The Impact on Medical Students of the 9/11 Attacks on New York's World Trade Center.

Phenomenon: Little is known about how participation in disaster relief impacts medical students. During the terror attacks of September 11, 2001, New York Medical College School of Medicine students witnessed the attacks and then became members of emergency treatment teams at St. Vincent's Hospital, the trauma center nearest to the World Trade Center. To date, only two reports describe how 9/11 influenced the lives of medical students. This study was designed to characterize the short- and long-term effects on NYMC students and to compare those effects between students assigned to St Vincent's Hospital and classmates assigned to rotations at facilities more remote from the attack site. We hypothesized that participation in direct relief efforts by students assigned to the St. Vincent's site might have long-lasting effects on their lives and these effects might vary when compared to classmates assigned elsewhere. Approach: This was a retrospective, survey-based, unmatched cohort study. Participants included all school of medicine graduates who were St. Vincent's rotators on 9/11 (N = 22) and classmates (N = 24) assigned to other sites who could be contacted and agreed to participate. Our primary measure was whether the 9/11 experience affected the participant's life, defined as an affirmative response to the item which asked whether the 9/11 experience affected the participant's "life thereafter, career choice, attitudes toward life or attitudes toward practice." Secondary measures included self-reported effects on career, life, attitudes, health, resilience, personal growth, personality features, and the temporal relationship between the attack and stress symptoms. Findings: Completed surveys were received from 16/22 (73%) St. Vincent's and 18/24 (75%) non-Saint Vincent's participants: 62% male, 82% had children, 74% identified as Caucasian/white and 76% employed full-time. Overall, slightly more than half (58%) of respondents reported an effect of 9/11 on their life, with a greater but non-significant proportion of St. Vincent's rotators reporting life impact (67% versus 50% for St. Vincent's versus other locations, respectively). High post-9/11 stress levels, current marriage, and ability to make and keep family and social relationships were associated with an effect on life which approached statistical significance. Participants reported positive or no post 9/11 effects on empathy and altruism (50%), resilience (47%), attitudes toward medical practice and career (32%), and charitable giving (24%), while positive, negative, or no effects were reported for attitude toward life, family and social relations, physical health, and conscientiousness. Mental health was the only domain in which all participants reported unchanged or negative effects. Two St. Vincent's rotators but no students assigned elsewhere believed they experienced 9/11-related post-traumatic stress disorder. Insights: Just over half of New York Medical College School of Medicine students rotating at St. Vincent's Hospital on 9/11 or elsewhere reported significant life-effects as a result of direct/indirect experiences related to the attack. Perceived stress may have been a more important driver of this life-change than other factors such as geographic proximity to the disaster site and/or direct participation in relief efforts. Further study of medical school interventions focused on stress reduction among students who participate in disaster relief is warranted.

Impact of weight on the efficacy and safety of direct-acting oral anticoagulants in patients with non-valvular atrial fibrillation: a meta-analysis.

AIMS: This study sought to determine the impact of weight and body mass index (BMI) on the safety and efficacy of direct-acting oral anticoagulants (DOACs) compared with warfarin in patients with non-valvular atrial fibrillation. METHODS AND RESULTS: A systematic literature search was employed in PubMed, Embase, and Cochrane clinical trials with no language or date restrictions. Randomized trials or their substudies were assessed for relevant outcome data for efficacy that included stroke or systemic embolization (SSE), and safety including major bleeding and all-cause mortality. Binary outcome data and odds ratios from the relevant articles were used to calculate the pooled relative risk. For SSE, the data from the four Phase III trials showed that DOACs are better or similarly effective with low BMI 0.73 (0.56-0.97), normal BMI 0.72 (0.58-0.91), overweight 0.87 (0.76-0.99), and obese 0.87 (0.76-1.00). The risk of major bleeding was also better or similar with DOACs in all BMI subgroups with low BMI 0.62 (0.37-1.05), normal BMI 0.72 (0.58-0.90), overweight 0.83 (0.71-0.96), and obese 0.91 (0.81-1.03). There was no impact on mortality in all the subgroups. In a meta-regression analysis, the effect size advantage of DOACs compared with warfarin in terms of safety and efficacy gradually attenuated with increasing weight. CONCLUSION: Our findings suggest that a weight-based dosage adjustment may be necessary to achieve optimal benefits of DOACs for thromboembolic prevention in these patients with non-valvular atrial fibrillation. Further dedicated trials are needed to confirm these findings. PROSPERO 2019 CRD42019140693. Available from: https://www.crd.york.ac.uk/prospero/display_record.php? ID=CRD42019140693.

Successful coronary artery bypass operation in a SARS-COV-2 infected patient with acute coronary syndrome.

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is overwhelming healthcare resources and infrastructure worldwide. Earlier reports have demonstrated complicated postoperative courses and high fatality rates in patients undergoing emergent cardiothoracic surgery who were diagnosed postoperatively with COVID-19. These reports raise the possibility that active COVID-19 might precipitate a catastrophic pathophysiological response to infection in the postoperative period and lead to unfavorable surgical outcomes. Hence, it is imperative to screen patients with SARS-CoV-2 infection before surgery and to carefully monitor them in the postoperative period to identify any signs of active COVID-19. In this report, we present the successful outcome of coronary artery bypass grafting (CABG) operation in a patient with asymptomatic SARS-CoV-2 infection presenting with an acute coronary syndrome and requiring urgent surgical intervention. We employed a thorough strategy to identify subclinical COVID-19 disease, and after confirming the absence of active disease, proceeded with the CABG operation. The patient outcome was successful with the absence of any overt COVID-19 manifestations in the postoperative period.

Cardiogenic shock during heart failure hospitalizations: Age-, sex-, and race-stratified trends in incidence and outcomes.

The objectives were to study the overall and age-, sex-, and race-stratified incidence of cardiogenic shock (CS) during heart failure hospitalizations (HFHs) not complicated by acute coronary syndromes (ACS), utilization of short-term mechanical circulatory support (MCS) and in-hospital mortality with non-ACS-related CS, and respective temporal trends. Data are lacking regarding the epidemiology of non-ACS-related CS during HFHs. METHODS: Retrospective observational analysis of the National Inpatient Sample 2005-2014 to identify all HFHs in adult patients without concomitant ACS. RESULTS: Of 8,333,752 HFHs, incidence rate of non-ACS-related CS was 8.7 per thousand HFHs (N = 72,668), a 4-fold increase from 4.1 to 15.6 per thousand HFHs between 2005 and 2014 (Ptrend < .001). Among those with non-ACS-related CS, utilization rates of intra-aortic balloon pump, extracorporeal membrane oxygenation, and temporary ventricular assist devices were 12.8%, 1.4%, and 2.5%, respectively. Respective 2005 to 2014 trends were 14.2% to 10.7%, 0.6% to 1.8%, and 0.8% to 2.7% (Ptrend for all, <.001). In-hospital mortality rate was 27.1%, with a substantial decrease from 42.4% in 2005 to 23.3% in 2014 (Ptrend < .001). These temporal trends were largely consistent across age, sex, and race subgroups. CONCLUSION: During HFHs in the United States, non-ACS-related CS occurred infrequently but was associated with substantial mortality. Non-ACS-related CS incidence and certain MCS utilization rates increased, and in-hospital mortality rate decreased between 2005 and 2014. These trends were generally homogenous across the age, sex, and race groups. The observed trends in incidence and mortality may be a reflection of increased identification of CS during HFHs, although further study is needed to assess whether temporal changes in care may have influenced outcomes.

Enhancing HIV Pre-exposure Prophylaxis Practices via an Educational Intervention.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for HIV involves using antiretroviral drugs to prevent individuals at high risk from acquiring HIV infection. Most practicing primary care providers believe PrEP to be safe and effective, but less than half have prescribed or referred for PrEP. Attitudes and prescribing patterns among house officers have not been well described previously. STUDY QUESTION: Can an educational intervention enhance HIV PrEP practices among internal medicine house officers? STUDY DESIGN: This study relied on a pretest/posttest design. All categorical trainees at a medium-sized internal medicine program were offered a baseline survey to assess their knowledge on PrEP. This was followed by a PrEP-focused educational intervention and a postintervention survey. MEASURES AND OUTCOMES: Likert scales captured perceptions regarding safety, effectiveness, barriers, factors that would promote PrEP use, potential side effects, impact on risk-taking behavior, and provider comfort level in assessing behavioral risks and in PrEP prescribing. Data were analyzed using descriptive statistics, Wilcoxon signed rank test, and the Kruskal-Wallis test. Significance was accepted for P < 0.05. RESULTS: Forty-eight (100%) trainees participated in the educational session, 45 (94%) in a preintervention survey, and 36 (75%) in a postintervention survey. Before PrEP training, 22% of respondents were unaware of PrEP, 78% believed PrEP was effective, 66% believed PrEP was safe, 62% had fair or poor awareness of side effects; 18% of residents had referred for or prescribed PrEP, and 31% believed they were likely to prescribe PrEP in the next 6 months. After the intervention, 94% of trainees believed PrEP was effective (P < 0.001), 92% believed PrEP was safe (P < 0.001), and two-thirds believed they were likely to prescribe PrEP in the next 6 months. CONCLUSIONS: Brief, focused training on HIV prevention promotes awareness, acceptance, and likelihood of prescribing PrEP by internal medicine trainees.

Exercise induced complete atrioventricular block: Utility of exercise stress test.

Exercise induced complete atrioventricular block (EIAVB) is a relatively uncommon condition. This phenomenon is clinically important because it can mimic symptoms of other cardiovascular conditions and may be associated with exercise intolerance and subsequent syncope. A 76year old man with long-standing hypertension and diabetes mellitus presented with recurrent episodes of lightheadedness and syncope with physical activity. ECG showed sinus rhythm with first degree atrioventricular block. Echocardiography did not show any valvular disease causing his symptoms. Coronoary angiographic evaluation revealed non-obstructive coronary artery disease. Because of the exertional nature of his symptoms, a symptom-limited treadmill exercise test was performed which revealed EIAVB. A permanent dual chamber pacemaker was implanted and his symptoms resolved completely.

Limitations of Sacubitril/Valsartan in the Management of Heart Failure.

BACKGROUND: The PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) trial was a double-blind trial that randomized 8442 patients with heart failure (HF) with reduced ejection fraction (HFrEF) to receive twice daily dosing of either 200 mg of LCZ696 or 10 mg of enalapril in addition to standard medical therapy for HF. AREAS OF UNCERTAINTY: Limitations of this trial include (1) sacubitril has not been tested by itself in the treatment of HFrEF; (2) the maximum recommended dose of valsartan for the treatment of HFrEF was used in this trial, but the maximum recommended dose of enalapril for the treatment of HFrEF was not used; (3) a run-in phase was used in this trial to test the tolerability of LCZ696, and patients who had adverse effects in this period were excluded from randomization; (4) the percent of blacks enrolled in this trial was only 5%; (5) LCZ696 caused a 14% incidence of hypotension; (6) neprilysin inhibition might favor the development of Alzheimer dementia, which was not assessed in the PARADIGM-HF trial; (7) patients with severe symptomatic HF were underrepresented in this trial; (8) major exclusions from this trial included an acute coronary event in the last 3 months, severe pulmonary disease, hepatic impairment, and an estimated glomerular filtration rate <30 mL per minute per 1.73 m. DATA SOURCES: Review of the PARADIGM-HF trial. RESULTS: At 27-month follow-up, the PARADIGM-HF trial showed that compared with enalapril, LCZ696 reduced the composite of cardiovascular death or hospitalization for HF 20% (absolute risk reduction 4.7%, P < 0.001). CONCLUSIONS: The numerous limitations discussed under the areas of uncertainty should be considered when prescribing LCZ696 for the treatment of HFrEF.

Prosthetic Aortic Valve Endocarditis Without Evidence of Vegetation.

Despite significant technological advances, the diagnosis of infective endocarditis (IE) remains a major challenge, and the condition continues to be associated with significant morbidity and mortality. Valvular vegetations have long been the diagnostic and pathologic hallmarks of IE. However, IE can be diagnosed even in the absence of vegetations using the modified Duke criteria. Vegetation-negative endocarditis is rare, and to the present authors' knowledge no cases of septic emboli in the absence of valvular vegetations have been reported. Herein is reported a case of prosthetic aortic valve endocarditis associated with both clinical and radiologic evidence of septic emboli, but in the absence of vegetations on both repeated transesophageal echocardiography and pathologic evaluation. This case highlights the importance of maintaining a high clinical suspicion and a low threshold for the surgical replacement of a possibly infected valve, in patients that meet other clinical criteria for IE, even in the absence of detectable valvular vegetations.

Six-month cardiovascular prognostic impact of type 1 And type 2 myocardial infarction in patients hospitalized for gastrointestinal bleeding.

BACKGROUND: Patients with gastrointestinal bleeding (GIB) are at an increased risk of cardiovascular events and myocardial infarction (MI). Myocardial supply-demand mismatch results in type 2 MI(T2MI) and atherosclerotic plaque rupture leads to type 1 MI(T1MI). Data comparing the prognostic impact of these MI types in GIB are sparse. METHODS: Patients hospitalized for GIB were identified in the 2019 US Nationwide Readmissions Sample. In this population, we studied the differences in management of T1MI and T2MI, and the association of these MI types with in-hospital mortality and risk for 6-month MI and MI-related mortality. RESULTS: Of 444,475 patients admitted for a GIB, 12,860 (2.9%) had an MI (1.7% T2MI, 1.2% T1MI). Patients with T1MI were more likely to receive coronary angiography and revascularization than patients with T2MI. In-hospital mortality occurred in 2.0% patients, at a significantly higher rate in patients with an MI (7.9% vs 1.8%; P < 0.001), and higher with T1MI (11.9%) than T2MI (5.3%; P < 0.001). Among the survivors, 2.2% patient had an MI within 6 months, at a significantly higher rate in patients with index MI (13.1% vs 2.0%, adjusted OR 4.3 95% CI 3.83-4.90; P < 0.001). Mortality during the subsequent MI occurred in 0.3% of all patients (12% with an MI), at a 6-fold higher rate in patients with index MI (1.7% vs 0.3%; adjusted OR 3.69 95% CI 2.75-4.95; P < 0.001). The elevated risks were associated with both MI types. The risks for 6-month MI and related mortality were similar between T1MI and T2MI (6-month AMI: adjusted OR for T2MI = 1.03, 95% 0.83-1.29; fatal MI: adjusted OR for T2MI = 1.5, 95% CI 0.85-2.7). CONCLUSION: The occurrence of an MI is associated with a substantially elevated risk for subsequent AMI and related mortality in patients hospitalized for a GIB. This future prognostic impact was similar between T1MI and T2MI.

Impact of chronic obstructive pulmonary disease on heart failure hospitalizations after an acute myocardial infarction.

Introduction: The presence of chronic obstructive pulmonary disease (COPD) can impact the management of acute myocardial infarction (AMI) and is associated with higher mortality. Few studies addressed COPD impact on heart failure hospitalisations (HFHs) in AMI survivors. Material and methods: Adult survivors of an AMI between January and June 2014 were identified from the US Nationwide Readmissions Database. The impact of COPD on HFH within 6 months, fatal HFH and the composite of in-hospital HF or 6-month HFH was studied. Results: Of 237,549 AMI survivors, patients with COPD (17.5%) were older, more likely female, had a higher prevalence of cardiac comorbidities and a lower coronary revascularization rate. In-hospital HF was more frequent in patients with COPD (47.0% vs. 25.4%; p < 0.001). HFH within 6 months occured in 12,934 (5.4%) patients, at a 114% higher rate in patients with COPD (9.4% vs. 4.6%, OR = 2.14, 95% CI : 2.01-2.29; p < 0.001), which was attenuated to a 39% higher adjusted risk (OR = 1.39, 95% CI: 1.30-1.49). Findings were consistent across subgroups of age, AMI type, and major HF risk factors. Mortality during a HFH (5.7% vs. 4.2%, p < 0.001) and the rate of the composite HF outcome (49.0% vs. 26.9%, p < 0.001) were significantly higher in patients with COPD. Conclusions: COPD was present in 1 of 6 AMI survivors and was associated with worse HF related outcomes. The increased HFH rate in COPD patients was consistent across several clinically relevant subgroups and these findings highlight the need for optimal in-hospital and post-discharge management of these higher-risk patients.

Impact of Acute and Chronic Kidney Disease on Heart Failure Hospitalizations After Acute Myocardial Infarction.

Very few studies evaluated the impact of acute kidney injury (AKI) and chronic kidney disease (CKD) on heart failure (HF) hospitalization risk following an acute myocardial infarction (AMI). For this retrospective cohort analysis, we identified adult AMI survivors from January to June 2014 from the United States Nationwide Readmissions Database. Outcomes were a 6-month HF, fatal HF, composite of HF during the AMI or a 6-month HF, and a composite of 6-month HF or death during a non-HF-related admission. We analyzed differences in outcomes across categories of patients without renal injury, AKI without CKD, stable CKD, AKI on CKD, and end-stage renal disease (ESRD). Of 237,549 AMI survivors, AKI was present in 13.8%, CKD in 16.5%, ESRD in 3.4%, and AKI on CKD in 7.7%. Patients with renal failure had lower coronary revascularization rates and higher in-hospital HF. A 6-month HF hospitalization occurred in 12,934 patients (5.4%). Compared with patients without renal failure (3.3%), 6-month HF admission rate was higher in patients with AKI on CKD (14.6%; odds ratio [OR] 1.99; 95% confidence interval [CI] 1.81 to 2.19), ESRD (11.2%; OR 1.57; 95% CI 1.36 to 1.81), stable CKD (10.7%; OR 1.72; 95% CI 1.56 to 1.88), and AKI (8.6%; OR 1.52; 95% CI 1.36 to 1.70). Results were generally homogenous in prespecified subgroups and for the other outcomes. In conclusion, 1 in 4 AMI survivors had either acute or chronic renal failure. The presence of any form of renal failure was associated with a substantially increased risk of 6-month HF hospitalizations and associated mortality with the highest risk associated with AKI on CKD.

Differences in Short-Term Outcomes and Hospital-Based Resource Utilization Between Septal Reduction Strategies for Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: Given clinical equipoise in a subset of obstructive hypertrophic cardiomyopathy (OHCM) patients who are candidates for both alcohol septal ablation (ASA) or septal myectomy (SM), other considerations such as cost, readmissions, and hospital length of stay (LOS) may be important to optimize healthcare resource utilization and inform shared decision making. METHODS: In this retrospective observational analysis of the United States Nationwide Readmissions Database years 2012-2014, we identified adults who underwent isolated septal reduction (SR) for OHCM. We studied the differences in short-term outcomes (inpatient mortality and 90-day readmission rate) and in-hospital resource utilization (LOS and costs) between the SR strategies. RESULTS: Of the 2250 patients in this study, ASA was performed in 1113 (49.5%) and SM in 1137 (50.5%). Inpatient mortality occurred in 21 patients (0.9%), with similar rates between strategies (10 SM patients [0.9%] vs 11 ASA patients [1.0%]; P=.30). Of the 2229 patients who survived to discharge, 298 (13.4%) were readmitted 386 times within 90 days with a similar readmission rate between SM (14.9%) and ASA (11.8%; P=.16). During the index admission, average LOS and cost were significantly lower for ASA (3.9 days, United States [US] $20,322) compared with SM (7.6 days, US $39,470; P<.001). Average LOS and cost during 90-day readmissions were similar between ASA and SM. Combining index admissions and readmissions, patients undergoing ASA had significantly lower LOS and hospitalization costs. CONCLUSIONS: In this non-randomized observational study of OHCM patients undergoing isolated septal reduction, ASA was associated with similar short-term outcomes, including mortality, but substantially lower hospitalization costs and LOS compared with SM.

Analysis of outcome of 6-month readmissions after percutaneous left atrial appendage occlusion.

OBJECTIVE: Percutaneous left atrial appendage occlusion (LAAO) is an alternative strategy for prevention of thromboembolic events in patients with atrial fibrillation and unsuitable for long-term oral anticoagulation. The study aimed to evaluate the causes and timing of readmissions within 6 months following percutaneous LAAO in a real-world setting. METHODS: We conducted a retrospective cohort study of percutaneous LAAO performed in the USA between January and June of 2016-2018 using the Nationwide Readmissions Database. RESULTS: Overall, 12 446 patients who underwent LAAO were included in the analyses and 3477 patients (28%) were readmitted within 6 months following the interventions. Readmitted patients were more often women (p=0.001). The index hospitalisation was characterised by longer duration of hospital stay (p<0.001) and complicated with acute kidney injury (p<0.001) among readmitted patients compared with those without readmissions. Readmissions within 6 months following the index intervention were mainly due to heart failure (13%) and gastrointestinal bleeding (12%). Characteristics associated with readmissions due to heart failure included previously known heart failure (HR 2.39; 95% CI 1.70 to 3.37), valvular heart disease (HR 1.39; 95% CI 1.05 to 1.84) and chronic kidney disease (HR 1.42; 95% CI 1.03 to 1.94). Readmissions due to gastrointestinal bleeding were associated with diabetes mellitus (HR 1.78; 95% CI 1.25 to 2.53), chronic kidney disease (HR 1.86; 95% CI 1.23 to 2.81) and previous anaemia (HR 2.41; 95% CI 1.54 to 3.77). CONCLUSIONS: After percutaneous LAAO, over a quarter of the patients in the USA required rehospitalisation within 6 months, mainly due to heart failure and gastrointestinal bleeding.

A Comparison of In-Hospital Outcomes Between the Use of Impella and IABP in Acute Myocardial Infarction Cardiogenic Shock Undergoing Percutaneous Coronary Intervention.

BACKGROUND: The use of Impella ventricular support systems and intra-aortic balloon pump (IABP) in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) has increased in recent years and expanded treatment options, although the comparative clinical outcomes and device safety remain unclear. METHODS: We used the Nationwide Inpatient Sample database (2012-2017) to identify adults who were admitted for AMI complicated by CS and received percutaneous coronary intervention (PCI). The study sample was divided into Impella and IABP groups. Patient characteristics, hospital characteristics, and comorbidities were balanced between groups using propensity-score matching. Regression analysis was utilized to study outcome differences between groups. RESULTS: We identified 51,150 patients, of whom 44,265 (86.54%) received IABP and 6885 (13.46%) received Impella. After propensity matching, compared with the Impella group (n = 1592), the IABP group (n = 8638) had lower rates of sepsis (6.44% vs 12.69%; P=.01), blood transfusion (8.92% vs 14.28%; P=.01), mortality (28.95% vs 49.59%; P<.01), and hospitalization costs ($49,420 vs $68,087; P<.001). The IABP group had similar rates of cardiac arrest (20.32% vs 22.22%; P=.32), in-hospital stroke (1.46% vs 1.59%; P=.37), and length-of-stay (8.56 days vs 8.64 days; P=.26) compared with the Impella group. CONCLUSION: In patients with CS complicating AMI who underwent PCI, Impella use compared with IABP was associated with higher mortality with no differences in in-hospital stroke and cardiac arrest rates, although study interpretation is limited by retrospective observational design and the potential for remaining confounders. Further prospective research is warranted to elucidate the optimal mechanical circulatory support device in these patients.