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Finding your way at a large national conference: tips and tricks

Attending a scientific conference can be daunting, especially for trainees. You’re still getting your sea legs so-to-speak with regard to your science, and on top of that, you may be presenting a poster or talk to an audience of the most distinguished researchers in your field. Many of us feel the same way, and it can be difficult to muster the courage to go up to someone and introduce yourself. But this is the perfect time to do it!

To really make the most out of your conference experience, especially at a large meeting like AHA Scientific Sessions, it is important to prepare ahead of time! Yes, you will need to book your flight and hotel and register for the conference itself, but you also need to consider how you’re getting to the airport or how you’re getting from the airport to your hotel. Do you know if there is a special lot for rideshare pickups or are you getting a shuttle? Does your hotel offer early check-in? These are all important questions, and at least in my experience, are often overlooked. Plan ahead for the little details, so your brain can be as stress-free as possible on the day of your travel.

Next, to the conference itself. Plan which sessions that you want to go to, but don’t overbook yourself. Scientific conferences often have some downtime, but perhaps you want to get a little exercise while you’re away or if you plan to get a late dinner with colleagues, you might want to skip the early-morning session. Find out what works best for you, so that you can focus on the science and network without feeling completely drained.

Planning which sessions you want to attend can be extremely important for poster presentations. Often, there are so many posters that you won’t have time to wander up and down the entire exhibit hall perusing at your leisure. Search the program using keywords and make a list of a handful of posters you’d like to see. Or if you have a colleague presenting a poster, do them a favor a pay a visit. If they have legions of people trying to get a glimpse of their work, then move on, but if they’re waiting and nobody is talking with them, go up and talk. It can be extremely isolating to stand next to a poster waiting anxiously for someone to come by and show interest.

One great way to get to know more people in any scientific society is to get involved. If you’re a trainee, there is usually some standard way that you can volunteer to join a committee. In AHA, you can apply to be an early career blogger! This is a surefire way to meet people. This serves many purposes. It helps the society in various ways. It also helps your CV. Finally, you are forced to meet and interact with people, many of whom may be in leadership roles. Knowing people at the conference you’re attending is a great way to boost the number of people that come to your poster or presentation and generally improves your conference experience.

My last tip is to have fun. If you use your time wisely, you can come away from a conference with a head full of new ideas in addition to some new friends.

 

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AHA FITs at Scientific Sessions 2019

It is hard to believe that a year has passed between my first blog for the Early Career Voice and now! That first blog was a dispatch from Sessions 2018 and covered the redesign of the Sessions programming for fellows-in-training (FIT) and early career (EC) members. Because of the success of last year’s iteration, the AHA FIT Steering Committee entrusted the FIT Planning Subcommittee with creating a bigger and better FIT/EC experience at Sessions 2019. After the first day of AHA 2019, I think we are on our way to fulfilling that charge.

Since last year, a few hundred additional FIT have joined the AHA FIT program and have benefited from the range of opportunities provided through AHA committees and councils. The FIT Planning Subcommittee also launched a quarterly membership newsletter that showcases our progress and initiatives over the past year.

Our goal for this year’s Sessions 2019 programming was to create a dynamic, diverse, and inclusive slate of sessions that incorporates the breadth of cardiovascular and neurovascular medicine and science. New this year are sessions in vascular neurology, pediatric cardiology, wellness and burnout, innovation and technology, cardiac critical care, cardiac electrophysiology, and the fellow-to-faculty transition. Even though we were gifted with a Lounge twice the size of last year’s, we aimed to maintain an intimate and casual atmosphere that would facilitate one-on-one interactions between FIT/ECs and our faculty.

Once again, the first day of programming exceeded our expectations. Saturday started with a session on careers in vascular neurology with Drs. Ashutosh Jadhav, Louise D. McCullough, and Brett Cucchiara. Drs, Mohamed B. Elshazly, Akl Fahed, Annabelle Volgman, and Seth Shay Martin joined us for an eye-opening session on exploring the intersections of entrepreneurship and clinical care. We revived one of last year’s favorite sessions – Matching into Cardiology Fellowship: The Inside Scoop from Program Directors & AHA FITs – with Drs. Omar Siddiqi, Pamela Mason, Eric Yang, and Julia Indik and heard from medical students, residents, and international medical graduates interested in careers in cardiovascular medicine. A highlight of the day was AHA President Dr. Robert Harrington’s visit to the FIT/EC Lounge in which he shared a preview of his Sunday presidential address and spoke about the importance of early career members to the AHA. Next, Drs. Erin Michos and Laxmi Mehta shared their personal and crowdsourced strategies for maintaining balance and wellness during training and practice. We focused our women in cardiology session around the issue of personal advocacy this year, and Drs. Harriette Van Spall, Biykem Bozkurt, Mary Cushman, and Monika Sanghavi gave powerful testimonies about their own experiences in self-advocacy both within and outside the workplace. We concluded the day with a high-yield session on developing careers in pediatric cardiology with Drs.  Kiona Allen, Bradley Marino, Joseph Rossano, Shelley Miyamoto, and Antonio Cabrera. FIT/EC Lounge programming continues into Sunday and Monday with 11 more hours of programming designed by FIT/ECs for FIT/ECs.

If you were unable to attend Sessions 2019, keep an eye out for our Sessions recap in our upcoming December 2019 AHA FIT Newsletter and follow the hashtags #AHAFIT and #AHAEarlyCareerBlogger on Twitter!

 

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It’s a small, small world…

It is probably fair to say that most of the #AHA19 attendees know that cardiovascular disease is the leading cause of death in their respective country. We’ve heard this fact repeatedly throughout our entire careers and its hard (but not impossible) to imagine this not being the case.

But we also know how much progress we have made in preventing and treating cardiovascular disease. Medications to reduce hypertension and hyperlipidemia are relatively inexpensive and available; there is widespread recognition of, and repeated UN commitments, to enhancing access to primary prevention strategies such as physical activity, better diet quality, and smoking cessation; and new evidence suggests that we can prevent heart attacks by medication alone in patients with some at-risk patients.

cvd realityYet, we may not always recognize that those at risk for cardiovascular disease in other parts of the world have challenges that don’t allow for equitable access to the benefits of this knowledge. Which is why I was delighted to see so many sessions on global cardiovascular disease at #AHA19. To kick off this programming, the World Heart Federation and the American Heart Association hosted a panel of Dr. Thomas Gaziano of Brigham and Women’s Hospital, Dr. Rita Kalyani of Johns Hopkins University School of Medicine, and Dr. Dorairaj Prabhakaran of the World Heart Federation. Together, they described the rapidly growing burden of cardiovascular disease; potential technological innovations for controlling cardiovascular risk factors in low and middle income countries; the increasing prevalence of shared risk factors with, and consequences of diabetes and cardiovascular diseases; and health system interventions to reduce cardiovascular morbidity. While this session highlighted challenges many low- and middle-income countries face in improving cardiovascular health including shortages of a trained healthcare workforce, inconsistent access to safe essential medicines, and more. It also provoked optimism because solutions are within our reach. Dr. Gaziano said that these strategies are “More about changing the mindset [of healthcare systems] to embrace chronic disease management rather than acute care or emergency needs only”.

Such a mindset was described by Dr. Craig Sable of Children’s National Medical Center during the T. Duckett Jones Memorial Lecture , who described the progress made in prevention, screening, and management of rheumatic heart disease around the globe. He concluded by saying that the end of rheumatic heart disease is within our reach, if we maintain the momentum of our recent gains.

I am impressed by the global cardiovascular programming at 2019 American Heart Association Scientific Sessions. And we still have two more days.

Some highlights include Sunday’s Bongai Mayosi Memorial Lecture on Disparities in Global Cardiovascular Disease, honoring a true legend in the field of global cardiology. Simultaneously, there will be an oral abstracts session on Implementation Science around Globe. The Presidential Keynote Address will be given by Murat Sönmez of the World Economic Forum… and so much more (search “world” in your AHA sessions planner).

Recognition of our shared commitment to be a relentless force for a world full of healthier lives is humbling.  It inspires a shared purpose for countless health care professionals-from community health workers to ministers of health in every nation throughout the globe.

So as you listen to members of the World Economic Forum and engage with scientists about their work on biomass fuel on cardiac function in Nepali women or women living with Rheumatic Heart Disease in Uganda please stop, take a deep breath, and think about how you will be a force for global good.

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Benefits of joining an early career investigator’s lab

In addition to learning about some fantastic science and research, one of the major benefits of attending American Heart Association’s Scientific Sessions (or any other national meeting) as a fellow-in-training is the networking opportunities. Trainees can take advantage of the opportunity to interact with principal investigators and/or members of labs that they may be interested in joining in the future.

While there are many benefits to joining an established lab, I strongly encourage trainees to consider meeting with and possibly consider joining a new/early career investigator’s lab. There are several benefits to joining an early career investigator’s lab.

I recently joined an early career investigator’s lab for my postdoctoral fellowship. I am a Cardiology physician-scientist trainee. I completed a Medical Scientist (MD/PhD) Program and then joined a Physician Scientist Training Program in Internal Medicine. I completed my Internal Medicine residency and then started my Cardiology fellowship. I spent a long time finding a lab to do my research postdoctoral fellowship. Fortunately, I had the opportunity to join Dr. Kurt Prins lab. Dr. Prins is a Cardiology physician-scientist who studies the mechanisms of right ventricular dysfunction in pulmonary hypertension and is an early career investigator.

Below are some of the benefits of joining an early career investigator’s lab:

  1. Mentorship: As my mentor’s first and only postdoctoral trainee so far, I have received a lot of individualized mentorship. His office door has always been open and I talk to him almost every day about science, career advice, and/or our personal lives. Due to Kurt’s approachability and availability, I feel that I may have been able to be more productive in the lab, partly due to the ease of working with him to troubleshoot experiments.
  2. Establishing the groundwork for many projects: In smaller labs, the lab members are often involved in multiple/all projects. It is exciting to be able to lay the groundwork for multiple projects that the lab may be involved in for years to come or may be the foundation of my lab in the future. Being involved in multiple projects may also lead to multiple publications.
  3. Learning how to start and set up a lab: I joined Kurt’s lab a year after he started his lab. Watching the process of starting and setting up a new lab is invaluable. As a trainee who is interested in starting her own lab in the future, being closely involved in writing/reviewing animal protocols, reviewing grant applications, and even organizing the freezer racks will help with tackling the inevitable steep learning curve of being an independent investigator. Sometimes in a more established lab, one may not receive the experience of learning all of the processes involved in setting up and running a lab.
  4. Mentor can empathize on the potential struggles of being an early stage investigator: Early career principal investigators can often empathize with trainees on the challenges of obtaining grant funding and publishing papers during the current research climate along with possible other scientific/personal challenges. Early stage investigator can provide trainees with relevant career advice that are applicable in today’s scientific environment.
  5. Doing experiments with principal investigator: At this time, my mentor spends a lot of time in the lab doing experiments alongside the other lab members, which makes the lab environment a lot of fun! Kurt and I have developed a lot of inside jokes between us because of the amount of time we spend together!

While there are many benefits to joining an early career investigator’s lab, there are also some potential difficulties that can easily be overcome. For further career development, it may also be valuable to have a senior mentor. As you have probably heard before, ultimately deciding which lab to join for your graduate or postdoctoral training is like finding a spouse – you have to find a good match. For those who are interested, there was an article published in Nature about the potential benefits of joining a new lab (1). For those of you who want to discuss more about potentially joining an early career investigator’s lab, please feel free to reach out to me. For those of you who joined an early career investigator’s lab, I would also be interested in hearing about your experiences.

 

References

  1. Woolston C. Why a new lab can be a valuable destination for postdocs and graduate students. Nature. 2018;558:333-335

 

 

 

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Vaping is a Public Health Problem. It’s Also an Equity Issue.

Image: Angus Maguire, via http://interactioninstitute.org/illustrating-equality-vs-equity/

Image: Angus Maguire, via http://interactioninstitute.org/illustrating-equality-vs-equity/

Vaping is a massive public health issue— and history shows us that public health issues often disproportionally affect vulnerable populations. While there has been some push-back from the vaping public about the scientific community’s alarm— focusing on the fact that the evidence of harm attributable to vaping isn’t yet fully developed— scientists and clinicians agree that the emerging pattern is deeply concerning, especially as it relates to children and adolescents. There are well-established theoretical and evidence-based reasons to associate vaping with cardiovascular disease and even death, but that’s beyond the scope of this discussion. What I will address is this: failing to address an imminent public health crisis early and aggressively can lead to real harm for vulnerable populations. Waiting for a preponderance of incontrovertible evidence before acting means that significant harm has already occurred. Intervening now is a chance to promote health equity.

We know there are disparities in tobacco use among populations. There is higher prevalence in the LGBT community, those living in poverty, those with mental health disorders, those with substance use disorders, and those living in South and Midwest , an those living in rural areas (CDC, 2015). Some evidence suggests that disparities in the use and promotion of other tobacco products and e-cigarettes mirror trends in cigarette use and marketing. In a session at #AHA19 today, Dr. Michael Blaha (@MichaelJBlaha on Twitter) noted that vaping specifically is more common among men, LGBTQ people, unemployed people, and people with less than a college education. We also know that data may hide some populations, especially homeless, incarcerated, marginalized, non-English-speaking people. So yes, this an equity issue. As we in the health community face the specter of vaping-related health crises, we must look at the impact through an equity lens.

As recently announced, the AHA is pledging $20 million to fund research on youth vaping. This is part of a program including a public information campaign (#QuitLying and #EndTheLies) and policy initiatives. Priority research areas, per the AHA’s statement, include nicotine’s impact on adolescent brain development, the impact of nicotine and other compounds in e-cigarettes on the cardiovascular system, how devices, flavors and other chemicals influence addiction, how to treat nicotine addition in youth, whether e-cigarettes are effective for smoking cessation, and what the impact of regulation is. As we scientists and clinicians proceed, we must design our research to address:

  • Racial, ethnic, gender, & socioeconomic factors
  • Comorbidities, including mental health disorders, substance use disorders, and disability
  • Whether proposed policy and information/communication solutions are effectively reaching those with the highest need

Some healthcare practitioners and researchers didn’t get the tools during their education to design equitable research and programs. If this is you, check out the resources below. Then, get your voice out— participate in research design and policy initiatives, communicate to the public and your professional community, and remember to put health equity at the top of the agenda.

Resources & References:

-Centers for Disease Control (2015). Best Practices for Health Equity in Tobacco Prevention and Control.  Available at: https://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-health-equity.pdf  (much of this information is applicable to vaping, as well as other public health concerns).

-MPH@GW: Milken Institute School of Public Health at the George Washington University. What’s the diffrence between equity and equality? Available at: https://publichealthonline.gwu.edu/blog/equity-vs-equality/

-Research presented at #AHA19 about vaping: https://newsroom.heart.org/news/e-cigarettes-take-serious-toll-on-heart-health-not-safer-than-traditional-cigarettes

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Being In The Room Where Science Happens

One of the most important functions of professional meetings, such as AHA Scientific Sessions presently here in Philadelphia, is the ability to bring together trail-blazers, leaders, senior distinguished folks, and put them in the same rooms as students, trainees, and early career professionals. These are the types of interactions that pollinate and spread knowledge, propel further discovery, promote and encourage generation after generation of scientists, doctors, healthcare professionals into carrying the torch further towards a healthier longer life for all.

It is of course of no surprise that the AHA Scientific Sessions meeting is one that attracts the participation of accomplished researchers to come and share their research insights, accumulated wisdom, and give a hint or two about what to do (or what to avoid, from first-hand knowledge perspective). In my personal career field, there are probably no names that come above Dr. Eric Olson in terms of status within the area of research. My former PhD supervisor holds Dr. Olson as a personal role model and mentor, and has mentioned his name countless times during my 5 years of training in his lab. In fact Eric Olson has been referred to in terms closer to a deity than just a scientist. While I’ve never met him, I knew all about him and a lot about his research, he’s the equivalent to a celebrity the likes of Will Smith or Julia Roberts, or at least that’s the best analogy I could make for this scenario.

Being here at AHA19 however has given me the chance to meet Dr. Olson finally, and just as I have heard countless times before, Eric is a humble and impressive scientist, approachable by anyone, since I just walked up to him without advance notice, introduced myself to him mere minutes from his scheduled lecture in the Science Catalyst Keynote session. His down to earth attitude and ability to engage with an unfamiliar early career scientist are reminders that the best, most distinguished researchers are not elitist, discriminating or unapproachable, but in fact are bridge-builders, promoters and seekers of knowledge, everywhere, and by and from everyone that has knowledge to share or seek out.

While Dr. Olson is an excellent example, he is by no means a unique case. Conferences and professional meetings, happening everywhere across the world, all provide chances like this one, where knowledge seekers and knowledge providers congregate in rooms to share, discuss and plan, so that most times everyone leaves these rooms more educated and enlightened, than when they first walked in. Here in Philadelphia this weekend, one of the mottos on everyone’s tongue, surely because we are provided a special performance from the hit play Hamilton is “Be in The Room,” which references the American nation building efforts done by the US constitution founders. Here I conclude by extending this motto into present day health and biomedical research, by saying to all, try if you can, and be in the rooms where science happens!

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What if? Making the most of your 72 hours at #AHA19

The two most powerful words in the English language are “What If.” These words have created new nations, led to the most memorable books, and landed humans on the moon. They have also inspired almost every scientific breakthrough throughout human history. What if we could isolate radio isotypes? What if we could ultrasound the heart? What if we could transplant heart valves? What if we could create a machine to function like a heart while awaiting transplant? Each breakthrough has led to thousands of additional, and unanticipated, “What If” questions that have formed the foundation of modern cardiology and saved millions of lives.

Dreaming up “What If” questions is the first step of innovation and science is the method of rigorously answering these questions in a reproducible way. At AHA Scientific Sessions (#AHA19) this year, scientific innovation will be on display in every corner of the Philadelphia Convention Center.

In many ways, the entire Health Tech and Innovation Summit is the result of “What If” questions. What if we use artificial intelligence to identify those at risk for heart attacks? What if my K award results in a new Blood Pressure device that can be commercialized? What if we can use our smart watches to detect Atrial Fibrillation? And after smart watches, sensors, medical records and artificial intelligence have been harnessed to their full potential, what nascent technology will next revolutionize cardiovascular health? To find the answers to these questions, and three days’ worth of cutting edge discoveries, please join us in the Health Innovation pavilion, Heart Hub, Science and Technology Hall, Level 2.

And to be truly inspired, please add the AHA competition for best artificial intelligence and machine learning to your itinerary. This year three incredible trailblazers, Dr. Suchi Saria from the Johns Hopkins Bloomberg School of Public Health, Dr. Ramaraju Rudraraju from the University of Alabama at Birmingham, and  Dr. Chun Yuan from the University of Washington, will compete for $10,000 prize sponsored to Amazon Web Service and Circulation: Genomic and Precision Medicine.

This year the World Economic Forum Collaborators will present sessions on big data and deep learning, blockchain in health care, and highlight the value in Healthcare Initiative for cardiovascular practice.

But not every innovation is new or digital. One of the most anticipated late-breaking science presentation is the results of the COLCOT study. The COLCOT study evaluated the impact of colchcine, an anti-inflammatory medication used for hundreds of years, on the recurrence of cardiovascular events in those who have recently experienced a heart attack. Results will be released Saturday morning at 10:45am.

What should you take away from Scientific Sessions this year? Yes, you will see, and hopefully experience, lots of cool and potentially life-changing innovations, develop lifelong networks, and walk a lot. And when you leave Philadelphia, you may be able to apply these innovation to your daily work. But, perhaps more importantly, I encourage you to take a step back and think about these innovations in the aggregate. Think about what prompted the “What If” questions that resulted in the presentations. Then think about your own “What if” questions.

As you attend Scientific Sessions this year, I hope you take away more than just (the important) knowledge about these innovations. I hope you take away the inspiration to ask your own “What If” questions. Let those questions change your practice or your daily work and inspire you to be a relentless force. And next year, or maybe in the next 10 years, bring your innovations back to Scientific Sessions and let them inspire others to dream bigger and see further.

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A Framework for Going to Professional Conferences & Meetings

During my graduate education years, my understanding and focus on attending conferences was almost exclusively centered on two priorities:

  1. Learning about the science happening in my area of interest, and the surrounding research that can complement and elevate my present projects.
  2. Being able to participate (via poster or a short talk) and deliver a useful and potentially distinguished presentation at the conference.

This is pretty much the default priority list for any grad student – not just in biomedical science, but this accurately applies to all academic fields. In fact I’d argue these are basically all that’s needed and required by students being exposed to academic conferences. Professional meeting events come with relatively steep learning curves when students are first experiencing them. Major conferences are (mostly, but not always) held in cities/towns that attendees don’t reside in, so the difficulty of housing, scheduling food, sleep and even clothing choices all come into play.

Unfamiliar surroundings and temporary changes in daily rhythms can lead to elevated stress levels; an effect called allostatic1 load, with measurable biological changes previously reported2, like elevated cortisol and Interlukin-1β levels measured from human salivary samples. Packed conferences potentially strain mental and emotional health, with the cognitive (over)loading that comes from the equivalent of attending a dozen classes (sessions) back-to-back, then doing it all over again the next day and so on, depending on how long the conference is.

These conference days are as demanding as can be, especially for the lesser experienced graduate students. Thankfully, none of what is mentioned here is presently unknown, denied, or ignored. These days enough writing3 exists, reporting all of these observations, sometimes in scientifically quantifiable4 and systematically assessed5 studies. Efforts towards counteracting these difficulties are now discussed, advised, and hopefully even the most ambitious and keen grad students are finding ways to mitigate and avoid negative experiences. Being a scientist in the cardiovascular field, I’ll emphasize two quick notes, extremely obvious, but worth highlighting whenever possible:

  1. Physical endurance is an undervalued factor in conference attendance, a lot of calories are getting burned moving from session to session, participating in posters/presentations, meeting people and asking questions – so it’s vital to learn, mind and strategize your conference attendance to best fit your physical endurance status
  2. What you eat matters (always!) and will affect every aspect of your time at the conference (too much/not enough coffee, too much/too little food intake during the conference, healthy vs. unhealthy available options), so again mind and strategize the food/drink variables as part of the overall conference equation.

With repetition and understanding of the general framework of conference proceedings, many of the initial difficulties and trip-ups become learned experiences, allowing attendees to become more comfortable and capable navigators of these unusual few days. This could and does happen sometimes in later grad-school years (senior PhD students, for example), but I’ll focus on the category of attendees that I myself now have become part of the early career professionals and AHA Early Career Blogger. Being in my third year of a postdoctoral fellowship in biomedical research, I’ve been to enough conferences to have a sense of the invisible “skeleton” of conferences. I can identify where the differences between various conferences exist, and where the similarities lie. I’ve learned to gauge how to pack for conferences (if at all possible, avoid checking in luggage! Pack clothing that best represents your professional ambitions. Comfortable shoes are a life saver!), how to navigate the sessions, what to eat and what to avoid. Of course there is no set formula to any of this, trial and error is the most used approach, and sharing experiences can be beneficial (at least that’s my hope in writing this piece!).

I’ll also highlight that for early career professionals, additional priorities/requirements emerge to be added to the original grad-school stage list of goals (namely: learning new information in the field, and fulfilling the level of participation duties offered when registering for the event, like poster or slide presentations). These new aspects are:

  • Networking, which I’ll define here as establishing professional lines of communication that can be of benefit in building, and maintaining relationships with others to advance professional goals. This is a valuable advanced priority in conference attendance, but I do want to emphasize that it shouldn’t be a requirement within the early stages of conference participation, since at the beginning, conferences can be overwhelming without the additional stress of having to do expert-level professional socializing!
  • The newest emerging priority I’ve added to my conference attendance efforts is discovering new elements, sufficiently outside the main field you’re involved in, that can enhance and elevate work/career forward. What I mean by that, being a biomedical research scientist, is seeking sessions in the program that address topics not directly related to: Heart Failure, genomic stability, inflammation, and similar keywords that relate to research my group and I work on. The new elements for me include things like: science communication, social media engagement, scientific advocacy, linking scientists to policy makers; and many other examples of topics that exist around health and scientific research but are not necessarily done in a lab or hospital setting.

Conferences, professional meetings, symposiums, and all types of organized events that occur within professional settings are designed to deliver a large impact to the attendees in a short period of time. Maximizing an individual’s professional development from these settings is key, understanding how to do so requires planning, optimization and gained experience from multiple trials. As with everything else in life, it takes one step at a time.

 

References:

  1. McEwen, Bruce S., and Ilia N. Karatsoreos. “Sleep deprivation and circadian disruption: stress, allostasis, and allostatic load.” Sleep medicine clinics1 (2015): 1-10.
  2. Auer, Brandon J., et al. “Communication and social interaction anxiety enhance interleukin-1 beta and cortisol reactivity during high-stakes public speaking.” Psychoneuroendocrinology94 (2018): 83-90.
  3. Elfering, Achim, and Simone Grebner. “Getting used to academic public speaking: Global self-esteem predicts habituation in blood pressure response to repeated thesis presentations.” Applied psychophysiology and biofeedback2 (2012): 109-120.
  4. Lü, Wei, et al. “Extraversion and cardiovascular responses to recurrent social stress: effect of stress intensity.” International Journal of Psychophysiology131 (2018): 144-151.
  5. Ebrahimi, Omid Vakili, et al. “Psychological interventions for the Fear of Public Speaking: a Meta-analysis.” Frontiers in Psychology10 (2019): 488.

 

Acknowledgement:

Extended gratitude goes to the University of Ottawa Heart Institute Librarian: Sarah Visintini, MLIS for assistance in compiling primary material sources in this article. Twitter @SVisin

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Hypertension and Stroke: Current State of Evidence

Stroke is the fifth leading cause of death in the country and the top reason for adult disability (1). Each year about 795,000 people experience a stroke in the United States with nearly 25% of these strokes being recurrent events in people with a prior history of a stroke (2).  Hypertension is the considered to be the most important modifiable risk factor for stroke. Therefore, treatment of hypertension is one of the most effective strategies for primary and secondary prevention of stroke (3). In a large meta-analysis from 2002, which included 1 million patients, a direct association was seen between blood pressure measurements and risk of vascular mortality including stroke and ischemic heart disease (4). There is a continuous relationship with risk throughout the normal range of blood pressure, down at least as far as 115/75 mm Hg according to this meta-analysis of 61 prospective clinical studies. However, there has been a lack of consensus among experts about the most appropriate blood pressure targets for cardiovascular disease and stroke prevention.

In the Secondary Prevention of Small Subcortical Strokes (SPS-3) trial, investigators compared systolic blood pressure targets of 130-149 mm Hg and less than 130 mm Hg (5). About 3000 patients with a recent history of an MRI confirmed lacunar stroke were randomized to one of the two treatment groups and followed for a mean of 3.7 years. Primary outcome of recurrent stroke was seen at a lower rate in the lower target group with an annualized stroke rate of 2.25% as compared to 2.77% in the higher target group. Despite a signal toward benefit of a lower BP target, these results did not reach statistical significance. The rates of intracerebral hemorrhage were noted to be significantly lower with a lower BP target.

In a clinical trial enrolling patients with diabetes and a high cardiovascular risk, blood pressure target of less than 120 mm Hg was not superior to a target of less than 140 mm Hg for reducing risk of cardiovascular events with the exception of stroke (6). In this study, the intensive blood pressure target lead to a significant risk reduction for stroke but not for myocardial infarction or all-cause mortality.

To further ascertain an ideal blood pressure target, investigators in the SPRINT trial enrolled over 9000 persons with SBP of more than 129 mm Hg without a history of diabetes (7). The participants were randomized to intensive treatment (target <120 mm Hg) or standard treatment groups (target <140 mm Hg). Primary outcome was a composite of myocardial infarction, heart failure, stroke or vascular death. After a median follow up of 3.3 years, the trial was stopped early due to a significantly lower rate of primary composite outcome in the intensive blood pressure group as compared to the standard treatment. Interestingly, even though there was a signal of benefit for stroke risk reduction, this was not statistically significant. The investigators of the study make note of this finding and hypothesize that this could be due to the fact that this trial excluded patients with a prior history of stroke and TIA. This has also raised questions about the limited applicability of these results to patients with a history of stroke.

The investigators also looked at cognitive outcomes for the two groups of patients in this trial (8). The composite outcome of mild cognitive impairment and dementia was seen in a significantly lower number of patients in the intensive BP treatment group as compared to the standard treatment group. Due to the early termination of SPRINT, the study was underpowered to show a significant difference in the risk of dementia.

The current guidelines (9) from the American Heart Association/ American College of Cardiology recommend initiating treatment at SBP>130 mm Hg for patients with a high cardiovascular risk. Using the current definition of hypertension, it is estimated that 46% of adults in the US have hypertension and about 36% should be prescribed antihypertensive medications (10). Applying these new guidelines, only about half of all US adults on medications for hypertension are currently below the target BP numbers.

With hypertension playing such an important role in the development of the two most common neurological illnesses (Stroke and cognitive disorders), authors of a recent paper in JAMA Neurology (11) urge neurologists to play a greater role in treatment of hypertension as a preventive strategy for their patients. Traditionally stroke neurologists and neurointensivists have been involved in treatment of the cardiovascular risk factors including hypertension but most of that is done after the patient has had a major event such as an ischemic stroke or intracerebral hemorrhage. The authors argue that neurologists should participate in treatment of hypertension for their patients as a primary preventive strategy as it would lead to an overall improved brain health of our ageing population.

To learn more about the latest advancements in the field of hypertension research, I encourage the readers to attend Hypertension 2019 Scientific Sessions being held in New Orleans September 5-8, 2019.

 

References:

  1. Vital Signs: Recent trends in stroke death rates – United States, 2000-2015. MMWR 2017;66.
  2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135:e229-e445.
  3. Katsanos AH, Filippatou A, Manios E, et al. Blood pressure reduction and secondary stroke prevention: a systematic review and metaregression analysis of randomized clinical trials. Hypertension. 2017;69(1):171-179.
  4. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R; Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies Lancet. 2002;360(9349):1903-1913.
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Telemedicine May Play A Role In Rural And Urban Community Engagement

Telemedicine may be the original term for remote patient care management using telecommunications beyond a phone call, but telehealth is also used. While the two terms are often used interchangeably, one could propose that telehealth could encompass more of a wellness approach that is proactive than the typical reactive nature of medicine. Traditionally, we have focused predominantly on management of disease. Yet, it may be more prudent and cost-effective to focus even more so on health, wellness, and prevention of disease. Nevertheless, for the purpose of this article, the term telemedicine will be used.

Many institutions are now pursuing telemedicine, or are planning to do so in the near future. Of course, several hospitals and medical systems are appropriately concerned about reimbursement. Reimbursement currently associates with more rural communities. However, there is also a role for telemedicine in less rural neighborhoods. If we are to ubiquitously implement telemedicine equitably, we may need to remove those boundaries of rural versus not, in telemedicine allocation decision-making. We need to be great stewards of our healthcare resources, and we need to determine where to best direct our efforts. Rural communities may benefit most from telemedicine, but other communities can as well. Perhaps in the most urban communities, telemedicine might be needed much more than anticipated. It is often in urban communities that we find limited community engagement with nearby health centers. Would the level of community engagement with health care centers in urban communities improve if telemedicine were more available in these areas? Availability and feasibility would depend on the source of provision and financing of the tools needed for telemedicine. These tools would include at a minimum internet access, computers or smart phones, physiology monitoring and diagnostic equipment, and free or costly apps. It should be recognized that telemedicine itself alone cannot effect community engagement. In fact, community engagement itself would be needed for adoption of telemedicine throughout the community. It might seem like a circular argument, because it is.

We often attempt to practice medicine or innovate in silos. Yet, it is when we remove the boundaries between the silos or blur the lines between neighborhoods and cross-pollinate that we can find nonlinear progress. Synergy can be found in the overlap of various kinds of disruptive innovation. Synergy can also be found in the overlap between the perspectives of community dwellers and healthcare professionals and innovators. Healthcare research and practice is now moving towards greater incorporation of the patient voice, choice, desires, values, and goals, not as bystanders, but as drivers. Not only should we take this approach at the level of the individual patient, but at the level of the population or community. Thus, community engagement is needed for adoption of telemedicine, and telemedicine itself perhaps may help to further catalyze community engagement. It therefore appears that telemedicine is not only about providing care for the individual patient in their home, whether due to patient location or mobility or simply patient preference. It would seem that telemedicine is also about providing care for the population and a community and enhancing relationships among community dwellers and their healthcare providers. This would potentially apply to rural, urban, and also global communities and populations.

It may also be more cost-effective to pursue telemedicine for patients in both rural and urban areas locally, regionally, nationally, and globally, before our patients in urban and rural communities become unwell and need to be hospitalized. Overall, medicine is very slowly moving towards prevention. Telemedicine could facilitate disease prevention in urban, rural, and global populations, as well as joint management of the most remote locally hospitalized patients before their inpatient status worsens. This could limit morbidity and mortality and decrease health care costs in the long run.