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Combating climate change may be the greatest public health opportunity of the 21st century. While physicians play an important role in addressing climate change, given their affluence in society, they may be an important source of greenhouse gas emissions themselves. We sought to examine the size and nature of the ecological footprint of physicians and medical students. We conducted an online survey from December 2021-May 2022 examining resource consumption, changes in consumption patterns over time, and beliefs about climate change. Participants were medical students, residents, and staff physicians in Canada, India, or USA. Only 20 out of 162 valid respondents had a low ecological footprint (12%), defined as meat intake ≤2 times per week, living in an apartment or condominium, and using public transport, bicycle, motorcycle or walking to work. 14 of these 20 participants were from India. 91% of participants were open to reducing their own ecological footprint, though only 40% had made changes in that regard. 49% participants who discussed climate change at work and at home had decreased their ecological footprint, compared to 29% of participants who rarely engaged in such conversations (OR 2.39, 95% CI 1.24-4.63, P = 0.01). We conclude that physicians have a large ecological footprint, especially those from Canada and USA. A majority of physicians are interested in reducing their ecological footprint, and those who engage in conversations around climate change are more likely to have done so. Talking frequently about climate change, at work and at home, will likely increase climate change action amongst physicians.
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Médicos , Humanos , Canadá , India , Cambio Climático , ComunicaciónRESUMEN
Background: Altered coagulation is a striking feature of COVID-19. Adult patients with congenital heart disease (ACHD) are prone to thromboembolic (TE) and bleeding complications. Objectives: The purpose of this study was to investigate the prevalence and risk factors for COVID-19 TE/bleeding complications in ACHD patients. Methods: COVID-19-positive ACHD patients were included between May 2020 and November 2021. TE events included ischemic cerebrovascular accident, systemic and pulmonary embolism, deep venous thrombosis, myocardial infarction, and intracardiac thrombosis. Major bleeding included cases with hemoglobin drop >2 g/dl, involvement of critical sites, or fatal bleeding. Severe infection was defined as need for intensive care unit, endotracheal intubation, renal replacement therapy, extracorporeal membrane oxygenation, or death. Patients with TE/bleeding were compared to those without events. Factors associated with TE/bleeding were determined using logistic regression. Results: Of 1,988 patients (age 32 [IQR: 25-42] years, 47% male, 59 ACHD centers), 30 (1.5%) had significant TE/bleeding: 12 TE events, 12 major bleeds, and 6 with both TE and bleeding. Patients with TE/bleeding had higher in-hospital mortality compared to the remainder cohort (33% vs 1.7%; P < 0.0001) and were in more advanced physiological stage (P = 0.032) and NYHA functional class (P = 0.01), had lower baseline oxygen saturation (P = 0.0001), and more frequently had a history of atrial arrhythmia (P < 0.0001), previous hospitalization for heart failure (P < 0.0007), and were more likely hospitalized for COVID-19 (P < 0.0001). By multivariable logistic regression, prior anticoagulation (OR: 4.92; 95% CI: 2-11.76; P = 0.0003), cardiac injury (OR: 5.34; 95% CI: 1.98-14.76; P = 0.0009), and severe COVID-19 (OR: 17.39; 95% CI: 6.67-45.32; P < 0.0001) were independently associated with increased risk of TE/bleeding complications. Conclusions: ACHD patients with TE/bleeding during COVID-19 infection have a higher in-hospital mortality from the illness. Risk of coagulation disorders is related to severe COVID-19, cardiac injury during infection, and use of anticoagulants.
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Background: Coarctation of the aorta (CoA) is associated with intracranial aneurysms (IAs); however, the prevalence and risk factors (RFs) are not well described. Current practice guidelines offer inconsistent recommendations on screening for IAs in this patient population ranging from "not recommended" (European Society of Cardiology 2020) to "recommended" (American Heart Association 2018). Objectives: The purpose of this study was to determine the prevalence and RFs for IAs in patients with CoA. Methods: We completed a systematic review and meta-analysis of studies utilizing computed tomography or magnetic resonance angiographic screening for IAs in patients with CoA. Results: Five cohort studies were included, representing 442 patients. The pooled prevalence of IAs in patients with CoA was 3.8% [95% CI: 0.1%-12.3%]. The results met our prespecified definition for high heterogeneity. Of 5 RFs evaluated, only hypertension was associated with the development of IAs with an odds ratio of 3.1 [95% CI: 1.1-8.2; P = 0.03]. There was an observed downward trend over time in the prevalence of IAs among the studies included. Conclusions: The development of IAs is likely multifactorial in etiology and there may be modifiable RFs in their development. Considering the low prevalence of IAs in the pooled result, routine screening of patients with CoA for IAs is likely of low-value.
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BACKGROUND: Adults with congenital heart disease (CHD) have been considered potentially high risk for novel coronavirus disease-19 (COVID-19) mortality or other complications. OBJECTIVES: This study sought to define the impact of COVID-19 in adults with CHD and to identify risk factors associated with adverse outcomes. METHODS: Adults (age 18 years or older) with CHD and with confirmed or clinically suspected COVID-19 were included from CHD centers worldwide. Data collection included anatomic diagnosis and subsequent interventions, comorbidities, medications, echocardiographic findings, presenting symptoms, course of illness, and outcomes. Predictors of death or severe infection were determined. RESULTS: From 58 adult CHD centers, the study included 1,044 infected patients (age: 35.1 ± 13.0 years; range 18 to 86 years; 51% women), 87% of whom had laboratory-confirmed coronavirus infection. The cohort included 118 (11%) patients with single ventricle and/or Fontan physiology, 87 (8%) patients with cyanosis, and 73 (7%) patients with pulmonary hypertension. There were 24 COVID-related deaths (case/fatality: 2.3%; 95% confidence interval: 1.4% to 3.2%). Factors associated with death included male sex, diabetes, cyanosis, pulmonary hypertension, renal insufficiency, and previous hospital admission for heart failure. Worse physiological stage was associated with mortality (p = 0.001), whereas anatomic complexity or defect group were not. CONCLUSIONS: COVID-19 mortality in adults with CHD is commensurate with the general population. The most vulnerable patients are those with worse physiological stage, such as cyanosis and pulmonary hypertension, whereas anatomic complexity does not appear to predict infection severity.
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COVID-19 , Procedimientos Quirúrgicos Cardíacos , Cianosis , Cardiopatías Congénitas , Hipertensión Pulmonar , Adulto , COVID-19/mortalidad , COVID-19/terapia , Prueba de COVID-19/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Causalidad , Comorbilidad , Cianosis/diagnóstico , Cianosis/etiología , Cianosis/mortalidad , Femenino , Salud Global/estadística & datos numéricos , Cardiopatías Congénitas/clasificación , Cardiopatías Congénitas/epidemiología , Cardiopatías Congénitas/fisiopatología , Cardiopatías Congénitas/terapia , Hospitalización/estadística & datos numéricos , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/mortalidad , Masculino , Mortalidad , Gravedad del Paciente , Factores de Riesgo , SARS-CoV-2/aislamiento & purificación , Evaluación de SíntomasRESUMEN
The adult congenital heart disease (ACHD) population continues to grow and most cardiologists, emergency room physicians and family doctors will intermittently come into contact with these patients. Oftentimes this may be in the setting of a presentation with atrial tachyarrhythmia; one of the commonest late complications of ACHD and problem with potentially serious implications. Providing appropriate initial care and ongoing management of atrial tachyarrhythmia in ACHD patients requires a degree of specialist knowledge and an awareness of certain key issues. In ACHD, atrial tachyarrhythmia is usually related to the abnormal anatomy of the underlying heart defect and often occurs as a result of surgical scar or a consequence of residual hemodynamic or electrical disturbances. Arrhythmias significantly increase mortality and morbidity in ACHD and are the most frequent reason for ACHD hospitalization. Intra-atrial reentrant tachycardia and atrial fibrillation are the most prevalent type of arrhythmia in this patient group. In hemodynamically unstable patients, urgent cardioversion is required. Acute management of the stable patient includes anticoagulation, rate control, and electrical or pharmacological cardioversion. In ACHD, rhythm control is the preferred management strategy and can often be achieved. However, in the long-term, medication side-effects can prove problematic. Electrophysiology studies and catheter ablation are important treatments modalities and in certain cases, surgical or percutaneous treatment of the underlying cardiac defect has a role. ACHD patients, especially those with complex CHD, are at increased risk of thromboembolic events and anticoagulation is usually required. Female ACHD patients of child bearing age may wish to pursue pregnancies. The risk of atrial arrhythmias is increased during pregnancy and management of atrial tachyarrhythmia during pregnancy needs specific consideration.
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There have been attempts to find new approaches to the treatment of multivessel coronary artery disease without increasing adverse events. Deployment of drug-eluting stents (DES) for complex lesions and bare-metal stents (BMS) for simpler lesions, although already in wide use, has not been well supported by clinical study. A cohort of 1,658 patients who underwent multivessel percutaneous coronary intervention from March 2003 through June 2011 was studied for 1 year. These patients were divided into 3 groups: BMS only (599 patients); DES only (481 patients); and hybrid stenting (578 patients). Baseline characteristics were similar except for hyperlipidemia and moderate-to-severe mitral regurgitation, which were more frequent in the DES and hybrid groups, respectively. Lesion characteristics were more complex in the DES group, compared with the other groups: more B2/C type lesions, longer stents, and smaller reference-vessel diameters (P <0.001). The rates of major adverse cardiac events (MACE) at 1 year were similar between the groups (BMS=5.2%, hybrid=3.9%, and DES=3.4%; P=0.248). Subgroup analysis yielded no differences in death, nonfatal myocardial infarction, target-vessel revascularization, or target-lesion revascularization. On multivariable analysis, the strongest predictors of 1-year MACE were percutaneous intervention complicated by dissection, renal failure, left ventricular ejection fraction below 0.40, mean lesion length, reference vessel diameter, and percutaneous intervention on the left circumflex coronary artery. The latter two had inverse relationships with MACE. In conclusion, implanting the DES for more complex lesions and the BMS for simpler lesions seems more sensible than the exclusive use of the DES or the BMS.
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Enfermedad de la Arteria Coronaria/cirugía , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea/instrumentación , Anciano , Estudios de Cohortes , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/mortalidad , Supervivencia sin Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to develop new models for prediction of short-term mortality risk in on-pump coronary artery bypass grafting (CABG) surgery using decision tree (DT) methods. METHODS: Between September 2005 and April 2006, 948 consecutive patients underwent CABG surgery at Rajaie Heart Center. Potential risk factors were reviewed and univariate and multivariate analysis for short-term mortality were performed. The whole dataset was divided into mutually exclusive subsets. An entropy error fuzzy decision tree (EEFDT) and an entropy error crisp decision tree (EECDT) were implemented using 650 (68.6%) patient data and tested with 298 (31.4%) patient data. Ten times hold-out cross validation was done and the area under the receiver operative characteristic curve (AUC) was reported as model performance. The results were compared with the logistic regression (LR) model and EuroSCORE. RESULTS: The overall short-term mortality rate was 3.8%, and was statistically higher in women than men (P<.001). The final EEFDT selected 19 variables and resulted in a tree with 39 nodes, 20 conditional rules, and AUC of 0.90±0.008. The final EECDT selected 15 variables and resulted in a tree with 35 nodes, 18 conditional rules, and AUC of 0.86±0.008. The LR model selected 10 variables and resulted in an AUC of 0.78±0.008; the AUC for EuroSCORE was 0.77±0.003. There were no differences in the discriminatory power of EEFDT and EECDT (P=.066) and their performance was superior to LR and EuroSCORE. CONCLUSIONS: EEFDT, EECDT, LR, and EuroSCORE had clinical acceptance but the performance and accuracy of the DTs were superior to the other models.
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Puente de Arteria Coronaria/mortalidad , Árboles de Decisión , Modelos Teóricos , Anciano , Femenino , Lógica Difusa , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Medición de Riesgo , Factores de Riesgo , Factores SexualesRESUMEN
Mitral regurgitation (MR) is a common valvular lesion in the general population with considerable impact on mortality and morbidity. The MitraClip System (Abbot Laboratories, Abbot Park, IL, USA) is a novel percutaneous approach for treating MR which involves mechanical edge-to-edge coaptation of the mitral leaflets. We present our initial experience with the MitraClip System in 5 patients. In our series, the cause of MR was both degenerative and functional. Two patients received two MitraClips due to unsatisfactory results after the implantation of the first clip. Acute procedural success was seen in 4 patients. Blood transfusion was required for 2 patients. All the patients, except one, reported improvement in functional status during a 2-month follow-up period. Our initial experience with MitraClip implantation indicates that the technique seems feasible and promising with acceptable results and that it could be offered to a broader group of patients in the near future.
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Coronary artery bypass grafting (CABG) is one of the leading operations performed worldwide. This treatment modality has been performed in Iran for several years; however, little is known about the current risk profile of Iranian cardiac surgical patients. The authors investigated the relationship between risk factors and mortality assessed by logistic regression analysis. The final Iranian risk stratification model consists of 15 variables, including sex, age, preoperative ejection fraction, chronic renal failure, recent myocardial infarction, unstable angina, preoperative critical situation, run off of left anterior descending artery, indications for surgery, CABG + mitral valve replacement, CABG + aortic valve replacement, postoperational myocardial infarction, postoperational low cardiac output, prolonged intubation, and central nervous system complication. A number of risk factors contribute to cardiac surgical mortality in Iran, which is used to develop a risk stratification system for predication of hospital mortality and the assessment of quality of care.