Improved Cardiac Rehabilitation Referral Rate Utilizing a Multidisciplinary Quality Improvement Team.

Introduction Cardiac rehabilitation (CR) is an underutilized resource in patients with ischemic heart disease, despite being a Class IA recommendation. In this study, a multidisciplinary quality improvement (QI) team aimed to improve CR referrals by standardizing the ordering process at our hospital system. Method By using a collaborative approach involving the electronic medical record (EMR), medical provider education, and hospital protocols, our two-hospital healthcare system was able to successfully identify barriers to CR referral rates and implement interventions for these barriers. All physicians and medical providers, including ancillary staff, were educated on the EMR order sets to improve compliance by using automated order sets in the EMR. The CR referral order in the EMR included a statement regarding the application of evidence-based medicine, and a computerized provider order entry was included as a reminder to the ordering provider. The use of EMR was monitored monthly by the QI committee. Chi-square test and odds ratios were obtained for statistical analysis. Results Through provider-EMR education and patient education on discharge, CR referral rates significantly improved from 51.2 to 87.1% (p = 0.0001) in a 12-month period. The study included 1,499 patients in total. The improvement was statistically significant regardless of patient gender, race, or insurance coverage. Additionally, subgroup analysis in this study found that prior to standardization of the ordering process, African American patients were significantly less likely to be referred to CR compared to Caucasian patients. (51.2% vs. 41.0%, p=0.01). There was no statistically significant difference in the likelihood of CR referral between Caucasian and African American patients following the intervention (84.0% vs. 78.0%, p = 0.166). Conclusion This study shows that CR is an underutilized resource and that effective QI initiatives may not only increase CR referral rates but also close the gap between racial inequities in referral rates. Future research with multi-center randomized control trials is needed to further enhance its external generalizability to other institutions.

Distinct Coagulopathy With Myocardial Injury and Pulmonary Embolism in COVID-19.

In this article, we report a case of a 61-year-old male who was diagnosed with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), presenting with acute respiratory distress syndrome requiring intubation and hemodynamic support, marked D-Dimer and troponin I elevation, worsening ST-elevation myocardial infarction on repeat electrocardiograms, and a negative coronary angiogram ruling out a coronary artery thrombosis or occlusion. With worsening diffuse ST-segment elevation on electrocardiograms and reduced ejection fraction on echocardiography in the setting of systemic inflammation, fulminant myocarditis was highly suspected. Despite optimal medical treatment, the patient's condition deteriorated and was complicated by cardiac arrest that failed resuscitation. Although myocarditis was initially suspected, the autopsy revealed no evidence of myocarditis or pericarditis but did demonstrate multiple microscopic sites of myocardial ischemia together with thrombi in the left atrium and pulmonary vasculature. Additionally, scattered microscopic cardiomyocyte necrosis with pathological diagnosis of small vessel micro-thrombotic occlusions. These findings are potentially exacerbated by inflammation-induced coagulopathy, hypoxia, hypotension, and stress, that is, a multifactorial etiology. Further research and an improved understanding are needed to define the precise pathophysiology of the coagulopathic state causing widespread micro-thrombosis with subsequent myocardial and pulmonary injury.

Serine Proteases and Chemokines in Neurotrauma: New Targets for Immune Modulating Therapeutics in Spinal Cord Injury.

Progressive neurological damage after brain or spinal cord trauma causes loss of motor function and treatment is very limited. Clotting and hemorrhage occur early after spinal cord (SCI) and traumatic brain injury (TBI), inducing aggressive immune cell activation and progressive neuronal damage. Thrombotic and thrombolytic proteases have direct effects on neurons and glia, both healing and also damaging bidirectional immune cell interactions. Serine proteases in the thrombolytic cascade, tissue- and urokinase-type plasminogen activators (tPA and uPA), as well as the clotting factor thrombin, have varied effects, increasing neuron and glial cell growth and migration (tPA), or conversely causing apoptosis (thrombin) and activating inflammatory cell responses. tPA and uPA activate plasmin and matrix metalloproteinases (MMPs) that break down connective tissue allowing immune cell invasion, promoting neurite outgrowth. Serine proteases also activate chemokines. Chemokines are small proteins that direct immune cell invasion but also mediate neuron and glial cell communication. We are investigating a new class of therapeutics, virus-derived immune modulators; One that targets coagulation pathway serine proteases and a second that inhibits chemokines. We have demonstrated that local infusion of these biologics after SCI reduces inflammation providing early improved motor function. Serp-1 is a Myxomavirus-derived serine protease inhibitor, a serpin, that inhibits both thrombotic and thrombolytic proteases. M-T7 is a virus-derived chemokine modulator. Here we review the roles of thrombotic and thrombolytic serine proteases and chemoattractant proteins, chemokines, as potential therapeutic targets for SCI. We discuss virus-derived immune modulators as treatments to reduce progressive inflammation and ongoing nerve damage after SCI.

Incidental Finding of a Large Right Atrial Thrombus in a Patient With Cerebral Lymphoma.

Right atrial (RA) masses are rare, challenging to diagnose, and potentially life-threatening with high mortality if untreated. We present a patient presenting with diffuse large B-cell lymphoma in the brain that was incidentally found to have a large RA mass. For a better definition of the RA mass, extensive workup using multimodality imaging including chest computed tomography, transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance imaging, and left heart catheterization was warranted. The imaging demonstrated a large RA mass extending through the tricuspid valve into the right ventricle and superior and inferior vena cava without a mobile component. The mass was then successfully resected, and further histology examination was performed to rule out lymphoma and rare subtypes of diffuse large B-cell lymphoma. The comprehensive workup proved the RA mass to be a calcified thrombus rather than a direct metastatic spread of lymphoma.

Elective Inguinal Hernia Surgery in the Setting of Unfollowed Congenital Complete Heart Block With No Postponement.

Most preoperatively discovered complete heart block cases without cardiac clearance in a non-emergent situation are managed with deferral of elective surgery until a cardiology workup can be completed. The medical consequences of surgical delays can manifest in increased costs to the healthcare system via the treatment of more advanced disease, often requiring more intense and more costly treatment in addition to the emotional burden of delay on a patient that has been waiting months for a particular surgery. Delays in surgery have real impacts on patient health outcomes, hospital finances, and patient satisfaction. We present a rare case in which a proactive anesthesiologist was able to take measures to stratify patient safety risk and safely prevent the delay of the surgery in an asymptomatic and unfollowed congenital third-degree heart block patient. The anesthesiologist demonstrates the use of established guidelines for non-elective noncardiac surgery to safely and effectively prevent the delay of an elective inguinal hernia repair in the setting of a situation that normally warrants its delay. Using these pre- and intraoperative measures, the anesthesiologist was able to prevent the delay of elective surgery, and this should set a precedent of the necessary steps involved to safely manage a patient with an unfollowed third-degree congenital heart block.

Chronological Impact of Earthquakes on Blood Pressure: A Literature Review and Retrospective Study of Hypertension in Haiti Before and After the 2010 Earthquake.

Objective: We review prior studies on the incidence of hypertension (HTN) after earthquakes and present a retrospective analysis of HTN after the 2010 earthquake in Haiti. Methods: Prior reports on HTN incidence were reviewed and a retrospective chart review for diagnosis of HTN in 4,308 patient charts was performed over a 7 year period (five clinics). A retrospective cohort study (RCS) was then performed on 11 patients with linear follow-up. Results: The Literature review revealed a significant increase in acute and subacute HTN following earthquakes. However, the chronic effects of earthquakes varied. Our chart review uncovered no significant difference in diagnosed HTN in a Fort-Liberté clinic 128 kilometers (km) distant and 4 weeks post-event. A secondary linear RCS for 11 individuals, prior to and after the earthquake, also did not detect a significant change in HTN prevalence. Conclusion: Prior studies demonstrate acute and subacute, increases in HTN after earthquakes, but late changes have varied. Retrospective studies in the Fort-Liberté clinic, 128 km distant and 4 weeks post-event, revealed no significant change in HTN, confirming prior findings that changes in HTN after earthquakes are early and local events. Further work examining HTN after earthquakes is needed to improve early health care after natural disasters.