Influence of anesthesia on hemodynamic assessment of mitral stenosis severity.

BACKGROUND: The treatment of choice for severe rheumatic mitral stenosis (MS) is balloon mitral valvuloplasty (BMV). Assessment of MS severity is usually performed by echocardiography. Before performing BMV, invasive hemodynamic assessment is also performed. The effect of anesthesia on the invasive assessment of MS severity has not been studied. The purpose of the present study was to assess changes in invasive hemodynamic measurement of MS severity before and after induction of general anesthesia. METHODS: The medical files of 22 patients who underwent BMV between 2014 and 2020 were reviewed. Medical history, laboratory, echocardiographic and invasive measurements were collected. Anesthesia induction was performed with etomidate or propofol. Pre-procedural echocardiographic measurements of valve area using pressure half time, and continuity correlated well with invasive measurements using the Gorlin formula. RESULTS: After induction of anesthesia the mean mitral valve gradient dropped by 2.4 mmHg (p = 0.153) and calculated mitral valve area (MVA) increased by 0.2 cm2 (p = 0.011). A wide variability in individual response was observed. While a drop in gradient was noted in 14 patients, it increased in 7. Gorlin derived MVA rose in most patients but dropped in 4. Assuming a calculated MVA of 1.5 cm2 and below to define clinically significant MS, 4 patients with pre-induction MVA of 1.5 cm2 or below had calculated MVA above 1.5 cm2 after induction. CONCLUSIONS: The impact of general anesthesia on the hemodynamic assessment of MS is heterogeneous and may lead to misclassification of MS severity.

Frailty and Sarcopenia Assessment upon HospitalAdmission to Internal Medicine Predicts Length ofHospital Stay and Re-Admission: A ProspectiveStudy of 980 Patients.

BACKGROUND: Frailty and sarcopenia are associated with frequent hospitalizations and poor clinical outcomes in geriatric patients. Ascertaining this association for younger patients hospitalized in internal medicine departments could help better prognosticate patients in the realm of internal medicine. METHODS: During a 1-year prospective study in an internal medicine department, we evaluated patients upon admission for sarcopenia and frailty. We used the FRAIL questionnaire, blood alanine-amino transferase (ALT) activity, and mid-arm muscle circumference (MAMC) measurements. RESULTS: We recruited 980 consecutive patients upon hospital admission (median age 72 years (IQR 65-79); 56.8% males). According to the FRAIL questionnaire, 106 (10.8%) patients were robust, 368 (37.5%) pre-frail, and 506 (51.7%) were frail. The median ALT value was 19IU/L (IQR 14-28). The median MAMC value was 27.8 (IQR 25.7-30.2). Patients with low ALT activity level (<17IU/L) were frailer according to their FRAIL score (3 (IQR 2-4) vs. 2 (IQR 1-3); p < 0.001). Higher MAMC values were associated with higher ALT activity, both representing robustness. The rate of 30 days readmission in the whole cohort was 17.4%. Frail patients, according to the FRAIL score (FS), had a higher risk for 30 days readmission (for FS > 2, HR = 1.99; 95CI = 1.29-3.08; p = 0.002). Frail patients, according to low ALT activity, also had a significantly higher risk for 30 days readmission (HR = 2.22; 95CI = 1.26-3.91; p = 0.006). After excluding patients whose length of stay (LOS) was ≥10 days, 252 (27.5%) stayed in-hospital for 4 days or longer. Frail patients according to FS had a higher risk for LOS ≥4 days (for FS > 2, HR = 1.87; 95CI = 1.39-2.52; p < 0.001). Frail patients, according to low ALT activity, were also at higher risk for LOS ≥4 days (HR = 1.87; 95CI = 1.39-2.52; p < 0.001). MAMC values were not correlated with patients' LOS or risk for re-admission. CONCLUSION: Frailty and sarcopenia upon admission to internal medicine departments are associated with longer hospitalization and increased risk for re-admission.

Self-reported influence of monetary grants in the choice of a medical residency in remote or under-served areas.

OBJECTIVES: To evaluate the effect of monetary grants on young physicians' choice of remote or rural hospital-based practice. BACKGROUND: In late 2011, The Israeli Ministry of Health attempted to address a severe physician maldistribution, which involved severe shortages in remotely-located institutions (RLI). The policy intervention included offering monetary grants to residents who chose a residency program in a RLI. METHODS: A total of 222 residents from various disciplines were recruited; 114 residents from RLI and 108 residents from central-located institutions (CLI), who began their residency during 2012-2014. Participants were surveyed on demographic, academic and professional data, and on considerations in the choice of residency location. RESULTS: Residents in RLI attributed significantly more importance to the grant in their decision-making process than did residents from CLI. This effect remained significant in a multivariate model (OR 1.65, 95% CI 1.20-2.27, p = 0.002). The only parameter significantly associated with attributing importance to the grant was older age (OR 1.09, 95% CI 1.00-1.19, p = 0.049). CONCLUSION: The choice of a RLI for residency may be influenced by monetary grants. This is consistent with real-life data showing an increase in medical staffing in these areas during the program's duration. Further studies are needed to determine causality and physical practicality of such programs.

The role of direct single monetary grants in residents' choice of field of residency.

BACKGROUND: In an attempt to address severe medical manpower shortages in several medical disciplines, the Israeli Ministry of Health offered grants to residents who chose one of these fields. METHODS: A total of 220 residents from various disciplines were surveyed on demographic, academic, and professional data, and asked to rank considerations in the choice of their field of residency. RESULTS: Residents in targeted fields attributed significantly more importance to the grant in their decision-making process (U = 3704.5, p < 0.001). This effect remained significant in a multivariate model (OR 1.67, 95%CI 1.32-2.10, p < 0.001). Higher age (OR 1.15, 95%CI 1.01-1.31, p = 0.031) and attribution of significance to the working conditions compared to other residency fields (OR 1.69, 95%CI 1.23-2.32, p = 0.001) were significantly associated with receptivity toward the grant in a multivariate analysis. DISCUSSION: Receptivity toward the offered grants correlated with real-life data shows a rise in physician in these fields, and the weak association between such receptivity and most variables tested may suggest that the grants were perceived as a property of the specific choice rather than a special bonus. CONCLUSIONS: Grants may be useful in diverting medical manpower. Further analysis and modeling are required to determine causal relationship and budgetary feasibility.