 1Institute of Cardiovascular Sciences, University College London, London, UK; 2Department of Cardiology, Barts Heart Centre, St Bartholomew’s Hospital, London, UK; 3Department of Cardiology and Cardiac Transplantation, Harefield Hospital, Royal Brompton & Harefield NHS Trust, London, UK; 4Community Gynaecology and Sexual & Reproductive Health Department, Waltham Forest, North East London Foundation Trust, London, UK Abstract: The Nexplanon® implant is a commonly used radiopaque contraceptive device that contains progestogen associated with an ethylene vinyl-acetate copolymer resulting in a slow release of the active hormonal ingredient. It is inserted into the subdermal connective tissue and provides contraceptive efficacy for up to 3 years. Device removal for clinical, personal or device “end-of-life span” reasons is straightforward. In rare cases, implant migration can occur locally within centimeters of the insertion site. Distant device embolization is extremely rare and can result in complications including chest pain, dyspnoea, pneumothorax and thrombosis or prevent conception until the active ingredient is depleted. We present one such case, where a Nexplanon® implant embolized into the pulmonary artery of a young female patient. We describe the initial “missed” diagnosis of embolized device on a chest radiograph and subsequent successful percutaneous removal once distant embolization was diagnosed. Keywords: Nexplanon®, pulmonary artery, embolization, extraction, snare

Objectives: To compare serum potassium concentrations in diabetic and non-diabetic patients in the early phase of acute coronary syndromes.Background: Acute phase hypokalaemia occurs in response to adrenergic activation, which stimulates membrane bound sodium-potassium-ATPase and drives potassium into the cells. It is not known whether the hypokalaemia is attenuated in patients with diabetes because of the high prevalence of sympathetic nerve dysfunction.Methods: Prospective cohort study of 2428 patients presenting with acute coronary syndromes. Patients were stratified by duration of chest pain, diabetic status, and pretreatment with beta blockers.Results: The mean (SD) serum potassium concentration was significantly higher in diabetic than in non-diabetic patients (4.3 (0.5) v 4.1 (0.5) mmol/l, p < 0.0001). Multivariate analysis identified diabetes as an independent predictor of a serum potassium concentration in the upper half of the distribution (odds ratio 1.66, 95% confidence interval 1.38 to 2.00). In patients presenting within 6 hours of symptom onset, there was a progressive increase in plasma potassium concentrations from 4.08 (0.46) mmol/l in patients presenting within 2 hours, to 4.20 (0.47) mmol/l in patients presenting between 2-4 hours, to 4.24 (0.52) mmol/l in patients presenting between 4-6 hours (p = 0.0007). This pattern of increasing serum potassium concentration with duration of chest pain was attenuated in patients with diabetes, particularly those with unstable angina. Similar attenuation occurred in patients pretreated with beta blockers.Conclusion: In acute coronary syndromes, patients with diabetes have significantly higher serum potassium concentrations and do not exhibit the early dip seen in non-diabetics. This may reflect sympathetic nerve dysfunction that commonly complicates diabetes. [ABSTRACT FROM AUTHOR]

Introduction: Anticoagulation in atrial fibrillation (AF) is strongly recommended in view of the fivefold increased risk of stroke. Current guidelines do not specify the timing of anticoagulation in patients admitted with new onset AF. There is no data comparing the effectiveness of inpatient vs. outpatient initiation of anticoagulation.Method: This was a single center, retrospective, observational study including patients admitted with new onset AF during 2013 (ICD-10 I48). We interrogated health records to identify patient characteristics, CHA2DS2VASc scores and contacted health care physicians to determine if anticoagulation was considered and the setting in which it was initiated.Results: We identified 234 patients admitted with a new diagnosis of AF (table 1). Anticoagulation was indicated in 201 patients (86%) but was considered in only 179 patients (89%) and no reason documented for the remaining 22 patients. 64 out of 179 patients had recognised contraindications. The remaining 115 patients were referred for inpatient (n=56) or outpatient anticoagulation (n=59, 32 anticoagulation clinic, 11 primary care and 16 secondary care)In the outpatient setting, only 69% were anticoagulated (29/32 anticoagulation clinic, 6/11 primary care and 6/16 secondary care). In those with (n-25) and without (n-7) scheduled anticoagulation clinic appointments on discharge, the mean delay was 6 vs. 37 days. In the primary and secondary care groups the time delay was 121 and 79 days respectively. This delay resulted in two patients, who were not anticoagulated as planned, suffering a stroke within 6 months of discharge.CHA2DS2VASc score (OR 0.72 95% 0.39-1.34, p- 0.31) or specialty team (cardiac vs. noncardiac) (OR 1.08 95% CI 0.58-2.00, p- 0.81) did not influence setting of anticoagulation.Conclusion: Anticoagulation is still not considered in all patients admitted with new onset AF. Outpatient referral for anticoagulation is associated with lack of uptake, significant delays and cerebrovascular events. Patient pathways need to be developed to minimise these delays; options include inpatient initiation, regulating clinic appointments and considering newer agents like NOACS.Table 1Patients baseline characteristicsTotalOutpatientInpatientMean Age (range)75 (22-99)77 (32-94)73 (45-97)M:F ratio1:1.21.1:11:1.5Diabetes (%)57 (24)22 (37)13 (23)Hypertension (%)169 (72)51 (86)46 (82)Congestive heart failure (%)90 (39)24 (41)26 (46)Stroke (%)37 (16)13 (22)11 (20)Peripheral vascular disease (%)9 (4)2 (3)1 (2)Mean CHA2DS2VASc score (SD)3.6 (2)4 (2)3.7 (2)Mean hospital stay in days (SD)10 (11)8 (6)12 (11) [ABSTRACT FROM PUBLISHER]