The use of quality improvement interventions in reducing rarely appropriate echocardiograms: A systematic review and meta-analysis.

BACKGROUND: The volume of cardiac imaging continues to increase, with many tests performed for rarely appropriate indications. Appropriate use criteria (AUC) documents were published by the American Society of Echocardiography and American College of Cardiology, with quality improvement (QI) interventions developed in various institutions. However, the effectiveness of these interventions has not been assessed in a systematic fashion. METHODS: We searched Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL for studies reporting association between cardiac imaging, AUC and QI. The search was not restricted to time or publication status. We selected studies assessing the effect of QI interventions on performance of rarely appropriate echocardiograms. The primary endpoint was reduction of rarely appropriate testing. RESULTS: Nine studies with 22,070 patients met inclusion criteria. Mean follow up was 15 months (1-60 months). QI interventions resulted in statistically significant reduction in rarely appropriate tests (OR 0.52, 95% CI: .41-.66; p < .01). The effects of QI interventions were analyzed over both the short (<3 months) and long-term (>3 months) post intervention (OR 0.62, 95% CI: .49-.79; p < .01 in the short term, and OR 0.47, 95% CI: .35-.62; p < .01 in the long term). Subgroup analysis of the type of intervention, classified as education tools or decision support tools showed both significantly reduced rarely appropriate testing (OR 0.54, 95% CI: .41-.73; p < .01; OR .47, 95% CI: .36-.61; p < .01). Adding a feedback tool did not change the effect compared to not using a feedback tool (OR 0.49 vs. 0.57, 95% CI: .36-.68 vs. 39-.84; p > .05). CONCLUSION: QI interventions are associated with a significant reduction in performance of rarely appropriate echocardiography testing, the effects of which persist over time. Both education and decision support tools were effective, while adding feedback tools did not result in further reduction of ordering rarely appropriate studies.

Full-Time Cardiac Intensive Care Unit Staffing by Heart Failure Specialists and its Association with Mortality Rates.

BACKGROUND: Cardiac intensive care units (CICUs) serve medically complex patients with multiorgan dysfunction. Whether a CICU that is staffed full time by heart failure (HF) specialists is associated with decreased mortality is unclear. METHODS AND RESULTS: A retrospective review of consecutive CICU admissions from January 1, 2012, to December 31, 2016, was performed. In January 2014, the CICU changed from an open unit staffed by any cardiologist to a closed unit managed by HF specialists. Patients' baseline characteristics were determined, and a multivariate regression analysis was performed to ascertain mortality rates in the CICU. Baseline severity of illness was higher in the closed/HF specialist CICU model (P< 0.001). Death occurred in 101 of 1185 patients admitted to the CICU (8.5%) in the open-unit model and in 139 of 2163 patients (6.4%) admitted to the closed/HF specialist model (absolute risk reduction 2.1%, 95% confidence interval [CI] 0.1-4.0%; P = 0.01). The transition from an open to a closed/HF specialist model was associated with a lower overall CICU mortality rate (odds ratio [OR] 0.63; 95% CI 0.43-0.93). Prespecified interaction with a mechanical circulatory support device and unit model showed that treatment with such a device was associated with lower mortality rates in the closed/HF specialist model of a CICU (OR 0.6; 95% CI 0.18-0.78; P for interaction <0.01). CONCLUSION: Transition to a closed unit model staffed by a dedicated HF specialist is associated with lower CICU mortality rates.

Report of ventricular fibrillation in a 44-year-old man using kratom.

Kratom is an unregulated kappa-opioid receptor agonist available for order on the internet that is used as a remedy for chronic pain. We present a case of a middle-aged man who suffered a cardiac arrest in the setting of kratom ingestion.

Outcomes of Coronary Artery Revascularization Procedures in Patients with Antiphospholipid Syndrome.

BACKGROUND: Published data on the outcome of coronary artery revascularization in patients with antiphospholipid syndrome (APS) are limited. Because APS is associated with a high rate of arterial thrombosis, there is concern that coronary revascularization in this group may be complicated by increased need for repeat revascularization. We aimed to determine the incidence and timing of repeat revascularization performed in patients with APS undergoing percutaneous coronary interventions (PCI) or coronary artery bypass grafting (CABG). METHODS: Our institutional database was queried for individuals (n = 575) testing positive for antiphospholipid antibodies between 2000 and 2012. From this group, 46 patients underwent cardiac catheterization. Charts were reviewed to identify subsequent revascularization procedures. RESULTS: The study sample consisted of 15 patients (67 ±â€¯11 years, 11 females) who underwent revascularization. All of the study subjects had prior history of arterial (stroke, TIA n = 7) or venous (n = 10) thrombosis. Ten of the subjects had initial revascularization (6 CABG, 4 PCI) at an outside facility, while another five underwent initial PCI at our hospital. Repeat revascularization occurred in five patients (33%) at a median of 6 years (range 4, 13) following the initial revascularization. The median follow-up for patients who did not require repeat revascularization (n = 10) was 10 years (range 2, 15). CONCLUSION: Amongst patients with APS who underwent CABG or PCI the need for repeat revascularization was infrequent and occurred several years after initial procedure. Based on this small sample size the periprocedural risk associated with coronary artery revascularization in subjects with APS is not prohibitively high.

Prevalence of myocardial infarction with non-obstructive coronary arteries (MINOCA) amongst acute coronary syndrome in patients with antiphospholipid syndrome.

Antiphospholipid antibody syndrome (APLS) is well known to cause thrombotic events and premature atherosclerosis leading to coronary artery occlusion. The association of non-thrombotic acute myocardial infarctions (AMI) with APLS is not as clearly delineated. The objective of this study was to determine the relative prevalence of myocardial infarction with non obstructive coronary arteries (MINOCA) compared to MI from vaso-occlusive disease amongst patients with known APLS at our institution. Out of 575 patients with positive antiphospholipid antibodies, cardiac catheterizations were performed in 40 patients presented with AMI and had cardiac catheterizations. MINOCA was found in 8 patients. We found that MINOCA is common in patients with APLS presenting with ACS and that spasm may also play a role in AMI in patients with APLS.

Spontaneous coronary artery dissection in a postpartum e-cigarette smoker.

Spontaneous coronary artery dissection (SCAD) is a rare but lethal cause of acute coronary syndrome that occurs in young women during the peripartum/postpartum periods. We present a case of a 41-year-old woman with no significant medical history, but was a habitual e-cigarette smoker who presented with atypical chest pain 2 weeks after an uncomplicated delivery while breast feeding. The patient was found to have elevated cardiac enzymes and ST segment elevations in the anterior leads. An urgent cardiac catheterisation was performed, which revealed dissection and occlusion of the left anterior descending artery, and a drug-eluting stent was placed that resulted in the resolution of chest pain. Physiological changes during the postpartum period may be linked to an increased risk of developing SCAD.1 In addition, e-cigarette smoking is associated with increased oxidative stress and sympathetic activity, which may predispose patients to an increased risk of acute coronary syndrome.

Case Report: My lung broke my heart! Takotsubo cardiomyopathy due to pneumonia.

Takotsubo cardiomyopathy (TTC), also known as stress-induced cardiomyopathy, is a cardiac syndrome that often mimics acute myocardial infarction. TTC is commonly triggered by physical or emotional stress; however, acute infection is a rarer etiology. This report concerns the case of an 82-year-old female who presented with non-positional and non-pleuritic chest pain, with an associated fever and cough and chest x-ray findings consistent with pneumonia. Cardiac enzymes and ECG findings were consistent with acute coronary syndrome (ACS); however, during coronary angiography, no coronary artery disease could explain the patient's ACS. A post-catheterization echocardiogram revealed an ejection fraction of 25%, with apical akinesis. A repeat echocardiogram 4 weeks after presentation showed a normal EF and normal wall motion, confirming a diagnosis of TTC.

Sleep Knowledge and Behaviors in Medical Students: Results of a Single Center Survey.

OBJECTIVE: There is little known about the demands of medical school on students' sleep behavior. The study's main goal was to examine the interplay between medical students' sleep knowledge, personal attitudes towards sleep, and their sleep habits. METHODS: An anonymous online survey was created and emailed to all students enrolled at a large metropolitan medical school. Data on demographics, sleep perception, and habits in addition to self-reported measures of students' sleep knowledge, beliefs, and sleepiness were collected. RESULTS: There were 261, out of a possible 720, responses to the survey. While 71.5% of respondents believed that they needed >7 h of sleep, only 24.9% of respondents stated they average >7 h of sleep. During the week of an examination, only 15.3% of students stated they averaged >7 h of sleep. A comparison of pre-clinical and clinical students revealed that reported median sleep during a school or rotation night was significantly lower in clinical students as compared to pre-clinical students while mean sleep during examination weeks between the two groups was not statistically different. In regard to sleep knowledge, clinical students were more knowledgeable (65.53% correct) than pre-clinical students (39.83% correct) (t(1) = -8.9, p = .00). However, there was no difference in the assessment of dysfunctional beliefs between the two groups (66.0 for preclinical students, 64.7 for clinical students (t(1) = 0.37, p = .71)) while clinical students had a higher score of sleepiness compared to pre-clinical students (9.12 to 7.83, t(1) = -2.3, p = .023). CONCLUSIONS: A majority of medical students are sleeping an inadequate amount of time during their 4 years, and as they progress from the pre-clinical to the clinical years, the amount of time they sleep decreases even though their knowledge about sleep increases. Increased awareness around sleep health is required beyond sleep education, as medical students appear to need help translating knowledge into strategies to improve their own sleep and well-being.

Assessment of indoor radon doses received by the students in the Azad Kashmir schools, Pakistan.

Several epidemiological studies conducted on thousands of underground miners suggest that long- term exposure to high radon concentration can increase the risk of lung cancer. Keeping in view the importance of the subject, numerous studies throughout the world have been carried out to measure indoor radon concentration and its resulting doses at occupational and non-occupational sites. The purpose of the current study was to measure indoor radon concentration and its resulting doses received by the students of Azad Kashmir government schools. For this purpose, CR-39 radon detectors were installed in 80 carefully selected schools. The detectors were placed at a height of 3-5 ft. (depending upon average height of students in particular class) from the ground. After exposure of 90 d detectors were etched for 9 h in 6 M NaOH at 70°C and the observed track densities were related to radon concentrations. The measured indoor radon concentration ranged from 22 ± 9 to 228 ± 3 Bq m(-3) with a mean value of 78 ± 5 Bq m(-3). Based on the measured indoor radon data, the annual effective doses were found to vary from 0.55 ± 0.04 to 0.71 ± 0.03 mSv y(-1). The overall mean effective dose for the studied area was found to be 0.63 ± 0.04 mSv y(-1). Reported values for radon concentrations and corresponding doses are lower than ICRP recommended limits for workplaces.