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To RESTART or Not to RESTART- That is The Question

During the European Stroke Organization conference, clinical trial results were presented, including investigation of treatments and outcomes of both ischemic and hemorrhagic stroke.

One of the most remarkable and surprising results were from the RESTART trial1 presented by Professor Rustam Al-Shahi Salman (Twitter @BleedingStroke) from the University of Edinburgh. This randomized open label trial was designed to answer the question whether antiplatelet medications can be safely restarted in patients who survive a recent intracerebral hemorrhage. The study participants were enrolled from 122 hospitals in the UK and included adults who had developed an intracerebral hemorrhage while on an antithrombotic medication for prevention of ischemic vascular disease.1 A total of 537 patients were randomly assigned to either restart or continue to avoid antiplatelet medication and followed for a median of 2 years for a primary outcome of recurrent symptomatic intracerebral hemorrhage.  In the group assigned to restarting antiplatelet medications, 12 of 268 subjects experienced recurrent intracerebral hemorrhage as compared to 23 of 268 in the group assigned to avoid antiplatelets (p=0.06).1 The rates of all major hemorrhage events in the two groups were similar: 7% in the treatment group and 9% in the avoiding group (p=0.27). There was no difference in the rates of occlusive vascular events which were seen at 15% in the treatment group and 14% in the avoiding group (p=0.92).1

Prior evidence suggests that aspirin is beneficial for secondary prevention of ischemic vascular events, notwithstanding a small increase in the risk of intracerebral hemorrhage2. RESTART is the first RCT studying the effects of restarting aspirin in patients with a prior history of ischemic vascular disease and a recent intracerebral hemorrhage. While not statistically significant, the results demonstrate a lower rate of recurrent hemorrhage if antiplatelet medications are resumed for prevention of occlusive vascular disease despite a recent intracerebral hemorrhage. The composite secondary outcome of non-fatal MI, non-fatal stroke or death from a vascular cause was seen at a significantly lower rate in the treatment group (p=0.025) as compared to the antiplatelet avoiding group.2

The reduced risk of recurrent hemorrhage risk is a surprising finding and needs further confirmation. The authors postulate that this can be potentially explained by shared mechanistic pathways between ischemic stroke and intracerebral hemorrhage.

The results from this trial provide reassurance that antiplatelet medications can be safely restarted for secondary ischemic event prophylaxis in patients with a recent intracerebral hemorrhage. There are ongoing clinical trials including RESTART-Fr3 and STAT ICH4 and the results from these would provide more insight into the effects of antiplatelet therapy resumption after an intracerebral hemorrhage.

 

References:

  1. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial. Lancet. 2019 May 21. RESTART Collaboration.
  2. Antithrombotic Trialists’ (ATT) Collaboration Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009; 373: 1849-1860. Baigent C, Blackwell L et al.
  3. https://clinicaltrials.gov/ct2/show/NCT02966119
  4. https://clinicaltrials.gov/ct2/show/NCT03186729
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Moving to a New Era of Clinical Trials

Frequently on rounds,  my colleagues argue that we should not do something to a patient since “there is no evidence that it works.”   This phenomenon of avoiding practice that has insufficient clinical trial evidence is often more common among young trainees in academic settings.    The practice of evidence-based medicine inherently involves integrating doctor’s experience, patient preferences and best available research. In an ideal world, every single question would have been tested in a clinical trial; but in reality this is not possible.   In fact, even the majority of recommendations in practice guidelines in cardiovascular disease are not supported by clinical trials.

Even for questions where there is a dire need for clinical trial evidence, such as adding new therapies to current standard of care or expanding or narrowing indications of existing therapies, multiple barriers remain.   Clinical trials are very expensive. In a recent analysis, the median cost of a clinical trial was estimated at 19 million U.S. dollars.   For pivotal cardiovascular disease trials, the numbers are much higher (north of 150 million USD) since those trials have to be larger and for longer duration to detect clinically meaningful outcomes (e.g. heart attack) and to also compare new interventions to current standards of care.   While cost is the biggest barrier, it is not the only one. Finding patients for trials has been a challenge that often leads to long periods of completion or even worse, aborting the trial due to inability to meet enrollment targets.  Even when patient enroll, they can easily lose interest and eventually dropout. Regulatory hurdles around accessing trial data add to the complexity. Even after successful trial completion, extensive inclusion and exclusion criteria_which often enable the trial to prove a positive outcome_ limit our ability to generalize the findings to many patients who do not fit those criteria.

A lot has changed in the world since we started doing randomized clinical trials in the mid 20th century, whether in science, health, technology, media, or even people’s behavior. Yet, we still do our trials the same.  It’s about time to move into a new era of clinical trials by thinking outside the box.  Smaller, smarter trials are possible. Analysis of big data from the real world could help drive hypotheses that we can test in clinical trials. For example in genomics a technique known as  Mendelian randomization uses genetic variation present as birth as a natural experiment to identify a causal relationship between an exposure and disease. Insights from big data could also help identify clusters of patients that are most likely to benefit from a treatment, have higher chance of having the outcome, or higher chance of having the side effect of the treatment, all of which could inform inclusion and exclusion criteria and increase the chance of having a smaller but more informative trial.

Another potential for innovating in design is by recruiting through direct-to-patient approaches. The Apple Heart Study recruited more than 400,000 people in a very short time and showed that this approach is possible. That should also be a coupled with  new approaches in statistical design as well as re-envisioning how we  ascertain outcomes, by capitalizing on the use of technology and patient engagement though ownership of their data. Changes in regulation are necessary to enable those innovations. Finally, despite the fact that clinical trials are so expensive, the value (yield divided by cost) has been low because we traditionally focused only on strong effects on the primary outcome. With appropriate data sharing of patient level data including those for negative trials, so much more could be learned.

As medical and scientific knowledge continues to increase, the cost of an incremental yield to health outcomes from new interventions will exponentially increase. Healthcare providers should be conscious of their practice of evidence-based medicine by always remembering that not all interventions necessarily require the highest level of evidence.  At the same time, we should re-envision our approaches to clinical research using the tools around us in today’s world to generate better evidence at lower cost.

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How To Train Your Leader?

Last month, I attended a meeting held by HFSA, entitled “Future Leaders in Heart Failure Symposia.” The meeting gathered together a multi-disciplinary team of trainees – cardiology fellows, nurses, pharmacists, post-doctoral researchers – to immerse them in discussions with current leaders in the world of heart failure. Session topics centered on themes such as having conversations with division chairs and effectively building and running a subspecialty clinic.

The HFSA Future Leaders program provided a venue for participants to actively engage in discussions with prominent faculty members (the current leaders in heart failure), as well as meet each other (our future, fellow leaders in heart failure). While the goal of the program was not necessarily designed to “train” us on how to be leaders per se, I could not help but think about the following:

  1. What are the qualities of an effective leader?
  2. Can you actually train someone to be a leader, or is leadership ability an innate quality one is simply born with or without?

I’m still trying to sort out my own answer to Question #2, but from my training experience thus far and after some fun discussions with colleagues, I’ve tried to distill my answer to Question #1 into 3 common qualities I have found in effective leaders in medicine and medical research:

  • Treat their team members with respect. When I was a medical student, the CEO of our hospital system spoke to our class as we were about to start our first clinical rotation. While the practice of a CEO speaking to medical students (infamously the lowest position on the totem pole in the hospital patient care setting) may potentially be a common practice, the CEO uncommonly spoke to us as peers, teammates in the collective mission to improve our patients’ health. At the end of his talk, he asked each of us to take our cell phones out of our pockets, and he gave us his personal cell phone number to enter into our Contacts directory. He urged us to call him with any issues we thought could help improve our patient care. Ten years later, I still have his number on my phone, and while I have never called him, this gesture had a tremendous impact on me as a trainee. The CEO was widely considered to be an outstanding leader for our hospital, and I’ve found that effective leaders similarly seek out opportunities to meet with their team members and earnestly listen to their stories. Great leaders know and respect the individuals of their teams.
  • Know their material. It is difficult to ascend into a leadership position without having demonstrated a superior grasp of the pertinent material in your field. Yet leaders actively find ways to demonstrate their knowledge of the field, whether it be through peer-reviewed publications, through presentations at local or national conferences, or even through small group discussions with their team members. This demonstration of knowledge elicits trust from their team members – trust that they “know their stuff” well enough to make appropriate, well informed decisions going forward and move their teams in the right direction.
  • Speak publicly with passion and clarity. Public speaking is a challenge for most people, and some may argue that being an excellent public speaker is not a requirement for being a great leader. But in my experience, I have found that the leaders whom I admire are those who can not only demonstrate their deep knowledge of a topic (e.g., the urgent need to improve our delivery of optimal HF therapy to our patients) during a public presentation, but can also excite the audience to go out and uptitrate their patients’ beta-blocker doses right away. A famous quote from President Dwight Eisenhower goes: “Leadership is the art of getting someone else to do something you want done because [they] want to do it.” Leaders who are engaging, eloquent speakers tend to be the ones who can convince you of the importance of achieving your collective goal and clearly articulate their vision for the team.

I am confident that this list will dynamically evolve over the course of my career, as I continue to be privileged to meet my professional heroes. But as trainees interested in becoming future leaders in cardiovascular medicine, I believe it is important for us to reflect on the important qualities of the leaders we follow and admire. Can we be trained, or even train ourselves, to cultivate these qualities in own leadership practice? Entire books and TED Talk series are devoted to these questions, and I hope to reflect further on these questions in future posts. But if your goal is to become a leader in medicine, perhaps the first step is to recognize these common characteristics of leaders you personally admire and find ways to incorporate these habits into your own routine.

 

What do you think are qualities of effective leaders? Do you think these qualities can be taught? I would love to hear your thoughts via Twitter (@JeffHsuMD).

 

 

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5 Things To Consider Before Choosing Your Dissertation Topic

As I am inching towards, what I hope would be my final year of PhD research, I have been thinking and analyzing a lot of my actions in retrospect. I thought of putting together a list of things I learned and things I wish I had considered in my first year.

 

1) Finding the “right” mentor.

We spend a lot of time in deciding the right lab or the best PhD supervisor. A lot has been said and done about finding the right fit. One thing I have learned is that apart from the usual parameters we set in finding the best supervisor for us personally, sometimes we forget to consider if the supervisor is right for the project. Sometimes the project may expand in an area beyond your and your mentor’s expertise. In such cases, it is important to consider whether your mentor will make the right resources available to you. Putting together a good research advisory committee, scientists who would have expertise in that specific topic, will come in handy. Research can be quite daunting and grad students deal with intense pressure and stress on a daily basis. Your time should be spent researching and not trying to find the right instrument in the cheapest core facility and definitely NOT YouTubing the workings of a new technique. Make sure to find someone to train you, attend workshops, shadow a technician and make sure your supervisor makes these available to you when needed. A mark of a good mentor is when they don’t hesitate to seek consultation or advise from an external or senior scientist who is an expert in the field.

 

2) Is this a good career investment?

Turns out most students forget about the crucial thing about spending years in grad school – landing the job! Most of us don’t think about job search or the next move until our final year, which I think is too late. While choosing a topic, you may want to consider things like job market, skill requirement, funding agencies and so on. For example, researching therapeutic drug targets for a disease that has no cure is far better than investing in a project discovering drug targets for a disease with multiple FDA approved drugs. Weigh the pros and cons carefully. Will your project help you acquire technical skills that are translatable to the industry? If you live in a city or country that is in dire need of science policy advisors or climate crisis advocates or good science communicators, will your PhD program give you enough skills to apply to these jobs?

 

3) Is there scope for collaborations?

Collaborations are a unique way to expand into different research topics in your field, whether it’s a collaboration within your group or research with a different research group altogether. This lets you become more versatile, get a flavor of how other researchers approach their science and if nothing else, learn a new scientific topic up-close. A productive collaboration is one which will take your expertise and enhance another project, without taking too much time away from your project. Inter-lab collaborations are a great way to demonstrate your negotiating, team management and interpersonal skills. Oh, and did I mention it’s good for networking? So finding aims in your proposal early on, that are good for teaming up with other groups is a good idea, especially while conferencing.

 

4) Will it help you AND your science grow?

I will start with the science part first. Obviously, we all want to learn and become an expert in the respective field when we started off, so what do I mean by growth here? If your research topic is only going to be a repeat of your previous techniques and scientific concepts, chances are, halfway through the project, you’re going to lose interest. It is great to start off the project with something familiar, but if it isn’t exploring in areas that are uncomfortable and challenging to you, is it really worth a PhD? Test new ideas, push your boundaries and give yourself a deadline to fully delve into answering these questions. But be wary not to spend too much time and get distracted. It is good to spend the first two years (in a five-year program) to be adventurous, but if it gets too challenging it really should not be pursued at the expense of your time.

I stress on personal growth next. PhD project is a LOT of time commitment. Especially to one very specific thing, that more often than not, will consume most, if not all of your time. This means one must consider having room for co-curricular activities that will in turn be an asset for your own research project. For example, I love to read about popular science, wildlife, climate science, conservation, policies and history. My program had a structured graduate minor alongside my PhD major and I decided to study science communication for this minor. Now, I get to write, read or watch other popular forms of science, engage with community, organize local events and dissect science policies as part of my curriculum. I have also gotten opportunities where I talked about my own research to strangers and thus, honed in my craft of communicating science. All of this will ultimately reflect in your resume and you know that apart from spending long hours fine-tuning your experiments, you will leave with heaps of useful skills for future jobs. So, I would recommend finding things that compliment your science early on, this will go a long way!

 

5) Will you need a backup plan?

If you are diving into something extremely challenging, let’s say it will not only require you to learn new, field-specific techniques, but it will mean questioning the dogma – make sure you have another small project to safely rely back on. If your program has at least one first-author paper requirement for dissertation, it is imperative you sit with your supervisor and make sure you will get a paper out in time. No dogma is worth challenging at the cost of your degree!

 

These are some pointers that I thought of, from personal experience. I hope that you will find it useful and informative.

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Heart Attack and Stroke: Same Disease, Different Organs?

I’m spending the last month of internal medicine residency on a neurology rotation.  I suppose that’s fair; my wife, a neurology resident, had to do a whole year of medicine.  To me, the most interesting part of neurology is the parallel between stroke and acute myocardial infarction (AMI).  Conceptually these are two manifestations of a common underlying disease process.  Yet, there are glaring differences in their management, and I can’t help but wonder why.

For instance, neurologists and cardiologists use different protocols for anticoagulation and thrombolysis.  Tissue plasminogen activator (tPA) is a first line therapy for ischemic stroke unless there are contraindications, including recent use of anticoagulation.  Thrombolytic therapy is also used to treat STEMI when percutaneous coronary intervention (PCI) is not immediately available.  In contrast to stroke, STEMI thrombolysis calls for higher doses of tPA as well as concurrent infusion of heparin to prevent recurrent thrombosis.1  Perhaps thrombolysis after stroke is a more cautious affair due to the risk of reperfusion injury and hemorrhagic conversion.

For decades STEMI PCI has largely replaced tPA, yet endovascular therapy for stroke is a relatively recent innovation and its utility is limited to proximal large vessel occlusions.  While PCI relies on balloon expandable stents designed to prevent restenosis, stenting is perhaps a less attractive option in stroke due to the tortuous anatomy of intracranial vessels and the bleeding risk associated with dual antiplatelet therapy.2 Instead, neurologists perform mechanical thrombectomy using stent retrievers and aspiration catheters.  While routine thrombectomy during STEMI PCI is generally not beneficial,3 aspiration and rheolytic catheters can be used selectively in the event of large thrombus burden.

Finally, evidence does not support facilitated PCI (i.e. pretreatment with tPA prior to PCI).4-5  Interestingly, it is common practice among neurologists to pretreat with tPA prior to mechanical thrombectomy.  Theoretically pretreatment may facilitate clot extraction, but does this strategy outweigh the additional bleeding risk?6

Heart attack and stroke are similar diseases occurring in different organs.  With widespread adoption of mechanical thrombectomy for acute stroke, the fields of neurology and cardiology increasingly share similar practices.  Still, there are striking differences in stroke and AMI management—no doubt a constant source of cognitive dissonance as I complete my neurology rotation and start cardiology fellowship.

 

References:

  1. Kijpaisalratana N, Chutinet A, Suwanwela N. Hyperacute simultaneous cardiocerebral infarction: Rescuing the brain or the heart first? Frontiers in Neurology 2017;8:664.
  2. Gralla J, Brekenfeld C, Mordasini P, Schroth G. Mechanical thrombolysis and stenting in acute ischemic stroke. Stroke 2012;43:280-285.
  3. Jolly SS, James S, Dzavik V, et al. Thrombus aspiration in ST-segment elevation myocardial infarction. An Individual Patient Meta-Analysis: Thrombectomy Trialists Collaboration. Circulation. 2016;135:143–152.
  4. The ASSENT-4 PCI Investigators. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI). Lancet. 2006;367:569–578.
  5. Ellis SG, Tendera M, de Belder MA, et al. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med. 2008;358:2205–17.
  6. Kasemacher J, Mordasini P, Arnold M, et al. Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis. J Neurointerv Surg. 2019;11:20-27.
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Let’s Talk About Race and Stroke Recurrence

There has been a growing body of evidence pointing to potential differences in outcomes of stroke based on race/ethnicity. Recent investigations by Hao et al1, presented at the ISC 19, examined ethnic variation in stroke recurrence, from the angle of intracranial atherosclerotic stenosis [ICAS]. ICAS is estimated to be the underlying pathology in about 15% of ischemic stroke patients2, and is associated with high risk of stroke recurrence even with utmost medical treatment1. The investigators of this study included patients with ICAS in major vessels with >50% stenosis identified on Magnetic resonance angiography or computed tomography angiography. The authors observed higher rate of 3-months as well as long-term recurrence among non-White compared to White patients, although this did not reach statistical significance, possibly due to insufficient power.

Going from ischemic stroke [IS] to intracerebral hemorrhage [ICH], King et al3 assessed recurrence of ICH based on race/ethnicity. They used comprehensive claims data that included hospital discharges in California between 2005-2011. The authors included patients who survived to discharge. Similar to what has been observed in IS, King et al found higher rates of ICH recurrence among Black and Asian compared to White patients.

There are some suggestions on potential explanations on those differences based on the burden of specific clinical conditions by race/ethnicity, such as hypertension4 and chronic kidney disease as reported by Hao et al1. However, this is an area that needs further investigations in representative samples of patients.

 

REFERENCES:

[1] Hao, Qing, et al. “Abstract TP157: Ethnic Difference in Stroke Recurrence for Patients With Intracranial Atherosclerotic Stenosis.” Stroke 50.Suppl_1 (2019): ATP157-ATP157.

[2] Bose, Arani, et al. “A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study.” Stroke 38.5 (2007): 1531-1537.

[3] King, Zachary A., et al. “Abstract WMP97: Racial/Ethnic Disparities in the Risk of Intracerebral Hemorrhage Recurrence.” Stroke 50.Suppl_1 (2019): AWMP97-AWMP97.

[4] Rodriguez-Torres, Axana, et al. “Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals.” Neurology 91.1 (2018): e37-e44.

 

 

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Paradigms and Progress in HIV and Cardiovascular Health

 “Led by a new paradigm, scientists adopt new instruments and look in new places” – Thomas S. Kuhn

For a lot of rational (and some irrational) reasons, hearing the word HIV evokes fear, anger, and sadness. When I first heard about HIV, I was an elementary school student in late 1980’s and at that time, HIV was almost always a death sentence.  But today that is not the case.  Today, due to the hard work of scientists, patients, volunteers, advocates, and countless others, HIV is a chronic, manageable disease. An accomplishment epitomized by the oldest known person living with HIV recently turning 100 years old.

living with HIV graph

While this progress and longevity should be celebrated, the flip-side of age is that it is the primary driver of cardiovascular disease (CVD). In fact, this longevity has ushered in a new era where adults living with HIV are at exceptionally high risk of cardiovascular diseases including heart attacks, heart failure, and stroke. A recent meta-analysis by Anoop Shah, MD, from the University of Edinburgh, found that the global burden of HIV-associated cardiovascular disease has tripled in the past 20 years, especially in low and middle-income countries. Now, after more than two decades of accumulating evidence in this field, the American Heart Association released earlier this month a Scientific Statement on the characteristics, prevention and management of cardiovascular disease in people living with HIV.

Directed at all who support adults living with HIV, this statement is a general roadmap for raising awareness about the increasing burden of CVD in this population. However, it offers few new tools for providers to use, due primarily to the lack of high-quality “clinical trial data on how to prevent and treat cardiovascular diseases in people living [and aging] with HIV investigating cardiovascular endpoints” said Matthew J. Feinstein, M.D., M.Sc., chair of the writing group for the statement and assistant professor of medicine at the Feinberg School of Medicine, Northwestern University.

Still, what the existing (mostly observational) evidence allowed the writing group to do was to develop a pragmatic approach to assessing and preventing cardiovascular disease in treated HIV (Figure above). This approach includes the following:

  • Ensure all patients living with HIV are on effective HIV treatment
  • Determine risk of cardiovascular disease using tools such as ACC/AHA 10-year ASCVD risk estimator and a family history
  • Optimize lifestyle approach to prevention (e.g., smoking cessation, physical activity, healthy diet intake)
  • If at high risk and between the ages of 40-75 years, talk with the patient about the risks and benefits of lipid-lowering therapy while exercising caution for drug-drug interactions

Yet, while the new AHA Scientific Statement will be an important catalyst for the field, in many ways it creates more questions than answers. For example, are we shifting to a new paradigm in HIV care? Do we need new tools to help reduce CVD in this population or are the general recommendations for risk stratification and lifestyle optimization sufficient?  What is the most effective way to get either existing or new clinical tools to the high-risk patients living with HIV?

Fortunately, some of these questions are starting to be answered. The REPRIEVE study is the first large scale (>8,000 people) clinical trial to test if a daily statin reduces cardiovascular disease in adults living with HIV. Results are expected in the next 3-4 years. Additionally, the PRECluDe grants at the National Heart, Lung, and Blood Institute have stimulated new implementation science research focused on understanding how to best adapt effective CVD prevention studies to the real-world settings where people living with HIV receive their health care. These initiatives, coupled with ongoing research on the discovery of mechanisms of CVD and the testing of CVD prevention interventions in people living with HIV, will eventually allow for the development of guidelines on the prevention and management of CVD in HIV—the true instrument needed to help improve cardiovascular health for all adults living with HIV.

 

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The History of the AHA

Following up on an earlier post about the history of the NIH R01 grant, which morphed into a history of the NIH and the National Cancer Institute, I wanted to find out more about the history of the American Heart Association and the first AHA research awards.

This was much easier information to obtain! It is on the AHA website. The first award went to biochemist, Dr. Albert Szent-Gyorgyi, who was fascinating and possibly the topic of a future post. He received the first AHA grant in 1948 while he was at the Marine Biological Laboratory in Woods Hole, MA. He primarily contractile components of muscle including the heart.

Dr. Albert Szent-Gyorgyi (https://en.wikipedia.org/wiki/Albert_Szent-Gy%C3%B6rgyi)

 

The first AHA logo

The first AHA logo (https://www.heart.org/en/about-us/history-of-the-american-heart-association)

Easily finding this answer led to another question. When and how did the AHA begin in the first place? The public and physicians knew little about cardiovascular diseases in the early 1900’s when the AHA was founded. Heart disease was thought to be a slow, drawn-out death sentence. A group of 6 physicians believed that with scientific research, a cure could be found.

One of the first AHA meetings.

One of the first AHA meetings.(https://www.heart.org/en/about-us/history-of-the-american-heart-association)

 

The 6 founding members of the AHA were: Drs. Lewis A. Conner, Robert H. Halsey, Paul D. White, Joseph Sailer, Robert B. Preble, and Hugh D. McCulloch. Since the founding in 1924, the AHA’s has been primarily a scientific association. After awarding the first research grant in 1948, AHA began publishing its first journal Circulation in 1950.

From that point on, the AHA was instrumental in funding research that linked smoking and saturated fats to heart disease. AHA research was instrumental in the development of implantable pacemakers, CPR, artificial heart valves, statins, and AEDs. They also established a personal favorite of mine, the Jump Rope for Heart, which I proudly participated in as a child.

There were several changes geared toward unifying the AHA’s objectives, research standards, and guidelines through the years. In 1995, the AHA declared its strategic driving force: Providing credible heart disease and stroke information for effective prevention and treatment. The AHA still functions as a scientific organization but one that faces first and foremost on the public. The AHA’s driving force guides the scientific efforts of AHA members to public benefit.

 

Are you an AHA member and interested in applying for a research program or award?

The AHA is now accepting applications for four research programs:

  1. AHA Predoctoral Fellowship
  2. AHA Postdoctoral Fellowship
  3. Merit Award
  4. Institutional Undergraduate Program

APPLICATION DEADLINES

  • Merit Award Letter of Intent (required) – July 11, 2019
  • AHA AIREA Award – July 17, 2019
  • Predoctoral Fellowship – August 14, 2019
  • Postdoctoral Fellowship – August 15, 2019
  • Institutional Undergraduate Fellowship Program – September 18, 2019

The Grants@Heart or AHA Application Information web page will contain updates about subsequent programs and you can begin preparing your application. Email  apply@heart.org or call 214- 360-6107 for questions.

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An Apple a Day Keeps the Doctor Away: Preparing For My First Teaching Experience

If you have been keeping up with my last few blog posts, then I’m sure you’re able to tell that I am a graduate student. As a part of the many training activities that I have partaken in throughout the time of my graduate training, I am excited to say that I can now officially add “course developer” to my curriculum vitae. This summer I will have the pleasure of working with high school students participating in the 4-H Teen Conference held at the University of Kentucky. Underneath their health major, another student and myself proposed a nutrition course titled #HealthGoals. Together, the objective of our course was to inform students of basic nutrition facts, guidelines, and consequences of over-nutrition, as well as to introduce the students to fruits that are traditionally less eaten and healthier snack options. The only catch was that the students were allowed to pick what classes they wanted to attend. So, my colleague and myself’s perspective course was in competition with several other potential classes and had the possibility of not being chosen. This was initially stressful because we knew that we had ideas for an exciting class, but how do we ensure the students know this as well? After days of tweaking the course description, we were finally able to settle on a name and description that perfectly, and succinctly, advertised the course. After submitting, a few months went by before we heard anything else about if we would have students participating or not. Finally in May, we received word that 11 students had signed up for our class. I know this may not seem like a lot to everyone, but to us, it was a win.

Now that we knew for sure we would be instructing a class we moved on to the official planning stage – and it was a lot harder than we thought it was going to be! We would be instructing 2 classes, each of which would be 3 hours and 15 minutes long. How were we going to fill all of this time? We also wanted to make the classes as interactive as possible to increase attention to, and retention of, the material. Drawing on our years of joint experience as students, we were able to come up with a final outline of what we would be doing down to the last minute. We thought, “Better to be over-prepared than to not have enough material to fill the time.” I would say that this experience was without a doubt more difficult than I thought it would be. Planning a class takes a lot more time than I was originally anticipating.

Going forward I now have a better understanding, and appreciation, of the planning my Professors do to make a successful class.

For those of you that teach, do you have any tips that make the lecture planning process smoother?

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Gender-Inclusive Research, Clinical Practice, and Education: Where to Start?

A person who has a scary symptom like chest pain is probably worried and stressed. For some people, their worry includes not only their health, but also whether they will be refused treatment, called by a name and pronouns that don’t reflect their identify, laughed or gawked at, assumed to have behavioral or sexual health issues, or offered treatments that have not been assessed in people like them. This is the reality that many transgender people face.

image via https://broadlygenderphotos.vice.com/, shared under a creative commons license

image via https://broadlygenderphotos.vice.com/, shared under a creative commons license

Fellow AHA Early Career Blogger, Allison Webel, PhD, recently wrote about cardiovascular disease in the transgender population. Please check out her post— it’s excellent. Some key background to remember is that transgender people live in all 50 states and over 1.4 million Americans identify as transgender1. This means that no matter where you work and what your specialty is, you are likely to encounter transgender and other gender non-conforming folks (including people who identify as genderqueer, non-binary, or other designations). It is up to you to decide to meet their needs— the systems currently in place will not ensure this. For the medical community to effectively reach transgender people, we must address their needs through research, clinical practice and education. Early career professionals need to be leaders in this effort — changing long-established ideas and practices is not easy.

 

Research:

Historically, the research community hasn’t done a great job of ensuring gender equity in science. As Dr. Paul Chan notes in a recent editorial, gender disparity research has picked up in recent years, but very little of it explicitly includes transgender people2. We are only beginning to generate evidence to direct our care of transgender people, and much of that evidence focuses on sexual or behavioral health. Thanks to a recent article by Dr. Talal Alzarhani and colleagues, however, we now know that the transgender population has a higher incidence of myocardial infarction than the cisgender population3. This finding is not surprising, but it is a clear sign that we must do better designing research to advance understanding the unique health needs of transgender people. But how?

  • Don’t make excuses. Women were excluded from medical research for a long time because of concerns about hormonal cycling and pregnancy. This choice has created persistent disparities4. Don’t perpetuate such inequality with the transgender population. Develop research and analysis strategies to deal with the diversity that exists rather than collapsing it or ignoring it for the sake of convenience or cost.
  • Use inclusive language to capture accurate data about gender. Dr. Chan suggests gender categories that include at a minimum cisgender male, cisgender female, transgender male, transgender female, and other2. Importantly, this strategy removes assumption that cisgender is normal and expected and allows people of all gender identities to respond authentically.

 

Clinical Practice: 

Much as women’s health isn’t limited to OB/GYN care, trans health is not limited to hormone therapy. Transgender people need the full spectrum of health care that cisgender people do, but many have been refused care or felt unwelcomed and mistreated in medical settings5. Primary care providers, behavioral health providers, and endocrinologists are likely to encounter transgender patients, but so are cardiologists, oncologists, surgeons, and others. Culturally and medically competent care is imperative in all of these contexts. Provider discomfort should not be a barrier. Here’s what you can do to improve:

  • Educate yourself about gender diversity. Remember that it is not your patient’s job to teach you the basics. Go to sessions at conferences, seek out knowledgeable colleagues, and read up.(Resources are listed at the end of this post to get you started).
  • Be welcoming: ask your patients what their pronouns are, and train staff to do this also. Don’t avoid addressing people because you are unsure or uncomfortable. Make sure your forms allow people to self-identify their gender with inclusive options. If you make a mistake, apologize and move on.
  • Practice with a trauma-informed approach (read an introduction to the topic here. Recognize that trust must be built. Transgender people are more likely to face significant psychosocial stressors and discrimination, including in health care. This will affect their experience.

 

Education: 

Though health professions students report a high level of comfort with lesbian, gay, bisexual, and transgender health, they receive little formal training6. Educators in the health professions can explicitly include transgender people across curriculums to improve this perception. Here are some strategies:

  • Use gender diverse images in your education materials. Find some here.
  • Create cases and content including trans people when teaching about common health concerns.
  • Invite an expert. Find someone who cares for transgender people in your community to speak to your students.

 

So, early career professionals, the ball is in your court. What are you doing to enhance gender inclusivity in your work?

 

Resources:

National LGBT Health Education Center (lgbthealtheducation.org)

UCSF center of excellence for transgender health (http://transhealth.ucsf.edu/)

GLMA (http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=1025&grandparentID=534&parentID=940&nodeID=1)

 

References

  1. Flores, A.R, Herman, J.L., Gates, G.J. & Brown, T.N.T. (2016). How Many Adults Identify as Transgender in the United States? Los Angeles, CA: The Williams Institute.
  2. Chan, P. (2019). Invisible gender in medical research. Circulation: Cardiovascular Quality & Outcomes, 2019(12).
  3. Alzahrani, T. et al. (2019). Cardiovascular disease risk factors and myocardial infarction in the transgender population. Circulation: Cardiovascular Quality & Outcomes, 2019(12).
  4. Shansky, R. (2019). Are hormones a “female problem” for animal research? Science, 364(6442),.
  5. Liszewski, W., Peebles, J., Yeung, H., & Arron, S. (2018). Persons of nonbinary gender— Awareness, visibility, and health disparities. The New England Journal of Medicine, 379(25).
  6. Greene, M., France, K., Kreider, E., Wolfe-Roubatis, E.,, Chen, K., & Yehla, B. (2018). Comparing medical, dental, and nursing students’ preparedness to address lesbian, gay, bisexual, transgender, and queer health. PLoS One, 13(9).