Brian Bergmark

US medical specialty global health training and the global burden of disease

Background Rapid growth in global health activity among US medical specialty education programs has lead to heterogeneity in types of activities and global health training models. The breadth and scope of this activity is not well chronicled. Methods Using a standardized search protocol, we examined the characteristics of US medical residency global health programs by number of programs, clinical specialty, nature of activity (elective, research, extended curriculum based field training), and geographic location across seven different clinical medical residency education specialties. We tabulated programmatic activity by clinical discipline, region and country. We calculated the Spearmans rank correlation coefficient to estimate the association between programmatic activity and country–level disease burden. Results Of the 1856 programs assessed between January and June 2011, there were 380 global health residency training programs (20%) working in 141 countries. 529 individual programmatic activities (elective–based rotations, research programs, extended curriculum–based field training, or other) occurred at 1337 specific sites. The majority of the activities consisted of elective–based rotations. At the country level, disease burden had a statistically significant association with programmatic activity (Spearmans ρ = 0.17) but only explained 3% of the total variation between countries. Conclusions There were a substantial number of US medical specialty global health programs, but a relative paucity of surgical and mental health programs. Elective–based programs were more common than programs that offer longitudinal experiences. Despite heterogeneity, there was a small but statistically significant association between program location and the global burden of disease. Areas for further study include the degree to which US–based programs develop partnerships with their program sites, the significance of this activity for training, and number and breadth of programs in medical specialty global health education in other countries around the world.

Fat Embolism Syndrome

A 49-year-old man with a history of prostate cancer metastatic to bone suffered a pathological fracture to the left femur while hospitalized (Figure 1A). Eighteen hours after the fracture, he developed hypoxemia and hypotension followed by confusion and a petechial rash in the left axilla. Chest X-ray obtained after intubation demonstrated new diffuse bilateral patchy infiltrates (Figure 1B). Urgent transthoracic echocardiogram showed right ventricular dilation and free wall hypokinesis with preserved contractility of the right ventricular apex (McConnell’s Sign; Figure 2, Movie I in the online-only Data Supplement). Based on the clinical presentation and supportive imaging, the patient was diagnosed with fat embolism syndrome. He was transferred to the intensive care unit for further management. Figure 1. Initial imaging. X-ray of the left lower extremity demonstrating a closed, oblique fracture of the left femur with displacement of the distal femoral fragment ( A ). Chest X-ray obtained shortly after endotracheal intubation showing bilateral patchy infiltrates consistent with acute respiratory distress syndrome (ARDS; B ). Figure 2. Transthoracic echocardiogram images obtained during diastole ( A ) and systole ( B ) demonstrating right ventricular dysfunction with hypokinesis of the mid right ventricular free wall and preservation of the apex. Although it was observed centuries ago that intravenous injection of oil resulted in mechanical obstruction of small vessels,1 the exact pathophysiology of fat embolism syndrome (FES) remains uncertain. Fat embolism (FE) is defined by the presence of fat globules in the pulmonary microcirculation regardless of clinical significance. FES describes a characteristic pattern of clinical findings that follow an insult associated with the release of fat into the circulation. FES is most commonly associated with orthopedic trauma, with highest incidence in closed, long bone fractures of the lower extremities, particularly the femur.2 The risk of FES complicating orthopedic trauma is highest in ages 10 to 40 years and occurs in …

Burden of disease and barriers to the diagnosis and treatment of group a beta-hemolytic streptococcal pharyngitis for the prevention of rheumatic heart disease in Dar Es Salaam, Tanzania.

To understand patient and clinician attitudes toward Streptococcus pharyngitis and rheumatic heart disease prevention in Tanzania, data from 3 sources were obtained: a survey of 119 clinicians, outpatient rapid test screening, and interviews with 17 rheumatic heart disease patients. Patients do not seek care for sore throat. Clinicians stated that identifying and treating Streptococcus pharyngitis is not prioritized.

The Surgeon General's Call to Action to Improve the Health and Wellness of Persons with Disabilities: historical review, rationale, and implications 5 years after publication.

This article reviews much of the history of the Surgeon Generals Call to Action to Improve the Health and Wellness of Persons with Disabilities and its implications 5 years after publication. This article also reviews historical trends related to disability legislation such as the Social Security Act, the Civil Rights Era and the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, and the New Freedom Initiative. Most Americans will have a disability at some point in their lives. The etiologies of disabilities are many, including genetic, congenital, traumatic, or due to chronic illnesses or the aging process.

Inhaled nitric oxide and cerebral malaria: basis of a strategy for buying time for pharmacotherapy.

There are approximately 225–600 million new malaria infections worldwide annually, with severe and cerebral malaria representing major causes of death internationally. The role of nitric oxide (NO) in the host response in cerebral malaria continues to be elucidated, with numerous known functions relating to the cytokine, endovascular and cellular responses to infection with Plasmodium falciparum. Evidence from diverse modes of inquiry suggests NO to be critical in modulating the immune response and promoting survival in patients with cerebral malaria. This line of investigation has culminated in the approval of 2 phase II randomized prospective clinical trials in Uganda studying the use of inhaled NO as adjuvant therapy in children with severe malaria. The strategy underlying both trials is to use the sytemic antiinflammatory properties of inhaled NO to “buy time” for chemical antiparasite therapy to lower the parasite load. This article reviews the nexus of malaria and NO biology with a primary focus on cerebral malaria in humans.

Diagnostic and prognostic value of myocardial blood flow quantification as non-invasive indicator of cardiac allograft vasculopathy

Aims Cardiac allograft vasculopathy (CAV) is a leading cause of death in orthotopic heart transplant (OHT) survivors. Effective non-invasive screening methods are needed. Our aim was to investigate the added diagnostic and prognostic value of myocardial blood flow (MBF) to standard myocardial perfusion imaging (MPI) with positron emission tomography (PET) for CAV detection. Methods and results We studied 94 OHT recipients (prognostic cohort), including 66 who underwent invasive coronary angiography and PET within 1 year (diagnostic cohort). The ISHLT classification was used as standard definition for CAV. Positron emission tomography evaluation included semiquantitative MPI, quantitative MBF (mL/min/g), and left ventricular ejection fraction (LVEF). A PET CAV severity score (on a scale of 0-3) was modelled on the ISHLT criteria. Patients were followed for a median of 2.3 years for the occurrence of major adverse events (death, re-transplantation, acute coronary syndrome, and hospitalization for heart failure). Sensitivity, specificity, positive, and negative predictive value of semiquantitative PET perfusion alone for detecting moderate-severe CAV were 83% [52-98], 82% [69-91], 50% [27-73], and 96% [85-99], respectively {receiver operating characteristic (ROC area: 0.82 [0.70-0.95])}. These values improved to 83% [52-98], 93% [82-98], 71% [42-92], and 96% [97-99], respectively, when LVEF and stress MBF were added (ROC area: 0.88 [0.76-0.99]; P = 0.01). There were 20 major adverse events during follow-up. The annualized event rate was 5%, 9%, and 25% in patients with normal, mildly, and moderate-to-severely abnormal PET CAV grading (P < 0.001), respectively. Conclusion Multiparametric cardiac PET evaluation including quantification of MBF provides improved detection and gradation of CAV severity over standard myocardial perfusion assessment and is predictive of major adverse events.

Variability in Antithrombotic Therapy Regimens Peri-TAVR: A Single Academic Center Experience

IntroductionThe aim of this study was to describe peri-procedural antithrombotic use in patients undergoing transcatheter aortic valve replacement (TAVR) at a single academic medical center.MethodsRetrospective collection of antiplatelet and anticoagulant use during the index hospitalization for all patients undergoing TAVR at our institution from April 2009 through March 2014.ResultsOf a total of 255 patients undergoing the procedure, 132 (51%) had an indication for anticoagulation pre-TAVR and 92 (70% of those with an indication) were on treatment. On discharge, 106 patients (44% of total surviving to discharge, 73% of those surviving with an indication for anticoagulation) were treated with oral anticoagulation. Of these patients, 89 (84%) were discharged on aspirin and an oral anticoagulant without clopidogrel. Only 122 (51% of total patients) were discharged on the regimen of aspirin and clopidogrel alone.ConclusionPeri-procedural antithrombotic regimens vary greatly following TAVR. More than half of patients have an indication for anticoagulation following the procedure. Most patients at our institution who require anticoagulation are discharged on aspirin and an oral anticoagulant, though the optimal regimen requires further investigation.

Blood pressure and cardiovascular outcomes in patients with diabetes and high cardiovascular risk

Aims Optimal blood pressure for prevention of cardiovascular (CV) events in patients with Type 2 diabetes mellitus (T2DM) remains uncertain and there is concern for increased risk with low diastolic blood pressure (DBP). This study analysed the association between blood pressure and CV outcomes in high-risk patients with T2DM. Methods and results Patients with T2DM and elevated CV risk were enrolled in the Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus-Thrombolysis in Myocardial Infarction 53 trial. Cardiovascular outcomes were compared in the biomarker subgroup (n = 12 175) after stratification by baseline systolic blood pressure (SBP) and DBP. Adjusted risk was calculated by blood pressure stratum using clinical covariates plus N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin-T (hsTnT). Trends were tested using linear and quadratic models. Adjusted risk of the composite endpoint of CV death, myocardial infarction (MI), or ischaemic stroke showed U-shaped relationships with baseline SBP and DBP (Pquadratic ≤ 0.01) with nadirs at SBP 130-140 or DBP 80-90 mmHg. Diastolic blood pressure <60 mmHg was associated with increased risk of MI (adjusted hazard ratio 2.30; 95% confidence interval 1.50-3.53) relative to DBP 80-90 mmHg. Adjusted odds of hsTnT concentration ≥14 ng/L showed U-shaped relationships with SBP and DBP (Pquadratic ≤ 0.01). The relationships between low DBP, elevated hsTnT, and increased MI remained after exclusion of patients with prior heart failure or NT-proBNP >median, suggesting that the relationship was not due to confounding from diagnosed or undiagnosed heart failure. Conclusions In patients with diabetes and elevated CV risk, even after extensive adjustment for underlying disease burden, there was a persistent association for low DBP with subclinical myocardial injury and risk of MI.

Baseline adiponectin concentration and clinical outcomes among patients with diabetes and recent acute coronary syndrome in the EXAMINE trial

To investigate adiponectin levels and cardiovascular (CV) outcomes in patients with diabetes and recent acute coronary syndrome (ACS).

Surgical Pulmonary Embolectomy

A 66-year-old man with a recent prosthetic knee infection, status post–prosthesis removal, was admitted with recurrent septic arthritis. On his seventh hospital day, as he was signing his discharge paperwork, he developed acute respiratory distress. On physical examination, he was tachycardic to 118 beats/min, relatively hypotensive from 144/78 mm Hg earlier in the day to 94/54 mm Hg, and hypoxemic, with an oxygen saturation of 94% on a 100% nonrebreather facemask. The ECG showed sinus tachycardia. An urgent contrast-enhanced chest computed tomogram (CT) demonstrated large saddle pulmonary embolism (PE) and severe right ventricular (RV) enlargement, with an RV diameter-to-left ventricular (LV) diameter ratio of 1.8 (Figure 1). The patient was administered a bolus of intravenous unfractionated heparin followed by a continuous infusion. An urgent bedside transthoracic echocardiogram showed severe RV dilation, moderate-to-severe pulmonary hypertension, and RV pressure overload as suggested by systolic deviation of the interventricular septum toward the LV (Figure 2). The Vascular Medicine and Cardiac Surgery services were consulted for consideration of advanced therapies. Because of concern for major bleeding associated with fibrinolytic therapy in the setting of recent major surgery, surgical pulmonary embolectomy was recommended. Figure 1. Contrast-enhanced chest computed tomogram (CT) demonstrating acute pulmonary embolism (PE) in a 66-year-old man who developed sudden dyspnea, severe hypoxemia, and relative hypotension. Coronal views demonstrating a large, dense filling defect straddling the bifurcation of the main pulmonary artery consistent with saddle PE ( A ) and extending into the right and left main pulmonary arteries (arrows, B ). Axial view demonstrating a right ventricular (RV) diameter of 4.8 cm in comparison with 2.6 cm for the left ventricle (LV; RV-to-LV diameter ratio of 1.8; normal <0.9) consistent with severe RV enlargement ( C ). Figure 2. Transthoracic echocardiogram, apical 4-chamber view, demonstrating right ventricular (RV) and right atrial (RA) dilation and RV pressure overload with interventricular septal …