Development and Feasibility of a Primary Care Provider Training Intervention to Improve Atrial Fibrillation Management.

The disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. As such, we sought to create a virtual education intervention for PCPs and to evaluate its impact on the use of stroke risk reduction strategies in patients with AF. A multidisciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared before and after the intervention. Hierarchical logistic regression modeling was used to evaluate change in oral anticoagulation (OAC) therapy in the patients seen by participants before or after training. Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 1-hour sessions. Overall, the appropriate use of OAC (for CHA2DS2-VASc score ≥1 man, ≥2 women) increased from 37% to 46% (p <0.001) comparing the patients seen before (n = 1,739) versus after (n = 610) intervention. The factors independently associated with appropriate OAC use included participant training (odds ratio [OR] 1.4, p = 0.002) and participant competence in AF management. The factors associated with decreased OAC use included patient age (OR 0.8 per 10 year, p = 0.008) and nonwhite race (OR 0.7, p = 0.028). Provider knowledge and confidence in AF care improved (p <0.001). In conclusion, we show that a virtual PCP training intervention improves the use of stroke risk reduction therapy in outpatients with AF and could be a widely scalable intervention to improve AF care in under-resourced communities.

Development and Feasibility of a Primary Care Provider Training Intervention to Improve Atrial Fibrillation Management.

Background: Disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. Objective: To create a virtual education intervention for PCPs and evaluate its impact on use of stroke risk reduction strategies in AF patients. Methods: A multi-disciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared pre- and post-intervention. Hierarchical logistic regression modeling was used to evaluate change in stroke risk reduction therapies among patients seen by participants before or after training. Results: Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 one-hour sessions. Overall, appropriate use of oral anticoagulation (OAC) therapy (CHA 2 DS 2 -VASc score ≥1 men, ≥2 women) increased from 37% to 46% (p<.001) comparing patients seen pre- (n=1739) to post- (n=610) intervention. Factors independently associated with appropriate OAC use included participant training (OR 1.4, p=.002) and participant competence in AF management (by survey). Factors associated with decreased OAC use included patient age (OR 0.8 per 10 years, p=.008), nonwhite race (OR 0.7, p=.028). Provider knowledge and confidence in AF care both improved (p<.001). Conclusions: A virtual case-based PCP training intervention improved use of stroke risk reduction therapy in outpatients with AF. This widely scalable intervention could improve AF care in under-resourced communities. CONDENSED ABSTRACT: A virtual educational model was developed for primary care providers to improve competency in AF care in their community. Following a 6-month training intervention, the rate of appropriate oral anticoagulation (OAC) therapy among patients cared for by participating providers increased from 37% to 46% (p<.001). Among participants, knowledge and confidence in AF care improved. These findings suggest a virtual AF training intervention can improve PCP competency in AF care. This widely scalable intervention could help improve AF care in under-resourced communities.

Association between morbidity among term newborns and low-risk caesarean delivery rates.

OBJECTIVE: To examine the association between county-level caesarean delivery (CD) rates among women at low risk and morbidity among term newborns. DESIGN: Cross-sectional study. SETTING: Population-based study of US county-level birth data from 2015 to 2017. POPULATION: Nulliparous women with term, singleton, vertex-presenting infants (NTSV) at low risk for morbidity. METHODS: The primary exposure was county-level CD rates. MAIN OUTCOME MEASURES: The outcome was morbidity among the low-risk NTSV cohort, categorised as severe (5-minute Apgar score of ≤3, assisted ventilation for ≥6 hours, severe neurologic injury or seizure, transfer or death) or moderate (5-minute Apgar score of <7 but >3, administration of antibiotics or assisted ventilation at delivery). We used linear regression models to determine the association between county NTSV CD and neonatal morbidity rates with cluster robust standard errors. RESULTS: The analysis included data from 2 753 522 births in 952 counties from all 48 states. The mean NTSV CD rate was 23.6% (standard deviation 4.8%). The median severe and moderate neonatal morbidity rates were 15.2 (interquartile range, IQR 9.4-23.6) and 52.5 (IQR 33.4-75.7) per 1000 births, respectively. In the unadjusted analysis using the risk-adjusted exposure and outcome, every percentage point increase in the CD rate of a county was associated with 0.6 (95% CI -0.9, -0.3) and 2.3 fewer (95% CI -3.4, -1.1) cases of severe and moderate neonatal morbidity per 1000 live births. After adjustment for other county factors, the relationships remained significant. These findings were tested in multiple sensitivity analyses. CONCLUSIONS: Lower county-level NTSV CD rates were associated with a small increase in morbidity among term newborns in the USA. TWEETABLE ABSTRACT: Lower county-level caesarean delivery rates were associated with an increase in morbidity among term newborns in the USA.

Impact of Left Atrial Bipolar Electrogram Voltage on First Pass Pulmonary Vein Isolation During Radiofrequency Catheter Ablation.

BACKGROUND: First pass pulmonary vein isolation (PVI) is associated with durable isolation and reduced recurrence of atrial fibrillation (AF). OBJECTIVE: We sought to investigate the relationship between left atrial electrogram voltage using multielectrode fast automated mapping (ME-FAM) and first pass isolation with radiofrequency ablation. METHODS: We included consecutive patients (pts) undergoing first time ablation for paroxysmal AF (pAF), and compared the voltage characteristics between patients with and without first pass isolation. Left atrium (LA) adjacent to PVs was divided into 6 regions, and mean voltages obtained with ME-FAM (Pentaray, Biosense Webster) in each region and compared. LA electrograms with marked low voltage (<0.5 mV) were identified and the voltage characteristics at the site of difficult isolation was compared to the voltage in adjacent region. RESULTS: Twenty consecutive patients (10 with first pass and 10 without) with a mean age of 63.3 ± 6.2 years, 65% males, were studied. Difficult isolation occurred on the right PVs in eight pts and left PVs in three pts. The mean voltage in pts without first pass isolation was lower in all 6 regions; posterior wall (1.93 ± 1.46 versus 2.99 ± 2.19; p < 0.001), roof (1.83 ± 2.29 versus 2.47 ± 1.99; p < 0.001), LA-LPV posterior (1.85 ± 3.09 versus 2.99 ± 2.19, p < 0.001), LA-LPV ridge (1.42 ± 1.04 versus 1.91 ± 1.61; p < 0.001), LA-RPV posterior (1.51 ± 1.11 versus 2.30 ± 1.77, p < 0.001) and LA-RPV septum (1.55 ± 1.23 versus 2.31 ± 1.40, p < 0.001). Patients without first pass isolation also had a larger percentage of signal with an amplitude of <0.5 mV for each of the six regions (12.8% versus 7.5%). In addition, the mean voltage at the site of difficult isolation was lower at 8 out of 11 sites compared to mean voltage for remaining electrograms in that region. CONCLUSION: In patients undergoing PVI for paroxysmal AF, failure in first pass isolation was associated with lower global LA voltage, more marked low amplitude signal (<0.5 mV) and lower local signal voltage at the site with difficult isolation. The results suggest that a greater degree of global and segmental fibrosis may play a role in ease of PV isolation with radiofrequency energy.

Influences on the ethical beliefs of graduate students concerning research.

Development of and influence on ethical beliefs were surveyed at a major research university campus. Courses were ranked by faculty and students as most important. Mentors were ranked eighth in a list of nine factors. Of the 1,152 returned student questionnaires, 97 (8.4%) made the effort to write comments, and of the 610 faculty questionnaires returned, 64 (10%) wrote comments. These comments were rich in detail and description.

The mandibular foramen: an anatomic study and its relevance to the sagittal ramus osteotomy.

The sagittal split ramus osteotomy is the most commonly used procedure to reposition the mandible surgically. Because it is more technically difficult and associated with a higher incidence of complications compared with other mandibular osteotomies, thorough knowledge of the anatomy of the mandibular ramus is a prerequisite. Anatomic measurements related to the mandibular foramen were obtained from 57 formalin-preserved non-Asian hemimandibles. As shown in previous reports, great variability was noted in the position of the mandibular foramen. However, these studies utilized Asian mandibles with a clear discrepancy in key anatomic measurements in comparison with the authors' data. This brings into question the validity of these earlier studies when applying their data to non-Asian groups. The "fade-out" point of the internal oblique ridge was found not to be a reliable anatomic reference for placement of the horizontal osteotomy along the medial ramus. Thus, familiarity with the described relationships of the mandibular foramen will assist in performing properly a sagittal split of the ramus and will reduce the chance for an unfavorable split.

Congenital primitive neuroectodermal tumor of the hand: a case report.

A congenital peripheral primitive neuroectodermal tumor of the hand demonstrating aggressive behavior by rapid growth and ulceration, as well as early diffuse metastasis is presented. Management consisted of below-elbow amputation and chemotherapy. Despite the tumor's initial response, intracranial metastases occurred 7 months later. The patient died shortly thereafter, 15 months after presentation.

Use of a tourniquet in panniculus resection.

The tourniquet technique is simple and provides an efficacious method for panniculectomy. Time spent during surgery and anesthesia can be offered. Furthermore, less fat necrosis can be anticipated because of the reduced use of electrocautery, which in turn should decrease the risk of seroma formation and infection.

Functional effects of protein kinase C activation on the human cardiac Na+ channel.

The cardiac Na+ current plays an important role in determining normal and abnormal impulse propagation in the heart. We have investigated the effects of protein kinase C (PKC) activation on the recombinant human cardiac Na+ channel (hH1) following heterologous expression in Xenopus laevis oocytes. Phorbol 12-myristate 13-acetate (PMA), which directly activates PKC, reduced current amplitude at all test potentials (43 +/- 12% at -10 mV). In contrast to the rat brain IIA (rBIIA) channel, there was no apparent change in either macroscopic Na+ current decay or the voltage dependence of channel gating. Further experiments indicate that the effects of PMA were mediated by PKC activation: (1) an inactive stereoisomer, 4 alpha-PMA, had no effect; (2) preincubation with the protein kinase inhibitor chelerythrine prevented the PMA effects; and (3) a hydrolyzable diacylglycerol analogue, 1-oleoyl-2-acetyl-glycerol, also reduced current (22 +/- 5%). In addition, when the alpha 1B-adrenergic receptor was coexpressed with hH1, the alpha-receptor agonist methoxamine reduced hH1 current (45 +/- 10%), an effect that could be eliminated by chelerythrine preincubation. When a conserved consensus PKC site (serine 1503) in the III-IV interdomain linker thought to be responsible for the PKC effects on rBIIA was mutated, PMA still reduced Na+ current, but the magnitude of the effect was smaller compared with that for the wild-type channel. Similar findings were obtained with alpha 1-receptor stimulation following receptor coexpression with the mutant channel. We conclude that activation of PKC modulates the human cardiac Na+ channel by at least two mechanisms, one similar to that seen with rat brain channels, involving a conserved putative PKC site, and a second more specific to the cardiac isoform.

Magnetic resonance imaging reveals micro-haemorrhage in the feet of diabetic patients with a history of ulceration.

Soft tissue haemorrhage in the foot is a possible precursor of ulceration in patients with diabetic peripheral neuropathy. High resolution 'targetted' magnetic resonance imaging was used to scan the forefoot. Neuropathic patients with and without previous ulceration were matched for degree of neuropathy, mean vibration perception threshold 33.5 +/- 4.2 V (previous ulcer) vs 31.0 +/- 6.9 V (no ulcer), age, sex, and duration of diabetes against non-neuropathic controls. There were nine patients in each category. Paramagnetic materials, e.g. iron compounds, cause a signal void ('drop-out') on gradient-echo images which disappear on spin-echo images. Evidence of haemorrhage was seen in 6 patients with previous ulceration, and none in the other groups (p = 0.009, chi square test). Autologous injection of 20 microliters of blood into the foot of a healthy volunteer produced similar images, a 'drop-out' 1 cm across being visible on magnetic resonance scanning 3 days later. Peak vertical forefoot pressures were not significantly different in the neuropathic groups 0.67 +/- 0.20 vs 0.60 +/- 0.13 Pa but were lower in the non-neuropathic group, 0.43 +/- 0.11 Pa (p = 0.0004, Mann-Whitney), and do not explain the appearance of these haemorrhages. Magnetic resonance imaging provides a sensitive way of detecting micro-haemorrhage and its presence may predict an increased risk of foot ulceration.

Chronic expanding hematoma within a periprosthetic breast capsule.

Three cases of chronic expanding hematoma occurring within the capsule surrounding breast implants are described. All developed at least 4 years after the last operation. No identifiable etiology could be demonstrated. Although this pathologic entity has been widely reported in other anatomic locations, a periprosthetic chronic expanding hematoma of the breast has not been described previously.

Scores of the Wechsler Individual Achievement Test and the Kaufman Test of Educational Achievement-Comprehensive Form for emotionally conflicted adolescents.

Subtest scores on the Wechsler Individual Achievement Test and the Kaufman Test of Educational Achievement-Comprehensive Form were compared for 27 emotionally conflicted adolescents. Correlations between subtests paired for assumed comparability ranged from .79 to .91 (median r = .69), and one of five mean comparisons was significant (Wechsler Mathematics Reasoning > Kaufman Mathematics Applications). The results suggest that these selected Wechsler subtests possess utility for assessing academic achievement and provide an acceptable alternative to the K-TEA.

Lateral force compared with frontal impact nasal fractures: need for reoperation.

Patient concern over the outcome of correction of nasal fractures is usually extremely high; often, a secondary procedure is necessary. Therefore, thorough consultation is mandatory. The clinical data of 50 patients who sustained nasal fractures was retrospectively reviewed to determine if there was any predictive value to classification of nasal fractures and the likelihood of a secondary surgical procedure. Using Stranc and Robertson's nasal fracture classification, 41 of 50 patients were described as lateral force fractures and 9 of 50 were frontal impact fractures. Five of 50 patients underwent a secondary surgical procedure, 4 from the frontal impact and 1 from the lateral force fracture group. The number of patients reoperated on approximately equaled the number who were dissatisfied with the result of the initial procedure (5 versus 6). However, objective assessment by the primary surgeon revealed 21 patients with an anatomic or functional defect. Of these, 15 were lateral force fractures (15 of 41, or 37%) and 6 were frontal impact fractures (6 of 9, or 67%). These results illustrate the difficulty in restoring preinjury nasal anatomy and function, especially in the more severe and complicated frontal impact types of nasal fracture. Using this information can aid in obtaining satisfactory informed patient consent.

Hemangiopericytoma of the palate: case report.

A case of hemangiopericytoma of the palate is presented. This is a locally aggressive tumor with a high propensity for recurrence and metastasis. Proper management is by wide local excision. Long-term follow-up is mandatory because this neoplasm can recur after several years.

Postpartum depression.

The occurrence of mood changes in the postpartum period is common. This presentation will discuss three cases of postpartum mood changes illustrating the "normal" changes, depression with suicidal ideation requiring brief hospitalization, and psychotic depression requiring intensive psychiatric treatment.

An unbalanced (6q;13q) translocation in a male with clinical features of Ehlers-Danlos type II syndrome.

Ehlers-Danlos syndrome has been divided into several different types according to the variety and severity of clinical manifestations, and may follow autosomal dominant, autosomal recessive, or X linked patterns of inheritance. Only rarely have chromosome anomalies been seen in patients manifesting phenotypic features of the syndrome and most are considered insignificant. However, one case report involved a balanced t(9;17)(q34;q11) in a female with the clinical features of Ehlers-Danlos type I and IV syndromes and, as noted by McKusick: "It is possible, furthermore, that certain very rare syndromes that are transmitted in a Mendelian manner are the result of small chromosome aberrations, such as deletion or inversion, affecting the action of several genes". We present a 14 year old male with features of Ehlers-Danlos type II syndrome and an unbalanced (6q;13q) translocation.

Haloperidol analgesia.

Haloperidol was observed to be an effective analgesic, alone and in combination with opiates, in a patient with severe radiation fibrosis and necrosis. Previously, high doses of methadone and morphine, along with amitriptyline, had caused dangerous sedative side effects without providing adequate pain relief. This case adds further support to the previous reports that haloperidol has significant analgesic or analgesic-potentiating properties. We suggest double-blind, controlled clinical trials and neurophysiologic studies to further clarify this exciting new role for haloperidol.