Infratemporal abscess: a rare complication of a common procedure.

The infratemporal fossa (ITF) is an anatomically complex cavity that houses a variety of muscular and neurovascular structures at the base of the skull. Infections involving the ITF, though uncommon, can be fatal due to the difficulties of accessing this anatomical space and its proclivity to evolve into a cavernous venous thrombosis (CVT). As a result, a multi-disciplinary approach involving several surgical and medical subspecialists is often warranted. We present a case of an infratemporal fossa abscess (IFA) after wisdom teeth extraction with a very complicated clinical course and a distinct microbiologic profile.

Left bundle branch area pacing vs biventricular pacing for cardiac resynchronization: A systematic review and meta-analysis.

Background: Left bundle branch area pacing (LBBAP) may offer greater physiological benefits than traditional biventricular pacing (BiVP). However, there are limited data comparing the efficacy of LBBAP vs BiVP in patients with systolic heart failure (HF). Objective: The purpose of this meta-analysis was to compare the feasibility and electromechanical and clinical outcomes of both LBBAP and BiVP. Methods: We conducted a systematic review of studies retrieved from various databases including PubMed, Embase, Google Scholar, Scopus, and Cochrane Central Register of Control Trials (CENTRAL) published up to May 22, 2023. The risk ratio (RR) and standardized mean difference (SMD) with corresponding 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes, respectively. Results: We included 12 studies with a total of 3004 patients (LBBAP = 1242, BiVP = 1762). Pooled results showed that LBBAP resulted in a significant increase in left ventricular ejection fraction (SMD 0.40, 95% CI 0.25, 0.54, P < .00001), echocardiographic response (RR 1.19, 95% CI 1.10 to 1.29, P < .0001), improvement in New York Heart Association functional class (SMD -0.44, 95% CI -0.65 to -0.23, P < .0001), QRS duration reduction (SMD -0.90, 95% CI -1.14 to -0.66, P < .00001), left ventricular end-diastolic diameter reduction (SMD -0.31, 95% CI -0.57 to -0.05, P = .02), fewer HF hospitalizations (RR 0.72, 95% CI 0.62, 0.85, P < .0001), and improved survival (RR 0.73, 95% CI 0.58, 0.92, P = .007). In addition, LBBAP was associated with shorter fluoroscopy time (SMD -0.94, 95% CI -1.42 to -0.47, P < .0001) and lower pacing threshold at implantation (SMD -1.03, 95% CI -1.32 to -0.74, P < .00001) and at 6 months (SMD -1.44, 95% CI -2.11 to -0.77, P < .0001) as compared with BiVP. Conclusion: Compared with BiVP, LBBAP was associated with better electromechanical and clinical outcomes, including left ventricular ejection fraction, QRS duration, echocardiographic response, New York Heart Association functional class, HF hospitalization, and all-cause mortality in patients with systolic HF.

Homicides of psychologists, physicians, nurses, pharmacists, social workers, and other health professionals: National Violent Death Reporting System data 2003-2020.

OBJECTIVE: Homicide is the extreme endpoint along the continuum of interpersonal violence. Violence in healthcare settings and directed toward healthcare workers has been a growing concern. Analysis of health professionals' homicides is needed to inform prevention interventions. METHODS: Decedent numbers, age, and sex in the National Violent Death Reporting System are reported for 10 types of health professionals: advance practice registered nurses, dentists, nurses, pharmacists, physicians, physician assistants, psychiatrists, psychologists, social workers, and veterinarians. RESULTS: Between 2003 and 2020, 944 homicides of these professionals were reported to the NVDRS. Nearly 80% of victims were women; 53% of homicides involved guns. Nurses, social workers, physicians, and pharmacists comprised the most victims. In 2020, nurses, social workers, pharmacists, and psychologists had the highest homicide rates relative to their workforce size. Few of these homicides were related to professionals' work. The number of homicides within these professions correlated highly with the size of professions' workforces. CONCLUSIONS: Health professionals' homicides constitute a small proportion of US homicides generally at lower rates than seen in the general population. Age is likely one of the protective factors. Future, more comprehensive data will provide greater insights into emerging trends to inform strategies to mitigate homicide risk in health professionals. Prevention needs to go beyond healthcare settings and address societal roots of violence.

Catheter ablation of atrial fibrillation in hypertrophic cardiomyopathy: A proportional meta-analysis and systematic review of single-arm studies.

Background: Atrial fibrillation (AF) is the most common arrhythmia in patients with hypertrophic cardiomyopathy (HCM). Limited data exists about the efficacy and clinical outcomes of AF ablation in HCM. Objective: The purpose of this meta-analysis was to evaluate the role of catheter-based ablation for treatment of AF in patients with HCM. Methods: PubMed, SCOPUS, Web of Science, Embase, Cochrane library, and ClinicalTrials.gov were searched for studies discussing outcomes of catheter-based ablation for AF in patients with HCM. Two reviewers independently screened studies and extracted relevant data. Incidence rate estimates from individual studies underwent logit transformation to calculate the weighted summary proportion under the random effect model. Results: A total of 19 reports met the inclusion criteria (1183 patients). The single ablation procedure was successful in 39% patients. Up to 34% patients underwent a repeat ablation. About 41% patients in normal sinus rhythm after successful AF ablation received postprocedure antiarrhythmic drug (AAD) therapy. Patients undergoing successful AF ablation experienced a significant improvement in the New York Heart Association functional class (standardized mean difference -1.03; 95% confidence interval -1.23 to -0.83; P < .00001). Conclusion: AF ablation appears to be safe and feasible in patients with HCM. Freedom from AF after undergoing successful ablation is associated with significant improvement in heart failure symptoms.

Incremental healthcare cost burden in patients with atrial flutter only.

Background: Limited information is available on the costs related to atrial flutter only. This study provides a comprehensive estimate of the cost in patients with atrial flutter only versus matched patients without any atrial arrhythmia. Methods: Patients over 20 years of age with a minimum of one inpatient or two outpatient diagnosis codes for atrial flutter in 2005 and a minimum of 12 months of continuous enrollment pre- and post-index were identified using the MarketScan Commercial and Medicare databases. Atrial flutter patients were propensity matched to patients without atrial arrhythmias. Total costs for each patient for 12 months post-index were calculated. National cost was estimated using the projected prevalence of atrial flutter for 2010. Results: A total of 1,042 patients with atrial flutter only were successfully matched with comparison patients. For atrial flutter patients compared to matched controls without atrial arrhythmias, total mean annual cost per patient was 81% higher ($23,008 vs. $12,717) and mean annual inpatient expenditure was 214% higher ($8,518 vs. $2,713). When applied to national atrial flutter prevalence data, total incremental cost burden was estimated to be $687.9 million per year more than patients without atrial arrhythmias, primarily due to cardiovascular specific expenditure ($377 million, 55% of total) with 58% ($218.5 million) of the increased inpatient expenditure due to cardiovascular specific admissions and $159 million (23%) for atrial flutter specific care. Sex-related differences were also present in atrial flutter only patients. Conclusion: Although atrial flutter-only patients are less prevalent than atrial fibrillation patients, the national incremental cost burden in atrial flutter is substantial on a per-patient level.

Sabbaticals in US Medical Schools.

BACKGROUND: Sabbaticals are an important feature of academia for faculty and their institutions. Whereas sabbaticals are common in institutions of higher learning, little is known about their role and utilization in US medical schools. This perspective piece examining sabbaticals in medical school faculty was undertaken at a time that well-being of health professionals was increasingly being recognized as a workforce health priority. METHODS: We surveyed associate deans at US medical schools in 2021 about faculty who had taken sabbaticals within the past 3 years, the parameters of the sabbaticals, and institutional policies and respondents' predictions of future sabbatical use. RESULTS: A total of 53% of respondents reported any faculty had taken sabbaticals in the past 3 years (M = 6.27; Median = 3; range = 1-60). Institutions rated enhancing research as the most important objective, while recognizing other benefits. Sabbaticals were more commonly taken by male, white, senior faculty PhDs. Details about sabbaticals, including eligibility, expectations, length, financial support, and benefits were reviewed. Most (54.8%) respondents expected no change in the number of faculty seeking sabbaticals. Nearly all anticipated the COVID-19 pandemic would not affect sabbatical policies. CONCLUSION: In contrast to other institutions of higher learning, sabbatical-taking by medical school faculty is rare. We explore factors that may contribute to this phenomenon (eg, the tripartite mission, faculty clinical responsibilities, culture of medicine, and student debt). Despite financial and other barriers, a closer look at the benefits of sabbaticals is warranted as a mechanism that may support faculty well-being, retention, and mental health.

Relationship of health-related social needs and hospital readmissions in patients following a hospitalization for atrial fibrillation.

Atrial fibrillation (AF) has a high economic burden on the healthcare system with rehospitalizations as the most significant contributing factor necessitating an understanding of aspects related to hospitalizations to minimize economic costs and improve patient outcomes. Our study aims to assess whether all-cause 30-day hospital readmission following AF-specific hospitalization is associated with health-related social needs (HRSN) using the Nationwide Readmissions Database (NRD). All hospitalization data were abstracted from the 2015-2019 NRD, including hospitalizations for patients at least 18 years of age with a primary discharge diagnosis of AF. For each hospitalization, we identified secondary diagnoses for five HRSN domains including employment, family, housing, psychosocial, and socioeconomic status. Primary outcomes included all-cause 30-day readmission rates. Secondary outcomes included all-cause 90-day readmissions and diagnosis on readmissions. An estimated 1,807,460 index hospitalizations in the United States included a primary discharge diagnosis of AF. Of these, 97.3 % included a diagnosis in only one HRSN domain with the most frequently diagnosed HRSN domain being housing (54.5 %) followed by socioeconomic (29.4 %), family (10.0 %), employment (6.1 %), and psychosocial (2.8 %). Index hospitalizations that included any HRSN diagnosis had 2.2-times greater unadjusted odds of all-cause 30-day readmission (95 % CI: 2.1 to 2.3-times greater, p < .001). Index hospitalizations that included an HRSN diagnosis were associated with higher rates of 90-day readmission due to conduction disorder and COPD. In conclusion, there is a significant association between HRSN and hospital readmissions in patients with AF. Further research is required to explain the true nature of this relationship with a specific emphasis on housing insecurity.

Healthcare resource utilization in patients with newly diagnosed atrial fibrillation in the United States.

OBJECTIVES: To summarize healthcare resource utilization (HCRU) in patients with newly diagnosed (incident) paroxysmal or persistent atrial fibrillation (AF). METHODS: This retrospective, observational cohort study assessed HCRU among patients with incident paroxysmal or persistent AF using data from 1 January 2015 to 30 September 2019 in the IBM MarketScan® Research Databases. RESULTS: A total of 50,796 patients were identified in the overall incident AF cohort. Rates of all-cause inpatient hospital stays, all-cause emergency room visits, and all-cause outpatient visits in the overall incident cohort were 46.8, 114.7, and 2,752.7 events per 100 patient-years (PY), respectively. Rates of cardiovascular-related inpatient stays for the overall population were 11.3 events per 100 PY. During follow-up, 50.4% of the overall cohort filled prescriptions for direct-acting oral anticoagulants and 5.0% had catheter ablation. CONCLUSIONS: Advances in anticoagulation and ablation have been realized since previously published HCRU analyses of patients with atrial fibrillation. This update suggests that HCRU among patients with incident AF in the US remains high with some subgroups of patients receiving more specialized care.

The Performance and Trajectory of Medical Students With Disabilities: Results From a Multisite, Multicohort Study.

PURPOSE: To conduct a post-Americans with Disabilities Act Amendments Act of 2008 multisite, multicohort study called the Pathways Project to assess the performance and trajectory of medical students with disabilities (SWDs). METHOD: From June to December 2020, the authors conducted a matched cohort study of SWDs and nondisabled controls from 2 graduating cohorts (2018 and 2019) across 11 U.S. MD-granting medical schools. Each SWD was matched with 2 controls, one from their institution and, whenever possible, one from their cohort for Medical College Admission Test score and self-reported gender. Outcome measures included final attempt Step 1 and Step 2 Clinical Knowledge scores, time to graduation, leave of absence, matching on first attempt, and matching to primary care. RESULTS: A total of 171 SWDs and 341 controls were included; the majority of SWDs had cognitive/learning disabilities (118/171, 69.0%). Compared with controls, SWDs with physical/sensory disabilities had similar times to graduation (88.6%, 95% confidence interval [CI]: 77.0, 100.0 vs 95.1%, 95% CI: 90.3, 99.8; P = .20), Step 1 scores (229.6 vs 233.4; P = .118), and match on first attempt (93.9%, 95% CI: 86.9, 100.0 vs 94.6%, 95% CI: 91.8, 97.4; P = .842), while SWDs with cognitive/learning disabilities had lower Step 1 scores (219.4; P < .001) and were less likely to graduate on time (81.2%, 95% CI: 69.2, 93.2; P = .003) and match on first attempt (85.3%, 95% CI: 78.0, 92.7; P = .009). Accommodated SWDs had Step 1 scores that were 5.9 points higher than nonaccommodated SWDs (95% CI: -0.7, 12.5; P = .08). CONCLUSIONS: Structural barriers remain for SWDs with cognitive/learning disabilities, which could be partially mitigated by accommodations on high-stakes exams.

Role of Connexin 43 phosphorylation on Serine-368 by PKC in cardiac function and disease.

Intercellular communication mediated by gap junction channels and hemichannels composed of Connexin 43 (Cx43) is vital for the propagation of electrical impulses through cardiomyocytes. The carboxyl terminal tail of Cx43 undergoes various post-translational modifications including phosphorylation of its Serine-368 (S368) residue. Protein Kinase C isozymes directly phosphorylate S368 to alter Cx43 function and stability through inducing conformational changes affecting channel permeability or promoting internalization and degradation to reduce intercellular communication between cardiomyocytes. Recent studies have implicated this PKC/Cx43-pS368 circuit in several cardiac-associated diseases. In this review, we describe the molecular and cellular basis of PKC-mediated Cx43 phosphorylation and discuss the implications of Cx43 S368 phosphorylation in the context of various cardiac diseases, such as cardiomyopathy, as well as the therapeutic potential of targeting this pathway.

US Antiarrhythmic Drug Treatment for Patients With Atrial Fibrillation: An Insurance Claims-Based Report.

Background Current American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines and European Society of Cardiology guidelines recommend antiarrhythmic drugs (AADs) for maintenance of sinus rhythm in patients with atrial fibrillation. We assessed the concordance between healthcare provider real-world practice and current guidelines with respect to first-line AAD rhythm management. Methods and Results Administrative claims data from the deidentified Optum Clinformatics Data Mart database were used. Patients were included if they were initiated on an AAD in 2015 to 2016, had 1 year of continuous data availability before their first AAD pharmacy claim, and had a diagnosis for atrial fibrillation within that period. Concordance was assessed by comparing the AAD initiated by the healthcare provider against guideline recommendations for first-line treatment, given the presence of heart failure, coronary artery disease, both, or neither (as determined by International Classification of Diseases, Ninth Revision and Tenth Revision [ICD-9 and ICD-10] codes). Concordance was also assessed by provider type using Medicare taxonomy codes. For the 15 445 patients included, 51% of healthcare providers initiated AAD treatments with amiodarone, 18% flecainide, 15% sotalol, 8% dronedarone, 5% propafenone, and 2% dofetilide. The overall rate of guideline concordance was 61%, with differences by provider type: 67% for electrophysiologists, 61% for cardiologists, and 60% for others (internal medicine, etc). Conclusions There continues to be a sizable gap in concordance between practice and guidelines in first-line rhythm management of patients with atrial fibrillation. Further research is needed to identify possible explanations for non-guideline-recommended use of AADs, in addition to enhanced AAD educational strategies for practitioners.

Practical Insight Into Anticoagulation for an Aging Population.

Anticoagulation is almost always required as a part of treatment for atrial fibrillation, but it is also one of the most potentially dangerous pharmacologic strategies. Recently, a number of guidance documents have been released with respect to anticoagulation. Some elements of the guidelines potentially create conflicting considerations for clinicians charged with selecting the safest and most effective anticoagulation protocol, especially for patients older than 75 years of age.