hidden

Sexual Harassment in Medicine: reflections from the other side

The first week of March on Twitter was rather shocking for the entire medical community with news of a 45-million-dollar sexual harassment lawsuit against Oregon Health & Science University (OHSU) and a former anesthesia resident. Dr. Jason Campbell is accused in the suit of sending overtly sexual text messages and photos and sexually assaulting a social worker at the hospital. Women in Medicine (WIM) on different social media outlets (Twitter, Facebook, Instagram, and clubhouse) were outraged and shared their sexual harassment stories. For me, it was truly disheartening and took me back to my own experiences of sexual harassment since the early days in medical school. It bought back difficult memories as I was reminded of how over the years as this “stuff” happened, I had decided to hide it somewhere in my memory closet from where it couldn’t escape. This news and the other stories by WIM jolted my memory about all those painful experiences from back in the day to right in front of my eyes, whether I was ready to relive them or not. Like many other WIM expressed on social media I was numb to these happenings. I was sad for days. I feel vulnerable now writing about it since I never have shared any of these stories even with my family or parents. I just “dealt” with these incidences. It was part of my “normal” life as a woman, I had stopped recognizing how in my micro-conscious brain, this “small stuff” whether it was a remark about my body or an intentional touch by male colleagues or “unusual” and uncomfortable attention by men at work or by patients, bothered me over the years traumatizing me except I never wanted to give it any attention.

Our lives begin to end the day we become silent about things that matter!

–Martin Luther King Jr.

Years ago, in medical school during my final year in India, a tutor who would decide the patient subjects for the viva exam threatened to fail me in the exam if I didn’t “go” with him to his place on campus. I was frightened. I always ranked top in university and he blatantly had asked me if I didn’t follow what he said, I would lose my ranking. Thankfully, I was strong then as I am strong now and refused. I still remember those terrifying days leading up to the exams, I feared that he would follow me wherever I went, like an ominous dark shadow that was ever-present. I would sit in the library where I always remained visible to others rather than choosing my favorite quiet corners. I was given a completely normal patient during the exam but delivered a robust discussion about the normal anatomy and physiology of a women’s body. It was difficult to impress the examiner with a discussion focused on what is normal rather than around pathology, so my score was not as high as it may have been if I was given a more appropriate patient to discuss. Another time I had a patient who had an erection and asked me to touch him as I was examining his inguinal hernia. I was deeply affected by such incidences in medical school. This shaped my vision of coming to the United States for further training since I had heard that women in medicine in the US worked in better environments without such overt sexual harassment, but alas, I didn’t know how global the problem truly was. I would never forget getting stalked by the campus police officer as I was getting my passport to come to the US. I had to visit the police station to get the proof of identity and then found that police officer every day for a month outside my hostel, waiting to talk to me. Despite polite ways of telling him, I was not interested; he would show up the following day. How was I safe if the campus police officer was trying to stalk me? I still remember feeling terrified and thinking of being hurt every time I stepped outside the medical school hostel.

“When it’s “he said/she said,” the woman can’t win. But when it’s “he said/she said/she said/she said/she said/she said,” transparency has a chance, and light can flood the places where abusive behavior thrives.”

— Melinda Gates

More recently in the United States, I was asked by a leader in a medical organization (not my current institute) to meet over coffee. I genuinely thought it was for discussion of my career path as I received some “mentoring” from this individual. Midway during the meeting, he took something from my plate and said if it was allowed to eat from the plate of a date. My face went completely pale. How was this “meeting” and discussing my career a “date” that I never agreed to? I felt intensely uncomfortable and decided to leave after making an excuse. There are numerous other examples where I felt uncomfortable by colleagues, patients, or men at work that I just avoided- forget about confronting or reporting them. This “stuff” that made me uncomfortable back then and causes sympathetic overdrive even right now, while I am writing it, are examples of sexual harassment that makes me feel emotionally numb and forces me to hide it! Sexual harassment, stalking and discrimination is rampant during training for WIM even in 2021 in the United States. The power differential through the medical training makes it hard for our trainees to report it and as a result, the culture of chauvinism, and sexual harassment continues to grow.

“Sexual Harassment is not about attraction or desirability. It’s about exerting control over people whenever you can.”

— Anonymous

For anyone reading this post, I want to make one thing clear, any conversation or contact that makes the opposite person uncomfortable can be considered sexual harassment. Even in the cases where one may think they may have consented; the power differential NEVER gives the opposite person the freedom to consent. Sexual harassment is really not about sex. It’s about power and aggression and manipulation. It’s an abuse of power problem. We need to make sure that our trainees are empowered to report these incidences. We also need to make sure men start discussing these topics amongst themselves and identify the troubling language and behavior in fellow men and start calling them out. Men have to be interested in our safety for the culture to change. For either gender, we should acknowledge the bravery victims exhibit when they are sharing their story and thank them for confiding in us but more importantly give them the courage to report or do it for them. Medical organizations seriously need to understand that completing sexual harassment modules online does very little to prevent sexual harassment at the workplace. A stepwise approach that empowers the victim to report such incidences without fearing retaliation is a must.

I seriously cannot wait for a world of equity, equality, and accountability, where no one has the audacity to “accidentally” touch a woman without their permission, where women can thrive and are valued for their talent and brilliance and aren’t asked for sexual favors for a deserving opportunity, I cannot wait for a world where no one can utter the words “grab ‘em by their p****” and where the locker room talk isn’t about insulting womanhood.

This fight is difficult. I know there will be lots of disappointment and sadness like there was this month, which will be with us for a long time, but I am hopeful since these conversations are increasingly happening on social media openly and with candor!

“Self-respect by definition is a confidence and pride in knowing that your behavior is both honorable and dignified. When you harass or vilify someone, you not only disrespect them, but yourself also. Street harassment, sexual violence, sexual harassment, gender-based violence and racism, are all acts committed by a person who in fact has no self-respect.

Respect yourself by respecting others.”

— Miya Yamanouchi  

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

Post-Stroke Cognitive Impairment And Dementia And Risk Factors and Prevention

Dr. Rebecca Gottesman presented on Thursday during the Stroke Conference of 2021. She addressed the past, present, and future related to vascular dementia, mixed dementia, early stroke recovery, and precision medicine.

https://pubmed.ncbi.nlm.nih.gov/30784556/

In the past, the definition of post-stroke dementia was not necessarily uniform. She explains this is related to the term vascular dementia being sort of “tricky”. When classifying dementia you should consider, when you look, where you look, and whom you are looking at?

Many people can have dementia prior to having the stroke, this important when reviewing the prevalence rates after the stroke. Nearly 10% has dementia prior to stroke onset (1).

Dr. Gottesman highlights the need to review mixed pathologies for vascular dementia. The trajectories of onset and recovery vary between people. There can be a decline in cognition, followed by a recovery, then a further decline or an improvement. The Individual-level risk is important in post-stroke dementia.

https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.117.017319

Dr. Gottesman shared that the same stroke does not affect the person the same way (not every stroke leads to the same outcome). The individual risk profile will help individualize treatments and allow for more precision in medicine. She acknowledges that it is difficult to identify everyone who may have a stroke before they have an actual stroke. The meta-analysis from Oberlin highlights leisure activity as a potential way to reduce post-stroke dementia (2). Near the end of the presentation, Dr. Gottesman suggests we consider the following questions:

1) How do you consider aphasia and other cognitive deficits from the stroke?

2) How much time should pass after the stroke before you call it “dementia”?

3) How do you characterize dementia?

4) How do you characterize the dementia subtype?

5) How might future studies improve post-stroke cognitive outcomes?

We should consider the different prevention approaches due to the number of the different pathologies related to post-stroke dementia.

References

  1. Pendlebury ST, Rothwell PM. Incidence and prevalence of dementia associated with transient ischaemic attack and stroke: analysis of the population-based Oxford Vascular Study. The Lancet Neurology. 2019 Mar 1;18(3):248–58.
  2. Oberlin LE, Waiwood AM, Cumming TB, Marsland AL, Bernhardt J, Erickson KI. Effects of Physical Activity on Poststroke Cognitive Function: A Meta-Analysis of Randomized Controlled Trials. Stroke. 2017 Nov;48(11):3093–100.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

The “PFO Headache”: PFO closer in severe and refractory migraine

Migraine headaches are a heterogeneous and recurrent condition with multiple potential phenotypes, making long-term management and preventive treatment extremely challenging on clinicians. In the general population, the prevalence of migraine headaches is approximately 15% with a female-to-male ratio of 3:1.  Once diagnosed, simple analgesics should be used in mild to moderate cases, while triptans, -ditans, or -gepants should be used in the treatment of severe migraines. Emerging evidence has suggested that patent foramen ovale (PFO) may be associated with the development of migraines.  Surprisingly, at least half of people who suffer from migraines, particularly those with aura, have a PFO.[1, 2] It is important to consider that the prevalence in the general population is quite high, with an estimated prevalence of 20-25%. Indeed, most individuals with a PFO do not develop related health issues and remain generally asymptomatic. My theory is that the pathogenesis of refractory migraines, particularly those with an associated aura, is multifactorial including activation of neurons in the central or peripheral nervous system, hormonal dysregulation, structural changes (e.g., PFO), and genetic heterogeneity. Echo screening for PFO in severe and refractory migraines may be useful.

There is emerging evidence regarding PFO closure in patients with severe, refractory migraines based on several recent clinical trials (MIST, MIST II, ESCAPE, EASTFORM, PRIMA, and PREMIUM trials). These RCTs assessed the effect of PFO closure on preventing migraines.  Although they did not demonstrate a significant benefit of PFO closure (e.g., a significant reduction in migraine attacks at 6, 9 months or 1 year), these RCTS shed some light on the potential benefits of PFO closure (e.g., migraine improvement) in this population, compared to medical therapy alone. Interestingly, in a recent study published in JACC: Cardiovascular Interventions with a median follow up 3.2 [2.1 to 4.9] years, investigators found that PFO closure was associated with a significant improvement in migraine burden (headaches both with and without aura) and, notably, the absence of residual right-to-left shunt was a predictor of a significant reduction in migraine burden.[3] Emerging evidence suggests that both presence of PFO and migraine headaches have a genetic predisposition. I believe that migraines and PFOs are primarily heterogeneous polygenic disorders (except familial hemiplegic migraine – monogenic) and that the triage and algorithmic approach should be similar to that taken for patients with hypertrophic cardiomyopathy (HCM).  HCM is a monogenic disorder with an autosomal dominant pattern of inheritance, and a recent study showed that PFO and Migraine may be inherited in an autosomal dominant pattern as well. Overall, there are still many lessons to be learned from the HCM in order to adapt this methodology to the treatment of patients with PFO and migraines. A good place to start might be to determine whether PFO closure in migraines using the -omic approach (e.g., GWAS and PheWAS) to identify markers (e.g., SNP, metabolites associated with atrial stunning) is needed. Ideally, testing common genetic mutations in individuals (e.g., endocardial and neuronal alteration-related genes) with both PFO and migraine may a good start before a genome-driven clinical trial of prophylactic PFO closure. I proposed the algorithm to use genetic-guided PFO-migraine management. (Figure)

In the future, PFO screening in Migraine patients with high-risk features (e.g., genetic mutations and deep-sea divers) may be needed and PFO closure in these populations may be beneficial. Currently, there is a significant lack of genetic data in this area, and future clinical trials are needed to determine the potential benefit from PFO closure in patients who suffer from migraine headaches.

REFERENCES

  1. Niessen, K. and A. Karsan, Notch signaling in the developing cardiovascular system. Am J Physiol Cell Physiol, 2007. 293(1): p. C1-11.
  2. Sadrameli, S.S., et al., Patent Foramen Ovale in Cryptogenic Stroke and Migraine with Aura: Does Size Matter? Cureus, 2018. 10(8): p. e3213.
  3. Ben-Assa, E., et al., Effect of Residual Interatrial Shunt on Migraine Burden After Transcatheter Closure of Patent Foramen Ovale. JACC: Cardiovascular Interventions, 2020. 13(3): p. 293-302.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

Effects of COVID-19 on Acute Ischaemic Stroke care: Comparative insights from Get With The Guidelines-Stroke registry

Much like acute myocardial infarctions, the optimal management of acute ischaemic stroke (AIS) is extremely time-sensitive. The foundation of favorable outcomes of AIS lies in the timely presentation and acute intervention by means of either intravenous thrombolysis and mechanical thrombectomy. Especially earlier on during the COVID-19 pandemic, there was a concern regarding a decline in non-COVID acute medical admissions, as well as hospital-based challenges to appropriate and timely delivery of acute stroke care.

A study led by Dr Pratyaksh Srivastava and colleagues, published in Stroke, uses data from the American Heart Association (AHA)’s Get With The Guidelines Stroke (GWTG-Stroke)® registry, to compare characteristics, treatment patterns, and in-hospital outcomes of 81,084 patients over two time periods: before COVID and after the first reported case of COVID-19 (1). The AHA’s GWTG-Stroke registry is a validated and reliable national registry of adults with stroke in the United States (2,3). This blog provides a brief summary of the key findings of this analysis.

The study cohort and comparisons:

81,084 AIS patients were included over a period extending from 01st November 2019 to 29th June 2020, from among 458 participating hospitals with at least one positive COVID-19 patient. They were divided into two groups, according to the first reported case of COVID-19 in the registry. The pre-COVID group consisting of 39,113 patients (01st November 2019 to 3rd February 2020) and the during COVID group, consisting of 41,971 patients (4th February 2020 to 29th June 2020).

The two groups were compared for characteristics, treatment patterns, and outcomes. These analyses were repeated in sensitivity analyses, comparing a later during COVID-19 time period (1st April 2020 to 29th June 2020) to the same pre-COVID-19 time period. There were no differences in general characteristics among patients of the two time periods. 48.8% of the cohort were women. 61.9% were White. 2.7% of patients in the during COVID-19 group had a diagnosis of COVID-19.

Key findings from the study & implications:

There was a 15.3% average reduction of stroke presentations per week in the during-COVID-time period (3rd February 2020 to 24th May 2020) when compared with similar months in 2019. This is perhaps a reflection of general trends (4,5) in the immediate aftermath of the pandemic, partially reflecting an anticipated lack of capacity in overburdened health systems, the effect of shelters in place and social distancing disorders (5), and patients delaying or avoiding seeking medical care due to concerns of contracting COVID-19(6).

Treatment patterns:

Similar rates of acute interventions for AIS were observed in pre-COVID and during-COVID time periods. There were no differences in rates of intravenous alteplase (11.7% vs. 11.4%, p=0.26) or endovascular therapy (10.2% vs. 10.1%, p=0.90) pre- and during COVID respectively.

Furthermore, there were also no additional delays in administering care. Median door to needle times (46 [32-65] minutes vs 46 [33-64] minutes; p= 0.69) and door to endovascular times (86 [53-129] minutes vs 90 [54-134] minutes; p=0.06) were not different between the pre-COVID and during COVID periods respectively. This is crucial and encouraging data, given the time-sensitive nature of acute stroke care and the delays that were anticipated during the COVID-19 period, from having to don personal protective equipment (PPE).

Also, door to computed tomography (CT) time was slightly shorter during the COVID-19 time period (median 35 [14-100] vs 37 [15-111] mins, p<0.001). A significant uptake of telestroke consult was observed during the COVID-19 period as compared with pre-COVID (6.0% vs 7.1%; p <0.0001).

GWTG-Stroke quality measures: 

Slight decreases were observed in rates of timely IV alteplase administration, prescription of antithrombotics at discharge, dysphagia screen, smoking cessation counseling, stroke education, and rehabilitation consideration in the during-COVID-19 group.  Despite this, these quality measures remained above the 85% target, suggesting the maintenance of quality care during the pandemic.

Outcomes:

Adjusted inpatient mortality of AIS was similar between pre- and during COVID-19 periods (4.8% vs. 5.2%; odd ratio 1.05, 95% CI 0.97-1.13), consistent with prior published studies (5,7). Also, in these adjusted models, no significant differences were observed for other outcomes such as symptomatic intracranial hemorrhage among IV alteplase patients, venous thromboembolism or pulmonary embolism during hospitalization.

In terms of patients’ disposition, there were reduced odds of discharge to skilled nursing facility (OR 0.78, 95% CI 0.74-0.82) and of a hospital stay >4 days during COVID-19 time period (OR 0.84, 95% CI 0.81-0.87), and increased odds of discharge to hospice (1.12, 95% CI 1.03- 1.21), and to home (OR 1.12, 95% CI 1.09-1.16) during COVID-19 period. These possibly reflect a hesitancy towards prolonged hospital stays, competing pressures on beds and skilled facilities, and tendency to triage away from high-risk environments.

Sensitivity analyses:

Apart from a slightly longer, and perhaps clinically insignificant, time from door to endovascular treatment in the later during COVID-19 group, findings remained largely similar in sensitivity analyses comparing those presenting in the later COVID-19 time period to those presenting pre-COVID-19.

Limitations:

Given its retrospective, observational nature, this study is limited in its ability to only evaluate, but not infer causality, with descriptive statistics performed being hypothesis generating. Not all data were complete and the observed decline in AIS patients during the pandemic may be due to lags in data entry. Furthermore, these findings may not be generalizable to hospitals that differ from GWTG-Stroke and international cohorts.

Key take-home message:

Despite an observed 15.3 % average decline in AIS presentations during the pandemic, this analysis from the GWTG-Stroke registry demonstrates preserved AIS care quality in the pre- and during COVID-19 time periods with similar door to needle, and door to endovascular times, similar rates of IV alteplase therapy, endovascular therapy, and adjusted in-hospital mortality.

For more latest science on Stroke and Neurology, be sure to register and attend the International Stroke Conference – happening now!

References

  1. Srivastava PK, Zhang S, Xian Y, et al. Acute Ischemic Stroke in Patients With COVID-19: An Analysis From Get With The Guidelines–Stroke. Stroke. 2021;52:00–00. DOI: 10.1161/STROKEAHA.121.034301
  2. Ormseth CH, Sheth KN, Saver JL, Fonarow GC and Schwamm LH. The American Heart Association’s Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol. 2017;2:94-105
  3. Xian Y, Fonarow GC, Reeves MJ, Webb LE, Blevins J, Demyanenko VS, et al. Data quality in the American Heart Association Get With The Guidelines-Stroke (GWTG-Stroke): results from a national data validation audit. Am Heart J. 2012;163:392-8, 398 e1.
  4. Diegoli H, Magalhaes PSC, Martins SCO, Moro CHC, Franca PHC, Safanelli J, Nagel V, Venancio VG, Liberato RB and Longo AL. Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era. Stroke. 2020;51:2315-2321.
  5. Nguyen-Huynh MN, Tang XN, Vinson DR, Flint AC, Alexander JG, Meighan M, Burnett M,Sidney S and Klingman JG. Acute Stroke Presentation, Care, and Outcomes in Community  Hospitals in Northern California During the COVID-19 Pandemic. Stroke. 2020;51:2918-2924
  6. American College of Emergency Physicians. Public Poll: Emergency Care Concerns Amidst COVID-19 https://wwwemergencyphysiciansorg/article/covid19/public-poll-emergency care-concerns-amidst-covid-19. 2020.
  7. Tejada Meza H, Lambea Gil Á, Sancho Saldaña A, Martínez-Zabaleta M, Garmendia Lopetegui E, López-Cancio Martínez E, et al; NORDICTUS Investigators. Impact of COVID-19 outbreak in reperfusion therapies of acute ischaemic stroke in northwest Spain. Eur J Neurol. 2020;27(12):2491-2498.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

Conquering the K99 (Part 2)

Greetings postdocs! Are you thinking about applying for a K99/R00 Pathway to Independence Award?  Here are ten tips to help you get started.

  1. Make a submission timeline and apply sooner rather than later

To apply for a K99, an applicant must not have more than four years of postdoctoral research experience. Surprisingly, determining your postdoctoral start date is not trivial. Generally speaking, the clock begins when your degree was conferred (a date documented by your university). Recently, the NIH released two notices indicating that an applicant can apply for a one-year extension on their eligibility window due to childbirth (NOT-OD-20-011) or a two-receipt cycle extension due to disruptions caused by COVID-19 (NOT-OD-20-158). In deciding when to apply, you need to do the submission math to ensure that you provide yourself enough time to resubmit your application if required. There are three times a year (or cycles) in which you can apply. The review process is long, and you must account for a gap cycle between the initial submission and resubmission. For example, if you apply for a K99 in the first cycle, you will not get your score and comments back in time to resubmit in the second cycle. The earliest you will be able to resubmit your application is in the third cycle.

  1. Make a checklist

The K99 is a beast of a proposal. In the end, my K99 application was 87 pages long. But, fear not. The trick is to divide and conquer. First, go to the NIH Grants and Funding website and download the application guide. Then, to stay organized and motivated, make a checklist of all the items you need to prepare. Here is the checklist I made below.

*Items that you will need to gather from others.

  1. Create and adhere to a writing routine

Establish a writing routine to avoid panic writing and sleepless nights. Specifically, create a list of writing rules for yourself. Determine when you will write, where you will write, and the conditions under which you will write. To build accountability, share your writing plan with others and establish artificial deadlines to ensure you stay on track to complete your application on time. For more writing routine ideas, check out the article “Ten simple rules for scientists: Improving your writing productivity” (Peterson et al., 2018) for inspiration.

  1. Sketch out your research plan before you write your specific aims

In writing a K99, one of the most intimidating tasks is to develop a research plan that is that the magic combination of significant, innovative, and feasible. In coming up with a plan, start early, create rough outlines, discuss your unrefined ideas with other scientists (i.e., friends, lab members, and mentors), and then edit as needed until you have a solid plan. Once you have a solid plan, then begin writing your specific aims. In preparing your research plan, avoid nested aims, where one aim’s success depends on another aim’s success. Also, focus on hypothesis-driven science where any outcome (positive or negative) is informative. Avoid writing yourself into experimental corners and dead ends.

  1. Identify the NIH institute that is right for you

The NIH consists of 27 different institutes and centers. To determine which institute to apply to, use the NIH RePORTER Matchmaker tool to find the institute that is the best match for your research. If there are multiple options available, look up the published success rate of an institute’s K99s and consider picking the institute with the higher success rate. Alternatively, choose the institute where your mentor has already successfully applied to and received an NIH grant.

  1. Contact your institute’s program officer

After you write a solid draft of your specific aims, contact your institute’s program officer. What is a program officer? Each NIH institute has program officers responsible for a set of grants (Ks, Fs, or Rs). Throughout the application process, the program officer is your primary NIH contact with whom you discuss materials regarding your grant’s content. The program officer makes significant funding decisions, including if your grant fits within the scope of the institute you are applying to. Thus, it is important to contact them sooner rather than later. Before you write the rest of your proposal, check in with your program officer to ensure that your grant matches the institute. You don’t want your grant to get rejected because of a poor fit.

  1. Gather an excellent scientific mentoring team

One of the joys of the K99 writing process is that you have the opportunity to submit six letters of support. Use this opportunity to initiate collaborations and build an incredible scientific mentoring team that will help you execute experiments and provide mentorship for the long uphill climb that is obtaining a faculty position.

  1. Don’t forget that the K99 is a transition grant, so let your training potential shine through

A common mistake is that people overstate their early postdoctoral accomplishments, elaborating on all that they have already learned and executed. Singing your praises is excellent, don’t take it out! However, don’t forget to include plans that beautifully elaborate on all the learning the K99 will fund and how this additional knowledge will elevate your science. Remember, the K99/R00 is a transition award. The K99 is supposed to be the training period that prepares you for the R00 independent phase.

  1. Plan ahead and carve out the time to prepare a solid application

My mentor told me that time is your most precious resource. The K99 requires a lot of time and planning to execute well. If possible, put your experiments on hold and commit focused time to prepare your application. In addition to communicating with your program officer at the NIH, initiate early communications with the individuals at your university/institute that will help you prepare your budget and potentially other components of your grant.

  1. Talk to others

Regardless of how much you read and how thoroughly you go through the application materials, you will have questions as you prepare your application. For these questions, your most powerful asset is your mentor and your postdoc peers that have already applied, so seek their advice. The process is long and hard, but regardless of the outcome, the exercise of writing the grant will help you think more deeply about your science and facilitate new collaborations.

Good luck and happy writing!

 

References

Peterson TC, Kleppner SR, Botham CM (2018) Ten simple rules for scientists: Improving your writing productivity. PLoS Comput Biol 14(10): e1006379. https://doi.org/10.1371/journal.pcbi.1006379

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

hidden

The Great Terror of Oral Anticoagulant Use: Intracerebral hemorrhage

I am pleased to summarize a recent paper published by Dr. Xian Et.al on the clinical characteristics and outcomes associated with oral anticoagulants (OAC) use among patients hospitalized with intracerebral hemorrhage (ICH)1.

Major question addressed in the paper: 

What is the association between prior oral anticoagulant use (FXa inhibitor, Warfarin or none) and in-hospital outcomes among patients with nontraumatic ICH?

Approach:  

The investigators used the American Heart Association Stroke Association Get with The Guidelines-Stroke (GWTG-Stroke) registry to evaluate patients between October 2013 and May 2018, that had experience non-traumatic ICH with preceding use of FXa inhibitor compared with warfarin or none.  Patients with subarachnoid hemorrhage, subdural hematoma, or taking dabigatran were excluded. Included patients were defined by documentation ICH and use for at least 7 days of OAC, in three different groups: FXa inhibitor (rivaroxaban, apixaban, edoxaban); warfarin, or no use of OAC prior to hospital arrival and ICH.

Main outcomes and measures:

  • Primary outcome: In-hospital mortality
  • Secondary outcome: Composite of in-hospital mortality or discharge to hospice, discharge home, independent ambulation, and modified Rankin Scale (mRS) score at discharge.

Results:

Generals

  • Of 219,701 patients in the study, 104,940 were women (47.8%), 189,069 were not taking any OAC prior to ICH (86%), 9202 were taking FXa Inhibitors (4.2%), and 21,430 (9.8%) were taking warfarin.
  • One third of patients were taking concomitant antiplatelet therapy. This was more prevalent amongst patients taking FXa inhibitor (27%) and warfarin (30.1%) than those without taking OAC (24.8%).
  • NIHSS median score was 9 amongst the three groups. Patients taking warfarin had a higher mean NIHSS (12.5 {SD:11.3}).

Major results

  • FXa inhibitors (aOR: 1.27; p<0.001) and warfarin (aOR: 1.67; p<0.001) were associated with greater odds of in-hospital mortality compared with no OAC.
  • FXa inhibitors (aOR: 1.19; p<0.001) and warfarin (aOR: 1.50; p<0.001) were associated with greater odds of death or discharge to hospice compared with no OAC.
  • Patients with FXa were less likely to die (aOR 0.76; p<0.001) or be discharged to hospice (0.79; p<0.001) compared to those taking Warfarin.
  • Patients taking FXa were more likely to be discharged at home (aOR1.18; p<0.001) and have better mRS scores at discharge (aOR 1.24; p<0.001).
  • No statistical difference was found amongst the three groups regarding rates of discharge home, independent ambulation, or mRS score.
  • The use of single or dual antiplatelet, in patients taking warfarin was associated with higher odds of in-hospital mortality (aOR 2.07; p<0.001), and dead or discharge to hospice (aOR 1.86; p<0.001).

Major study limitations:

  1. The use of OAC use was defined as patients taking them 7 days prior to ICH, however the timing of the last doses of the OAC was not document, and it is possible that some patients might have not taken it or received a lower dose.
  2. Data regarding platelet transfusion was not recorded on the registry, and this might have influenced outcomes.

Key take-home message:

One of the most devastating complications of the use of FXa inhibitors is ICH, and although its prevalence is low (<0.5%), the in-hospital mortality can be as high as 27% as it was found on this study.  Although its high, when compared with prior use of warfarin, taking FXa inhibitors has a lower risk of mortality and dead or discharge to a hospice in the setting of ICH.

Potential future research:

  • Develop prospective studies that compare the available treatments for spontaneous ICH bleeding, four-factor prothrombin complexes concentrate vs. reverse factor Xa inhibitors (Andexanet). An underpowered retrospective study by Ammar et. Al,2 found no difference between these treatments due to the low number of patients analyzed in this study. Due to the burden of this complication we must find the most adequate treatment for non-traumatic ICH in the setting of FXa inhibitor use.

 

References:

  1. Xian Y, Zhang S, Inohara T, et al. Clinical Characteristics and Outcomes Associated With Oral Anticoagulant Use Among Patients Hospitalized With Intracerebral Hemorrhage. JAMA Network Open. 2021;4(2):e2037438-e2037438.
  2. Ammar AA, Ammar MA, Owusu KA, et al. Andexanet Alfa Versus 4-Factor Prothrombin Complex Concentrate for Reversal of Factor Xa Inhibitors in Intracranial Hemorrhage. Neurocrit Care. 2021.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

Why Diversity Matters: from a fellow perspective

In this blog, I want to share my thoughts on diversity, why it matters in medicine, especially in cardiology.

Why does diversity matter in medicine?

We all are seeing more and more diverse patients, especially in the United States, where “minorities” who come from various backgrounds and cultures constitute a significant proportion of our patients, yet there remain significant disparities across various levels of social life and health care.

Effective Communication

While the language is key in order to provide effective communication between patients and physicians, optimal care should be provided to all patients, irrespective of their origin or language proficiency. Interpreters can help in person or using online resources.

Understanding the Culture

In addition to the language, culture differs significantly between various populations, even those speaking the same language might have different cultures. This is an important part of the patient-physician relationship. One example of how to improve that would be that we try to talk briefly with our patients about their preferences and what is important to them, especially when it comes to goals of care.

Diversity in the Workplace

The importance of culture and diversity in the workplace is tremendous; not only does it add to the various perspective each physician has on the discussion table or their different approaches in taking care of patients, but also it familiarizes our patients with our diverse workforce. With that being said, seeing more women in cardiology, and cardiologists of various backgrounds is crucial to deliver that message.

What are our leading societies doing to promote diversity?

Thankfully, our leading societies, in medicine, cardiology, and other specialties, have recognized the impact of diversity on the workforce and its role in taking care of the growing diverse population we have been seeing. The American Heart Association (AHA) and American College of Cardiology (ACC) among other societies have continued to work relentlessly to advocate for our patients, fight structural racism and health inequity while promoting diversity and inclusion in the cardiology workforce [1,2]. With that being said, having mentors from similar backgrounds helps juniors find role models to look up to, including students, residents, and maybe fellows who have just started their journey and looking for guidance. Talking about my own experience, I have had mentors from various backgrounds, including my background, and this helped me in so many different ways. I do believe our cardiology community has amazing leaders and role models, and together we can make the future brighter for everyone!!

 

References

  1. AHA website: Diversity and inclusion https://www.heart.org/en/about-us-shared/diversity-inclusion
  2. ACC Diversity and inclusion https://www.acc.org/about-acc/diversity-and-inclusion

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

Hindsight 2020: Lessons From a Calendar Year of COVID

This month signifies a full calendar year since the covid-19 pandemic has been declared a crisis and activated a worldwide response. To be exact, the WHO declared covid-19 a pandemic on March 11th, 2020. Of course, the signs were there beforehand. Starting in December 2019, there were officials in China focusing their attention on the city of Wuhan, where a flu-like disease was spreading in a cluster linked to a specific local market. By January 2020, reports of first deaths and first confirmed cases outside of China started to pop up around the world. And in early February, the news about clusters in France, Germany, cruise ships and more, should have made it clear (in retrospect) that we have a global infectious disease spreading around us. It took the world another 5-6 weeks to actually call it a Pandemic. As of mid-March 2020, our approaches have dramatically pivoted, and here we are a year later, living (with tragic numbers of losses and challenges) in a new world.

I wanted to take this calendar-year anniversary to reflect and examine some of my early thoughts and approaches to navigating the covid-19 pandemic. I’m taking full advantage of the fact that I was afforded the ability to write a blogpost on a monthly basis here in the AHA Early Career Voice (author page) as the crisis was unfolding. Within this space of reflection, I’ll try to spotlight and share some learning moments and lessons learned, in an effort to progress and adapt to the ever-changing world I was (and still am) navigating, as an early career scientist in cardiovascular & biomedical research.

In March 2020 I wrote a blog titled “Science Communication Is The Bridge We Need”, not specifically addressing Covid-19, but the pandemic was definitely was a topic on my mind from what I was reading early last year. I wanted to share my thoughts and personal viewpoint, that echo chambers and microenvironments of news sharing are dominating the internet, and scientific facts are getting missed/lost/covered up. In hindsight, it’s pretty clear that many decision-makers and lots of folks were simply not placing the required amount of urgency and focus on the news about Covid-19 that was spreading worldwide. My two-cents back in March 2020 were that more robust science communication can help with evidence-based news information sharing. I admit I’m proud of that March 2020 blogpost, no redo needed!

By April of last year, my thinking was already shifting with regards to how the pandemic is going to affect early career advancement, and what paths may be ahead. The title of that blog post was “Future Planning in the Time of Corona”, and again, I feel good about how this blogpost holds up! The theme in that written piece was centered on the often cited political tagline “Never let a crisis go to waste”. My take was that a global pandemic is one of the few causes that can truly bring to attention plans and areas of need that a vast majority of the world population can together work on.

A month later, in May 2020 I think I was slightly too optimistic and jumping a little bit ahead of myself! The title of the blogpost was “COVID-19 Stage 2: Embracing Progress, Cautiously”, and while I’m glad I measured my wording… it is now more accurate to say that most of the globe was still in Stage 1 of dealing with the pandemic back in May of last year. In June I wrote about my year-long leadership experience in my local institute’s trainee committee, my way of taking a break from always writing about the pandemic.

By July of 2020 I noticed what we now call pandemic (or covid) fatigue, and the rising tides of anti-science sentiments that started to build up as a result of the masking and social distancing regulations that have changed from one set of recommendations to a different set of ideas within a few months (from March to July). This is why I felt the need to write “Knowledge Advances Incrementally”, a blogpost where I spotlight the main working ethos of the scientific method, which boils down to:

  • Have a question
  • Come up with a testable hypothesis
  • Run the experiment
  • Collect data and analyze results
  • Verify/validate results by replication
  • Conclude what new information you can, making sure to stay exactly within the boundaries of the experiments and data you collected.

The last thing I’ll highlight is my blogpost recapping my experience in attending and participating in the annual Basic Cardiovascular Sciences (BCVS) meeting. This was the first major conference meeting that I have previously attended in-person that switched to a virtual format. I titled that blog post “A New Way To Participate”, and in retrospect, it was one of the most instructional and useful learning experiences that summer. I discussed the advantages (and challenges) that the virtual conference format brings to early-career scientists. Additionally, I pointed out some tips and tricks on how to navigate a fully online annual meeting. Back then there were a lot of wrinkles and tweaks that we learned from, and have implemented in other virtual conferences later in the year. My overall opinion still is positive, and I think that a future that includes an in-person meeting supplemented and balanced with an online component is the best way to progress and upgrade the conference format.

My take-home message today, looking back at this full calendar-year of covid exceptional circumstances, boils down to this: Humility, empathy, and optimism for a better future are essential keys to navigating the rough waters of living through a pandemic. Take care of yourself, and if possible, be helpful to others.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

Entresto Use in Heart Failure w Preserved Function

Heart failure is a pervasive diagnosis and unfortunately about 6.2 million adults in the United States suffer from this disease.1 Furthermore, heart failure represents a significant proportion of total healthcare expenditures including the cost of healthcare services, medicines to treat heart failure, and missed days of work. While we often focus on the management of heart failure with reduced ejection fraction, epidemiological studies report about 50% of all heart failure patients have preserved function.2 Heart failure patients with preserved function have similar rates of hospitalization and death when compared to heart failure patients with reduced function.2

While there are several treatment options that have proven mortality benefit in chronic heart failure patients with reduced function, the treatment options for patients with preserved function are limited. 

Following the results of the PARADIGM-HF trial, PARAGON-HF was an industry funded, multi-national, double blinded trial that attempted to determine whether entresto was more effective than valsartan at lowering the rate of total hospitalizations for heart failure and death from cardiovascular causes. The investigators of this trial randomly assigned 4822 patients with symptomatic heart failure with preserved function (left ventricular ejection fraction [LVEF] ≥ 45%) to entresto or valsartan alone. The primary endpoint was total hospitalizations for heart failure and death due to cardiovascular causes.

Regarding the patient group studied; the mean age of the patients was 73 years, 52% were female, only 2% were black, and the average ejection fraction was approximately 57%.  The investigators found that entresto did reduce the rate of the primary endpoint by 13% (rate ratio, 0.87; P = .06). The data shows that the lower event rate was mostly driven by fewer hospitalizations for heart failure. Notably, death due to cardiovascular causes was essentially the same with 204 deaths in the Entresto group  and 212 deaths in the valsartan group.3

Following the PARAGON-HF trial, the FDA has now granted an expanded indication to Entresto that would allow for use of the therapy in at least some patients with heart failure and preserved ejection fraction (HFpEF). The manufacturer Novartis touts that this is the first time that there is a heart failure treatment with an indication that includes patients with preserved function. While it is truly an amazing feat to now have an FDA indicated drug for this patient population, the effect on hard cardiovascular outcomes as suggested by PARAGON-HF are marginal. Further studies should be conducted to determine whether the drug is more effective in certain patient populations in order to truly understand the potential benefits of entresto in heart failure with preserved function.

  1. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association external icon Circulation. 2020;141(9):e139-596.
  2. 1.Gladden JD, Linke WA, Redfield MM. Heart failure with preserved ejection fraction. Pflugers Arch 2014;466:1037-1053
  3. Solomon SD, McMurray JJV, Anand IS, Ge J, Lam CSP, Maggioni AP, Martinez F, Packer M, Pfeffer MA, Pieske B, Redfield MM, Rouleau JL, van Veldhuisen DJ, Zannad F, Zile MR, Desai AS, Claggett B, Jhund PS, Boytsov SA, Comin-Colet J, Cleland J, Düngen HD, Goncalvesova E, Katova T, Kerr Saraiva JF, Lelonek M, Merkely B, Senni M, Shah SJ, Zhou J, Rizkala AR, Gong J, Shi VC, Lefkowitz MP; PARAGON-HF Investigators and Committees. Angiotensin-Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction. N Engl J Med. 2019 Oct 24;381(17):1609-1620. doi: 10.1056/NEJMoa1908655. Epub 2019 Sep 1. PMID: 31475794.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

Building an academic portfolio during medical training: Part 3 – The art of reaching out

A year ago, I started a blog series about how to build an academic portfolio during medical training. After the first 2 blogs, COVID-19 hit us hard, and I felt the need to switch gears to address more pressing issues. Now that things are starting to finally move in the right direction, I thought it would be a good time to pick up where we left off.

In Part 1, I discussed why I believe that it is important for medical students and trainees to consider research collaborations outside their own institutions, and what types of research studies can be performed using this type of collaboration between young researchers. In Part 2, I expanded on the different ways you can find established multi-institutional teams of young researchers.

Once you have decided on the researchers that you would like to collaborate with and join their established teams, the next logical step in this process would be to reach out. What is the best approach to use when reaching out, and how can you maximize your chances of success? The following tips may help you achieve this (Figure*):

  • Be as detailed as possible. When reaching out, it is essential that you provide as many details as possible: who you are on the professional level (level of training, career plan, etc..), what area of research you are interested in, how novice or advanced you are in the field of research (prior experiences) and what research skills you possess (basic data collection, literature review, statistical knowledge, experience with particular software or database, etc..). The more details you provide, the more likely it that you will receive a favorable response to your request. It also ensures that you join a team that constitutes the best fit for your career goals, and increases the likelihood of this collaboration being productive.
  • Be honest. As much as it is important to present yourself in the best possible way, it is even more important, to be honest about what you are able or not able to do, and what you are willing to learn. One of the crucial aspects of collaboration is reliability.
  • Don’t be afraid of presenting ideas. If you happen to have some research ideas that you would like to pursue, don’t be afraid of bringing them up on your first contact. You don’t have to provide all the details of what you have in mind, but simple broad lines about some of the areas that you would like to explore may help the person you are contacting in evaluating the utility of potential collaboration.
  • Ask about what the team needs. If you are really serious about joining a specific research team, it may be a good idea when you first reach out, to inquire about the skillsets that the team is currently looking for in a collaborator. This not only shows how dedicated you are but increases the likelihood of having a productive collaboration.
  • Reach out to more than one team/ person. Research is a very dynamic process, and at any given time a certain team may or may not have an ongoing project with room for additional collaborators. Therefore, reaching out to more than one team is a reasonable approach to avoid a long waiting time before embarking on your first project.
  • Circle back. For the same reason mentioned in the prior comment, it is common that you will receive a response like “we would be happy to collaborate, but we don’t currently have a new project for you to join”. Don’t take this as a polite rejection, because it usually is not. Circle back in a couple of months and ask nicely if the situation has changed. In the meantime, you may use tip #4 to make use of the waiting time in a way that shows dedication and improves your portfolio.

Importantly, keep in mind the general rules for teamwork. As much as teams are looking for someone who is valuable and resourceful, they are also looking for someone who is easy to work with. Being professional, collegial, hard worker, flexible and enthusiastic always goes a long way!

Figure created with BioRender.com