Use of a Pulmonary Artery Pressure Sensor to Manage Patients With Left Ventricular Assist Devices.

BACKGROUND: Hemodynamic-guided management with a pulmonary artery pressure sensor (CardioMEMS) is effective in reducing heart failure hospitalization in patients with chronic heart failure. This study aims to determine the feasibility and clinical utility of the CardioMEMS heart failure system to manage patients supported with left ventricular assist devices (LVADs). METHODS: In this multicenter prospective study, we followed patients with HeartMate II (n=52) or HeartMate 3 (n=49) LVADs and with CardioMEMS PA Sensors and measured pulmonary artery pressure, 6-minute walk distance, quality of life (EQ-5D-5 L scores), and heart failure hospitalization rates through 6 months. Patients were stratified as responders (R) and nonresponders to reductions in pulmonary artery diastolic pressure (PAD). RESULTS: There were significant reductions in PAD from baseline to 6 months in R (21.5-16.5 mm Hg; P<0.001), compared with an increase in NR (18.0-20.3; P=0.002), and there was a significant increase in 6-minute walk distance among R (266 versus 322 meters; P=0.025) compared with no change in nonresponder. Patients who maintained PAD <20 compared with PAD ≥20 mm Hg for more than half the time throughout the study (averaging 15.6 versus 23.3 mm Hg) had a statistically significant lower rate of heart failure hospitalization (12.0% versus 38.9%; P=0.005). CONCLUSIONS: Patients with LVAD managed with CardioMEMS with a significant reduction in PAD at 6 months showed improvements in 6-minute walk distance. Maintaining PAD <20 mm Hg was associated with fewer heart failure hospitalizations. Hemodynamic-guided management of patients with LVAD with CardioMEMS is feasible and may result in functional and clinical benefits. Prospective evaluation of ambulatory hemodynamic management in patients with LVAD is warranted. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03247829.

The Impact of Angiotensin Receptor-Neprilysin Inhibitors on Arrhythmias in Patients with Heart Failure: A Systematic Review and Meta-analysis.

Angiotensin receptor-neprilysin inhibitor (ARNI) use has become increasingly popular. Current guidelines recommend using ARNI therapy for heart failure with reduced (HFrEF) and preserved ejection fraction (HFpEF). As therapies become more widely available, heart failure-associated burdens such as ventricular arrhythmias and sudden cardiac death (SCD) will become increasingly prevalent. We conducted a systematic review and meta-analysis to assess the impact of ARNI therapy on HFrEF and HFpEF pertaining to arrhythmogenesis and SCD. We performed a search of MEDLINE (PubMed), the Cochrane Library, and ClinicalTrials.gov for relevant studies. The odds ratios (ORs) of SCD, ventricular tachycardia (VT), ventricular fibrillation (VF), atrial fibrillation/flutter (AF), supraventricular tachycardia (SVT), and implantable cardioverter-defibrillator (ICD) shocks were calculated. A total of 10 studies, including 6 randomized controlled trials and 4 observational studies, were included in the analysis. A total of 18,548 patients from all studies were included, with 9,328 patients in the ARNI arm and 9,220 patients in the angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB) arm, with a median follow-up time of 15 months. There was a significant reduction in the composite outcomes of SCD and ventricular arrhythmias in patients treated with ARNIs compared to those treated with ACEIs/ARBs (OR, 0.71; 95% confidence interval, 0.54-0.93; P = .01; I2 = 17%; P = .29). ARNI therapy was also associated with a significant reduction in ICD shocks. There was no significant reduction in the VT, VF, AF, or SVT incidence rate in the ARNI group compared to the ACEI/ARB group. In conclusion, the use of ARNIs confers a reduction in composite outcomes of SCD and ventricular arrhythmias among patients with heart failure. These outcomes were mainly driven by SCD reduction in patients treated with ARNIs.

Resident Engagement in a Wellness Program in a Large Academic Residency: A Follow-Up After Two Years of Wellness.

INTRODUCTION: The rate of burnout among residents has reached an alarming level and negatively impacts learning, attrition, and patient care. We implemented a comprehensive Surgery Resident Wellness Program in a large academic program and aimed to assess the degree this initiative improved resident burnout based on validated burnout and well-being models utilizing voluntary surveys. MATERIALS AND METHODS: A voluntary survey was sent to surgical residents and included the Maslach Burnout Inventory and The Psychological General Well-Being Index. These were graded according to the respective validated scale for each test. The survey was administered prior to establishing a wellness program, and at 6 month- and 24 month-intervals following its establishment. These data were analyzed using univariate analysis based on survey data from each of the time points. RESULTS: The survey had a 51% response rate. The baseline, 6-month, and 24-month mean scores for MBI personal accomplishment were 32.80, 32.91, and 35.57, emotional exhaustion was 23.48, 23.0, and 24.42, and depersonalization were 10.94, 9.54, and 11.11. Resident burnout was present in 16 of 31 (51.61%), 14 of 33 (42.42%), and 12 of 27 (44.44%) residents at each time point. The rate of change in resident burnout was -17.8% at 6 months and -13.9% at 24 months. The averaged PGWBI global scores were 66, 73, and 83 among the participants who took the survey at each time interval. CONCLUSIONS: Conclusion Implementation of a structured wellness program was associated with a decrease in resident burnout and an increase in overall resident wellness.

The Relationship Between Surgeon Faculty Emotional Intelligence and Medical Student Evaluations.

OBJECTIVE: We sought to measure the emotional intelligence (EI) of surgical faculty and the relationship between faculty EI and medical student (MS) evaluations of faculty. DESIGN: Faculty completed the Emotional Intelligence Appraisal. Aggregate, anonymous MS evaluations were collected from the Program Director's office. Parametric and nonparametric tests were used for analysis. SETTING: This study was first performed in a single surgical division at 1 center which informed an expanded study including the entire General Surgery Department at a single academic institution. PARTICIPANTS: A pilot study was conducted in 1 surgical division which was then expanded to all clinical faculty in the Department of Surgery. All clinical faculty in the Department of Surgery were eligible for enrollment. RESULTS: Pilot study faculty EI scores were positively correlated with MS evaluations (r = 0.92, p < 0.001). The follow-up study enrolled 41 surgeons with a median age of 48 (inter-quartile range 12). The sample was mostly white (70.7%). Mean EI for the group was 76 (standard deviation ± 7.8). Total faculty EI scores were not significantly correlated with MS evaluations (r = 0.30, p = 0.06). CONCLUSIONS: MS evaluations of surgeon faculty were not related to EI in the larger sample. However, EI did correlate to MS evaluations in 2 surgical specialties. Further exploration into the utility of EI training in surgical departments should be conducted to determine the true value of such endeavors.

Faculty Emotional Intelligence Matters for Resident Education.

OBJECTIVE: This study aimed to determine the emotional intelligence (EI) of surgical faculty and evaluate its relationship with resident evaluations of faculty behaviors. DESIGN: This study retrospectively collected faculty EI scores as well as general surgery resident evaluations of faculty. Parametric and nonparametric tests were used for statistical analysis. SETTING: The study was conducted at the University of Texas Southwestern in the Department of Surgery in Dallas, Texas. This is an academic, tertiary care center. PARTICIPANTS: Surgical faculty members at a single institution in 2018 completed the Emotional Intelligence Appraisal, a 28-item, electronic assessment with possible scores ranging from zero to 100. Aggregate, anonymous resident evaluations of faculty members were collected from the program director's office. Faculty with fewer than 8 resident evaluations were excluded. RESULTS: In total, 59 faculty members participated (89%). The sample was mostly white (69.2%), male (63.5%), with an average of 47 ± 10 years of age, 12.2 ± 10 years in practice, and 44 ± 24 evaluations per faculty member. The group's mean EI score was 76 ± 7.7. Faculty EI scores were found to have a moderate, positive correlation with resident rotational evaluations of faculty (r(51) = 0.52, p < 0.001). Faculty EI scores did not significantly correlate with resident evaluations of faculty intraoperative behaviors. CONCLUSIONS: The results of this study suggest that a majority of our faculty are competent with regard to EI. Furthermore, faculty EI is an important factor in the clinical learning environment and correlates with resident rotational evaluations of teaching behaviors.

Comparing Measures to Assess Health-Related Quality of Life in Heart Failure With Preserved Ejection Fraction.

OBJECTIVES: This study sought to compare the performance of 2 health-related quality of life (HRQOL) questionnaires in patients with heart failure with preserved ejection fraction (HFpEF). BACKGROUND: The ability to accurately assess HRQOL over time is important in the care of patients with heart failure. The validity and reliability of HRQOL tools including the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Questionnaire (KCCQ) has not been fully determined or compared in patients with HFpEF. METHODS: Among patients with stable chronic HFpEF enrolled in the NEAT (Nitrate Effect on Activity Tolerance in Heart Failure) trial (n = 110), the study evaluated and compared reliability, validity, and responsiveness to change of the MLHFQ and KCCQ at baseline, 6 weeks, and 12 weeks. RESULTS: Internal consistency was good and comparable for MLHFQ and KCCQ domains measuring similar aspects of HRQOL at baseline including the MLHFQ physical (Cronbach's α = 0.93) compared with the KCCQ clinical summary (α = 0.91), and the MLHFQ emotional (α = 0.92) compared with the KCCQ quality of life (α = 0.87). Correlations with New York Heart Association functional class (Spearman rho; rs= -0.37 vs. 0.30) and 6-min walk test (6MWT) (rs = 0.38 vs. -0.23) at baseline were slightly stronger for the KCCQ overall summary score than for the MLHFQ total score. The MLHFQ was more responsive to change in 6MWT based on responsiveness statistics. CONCLUSIONS: These data suggest that both the MLHFQ and KCCQ are reliable and valid tools to assess HRQOL in HFpEF. The KCCQ was more strongly correlated with baseline functional status parameters, while the MLHFQ was more responsive to improvement in 6MWT.

Prinzmetal angina: An unrecognized cause of recurrent ST elevation myocardial infarction.

BACKGROUND: Prinzmetal's angina is characterized by a transient reduction in luminal diameter of a coronary artery resulting in spontaneous and often recurrent episodes of angina with electrocardiography (ECG) findings consistent with ST elevation. CASE REPORT: A 67-year-old male presented with complaint of intermittent chest discomfort during the previous 2-3 weeks. ECG obtained at presentation was consistent with ST elevation in inferior leads. The patient underwent urgent cardiac catheterization with uncomplicated balloon angioplasty to proximal and distal right coronary artery (RCA). At two-week follow up, the patient continued to complain of recurrent chest discomfort with repeat ECG showing ST elevation in inferior leads. He was given nitroglycerin with symptomatic improvement and gradual resolution of ST elevation. Given concern for reocclusion, the patient again underwent urgent cardiac catheterization showing subtotal occlusion of the proximal RCA. During the procedure, intracoronary nitroglycerin was administered with visible resolution of the occlusion via angiography consistent with coronary vasospasm. The patient was therefore initiated on therapy with amlodipine and isosorbide mononitrate and remained symptom free at subsequent follow-up visits. CONCLUSION: Prinzmetal's angina is a well-documented but under-recognized etiology of recurrent ST elevation myocardial infarction which should be considered in those with both typical and atypical cardiovascular risk profiles.

Insurance billing and coding.

The purpose of this article is to highlight the importance of understanding various numeric and alpha-numeric codes for accurately billing dental and medically related services to private pay or third-party insurance carriers. In the United States, common dental terminology (CDT) codes are most commonly used by dentists to submit claims, whereas current procedural terminology (CPT) and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD.9.CM) codes are more commonly used by physicians to bill for their services. The CPT and ICD.9.CM coding systems complement each other in that CPT codes provide the procedure and service information and ICD.9.CM codes provide the reason or rationale for a particular procedure or service. These codes are more commonly used for "medical necessity" determinations, and general dentists and specialists who routinely perform care, including trauma-related care, biopsies, and dental treatment as a result of or in anticipation of a cancer-related treatment, are likely to use these codes. Claim submissions for care provided can be completed electronically or by means of paper forms.