human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The management of emergency department ( ED ) patients with presumed recent-onset atrial fibrillation or flutter≤48h in duration varies widely . OBJECTIVE AND METHOD We conducted a prospect i ve study across three affiliated community EDs within a large integrated health care delivery system to describe the management of patients with recent-onset atrial fibrillation or flutter , to determine the safety and effectiveness of  ED cardioversion  , and to measure the incidence of thromboembolism 30 days after discharge . RESULTS We enrolled 206 patients with convenience sampling between June 2005 and November 2007 . Mean age was 64.0±14.4 years ( range 21 - 96 years ) . Patients were grouped for analysis into four categories based on whether cardioversion was 1 ) spontaneous in the ED ( 59 ; 28.6 % ) ; 2 ) attempted with electrical or pharmacological means ( 115 ; 56.3 % ) , with success in 110 ( 95.7 % ) ; 3 ) hoped for during a short stint of home observation ( 16 ; 7.8 % , 11 of which spontaneously converted to sinus rhythm within 24h ) ; or 4 ) contraindicated ( 16 ; 7.8 % ) . Of the entire group , 183 ( 88.8 % ) patients were discharged home . Adverse events requiring ED interventions were reported in 6 ( 2.9 % ; 95 % confidence interval [ CI ] 1.1 - 6.2 % ) patients , all of whom recovered . Two ( 1.0 % ; 95 % CI 0.1 - 3.5 % ) patients were found to have an embolic event on 30-day follow-up . CONCLUSIONS Our approach to ED patients with presumed recent-onset atrial fibrillation or flutter seems to be safe and effective , with a high rate of cardioversion and discharge to home coupled with a low ED adverse event and 30-day thromboembolic event rate OBJECTIVE Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation ( AF ) and atrial flutter ( AFl ) . Previous studies conducted outside the ED setting have demonstrated conversion rates of 60 % to 80 % . This response has been highest in patients with recent-onset AF-AFl . These observations and the 4-hour half-life of ibutilide suggest that it may be an excellent drug with which to treat AF-AFl in the ED . The purpose of the study was to examine the efficacy and safety of ibutilide in terminating AF-AFl in patients who present to the ED with symptoms of less than 3 days ' duration , neither angina nor heart failure , and no comorbid conditions that require admission . METHODS Among 36 enrolled patients , the admission electrocardiogram demonstrated AF in 26 and AFl in 10 .  Ibutilide 1 mg was administered intravenously for 10 minutes . If sinus rhythm was not present 10 minutes after the infusion concluded , a second infusion of 1 mg was given . Successful conversion was defined as restoration of sinus rhythm within 1 hour after the last dose of ibutilide . RESULTS Sixteen ( 61.5 % ) of 26 patients with AF and 9 ( 90 % ) of 10 patients with AFl converted to sinus rhythm ( overall conversion rate=69 % ) . The mean time to arrhythmia termination was 19+/-9 minutes . The mean stay in the ED was 16.2 hours . No significant complications occurred . CONCLUSION We conclude that ibutilide is an excellent therapy option for restoring sinus rhythm in the ED . Its use may obviate the need for admission , avoid the risks and inconveniences of general anesthesia to perform electrical cardioversion , and reduce the ED length of stay in selected patients with recent-onset atrial arrhythmias OBJECTIVES While the short-term ( < 7-day ) safety and efficiency of electrical cardioversion for emergency department ( ED ) patients with atrial fibrillation or flutter have been established , the 30-day outcomes with respect to stroke , thromboembolic events , or death have not been investigated . METHODS A two-center cohort of consecutive ED patients undergoing cardioversion for atrial fibrillation or flutter between January 1 , 2000 , and September 30 , 2007 , was retrospectively investigated . This cohort was probabilistically linked with both a regional ED data base and the provincial health registry to determine which patients had a subsequent ED visit or hospital admission , stroke , or thromboembolic event or died within 30 days . In addition , trained review ers performed a detailed chart abstract ion on 150 r and omly selected patients , with emphasis on demographics , vital signs , medical treatment , and predefined adverse events . Hemodynamically unstable patients or those whose condition was the result of an underlying acute medical diagnosis were excluded . Data were analyzed by descriptive methods . RESULTS During the study period , 1,233 patients made 1,820 visits for atrial fibrillation or flutter to the ED . Of the 400 eligible patients undergoing direct-current cardioversion ( DCCV ) , no patients died , had a stroke , or had a thromboembolic event in the following 30 days ( 95 % confidence interval [ CI ] = 0.0 to 0.8 % for all outcomes ) . A total of 141 patients were included in the formal chart review , with five patients ( 3.5 % , 95 % CI = 0.5 % to 6.6 % ) failing cardioversion , six patients ( 4.3 % , 95 % CI = 0.9 % to 7.6 % ) having a minor adverse event that did not change disposition , and five patients ( 3.5 % , 95 % CI = 0.5 % to 6.6 % ) admitted to hospital at the index visit . CONCLUSIONS Cardioversion of patients with atrial fibrillation or flutter in the ED appears to have a very low rate of long-term complications STUDY OBJECTIVE Patients presenting to the emergency department with acute atrial fibrillation are traditionally admitted to hospital . The objective of this study was to review the success and safety of ED cardioversion and discharge of patients with acute atrial fibrillation . METHODS This health records survey included a cohort sample of consecutive patients presenting with acute atrial fibrillation to the ED of a university-affiliated tertiary hospital . Patients who were in unstable condition on presentation , who had a complicating cardiac diagnosis , or those with other medical or surgical conditions requiring admission were excluded from the study analysis . Patient visit information was entered into a data base that included demographics and clinical presentation , investigations , ED therapy , complications , consultations , disposition , and follow up . Patient visits were then categorized into the following groups : no ED intervention , spontaneous resolution , heart rate control , attempted chemical cardioversion , or electrical cardioversion . The data were analyzed using descriptive methods . RESULTS Of the 289 eligible patients seen during an 18-month period , 62 % ( 180 ) underwent attempted chemical cardioversion with a 50 % success rate and 28 % ( 80 ) had attempted electrical cardioversion with a 89 % success rate . Ninety-three percent of electrical cardioversions were performed by emergency physicians . There was an overall 6 % ( 19 ) complication rate , 95 % of which were regarded as minor . One patient had a complication caused by a rate control medication , which necessitated hospital admission . Ninety-seven percent ( 280 ) of the patients were discharged home directly from the ED . CONCLUSION Cardioversion and immediate discharge of patients who present to the ED with acute atrial fibrillation appears to be both safe and effective . This management approach should be prospect ively evaluated in multiple setting STUDY OBJECTIVE We sought to describe the feasibility of an emergency department observation unit ( EDOU ) treatment protocol for the management of uncomplicated acute-onset atrial fibrillation ( AAF ) .  METHODS This descriptive case series took place at a major suburban , university-affiliated teaching hospital . Patients were prospect ively enrolled in an EDOU treatment protocol if they had uncomplicated AAF that failed initial ED attempts to convert to sinus rhythm . In the EDOU , patients underwent ECG monitoring , serial creatine kianse MB measurements , and further rate control with optional electrical cardioversion . Primary outcomes measured were EDOU rate of conversion to sinus rhythm , rate of discharge home , length of stay , positive diagnostic outcomes , complications of AAF , and 7-day return visits . RESULTS Sixty-seven patients were studied . Patients were symptomatic for a median of 4.0 hours , had mean initial ED pulse rates of 137+/-23 beats/min , and spent 4.7+/-2.2 hours in the ED before transfer to the EDOU . While in the EDOU , 55 ( 82 % ) patients converted to sinus rhythm . Five ( 7 % ) patients were admitted because of positive test results : 2 for myocardial infa rct ion , 2 for fever , and 1 for ventricular tachycardia . Twelve ( 18 % ) patients remained in atrial fibrillation , with 9 admitted and 3 discharged . Overall , 81 % of patients were discharged in 11.8+/-7.0 hours , and 19 % were admitted after 17.6+/-9.5 hours of observation . Three discharged patients returned within 7 days , 2 for uncomplicated recurrent AAF and 1 for chest pain subsequently found to be noncardiac in origin . There were no major complications attributable to the EDOU protocol . CONCLUSION Selected patients with AAF for whom initial ED management fails can subsequently be managed in an EDOU with a high short-term conversion and discharge rate There is wide variation in the management of patients with atrial fibrillation ( AF ) in the emergency department ( ED ) . We aim ed to derive and internally vali date the first prospect i ve , ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events . We performed a prospect i ve cohort study at a university-affiliated tertiary-care ED . Patients were enrolled from June 9 , 2010 , to February 28 , 2013 , and followed for 30 days . We enrolled a convenience sample of patients in ED presenting with symptomatic AF .  C and i date predictors were based on ED data available in the first 2 hours . The decision aid was derived using model approximation ( preconditioning ) followed by strong bootstrap internal validation . We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation . Of 497 patients enrolled , stroke and AF-related death occurred in 13 ( 3 % ) and 4 ( < 1 % ) patients , respectively . The decision aid included the following : age , triage vitals ( systolic blood pressure , temperature , respiratory rate , oxygen saturation , supplemental oxygen requirement ) , medical history ( heart failure , home sotalol use , previous percutaneous coronary intervention , electrical cardioversion , cardiac ablation , frequency of AF symptoms ) , and ED data ( 2 hours heart rate , chest radiograph results , hemoglobin , creatinine , and brain natriuretic peptide ) . The decision aid 's c-statistic in predicting any 30-day adverse event was 0.7 ( 95 % confidence interval 0.65 , 0.76 ) . In conclusion , in patients with AF in the ED , Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence -based decision aid for identifying patients who are at low risk for 30-day adverse events and c and i date s for safe discharge STUDY OBJECTIVE An emergency department ( ED ) observation unit protocol for the management of  acute onset atrial fibrillation  is compared with routine hospital admission and management . METHODS Adult patients presenting to the ED with atrial fibrillation of less than 48 hours ' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled . Participants were r and omized to either ED observation unit care or routine inpatient care .  The ED observation unit protocol included pulse rate control , cardiac monitoring , re assessment , and electrical cardioversion if atrial fibrillation persisted . Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days , whereas those still in atrial fibrillation were admitted . All cases were followed up for 6 months and adverse events recorded . RESULTS Of the 153 patients , 75 were r and omized to the ED observation unit and 78 to routine inhospital care . Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73 % in the routine care group ( difference 12 % ; 95 % confidence interval [ CI ] -1 % to 25 % ] ; P=.06 ) . The median length of stay was 10.1 versus 25.2 hours ( difference 15.1 hours ; 95 % CI 11.2 to 19.6 ; P<.001 ) for ED observation unit and inhospital care respectively . Nine ED observation unit patients required inpatient admission . Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10 % of the routine inpatient care group ( difference 1 % ; 95 % CI -9 % to 11 % ; P=.93 ) . There was no significant difference between the groups in the frequency of hospitalization or the number of tests , and the number of adverse events during follow-up was similar in the 2 groups . CONCLUSION An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay Health care re source utilization is high for patients presenting 
    Output:
    
agent
The articles were grouped into four main categories : decision aids and outcome predictors , electrical cardioversion-based protocol s , antiarrhythmic-based protocol s , and general management protocol s. Conclusion This systematic review is the first study to our knowledge to evaluate the optimal management of symptomatic AF/AFLin  the ED with a direct impact on ED disposition .
There are several viable management strategies that can result in safe discharge from the ED in the right patient population , and decision aids can be utilized to guide selection of appropriate patients for discharge
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The management of emergency department ( ED ) patients with presumed recent-onset atrial fibrillation or flutter≤48h in duration varies widely . OBJECTIVE AND METHOD We conducted a prospect i ve study across three affiliated community EDs within a large integrated health care delivery system to describe the management of patients with recent-onset atrial fibrillation or flutter , to determine the safety and effectiveness of  ED cardioversion  , and to measure the incidence of thromboembolism 30 days after discharge . RESULTS We enrolled 206 patients with convenience sampling between June 2005 and November 2007 . Mean age was 64.0±14.4 years ( range 21 - 96 years ) . Patients were grouped for analysis into four categories based on whether cardioversion was 1 ) spontaneous in the ED ( 59 ; 28.6 % ) ; 2 ) attempted with electrical or pharmacological means ( 115 ; 56.3 % ) , with success in 110 ( 95.7 % ) ; 3 ) hoped for during a short stint of home observation ( 16 ; 7.8 % , 11 of which spontaneously converted to sinus rhythm within 24h ) ; or 4 ) contraindicated ( 16 ; 7.8 % ) . Of the entire group , 183 ( 88.8 % ) patients were discharged home . Adverse events requiring ED interventions were reported in 6 ( 2.9 % ; 95 % confidence interval [ CI ] 1.1 - 6.2 % ) patients , all of whom recovered . Two ( 1.0 % ; 95 % CI 0.1 - 3.5 % ) patients were found to have an embolic event on 30-day follow-up . CONCLUSIONS Our approach to ED patients with presumed recent-onset atrial fibrillation or flutter seems to be safe and effective , with a high rate of cardioversion and discharge to home coupled with a low ED adverse event and 30-day thromboembolic event rate OBJECTIVE Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation ( AF ) and atrial flutter ( AFl ) . Previous studies conducted outside the ED setting have demonstrated conversion rates of 60 % to 80 % . This response has been highest in patients with recent-onset AF-AFl . These observations and the 4-hour half-life of ibutilide suggest that it may be an excellent drug with which to treat AF-AFl in the ED . The purpose of the study was to examine the efficacy and safety of ibutilide in terminating AF-AFl in patients who present to the ED with symptoms of less than 3 days ' duration , neither angina nor heart failure , and no comorbid conditions that require admission . METHODS Among 36 enrolled patients , the admission electrocardiogram demonstrated AF in 26 and AFl in 10 .  Ibutilide 1 mg was administered intravenously for 10 minutes . If sinus rhythm was not present 10 minutes after the infusion concluded , a second infusion of 1 mg was given . Successful conversion was defined as restoration of sinus rhythm within 1 hour after the last dose of ibutilide . RESULTS Sixteen ( 61.5 % ) of 26 patients with AF and 9 ( 90 % ) of 10 patients with AFl converted to sinus rhythm ( overall conversion rate=69 % ) . The mean time to arrhythmia termination was 19+/-9 minutes . The mean stay in the ED was 16.2 hours . No significant complications occurred . CONCLUSION We conclude that ibutilide is an excellent therapy option for restoring sinus rhythm in the ED . Its use may obviate the need for admission , avoid the risks and inconveniences of general anesthesia to perform electrical cardioversion , and reduce the ED length of stay in selected patients with recent-onset atrial arrhythmias OBJECTIVES While the short-term ( < 7-day ) safety and efficiency of electrical cardioversion for emergency department ( ED ) patients with atrial fibrillation or flutter have been established , the 30-day outcomes with respect to stroke , thromboembolic events , or death have not been investigated . METHODS A two-center cohort of consecutive ED patients undergoing cardioversion for atrial fibrillation or flutter between January 1 , 2000 , and September 30 , 2007 , was retrospectively investigated . This cohort was probabilistically linked with both a regional ED data base and the provincial health registry to determine which patients had a subsequent ED visit or hospital admission , stroke , or thromboembolic event or died within 30 days . In addition , trained review ers performed a detailed chart abstract ion on 150 r and omly selected patients , with emphasis on demographics , vital signs , medical treatment , and predefined adverse events . Hemodynamically unstable patients or those whose condition was the result of an underlying acute medical diagnosis were excluded . Data were analyzed by descriptive methods . RESULTS During the study period , 1,233 patients made 1,820 visits for atrial fibrillation or flutter to the ED . Of the 400 eligible patients undergoing direct-current cardioversion ( DCCV ) , no patients died , had a stroke , or had a thromboembolic event in the following 30 days ( 95 % confidence interval [ CI ] = 0.0 to 0.8 % for all outcomes ) . A total of 141 patients were included in the formal chart review , with five patients ( 3.5 % , 95 % CI = 0.5 % to 6.6 % ) failing cardioversion , six patients ( 4.3 % , 95 % CI = 0.9 % to 7.6 % ) having a minor adverse event that did not change disposition , and five patients ( 3.5 % , 95 % CI = 0.5 % to 6.6 % ) admitted to hospital at the index visit . CONCLUSIONS Cardioversion of patients with atrial fibrillation or flutter in the ED appears to have a very low rate of long-term complications STUDY OBJECTIVE Patients presenting to the emergency department with acute atrial fibrillation are traditionally admitted to hospital . The objective of this study was to review the success and safety of ED cardioversion and discharge of patients with acute atrial fibrillation . METHODS This health records survey included a cohort sample of consecutive patients presenting with acute atrial fibrillation to the ED of a university-affiliated tertiary hospital . Patients who were in unstable condition on presentation , who had a complicating cardiac diagnosis , or those with other medical or surgical conditions requiring admission were excluded from the study analysis . Patient visit information was entered into a data base that included demographics and clinical presentation , investigations , ED therapy , complications , consultations , disposition , and follow up . Patient visits were then categorized into the following groups : no ED intervention , spontaneous resolution , heart rate control , attempted chemical cardioversion , or electrical cardioversion . The data were analyzed using descriptive methods . RESULTS Of the 289 eligible patients seen during an 18-month period , 62 % ( 180 ) underwent attempted chemical cardioversion with a 50 % success rate and 28 % ( 80 ) had attempted electrical cardioversion with a 89 % success rate . Ninety-three percent of electrical cardioversions were performed by emergency physicians . There was an overall 6 % ( 19 ) complication rate , 95 % of which were regarded as minor . One patient had a complication caused by a rate control medication , which necessitated hospital admission . Ninety-seven percent ( 280 ) of the patients were discharged home directly from the ED . CONCLUSION Cardioversion and immediate discharge of patients who present to the ED with acute atrial fibrillation appears to be both safe and effective . This management approach should be prospect ively evaluated in multiple setting STUDY OBJECTIVE We sought to describe the feasibility of an emergency department observation unit ( EDOU ) treatment protocol for the management of uncomplicated acute-onset atrial fibrillation ( AAF ) .  METHODS This descriptive case series took place at a major suburban , university-affiliated teaching hospital . Patients were prospect ively enrolled in an EDOU treatment protocol if they had uncomplicated AAF that failed initial ED attempts to convert to sinus rhythm . In the EDOU , patients underwent ECG monitoring , serial creatine kianse MB measurements , and further rate control with optional electrical cardioversion . Primary outcomes measured were EDOU rate of conversion to sinus rhythm , rate of discharge home , length of stay , positive diagnostic outcomes , complications of AAF , and 7-day return visits . RESULTS Sixty-seven patients were studied . Patients were symptomatic for a median of 4.0 hours , had mean initial ED pulse rates of 137+/-23 beats/min , and spent 4.7+/-2.2 hours in the ED before transfer to the EDOU . While in the EDOU , 55 ( 82 % ) patients converted to sinus rhythm . Five ( 7 % ) patients were admitted because of positive test results : 2 for myocardial infa rct ion , 2 for fever , and 1 for ventricular tachycardia . Twelve ( 18 % ) patients remained in atrial fibrillation , with 9 admitted and 3 discharged . Overall , 81 % of patients were discharged in 11.8+/-7.0 hours , and 19 % were admitted after 17.6+/-9.5 hours of observation . Three discharged patients returned within 7 days , 2 for uncomplicated recurrent AAF and 1 for chest pain subsequently found to be noncardiac in origin . There were no major complications attributable to the EDOU protocol . CONCLUSION Selected patients with AAF for whom initial ED management fails can subsequently be managed in an EDOU with a high short-term conversion and discharge rate There is wide variation in the management of patients with atrial fibrillation ( AF ) in the emergency department ( ED ) . We aim ed to derive and internally vali date the first prospect i ve , ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events . We performed a prospect i ve cohort study at a university-affiliated tertiary-care ED . Patients were enrolled from June 9 , 2010 , to February 28 , 2013 , and followed for 30 days . We enrolled a convenience sample of patients in ED presenting with symptomatic AF .  C and i date predictors were based on ED data available in the first 2 hours . The decision aid was derived using model approximation ( preconditioning ) followed by strong bootstrap internal validation . We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation . Of 497 patients enrolled , stroke and AF-related death occurred in 13 ( 3 % ) and 4 ( < 1 % ) patients , respectively . The decision aid included the following : age , triage vitals ( systolic blood pressure , temperature , respiratory rate , oxygen saturation , supplemental oxygen requirement ) , medical history ( heart failure , home sotalol use , previous percutaneous coronary intervention , electrical cardioversion , cardiac ablation , frequency of AF symptoms ) , and ED data ( 2 hours heart rate , chest radiograph results , hemoglobin , creatinine , and brain natriuretic peptide ) . The decision aid 's c-statistic in predicting any 30-day adverse event was 0.7 ( 95 % confidence interval 0.65 , 0.76 ) . In conclusion , in patients with AF in the ED , Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence -based decision aid for identifying patients who are at low risk for 30-day adverse events and c and i date s for safe discharge STUDY OBJECTIVE An emergency department ( ED ) observation unit protocol for the management of  acute onset atrial fibrillation  is compared with routine hospital admission and management . METHODS Adult patients presenting to the ED with atrial fibrillation of less than 48 hours ' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled . Participants were r and omized to either ED observation unit care or routine inpatient care .  The ED observation unit protocol included pulse rate control , cardiac monitoring , re assessment , and electrical cardioversion if atrial fibrillation persisted . Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days , whereas those still in atrial fibrillation were admitted . All cases were followed up for 6 months and adverse events recorded . RESULTS Of the 153 patients , 75 were r and omized to the ED observation unit and 78 to routine inhospital care . Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73 % in the routine care group ( difference 12 % ; 95 % confidence interval [ CI ] -1 % to 25 % ] ; P=.06 ) . The median length of stay was 10.1 versus 25.2 hours ( difference 15.1 hours ; 95 % CI 11.2 to 19.6 ; P<.001 ) for ED observation unit and inhospital care respectively . Nine ED observation unit patients required inpatient admission . Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10 % of the routine inpatient care group ( difference 1 % ; 95 % CI -9 % to 11 % ; P=.93 ) . There was no significant difference between the groups in the frequency of hospitalization or the number of tests , and the number of adverse events during follow-up was similar in the 2 groups . CONCLUSION An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay Health care re source utilization is high for patients presenting 
    Output:
    