Salma I. Patel

Long-term follow-up of a facilitated peer mentoring program

Background: Mentoring plays an important role in career success of academic medical faculty. New mentoring models such as peer mentoring have emerged. Aim: To evaluate the long-term impact of a facilitated peer mentoring program on academic achievements. Method: Women faculty at the instructor or assistant professor rank were recruited to voluntarily participate in a facilitated peer mentoring program. Recruitment occurred over 3.8 years between 2005 and 2009. A 26-item questionnaire to assess academic skill, career satisfaction, and self-efficacy was administered before program participation and again with seven additional questions in 2011. Curriculum vitae were reviewed retrospectively to tally peer-reviewed publications, other academic activities, and promotions. Results: Participants had long-term improvement in their perceived mastery of academic skills. Peer-reviewed publications, book chapters, abstracts, posters, and other academic activities increased when activities before the program were compared to those in the five years after program enrollment. At follow-up, participants reported positive perceptions of the program and 44% continued to work with their original peer mentor groups. Conclusions: Involvement in the facilitated peer mentoring program was associated with increased skills and academic activities for most participants. Future studies are needed to assess its applicability and success among various demographic groups in academic medicine.

Catheter-Directed Treatment of Pulmonary Embolism: A Systematic Review and Meta-Analysis of Modern Literature:

We summarize the evidence for the safety and efficacy of catheter-directed thrombolysis (CDT) with and without ultrasound-assisted therapy for treating submassive and massive pulmonary embolism (PE) in a systematic review. The primary efficacy outcome was mortality. Outcomes were pooled across studies with the random-effects model. Twenty-four studies enrolled 700 patients in total; 653 received mechanical thromboembolectomy treatments for PE (mortality rate, 9% [95% confidence interval (CI), 6%-13%], P = .12; rate of minor complications, 6% [95% CI, 2%-13%]). In the ultrasound-accelerated thrombolysis (USAT) studies, the mortality rate was 4% (95% CI, 1%-11%) and in the non-USAT studies, it was 9% (95% CI, 6%-13%). Secondary safety outcomes were all bleeding events, which occurred in 12% (95% CI, 7%-20%) of the USAT studies and in 10% (95% CI, 5%-20%) of the non-USAT studies. Current clinical evidence does not prove USAT is superior over CDT methods.

Cerebral Venous Thrombosis: Current and Newer Anticoagulant Treatment Options.

Background:Cerebral venous thrombosis (CVT) is rare and involves thrombosis of the veins and sinuses of the brain, most commonly the superior sagittal sinus. Approximately 5 CVT cases occur per 1 million persons in western countries. CVT causes 0.5% of strokes. Early diagnosis is crucial to prevent such outcomes as hydrocephalus, intracranial hypertension, and further seizures. Standard medical treatment of CVT consists of low-molecular-weight heparin and endovascular thrombolysis. Small case reports have found that the newer oral anticoagulants can be used for CVT treatment; however, they are associated with increased risk of bleeding and other adverse effects. Review Summary:CVT can be triggered by an imbalance of the body’s homeostasis or reduced action of the intrinsic antithrombotic mechanism. Factors influencing this change include infection, brain tumor, inflammatory conditions, genetic thrombophilias, head trauma that causes intracranial bleeding, and certain medications. CVT may cause brain infarction and increased intracranial pressure. Sometimes, idiopathic intracranial hypertension presents as the only clinical manifestation. Confirmation of the diagnosis typically is through neuroimaging. Current CVT treatment depends on disease extent and severity. Conclusions:CVT is a rare neurological disease with potentially serious implications and high neurological morbidity and mortality rates. Understanding the role of risk factors—such as genetic or acquired thrombophilia, pregnancy, use of oral contraceptives, and hyperhomocysteinemia—in CVT development is important. Although heparin and warfarin have been used for more than 50 years, newer oral anticoagulants (eg, dabigatran, rivaroxaban, apixaban) might offer an alternative to traditional therapy.

Peripheral arterial disease preoperatively may predict graft failure and mortality in kidney transplant recipients

Patients with end-stage renal disease undergoing kidney transplant often have diffuse atherosclerosis and high cardiovascular morbidity and mortality rates. We analyzed the correlation of peripheral arterial disease (PAD), here quantified by an abnormal ankle–brachial index (ABI) measured within the 5 years prior to kidney transplant, with graft failure and mortality rates (primary end points) after adjusting for known cardiovascular risk factors (age, sex, smoking history, hypertension, diabetes, stroke, known coronary artery disease or heart failure, years of dialysis). Of 1055 patients in our transplant population, 819 had arterial studies within the 5 years prior to transplant. Secondary end points included myocardial infarction; cerebrovascular accident; and limb ischemia, gangrene, or amputation. Low ABI was an independent and significant predictor of organ failure (OR, 2.77 (95% CI, 1.68–4.58), p<0.001), secondary end points (HR, 1.39 (95% CI, 0.97–1.99), p<0.076), and death (HR, 1.84 (95% CI, 1.26–2.68), p=0.002). PAD was common in this population: of 819 kidney transplant recipients, 46% had PAD. Low ABI was associated with a threefold greater risk of graft failure, a twofold greater risk of death after transplant, and a threefold greater risk of secondary end points. Screening for PAD is important in this patient population because of the potential impact on long-term outcomes.

CHA2DS2-VASc Score: A Predictor of Thromboembolic Events and Mortality in Patients With an Implantable Monitoring Device Without Atrial Fibrillation

Objective: To determine if the CHA2DS2‐VASc score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65–74 years, sex category) predicts thromboembolism and death in patients without atrial fibrillation in a population with implantable cardiac monitoring devices. Patients and Methods: A retrospective review utilizing the Rochester Epidemiology Project research infrastructure was conducted to evaluate the CHA2DS2‐VASc tool as a predictor of mortality and ischemic stroke, transient ischemic attack, or systemic embolism in patients without atrial fibrillation. An implantable device was required in the inclusion criteria to discern the absence of atrial fibrillation. The study period was January 1, 2004, through March 7, 2016. Results: The study population (N=1606) had a mean (SD) age of 69.8 (12.6) years and median follow‐up of 4.8 years (range, 0–12 years; quartile 1, 2.6 years and quartile 3, 8.1 years). The number of thromboembolic and mortality events stratified by CHA2DS2‐VASc score groupings of 0 to 2 (399 patients), 3 to 5 (756 patients), and 6 to 9 (451 patients) were 12 (3.0%), 109 (14.4%), and 123 (27.3%) and 22 (5.5%), 205 (27.1%), and 214 (47.4%), respectively. The CHA2DS2‐VASc score predicted thromboembolism and death. The hazard ratios (HRs) for thromboembolic events for CHA2DS2‐VASc scores 3 to 5 and 6 to 9 were 4.84 (95% CI, 2.66–8.80) and 10.53 (95% CI, 5.77–19.21) (reference group, scores 0–2). The HRs for death for the corresponding score categories were 4.45 (95% CI, 2.86–6.91) and 8.18 (95% CI, 5.23–12.78). The CHA2DS2‐VASc score also predicted development of atrial fibrillation, for which the HRs for scores 3 to 5 and 6 to 9 were 1.51 (95% CI, 1.13–2.00) and 2.17 (95% CI, 1.60–2.95). Conclusion: The CHA2DS2‐VASc tool predicts thromboembolic events and overall mortality in patients without atrial fibrillation who have implantable devices.

A Practical Review of the Emerging Direct Anticoagulants, Laboratory Monitoring, and Reversal Agents

Millions of patients in the United States use anticoagulation for a variety of indications, such as the prevention of stroke in those with atrial fibrillation (AF) and the treatment and prevention of venous thrombosis. For over six decades warfarin was the only available oral anticoagulant, but now several DOACs are available and their use has become more prevalent in recent years. In spite of this increased use, many physicians remain reluctant to prescribe DOACs due to concerns about bleeding and reversibility.

QT prolongation and sudden cardiac death risk in hypertrophic cardiomyopathy

Abstract Introduction: Risk assessment for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) remains complex. The goal of this study was to assess electrocardiogram (ECG)-derived risk factors on SCD in a large HCM population Methods: Retrospective review of adults with HCM evaluated at Mayo Clinic, Rochester, MN from 1 December 2002 to 31 December 2012 was performed. Data inclusive of ECG and 24-hour ambulatory Holter monitor were assessed. SCD events were documented by ventricular fibrillation (VF) noted on implantable cardioverter defibrillator (ICD), or appropriate VT or VF-terminating ICD shock. Results: Overall, 1615 patients (mean age 53.7 ± 15.2 years; 943 males, 58.4%) were assessed, with mean follow-up 2.46 years and 110 SCD events. Via logistic regression (n = 820), the odds of SCD increased with increasing number of conventional risk factors. With one risk factor the OR was 4.88 (p < .0001; CI 2.22–10.74), two risk factors the OR was 6.922 (p < .0001; CI 2.94–16.28) and three or more risk factors, the OR was 13.997 (p < .0001; CI 5.649–34.68). Adding QTc > 450 to this logistic regression model had OR 1.722 (p = .04, CI 1.01–2.937) to predict SCD. QTc ≥ 450 was a significant predictor for death (HR 1.88, p = .021, CI 1.10–3.20). There was no correlation between sinus bradycardia, sinus tachycardia, first degree AV block, atrial fibrillation, left bundle branch block, right bundle branch block, premature atrial complexes, premature ventricular complexes, supraventricular tachycardia, PR interval, QRS interval and SCD. Conclusions: Prolonged QTc was a risk factor for SCD and death even when controlling for typical risk factors.

Imploding and Exploding Migraine Headaches: Comparison of Methods to Diagnose Pain Directionality

The study aims to compare methods of determining headache directionality (imploding, exploding, and/or ocular headaches) in women with migraine, investigate the concordance between physician assignment and patient self‐assignment of pain directionality, and evaluate whether patients assigned their headaches to the same direction when queried using different methods. Directionality of migraine headache pain (imploding, exploding, or ocular) may reflect differences in the underlying pathogenesis of individual migraine attacks among and within individuals. Emerging evidence suggests that directionality of pain in migraine sufferers may predict response to onabotulinumtoxin A. The best method of determining headache directionality in migraine sufferers has not been systematically explored.

Cardiac Troponin T Risk Stratification Model Predicts All-Cause Mortality Following Kidney Transplant

Background: We evaluated the role of increased cardiac troponin T (cTnT), vascular, and cardiac diseases in predicting 5 and 10-year all-cause mortality after kidney transplantation. Methods: We reviewed a cohort of 764 kidney transplant recipients and analyzed pertinent cardiovascular risk factors at the time of transplant evaluation. Proportional hazards regression analysis with bootstrapping method was utilized to provide a risk stratification score for mortality. Results: Mean age was 58.8 years (SD 12.1) and median follow-up was 7.0 years (range 1 day to 18.0 years). Fifty-four percent of patients (n = 415) had cTnT measured (median 0.02 ng/mL, range 0.01–4.91). Fifty-three percent (n = 407) had vascular disease, 59% (n = 448) had diabetes, and 44% (n = 336) had cardiac disease pre-transplant. Sixty percent (n = 460) required dialysis. Older age, increased cTnT, pre-transplant vascular and cardiac diseases predicted mortality in multivariate analysis. We derived 2 scoring systems with and without cTnT – the ACV and ACTV scores (age, cardiac disease, elevated cTnT, and vascular disease) – as predictors of mortality after kidney transplant. Point assignments were: age 60–69 years (1), age ≥70 years (2), cardiac disease (1), cTnT ≥0.04 ng/mL (1), and vascular disease (1). Both scoring systems significantly predicted mortality. The ACTV score better delineated risk stratification across score levels (0–2, 3–4, and 5 points). Conclusions: We developed a risk schema predictive of all-cause mortality after kidney transplant in a derivation cohort. The ACTV score, including an elevated cTnT, provided superior prediction compared to a scoring system without cTnT. Further studies to validate these findings are needed.

Relationship between the timing of preoperative medical visits and day-of-surgery glucose in poorly controlled diabetes

Background: This study evaluated referral patterns for preoperative evaluations of patients with poorly controlled diabetes mellitus (DM) and determined whether intervals between evaluations and surgery day were associated with preoperative glucose levels. Results/methodology: In this retrospective analysis of DM patients with a hemoglobin A1c level greater than 8.0%, of the 163 patients who underwent preoperative medical evaluation, only 45% were evaluated by endocrinology. Patients who had surgery earlier than 10 days after the preoperative medical evaluation had preoperative glucose levels 18% higher than those of patients who waited more than 10 days. Preoperative outpatient contact with endocrinology was not associated with preoperative glucose level (p = 0.90). Conclusion: For poorly controlled DM, more than 10 days are needed to achieve preoperative glycemic control.