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What will training look like in the post-pandemic era?

I remember my first week of internship very clearly – I was a part of my first code blue as a physician. Later that week, I had to have a goals of care discussion with a patient who had been in the hospital for 3 weeks (longer than I had been a doctor at that point). These were new experiences that I was eager for, but I was fortunate to have my routine that maintained a sense of normalcy for me, very much like naptime to my toddler. I was diligent in pre-rounding and seeing all my patients before my attending showed up, and would have formed a plan for their care before 8 AM.

Once the COVID-19 pandemic was in full swing here in the US, a lot of these things that were part of my routine as an intern suddenly went to the wayside. At my institution, interns were instructed not to pre-round on patients such as to minimize contact and potential infection transmission. Family meetings could only be conducted via telephone, or in some cases, video conference. Code blues were no longer a mad dash to the patient’s room, but rather, different hospital wards had different teams, such that a provider taking care of COVID+ patients does not go to a code blue for non-COVID patients and vice versa.

Rounding on these revamped inpatient teams has been…interesting to say the least. I can’t tell you the amount of times I or an attending will ask the patient a question about the patient and the response is “I don’t know, I haven’t seen them.” It’s great that interns are more comfortable admitting they don’t know something rather than lie about it, but at the same time, I can’t help but feel a sense of lack of ownership on their behalf.

Everybody will tell you that intern year sucks, and it’s rough, and they would hate to go back and do it again. But many people will also admit that they are impressed with how much they have learned and managed to push themselves beyond their perceived level of comfort during that time frame. I didn’t particularly enjoy coming to the hospital early each day I was on an inpatient service just to see my patients and review their charts, or going to the patient’s room for the umpteenth time in a day, but there have been a number of times where something meaningful was gleaned, and my ability to think critically and manage patients independently grew a little that day.

The thing that bothers me the most about these precautions is the huge change to goals of care discussions and family meetings. The logic behind it – minimizing spread of infection and exposures – makes sense and I agree with it completely. But it’s hard to develop good rapport with an individual only over the phone, and similarly, it’s difficult to comfort another human being digitally. There’s something about the physical presence of another person, the eye contact, and even the slightest gestures, that can help make the worst day of someone’s life a little less painful.

It’s quite fortunate that these protocol changes came more than halfway through the academic year, when interns at least have a handle on what things to look out for and have developed their own sense of alarm from glancing at the chart. I can’t imagine starting intern year where I only physically interact with “my” patients during rounds with my attending, or via telephone, unless there is some kind of emergency.

On the other hand, this is accelerating our embrace of telemedicine on the outpatient side, which is good for both patients and providers in many cases, and from my anecdotal experience, has resulted in a lot fewer “no-shows.” Interns are afforded more sleep, and arguably learning to pay more attention to vital signs changes and lab value changes – or at least they’re getting a better sense of when they should actually get up and go see the patient (sometimes at the urging of their senior 😊). This could simply be an inevitable step in the evolution of medical education that was accelerated by the pandemic, but I can’t say I feel that all these changes should be here to stay.

Whether it was fumbling through morning rounds and trying to formulate a new plan based on overnight events, or developing my emotional intelligence and flexing that empathy muscle, these were formative experiences for me during my intern year that have significantly contributed to my development as a clinician. These could just be the ramblings of a dinosaur, much akin to the older physicians talking about their paper charts, fibrinolytics and 48 hour calls, but I do hope some of these changes can be undone soon, for the sake of our trainees as well as our patients and their families.

“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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The COVID-19 Pandemic: A Master Class in Health Inequity

In my course, Social and Economic Determinants of Health Disparities, we spend the semester discussing the complex web of factors rooted in social and economic policies that propagate disparities in health. These include education, employment, housing, broader neighborhood structures and, of course, healthcare. We also contextualize individual and interpersonal health behaviors within those structures. When news of the virus really gained steam in mainstream media, one of my students commented that this was an “inverse disparity”—that predominantly rich, white people who’d vacationed in far-off places were affected. I assured him that as data by race and ethnicity surfaced, we would find minorities bearing the brunt of the burden. Unfortunately, as data began to roll in state-by-state, my prediction was accurate. Further, I knew that this was bigger than who was or wasn’t wearing a mask in public, or of the disproportionate number of minorities with pre-existing conditions that may place them at higher risk. It is about a system that consistently favors the physical, mental, emotional, and financial health of certain sects of the population over others.

When the novel coronavirus came to the US public’s attention just months ago, very few of us expected that our lives would change as much as it has in subsequent months. There were so many uncertainties with this unique virus—its transmission, incubation period, symptoms, and appropriate treatment—that we were left whirling in unpreparedness. US culture, built on the foundational value of individual freedom, found itself at odds with the need to protect a more social interest: stopping the spread.

Our best defensive effort was to stay away from each other, or social distancing—a solution (with all of its benefits) that is fundamentally steeped in privilege. It didn’t account for an invisible, operational background of millions of people who occupy the less educated, often undervalued workforce who, ironically, have come to be regarded as “essential”. There are people who must travel on crowded buses to work elbow-to-elbow in order to feed us, sanitize spaces that we might encounter, and help maintain a semblance of normalcy. While some of those workers may view their efforts as an act of service, there is undoubtedly some life or death decision-making happening. On the one hand, they face the risk of exposure to a potentially deadly virus. On the other hand, they face the equally compelling risk of not being paid if they choose not to show up to work, or if they fall ill. For many, there is really no choice at all: the financial strain posed by the latter and its negative effects on their families is non-negotiable. So, they put themselves in harm’s way, hoping against hope that they won’t contract the virus and/or bring it home to their loved ones.

Although we’re “in this together,” we have left many of the most vulnerable to fend for themselves. They live in food deserts and now have even fewer options at their disposal than before, as those with disposable income and time stocked up on supplies. They are disconnected from accurate, timely information, which is even more important as we learn new lessons about the virus daily. For some, their experience with this pandemic can best be described as “inconvenienced,” while others don the armor of homemade masks to preserve their (and our) lives.

My students are learning the same lessons many are starting to awaken to: when systems fail, the marginalized become more marginalized. The pandemic operationalizes the very definition of “disparities” that we discussed during the first lecture. We are all seeing that “differences rooted in social disadvantages that further expose individuals to additional disadvantage” mean that those who are the least equipped with the resources to withstand a pandemic are placed at higher risk of exposure, unable to effectively employ best-practices for protection against an unpredictable virus. The novel coronavirus has set the stage for a master class in health inequity and demands that we pay attention to the socially and racially stratified patterns emerging from the COVID-19 pandemic.  Luckily, experts have provided a game plan for helping the most vulnerable. Hopefully, this experience will build our empathy towards the overlooked among us as we tackle health inequity together.

Class is in session.

“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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Innovations in 3-D and 4-D Technology in the Cath Lab

There have been tremendous advances in 3-dimensional (3-D) technologies in the past few years, not only in various medical and surgical fields but also in our daily lives outside of work; with more and more new features in cell phones, computer design programs, and movies!!  4-dimensional (4-D) imaging captures 3-D images over time. These technologies are particularly important in cardiology, especially in interventional cardiology. The heart is a very dynamic organ, and understanding the variation in the anatomy of vessels and geometry of cardiac structures is key to ensuring successful procedures, patient’s safety and good outcomes. More recently, newer innovations in both 3-D and 4-D technologies have been developed, so I decided to shed light on some of these innovations and how they can be potential game-changers in the cath lab.

  • 3-D Holograms

This technology was actually displayed at the Transcatheter Cardiovascular Therapeutics (TCT) 2019 meeting. It converts live transesophageal echo (TEE) imaging into real-time 3-D holographic video in the cath lab to aid structural heart procedures.  The 3-D hologram is projected on a special display screen, and the interventional cardiologist uses hand movements and a foot pedal/switch to change the image orientation without breaking the sterile field. It also allows the operator to see the tools they use in the cath lab, including catheters or devices, in real-time in a 3-D format. This technology does not even require the user to wear 3-D glasses! It was submitted for FDA regulatory review in September 2019.

  • HeartFlow Planner

This is a noninvasive, real-time virtual tool for coronary artery disease intervention. It allows interventional cardiologists to virtually map vessels on a 3-D coronary tree, with color codes indicating the fractional flow reserve-computed tomography (FFR-CT) values for each vessel as measured by a computational fluid dynamics algorithm. This seems to be a good tool for percutaneous coronary intervention (PCI) planning in vessels with significant disease; as it aims to provide us with a non-invasive way to determine whether a stenotic lesion if potentially flow limiting. However, it is important to note the CT-FFR has its own limitations, and some patients might still need invasive FFR for accurate assessment. This tool was approved by the FDA in September 2019.

Figure 1: 3-D CT-FFR coronary tree showing both flow limiting and non-flow limiting lesions [from reference 1].

  • 3-D Printing

3-D printing has been used in the surgical fields for more than a decade. It refers to making complex 3-D objects from computer-aided designs. This technology has been increasingly utilized in structural heart procedures in the past few years, where these 3-D models can be printed from a patient’s CT, magnetic resonance imaging (MRI), or 3-D ultrasound images (Figure 1). These 3-D printed structures not only help with procedural planning and device sizing but also allow operators to practice dry runs and perform pre-procedural navigation.

Figure 2: Image of a 3-D printed model which shows cardiac valves and major vessels with their geometric locations relative to each other (reference 3).

  • 4-D Imaging

4-D imaging adds an important component to 3-D imaging, which is the change of these 3-D images over time. 4-D flow images include the direction of blood flow, blood velocities and shear wall stress [2] (Figure 3). This is particularly important in coronary interventions, structural heart procedures and different congenital abnormalities where identification of blood flow in the 4-D view is useful, especially when the anatomy is complex. These changes in position over time help guide our procedures, not only to ensure successful outcomes but also to avoid potential complications. These 4-D images require large amounts of data, but they can be obtained from either cardiac MRI or computational fluid dynamics, which is a specialized area of mathematics and fluid mechanics in engineering [2]. 4-D imaging is still in its early phases, but it is another exciting advancement in our field.

Figure 3: Representation of an MRI-generated 4-D flow image showing blood flow through the aorta and major vessels (reference 4).

In conclusion, we have seen and continue to see tremendous advances in the innovations of 3-D and 4-D imaging with important implications in our work in the cath lab. With our continued collaboration with informational technology experts, engineers, and scientists, these innovations are potentially game-changers in different fields, including coronary interventions and structural heart procedures. I look forward to seeing how this technology continues to evolve in the coming decades!!

References:

  • Fornell, Dave “Overview of the top news and new technologies at the 2019 Transcatheter Cardiovascular Therapeutics meeting”, November 2019,

https://www.dicardiology.com/article/6-hot-topics-interventional-cardiology-tct-2019

https://www.itnonline.com/content/arterys-showcases-fda-cleared-4d-flow-mri-software-rsna-2016

“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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COVID-19 Stage 2: Embracing Progress, Cautiously.

In these early days of May 2020, it seems like “change is in the air”. In the northern parts of this planet (myself based in Canada’s capital), winters’ cold, icy grip has thawed, and signs of nature and life are starting to be spotted everywhere. Of course, no mention of the year 2020 is complete without placing the Covid-19 pandemic in its proper context within the topic discussed. I’ve been seeing a lot of articles and discussions online that too easily link the “spring is upon us” and “life is getting back to its normal rhythm” ethos with the recent positive stories about Covid-19 infections. Reports of daily hospital admittance and mortality rates dropping are signs of progress indeed, specifically in nation states that were hit early and hard by the disease at the start of the year, and in the ensuing first few months.

While this is welcome and encouraging news, I can’t shake the feeling that people are either consciously or subconsciously paralleling the arrival of seasonal change, an end of the typical academic school year, and the learned attitudes of past years, onto what this 2020 calendar year will be like, moving forward from this stage. Undoubtedly, overall status of the Covid-19 pandemic is now changing, with factors like spread rate seemingly decreasing (in spots), knowledge about the virus increasing (everywhere), and local and national healthcare systems all working and adjusting to better handle the situation (with some exceptions). This, in addition to coordinated social, governmental and economical efforts, working in concert to prevent a much worse outcome from unfolding, all indicate advancement and positive aspects of where we stand at the moment, in early May of 2020.

                                                      (Image from pixabay.com CC-0)

However, and you knew I was going to bring up the “however” adverb! Equating what normally is the care-free, and bright-sunshine attitude of previous years to where we are this year, at this stage in the pandemic, is simply not appropriate and could be dangerous. There are still many unknowns about how SARS-CoV-2 may change with the seasonal transitions, not just within the northern hemisphere where we are coming out of winter and into spring and warmer weather, but also minding how will the seasonal changes affect the southern hemisphere, where the temperature changes go from warmer to cooler at this time of year. There are also questions remaining about how different cities and nations are implementing the various step-wise stages of coming out of the strict physical distancing parameters, which helped limit the size of the surge of infection. Will certain districts and cities experience a second wave of infectious spread? Will citizens be able and willing to go back into physical distancing status if needed? Those and many other questions are still left unanswered presently, and it’s too difficult to forecast with the limited data we have at this stage, in early May of 2020.

Having said that, I still want to bring back the sense of positive momentum we are presently experiencing. From a bird’s eye view point: We the people of this planet, united, are more informed, have a better handle over, and are able to deal with the Covid-19 crisis today much better than we were a couple of months ago. Together we can and will progress into the desired advantageous state of preparedness and better reaction to SARS-CoV-2 infection, and resulting disease, this is a fact. We just need to continue to investigate, learn, and plan appropriate steps to take, so that we can all safely reduce the dangers that still are posed by the virus, and take note and find ways to reduce the pain and loss that our communities have experienced so far, and moving forward. Only through those careful steps, and planning ahead, would we really feel like “spring is in the air”, and not a minute before then! Be safe, stay healthy, and care for one another.

“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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The Importance of Maintaining the Public’s Trust in Science and Medicine

Often, and especially during the COVID-19 pandemic, there is a plethora of misinformation that is spread. We have all probably seen at least one scientific publication, news article, social media post, or YouTube video that is spreading information that is not accurate. Every day, I am bombarded by conspiracy theories or unfounded scientific claims while skimming through social media. During a time when information is rapidly disseminated through the internet, it is often difficult to extinguish a lie.

Sometimes, misinformation is inadvertently spread by well-meaning individuals who have not had the time or energy to confirm or critically appraise the information shared. “Liking”, “retweeting”, and/or sharing a post from a colleague/friend/relative is facile. We have all probably “retweeted” or shared certain articles and posts that we did not completely critically assess before sharing. Sometimes dissecting truth from fallacy is difficult, especially when information is disseminated widely. Our current technological advances with the internet and social media magnify opinions, good and bad. Occasionally, one may think, if multiple people I know and/or respect are sharing certain information and the number of posts about the false information outnumber those on the truth, then the misinformation must be true.

Occasionally, misinformation about science or medicine is shared by members of our own scientific and/or medical communities, which can sometimes be more damaging to our profession. For example, more assumed credibility may be given to a scientist or healthcare provider, even if his/her expertise is not in the area that is commented on. Conspiracy theorists may continually reference these “experts” to support their arguments. Sometimes, refuting incorrect information requires massive efforts but may never eliminate the long-lasting negative effects of the misinformation. For example, Andrew Wakefield’s infamous, now retracted scientific article that was published in The Lancet and falsely claimed an association between the measles, mumps, and rubella vaccine with autism is unfortunately still being referenced to support arguments against vaccinations even though multiple studies have overwhelmingly refuted the claims made in the retracted article.

With less malicious intent, some misinformation may be spread by the media or others in reference to research articles. Certain conclusions of research papers are sometimes not justified by the data presented due to inadequate sample size, biases, issues with the experimental design, etc. During a pandemic, since rapid dissemination of scientific and medical information is needed, there is frequently a tradeoff with the scientific rigor and reproducibility of the results. Since access to papers in preprint servers are available to the public, the media and public figures may tout certain research findings as truth when they have not been vetted by the peer-review process. A fellow AHA early career blogger, Dr. Allison Webel (@allisonwebelPhD), recently wrote an outstanding blog discussing the importance of the peer-review process (https://earlycareervoice.professional.heart.org/in-defense-of-peer-review/). Of note, even peer-reviewed articles are not free from research misconduct and incorrect conclusions. There are many articles retracted from high impact journals. Before the development of the internet and social media, critiques and feedback of research findings were typically only discussed at scientific meetings or at other selective venues (e.g., local conferences/presentations, journals typically not viewed by lay people, etc.). Now, these debates occur in the public arena with beneficial and negative aspects and frequently with nonexperts. These public debates may dilute the truth when unfounded comments are perpetuated.

What should we do about the spread of misinformation? Propaganda and false information are always going to be spread but we should try to mitigate their breadth and potential damage. On an individual level, researchers should thoroughly assess their results and determine whether their data are valid and whether the claims they make in publications are justified by the data before presenting the findings to the public. Limit overreaching conclusions. Scrutiny of results by authors and the research community is essential to the scientific process. Developments and advances in science often occur when findings are reproduced either within a specific lab/group or by other labs/groups and this is especially important to realize during a time when a deluge of single-center, small sample size papers are published about the COVID-19 pandemic. Dr. Elizabeth Knight (@TheKnightNurse), another fellow AHA early career blogger, recently calls to attention the scientific lessons learned from the current pandemic (https://earlycareervoice.professional.heart.org/evidence-whats-good-whats-good-enough-whats-dangerous-lessons-for-now-and-later/).

How do we influence other people’s opinions? Internal changes are often easier to make than changing other people’s opinions. However, we are all likely an influential source of information within our own social circles and networks. We may feel more comfortable directly communicating with people we know to correct misinformation. Altering the opinions of people who we do not personally know is more challenging. At minimum, as researchers and healthcare providers, we should not intentionally try to deceive the public. Flagrant dishonesty from researchers and/or healthcare providers may erode the public’s trust in our profession, possibly to a greater extent than a nonexpert’s comments. We all make mistakes and honest misunderstandings and misinterpretations can affect all of us. However, deliberately lying and abusing the influence of one’s position as a scientist or healthcare professional is more offensive. I do not know how best to address colleagues who blatantly mislead the public. If an individual we personally know is deceiving others, we can directly communicate with him/her about the impact of the misinformation. Depending on the extent of the damage created by an individual in our professional community who is propagating false information, should we review his/her ability to maintain as a member of our profession?

What are your thoughts on how we can preserve the public’s trust in science and medicine?

“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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A new and evolving health struggle for Heart failure patients: COVID-19

It’s safe to say we are not living in normal times.  This is Heart Failure (HF) in the time of the coronavirus disease-2019 (COVID-19). Patients with COVID-19 and preexisting cardiovascular disease (CVD) are at an increased risk of severe disease and death. Moreover, infection has also been associated with cardiac injury such as acute myocardial infarction (AMI), myocarditis, and stress-induced cardiomyopathy leading to subsequent cardiogenic shock (CS) requiring advanced heart failure therapies. There is a bidirectional relationship between viral upper respiratory traction infection(URI) and worsening HF with an increase in hospital re-admission rate as previously noted with influenza. Patients with HF are especially susceptible to influenza-related complications, including acute decompensated HF and secondary pneumonia. Furthermore, HF is associated with greater in-hospital mortality and adverse clinical outcomes. With around 1 million confirmed COVID-19 cases and counting in the US, one would expect an increase in heart failure admissions. Over the past several weeks as the number of COVID-19 admissions increase, the number of patients admitted with heart failure admissions have been at their lowest, which raises the following question: Where are all the HF patients?

We can speculate that people are terrified at home so they are not showing up to the emergency departments. Patients could be slowly accumulating fluids and getting into a decompensated state. On the other hand, being less active, they could also have been experiencing less symptoms. First it was influenza season now overlapping with a COVID-19 pandemic. It would be expected to see an increased number of HF admissions.  It is suggested that we might be experiencing the calm before the storm when it comes to HF decompensation requiring hospitalization. The alternative is that social distancing is the remedy that we have long been waiting for to help decrease heart failure exacerbation and hospital re-admissions rates.

On one bright note, during a telehealth cardiology visit follow up with a long-term patient with chronic systolic heart failure known to have been admitted several times during the past year secondary to medication non-adherence, who admits that he has been feeling great. He takes all his medications religiously now, including his diuretics. He states that the fact that he stays home, he doesn’t have to worry about going to the bathroom to urinate so often when he gets out of the house, therefore he doesn’t miss any of his diuretic doses. He is also compliant with diet as he doesn’t eat out as often as he is used to. He admits that he stopped going out to fast food places. This is one very small sample. On the other hand, on another telehealth visit, there is a patient with newly diagnosed Non-Ischemic Cardiomyopathy and HF with reduced ejection fraction, who is been followed for up-titration of guideline directed medical therapy. It was a challenge to safely increase the dose of his medications without vital signs and avoiding to have the patient physically get to a laboratory to get blood work done. As of now, no major changes were made in the patient current management. Of note, patient did ask about holding angiotensin-converting enzyme (ACE) inhibitors because of what he heard from another source. Once more, no changes were made to the medical regimen and it was explained that it has been recommended based on different society guidelines and expert consensus report, to continue with ACE inhibitors1.

COVID-19 times are dynamic and medical information is constantly being updated. This is an ongoing discussion as the clinical data comes in. As the pandemic evolves and more telehealth visit under our belts, we will continue to find out more. Although as our health care system is currently fighting the COVID-19; we must brace ourselves for the aftermath whether our patients are dying at home, or slowly decompensating. Only time will tell.  As we are flattening to curve with social distancing, our patients with chronic conditions like HF are waiting at home with so much uncertainties surrounding their current and future medical care. “When life gives you lemon, make lemonade”.

The following suggestions can be useful when taking care of heart failure patients during these unprecedented times. (Figure 1) With COVID-19, we should let our HF patients know although social distancing is essential, they are a higher risk population for a complicated course if infected. It is important to inform them on when to seek medical care, whether it’s to contact a health care provider, call emergency medical services, or go to the emergency department. Although, prevention remains the best medicine. They should take the extra step in precautions and follow the latest recommendations from their local department of public health as we should always remind them of what those recommendations consist of via our telehealth visits.  From a cardiologist stand point, it is important to remain available whether it is via email, pager and/or more frequent telehealth visit if possible.  If they don’t have a scale and/or automatic blood pressure machines, it should be suggested to obtain them along with a thermometer from their local pharmacies. With a phone camera, it is feasible to assess Jugular Venous Distention, pitting edema. In addition, with weight trends, blood pressure and heart rate, clinical decisions could be made.  If available, assessment of data via CardioMEMS can also be very helpful in making medical decisions. Desperate times call for desperate measures.  This is too shall pass. If this is the calm before the storm for our heart failure patients, we should be ready when it hits remembering the sun always shines after a storm.

Figure 1. Heart Failure Care Suggestions During COVID-19

“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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Evidence: What’s good, What’s good enough, What’s dangerous? Lessons for now and later.

COVID-19 has created a complex environment for health research. In an evidence vacuum with a clinical imperative to act, we have few choices. They include relying on analogues (such as SARS or MERS), trying treatments based on theoretical biological plausibility, relying on anecdotal evidence and case reports, and rushing evidence from small studies that may have significant limitations into print. There is a need for answers that are definitive but also rapid: a condition that science as we currently practice it can’t satisfy. Additionally, peer review relies on content-area experts, which are hard to find for a rapidly evolving area when potential experts are also stretched thin with clinical and research roles. The result is that evidence may look different from what we are accustomed to.

Some healthcare practitioners and scientists have reacted with alarm when low-quality studies have been published by normally meticulous journals. Are we abandoning the RCT, they ask? Is appropriate statistical analysis no longer required? Does the name of a prestige journal no longer guarantee rigor? Is low-quality evidence worse than no evidence at all? Is it wise to publish clinical observations in a newspaper rather than a medical journal? Who is responsible when a public (or public official) not equipped to recognize the limits of early evidence spreads misinformation? Are resulting adverse events or medication shortages partially the responsibility of the publication? The researcher?

These are debates worth having, and there will be compelling arguments on both sides. No matter your stance, though, there will be an impact on the future of science.

Lessons include:

  • Critically reading studies and understanding their strengths and limitations remains a valuable skill. Just because something is in print doesn’t mean it should be in practice. Scientific education in all disciplines needs to continue to focus on this skill.
  • Perhaps the standard glacial pace of evidence dissemination can, in fact, improve. Faced with undeniable urgency, the mechanisms of publication are adapting. Turnaround time measured in days or weeks rather than months or years is possible.
  • Lots of content related to COVID-19 from academic and lay publications alike is open-access— because it is seen as for the public good. Perhaps that perception can broaden, and alternative payment structures will make science more accessible.
  • The translation of basic science to clinical application (bench to bedside) can move rapidly when needed. As my fellow blogger Sasha Prisco has noted, there are currently administrative barriers that hinder this work, and their long-term necessity may need to be reevaluated.
  • Real-time information sharing and collaboration occurs through multiple channels beyond academic journals, including social media sites.

Have you considered the potential impact of this pandemic on the future of scientific publication and knowledge dissemination? Has it changed your ideas about publishing, research, evidence-based practice?

“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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Thoughts from a Physician Scientist Trainee During the COVID-19/SARS-CoV-2 Pandemic

I had a very difficult time figuring out a blog topic for this month. It has been difficult to think about topics other than COVID-19. Like a lot of you, my usual routine has dramatically changed over the last couple of weeks. Additionally, I find myself having a difficult time concentrating with emotions sometimes fluctuating from fear, anger, grief, and frustration, to hope and pride. Some of my recent days have been occupied by reading a plethora of articles, blogs, or social media posts about COVID-19, being anxious about the next time my husband or I see patients, urging people to practice social distancing and to donate PPE, and contacting family and friends to check on their physical and emotional well-being along with trying to complete some work.

I am currently a Cardiology postdoctoral fellow who has protected time to complete basic science research. I started my postdoctoral research fellowship this academic year and my hope was to immerse myself in basic science research over the next couple of years. I was hoping to have a productive lab experience and find an area that I could ultimately build my future research career. These few years of protected research time are critical to my development as a physician-scientist. From a research perspective, I have recently experienced a multitude of failures and disappointments this year (with some intermittent successes): failed experiments that have required an extensive amount of troubleshooting, rejected papers, triaged grant applications, etc. I know that I am not alone in experiencing the frequent failures that one encounters in research. My usual strategy is to be persistent, keep busy, and continue to move all research projects forward in the hopes that at least one of the projects will be fruitful which is currently difficult to do. A few weeks ago, we were informed that all non-essential experiments should stop and that no new experiments should be started. Fortunately, my lab mentor respected this request and prioritized our health and safety. However, as we reduced our wet lab work to only essential animal experiments that were already started, I could not help but feel grief for the loss of potential research milestones.

The COVID-19 pandemic has further emphasized the societal importance of investing in research endeavors and researchers longtime. There are many articles and commentaries on early career investigators being disheartened by the challenges of an academic research career along with the diminishing pool of physician scientists. The presence of the COVID-19 pandemic has further highlighted the below changes that should be made:

  1. Increased funding for research: The study of mechanisms of disease along with development of therapies requires extensive time and effort. Multiple valiant researchers are currently studying COVID-19/SARS-CoV-2 with the fundamental goal of saving lives. Continuous societal investment in research will hopefully lead to the prevention of pandemics and earlier development of therapies for various diseases in the future.
  2. Increased financial and other support for trainees and early career investigators: Supporting early career investigators through training/career development grants, travel awards, local/national/international workshops, and opportunities to present work at national/international meetings will decrease attrition from academic research careers.
  3. Consideration of changes to the peer review process: The COVID-19 pandemic has emphasized the importance of rapid dissemination of information. While the peer review process is important in trying to only publish scientifically valid results, the process is imperfect. Frequently, the peer review process is inefficient (which is difficult since reviewers and editors are busy). Often there are many additional experiments that are requested for. During a time where completing additional experiments is difficult, I think reviewers should consider whether the request to complete additional experiments is necessary and would change the conclusion or validity of the study. In order to more quickly disseminate findings, many investigators are now putting their publications in preprint servers. However, some investigators have reservations about putting unpublished material on preprint servers while their papers are simultaneously undergoing the peer review process.
  4. Improve the efficiency of translating basic science research to the bedside: There are several bureaucratic and administrative barriers that impede translating basic science findings to the bedside. Processes that balance patient safety and improve efficiency are needed.

We will continue to learn a lot about how about to improve science and medicine during this time. Stay safe and be kind!

“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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The Health Costs of Hunger

I hope someday we will be able to proclaim that we have banished hunger in the United States, and that we’ve been able to bring nutrition and health to the whole world. –Senator George McGovern

Food. Nothing is more basic to our existence than eating. However, in our modern era of plenty, we often take the presence of food for granted. That is, we take it for granted until we no longer have access to it or it makes us sick.

Food insecurity, when individuals lack access to adequate and safe food due to limited resources, is pervasive in the United States. In 2018, 37.2 million Americans were food insecure and of that, 6 million were children. A recent analysis found that 20-50% of college students were food insecure and hunger affects their ability to learn, be economically stable, and navigate social situations. While food insecurity tends to be higher in rural areas, it affects people of every gender, age, race and ethnicity throughout the United States.

The health consequences of food insecurity are well-described and have a disproportionate impact on cardiovascular health. In children, food insecurity is associated with birth defects, cognitive and behavioral problems, increased rates of asthma, depression, suicide ideation, and an increased risk of hospitalization.  In adults, food insecurity is linked to mental health problems, diabetes, high blood pressure, and high cholesterol. Food insecurity affects health in multiple ways (Figure 1). Conceived of as a cyclical process (in which people have periods fluctuating between food adequacy and inadequacy), fewer dietary options lead to increased consumption of cheap, energy dense, but nutritionally poor foods. Over-consumption of these foods during periods of food adequacy can lead to weight gain and high blood sugar, and reduced consumption of food during food shortages can lead to weight loss and low blood sugar. These cycles are exacerbated by stress and result in obesity, high blood pressure, and ultimately diabetes and coronary artery disease. The cycle continues until access to adequate, safe, high-nutrition foods stabilizes.

As a driver of poor nutritional intake, food insecurity is among the leading causes of chronic disease-related morbidity. As such, there is increasing recognition that for many food insecurity is not behavioral challenge but a structural one. Indeed this is the reason for the creation and continued re-authorization of the supplemental nutritional assistance program (or SNAP) that in 2018 provided $60.8 billion to more than 40 million Americans. SNAP was initially conceived during the Great Depression as a strategy to stave off mass starvation while providing American farmers with a fair price for their surplus agricultural products. It has gone through many legislative and administrative updates since the 1930’s (for a full history, please see Dr. Marion Nestle’s recent review in the American Journal of Public Health) and today remains the 3rd largest, and one of the most effective anti-hunger programs in the United States. Yet, despite its success at reducing food insecurity, today, proposals to reduce the monthly benefit levels and impose restrictions to limit access to SNAP are gaining political traction.  If the proposed SNAP reforms were enacted, 2.2 million American households would no longer be eligible for SNAP and an additional 3.1 million households would receive reduced benefits–many of those affected would be elderly and disabled. Thus, the cycle of food insecurity and chronic disease would worsen.

Food nourishes us and provides the sustenance we need to get through each day with our health, livelihood, and dignity intact.  While I have outlined the public health case for mitigating food insecurity; it is clear that food insecurity is not just a health issue, or even just a political issue. Above all else, it is a moral issue and one that we that we cannot be on the fence on. We must decide if today, in the richest country on the planet, at its most prosperous time in history, our friends, patients, and neighbors – men, women, and children who are just like us – should be hungry.

If your answer is no, then thankfully there is much that we can do about it. Check back for next month’s blog on strategies that health care providers, neighbors, citizens, and professional associations can do to help address food insecurity in America. In the meantime, please share your experiences addressing food insecurity in your own practice or community with me at @AllisonWebelPhD.

“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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Nutrition in the New Year: What is Our Role as Cardiologists?

As we embark on this new year, we are bound to field questions from our patients (and likely, family members) centered around the most popular new year’s resolution: Eating healthier. Reflecting upon my own answers to these questions in clinic over the years, I realize they have been some combination of:

“Eat smaller portions.” “Eat less meat.” “Cut out soda or juice.” “Don’t eat for 3 hours before going to bed.” “Have you heard of the Mediterranean diet?”

And the basis for my recommendations? While I’m sure my years of medical training were factored in somewhere, I feel like these suggestions were largely based on a combination of my own experiences with managing my nutrition, anecdotes from colleagues and friends, and quite possibly my favorite podcasts.

Upon further reflection, though, this is not all too surprising. For all the years that we spend in medical school, residency, and fellowship learning about pathophysiology and pharmacology, we receive much less structured education on nutrition.1 In four years of medical school, one study estimates that the average medical student receives approximately only 19 hours of didactic lectures in total on nutrition, with most of this education focusing on the manifestations of nutritional deficiencies (thiamine, vitamin C, etc.).2 If your recollection is like mine though, 19 hours seems like an overestimation, and it only declines in post-graduate medical training. In a recent study published in the American Journal of Medicine, 31% of cardiologists reported receiving no nutrition education in medical school, 59% reported none during residency, and 90% reported receiving no or minimal nutrition education during fellowship.3

Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

Figure 1: Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

“But we are cardiologists, not nutritionists,” one might say. Yet in the same study, 95% of cardiologists believed that their role is to provide their patients at least basic nutrition information (68.6% believed they should personally provide detailed nutrition information to patients).3 While many of our cardiovascular care teams include dieticians specifically trained to counsel our patients on their nutrition habits, we as cardiologists often find ourselves directly answering these questions from our patients.

Indeed, some physicians have made names for themselves by proselytizing specific diets for their patients. Yet what I find a bit unsettling is the variability of the messages we deliver to our patients when it comes to nutrition. While the AHA provides dietary recommendations we can share with our patients, new diets continue to pop up and gain traction in the headlines, inevitably leading to questions from our patients about whether it is safe for them to adhere to these diets. Notably, (1) intermittent fasting, (2) plant-based or vegan, and (3) ketogenic or “keto” appear to be the diets du jour.

While I personally have experimented with intermittent fasting and a plant-based diet, I am a bit uncomfortable fully endorsing one or the other to my patients, each with his or her own metabolic profile and potential list of glucose-lowering medications. When it comes to diet, more than anything, individualization is key. More so than exercise and medications, diet has deeper roots in the cultural, financial and societal environments in which our patients live. Helping them navigate a healthy lifestyle through these obstacles requires not only more time in clinic but also a deeper, more evidence-based foundation in cardiovascular nutrition.

Fortunately, we are entering an era in which we are gathering more evidence in nutrition science. A recent study published earlier this month in Cell Metabolism studied “time-restricted eating” (AKA intermittent fasting with a 10-hour eating window) in patients with metabolic syndrome,4 finding that it had beneficial effects on weight loss and metabolic profile in its albeit small sample size. (Figure 2) Additionally, a New England Journal of Medicine review article published over the holidays highlighted the existing evidence we have, both in animals and in humans, of intermittent fasting on health, longevity, and various disease states (including cardiovascular disease and cancer).5 Importantly, these recent publications and the responses they have elicited in the news and on social media have called attention to the need for more dedicated studies to address the safety and efficacy of specific diets and dietary patterns in our patients with metabolic and/or cardiovascular diseases. Indeed, more clinical trials are underway: a quick search on ClinicalTrials.gov shows that 24 registered clinical trials with an “intermittent fasting” intervention are actively recruiting participants, including the LIFE AS IF trial from the University of Chicago.

Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

Figure 2: Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

In a prior blog post on “Wearables in Medicine,” I recommended that we consider trialing wearable devices ourselves before counseling patients based on data obtained from them. While I do think our own experiences with diets and dietary patterns may be informative, our personal experiences should not be the sole pillar upon which we base our nutritional recommendations to our patients. Again, individualization is key, and a nuanced approach, factoring in living environments, medications, and metabolic profiles, is necessary.

So what should we do as members of cardiovascular care teams? Well, to provide basic nutrition recommendations to our patients, we can use the AHA Diet & Lifestyle Recommendations. However, we must acknowledge our own limitations regarding the lack of formal training on nutrition during our medical education. As such, my resolution this year is to further my education on nutritional science and attempt to understand how these popular diets may fit within modern cardiovascular disease management. To achieve these goals, I will:

  • Read: Some books recommended by my attendings that I plan to read include The Obesity Code by Jason Fung, MD and The Plant Paradox by Steven Gundry, MD. Additionally, for those interested in learning more about the role of a “keto” diet in cardiology, the ACC.org Sports and Exercise Cardiology section recently published a series of high-yield, informative articles (Link 1 and Link 2).
  • Collaborate: We have a dietician in our cardiovascular care team with whom I regrettably had not spoken directly with until recently. I previously had just referred patients to her, but I did not necessarily know exactly what advice she was giving to our shared patients. Opening and maintaining this channel of communication is essential to delivering a consistent message from our team.
  • Ask: I am now making it a habit to include a simple question in my clinic encounters: “How’s your diet?” I have found the open-endedness of the question to be quite enlightening, often helping me to uncover a new aspect of the world my patient lives in and their own perspective on how their nutrition impacts their health.

I would love to hear your input on this topic. What do you feel our roles are in nutrition counseling for our patients? What are reliable resources to learn more about this topic? How can we be better at delivering appropriate nutrition information to our patients? Please reach out to me on Twitter (@JeffHsuMD) with your thoughts and ideas.

References:

  1. Devries S, Willett W, Bonow RO. Nutrition Education in Medical School, Residency Training, and Practice. JAMA. 2019;321:1351–1352.
  2. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. Journal of Biomedical Education. 2015;2015:357627.
  3. Devries S, Agatston A, Aggarwal M, Aspry KE, Esselstyn CB, Kris-Etherton P, Miller M, O’Keefe JH, Ros E, Rzeszut AK, White BA, Williams KA, Freeman AM. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130:1298–1305.
  4. Wilkinson MJ, Manoogian ENC, Zadourian A, Lo H, Fakhouri S, Shoghi A, Wang X, Fleischer JG, Navlakha S, Panda S, Taub PR. Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome. Cell Metab. 2020;31:92-104.e5.
  5. de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019;381:2541–2551.

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.