Early diastolic heart sounds caused by the atrial kick.

An 81-year-old male with a history of coronary artery disease, hypertension, paroxysmal atrial fibrillation and chronic kidney disease presents with asymptomatic bradycardia. Examination was notable for an early diastolic heart sound. 12-lead electrocardiogram revealed sinus bradycardia with a markedly prolonged PR interval and second-degree atrioventricular block, type I Mobitz. We review the differential diagnosis of early diastolic heart sounds and present a case of Wenckebach associated with a variable early diastolic sound on physical exam.

Understanding the relationship between health insurance and kidney stones: an examination of NHANES data.

INTRODUCTION: To investigate the relationship between socioeconomic factors, specifically insurance status, and kidney stones using a nationally representative cohort. MATERIALS AND METHODS: A retrospective secondary data analysis of National Health and Nutrition Examination Survey (NHANES) data from 2007 to 2014 was performed. Using univariate statistics and multiple logistic regressions, we examined the relationship between socioeconomic factors and kidney stone history. RESULTS: The weighted national prevalence of nephrolithiasis between ages 20 and 64 was 7.7% of a population of over 95.3 million. Fifty-three percent of the total population was female. The mean age was 42 years and the mean body mass index (BMI) was 28.7. The prevalence of nephrolithiasis was higher among individuals who had state-assisted insurance compared to those with private insurance (10.3% versus 7.3%, p = 0.005). On univariate regression analysis, having a college education was protective against stones compared to having less than a high-school degree (OR 0.62, 95% CI 0.43-0.84; p = 0.009). Income was also significantly associated with kidney stone prevalence. After adjusting for race, BMI, gender, water intake, income, and education level through multivariable analysis, having private insurance was associated with lower odds of developing nephrolithiasis compared to having state-assisted insurance (OR 0.62, 95% CI 0.44-0.89; p = 0.01). CONCLUSIONS: Individuals with state-assisted insurance were found to have significantly increased odds of a kidney stone compared to those with private insurance. Urologists, primary care, and policy makers should recognize this disparity exists and target opportunities to elucidate mechanisms and provide intervention for this high-risk group.

Impact of Glabellar Paralysis on Facial Expression of Emotion.

BACKGROUND: Many prospective patients remain wary of the effects that glabellar muscle paralysis may have on their ability to normally communicate emotion with their face. OBJECTIVE: We undertook a direct empirical test of the effects of glabellar onabotulinum toxin type A injections on the ability to convey 6 universally recognized facial expressions of emotion. METHODS: Fifty-two female subjects ("expressors") were recorded on hidden camera while viewing video clips intended as a mood induction procedure that stimulates the 6 cardinal emotions (amusement, anger, disgust, fear, sadness, surprise). The subjects were then injected with 25 units of onabotulinum toxin A in the glabellar region. The subjects returned 1 month later and were again recorded while being spontaneously induced to express emotion. All video clips from both time periods from the 10 maximal expressors were extracted and shown to a group of 31 "perceivers" who rated the facial expressions for intensity (Likert 1-7) and identity of emotion (percent correct emotion identified). RESULTS: Glabellar paralysis significantly diminished mean perceived intensity of anger (50.4% relative reduction, P < 0.001) and surprise (20.6% relative reduction, P < 0.001). The mean intensity of disgust increased (39.0%, P < 0.001). Importantly, however, glabellar paralysis did not result in a significant change in observers' ability to discern provoked cardinal emotions. CONCLUSIONS: We believe these findings provide a measure of reassurance to patients and their providers that the use of onabotulinum toxin A to paralyze the glabellar musculature for aesthetic purposes may not pose a meaningful risk to the overall ability to express emotion during social interaction.

Trends in urinary diversion after radical cystectomy for urothelial carcinoma.

PURPOSE: To assess how trends in urinary diversion (UD) type following radical cystectomy (RC) have changed in recent years and investigate pre-operative predictors of UD type. METHODS: Data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2011 to 2015. We quantified the percentages of continent diversions (CD) versus incontinent diversions (ID) completed over this time frame. Using univariate and multivariable logistic regression analyses, we compared UD type across year of operation as well as predictors of type of diversion. RESULTS: We identified 4790 patients in the cohort, of which 81% underwent an incontinent diversion. Patients undergoing incontinent diversions were older (p < 0.001), more likely to be female (p < 0.001), had higher American Society of Anesthesiologists (ASA) classification (p < 0.001) and had more comorbidities with worse preoperative lab values. On multivariable analysis, the odds of incontinent diversion increased per year (OR 1.16, 95% CI 1.06-1.26; p = 0.001). Neoadjuvant chemotherapy (NAC) was associated with lower odds of receiving an ID (OR 0.33, 95% CI 0.17-0.64; p = 0.001). Being male, healthy and young were associated with higher odds of CD. CONCLUSION: We demonstrate that there has been a decrease in continent diversion use in recent years. Neoadjuvant chemotherapy, proxies of life expectancy and gender are significant predictors of continent diversion. Further investigation to determine the underlying cause of decreased utilization of CD is warranted.

Predicting When Women Will Achieve Equitable Representation in Four Specialties: The WHEN Study.

BACKGROUND: For 2 decades, women have made up nearly half of medical school graduates, yet this has not translated to equity in promotion. We compare historical trends in the academic career pipeline among 4 specialties by sex. METHODS: Using the Association of American Medical Colleges database, faculty sex and rank were examined in oncology, gastroenterology, cardiovascular medicine, and general surgery for the years 2000 and 2020. RESULTS: Cardiovascular medicine, gastroenterology, and general surgery all had similar lower representation of women faculty in 2000 (17%, 17%, and 15%, respectively) compared with oncology (26%). Cardiovascular medicine and general surgery have seen smaller increases in representation over the last 20 years compared with gastroenterology and oncology. Oncology and gastroenterology are projected to reach sex parity in 2024 and 2029, followed by general surgery in 2054. At the current rate, cardiovascular medicine will not reach sex parity until 2070. CONCLUSION: Oncology and gastroenterology, compared with cardiovascular medicine and general surgery, have seen larger gains in representation of women over the past 2 decades, including at Professor rank. Disparities persist in specific fields; lessons may be learned from other specialties in which women are more likely to be promoted to leadership positions.

A 77-Year-Old Woman With Capillary Hypoxia and Perioral Cyanosis.

CASE PRESENTATION: A 77-year-old woman with asthma, hypothyroidism, irritable bowel syndrome, overactive bladder, and multiple rheumatologic conditions was sent from the clinic to the ED for evaluation of hypoxia. In the clinic, she reported dizziness without shortness of breath and was noted to have perioral cyanosis with an oxygen saturation measured by pulse oximetry (Spo2) of 80%. She was given a nonrebreather mask delivering oxygen at 8 L/min, but the Spo2 remained at 77% to 82%. In the ED, the patient reported intermittent shortness of breath, 2 to 3 days of mild left lower extremity swelling, and a brief episode of lightheadedness earlier in the day that had since resolved. She denied fevers/chills, upper respiratory symptoms, and chest pain. She had been referred to the pulmonology clinic 3 years earlier to evaluate mild hypoxia with Spo2 readings in the low 90% range, but pulmonary function testing failed to identify an etiology. There was no history of VTE. Her rheumatologic conditions included osteoarthritis, rheumatoid arthritis, Sjögren's syndrome, and fibromyalgia.

Women in procedural leadership roles in cardiology: The Women In Local Leadership (WILL) observational study.

BACKGROUND: Although 50% of U.S. medical students are women, this percentage fails to translate to cardiology. Gender disparities are striking in interventional cardiology (IC) and electrophysiology (EP) and in leadership. Left atrial appendage closure with the WATCHMAN device, as a novel procedure, is a lens into inequities. OBJECTIVE: The purpose of this study was to identify the characteristics and prevalence of women (1) as early WATCHMAN implanters and (2) in related leadership. METHODS: Data were collected on WATCHMAN implanters and hospitals from January 2017 to December 2018. The gender of physicians in leadership positions was identified via survey as Director of IC, Director of EP, and Chief of Cardiology. The Firth logistic model controlling for covariates modeled the rare event of a woman implanter. RESULTS: Data were obtained for 100% of the cohort. Men comprised 97% of implanters (860/886). No differences in subspecialty or implants by gender were observed. There were 414 hospitals performing WATCHMAN: 24% academic, 97% urban, and most medium/large size (94%). EP made up 61% of implanters. Only 4.8% of hospitals had women in selected leadership roles. Women represented <1% of Directors of IC and only 2.6% of both Directors of EP and Chiefs of Cardiology. Hospitals with a woman in leadership had a 4 times greater odds of a woman implanter (odds ratio 4.24; 95% confidence interval 1.16-15.41; P = .028). CONCLUSION: Women are underrepresented in cardiology procedural subspecialties in the use of novel technology and in key leadership roles. There was a greater odds of women early implanters of WATCHMAN if a woman led locally. Increasing women in leadership may improve gender diversity through visibility of role models.

Overall survival in patients with metastatic renal cell carcinoma and clinical N1 disease undergoing cytoreductive nephrectomy and lymph node dissection.

BACKGROUND: Patients with metastatic renal cell carcinoma (mRCC) have limited treatment options. Cytoreductive nephrectomy (CN) in select patients has been associated with improved survival. We aim to assess the survival in patients with mRCC and cN1 disease who underwent CN with and without lymph node dissection (LND). METHODS: Data were abstracted from the National Cancer Database for patients diagnosed with mRCC and cN1 from 2003 to 2014. Using propensity matching, we compared overall survival (OS) in patients who underwent a LND. Kaplan-Meier survival analysis and multivariable Cox proportional hazards modeling were used. We performed a logistic regression to assess predictors of LND. RESULTS: We identified 1,780 patients in the matched cohort, of which 71% underwent a LND. Patients undergoing LND were younger (P = 0.01) and had similar size tumors (5cm; P = 0.31). Increased LN yield was associated with LND at an academic center (odds ratio = 1.91; 95% CI: 1.51-2.42; P<0.01). LND was associated with worse OS on KM analysis (log rank; P = 0.01). However, on multivariable analysis, we found no significant difference in OS (hazard ratio = 1.10; 95% CI: 0.94-1.29; P = 0.22). However, when adjusting for number of positive LN removed, an increase in LN yield was associated with improved OS (hazard ratio = 0.97; 95% CI: 0.95-0.99; P = 0.01). CONCLUSION: We demonstrate that patients with mRCC and cN1 disease undergoing LND did not have a survival benefit when compared with patients undergoing CN. However, lymph node yield showed an increase in survival when adjusting for the number of positive lymph nodes. Further research and validation of the ideal number of LN removed that may benefit patients is warranted.