Relation of Left Ventricular Mass and Infarct Size in Anterior Wall ST-Segment Elevation Acute Myocardial Infarction (from the EMBRACE STEMI Clinical Trial).

Biomarker measures of infarct size and myocardial salvage index (MSI) are important surrogate measures of clinical outcomes after a myocardial infarction. However, there is variability in infarct size unaccounted for by conventional adjustment factors. This post hoc analysis of Evaluation of Myocardial Effects of Bendavia for Reducing Reperfusion Injury in Patients With Acute Coronary Events (EMBRACE) ST-Segment Elevation Myocardial Infarction (STEMI) trial evaluates the association between left ventricular (LV) mass and infarct size as assessed by areas under the curve for creatine kinase-MB (CK-MB) and troponin I release over the first 72 hours (CK-MB area under the curve [AUC] and troponin I [TnI] AUC) and the MSI. Patients with first anterior STEMI, occluded left anterior descending artery, and available LV mass measurement in EMBRACE STEMI trial were included (n = 100) (ClinicalTrials.govNCT01572909). MSI, end-diastolic LV mass on day 4 cardiac magnetic resonance, and CK-MB and troponin I concentrations were evaluated by a core laboratory. After saturated multivariate analysis, dominance analysis was performed to estimate the contribution of each independent variable to the predicted variance of each outcome. In multivariate models that included age, gender, body surface area, lesion location, smoking, and ischemia time, LV mass remained independently associated with biomarker measures of infarct size (CK-MB AUC p = 0.02, TnI AUC p = 0.03) and MSI (p = 0.003). Dominance analysis demonstrated that LV mass accounted for 58%, 47%, and 60% of the predicted variances for CK-MB AUC, TnI AUC, and MSI, respectively. In conclusion, LV mass accounts for approximately half of the predicted variance in biomarker measures of infarct size. It should be considered as an adjustment variable in studies evaluating infarct size.

First-year medical students' perspectives on continuity of care.

BACKGROUND AND OBJECTIVES: The objective of this research was to obtain and describe medical students' perspectives about continuity of care while they are participating in a preclinical practice-based preceptorship. METHODS: Within the context of a preclinical preceptorship, students completed directed readings, conducted patient and physician interviews, and wrote reflections about continuity of care. Two coders independently analyzed a randomly selected subset of de-identified reflections (78 of 170) to describe predominant themes. RESULTS: During preceptorship, students interacted with patients affected by wide-ranging diseases, from diabetes to multiple sclerosis, within primary care and specialty clinical settings located in geographically diverse regions. Drawing on personal experience and interviews with patients and physicians, students reported benefits of continuity of care for patients and physicians concordant with claims from the literature, including improved medical management, better interpersonal communication, increased patient compliance, and higher levels of trust. Students also offered perspectives regarding challenges of and impediments to providing continuity of care, including managed care and work hour constraints, lack of comprehensive coordinated services, and specialty-driven care. CONCLUSIONS: Preclinical medical students are able to identify both benefits and barriers to continuity of care. These topics can provide a foundation for a future curriculum and may need to be explicitly addressed as students choose careers in medicine.