An Insight Into Pathophysiology, Epidemiology, and Management of Cardiovascular Complications of SARS-CoV-2 Infection, Post-acute COVID Syndrome, and COVID Vaccine.

Coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic health emergency in March 2020. Elderly patients and those with pre-existing medical conditions including cardiovascular disease are at increased risk of developing severe disease. Not only is the viral infection with SARS-CoV-2 associated with higher mortality in patients with underlying cardiovascular disease, but development of cardiovascular complications is also common in patients with COVID-19. Even after recovery from the acute illness, post-acute COVID syndrome with cardiopulmonary manifestations can occur in some patients. Additionally, there are rare but increasingly recognized adverse events, including cardiovascular side effects, reported with currently available COVID-19 vaccines. In this review, we discuss the most common cardiovascular complications of SARS-CoV-2 and COVID-19 vaccines, cardiopulmonary manifestations of post-acute COVID syndrome and the current evidence-based guidance on the management of such complications.

Which hospital-acquired conditions matter the most in trauma? An evidence-based approach for prioritizing trauma program improvement.

BACKGROUND: Prevention of hospital-acquired conditions (HACs) is a focus of trauma center quality improvement. The relative contributions of various HACs to postinjury hospital outcomes are unclear. We sought to quantify and compare the impacts of six HACs on early clinical outcomes and resource utilization in hospitalized trauma patients. METHODS: Adult patients from the 2013 to 2016 American College of Surgeons Trauma Quality Improvement Program Participant Use Data Files who required 5 days or longer of hospitalization and had an Injury Severity Score of 9 or greater were included. Multiple imputation with chained equations was used for observations with missing data. The frequencies of six HACs and five adverse outcomes were determined. Multivariable Poisson regression with log link and robust error variance was used to produce relative risk estimates, adjusting for patient-, hospital-, and injury-related factors. Risk-adjusted population attributable fractions estimates were derived for each HAC-outcome pair, with the adjusted population attributable fraction estimate for a given HAC-outcome pair representing the estimated percentage decrease in adverse outcome that would be expected if exposure to the HAC had been prevented. RESULTS: A total of 529,856 patients requiring 5 days or longer of hospitalization were included. The incidences of HACs were as follows: pneumonia, 5.2%; urinary tract infection, 3.4%; venous thromboembolism, 3.3%; surgical site infection, 1.3%; pressure ulcer, 1.3%; and central line-associated blood stream infection, 0.2%. Pneumonia demonstrated the strongest association with in-hospital outcomes and resource utilization. Prevention of pneumonia in our cohort would have resulted in estimated reductions of the following: 22.1% for end organ dysfunction, 7.8% for mortality, 8.7% for prolonged hospitalization, 7.1% for prolonged intensive care unit stay, and 6.8% for need for mechanical ventilation. The impact of other HACs was comparatively small. CONCLUSION: We describe a method for comparing the contributions of HACs to outcomes of hospitalized trauma patients. Our findings suggest that trauma program improvement efforts should prioritize pneumonia prevention. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Teleneurology Comprehensive Inpatient Consultations Expedite Access to Care and Decreases Hospital Length of Stay.

BACKGROUND AND PURPOSE: While the successful provision of telestroke care has been well documented in the literature, studies on the impact of comprehensive teleneurology service (TN) to hospital measures are lacking. We evaluated 3 traditional health services metrics of hospital performance: time from consult request to consult completion, inpatient length of stay (LOS), and the rate of patients transferred for tertiary care. METHODS: Medical records (n = 899) from 3 community hospitals and our TN consultation database were retrospectively reviewed during the 2 years before (n = 703, 3 hospitals) and 4 months (n = 2 hospitals) to 2 years (n = 1 hospital) after implementation (n = 196) of a TN program for routine and urgent consult requests. Consult order time, consult completion time, total length of stay and discharge disposition were compared across the pre-TN implementation group, which consisted of in-person consultations and the post-TN implementation group, which consisted of TN consultations only. RESULTS: After TN implementation, median length of stay decreased 28% (3.9 vs. 2.8 days, p < 0.0001) and median time from consult order to consult completion decreased by 74% across all diagnoses (5.8 vs. 1.5 hours, p < 0.0001). There were no significant differences in the percentage of patients discharged home (52.3% vs. 56.1%, p = 0.10) or transferred to tertiary care (6.1% to 9.2%, p = 0.10). CONCLUSIONS: Implementation of TN program was associated with significant reductions in LOS and time to consultation completion without an increase in shunting of patients to more advanced facilities. Further research is warranted to confirm these findings in independent cohorts and other models of teleneurology delivery.

Leading with Love: Five Practical Tips.

We believe, as Donabedian taught us, that "the secret of quality is love." It is possible to lead with love and discover abundance among teams who feel safe, cared for, and aligned toward common purpose and their own professional growth. We offer five practical tips for leaders' consideration: (1) focus on the people; (2) develop a culture of professional diastole; (3) foster relational trust by reducing the vulnerability of others; (4) make sure the right people are in the right seats on the bus; and (5) administer policies with kindness and common sense. The return on this investment is non-linear and difficult to tally on a spreadsheet, yet it delivers the results that matter most. In the end, we are human, and this is human work. What better time than now to make love the center of what we do.

Teleneurology-Enabled Determination of Death by Neurologic Criteria After Cardiac Arrest or Severe Neurologic Injury.

OBJECTIVE: To determine whether providing teleneurology (TN) consultations aiding in determination of death by neurologic criteria (DNC) to a bedside intensivist is feasible and whether timely access and expert input increase the quality of the DNC examination and identification of potential organ donors, we reviewed retrospective data related to outcomes of such consultations. METHODS: Between November 2017 and March 2019, TN consults were requested for sequential comatose patients in the intensive care unit (ICU). We recorded patients' demographic information, causes leading to coma or suspected DNC, and the results of TN consultations. We obtained data on the number of referrals to the organ bank and number of organ donors. RESULTS: Ninety-nine consults were performed with a median time from request to start of the consult of 20.2 minutes (interquartile range 5.4-65.3 minutes). Eighty consults were requested for determination of prognosis, whereas 19 consults were requested for supervision of the DNC examination. In 1 of 80 (1.2%) prognostication consults, the patient was determined by the neurologist to require assessment of DNC and was found to meet DNC criteria; determination of DNC occurred in 11 of the 19 (57.9%) consultations for a supervised DNC examination. In a comparison of the pre-TN (94 months) and post-TN (17 months) periods, there was 2.56-fold increase in the proportion of patients meeting DNC criteria who were medically suitable for donation (pre-TN 8.9% vs post-TN 21.1%, p = 0.02) and a 2.12-fold increase in the proportion of donors (pre-TN 6.14% vs post-TN 13.1%, p = 0.14). CONCLUSIONS: It is feasible to perform TN consultations for patients with severe neurologic damage and to allow expert supervision for DNC examination. Having a teleneurologist as part of the ICU assessment team helped differentiate severe neurologic deficits from DNC and was associated with increase in organ donation.

Quality of care in integrated community case management services in Bugoye, Uganda: a retrospective observational study.

BACKGROUND: Village health workers (VHWs) in five villages in Bugoye subcounty (Kasese District, Uganda) provide integrated community case management (iCCM) services, in which VHWs evaluate and treat malaria, pneumonia, and diarrhoea in children under 5 years of age. VHWs use a "Sick Child Job Aid" that guides them through the evaluation and treatment of these illnesses. A retrospective observational study was conducted to measure the quality of iCCM care provided by 23 VHWs in 5 villages in Bugoye subcounty over a 2-year period. METHODS: Patient characteristics and clinical services were summarized using existing aggregate programme data. Lot quality assurance sampling of individual patient records was used to estimate adherence to the iCCM algorithm, VHW-level quality (based on adherence to the iCCM protocol), and change over time in quality of care (using generalized estimating equations regression modelling). RESULTS: For each of 23 VHWs, 25 patient visits were randomly selected from a 2-year period after iCCM care initiation. In these visits, 97% (150) of patients with diarrhoea were treated with oral rehydration and zinc, 95% (216) of patients with pneumonia were treated with amoxicillin, and 94% (240) of patients with malaria were treated with artemisinin-based combination therapy or rectal artesunate. However, only 44% (44) of patients with a negative rapid test for malaria were appropriately referred to a health facility. Overall, 75% (434) of patients received all the correct evaluation and management steps. Only 9 (39%) of the 23 VHWs met the pre-determined LQAS threshold for high-quality care over the 2-year observation period. Quality of care increased significantly in the first 6 months after initiation of iCCM services (p = 0.003), and then plateaued during months 7-24. CONCLUSIONS: Quality of care was high for uncomplicated malaria, pneumonia and diarrhoea. Overall quality of care was lower, in part because VHWs often did not follow the guidelines to refer patients with fever who tested negative for malaria. Quality of care appears to improve in the initial months after iCCM implementation, as VHWs gain initial experience in iCCM care.

Chondrogenesis of Embryonic Stem Cell-Derived Mesenchymal Stem Cells Induced by TGFß1 and BMP7 Through Increased TGFß Receptor Expression and Endogenous TGFß1 Production.

For decades stem cells have proven to be invaluable to the study of tissue development. More recently, mesenchymal stem cells (MSCs) derived from embryonic stem cells (ESCs) (ESC-MSCs) have emerged as a cell source with great potential for the future of biomedical research due to their enhanced proliferative capability compared to adult tissue-derived MSCs and effectiveness of musculoskeletal lineage-specific cell differentiation compared to ESCs. We have previously compared the properties and differentiation potential of ESC-MSCs to bone marrow-derived MSCs. In this study, we evaluated the potential of TGFß1 and BMP7 to induce chondrogenic differentiation of ESC-MSCs compared to that of TGFß1 alone and further investigated the cellular phenotype and intracellular signaling in response to these induction conditions. Our results showed that the expression of cartilage-associated markers in ESC-MSCs induced by the TGFß1 and BMP7 combination was increased compared to induction with TGFß1 alone. The TGFß1 and BMP7 combination upregulated the expression of TGFß receptor and the production of endogenous TGFßs compared to TGFß1 induction. The growth factor combination also increasingly activated both of the TGF and BMP signaling pathways, and inhibition of the signaling pathways led to reduced chondrogenesis of ESC-MSCs. Our findings suggest that by adding BMP7 to TGFß1-supplemented induction medium, ESC-MSC chondrogenesis is upregulated through increased production of endogenous TGFß and activities of TGFß and BMP signaling. J. Cell. Biochem. 118: 172-181, 2017. © 2016 Wiley Periodicals, Inc.

Ambulatory training for primary care general internists: innovation with the affordable care act in mind.

BACKGROUND: Although primary care general internists (PCGIs) are essential to the physician workforce and the success of the Affordable Care Act, they are becoming an endangered species. OBJECTIVE: We describe an expanded program to educate PCGIs to meet the needs of a reformed health care system and detail the competencies PCGIs will need for their roles in team-based care. INTERVENTION: We recommended 5 initiatives to stabilize and expand the PCGI workforce: (1) caring for a defined patient population, (2) leading and serving as members of multidisciplinary health care teams, (3) participating in a medical neighborhood, (4) improving capacity for serving complex patients in group practices and accountable care organizations, and (5) finding an academic role for PCGIs, including clinical, population health, and health services research. A revamped approach to PCGI education based in teaching health centers formed by community health center and academic medical center partnerships would facilitate these curricular innovations. ANTICIPATED OUTCOMES: New approaches to primary care education would include multispecialty group practices facilitated by electronic consultation and clinical decision-support systems provided by the academic medical center partner. Multiprofessional and multidisciplinary education would prepare PCGI trainees with relevant skills for 21st century practice. The centers would also serve as sites for state and federal Medicaid graduate medical education (GME) expansion funding, making this funding more accountable to national health workforce priorities. CONCLUSIONS: The proposed innovative approach to PCGI training would provide an innovative educational environment, enhance general internist recruitment, provide team-based care for underserved patients, and ensure accountability of GME funds.

Modern cholera in the Americas: an opportunistic societal infection.

In the Americas, the only two cholera epidemics of the past century have occurred in the past 25 years. Lessons from the 1991 Peruvian cholera epidemic can help to focus and refine the response to the current Haitian epidemic. After three years of acute epidemic response, we have an opportunity to refocus on the chronic conditions that make societies vulnerable to cholera. More importantly, even as international attention wanes in the aftermath of the earthquake and acute epidemic, we are faced with a need for continued and coordinated investment in improving Haiti's structural defenses against cholera, in particular access to improved water and sanitation.

A model for 'reverse innovation' in health care.

'Reverse innovation,' a principle well established in the business world, describes the flow of ideas from emerging to more developed economies. There is strong and growing interest in applying this concept to health care, yet there is currently no framework for describing the stages of reverse innovation or identifying opportunities to accelerate the development process. This paper combines the business concept of reverse innovation with diffusion of innovation theory to propose a model for reverse innovation as a way to innovate in health care. Our model includes the following steps: (1) identifying a problem common to lower- and higher-income countries; (2) innovation and spread in the low-income country (LIC); (3) crossover to the higher-income country (HIC); and (4) innovation and spread in the HIC. The crucial populations in this pathway, drawing from diffusion of innovation theory, are LIC innovators, LIC early adopters, and HIC innovators. We illustrate the model with three examples of current reverse innovations. We then propose four sets of specific actions that forward-looking policymakers, entrepreneurs, health system leaders, and researchers may take to accelerate the movement of promising solutions through the reverse innovation pipeline: (1) identify high-priority problems shared by HICs and LICs; (2) create slack for change, especially for LIC innovators, LIC early adopters, and HIC innovators; (3) create spannable social distances between LIC early adopters and HIC innovators; and (4) measure reverse innovation activity globally.

A United Nations General Assembly Special Session for mental, neurological, and substance use disorders: the time has come.

Mental, neurological, and substance use (MNS) disorders are leading causes of the global burden of disease and profoundly impact the social and economic well-being of individuals and communities. The majority of people affected by MNS disorders globally do not have access to evidence-based interventions and many experience discrimination and abuses of their human rights. A United Nations General Assembly Special Session (UNGASS) is needed to focus global attention on MNS disorders as a core development issue requiring commitments to improve access to care, promote human rights, and strengthen the evidence on effective prevention and treatment.

Bridging the global health training gap: Design and evaluation of a new clinical global health course at Harvard Medical School.

BACKGROUND: Medical student and resident interest in global health has been growing rapidly. Meanwhile, educational opportunities for trainees remain limited, and many trainees participate in global health experiences abroad without adequate preparation. Medical institutions are attempting to respond to this training gap by developing global health curricula. AIMS: We describe a novel clinical skills-based curriculum recently established among Harvard medical students and residents with the primary objective of providing essential clinical knowledge and skills to work effectively in resource-limited settings. METHODS: The course consisted of 10 evening sessions taught by a multidisciplinary faculty and focusing on practical management of the leading causes of the global burden of disease. Didactic discussions were reinforced by case studies and practical skills sessions, such as tropical microscopy, basic bedside ultrasound, simple dental extraction, and newborn resuscitation. RESULTS: Student mean knowledge scores increased significantly, from 64.5% (SD 8.9) before the course to 79.5% (SD 8.6) after the course (p < 0.001). Students also gave strongly positive evaluations and particularly valued the course's practical skills-building and the horizontal and vertical mentorship that developed among the diverse student, resident, and faculty participants. CONCLUSIONS: This clinical course in global health may serve as one model for more effectively preparing trainees to work in developing countries.

Global Health Fellowships: A National, Cross-Disciplinary Survey of US Training Opportunities.

INTRODUCTION: Medical trainee interest and participation in global health programs have been growing at unprecedented rates, and the response has been increasing opportunities for medical students and residents. However, at the fellowship level, the number and types of global health training opportunities across specialties have not previously been characterized. METHODS: A cross-sectional survey was conducted between November and December 2010 among all identified global health fellowship programs in the United States. Programs were identified through review of academic and institutional websites, peer-reviewed literature, web-based search engines, and epidemiologic snowball sampling. Identified global health fellowship programs were invited through e-mail invitation and follow-up telephone calls to participate in the web-based survey questionnaire. RESULTS: The survey identified 80 global health fellowship programs: 31 in emergency medicine, 14 in family medicine, 11 in internal medicine, 10 in pediatrics, 8 interdisciplinary programs, 3 in surgery, and 3 in women's health. Of these, 46 of the programs (57.5%) responded to the survey. Fellowship programs were most commonly between 19 and 24 months in duration and were nearly equally divided among 2 models: (1) fellowship integrated into residency, and (2) fellowship following completion of residency. Respondents also provided information on selection criteria for fellows, fellowship training activities, and graduates' career choices. Nearly half of fellowship programs surveyed were recently established and had not graduated fellows at the time of the study. CONCLUSION: Institutions across the nation have established a significant, diverse collection of global health fellowship opportunities. A public online database (www.globalhealthfellowships.org), developed from the results of this study, will serve as an ongoing resource on global health fellowships and best practices.

An analysis of Liberia's 2007 national health policy: lessons for health systems strengthening and chronic disease care in poor, post-conflict countries.

BACKGROUND: Globally, chronic diseases are responsible for an enormous burden of deaths, disability, and economic loss, yet little is known about the optimal health sector response to chronic diseases in poor, post-conflict countries. Liberia's experience in strengthening health systems and health financing overall, and addressing HIV/AIDS and mental health in particular, provides a relevant case study for international stakeholders and policymakers in other poor, post-conflict countries seeking to understand and prioritize the global response to chronic diseases. METHODS: We conducted a historical review of Liberia's post-conflict policies and their impact on general economic and health indicators, as well as on health systems strengthening and chronic disease care and treatment. Key sources included primary documents from Liberia's Ministry of Health and Social Welfare, published and gray literature, and personal communications from key stakeholders engaged in Liberia's Health Sector Reform. In this case study, we examine the early reconstruction of Liberia's health care system from the end of conflict in 2003 to the present time, highlight challenges and lessons learned from this initial experience, and describe future directions for health systems strengthening and chronic disease care and treatment in Liberia. RESULTS: Six key lessons emerge from this analysis: (i) the 2007 National Health Policy's 'one size fits all' approach met aggregate planning targets but resulted in significant gaps and inefficiencies throughout the system; (ii) the innovative Health Sector Pool Fund proved to be an effective financing mechanism to recruit and align health actors with the 2007 National Health Policy; (iii) a substantial rural health delivery gap remains, but it could be bridged with a robust cadre of community health workers integrated into the primary health care system; (iv) effective strategies for HIV/AIDS care in other settings should be validated in Liberia and adapted for use in other chronic diseases; (v) mental health disorders are extremely prevalent in Liberia and should remain a top chronic disease priority; and (vi) better information systems and data management are needed at all levels of the health system. CONCLUSIONS: The way forward for chronic diseases in Liberia will require an increased emphasis on quality over quantity, better data management to inform rational health sector planning, corrective mechanisms to more efficiently align health infrastructure and personnel with existing needs, and innovative methods to improve long-term retention in care and bridge the rural health delivery gap.