Considerations for specific cardiomyopathies during pregnancy.

PURPOSE OF REVIEW: Maternal mortality in the United States continues to increase. Cardiovascular disease, and in particular, cardiomyopathy and heart failure, serves as one of the principal causes of pregnancy-related mortality. The goal of this review is to summarize current knowledge on various cardiomyopathies in pregnancy, with an emphasis on cardiomyopathies beyond the most common in pregnancy, peripartum cardiomyopathy. RECENT FINDINGS: Although existing literature is somewhat limited, outcome studies of cardiomyopathy in pregnancy have demonstrated increased risk for adverse cardiovascular events and maternal morbidity and mortality. Herein, we review and synthesize recent studies focusing on preconception risk and counseling, pharmacologic management, and maternal outcomes in various cardiomyopathies during pregnancy including: dilated cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, noncompaction cardiomyopathy, and chemotherapy-induced cardiomyopathy. SUMMARY: In an effort to optimize maternal outcomes, it is critical to recognize the risk associated with various cardiomyopathies in pregnancy and understand the tools for risk stratification and antepartum management. Further research on less common cardiomyopathies in pregnancy is warranted to provide more standardized recommendations.

Intensive Home Care for COVID-19 to Reduce Admissions.

Hospitalization for COVID-19 has placed a significant financial and logistical burden on hospitals and health care systems. Limitations on visitation and isolation precautions have made hospitalization more isolating for patients in the time of COVID-19. Increasing the provision of healthcare delivered at home has the potential to decrease healthcare costs by providing care at home which may be preferred for many patients. We describe a series of 39 patients who were treated with intravenous remdesivir at home in addition to oxygen, dexamethasone, and anticoagulants. These patients were at high risk for decompensation due to COVID-19 and met accepted criteria for admission-need for supplemental oxygen and intravenous remdesivir. All patients had home lab monitoring and frequent telehealth visits. Over the study period 13 (33%) of patients were admitted for worsening COVID-19 and 5 (13%) died. Twenty-six patients avoided admission, and none experienced a severe adverse effect from in-home treatment. The expanded use of telehealth services due to the COVID-19 pandemic has the potential to increase the frequency of patient monitoring by physicians and the provision of care and monitoring usually restricted to hospitalized patients.

Frequency of Comfort Care and Palliative Care Consultation after ST-Elevation Myocardial Infarction.

INTRODUCTION: ST-elevation myocardial infarction (STEMI) remains a leading cause of death despite advances in revascularization and post-STEMI care. Especially for patients with a poor prognosis, there is increasing emphasis on comfort-focused care. METHODS: We conducted a single-center retrospective cohort study of patients with STEMI at a large tertiary care academic medical center, abstracting patient-level data, causes of death, and use of palliative care consultation from the medical records. We sought to investigate the frequency of comfort-focused approaches and palliative care consultation after STEMI. RESULTS: A total of 536 patients presented with or were transferred with STEMI from January 2010 to July 2018, of whom 61/536 (11.4%) died during index hospitalization. Among those who underwent percutaneous intervention (PCI), the in-hospital mortality rate was 6.8%. Median (IQR) and time to death was two (0-6) days. Among those who died, 25/61 (41%) were treated with mechanical circulatory support (MCS). A total of 25/61 (41%) patients died following transition to a comfort-focused approach. Rate of MCS utilization during hospitalization was higher in the group that was ultimately transitioned to comfort-focused measures than the group who received full treatment measures. Palliative care was consulted in the case of 6/61 (9.8%) patients. Median time to consultation was 5 (1-7) days and time to death was 6.5 (2-28) days. DISCUSSION: Transition to comfort-focused care before death after STEMI is common, particularly in those with cardiogenic shock and/or treated with MCS, highlighting the critical status of such patients. Although increasingly employed in recent years, palliative care consults remain rare and are often employed late in the hospitalization.

Comparison of the Multiple Mini-Interview and the Traditional Interview in Medical School Admissions: Lessons Learned Using a Hybrid Model at One Institution.

PURPOSE: Medical school admissions interviews are a critical form of assessment; however, the most effective interview strategy is debated. This study compares the traditional interview (TI) and multiple mini-interview (MMI) within a hybrid TI-MMI model at one medical school to determine whether the interview approaches reveal different information about applicants and whether a hybrid model results in a more diversified applicant pool. METHOD: Admissions data from 3 application cycles at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell were used. The TI was used in 2017-2018 and the hybrid TI-MMI model in 2018-2019 and 2019-2020. Applicants were scored on a 5-point scale and referred to a voting committee for acceptance consideration if interview scores met threshold criteria. Changes in the number of students referred to the committee using the TI vs the TI-MMI score criteria were analyzed. RESULTS: In 2017-2018 (TI only), 683 applicants were interviewed; in 2018-2019 (TI-MMI), 844 applicants were interviewed; and in 2019-2020 (TI-MMI), 805 applicants were interviewed. Medium correlations were found between total MMI and TI scores in 2018-2019 ( ρ = 0.37, P < .001) and 2019-2020 ( ρ = 0.33, P < .001). No differences were found in TI scores between 2017-2018 and 2018-2019 ( P = .30), but TI scores were significantly lower in 2019-2020 vs 2017-2018 ( P < .001) and 2018-2019 ( P = .002). Overall, a 10% to 18% increase was found in the number of applicants referred to the voting committee when using hybrid criteria, with a 19% to 27% increase in underrepresented in medicine applicants. CONCLUSIONS: The TI-MMI model may allow for a more holistic interview approach and an expanded pool of applicants, particularly underrepresented in medicine applicants, considered for acceptance.

Dolichoectatic Carotid Arterial Compression of the Optic Nerve: The Unusual Suspect in the Setting of a Coexisting Incidental Pituitary Adenoma.

BACKGROUND: Anatomic compression of the optic nerve secondary to a dolichoectatic cerebrovascular compression is a rare clinical entity. Because of the limited number of published cases and variable clinical presentation, the natural history remains ambiguous and no consensus exists regarding management. In addition, there is an ongoing debate regarding whether a dolichoectatic cerebral blood vessel can actually cause optic neuropathy, or it merely represents an incidental finding. As a result, it is thought that a diagnosis of compressive optic neuropathy from an adjacent dolichoectatic internal carotid artery (ICA) should be considered only after other possible etiologies are excluded. Although this might seem straightforward, the clinical scenario becomes complex if the patient is also found to have additional incidental pituitary lesions. Such coexistence has not been reported previously in the literature. CASE DESCRIPTION: A 52-year-old left-handed man presented to us with intermittent headache and painless progressive visual deterioration in the right eye for 1 month. Screening magnetic resonance imaging (MRI) scan revealed a 9-mm eccentrically placed pituitary adenoma with right optic nerve compression because of dolichoectatic ICA. He underwent microvascular decompression of the right optic nerve. On follow-up, significant vision improvement was noticed and MRI scan revealed no change in the size of the pituitary adenoma. CONCLUSIONS: The compression of the optic nerve by dolichoectatic ICA is commonly thought to be a diagnosis of exclusion. However, the presence of a coexisting pathology should not prompt the exclusion in every case and a case-based approach is highly recommended to correctly manage this rare clinical condition.

Update on glioma biotechnology.

Neuro-oncological research is at the forefront of the rising cancer therapy market, as evidenced by its growing revenue and the multitude of clinical trials investigating innovative treatment approaches. The Feinstein Institute for Medical Research, in conjunction with the Department of Neurosurgery at Lenox Hill Hospital and the Zucker School of Medicine at Hofstra / Northwell, sponsored The Brain Tumor Biotech Summit in New York City in June 2019. The aim of the Summit was to provide a forum that encourages collaboration between cancer specialists, biotechnology and pharmaceutical industry leaders, and the investment community in order to promote innovation and advance emerging therapies for brain tumors. Areas highlighted during the Summit included immunotherapy, precision medicine, and novel applications and experimental treatments such as receptor targeting, methods for improved drug delivery, and innovative intraoperative techniques and technologies. This review synthesizes the recent breakthroughs in brain tumor research as presented at The Brain Tumor Biotech Summit.

Vascularized Temporoparietal Fascial Flap: A Novel Surgical Technique to Bypass the Blood-Brain Barrier in Glioblastoma.

BACKGROUND: The major difficulty in treating glioblastoma stems from the intrinsic privileged nature of the brain. This complicates therapy, as many traditionally potent chemotherapeutics cannot access their target sites in the brain. Several techniques have been investigated to overcome this barrier and facilitate drug delivery. However, these techniques have inherent shortcomings related to the delivery system, the drug itself, or its bioactivity. Periosteal flaps and temporoparietal fascial flaps (TPFFs) are widely used options because they have predictable vasculature and a wide rotational arc. These flaps are not restricted by the blood-brain barrier, as they derive their vascular supply from branches of the external carotid artery, which can be readily identified with Doppler ultrasound. We hypothesized that transposition of a vascularized TPFF to the walls of a resected tumor surgical cavity may bring autologous tissue not restricted by the blood-brain barrier in close vicinity of the resected tumor bed microenvironment. This offers a nonselective, long-lasting gateway to target the residual tumor cells nesting in the brain adjacent to the tumor. CASE DESCRIPTION: A 47-year-old, right-handed woman with newly diagnosed multifocal glioblastoma underwent excision of the tumor and TPFF placement. This illustrative case report represents the first case of the use of this novel surgical technique with radiologic follow-up. CONCLUSIONS: The blood-brain barrier is identified as a major barrier for effective drug delivery in glioblastoma. This study demonstrates the feasibility of the TPFF technique to bypass this barrier and help facilitate the goal of improving drug delivery.

Athletes With Musculoskeletal Injuries Identified at the NFL Scouting Combine and Prediction of Outcomes in the NFL: A Systematic Review.

BACKGROUND: Prior to the annual National Football League (NFL) Draft, the top college football prospects are evaluated by medical personnel from each team at the NFL Scouting Combine. On the basis of these evaluations, each athlete is assigned an orthopaedic grade from the medical staff of each club, which aims to predict the impact of an athlete's injury history on his ability to participate in the NFL. PURPOSE: (1) To identify clinical predictors of signs, symptoms, and subsequent professional participation associated with football-related injuries identified at the NFL Combine and (2) to assess the methodological quality of the evidence currently published. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We reviewed all studies that examined musculoskeletal injuries identified among athletes at the NFL Combine and associated outcomes. Data on signs, symptoms, and subsequent NFL participation were collected, and the methodological quality of the studies was assessed. RESULTS: Overall, 32 studies, including 30 injury-specific studies, met the inclusion criteria. Twenty studies analyzed data collected at the NFL Combine from 2009 and later. When compared with matched controls, athletes with a history of a cervical or lumbar spine injury, rotator cuff repair, superior labrum anterior-posterior repair, anterior cruciate ligament reconstruction, full-thickness chondral lesions of the knee, or Lisfranc injury played in significantly fewer games early in their NFL careers. Additionally, athletes with a history of a cervical or lumbar spine injury, rotator cuff repair, and navicular injury had decreased career lengths versus controls. Defensive players and linemen were found to have decreased participation in the NFL for several injuries, including prior meniscectomy, anterior cruciate ligament reconstruction, and shoulder instability. Career length follow-up, measures of athletic participation, and matching criteria were highly variable among studies. CONCLUSION: For medical professionals caring for professional football athletes, this information can help guide orthopaedic grading of prospects at the NFL Combine and counseling of athletes on the potential impact of prior injuries on their professional careers. For future studies, improvements in study methodology will provide greater insight into the efficacy of current treatments and areas that require further understanding.