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Coronary Allograft Vasculopathy – The Achilles’ Heel of Heart Transplant

As a 3rd year medical student in the coronary care unit (CCU), I helped care for a patient whose story I will never forget. She had developed advanced heart failure due to peripartum cardiomyopathy in her 20s giving birth to her only child and required a heart transplant. She did well for a number of years, but I met her in her 30s when she was admitted post-MI in cardiogenic shock. Her coronary atherosclerosis was due to severe coronary allograft vasculopathy (CAV), an aggressive form of CAD transplant patients may develop. She got a LAD stent and was supported with a balloon pump but was tenuous at best. Some days after her PCI, in a moment seared into my memory, she let out an ear-piercing yell and suddenly arrested and died, her daughter at the bedside. I’ll always remember the pain on her child’s face when she passed, and I will always have a sincere appreciation for the misery CAV can cause. This blog is meant to provide some historical context to heart transplantation and the issue of CAV, as well as to discuss ways we can prevent it.

Since the first heart transplant in Cape Town, South Africa, there have been tremendous advances in cardiac transplantation with median survival now around 12 years. It didn’t always appear that this would be the case, with mortality so high in the early days that many felt heart transplant wasn’t worth it. The advent of calcineurin inhibitors with cyclosporine in the 1980s and tacrolimus in the 1990s were key (Figure 1). Steady improvements in infection prophylaxis, screening for and treating rejection, and surgical technique and expertise further helped the cause.

But as we addressed one set of problems, we found another. CAV is an aggressive form of coronary artery disease (CAD) present in 30% of heart transplant recipients at 5 years and 50% at 10 years. Those with it have worse survival. It shares some risk factors with classic CAD but has several of its own, and there are key pathophysiologic differences (Figures 2 and 3). Our patient was unique in that she had a true plaque rupture MI, typically occurring less often with CAV relative to classic CAD, but this may have been related to a donor transmitted lesion acting more as typical CAD would.

Figure 2. Pathophysiologic Differences

Figure 3. Risk Factors

So how do we prevent CAV? Our best data comes from statin trials in the 1990s-2000s (pravastatin, simvastatin, and atorvastatin studied), showing lower rates of rejection and CAV with improved survival in transplant patients treated with statins. This makes intuitive sense, as dyslipidemia is a rock-solid risk factor for classic CAD and nearly universally seen post solid organ transplantation due to the metabolic consequences of common immunosuppressives. These immunosuppressives, while life-saving in their own right, also lead to worsening glucose control, hypertension, obesity, and kidney disease. Addressing each of these while encouraging a heart-healthy diet and routine exercise is of paramount importance in keeping our transplant patients healthy. Finally, a reminder that there are many drug-drug interactions with transplant medications. Figure 4 is adapted from Warden et al and shows the relative degree of interactions between immunosuppressives and common lipid-lowering drugs.

Figure 4. Drug-Drug Interactions

While this story was tragic for the patient and her family, it’s given me a profound respect for CAV that I will carry forward when I eventually care for heart transplant patients in my career.  Below are the references for this article from which parts of the figures were taken. Each of these is a fantastic resource for further learning.

References:

  1. Stehlik, J., et al. (2018). “Honoring 50 Years of Clinical Heart Transplantation in Circulation: In-Depth State-of-the-Art Review.” Circulation 137(1): 71-87.
  2. Warden, B. A. and P. B. Duell (2019). “Management of dyslipidemia in adult solid organ transplant recipients.” J Clin Lipidol 13(2): 231-245.
  3. Costanzo, M. R., et al. (2010). “The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients.” J Heart Lung Transplant 29(8): 914-956.

 

 

 

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Equity & Inclusion in Medicine – Part III: How to Create a Diverse Cardiology Workforce

In Part I, I discussed experiences of BIPOC in medicine as well as those underrepresented in cardiology as a framework to build understanding. In Part II, I made a good case for why diversity will help cultivate innovation and improve health disparities. In the final part of this blog series, I will review how cardiology programs can improve diversity.

We are in an era of great reflection and growth as we endure the extreme pressures of the COVID19 pandemic. This horrendous experience has fostered some positivity which is the strong motivation towards racial harmony and equity. This is a special time of modernity and we can capitalize on this momentum by amplifying initiatives towards increasing diversity in cardiology.

The Duke cardiology group published a data-driven manual on how cardiology fellowships can improve diversity, especially for those who are underrepresented. In this article, Rymer et al. 1 designed a quality improvement study from 2017-2019 with the aim of increasing the numbers of underrepresented cardiology fellows in their training program. This initiative included reorganizing the fellowship recruitment committee, changing the applicant process and interview day, as well as making changes to the applicant ranking process. Finally, there was a postmatch intervention. This involved developing a diversity and inclusion task force to spearhead these initiatives. Comparing applicants 10 years before and during the intervention period, there was a significant increase in women and underrepresented applicants. Women increased from a 5-year mean of 27% to 54.2% after the intervention and underrepresented fellows increased from 5.6% to 33.3%. After the intervention, the fellowship population was 2/3rds either women or members from an underrepresented ethnic group!

Williams et al. further pushed toward cultivating an antiracist cardiology culture in their article entitled: How to Build an Antiracist Cardiovascular Culture, Community, and Profession 2. The authors took a deep dive into several ways to build a diverse team. They state that to purposely create a culture of diversity, especially for those that lack diversity; programs should aim to share their objectives in creating a less biased training program for applicants. This strategy also includes having a diversity and inclusion committee to evaluate promotional materials to ensure they do not include racially biased language. Once trainees are there, they recommend continuing this initiative by having structured teaching sessions that include implicit bias training. They further recommend allowing for space for underrepresented trainees to share microaggressions. One example of a microaggression expressed by underrepresented physicians is constant questioning regarding country of origin or ability to speak English with a condescending tone. These stories can be shared on a personal level to help each other understand and appreciate different experiences.

There are professional ways to support trainees and create an inclusive environment. The authors suggest encouraging respect by introducing fellows as “Dr.” and leaders of the team. They emphasize intentional mentorship for underrepresented trainees shared amongst faculty. They further warn against perpetuating the “minority tax”, which puts the entire onus of diversity and inclusion on faculty of color with often a lack of compensation. In addition, the authors encourage all faculty to help introduce trainees into a network and provide a platform for successful promotion by nominating under-represented minority members to appropriate positions. Certainly, this can extend beyond fellowship. It goes without saying, that nomination and promotion is suggested for those who earn it; however, not uncommonly underrepresented fellows meet this criterion and may be overlooked.

The future of this country is one in which there may not be a majority. It is important that we understand one another and work together to move forward. Diversifying cardiology will bring about innovation and growth in the field. The patient experience can improve as well with more physicians who share their personal experiences. This can build communication and preventative measures. I hope that we continue this momentum and cultivate a better experience for all.

References:

  1. Rymer et al. Evaluation of Women and Underrepresented Racial and Ehnic Group Representation in a General Cardiology Fellowship After a Systematic Recruitment Initiative. JAMA Netw Open. 2021; 4(1)
  2. Williams et al. How to Build an Antiracist Cardiovascular Culture, Community, and Profession. JACC 2021 77 (9)

“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.”

 

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Alcohol Consumption and Cardiovascular Disease: How much is too much?

Most enjoy sipping on a glass of wine, a beer, or cocktail from time to time on their own, or with a group of others. And in more of these occasions than not, the individual determines how much he or she could or could drink given future plans (e.g. driving a vehicle).

But, why don’t people consider the impact a drink of alcohol consumption could have on their health more?

This is likely because of the recommendations of drinking alcohol in moderation. Alcohol has been shown to have protective effects regarding how we use our fats in our blood (3). There is even data that shows a reduction in the incidence of heart attacks related to alcohol consumption (4).

In 2019, about 26%  of people ages 18 and older (29.7 percent of men in this age group and 22.2 percent of women in this age group) reported that they engaged in binge drinking in the past month (1). Binge drinking is 5 or more drinks for men and 4 or more drinks for women in about 2 hours (2). The Dietary Guidelines of 2020-2025 define Alcoholic beverages as the following:

“Adults of legal drinking age can choose not to drink, or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed. Drinking less is better for health than drinking more.”

It is important to define what one alcoholic drink equivalent. About 14 grams (0.6 fl oz) of pure alcohol is one drink, 12 fluid ounces of regular beer (5% alcohol), 5 fluid ounces of wine (12% alcohol), or 1.5 fluid ounces of 80 proof distilled spirits (40% alcohol) (2).

Benefits of Alcohol Consumption Source: https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials

Most importantly, what is a moderate amount of alcohol consumption?

A moderate amount is 2 drinks of less a day for men and 1 drink of less a day for women. Okay, what if we drink alcohol above the defined moderation?

Well, the National Institute on Alcohol Abuse and Alcoholism reported that people who drank alcohol two times the gender-specific binge drinking thresholds were 70 times more likely to have an alcohol-related visit to the emergency department. Furthermore, those who consumed alcohol at three times the gender-specific binge thresholds were 93 times more likely to have an emergency department visit.

Perception of a lot and little:

How good are we in determining moderation? In a 2015, a cross-sectionally analysis from the eHeart Health Study dataset had participants answer the following questions (5):

Source: https://www.sciencedirect.com/science/article/pii/S0002914915013533?casa_token=6RqulqCY-doAAAAA:mQDOG8ZbJEp_w4WXk4v7p4cDLT3R3LT8lIzAMQBrUxLx0giLTI0g67EhdTXksWvsLCNAsQ6d

Do you believe alcohol is good for your heart?” – “Yes,”“No,”or“I don’t know.”

You believe alcohol is good for your heart because?” –“ Your doctor told you,” “You learned this in school,” “You learned from reading lay press,” “You learned this from friends, colleagues, or word of mouth, ”or “Other [free text]. Over 5,000 people answered the questions and approximately 30% felt alcohol consumption was health healthy, 39% felt it was unhealthy and 31% were unsure. The majority of the perceptions were related to information retained from the lay press.

The lay press giving us some health guidance! Shocking, I know.

More importantly, it is important to determine the causal effects we see in observational studies. Those are studies that conclude “x” amount of alcohol is related or associated “y” outcome of health. So researchers design studies termed “Mendelian Randomization”. The study looks at genes known to function to look at modifiable (lifestyle) exposure to disease. Larsson et al. published a Mendelian Randomization study in 2020 that investigated the effect of alcohol consumption on 8 cardiovascular diseases (6). The authors found that high alcohol consumption may be causally associated with an increased risk of stroke and peripheral artery disease. Furthermore, the link may occur through blood pressure changes.

Source: https://www.cvphysiology.com/Hemodynamics/H014

Blood pressure changes are controlled by our nervous system. A recent study from Greenlund et al. investigated the effects of night binge alcohol consumption on sleep, morning-after blood pressure, and muscle sympathetic activity (7).  Twelve men and ten women were included in this randomized cross-over design. The alcohol had a 1:3 ratio of 95% ethanol mixed orange or cranberry juice. Sounds pretty yummy. The alcohol dose was a 1 g/kg dose for men and a 0.85 g/kg dose for women.. The authors utilize the Valsalva maneuver to observe the changes in blood pressure after the night of binge drinking.  The Valsalva maneuver leads to a decrease in heart rate and blood pressure, which then stimulates the sympathetic nervous system and allowing the investigators to examine changes in sympathetic function.

There were increases in resting heart rate the next morning, but blood pressure remained unchanged compared to the fluid control condition. During the Valsalva maneuver, there was a heightened sympathoexcitatory response and a reduced baroreflex response. Furthermore, a night of binge drinking disrupted sleep quality (reduced REM sleep).

Studies that use Mendelian randomization, or have a practical approach of viewing the morning effect effects have significant roles in improving the comprehension of the information received from the lay news. Alcohol consumption is certainly linked with cardiovascular disease. The idea of everything in moderation seems to prevail. However, the amount that is perceived to be a lot person to person varies, making alcohol consumption a known risk to health. People’s perceptions of themselves could change the amount of alcohol consumed in one sitting, which could increase the risk of binge drinking (8).

References

  1. Alcohol Facts and Statistics | National Institute on Alcohol Abuse and Alcoholism (NIAAA) [Internet]. [cited 2021 Mar 14]. Available from: https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics
  2. Dietary Guidelines for Americans, 2020-2025 and Online Materials | Dietary Guidelines for Americans [Internet]. [cited 2021 Mar 14]. Available from: https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials
  3. Gaziano JM, Buring JE, Breslow JL, Goldhaber SZ, Rosner B, Vandenburgh M, et al. Moderate Alcohol Intake, Increased Levels of High-Density Lipoprotein and Its Subfractions, and Decreased Risk of Myocardial Infarction. New England Journal of Medicine. 1993;329(25):1829–34.
  4. Camargo Jr. CA, Stampfer MJ, Glynn RJ, Grodstein F, Gaziano JM, Manson JE, et al. Moderate Alcohol Consumption and Risk for Angina Pectoris or Myocardial Infarction in U.S. Male Physicians. Ann Intern Med. 1997 Mar 1;126(5):372–5.
  5. Whitman IR, Pletcher MJ, Vittinghoff E, Imburgia KE, Maguire C, Bettencourt L, et al. Perceptions, Information Sources, and Behavior Regarding Alcohol and Heart Health. The American Journal of Cardiology. 2015 Aug 15;116(4):642–6.
  6. Larsson Susanna C., Burgess Stephen, Mason Amy M., Michaëlsson Karl. Alcohol Consumption and Cardiovascular Disease. Circulation: Genomic and Precision Medicine. 2020 Jun 1;13(3):e002814.
  7. Greenlund IM, Cunningham HA, Tikkanen AL, Bigalke JA, Smoot CA, Durocher JJ, et al. Morning sympathetic activity after evening binge alcohol consumption. Am J Physiol Heart Circ Physiol. 2021 Jan 1;320(1):H305–15.
  8. Cromer JR, Cromer JA, Maruff P, Snyder PJ. Perception of alcohol intoxication shows acute tolerance while executive functions remain impaired. Experimental and Clinical Psychopharmacology. 2010;18(4):329–39.

“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.”

 

 

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PFO Closure in PFO-related Stroke

Last week, Gore REDUCE study, a randomized open-label trial with a median duration of follow-up of 5.0 years [4.8 to 5.2] demonstrated that 1.8% of patients with PFO closure had recurrent ischemic strokes (hazard ratio, 0.31; 95% confidence interval, 0.13 to 0.76), compared with 5.4% patients who treated with an antiplatelet-only group (Figure).1 A patent foramen ovale (PFO) is far and away from the most common congenital heart defect with an estimated prevalence of 1 in 4 adults.  The FDA has previously approved the Amplatzer PFO Occluder device in 2016, however initial trials such as the RESPECT, PC, and CLOSER I trials did not show any benefit for PFO closure in the reduction of recurrent embolic stroke, compared to medical therapy. Interestingly, more recent trials conducted within the last 5 years, such as the DEFENSE‐PFO, REDUCE, CLOSE and RESPECT trials, demonstrated that PFO closure had reduced incidence of stroke compared to medical therapy. Given this influx of new evidence from recent trials, it has been suggested that PFO closure be considered in patients 60 years or younger with a PFO-related stroke. However, other potential etiologies such as atrial fibrillation (AF, requires at least 30 days of cardiac monitoring based on recent trials), autoimmune disorders, uncontrolled diabetes or hypertension must first be ruled out.

Last year, the 2020 practice advisory update summary by the American Academy of Neurology suggested that PFO closure probably reduces the risk of stroke recurrence with an HR of 0.41 with acceptable heterogeneity (I2 = 12%) and an absolute risk reduction of 3.4% at 5 years for patients with cryptogenic stroke and presence of a PFO based on meta-analyses using fixed-effect.2 This was unsurprising to me given the trends seen in the RESPECT and CLOSE trials. Interestingly, the report suggested an increased risk of developing AF with RR 3.12 in participants who received closure compared with those receiving medical treatment. This raised an interesting causality dilemma similar to the story of the chicken and the egg. Did these trials capture paroxysmal AF using 30 days of ambulatory monitoring and exclude those with paroxysmal AF prior to PFO closure? If that is the case, what was the primary mechanism for the development of AF after PFO closure? Atrial stunning? If a patient were to develop AF following PFO closure would that increase their risk of recurrent stroke?  And if so, is the risk of recurrent stroke higher or lower with PFO closure compared to those without PFO closure? Indeed, it would be interesting see which echo parameters are independent predictors of developing AF in PFO closure (after adjustment for potential confounders). Moreover, the American Academy of Neurology recommends (level C) that aspirin or anticoagulation may be considered in patients who opt to receive medical therapy alone without PFO closure.2 In fact, the comparison between PFO closure and systemic anticoagulation (e.g., DOAC) to prevent recurrent ischemic stroke remains unknown.

Switching gears, let us look at post-PFO closure management. Again, very limited data currently exists on the optimal duration of DAPT (dual antiplatelet therapy) after PFO closure. RESPECT and CLOSE used DAPT for 1 and 3 months, respectively, while some experts recommend ranges DAPT anywhere from 1 to 6 months. A European position paper on the management of PFO, suggested that following PFO closure patients should be on DAPT for 1-6 months followed by antiplatelet monotherapy for ≥5 years.3

In a nutshell, PFO closure should be considered for patients 60 years or younger with PFO-related stroke patients without the comorbidities of the previously mentioned risk factors.  A multidisciplinary discussion between neurology, geriatrics, and interventional cardiology are key in decision-making regarding PFO management.  Further research should include a randomized controlled trial regarding DAPT duration and the use of DOACs (direct oral anticoagulants) following PFO closure in patients with PFO-related left circulation embolism.

Credit: Figure from the New England Journal of Medicine 2021; 384:970-971

Reference

  1. Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, Settergren M, Sjöstrand C, Roine RO, Hildick-Smith D, Spence JD, Søndergaard L; Gore REDUCE Clinical Study Investigators. Five-Year Outcomes of PFO Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med. 2021 Mar 11;384(10):970-971. doi: 10.1056/NEJMc2033779.
  2. Messé SR, Gronseth GS, Kent DM, Kizer JR, Homma S, Rosterman L, Carroll JD, Ishida K, Sangha N, Kasner SE. Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the Guideline Subcommittee of the American Academy of Neurology. Neurology. 2020 May 19;94(20):876-885. doi: 10.1212/WNL.0000000000009443. Epub 2020 Apr 29.
  3. Pristipino C, Sievert H, D’Ascenzo F, Louis Mas J, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J; Evidence Synthesis Team; Eapci Scientific Documents and Initiatives Committee; International Experts. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. Eur Heart J. 2019 Oct 7;40(38):3182-3195. doi: 10.1093/eurheartj/ehy649.
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From “Medicare for All” to “Health for All”: Redefining the Who and Where of Care Delivery (Part 2 of 3)

In my last post, I discussed the need for physicians to engage in discussions of meaningful health systems reform in order to help realize the ideal of a healthier society for all Americans. However, innovative solutions addressing the shortcomings of our current care-delivery model designed and tested within the United States are few and far between. Instead, over the next two posts, I describe some of the strategies developed in and for resource-limited settings that may have applicability to the U.S. context.

The current post details two categories of interventions with the potential to provide expanded access to healthcare providers that may be particularly valuable for the provision of preventive cardiac services. Task-shifting interventions, which comprise the first category of this discussion, are defined by the Centers for Disease Control and Prevention as “the process of delegation” of health responsibilities and duties from skilled to less specialized healthcare workers and operate by means of rapid expansion of the healthcare workforce with the inclusion of a new cadre of providers.1 The second category includes mobile health interventions, which range from low-tech appointment reminders to more technologically advanced home cardiac rehabilitation programs and medical counseling curricula. The combined anticipated effect of both groups of interventions is to simultaneously grow the workforce able to provide high-value cardiac care, while also redefining the clinical setting in order to enhance the accessibility of health services. Below, we briefly explore potential applications of both categories of interventions to cardiac care in the U.S., highlighting existing experience with each.

Task-shifting interventions for cardiovascular care:

Although the COVID-19 pandemic exacerbated shortages in the healthcare workforce globally, the problem can be traced back long before the current crisis, with devastating consequences in rural and low-income communities. Assuming no expansion of health services beyond current levels, the American Association of Medical Colleges (AAMC) projects that by 2033 the United States will face a shortage of between 55 and 139 thousand physicians, up from prior years and including both primary care providers and specialists.2 Should universal health coverage become a reality in the coming decade, this gap in providers is likely to balloon as individuals previously excluded from health services attempt to gain access to the system. The solutions proposed to this problem have long focused on increasing the training capacity of the current medical education system and aggressive recruitment of skilled providers from outside the U.S., however, both strategies are costly and may take years—if not longer—to realize gains.

Developed in low- and middle-income countries (LMIC), task-shifting—which incorporates greater numbers of non-physician healthcare workers (NPHW) and minimally trained community healthcare workers into the medical workforce—may provide a pragmatic and low-cost solution to shortages in the U.S, just as it has done in LMIC. Demonstrating potential applications to cardiac care, a 2019 Lancet meta-analysis including task-shifting interventions where community healthcare workers, dietitians, nurses, and pharmacists delivered versions of algorithm-driven hypertension care and lifestyle counseling found that the strategy led to a statistically significant 5-point reduction in systolic blood pressure. Moreover, recent randomized trials in low-income settings have employed non-physician health workers to achieve both blood pressure improvements and reductions in mortality.3-5 Such interventions have effectively implemented short training periods (ranging from 3-7 days in many cases with periodic ‘refresher’ training) combined with clinical decision support tools to guide algorithm-driven care for screening, counseling, and treatment of basic cardiac conditions, all at low cost to the system.6

Yet uptake of such interventions in resource-limited settings within high-income countries such as the U.S. has been minimal. A 2019 JAMA Surgery editorial highlights this contradiction: commending the innovative use of NPHWs and non-surgically trained physicians in performing low-complexity surgeries such as hernia repairs in low-income countries, while acknowledging the failure to translate such benefits to communities in need in the U.S.7 One notable example within cardiovascular prevention in the U.S. bears remembering, however. The barbershop-based blood pressure study, led by Dr. Ronald Victor and published in the New England Journal of Medicine in 2018, evaluated the effect of a pharmacist-led hypertension treatment based in community barbershops in improving blood pressure among Black men when compared to counseling in the barbershops alone.8 The study demonstrated a whopping mean systolic blood pressure reduction of 27 points among those receiving the pharmacist-led intervention, with more than two-thirds of intervention participants achieving blood pressure control by the end of the study. The takeaway? With innovative adaptation of task-shifting approaches to local contexts in the U.S., such strategies have the potential to transform the model for care-delivery, reduce gaps in access to care and drive meaningful reductions in cardiovascular disease.

Mobile & virtual health interventions:

Over the past year, virtual and telehealth medical services have rapidly expanded, propelled by the desire to protect patients and providers alike during the height of pandemic lockdowns. The shift is likely to be one of the longest-lasting impacts of the pandemic on the way we practice medicine, but calls to incorporate mobile and virtual health services are not new within the pandemic era. Prior studies have demonstrated potential applications of mobile health or mHealth interventions to provide patient-centered education, communicate clinical reminders and advice, and perform complex health training, including cardiac rehabilitation, though mHealth tools can be more broadly categorized as patient-facing, provider-facing, and communication oriented.9-11 Additional applications in the treatment and counseling of high-risk conditions, including heart failure, hypertension, hyperlipidemia and coronary artery disease  have additionally been proposed, though implementation in these instances has lagged. Nonetheless, such interventions have demonstrated potentially dramatic results in LMIC with significant and sustained reductions in blood pressure, LDL levels, and improvements in metrics such as 6-minute walk distance with physical activity training, at little cost to the health system.12-14

Three recent developments and trends do bode well for the future of mobile and virtual health expansion in cardiovascular care. First, smartphones and wearable mobile health devices have become increasingly common in the U.S., with more than three-quarters of the U.S. population reporting use of a smartphone and wearable technology rapidly advancing to gain FDA-approval for detection of atrial fibrillation and in the near future likely continuous blood pressure and glucose monitoring.11,15 As such technology becomes more ubiquitous, moreover, the potential for such interventions to be used to reach under-resourced populations, including low-income and elderly individuals, is far more likely, expanding the potential reach of the healthcare system. Second, although high-quality evidence for mHealth interventions is lacking currently, the ability for mHealth applications to rapidly enroll large numbers of participants at low cost suggests an opportunity to grow the evidence base rapidly.16 Recent partnerships between academia and tech companies, including an ongoing study led by Yale University and Boehringer Ingelheim evaluating multiple mHealth based interventions for the management of heart failure, demonstrate the potential to generate new, high-quality evidence to guide future interventions.17 Finally, the past decade has been a time of tremendous investment in digital health, with venture capital investment exceeding $4 billion in 2014 alone and new startups emerging monthly.11

The result of this innovation and investment could be ground-shifting for low-income populations. What mobile and virtual technology ultimately offer is a means for redefining the clinic and hospital to bring healthcare directly into homes within underserved communities. Done well, mHealth interventions could address numerous barriers to care in under-resourced communities, improving health literacy, removing the financial and time cost of transportation to brick and mortar health institutions, and guiding care via simple and easy-to-access applications. This will require thoughtful application of technology to the goal of expanded care, however, as residual high costs of such services could ultimately undermine efforts at equity.

The bottom line: innovative approaches to care delivery that focus on both the who and where of healthcare have the potential to meaningfully alter care for low-income populations in the United States. Many such interventions have demonstrated efficacy already on a small-scale, but incorporation of such strategies into a new national approach to healthcare could go beyond these efforts in pairing an expanded vision of healthcare with universal health coverage. The potential for change is there, we just need the creativity and willpower to utilize it.

REFERENCE

  1. Sharing and Shifting Tasks to Maintain Essential Healthcare During COVID-19 in Low Resource, Non-US Settings. Centers for DIsease Control and Prevention;2020.
  2. Boyle P. U.S. physician shortage growing. In: Colleges AAoM, ed2020:https://www.aamc.org/news-insights/us-physician-shortage-growing.
  3. Jeemon P, Joseph LM, Anand TN. Task sharing with non-physician health-care workers for management of blood pressure – Authors’ reply. Lancet Glob Health. 2019;7(10):e1327.
  4. He J, Irazola V, Mills KT, et al. Effect of a Community Health Worker-Led Multicomponent Intervention on Blood Pressure Control in Low-Income Patients in Argentina: A Randomized Clinical Trial. JAMA. 2017;318(11):1016-1025.
  5. Jafar TH, Gandhi M, de Silva HA, et al. A Community-Based Intervention for Managing Hypertension in Rural South Asia. N Engl J Med. 2020;382(8):717-726.
  6. Joshi R, Thrift AG, Smith C, et al. Task-shifting for cardiovascular risk factor management: lessons from the Global Alliance for Chronic Diseases. BMJ Glob Health. 2018;3(Suppl 3):e001092.
  7. Wren SM, Kushner AL. Task Shifting in Surgery-What US Health Care Can Learn From Ghana. JAMA Surg. 2019;154(9):860.
  8. Victor RG, Lynch K, Li N, et al. A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. N Engl J Med. 2018;378(14):1291-1301.
  9. Piette JD, List J, Rana GK, Townsend W, Striplin D, Heisler M. Mobile Health Devices as Tools for Worldwide Cardiovascular Risk Reduction and Disease Management. Circulation. 2015;132(21):2012-2027.
  10. Dorn SD. Digital Health: Hope, Hype, and Amara’s Law. Gastroenterology. 2015;149(3):516-520.
  11. Eapen ZJ, Turakhia MP, McConnell MV, et al. Defining a Mobile Health Roadmap for Cardiovascular Health and Disease. J Am Heart Assoc. 2016;5(7).
  12. Srinivasapura Venkateshmurthy N, Ajay VS, Mohan S, et al. m-Power Heart Project – a nurse care coordinator led, mHealth enabled intervention to improve the management of hypertension in India: study protocol for a cluster randomized trial. Trials. 2018;19(1):429.
  13. Prabhakaran D, Jha D, Prieto-Merino D, et al. Effectiveness of an mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care: The mWellcare Cluster-Randomized Controlled Trial. Circulation. 2018.
  14. Beratarrechea A, Abrahams-Gessel S, Irazola V, Gutierrez L, Moyano D, Gaziano TA. Using mH ealth Tools to Improve Access and Coverage of People With Public Health Insurance and High Cardiovascular Disease Risk in Argentina: A Pragmatic Cluster Randomized Trial. J Am Heart Assoc. 2019;8(8):e011799.
  15. Jia X, Kohli P. Telehelath and Cardiovascular Disease Prevention: A Discussion of the Why and How. American College of Cardiology2020.
  16. Rowland SP, Fitzgerald JE, Holme T, Powell J, McGregor A. What is the clinical value of mHealth for patients? NPJ Digit Med. 2020;3:4.
  17. Wicklund E. Yale Studies 3 Different Telehealth, mHealth Tools for Cardiac Care. mHealth Intelligence. 2020. https://mhealthintelligence.com/news/yale-studies-3-different-telehealth-mhealth-tools-for-cardiac-care.

“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.”

 

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Protecting Your Peace- 5 Things to Consider Before Saying Yes

Early in my career, I jumped at nearly every opportunity that came along. I wanted to impress everyone, and I wanted to prove to them that I deserved to be there. At that point in my career, I felt it was important to seize every chance because, even though I had endured years of school and training, I hadn’t yet figured out exactly what I wanted to do with my life. Taking on every challenge that came along was extremely enlightening. It allowed me to realize what I loved, what I just liked, and what I could barely stand doing. This approach also connected me with many people from so many different specialties. Eventually, it simply became exhausting.

When I took on a task, and I took on a lot of them, I wanted to do everything to the very best of my ability. I would eventually learn that you have to put even more energy into doing things you do not actually like. While the networking and building human connections aspect of my work was incredible, it became very clear that I could not go on doing work I had no interest in.

Now I approach new opportunities a little differently. Instead of eagerly jumping in, I take some time to consider what this might mean for my schedule, my well-being, and my overall goals. Burnout is very real, and I’m already a very busy person. For new chances like this, I evaluate them in terms of my Five Ps: Pay, Promote, Passion, Push, and Purpose.

  1. Pay

What is the financial compensation? Is there a budget attached, and is it reasonable? For many opportunities I research the pay history to find out what my white, male counterparts would make for the same position. When it comes to pay, remember: If you don’t ask for it, you’ll never get it.

  1. Promote

Will this opportunity promote me? Some people are okay being right where they are in their career, but others are still eagerly climbing that ladder. Sometimes opportunities are exactly what you need to take you to the next level, regardless ofpay or how satisfying they might appear.

  1. Push

Will this opportunity push me? Will it challenge me? Will I learn something new, or will it force me out of my comfort zone? Opportunities that push you are often the ones that help you grow.

  1. Passion

Am I passionate about this opportunity? Is it something I love doing so much that I’d do it for free just because it enriches my life? In the past, opportunities like mentoring or health advocacy have been obvious choices simply because of my passion for them.

  1. Purpose

Does this opportunity align with my Purpose? We all have a purpose on this earth and opportunities that present themselves to us are the best when they align with our purpose.

After asking these five questions, if a given opportunity meets one or more of my Five Ps, I say yes! Otherwise, I have to pass. Just setting boundaries isn’t enough, you have to work to enforce those boundaries as well.

Protect your peace, Queens, and Kings.

 

“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.”

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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.”

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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.”

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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.”

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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.”