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Artificial Intelligence in Cardiology: Opportunities for Cardio-Oncology

History was made recently with the inaugural and first ever continuing medical education conference on artificial intelligence (#AI) in Cardiology. While most of the presentations were on artificial intelligence or cardiology or both, several sessions also made reference to other fields in which AI has been or is being used, such as Oncology. There was even one study presented on Cardio-Oncology. As study after study was presented, it became clear to me that perhaps several of these techniques and methodologies could potentially be useful to our patients in Cardio-Oncology.

Every single piece of technology started with one single prototype. Every single new piece of software started with one single algorithm. Every single patent started with one single idea. Every single idea started with the impact that disruptive technology could have for at least one single patient – one single case.

As I view various case reports in Cardio-Oncology, I think about how #AI could influence care delivery to potentially improve outcomes and the experience for each patient and their health professionals.

One example that was reiterated in multiple presentations was that of the ECG. Applying #AI to the ECG has been shown in the studies presented to determine the age, sex, and heart condition of the individual. Details were shown for a case of hypertrophic cardiomyopathy (yes, HCM, not just left ventricular hypertrophy) diagnosed via #AI analysis of an ECG that appeared relatively unremarkable to physicians’ eyes. After the septal surgery/procedure, although the ECG then looked remarkably abnormal to physicians’ eyes, the #AI algorithm could identify resolution of the hypertrophic cardiomyopathy.

Another example reiterated throughout the conference was identifying undiagnosed left ventricular systolic dysfunction, in a general community population and also in patients referred to a cardio-oncology practice at a large referral center.

Recently, #AI in Cardiology has been used most frequently for monitoring and detection of arrhythmias, such as atrial fibrillation. Everyone can purchase their own wearable to determine this. Physicians are also now prescribing these wearables for ease-of-use, given their pervasive presence and coupling with smartphones owned by much of the population or provided temporarily by the physician group. Such wearables are transitioning from standalone electrodes, to watches, skin patches, and clothing (e.g., shirts, shorts).

Many direct-to-consumer #AI applications in daily life actually are not wearable, such as Alexa and Siri. One study described the ability of #AI to help diagnose mood disorders and cardiac conditions and risk factors by simply “listening to” and analyzing voice patterns. The timing of a young man’s “voice breaking” can potentially predict his risk for heart disease!

A popular use for #AI in medicine overall is to assist with interpretation of various imaging, such as chest X-rays, MRIs, or CT scans. This applies in Cardiology as well. Further, in Cardiology, #AI is being used to help guide the procurement of echocardiograms. The algorithms provide visual instructions (such as curved arrows) to indicate directions in which the ultrasound probe should be moved to obtain the standard view, to which the algorithm is comparing the image being procured moment-by-moment. The idea is for #AI to help less experienced sonographers or echocardiographers learn and perform echocardiography even more expediently.

The theme of the conference was current advances and future applications of #AI in Cardiology. Accordingly, a historical perspective was given, describing some of the earliest attempts at #AI in various fields. A video of a possible precursor to current automated vacuum cleaners was shown, from archives dating back to the 1960s. In addition to ways in which #AI is now being studied or applied, future opportunities for using #AI were also postulated, for example for coronary artery disease, since stress tests are not 100% sensitive and the gold standard coronary angiography is invasive. #AI could help stratify patients who needed versus did not need the invasive procedure for recurrent convincing symptoms in the absence of a positive stress test. Of course, coronary CT angiography could help fill this gap, but #AI might assist with decision-making sooner.

There have been studies on #AI in Cardiology, and studies on #AI in Oncology, and at least one study in #AI in Cardio-Oncology – a study I predicted; one that is quite intuitive and mentioned above. I propose that we continue to apply #AI in Cardio-Oncology, so that the field can catch up with the rest of Cardiology and Oncology, and help us continue to develop this emergent and burgeoning multidisciplinary subspecialty.

This is an exciting time for me to be alive. I am an early adopter of artificial intelligence. I look forward to seeing more and more the availability of #AI to enhance our use of electrocardiography, echocardiography, wearables, biosensors, voice analysis, and more in Cardiology, and particularly in Cardio-Oncology, with an emphasis on primary and primordial prevention even before secondary and tertiary prevention in the area of Preventive Cardio-Oncology, and especially in women.

 

 

 

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Cardiovascular Maternal Morbidity and Mortality In the United States – What is the Cardiovascular State of Health for Pregnant Women and What is the Role of the Cardiologist?

Introduction

Despite advances in health care in the United States (US) maternal morbidity and morbidity remains significantly higher in the US relative to other developed nations with a reported maternal mortality of 14 per 100,000 live births in 20151.  Unfortunately, maternal morbidity and mortality rate has steadily increased over the last 2 decades2. The Centers for Disease Control (CDC) implemented the Pregnancy Mortality Surveillance System. The CDC defines a pregnancy-related death as the death of a woman while pregnant or within 1 year of the end of a pregnancy – regardless of the outcome, duration or site of the pregnancy–from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes2.  Although the maternal morbidity and mortality rate declined in the 20th century, recent statistics have shown that this rate has increased more than 2 fold as the number of reported pregnancy-related deaths in the United States steadily increased from 7.2 deaths per 100,000 live births in 1987 to 17.2 deaths per 100,000 live births in 2015. More recent date has suggested that this rate is even higher at 26.4 per 100,000 live births3. Cardiovascular disease (CVD) accounts for approximately a third of pregnancy related deaths and is the leading cause of maternal morbidity and mortality2.  According to the American College of Obstetrics and Gynecology (ACOG) acquired heart disease is thought to be the cause for the rising cardiovascular mortality in women with an increasing number of mothers entering  pregnancy with a greater burden of common risk factors for CVD such as age, obesity, diabetes and hypertension2,3.

 

Disparities in Outcomes

There are also significant racial and ethnic disparities seen in maternal morbidity and mortality rates in the US with Black women having  a greater than 3 fold higher rate compared to White, non-Hispanic women (42.8 per 100,000 vs. 13 per 100,000 live births)2. The lowest maternal morbidity and mortality rate is seen in Hispanic women with a rate of 11.4 per 100000 live births. This rate progressively increases with White Non Hispanic women having a rate of 13.0 per 100,000 live births followed by 14.2 per 100,000 in Asians/Pacific Islander, 32.5 in American Indian Alaskan Native, and is highest in Black Non-Hispanic Women of 42.5 per 100,000 live births2 Figure 1.

The cause of this disparity is multifold and may also be related to a higher prevalence of CVD risk factors such as obesity and hypertension in Black non-Hispanic women4. There may also be limited access to adequate postpartum care in this patient population. There has been some action taken by ACOG with regards to providing recommendations for addressing these disparities5,6. However, there is a lot of work left to be done in resolving these inequities in maternal healthcare.

 

Role of the Cardiologist

It is vital that mothers who are at increased risk for CVD or have established CVD be referred to a Cardiologist for cardiovascular assessment and management in the early postpartum period. Therefore, raising the awareness amongst the Obstetrics and Gynecology community of this necessity of cardiovascular care in these women is important. Additionally, for us in the Cardiology community it is important to recognize these female patients when they present to us for the first time for care. Their presentation may be in the antepartum or postpartum period. In the antepartum period it is vital for us to be able to differentiate pathologic cardiovascular signs and symptoms from the physiologic cardiovascular changes related to pregnancy. It is also important that if these women present to us in the antepartum or postpartum period that they have an adequate assessment of their cardiovascular risk. Key historical features to obtain includes a thorough obstetrics history as there are several pieces of the obstetric history that may indicate a higher cardiovascular risk such as preterm deliveries, pre-eclampsia and frequent first trimester miscarriages. A systematic review and meta-analysis published in Circulation in 2018 by Grandi S, et al analyzed 84 studies that included more than 28 million women and had indicated that women with placental abruption and stillbirth in addition to hypertensive disorders of pregnancy, gestational diabetes mellitus, and preterm birth are at increased risk of future cardiovascular disease7  Figure 2. In addition to an obstetrics history, a family history of heart disease particularly premature heart disease is also important. These women should also be assessed for common CVD risk factors such as obesity, hyperlipidemia, diabetes, hypertension, smoking and a sedentary lifestyle. These risk factors should be appropriately and intensively managed through a combination of therapeutic lifestyle changes and medications where appropriate.

In the prepartum period women intending to become pregnant should also be screened  with regards to their CVD risk assessment and these risk factors should be appropriately managed to improve their overall CVD health prior to becoming pregnant. This is especially so as pregnancy could be viewed as nature’s stress test and the more cardiovascularly healthy women are when they conceive the more likely they will have better cardiovascular outcomes in the postpartum period.

In unique cases of women with Congenital Heart disease, it is imperative that these patients are seen by an Adult Cardiologist with expertise in Adult Congenital heart disease before considering pregnancy as there may be cases where women with certain Adult Congenital heart diseases or pathology such as Eisenmenger’s syndrome should be advised to avoid pregnancy. Additionally, there may be cases where therapies or procedures may have to be considered prior to becoming pregnant such as women with Marfan’s syndrome with significant aortic root dilation.

 

Solutions to the Problem

The rise in maternal morbidity and mortality in the US has been attributed to acquired CVD1 and is therefore preventable. In order to address this problem the following should be considered:

  1. Recognition and management of CVD risk factors in the prenatal Period
  2. Appropriate cardiovascular assessment in the prenatal period for women with congenital heart disease to determine if pregnancy is contraindicated and if not contraindicated to determine suitable follow up of these women in the ante and postpartum period. Appropriate delivery plan should be outlined in an appropriate tertiary high Obstetrics risk center with appropriate cardiovascular and neonatal services available.
  3. Adequate cardiovascular follow up during the pregnancy and postpartum period for women with an intermediate as well as a high CVD risk.
  4. A multidisciplinary Pregnancy Heart Team approach is important for women with intermediate and high CVD risk in the antepartum and postpartum period.
  5. Early postpartum period cardiovascular assessment is important in the first 1-2 weeks post delivery for women with high CVD risk features such as women with placental abruption and stillbirth in addition to hypertensive disorders of pregnancy, gestational diabetes mellitus, and preterm births.
  6. Women with high CVD risk should have long term cardiovascular care not only in the first year postpartum but these women will likely require long term cardiovascular follow up even beyond a year to improve their lifelong cardiovascular risk.
  7. Removal of barriers to access to appropriate prenatal, antepartum and postpartum cardiovascular care is important for all women regardless of race or ethnicity.
  8. Raising awareness of the elevated maternal morbidity and mortality risk predominantly due to CVD is important in both the Cardiovascular and Obstetric Gynecology medical community so that as providers we can deliver the best possible care to these patients to improve their outcomes.

 

Future Directions

With the increasing maternal morbidity and mortality in the US that has been attributed to CVD there is a role for increased collaboration between the Cardiologist and the Obstetrician with regards to a Pregnancy Heart Team. The role of this team is vital in improving CVD outcomes in the antepartum and postpartum period for these women. Hopefully the research collaborative called the Heart Outcomes in Pregnancy: Expectations (HOPE) for Mom and Baby Registry which aims to address key clinical questions surrounding the preconception period, antenatal care, delivery planning and outcomes, and long-term postpartum care and outcomes of women will help to address the knowledge gaps and disparities in the care of women with heart disease in pregnancy8.

There is also a need for greater risk prediction tools with regards to assessing CVD risk in the prenatal, antenatal and postnatal period. The recently concluded Cardiac Disease in Pregnancy (CARPEG II) study indicated that there were 10 predictors that could be utilized to assess maternal CVD risk9. These 10 predictors include:

  1. 5 general predictors;
    1. Prior cardiac events or arrhythmias (3 points)
    2. Poor functional class or cyanosis (3 points)
    3. High-risk valve disease/left ventricular outflow tract obstruction (3 points)
    4. Systemic ventricular dysfunction (2 points)
    5. No prior cardiac interventions (1 point)
  2. 4 lesion-specific predictors:
    1. Mechanical valves (2 points)
    2. High-risk aortopathies (2 points)
    3. Pulmonary hypertension (2 points)
    4. Coronary artery disease (2 points)
  3. 1 delivery of care predictor (late pregnancy assessment) (1 point)

Patients with a higher CARPREG II score had a higher incidence of adverse cardiac events in pregnancy.

It is hopeful that these new initiatives will assist providers in improving their ability to appropriately risk stratify women in the prenatal, antepartum and postpartum period with regards to CVD risk. Additionally, it is hoped that  these initiatives will also improve care of these women through improved collaboration between the cardiologist and the obstetrician.

 

 

References:

  1. World Bank Statistics -2018 https://data.worldbank.org/indicator/SH.STA.MMRT?locations=FI-VE&year_high_desc=false Accessed July 28, 2019
  2. Centers for Disease Control Pregnancy Mortality Surveillance System. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpmss.html Accessed July 28, 2019.
  3. American College of Obstetrics and Gynecologist (ACOG) Releases Comprehensive Guidance on How to Treat the Leading Cause of U.S. Maternal Deaths: Heart Disease in Pregnancy News Releases 2019. https://www.google.com/url?q=https://www.acog.org/About-ACOG/News-Room/News-Releases/2019/ACOG-Releases-Comprehensive-Guidance-on-How-to-Treat-Heart-Disease-in-Pregnancy?IsMobileSet%3Dfalse&sa=D&ust=1564343293391000&usg=AFQjCNGL5pYJww-2z_FrcgJuZhx4vTeRGA Accessed July 28, 2019.
  4. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O’Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee.Circulation. 2019 Mar 5;139(10):e56-e528. doi: 10.1161/CIR.0000000000000659
  5. American College of Obstetrics and Gynecology (ACOG) Committee Opinion No. 729: Importance of Social Determinants of Health and Cultural Awareness in the Delivery of Reproductive Health Care.Committee on Health Care for Underserved Women.Obstet Gynecol. 2018 Jan;131(1):e43-e48. doi: 10.1097/AOG.0000000000002459. Review.
  6. American College of Obstetrics and Gynecology (ACOG) Committee Opinion No. 649: Racial and Ethnic Disparities in Obstetrics and Gynecology.Obstet Gynecol. 2015 Dec;126(6):e130-4. doi: 10.1097/AOG.0000000000001213
  7. Grandi SM, Filion KB, Yoon S, Ayele HT, Doyle CM, Hutcheon JA, Smith GN, Gore GC, Ray JG, Nerenberg K, Platt RW. Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications. Circulation. 2019 Feb 19;139(8):1069-1079.
  8. Grodzinsky A, Florio K, Spertus JA, Daming T, Schmidt L, Lee J,
    Rader V, Nelson L, Gray R, White D, Swearingen K, Magalski
    A.Maternal Mortality in the United States and the HOPE Registry.
    Curr Treat Options Cardiovasc Med. 2019 Jul 25;21(9):42.
  9. . Silversides CK, Grewal J, Mason J, Sermer M, Kiess M, Rychel V,
    Wald RM, Colman JM, Siu SC. Pregnancy Outcomes in Women With
    Heart Disease: The CARPREG II Study J Am Coll Cardiol. 2018 May
    29;71(21):2419-2430

 

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BCVS 2019 Put Early Career Investigators at the Forefront

Attending conferences can feel overwhelming for young scientists because there’s a lot expected from us at these events — we’re supposed to learn the latest science, present our own work and make connections with potential collaborators or future employers.

It’s a lot.

Luckily, many meetings are building resources into the actual conference programming to help early career scientists with these daunting tasks. I was happy to see last week when I attended the American Heart Association’s Basic Cardiovascular Sciences (BCVS) conference, that the program was sprinkled with a multiple sessions specifically tailored for young scientists.

Attendees during the Early Career Investigator Social Event at AHA’s BCVS 2019 conference. Photo by © AHA/Todd Buchanan 2019

Attendees during the Early Career Investigator Social Event at AHA’s BCVS 2019 conference. Photo by © AHA/Todd Buchanan 2019.

Two sessions in particular called “Oh All the Places You Can Go … With a Degree” and “What I Wish My Mentor/Mentee Told Me” were a welcome change from the rest of the conference — and they were actually helpful.

Both events were career development panels, but they each had their own twist.

The “Oh All the Places You Can Go … With a Degree” panel had professors, a grant writer/instructor at a large cardiovascular institute and an industry scientist. The panelists’ diverse backgrounds and experiences allowed for an engaging discussion about the most effective way to start searching for a job, especially if you’re not looking to go the traditional academia route. This was particularly welcome since the chance of young scientists landing an academic position is insanely low. Young scientists need to be prepared for this environment.

During the “What I Wish My Mentor/Mentee Told Me” session, graduate students, postdocs and faculty talked about the academic side of mentoring — how to find a good mentor, how to be a good mentor and what to do if problems arise. Overall, I thought this session was interesting but most of the questions were geared towards the professor’s perspective. Also, it quickly became apparent that the participating professors were the actual mentors of the trainees on the panel, so it didn’t seem like an environment where the trainees could be completely honest about their work experiences because their bosses were sitting right next to them.

Both sessions were really well attended with almost every seat filled. I’m really excited to see events like these at future BCVS conferences and it seems like I’m not the only one.

 

 

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Bifurcations – EPISODE 2: CULOTTE TECHNIQUE

It’s been a very hot summer so far. These days many of us are spending time with our families under the sun. Somehow, medicine still creeps into our summer days. Many of us will steal brief moments to check emails, open a link to an article or interact with colleagues on social media under a colorful parasol umbrella with a cold iced juice in our hand.

My last blog was the first of a series describing bifurcation stent strategies. This month the focus is Culotte technique. My intention is to provide a breezy summer reading that’s concise and illustrative, designed especially for those of us still on our summer ventures.

Here is Episode 2: CULOTTE TECHNIQUE

The Culotte technique, also commonly known as Y or Trouser stenting, was initially described by Chevalier et al in 1998.1 At that time, two equal sized bare metal stents were deployed in the main branch (MB) and side branch (SB) with an overlapped segment in the MB before the bifurcation. This was studied in a small population of only 50 patients with true bifurcation lesions. There was a 94% clinical success rate with 3 non-Q wave myocardial infarctions. A 24% late target lesion revascularization rate (TLR) was reported. Although this trial registered excellent short-term results, the technique itself was largely abandoned in the absence of any robust long-term data.  With the advent of drug-eluting stents (DES), culotte stenting resurfaced as a viable technique. In principal, this strategy is a trade-off. There is complete coverage of the carina and the ostium of the SB as well as a more uniform drug distribution. However, this is only achieved with a long segment of double layers of metal proximally. The culotte strategy using DES was evaluated in several randomized trials summarized below.

 

Culotte stenting technique in coronary bifurcation disease: angiographic follow-up using dedicated quantitative coronary angiographic analysis and 12-month clinical outcomes. 

A decade after Chevalier, Adriaenssens et al in 2008 published the results of their prospective randomized trial that enrolled patients undergoing culotte stenting with DES (Cypher, Endeavor, polymer-free rapamycin-eluting, Taxus).2 The Medina classification was used to describe the lesions. Angiographic follow-up was performed between 6 and 12 months post-index procedure. Clinical follow-up was 12 months. Culotte technique was used in 134 lesions of which 92.5% were true bifurcations. Angiographic success was achieved in all cases. Restenosis occurred in 22% (0% in the proximal MB, 9.1% in the distal MB, and 16% in the SB). At 12 months, 21% had TLR and stent thrombosis (ST) was 1.5%. Predictors of restenosis were older age, increased bifurcation angle, small SB reference diameter and severe distal main branch stenosis.

 

Randomized Comparison of Coronary Bifurcation Stenting With the Crush Versus the Culotte Technique Using Sirolimus Eluting Stents

In 2009, Ergilis et al compared two dedicated bifurcation stent strategies, the crush and the culotte, using sirolimus eluting stents.3 A total of 424 patients were randomized (crush [n=209] and culotte [n=215]). The primary end point was major adverse cardiac events (MACE); cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), or ST at 6 months.  The results noted that at 6 months there were no significant differences in MACE rates between both groups; crush 4.3%, culotte 3.7% (P=0.87). Procedure and fluoroscopy times and contrast volumes were similar. The rate of myocardial injury defined by elevated biomarkers was 15.5% in crush versus 8.8% in culotte (P=0.08). In-segment restenosis was 12.1% versus 6.6% (P=0.10) and in-stent restenosis (ISR) was 10.5% versus 4.5% (P=0.046) for crush and culotte groups, respectively. The investigators conclude that the angiographic results of both strategies were similar with a trend to less ISR with culotte.

Ergilis et al, Circ Cardiovasc Interv. 2009;2:27-34

Ergilis et al, Circ Cardiovasc Interv. 2009;2:27-34

 

 

Comparison of Double Kissing Crush Versus Culotte Stenting for Unprotected Distal Left Main Bifurcation Lesions: Results From a Multicenter, Randomized, Prospective DKCRUSH-III Study

More comparative data was made available in 2013 by Chen et al that employed more contemporary and developed techniques: Double Kiss Crush (DK) and Culotte.4 This study also examined the utility of these techniques in left main lesions. A total of 419 patients with unprotected left main bifurcation lesions were randomly assigned to Double Kiss Crush (210) or Culotte (209) strategies. The primary endpoint was MACE at 1 year, including cardiac death, MI, and target vessel revascularization (TVR).  ISR at 8 months was a secondary endpoint. ST was as a safety endpoint. Patients were stratified by SYNTAX (Synergy between Percutaneous Coronary Intervention   with Taxus and Cardiac Surgery) and NERS (New Risk Stratification) scores. In this cohort, the Culotte group had significant higher 1-year MACE rate (16.3%), driven by increased TVR (11.0%), compared with the DK group (6.2% and 4.3%, respectively; all p < 0.05). ISR of the SB was reported to be 12.6% in Culotte and 6.8% in DK (p = 0.037). ST rate was 1.0% in Culotte and 0% in DK (p = 0.248). Furthermore, when stratifying patients with bifurcation angle ≥70°, NERS score ≥20, and SYNTAX Score ≥23, the 1-year MACE rate for DK was 3.8%, 9.2%, and 7.1%, respectively. These rates were higher in Culotte (16.5%, 20.4%, and 18.9%, respectively; all p < 0.05). The investigators concluded that Culotte stenting for unprotected Left Main bifurcation lesions is associated with significantly higher MACE.

Chen et al, J Am Coll Cardiol. 2013;61:1482-8

Chen et al, J Am Coll Cardiol. 2013;61:1482-8

 

 

Clinical Outcome After Crush Versus Culotte Stenting of Coronary Artery Bifurcation Lesions: The Nordic Stent Technique Study 36-Month Follow-Up Results

The Nordic trialists also examined the outcomes of this technique in their study.5 The trial provided long term outcome data which is lacking in some of the other published data. A total of 424 patients were randomized to crush or culotte techniques using sirolimus-eluting stents and followed for 36 months. The primary endpoint was MACE (composite of cardiac death, MI, ST or TVR) at 36 months. At 36 months, the primary endpoint rate was 20.6% versus 16.7% (p = 0.32), TLR 11.5% versus 6.5% (p = 0.09), and ST 1.4% versus 4.7% (p = 0.09) in the crush and the culotte groups, respectively. The investigators concluded that outcomes were similar in both strategies.

Kervinen et al, JACC Cardiovasc Interv. 2013;6:1160-5

Kervinen et al, JACC Cardiovasc Interv. 2013;6:1160-5

 

 

Differential Prognostic Impact of Treatment Strategy Among Patients With Left Main Versus Non–Left Main Bifurcation Lesions Undergoing Percutaneous Coronary Intervention: Results From the COBIS (Coronary Bifurcation Stenting) Registry II

In 2014, Song et al provided outcome data from their retrospective Korean COBIS II registry.6 This registry was unique in that it compared outcomes of left main and non-left main bifurcation lesions using a two stent and single stent strategy. A total of 2,044 patients with non-left main bifurcation lesions and 853 with left main bifurcation lesions were enrolled. The primary outcome was TLF defined as a composite of cardiac death, MI, and TLR.  The 2-stent strategy was used more frequently employed in left main disease. At 36 months, the 2-stent strategy was not associated with a higher incidence of cardiac death, MI or target lesion failure (TLF) in the non-left main bifurcation group. However, in those with left main lesions, the 2-stent strategy was associated with a higher incidence of cardiac death, MI and TLF. Investigators, therefore, recommend a single strategy when possible especially for left main lesions.

Song et al, JACC Cardiovasc Interv.2014;7:255-63

Song et al, JACC Cardiovasc Interv.2014;7:255-63

 

 

Culotte stenting for coronary bifurcation lesions with 2nd and 3rd generation everolimus-eluting stents: the CELTIC Bifurcation Study

The CELTIC study provides more contemporary outcome data for patients with Medina 1,1,1 lesions treated with a culotte two-stent technique using latest generation Everolimus DES, the 3-connector XIENCE and the 2-connector SYNERGY.7 A total of 170 patients were included. Technical success was noted in >96% of those enrolled. MACE was reported in 5.9% by 9 months. The primary endpoint was a composite of death, MI, CVA, TVF, ST and binary angiographic restenosis. At nine months, the primary endpoint occurred in 19% of XIENCE group and 16% of SYNERGY group (p=0.003). Although this was not a direct comparison of 2-stent strategy to provisional strategy, this trial is more representative of modern day practice with radial access in 96%, latest generation DES and standard proximal optimization techniques.

Walsh et al, EuroIntervention 2018;14:e318-e324

Walsh et al, EuroIntervention 2018;14:e318-e324

 

As noted in the trials, the rate of employing this varies considerably, 2% in the COBIS II registry and 66% in Nordic Baltic Bifurcation Study IV. This strategy is most suitable when the SB and MB are similar in size. A mismatch can lead to incomplete SB stent apposition. Additionally, a wide angle between the two branches is an independent predictor of restenosis after culotte stenting. The advantages of this strategy are numerous. It permits one to begin with a provisional strategy that can be converted to 2-stents if necessary. With culotte technique there are only two and not three stent layers in the proximal segment. This facilitates re-wiring into the SB when performing kissing inflations. Culotte ensures complete coverage of all segments especially the ostium with little recoil at the ostium and stent distortion. Below is an illustration of the different steps.

Animations/illustrations courtesy of Graphic Designer Dania Al-Shaibi

Email: dn.alshaibi@gmail.com

 

 

References:

  1. Chevalier B, Glatt B, Royer T, Guyon P. Placement of coronary stents in bifurcation lesions by the “culotte” technique. Am J Cardiol.1998;82:943-9.
  2. Adriaenssens T, Byrne RA, Dibra A, Iijima R, Mehilli J, Bruskina O, Schömig A, Kastrati A. Culotte stenting technique in coronary bifurcation disease: angiographic follow-up using dedicated quantitative coronary angiographic analysis and 12-month clinical outcomes. Eur Heart J.2008;29:2868-76.
  3. Erglis A, Kumsars I, Niemelä M, Kervinen K, Maeng M, Lassen JF, Gunnes P, Stavnes S, Jensen JS, Galløe A, Narbute I, Sondore D, Mäkikallio T, Ylitalo K, Christiansen EH, Ravkilde J, Steigen TK, Mannsverk J, Thayssen P, Hansen KN, Syvänne M, Helqvist S, Kjell N, Wiseth R, Aarøe J, Puhakka M, Thuesen L; Nordic PCI Study Group. Randomized comparison of coronary bifurcation stenting with the crush versus the culotte technique using sirolimus eluting stents: the Nordic stent technique study. Circ Cardiovasc Interv. 2009;2:27-34.
  4. Chen SL, Xu B, Han YL, Sheiban I, Zhang JJ, Ye F, Kwan TW, Paiboon C, Zhou YJ, Lv SZ, Dangas GD, Xu YW, Wen SY, Hong L, Zhang RY, Wang HC, Jiang TM, Wang Y, Chen F, Yuan ZY, Li WM, Leon MB. Comparison of double kissing crush versus Culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol.2013;61:1482-8.
  5. Kervinen K, Niemelä M, Romppanen H, Erglis A, Kumsars I, Maeng M, Holm NR, Lassen JF, Gunnes P, Stavnes S, Jensen JS, Galløe A, Narbute I, Sondore D, Christiansen EH, Ravkilde J, Steigen TK, Mannsverk J, Thayssen P, Hansen KN, Helqvist S, Vikman S, Wiseth R, Aarøe J, Jokelainen J, Thuesen L; Nordic PCI Study Group. Clinical outcome after crush versus culotte stenting of coronary artery bifurcation lesions: the Nordic Stent Technique Study 36-month follow-up results. JACC Cardiovasc Interv.2013;6:1160-5.
  6. Song YB, Hahn JY, Yang JH, Choi SH, Choi JH, Lee SH, Jeong MH, Kim HS, Lee JH, Yu CW, Rha SW, Jang Y, Yoon JH, Tahk SJ, Seung KB, Oh JH, Park JS, Gwon HC. Differential prognostic impact of treatment strategy among patients with left main versus non-left main bifurcation lesions undergoing percutaneous coronary intervention: results from the COBIS (Coronary Bifurcation Stenting) Registry II. JACC Cardiovasc Interv.2014;7:255-63.
  7. Simon J. Walsh, Colm G. Hanratty, Stuart Watkins, Keith G. Oldroyd, Niall T. Mulvihill, Mark Hensey, Alex Chase, Dave Smith, Nick Cruden, James C. Spratt, Darren Mylotte, Tom Johnson, Jonathan Hill, Hafiz M. Hussein, Kris Bogaerts, Marie-Claude Morice, David P. Foley. Culotte stenting for coronary bifurcation lesions with 2nd and 3rd generation everolimus-eluting stents: the CELTIC Bifurcation Study. EuroIntervention 2018;14:e318-e324.

 

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Going the Distance: Setbacks and a Meaningful Career in Science

On July 4th, me and 60,000 of my closest friends ran in the 50th Peachtree Road Race in Atlanta, Georgia. This was my first 10K run and as a relatively new runner, my inclination for training for this race was to go hard and go fast – a manta not just for running but possibly for my entire generation. But as I would eventually learn, distance running is not about just getting it done. It is about being patient, listening to (and adjusting) my body, and having a long-term mindset focused on the process as much as the goal.

nih rejectionsThroughout my training, I was struck by how similar distance running is to a career in science and to grant writing in particular. When I finished my PhD 10 years ago, I was confident in my ability to write manuscripts and proposals, secure funding, and ultimately do and disseminate the science that would leave a lasting impact on the health of vulnerable populations. This confidence continued even when, during the last few years of my K award, I submitted grant after grant to the NIH only to have them be not discussed repeatedly.  I understood that NIH success rates were low, with institutes reporting a range of success rates from ~10% to 35% in 2018. Mentors reminded me that failure was part of the process and that everyone has a string of not discussed grants in the early phase of their career. I just needed to keep listening to the reviewers, getting more preliminary data, refining my ideas, developing great teams, and above all writing, and eventually my ideas would hit. However, when my string of not discussed/not funded grants grew to 15 (Figure 1), each set of pink sheets more soul crushing than the last, I knew that statistically I was failing more than I should. And I questioned if I should even be in science or if these past few years were just wasted time.

These setbacks can be devastating – causing approximately 10-15% of early career scientists to leave the field. But what about those who stick it out? What happens to them and, more importantly, what is their long-term impact on science? These are the questions explored in a recent article by Yang Wang, Benjamin Joes, and Dashun Wang, “Early-Career Setbacks and Future Career Impact”. Through a series of pretty cool analyses they examined if early success in obtaining an R01 award from the National Institutes of Health led to more success and a higher impact (measured as highly-cited manuscripts) compared to those who almost, but just missed the funding threshold. Essentially, they wanted to figure out among early career health scientists which perspective is true: Do the “the rich get richer” or will “what doesn’t kill you makes you stronger”?

Unsurprisingly, the results were somewhat mixed but encouraging for an early career scientist who has had many misses. While those with near misses had approximately a 10% chance of leaving the NIH funding system entirely over the next 10 years; of the scientists remaining, those who had an early career funding failure wrote higher impact manuscripts, compared to those who had early funding success. This is a striking finding which needs to be carefully considered (specifically that junior scientists do not need additional roadblocks in their path in order to become “stronger scientists”). Yet, the authors do suggest that for those scientists who persevere, “early failure should not be taken as a negative signal” rather viewed as a chance for refining and improving their program of research.

Wang and colleagues start their manuscript with a quote by Robert Lefkowitz, winner of the 2012 Nobel Prize in Chemistry, “Science is 99 percent failure, and that’s an optimist view.”  While he many have been referring to failed experiments, what Wang’s  new analysis reveals is that even the process of obtaining the funding to support research is likely to be fraught with heartbreaking setbacks. But if you’re in science because you believe in its power to answer important questions which will help us to better understand and improve the human condition, perseverance is necessary.

I finished my first 10K in under 60 minutes. Not a medal-winning time but I preserved through the heat, sun, fatigue, and even a bit of pain to cross the finish line. Similarly, late last year I received the Notice of Award for my first R01 from the NIH- leading a research study that I believe in with a team that inspires me every day.  So whether you are submitting your first or 15th research grant, know that setbacks are common and despite the outcome on any one application, with a long-term mindset you can have a lasting impact on science.

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Registry Based Randomised Clinical Trials: A New Era in Randomised Trials

Adequately powered, appropriately designed and prospective randomized clinical trials are considered to be the gold standard for evidence generation for evaluating efficacy and safety of a treatment interventions, especially when compared to non-randomized or under powered trials1. The strength of these clinical trials design rely on selection bias being eliminated by the randomization process. In particular, a double-blinded randomization, where neither researcher nor participant know the exact intervention they are receiving minimizes bias2. However, randomized clinical trials suffer several limitations inherent in their design and thus international guidelines frequently require two or more supporting randomised trials3. Many of these trials suffer from the strict inclusion and exclusion criteria leading to questions about the trials real-world application4. Furthermore, large clinical trials are expensive and require considerable resources. Due to which, patients are sometimes subjected to treatment strategies that have not been verified for their safety or efficacy and for treatments.

In recent times, the interest is shifting towards registry based randomized trials as a novel way to conduct clinical trials. This concept allows a clinical trial to use existing data collection method and can provide enhanced patient enrollment. A randomized clinical trial needs identification of eligible patients, consenting, clinical characteristics at baseline, treatment randomization, and clinical outcomes. A registry by default collects many of these elements and by incorporating randomization, a prospective randomized trial can be included within the registry features. This will allow selective yet consecutive recruitment and automated follow up of the study participants.

Registry based randomized clinical trials (RRCT) are effective to assess hard clinical endpoints in large participant cohort and is particularly suited for open-label evaluation of commonly used therapeutic interventions5. RRCT may be limited in trials with interventions that need comprehensive safety assessments, pharmacokinetic or pharmacodynamic modelling and require strictly defined end points6. However, linking of numerous functionalities to a clinical registry might still be possible. Furthermore, RRCT design reduces cost and regulatory burden associated with trials6.

The RRCT concept was first instrumented within the SWEDEHEART ((Swedish Web‐System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) registry7 from Sweden in TASTE (Thrombus Aspiration in ST-Elevation Myocardial Infarction Trial8. In which manual thrombus aspiration was prospectively evaluated as an adjunctive treatment to PCI for AMI with all-cause mortality as the primary end point. The registry was used to identify STEMI patients suitable for inclusion and the treating clinician further confirms the eligibility of the patient and obtained consent. All-cause mortality was routinely collected from the national population registry. No patients were lost to follow-up for the primary end point owing to automated, personalized identification number tracking. The main finding from the trial is that routine thrombus aspiration before PCI in patients with STEMI did not reduce the rate of all-cause mortality at 1 year or the composite of death from any cause, rehospitalization for myocardial infarction, or stent thrombosis at 1 year. Comparing it to the TAPAS (Thrombus Aspiration during Percutaneous Coronary Intervention in Acute Myocardial Infarction) trial, a single-centre trial that was not designed for the evaluation of clinical outcomes, thrombus aspiration was associated with a significant 40% relative reduction in all-cause mortality at 1 year9. In contrast to TAPAS, the TASTE trial was a large, multicentre study designed to have statistical power for the evaluation of all-cause mortality8.  From the TASTE experience, the strength of RRCT is clear. Furthermore, the cost of such a trial is subsidized by the existing registry and willingness of investigators to participate for minimal monetary compensation.

SAFE PCI for women using NCDR CATH-PCI Registry10, DETOzX-AMI (Determination of the role of oxygen in suspected Acute Myocardial Infarction) trial using SWEDEHEART registry11, MINOCA-BAT (ClinicalTrials.gov Identifier: NCT03686696)  (Randomized Evaluation of Beta Blocker and Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker Treatment in MINOCA Patients) using SWEDEHEART & CADOSA (Coronary Angiogram Database of South Australia) registries are few other examples of such RRCTs.

The need for novel approaches to minimise the limitations of the randomised clinical trials are quite evident. The integration of clinical trials and real-world practice is critical to determine which interventions are efficient. In this context, the prospective RRCTs are a powerful and highly cost-effective tool to establish clinical evidence that might not otherwise be appropriately evaluated.

 

References:

  1. Jones DS and Podolsky SH. The history and fate of the gold standard. The Lancet. 2015;385:1502-1503.
  2. Altman DG and Bland JM. Treatment allocation in controlled trials: why randomise? BMJ. 1999;318:1209.
  3. Tricoci P, Allen JM, Kramer JM, Califf RM and Smith SC, Jr. Scientific evidence underlying the ACC/AHA clinical practice guidelines. Jama. 2009;301:831-41.
  4. Furberg CD. To whom do the research findings apply? Heart (British Cardiac Society). 2002;87:570-574.
  5. Yndigegn T, Hofmann R, Jernberg T and Gale CP. Registry-based randomised clinical trial: efficient evaluation of generic pharmacotherapies in the contemporary era. Heart. 2018;104:1562.
  6. James S, Rao SV and Granger CB. Registry-based randomized clinical trials—a new clinical trial paradigm. Nature Reviews Cardiology. 2015;12:312.
  7. Jernberg T, Attebring MF, Hambraeus K, Ivert T, James S, Jeppsson A, Lagerqvist B, Lindahl B, Stenestrand U and Wallentin L. The Swedish Web-system for enhancement and development of evidence-based care in heart disease evaluated according to recommended therapies (SWEDEHEART). Heart. 2010;96:1617-21.
  8. Lagerqvist B, Fröbert O, Olivecrona GK, Gudnason T, Maeng M, Alström P, Andersson J, Calais F, Carlsson J, Collste O, Götberg M, Hårdhammar P, Ioanes D, Kallryd A, Linder R, Lundin A, Odenstedt J, Omerovic E, Puskar V, Tödt T, Zelleroth E, Östlund O and James SK. Outcomes 1 Year after Thrombus Aspiration for Myocardial Infarction. New England Journal of Medicine. 2014;371:1111-1120.
  9. Svilaas T, Vlaar PJ, van der Horst IC, Diercks GFH, de Smet BJGL, van den Heuvel AFM, Anthonio RL, Jessurun GA, Tan E-S, Suurmeijer AJH and Zijlstra F. Thrombus Aspiration during Primary Percutaneous Coronary Intervention. New England Journal of Medicine. 2008;358:557-567.
  10. Hess CN, Rao SV, Kong DF, Aberle LH, Anstrom KJ, Gibson CM, Gilchrist IC, Jacobs AK, Jolly SS, Mehran R, Messenger JC, Newby LK, Waksman R and Krucoff MW. Embedding a randomized clinical trial into an ongoing registry infrastructure: Unique opportunities for efficiency in design of the Study of Access site For Enhancement of Percutaneous Coronary Intervention for Women (SAFE-PCI for Women). American Heart Journal. 2013;166:421-428.e1.
  11. Hofmann R, James SK, Svensson L, Witt N, Frick M, Lindahl B, Ostlund O, Ekelund U, Erlinge D, Herlitz J and Jernberg T. DETermination of the role of OXygen in suspected Acute Myocardial Infarction trial. Am Heart J. 2014;167:322-8.

 

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Keep Out The Rain

cvd umbrella

It has been well established that cardiovascular disease (CVD) is a condition that leads to chronic symptoms that are generally thought of as a primary disease. However, vascular injury leads to subsequent disease such as metabolic disease, obesity, high blood pressure and kidney disease. There are several contributing factors starting a person on the path of having cardiovascular disease. Some of these include:

  1. Oxidative (ox)stress—potentially results in DNA damage
  2. Increased low density lipid (LDL) that can become oxidized into oxLDLs
  3. Overeating/over-nutrition leads to hormonal imbalances and subsequently obesity and/or metabolic disease
  4. Distress/Eustress is controversial, but the body does not know the difference and they can both lead to shear stress due to increased blood flow through laminar areas of the vascular system.
  5. Toxins that come produced within the body (endobiotics) or enter the body from outside source (xenobiotics). Environmental effects have strong impacts on how the body responds. It is important to manage the things that are within one’s control such as smoking, exercise, and consuming a well-balanced diet.

With people livings becoming busier, it is easy to miss the warning signs. A slight weight gain here or a headache there. What then can be done about the progression of CVD and other disease states such as hypertension? I am glad you asked. Controlling hypertension for example can be maintained by making lifestyle changes consisting of exercising at least 150 minutes per week, modifying one’s diet to potentially include the dash diet, and reducing stress levels. This sounds like a lot but planning ahead is key. Often times I find myself going to a fast food restaurant because I have gotten too hungry to cook, or because I have not had time to go shopping. When I plan ahead and purchase my food for a week and pack healthy snacks, I evade the urge to go for those french fries (my go-to weapon against hunger). Additionally, I find I am less stressed if I spend some time performing rigorous exercises or get moving throughout the day. I attempt at least 250 steps every hour and 10,000 steps over the course of the day.

However, the symptoms are not the same for everyone, thus one should know what to look for to identify vascular disease early as well as forming a trusting relationship with a primary care provider because, “You’re the Cure”!! Let’s keep this conversation going. Follow me on Twitter (@AnberithaT) or on my site. I will take a deeper look at each of these topics and discuss what, if anything, can be done to combat or control these symptoms.

 

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Get a Mentor, Be a Mentor

mentorship bubbleEarly in our careers, academics are encouraged to find good mentors. You need an advisor to get a doctorate, and this person is a mentor. You might be working in someone’s lab as a grad student or post-doc, and that person can be a mentor. You might be junior faculty and have a senior mentor to show you the ropes. There are formal mentorship relationships and informal mentoring relationships, and you’ve likely had both in your career. They’re a key part of professional development.

But what about being a mentor? The other day, a colleague came into my office and asked me to mentor her. My first response was to say “no, I can’t, I’m really new, we’re the same age, I don’t know anything you don’t know, you’re smarter than me. . .” But I paused. What made her ask for a mentor? What made her ask me? What can I offer this person to help her thrive professionally, so we don’t lose a much needed person in the field?

On reflection, I considered what mentorship means. Having a senior, accomplished mentor is a gift, especially if that person also works as a sponsor for you. Yet it’s also valuable to have a mentor who’s closer to where you are— someone whose life and struggle more closely resemble yours. A young(-ish) woman in academia can mentor another young woman in academia. Non-hierarchical and team models of mentorship also hold enormous promise. I attended a great session on this at #AHA18 in Chicago — I hadn’t thought of that before. Mentorship as a tool to encourage success is much broader than the classic senior-junior one-way relationship. My mentor-seeking colleague and I could certainly benefit from this kind of arrangement.

It’s also easy to forget that as early career scientists, clinicians, and educators, we are already accomplished. A grad student, an undergraduate student, a high schooler, or a middle schooler who’s interested in your field could benefit from your guidance and experience right now. Also at #AHA2018, AHA president Dr. Ivor Benjamin spoke about mentoring young black doctors. He then dug deeper, urging us to mentor young people earlier, before there’s a leak in the pipeline. This is such a crucial idea— the value of mentoring people from underrepresented groups in your profession is enormous. Science and medicine desperately need diversity, but this diversity cannot grow and flourish without the attention of dedicated mentors. Support is especially crucial for racial and ethnic minorities, LGBTQ people, and women, who remain underrepresented in many areas of STEM, including crucial leadership roles. In addition to perpetuating oppression by limiting access to career paths for individuals and groups, the downstream effects of this underrepresentation undermine equity in our science and clinical care. We can’t ignore the need for diversity and the crucial role for mentorship in building it.

 

So, early career scientists, educators, and clinicians, will you take up the challenge of mentorship?

 

Need a resource or want some further reading?

Check out this discussion of The Mentorship Guide.

 

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Lost and Found – At The Time of A Grand Round!

As may be easily inferred, opportunities for invited grand rounds are few and far between for early career cardiologists. Such an opportunity presented itself serendipitously to me recently – and I was excited at the chance. It did involve air travel and a single change of flights. Being a big believer of traveling light, I wore casuals and had my suit in my strolley, which usually fits in most overhead bins on planes. As luck would have it, as I got off at the single stop to change planes, the airlines requested a gate “check in” for the strolley – the flight being anticipated to be full, with consequent lack of storage space in the main cabin. Never having had any issues with this – especially with dropping off a bag at point of departure and picking up gate side on arrival at the destination in the past, I was happy to oblige. Unfortunately this time, fate had planned a twist.

When I arrived at my final destination, I got off with a smile of relief at journey’s end, a cheery wave to the airline crew, and began to look for my bag at the gate side. Initially there was a crowd expectantly waiting like me right after disembarking, but gradually each one of them happily collected their own and moved on. In the end it was just me left at the gate with no bag and no airline crew or anyone else around – disconcerting at the very least the day before a presentation.

I walked on into the terminal and walked up to the appropriate airline desk and they directed me to the baggage carousel expecting the bag to have been placed there with the other checked luggage. A subsequent wait at the carousel followed, unfortunately with a similar experience as at the gate. I did have the baggage tag which had been quickly put on at the departure gate, and fortunately I had made sure that it had been scanned to enable me to go back to the counter and try to trace the same. It could not be located immediately in the airline’s tracking system. However the airline did promise to update me with the status as soon as it became available and took down my contact information. Raised a quandary even with this – since I was only there in town for my grand rounds the next day and was due to leave the next night – would it be better just to provide my home address for them to forward the bag? Either way, it did not seem like my formal wear could be delivered in time for the grand rounds.

Then came the more pressing issue of trying to address the immediate need to obtain appropriate ‘threads’ for the presentation next morning. It was a late Sunday evening with potentially limited options available, while the presentation was early next morning when most stores would probably still remain closed. Fortunately the car service driver who came to pick me up knew of a couple of malls nearby en route to the hotel which were open, and expediently took me to one. After obtaining a new suit, to my relief, I did remember that the last version of my presentation on a thumb drive was in a side compartment in the stroller. This meant spending time on the laptop after reaching the hotel – which was still with me as I had taken it off the strolley before getting on the flight. Meanwhile, the airlines did call me to update me that they had located the bag at the point of departure, and agreed to forward it to the airport at my destination so as to enable me to pick it up on my way back home. They were gracious to agree to reimburse me for expenses incurred for the delay in baggage delivery.

The next day came – donning the new suit and having delivered the grand round hopefully without too much damage or discredit, I picked up my strolley on my way back home at the airport. Important lessons I learned in the process which potentially could help someone in the future:

1. If possible, try not to get separated from carry-on bags. Make sure the dimensions of the same adhere strictly to the specific airlines’ recommendations.

2. If a gate ‘check-in’ is inevitable, consider quickly changing into formal wear prior to handing off the bag, so that it remains available to you irrespective of the fate of the luggage. Alternately, carry the formal wear in a suit bag, and request to carry that on-board.

3. Hold on closely to the baggage claim check ticket provided at the gate and make sure the airline scans the ticket before you drop off the baggage. In my prior travels (those without baggage-related ‘incidents’), there were instances where the claim check may not even have been scanned in the rush at the gate in my recollection – please insist on the same prior to boarding, if a gate-check in is requested/mandated.

4. Have all presentation material available in multiple devices or maintain a version in the cloud for ease of access.

5. Thank heavens (if you are religious), and the airlines as well as everyone who helps with the process if you get back your baggage intact!

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“Run, Forrest, Run!” – Effects of Cardiovascular Exercising on Mental Health

running

Source:pixabay

If life gave me a box of chocolates, I am pretty sure I would eat them all. As a basic science researcher, I am all too familiar with burn-outs and stress, and more recently to the effects of stress-induced anxiety. So, I started running. I ran when my worries got too overwhelming, I ran when I had a bad day in the lab. Next thing I knew, I was running for pleasure. And this is something I did not see coming, especially because I hated running before!

Long before medications were available or even prescribed for mental or emotional disorders, exercising remained the only prescription for tacking problems of mental health by doctors.1 The AHA recommends 150 minutes of moderate-high intensity aerobic exercising a week for adults. Researchers have found this to improve balance of neurotransmitters and show effects as early as the first thirty minutes.

Here are some evidence-based effects of exercising on mental health –

  1. Stress and anxiety – Chronic stress can shrivel parts of the brain. Exercises have found to reverse this effect and even induce growth of neurons and improve synaptic plasticity in the brain.1,2
  2. Depression – Regular aerobic exercising can improve blood circulation to the brain and it is known to positively influence hypothalamus-pituitary-adrenal axis of the brain. All of this bounce back the balance of neurotransmitters, elevate mood, attenuate stress and fight back fear.3
  3. Addiction – While dealing with addiction, exercising has been shown to give a sense of control. Individuals with a tendency to be obsessive, need to fill a void quickly and exercising has shown to be effective in this regard.
  4. Hormonal fluctuations in women – Hormones estrogen and progesterone play an important role for neurotransmitter in the brain, by providing receptors for them to bind. In some women, this complex pathway can behave in a way that increases aggressive behavior which is found to be dramatically reduced by exercise. Exercising is certainly known to increase levels of tryptophan, the precursor to the happy chemical serotonin. This helps in dealing with the constant fluctuations of hormones during a cycle.1
  5. Attention deficits – Aerobic exercising has been successful with disorders of distractions, improving focus, concentration and memory of a task.

As with any given task, starting it – is always a challenge. If you are someone like me who is a novice at running, or the thought of running itself induces fear and anxiety – then start with small steps. Take a walk, slowly increase that to brisk walking and when you feel comfortable start jogging. It doesn’t necessarily even need to be running – jumping rope, biking, throwing ball – any activity that spikes your heart rate are good.

So, will you run away from your problems?

 

References:

  1. John Ratey, Spark: The Revolutionary New Science of Exercise and the Brain, ISBN:0316028355
  2. Carek PJ, Laibstain SE, Carek SM, Exercise for the treatment of depression and anxiety. Int J Psychiatry Med. 2011;41(1):15-28.
  3. Toups M, Carmody T, Greer T, Rethorst C, Grannemann B, and Trivedi MH. Exercise is an effective treatment for positive valence symptoms in major depression. J Affect Disord 2017; 209: pp. 188-194