Perceived Gaps in Knowledge for the Advanced Heart Failure and Transplant Cardiology Fellow: the Results of a National Needs-Assessment Survey.

BACKGROUND: The field of Advanced Heart Failure and Transplant Cardiology has evolved greatly since it was first established. We sought to elicit program directors' and fellows' viewpoints on potential curricular deficits so we can better meet the educational goals of current and future fellows. METHODS AND RESULTS: We surveyed advanced heart failure and transplant cardiology program directors and fellows concerning their perceptions of the current adequacy of training and their desire for additional training needed to achieve medical competency in advanced heart failure and transplant cardiology at their institutions, as defined by the 2017 ACC Advanced Training Statement. Survey results identified key competencies deemed to be inadequately addressed during training and those in which a moderate or significant additional amount of training was desired. These competencies were identified within the 4 main domains of the fellowship: heart failure, pulmonary hypertension, mechanical circulatory support, and heart transplantation. CONCLUSIONS: This study highlights key medical-knowledge competencies that are inadequately addressed by current fellowship training in advanced heart failure and transplant cardiology. Fellowship programs should develop curricula that focus on the integration of these competencies into training to ensure that fellows are well equipped to care for patients.

A single population of red globular clusters around the massive compact galaxy NGC 1277.

Massive galaxies are thought to form in two phases: an initial collapse of gas and giant burst of central star formation, followed by the later accretion of material that builds up their stellar and dark-matter haloes. The systems of globular clusters within such galaxies are believed to form in a similar manner. The initial central burst forms metal-rich (spectrally red) clusters, whereas more metal-poor (spectrally blue) clusters are brought in by the later accretion of less-massive satellites. This formation process is thought to result in the multimodal optical colour distributions that are seen in the globular cluster systems of massive galaxies. Here we report optical observations of the massive relic-galaxy candidate NGC 1277-a nearby, un-evolved example of a high-redshift 'red nugget' galaxy. We find that the optical colour distribution of the cluster system of NGC 1277 is unimodal and entirely red. This finding is in strong contrast to other galaxies of similar and larger stellar mass, the cluster systems of which always exhibit (and are generally dominated by) blue clusters. We argue that the colour distribution of the cluster system of NGC 1277 indicates that the galaxy has undergone little (if any) mass accretion after its initial collapse, and use simulations of possible merger histories to show that the stellar mass due to accretion is probably at most ten per cent of the total stellar mass of the galaxy. These results confirm that NGC 1277 is a genuine relic galaxy and demonstrate that blue clusters constitute an accreted population in present-day massive galaxies.

Sequencing Quadruple Therapy for Heart Failure with Reduced Ejection Fraction: Does It Really Matter?

The conventional sequence of guideline-directed medical therapy (GDMT) initiation in heart failure with reduced ejection fraction (HFrEF) assumes that the effectiveness and tolerability of GDMT agents mirror their order of discovery, which is not true. In this review, the authors discuss flexible GDMT sequencing that should be permitted in special populations, such as patients with bradycardia, chronic kidney disease, or atrial fibrillation. Moreover, the initiation of certain GDMT medications may enable tolerance of other GDMT medications. Most importantly, the achievement of partial doses of all four pillars of GDMT is better than achievement of target dosing of only a couple.

Musculoskeletal and Sports Medicine Curriculum Guidelines for Pediatric Residents.

ABSTRACT: Musculoskeletal (MSK) and sports-related conditions are relatively common in the pediatric population. Pediatric residencies should provide residents with the knowledge and skills to assess and manage both acute and chronic MSK and sports injuries and complaints. Residents should develop the competencies and attitudes to safeguard and promote a healthy and active lifestyle for youth. Programs can use a variety of educational tools, both in the clinic and on the field, to provide a well-rounded MSK curriculum throughout the residency years. This article provides a review of general pediatric sports medicine curriculum guidelines and suggested implementation strategies.

Heart failure documentation in outpatients with diabetes and volume overload: an observational cohort study from the Diabetes Collaborative Registry.

BACKGROUND: Heart failure is a common and devastating complication of type 2 diabetes (T2D). Prompt recognition of heart failure may avert hospitalization, facilitate use of guideline-directed therapies, and impact choice of T2D medications. We sought to determine the rate and factors associated with heart failure documentation in T2D patients with evidence of volume overload requiring loop diuretics. METHODS: DCR is an on-going, prospective US registry of outpatient T2D patients from > 5000 cardiology, endocrinology, and primary care clinicians (current analysis used data from 2013-2019). Among T2D patients receiving loop diuretics, we examined the rate of chart documentation of heart failure. We used a 3-level hierarchical logistic regression model (patients nested within physician within practice) to examine factors associated with heart failure diagnosis. RESULTS: Among 1,322,640 adults with T2D, 225,125 (17.0%) were receiving a loop diuretic, of whom 91,969 (40.9%) had documentation of heart failure. Male sex, lower body mass index, atrial fibrillation, chronic kidney disease, and coronary artery disease were associated with greater odds of heart failure diagnosis. After accounting for patient factors, patients seen by cardiologists were the most likely to have HF documented followed by PCPs and then endocrinologists. CONCLUSIONS: Among US outpatients with T2D, 17% of patients had evidence of volume overload-defined by loop diuretic prescription-of whom fewer than half had a clinical diagnosis of heart failure. While there may be non-heart failure indications for loop diuretics, our data suggest that a substantial proportion of T2D patients may have unrecognized heart failure and therefore could be missing opportunities for targeted therapies that could alter the clinical course of heart failure.

Initial somatic symptoms are associated with prolonged symptom duration following concussion in adolescents.

AIM: To determine which initial postinjury symptom domains are independently associated with symptoms lasting >28 days in youth athletes who sustained sport-related concussions. METHODS: Patients who presented for care at a sport concussion clinic completed the postconcussion symptom scale. They were classified into two groups: those who reported symptom resolution within 28 days of injury and those who did not. Logistic regression models were constructed for children and adolescents to determine the independent association between symptom recovery and potential predictor variables: initial symptom scores in 5 postconcussion symptom scale domains (somatic, vestibular-ocular, cognitive, sleep and emotional), sex, loss of consciousness or amnesia at the time of injury, history of prior concussion, prior treatment for headaches or migraines, or family history of concussion. RESULTS: Sixty-eight child (8-12 years of age) and 250 adolescent (13-18 years of age) athletes were included. For adolescents, initial somatic symptom severity was independently associated with prolonged symptom duration (adjusted odds ratio = 1.162; 95% CI: 1.060, 1.275) and no other predictor variables were. No potential predictor variables were independently associated with prolonged symptom duration for children. CONCLUSION: Among adolescent athletes, a high initial somatic symptom burden (e.g. headache, nausea, vomiting, etc.) is associated with increased odds of symptoms beyond 28 days postinjury.

Knee injury patterns in young irish dancers.

OBJECTIVE: To characterize knee injury patterns in Irish dancers. METHODS: A retrospective chart review was performed for Irish dancers under age 19 who presented with knee injuries to the sports medicine or orthopedic clinic from January 1, 2000 to December 31, 2010. Data were collected on all knee injuries partially or directly related to Irish dance. Injury was defined as dance-related pain or damage to the structures in the knee that resulted in evaluation in the clinic. Survey data were collected to determine the number of different schools/studios represented by the dancers in the study. RESULTS: Sixty-seven Irish dancers with 86 knee injuries were evaluated. Half (50.7%) of these patients received more than one diagnosis during these visits. Overuse injuries accounted for 90.7% of knee injuries. Time to presentation ranged from less than 1 week to over 1 year. There was a significant difference in time to presentation, with traumatic injuries being evaluated sooner than overuse injuries. The most common diagnoses, accounting for 53.5% of injuries, were patellar tracking disorders, including patellofemoral syndrome, hypermobile patella, and patellar subluxation. CONCLUSION: In Irish dance overuse injuries represent the great majority of knee injuries, and patellofemoral tracking disorders are the most common diagnosis. For many dancers, there is often a delay of weeks to months between the onset of symptoms and evaluation in clinic. Prevention programs could potentially eliminate a large portion of knee pain experienced by young Irish dancers.

A Vision For the Future of Cardiovascular Medicine Practise in Ghana: Inspiration From the Yale-New Haven Health System.

The Ghana Physicians and Surgeons Foundation (GPSF) of North America sponsors Ghanaian clinical fellows to undertake an eight-weeklong clinical observation with the Yale University School of Medicine and Yale-New Haven Health (YNHH) annually, through the Residents in Training Educational Stipend (RITES) programme. This offers the opportunity to appreciate new perspectives in clinical care to improve Ghana's healthcare standard. The cardiovascular medicine workforce at the YNHH is heterogenous, with significant reliance on non-doctor cadres of health workers who demonstrate competence. This is contrasted from the Ghanaian system which despite having a poorer physician-patient ratio, is heavily dependent on doctors. Technological advancements are minimal in Ghana, posing diagnostic and therapeutic challenges which are otherwise minimised at the YNHH. A strong patient-centred culture, coupled with a coordinated emergency response system that ensures appropriate timely transfers, culminate in good care and outcomes. Ideas on how the experience can be translated to Ghanaian clinical practise in cardiovascular medicine, after participating in the RITES programme, are shared in this paper with an emphasis on task sharing, strengthening emergency response systems and improving technological sophistication through capacity building, mentorship and improved health financing.

Characteristics of Lumbar Pars Interarticularis and Pedicle Stress Injuries by Sport in 902 Pediatric and Adolescent Athletes: A Retrospective Study.

BACKGROUND: Recent studies utilizing magnetic resonance imaging (MRI) for the evaluation of symptomatic lumbar spondylolysis in pediatric and adolescent athletes have indicated that upper level lumbar involvement has a higher incidence than previously reported. There has been a paucity of literature evaluating sport-specific patterns of lumbar spondylolysis, specifically upper versus lower level involvement. PURPOSE: To assess the potential risk factors for upper level stress injuries of the lumbar spine in pediatric and adolescent athletes. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The medical records of 902 pediatric and adolescent athletes (364 female, 538 male; mean age, 14.5 ± 2.1 years) diagnosed with symptomatic pedicle and pars interarticularis stress injuries at 2 academic medical centers (July 2016 to June 2021) were reviewed. All patients had undergone MRI at the time of diagnosis. Only patients with pars/pedicle edema on MRI were included. Data regarding single-sport specialization, sport participation, sport category by biomechanics (axial rotation vs extension/axial loading), and vertebral level of injury over the 5-year period were analyzed. Stress reaction or active spondylolysis (SRAS) was the terminology used to designate grade 1, 2a, or 3 stress injuries according to the adapted Hollenberg classification system on MRI. Upper level vertebrae were defined as L3 or superior, whereas lower level vertebrae included L4 or inferior. RESULTS: Of the 902 patients with SRAS injuries, most (n = 753 [83.5%]) had exclusively single-level lower stress injuries, while 67 (7.4%) had multilevel stress injuries. There were 82 athletes (9.1%) who had single-level upper stress injuries. Athletes with upper level pars/pedicle stress injuries were older at the time of diagnosis (15.8 ± 1.9 vs 14.3 ± 2.1 years, respectively; P < .001), had a shorter duration of low back pain before presentation (2.50 ± 2.70 vs 4.14 ± 6.73 months, respectively; P < .001), were more likely to specialize in a single sport (43.9% vs 32.3%, respectively; P = .046), and had a lower incidence of active spondylolysis on MRI at the time of diagnosis (42.7% vs 59.8%, respectively; P = .004) compared with athletes with lower level stress injuries. Athletes with lumbar stress injuries who specialized in a single sport had nearly twice the odds of having upper level involvement compared with multiple-sport athletes (adjusted odds ratio, 1.80 [95% CI, 1.06-3.04]; P = .03). Athletes with active spondylolysis on MRI at the time of diagnosis had nearly half the odds of having upper level involvement (adjusted odds ratio, 0.55 [95% CI, 0.33-0.91]; P = .02). CONCLUSION: Age at the time of diagnosis, duration of low back pain, single-sport specialization, and presence/absence of active spondylolysis on MRI at the time of diagnosis were primary predictors of whether an athlete's lumbar stress injury was classified as either upper or lower level involvement. Overall, the variables included in multivariate analysis were modest predictors, explaining only 15.1% of the variance in the rates of lumbosacral stress injuries classified by spinal level. These specific biomechanical factors and other potential contributors to these findings warrant further investigation.

Changes in training patterns and confidence to return to sport in United States collegiate athletes during the COVID-19 pandemic.

OBJECTIVE: To describe the training patterns, return to sport (RTS) confidence, and perceived fitness during the COVID-19 pandemic summer 2020 and to compare training patterns and RTS readiness during COVID-19 versus during the 2019 summer in a cohort of Division III collegiate athletes. METHODS: An electronic survey of varsity athletes ≥18 years at three United States Division III colleges querying athlete demographics, Modified Athletic Identity Scale (mAIMS), changes in training regimen summer 2020 vs. 2019, RTS confidence, and perceived physical fitness. RESULTS: One hundred and ninety-two surveys were completed (19% response). Total reported summer 2020 training decreased by 4 hours/week, with increased aerobic (56% vs. 53%, p = 0.03) and decreased sport-specific training (48% vs 70%, p < 0.001). Median RTS confidence score for formal training and competition was 3 ('neither more or less confident') in men's versus 2 ('less confident') in women's athletes. Median fitness self-assessment for men's athletes was 3 ('neither more nor less physically fit') compared to previous season versus median score of 2 ('less physically fit) among women's athletes (p = 0.004). For each mAIMS unit, training increased by 11 minutes/week (95% CI: 2-19 minutes; p = 0.01) and sport-specific training increased by 1.3% (95% CI: 0.5-2.2%; p = 0.003), controlling for age, sport, grade, and school. mAIMS was not associated with confidence or fitness rating. CONCLUSION: Collegiate athletes decreased overall training hours, particularly sport-specific training time during the COVID-19 summer compared to the prior summer. Athletic identity was related to overall and sport-specific training hours but not confidence to RTS or fitness.

Sequencing Quadruple Therapy for Heart Failure with Reduced Ejection Fraction: Does It Really Matter?

The conventional sequence of guideline-directed medical therapy (GDMT) initiation in heart failure with reduced ejection fraction (HFrEF) assumes that the effectiveness and tolerability of GDMT agents mirror their order of discovery, which is not true. In this review, the authors discuss flexible GDMT sequencing that should be permitted in special populations, such as patients with bradycardia, chronic kidney disease, or atrial fibrillation. Moreover, the initiation of certain GDMT medications may enable tolerance of other GDMT medications. Most importantly, the achievement of partial doses of all four pillars of GDMT is better than achievement of target dosing of only a couple.

Anesthesia duration as a marker for surgical complications in office-based plastic surgery.

BACKGROUND: Office-based plastic surgery has continued to rise in the past 2 decades with the increased demand for cosmetic surgery. Although several large studies have shown the safety of office-based surgery, current regulations place some restrictions on ambulatory office-based surgical facilities. To provide further evidence-based literature on the safety of office-based plastic surgery, we examine surgical complication rates as a function of anesthesia duration. METHODS: This is a retrospective review of 2595 patients who underwent office-based plastic surgery procedures between October 2000 and January 2005. All patients received general anesthesia for a broad range of cosmetic surgeries. The primary measured outcome was minor and major surgical complications. Complication rates were examined as a function of anesthesia duration of less than or greater than 4 hours. The follow-up period was 30 days. Statistical analysis was completed using SPSS v.19. RESULTS: Most of the patients were female with an average age of 41 years. An increase in the occurrence of minor surgical complications such as postoperative nausea and vomiting (2.8% vs 5.7%, P=0.0175) and urinary retention (0.7% vs 7.6%, P<0.0001) was noted in the greater than 4-hour anesthesia duration group. Overall, there were 66 (2.5%) patients that required reoperation because of surgical complications with no statistical difference between the 2 groups (P=0.098). The only major morbidities were 1 pulmonary embolism (<4 hours) and 1 deep vein thrombosis (>4 hours). Five (0.19%) patients were admitted to the hospital during the follow-up period for surgical and/or medical management (3 hematomas, 1 deep vein thrombosis, and 1 pulmonary embolism). There were no cases of reintubation, major cardiac complications, or death in this series. CONCLUSIONS: Duration of general anesthesia in office-based plastic surgery does not seem to be an indicator of major morbidity and mortality. Although minor complications such as postoperative nausea and vomiting and urinary retention were higher in patients with anesthesia greater than 4 hours, there was no significant increase in major complications. Change in surgical venue would not likely alter the outcome of the increase in minor complications. Therefore, anesthesia duration should not be used as a guideline for safety of office-based plastic surgery.

Factors influencing palliative care referral for hospitalised patients with heart failure: an exploratory, randomised, multi-institutional survey of hospitalists and cardiologists.

OBJECTIVE: To identify factors influencing cardiologists' and hospitalists' decisions regarding palliative care referral among hospitalised patients with advanced heart failure. DESIGN: An exploratory, randomised vignette-based survey. SETTING: Cardiology and hospitalist divisions at three Michigan State institutions and the Society of Hospital Medicine's Michigan Chapter. PARTICIPANTS: 145 hospitalists and 64 cardiologists. OUTCOME MEASURES: Primary outcomes included participants' reports of their likelihood of referring a standardised patient with an acute heart failure exacerbation with multiple prior hospital admissions and acute renal failure to palliative care (scale of 0%-100%) after the initial stem and after being cued with three randomised vignette modifiers, including the presence versus the absence of continuity with an outpatient cardiologist; the presence versus the absence of documented advance care planning; and the patient voicing that he is accepting of his severe illness versus wanting everything done. Adjusted generalised linear models and predictive margins were used to evaluate the impact of each randomised modifier on referral decisions. An interaction term evaluated the effect of provider specialty on outcomes. Secondary outcomes included participants' reports of their general practices around palliative care delivery to hospitalised patients with heart failure. RESULTS: Response rate was 31.3%. Predictive margins from generalised linear models demonstrated a statistically significantly higher likelihood of referral to inpatient palliative care if the patient lacked an outpatient cardiologist (mean difference: 6.3% (95% CI 1.8% to 10.8%)); had prior advance care planning documentation (mean difference: 9.7% (95% CI 4.4% to 15.0%)); and was accepting of illness severity (mean difference: 29.6% (95% CI 24.8% to 34.4%)). No interaction effect was noted based on provider specialty. Most hospitalists and cardiologists were unaware of palliative care guidelines for patients with heart failure (74.3% vs 70.3%, p=0.71). CONCLUSIONS: A number of patient and provider factors influence palliative care referral decisions in hospitalised patients with advanced heart failure.

Patients' perspectives in high-risk medical decision-making.

People faced with making risky treatment decisions in the context of life-threatening illness are typically well-informed about their disease, alternative courses of action, and the odds. But they often need help dealing with the emotional and mental challenges of making high-stakes decisions in unfamiliar areas on an accelerated timetable at a time of personal, existential threat. Reframing the situation can help such individuals transcend ingrained perspectives, freeing them from traditional ways of thinking and, in the process restoring their ability to decide, fostering the courage they so desperately need, and even instilling hope in the darkest of times.

Poisoning due to tutin in honey-a report of an outbreak in New Zealand.

AIM: In autumn 2008, an outbreak of toxic honey poisoning was identified. The outbreak was not recognised initially until three cases from one family group presented to hospital, with a common factor of recent consumption of locally produced honey. The aim of this study was to investigate potential cases of this honey poisoning and determine which toxin was involved. METHOD: The incident was investigated retrospectively by Waikato District Health Board's Population Health unit and the New Zealand Food Safety Authority (NZFSA). Identified patients were followed up by questionnaire to gather case information. HortResearch (now Plant and Food Research) tested honey samples for toxins. RESULTS: The causative agent was identified as tutin, which comes from the New Zealand native plant tutu (Coriaria arborea) which has long been known as a potential source of contamination of honey produced in the warmer parts of New Zealand. Retrospective case investigation identified a total of 22 possible or probable cases, based on a clinical case definition. The spectrum of toxic effects reported were broadly similar to those previously described for tutin, derived either directly from the plant itself or indirectly from honey. There were 13 samples of honey, linked to symptomatic individuals, which were available for testing. Of these, 10 were positive for tutin and its hydroxy metabolite hyenanchin (hydroxytutin) and one was positive for hyenanchin alone. CONCLUSION: Toxic honey production is a significant risk in parts of New Zealand. Beekeepers and health professionals need to be informed of this risk and know how best to manage it. Due to this poisoning incident, public and professional awareness of honey poisoning has been substantially enhanced. This incident led to development of new food safety standards for New Zealand honey.

The Effect of Prior Concussion History on Dual-Task Gait following a Concussion.

Sustaining repeated concussions has been associated with worse outcomes after additional injuries. This effect has been identified using symptom inventories and neurocognitive tests; however, few investigations have examined how a prior concussion history affects gait soon after a subsequent concussion. We examined the gait characteristics of athletes with no documented concussion history (n = 31), athletes recovering from their first lifetime concussion (n = 15), and athletes recovering from their second or greater lifetime concussion (n = 22). All participants completed a single-task and dual-task gait examination, a medical history questionnaire, and a postconcussion symptom scale. Multivariate analyses of covariance (MANCOVA) models were used to evaluate mean gait differences among groups, and Spearman's ρ analyses were used to assess correlations between the number of lifetime concussions and gait characteristics. Patients reporting to the clinic with their second or greater lifetime concussion demonstrated smaller stride lengths than healthy control participants during dual-task walking (p = 0.01; d = 0.70). A moderate but insignificant correlation was detected between dual-task gait speed and the number of prior concussions (ρ = 0.41, p = 0.07). These results indicate that a cumulative effect of concussions across the lifetime may contribute to worsening dual-task dynamic motor function after concussion.

Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures.

Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (<24 hours). One patient had an emergent intubation. No prolonged adverse effects were noted. There was a 30-day follow-up minimum. Outpatient surgery is an important aspect of plastic surgery. It was shown that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe. Appropriate accreditation, safe anesthesia protocols, and proper patient selection constitute the basis for safe and efficacious office-based outpatient plastic surgery.

Pediatric neck masses.

The majority of neck masses in the pediatric population are congenital or inflammatory in origin requiring a thorough understanding of embryology and anatomy of the cervical region. However, malignancy must always be ruled out as they represent 11%-15% of all neck masses in the pediatric population. The initial history and physical are of utmost important to correctly work-up and eventually diagnose the lesion. This article addresses many aspects of the workup, diagnosis and eventual proper surgical or medical management of pediatric neck masses.