Conservative Management of LVAD-Associated Ventricular Pseudoaneurysm.

Left ventricular assist devices (LVAD) are surgically implanted mechanical support devices utilized with increasing frequency as a bridge to myocardial recovery, destination therapy, and heart transplantation. While the use of such devices in patients with advanced heart failure has shown significant survival benefits and improved quality of life, they bear their own risks and complications.1 Bleeding, infection, pump thrombosis, and stroke are just some of the serious complications associated with LVADs.2 LVAD-associated pseudoaneurysms are rare, with prior reports of occurrence at the left ventricular apex and at the anastomosis site of the outflow graft to the ascending aorta.3,4 Typically, this device-related complication requires surgical repair and, if at all feasible, heart transplantation. However, in cases of difficult anatomy, unfavorable position, and significant comorbidities, surgery may be contraindicated due to high surgical risk. This case portrays a patient suffering from a left ventricular pseudoaneurysm after HeartMate-III implantation that was not amenable to surgical repair due to heightened surgical risk. We document the first pseudoaneurysm associated with the HeartMate-III in available literature and describe a novel management strategy of documented nonoperative course of LVAD-associated pseudoaneurysm, with the patient surviving 56+ months with medical optimization and management.

Using Artificial Intelligence to Semi-Quantitate Coronary Calcium as an 'Incidentaloma' on Non-Gated, Non-Contrast CT Scans, A Single-Center Descriptive Study in West Michigan.

INTRODUCTION: Non-gated, non-contrast computed tomography (CT) scans are commonly ordered for a variety of non-cardiac indications, but do not routinely comment on the presence of coronary artery calcium (CAC)/atherosclerotic cardiovascular disease (ASCVD) which is known to correlate with increased cardiovascular risk. Artificial intelligence (AI) algorithms can help detect and quantify CAC/ASCVD which can lead to early treatment and improved outcomes. METHODS: Using an FDA-approved algorithm (NANOX AI) to measure coronary artery calcium (CAC) on non-gated, non-contrast CT chest, 536 serial scans were evaluated in this single-center retrospective study. Scans were categorized by Agatston scores as normal-mild (<100), moderate (100-399), or severe (≥400). AI results were validated by cardiologist's overread. Patient charts were retrospectively analyzed for clinical characteristics. RESULTS: Of the 527 patients included in this analysis, a total of 258 (48.96%) had moderate-severe disease; of these, 164 patients (63.57%, p< 0.001) had no previous diagnosis of CAD. Of those with moderate-severe disease 135 of 258 (52.33% p=0.006) were not on aspirin and 96 (37.21% p=0.093) were not on statin therapy. Cardiologist interpretation demonstrated 88.76% agreement with AI classification. DISCUSSION/CONCLUSION: Machine learning utilized in CT scans obtained for non-cardiac indications can detect and semi-quantitate CAC accurately. Artificial intelligence algorithms can accurately be applied to non-gated, non-contrast CT scans to identify CAC/ASCVD allowing for early medical intervention and improved clinical outcomes.

A Framework for Engaging Healthcare Professional Trainees as Continuing Education Activity Planners and Speakers.

Health professional education and post-graduate training programs, including residencies, fellowships, and other post-graduate training experiences, may encourage or require trainee participation in continuing education (CE) activity planning and development. Providers of CE should ensure appropriate mentorship and faculty guidance during development of the activity and provide direction on the expectations of adult learning principles (e.g. identification of an educational gap; development of measurable learning objectives; inclusion of independent, balanced, and evidenced-based content; use of active learning techniques; and incorporation of learning assessment methods). Nonetheless, there is no established best practice or approach for how CE providers should ensure trainees are prepared to serve as CE activity faculty. New practitioners provided with an opportunity to participate may be unsure of where to begin and may be hesitant to engage in this new activity. In this manuscript, authors delineate key principles to incorporate when introducing trainees to CE activity development and share outcomes associated with a comparison of trainee- vs. faculty-developed and delivered CE.

Interactive Patient Safety and Quality Improvement capstone during transition-to-residency program: virtual and in-person focused workshop for EPA 13.

Identifying systems failures and contributing to a safety culture is the Association of American Colleges (AAMC's) thirteenth Entrustable Professional Activity (EPA). While most curricula teach Patient Safety (PS) and Quality Improvement (QI) principles, student participation in live QI/PS activities remains limited. This workshop enabled late Clerkship phase students to apply these Health Systems Science (HSS) principles to real adverse patient event cases through team-based simulation.This 3-h capstone included both a didactic review of QI, PS, and TeamSTEPPS® tools and an experiential component where student-led interactive small group discussions were augmented by resident and faculty preceptors. Collaboratively, students composed an adverse patient event report, conducted a Root Cause Analysis (RCA) during role-play, and proposed error prevention ideas after identifying systems problems. In April 2020, the in-person workshop became fully virtual due to the COVID-19 pandemic.A statistically significant increase in ability to identify Serious Safety Events, Escalation Chain of Command, and define a Plan-Do-Study-Act (PDSA) cycle was observed. Comfort with RCA increased from 48 to 87% and comfort with TeamSTEPPS® principles increased from 68% to 85.5%This novel capstone provided students with the tools to synthesize HSS concepts through problem-solving processes and recognize EPA 13's importance. Their increased capability to identify appropriate chain of command, escalate concerns, and recognize serious adverse patient events also has training and practice readiness implications.

Critical Care Teamwork in the Future: The Role of TeamSTEPPS® in the COVID-19 Pandemic and Implications for the Future.

At our institution, we observed inconsistency in the application of structural facilitators for interprofessional teamwork such as handoffs and communication of contingency planning, complete formation and engagement of teams on interprofessional rounds, regular situation monitoring, interprofessional huddles, use of "check back" during code situations, and standard debriefings after codes and procedures (TeamSTEPPS®). To enhance team performance, we piloted TeamSTEPPS® training and reinforcement for all healthcare team members in the medical intensive care unit (MICU), inclusive of trainees, advanced practice providers (APPs), nurses, and respiratory therapists rotating through the unit. Seven months after the training launch, the initial COVID-19 surge interrupted the reinforcement stage of the pilot providing an opportunity to study the retention of TeamSTEPPS® principles and its potential role in response to a crisis. We conducted interprofessional focus groups after a year of crisis management during the pandemic. Themes revealed how TeamSTEPPS® training impacted teamwork and communication, as well as factors that influenced the use of TeamSTEPPS®. This work points to the value of team training in unexpected scenarios. Additional studies at multiple sites are needed to determine scalability for all MICU teams or for onboarding new team members.

Cardiotoxicity of Biological Therapies in Cancer Patients: An In-depth Review.

Cardiotoxicity from chemotherapy regimens has been long reported. However, the understanding of cardiac side effects of biological therapies is rapidly evolving. With cancer patients achieving higher life expectancy due to the use of personalized medicine and novel targeted anticancer agents, the occurrence of cardiotoxicity is becoming more significant. Novel biological therapies include anti-HER2 antibodies, tyrosine kinase inhibitors, bruton kinase inhibitors, antivascular endothelial growth factors, proteasome inhibitors, immunomodulator drugs, and immune checkpoint inhibitors. Potential cardiovascular toxicities linked to these anticancer agents include hypertension, arrhythmias, QT prolongation, myocardial ischemia and infarction, left ventricular dysfunction, congestive heart failure, and thromboembolism. Cardiac biomarkers, electrocardiography, echocardiography and magnetic resonance imaging are common diagnostic modalities used for early detection of these complications and timely intervention. This review discusses the various types of cardiotoxicities caused by novel anticancer biologic agents, their molecular and pathophysiological mechanisms, risk factors, and diagnostic and management strategies that can be used to prevent, minimize, and treat them.

Comfort With Telehealth Among Residents of an Underserved Urban Area.

BACKGROUND: Deployment of telehealth has been touted as a means of reducing health disparities in underserved groups. However, efforts to reduce regulatory barriers have not been associated with greater telehealth uptake. The goal of this study was to examine engagement with technology among low-income people of color living in Newark, New Jersey. METHODS: Using surveys and focus groups, we examined study participants' daily use of technology (eg, Internet) and comfort with telehealth services (eg, use of teleconferencing for medication refills) before and after COVID-related social distancing mandates went into effect. RESULTS: Use of technology was significantly lower in the pre-COVID period. However, prior months' use of technology had a weak but significant correlation with comfort with telehealth (r = .243, P = .005) in bivariate analyses and was the only significant predictor in multivariate analyses. Analyses of focus group discussions confirmed that lack of experience with technology and distrust of the security and privacy of digital systems were the most important barriers to comfort with telehealth in our sample. CONCLUSION: Our study found that approximately 20% of people in this under-resourced community lacked access to basic technologies necessary for successful deployment of telehealth services. The study's timing provided an unexpected opportunity to compare experiences and attitudes relating to telehealth in 2 regulatory environments. Although uptake of telehealth services increased with the Federal governments' relaxation of regulatory barriers, there was not a similar increase in comfort with telehealth use. Investments in broadband access and equipment should be accompanied by educational programs to increase day-to-day use of and comfort with associated technologies which would improve consumer confidence in telehealth.

Age Demographics of Subjects Enrolled in Global, Interventional Phase 3 Melanoma Clinical Trials.

BACKGROUND: Melanoma is a skin cancer with a rising worldwide incidence of just over 280,000 individuals with the greatest burden of illness in European, New Zealander, and Australian populations. Patients are diagnosed with melanoma with the mean and median ages being 65 and 59 years old, respectively. Phase 3 trials not only provide a wide representation of the target population but also study the efficacy for a certain intervention. OBJECTIVE: The objective of this literature review is to analyze patient demographics of phase 3 trials for melanoma and identify if there is a true disparity between the clinical trial age demographics and the natural epidemiological age demographics. DATA SOURCES: The authors conducted a search on clinicaltrials.gov, a publicly available resource that lists clinical trials and their data. The reported mean and median ages for each trial were extracted after determining if each trial meets our inclusion criteria. Weighted mean and median ages were calculated using an online calculator. Data from 35 trials were evaluated with 30 trials reporting a weighted mean age of 55.85 years and 5 trials reporting a weighted median age of 55.14 years. CONCLUSION: Based on the results, melanoma clinical trials enroll patients who are younger than the epidemiological mean and median ages. Due to this underrepresentation of the elderly patients with melanoma, clinical trials may provide limited application for the use of their results.

Age demographics of subjects enrolled in interventional phase 3 multiple myeloma clinical trials.

The mean and median ages of diagnosis of multiple myeloma range from 70 to 73 years old, with 63% of patients being over the age of 65. Phase 3 clinical trials are designed to study efficacy in the target disease population and are meant to have the most representative subject pool. The purpose of this review is to identify the age demographic of subjects participating in interventional phase 3 clinical trials that aim to treat multiple myeloma and to determine if they encompass the true age demographic of the disease. To complete this review, a search of phase 3 multiple myeloma research trials with reported results was conducted on clinicaltrials.gov, a national, publicly available resource listing clinical trials. Reported mean or median ages of subjects were identified for each trial, and adjusted averages of these values were calculated. Data from 81 clinical trials were assessed, with 42 trials reporting an average mean age of 65.78 years and 15 trials reporting an average median age of 63.29 years. Based on these results, it was determined that the clinical trials reported in this study enrolled patients that were younger than the true age demographic of the disease. There is an unmet need in research in the older population of patients with multiple myeloma, and this may hinder the generalizability and utility of clinical trial results.

Inner Retinal Changes in Primary Open-Angle Glaucoma Revealed Through Adaptive Optics-Optical Coherence Tomography.

PURPOSE: To examine the microstructural changes in the inner nuclear layer (INL) and ganglion cell layer (GCL) in a primary open-angle glaucoma (POAG) subject at 2 timepoints, 4 months apart. PATIENTS AND METHODS: This case-control study (1 POAG subject and 1 normal control) used the single cell, 3-dimensional volumetric imaging capability of an adaptive optics-optical coherence tomography-scanning laser ophthalmoscopy system to examine the inner retina. RESULTS: At the area of greatest glaucomatous change in the POAG subject [3-degrees temporal (T), 3-degrees inferior (I), right eye], the GCL was greatly thinned at both timepoints, yet retinal ganglion cell soma remained visible amid a meshwork of capillaries. Microcystic lesions in the INL were visible at both timepoints, ranging in diameter from 8 to 43 µm on day 1 to 11 to 64 µm at 4 months, with an average diameter increase of ∼124%. Small hyperreflective features (not seen in the contralateral eye or control subject) at a depth midway through the INL seemed correlated to the development of microcysts. CONCLUSIONS: We demonstrate the ability to image microcystic lesions early in their development and have quantified longitudinal changes. The presence of small hyperreflective structures at a layer midway through the INL seems to be a precursor to their formation and is a potential biomarker for assessing POAG severity and progression. The adaptive optics imaging system is also able to visualize retinal ganglion cells in this subject, despite severe thinning of the GCL.

Assessing Entrepreneurial Characteristics of Healthcare Students Participating in an Entrepreneurial-Medicine Curriculum.

This article was migrated. The article was marked as recommended. As innovation transforms the healthcare industry, medical institutions are increasingly incorporating business skills and concepts into their curricula. The goal of this study was to characterize the types of students who engage in these supplemental curricula with respect to four entrepreneurial characteristics: entrepreneurial interest, support, confidence, and intention. We sampled students participating in a healthcare Innovation Summit using a validated survey to assess these characteristics. The sampled population reported significantly positive Interest and Support regarding an entrepreneurial career (5.18 and 5.80; p-values <0.01), whereas Intention and Confidence did not significantly differ from neutral (4.02 and 3.78; p>0.05). There were significant positive correlations between individuals' entrepreneurial Interest and all other characteristics; demonstrated by Pearson's Correlation Coefficients of 0.74, 0.62, and 0.59 when comparing sample means of Interest versus Intention, Confidence, and Support, (p-values <0.05). In addition, significant correlation between Intention and Confidence was observed (Pearson's R = 0.78: p-values <0.05). Conversely, sample means for entrepreneurial Support were not significantly correlated with either Intent or Confidence (p-values >0.05). Our findings supply foundational data for understanding the growing cohort of individuals engaging in entrepreneurial-medicine. These data demonstrate the integrated nature of various entrepreneurial characteristics in these populations and support the idea that investment, which promotes one area, would translate to increases in others.

The probability and severity of decompression sickness.

Decompression sickness (DCS), which is caused by inert gas bubbles in tissues, is an injury of concern for scuba divers, compressed air workers, astronauts, and aviators. Case reports for 3322 air and N2-O2 dives, resulting in 190 DCS events, were retrospectively analyzed and the outcomes were scored as (1) serious neurological, (2) cardiopulmonary, (3) mild neurological, (4) pain, (5) lymphatic or skin, and (6) constitutional or nonspecific manifestations. Following standard U.S. Navy medical definitions, the data were grouped into mild-Type I (manifestations 4-6)-and serious-Type II (manifestations 1-3). Additionally, we considered an alternative grouping of mild-Type A (manifestations 3-6)-and serious-Type B (manifestations 1 and 2). The current U.S. Navy guidance allows for a 2% probability of mild DCS and a 0.1% probability of serious DCS. We developed a hierarchical trinomial (3-state) probabilistic DCS model that simultaneously predicts the probability of mild and serious DCS given a dive exposure. Both the Type I/II and Type A/B discriminations of mild and serious DCS resulted in a highly significant (p << 0.01) improvement in trinomial model fit over the binomial (2-state) model. With the Type I/II definition, we found that the predicted probability of 'mild' DCS resulted in a longer allowable bottom time for the same 2% limit. However, for the 0.1% serious DCS limit, we found a vastly decreased allowable bottom dive time for all dive depths. If the Type A/B scoring was assigned to outcome severity, the no decompression limits (NDL) for air dives were still controlled by the acceptable serious DCS risk limit rather than the acceptable mild DCS risk limit. However, in this case, longer NDL limits were allowed than with the Type I/II scoring. The trinomial model mild and serious probabilities agree reasonably well with the current air NDL only with the Type A/B scoring and when 0.2% risk of serious DCS is allowed.

Three-Dimensional Strains in Human Posterior Sclera Using Ultrasound Speckle Tracking.

Intraocular pressure (IOP) induced strains in the peripapillary sclera may play a role in glaucoma progression. Using inflation testing and ultrasound speckle tracking, the 3D strains in the peripapillary sclera were measured in nine human donor globes. Our results showed that the peripapillary sclera experienced through-thickness compression and meridional stretch during inflation, while minimal circumferential dilation was observed when IOP was increased from 10 to 19 mmHg. The maximum shear was primarily oriented in the through-thickness, meridional cross sections and had a magnitude slightly larger than the first principal strain. The tissue volume had minimal overall change, confirming near-incompressibility of the sclera. Substantial strain heterogeneity was present in the peripapillary region, with local high strain areas likely corresponding to structural heterogeneity caused by traversing blood vessels. These 3D strain characteristics provide new insights into the biomechanical responses of the peripapillary sclera during physiological increases of IOP. Future studies are needed to confirm these findings and investigate the role of these biomechanical characteristics in ocular diseases.

Bright attosecond soft X-ray pulse trains by transient phase-matching in two-color high-order harmonic generation.

We study two-color high-order harmonic generation in Neon with 790 nm and 1300 nm driving laser fields and observe an extreme-ultraviolet continuum that extends to photon energies of 160 eV. Using a 6-mm-long, high pressure gas cell, we optimize the HHG yield at high photon energies and investigate the effect of ionization and propagation under phase-matching conditions that allow us to control the temporal structure of the XUV emission. Numerical simulations that include the 3D propagation of the two-color laser pulse show that a bright isolated attosecond pulse with exceptionally high photon energies can be generated in our experimental conditions due to an efficient hybrid optical and phase-matching gating mechanism.

Arsenic and copper stabilisation in a contaminated soil by coal fly ash and green waste compost.

In situ metal stabilisation by amendments has been demonstrated as an appealing low-cost remediation strategy for contaminated soil. This study investigated the short-term leaching behaviour and long-term stability of As and Cu in soil amended with coal fly ash and/or green waste compost. Locally abundant inorganic (limestone and bentonite) and carbonaceous (lignite) resources were also studied for comparison. Column leaching experiments revealed that coal fly ash outperformed limestone and bentonite amendments for As stabilisation. It also maintained the As stability under continuous leaching of acidic solution, which was potentially attributed to high-affinity adsorption, co-precipitation, and pozzolanic reaction of coal fly ash. However, Cu leaching in the column experiments could not be mitigated by any of these inorganic amendments, suggesting the need for co-addition of carbonaceous materials that provides strong chelation with oxygen-containing functional groups for Cu stabilisation. Green waste compost suppressed the Cu leaching more effectively than lignite due to the difference in chemical composition and dissolved organic matter. After 9-month soil incubation, coal fly ash was able to minimise the concentrations of As and Cu in the soil solution without the addition of carbonaceous materials. Nevertheless, leachability tests suggested that the provision of green waste compost and lignite augmented the simultaneous reduction of As and Cu leachability in a fairly aggressive leaching environment. These results highlight the importance of assessing stability and remobilisation of sequestered metals under varying environmental conditions for ensuring a plausible and enduring soil stabilisation.

Delayed topiramate-induced bilateral angle-closure glaucoma.

PURPOSE: To report a unique case of delayed topiramate-induced bilateral angle closure. METHODS: A case report of a 40-year-old woman who experienced bilateral acute angle-closure glaucoma and induced myopia on a standard and consistent dose of topiramate for 262 days before the onset of symptoms. Initial and follow-up examination findings were reviewed. RESULTS: Initial examination revealed finger counting at one foot OU, intraocular pressures of 38 mm Hg OD and 37 mm Hg OS, and bilaterally closed angles with no view of anterior trabecular meshwork (Shaffer grade 0). Discontinuation of topiramate and administration of topical drops were able to break the attack. At 3 months of follow-up, the patient was 20/25 OU with deep angles open to the scleral spur (Shaffer grade III) and had intraocular pressures of 14 mm Hg in both the eyes. CONCLUSIONS: This case provides evidence of delayed bilateral angle closure from topiramate and raises questions as to the cellular mechanism of topiramate-induced angle closure, both immediate and delayed.

Corneal biomechanical properties affect Goldmann applanation tonometry in primary open-angle glaucoma.

PURPOSE: To study differences in corneal biomechanical properties between primary open-angle glaucoma (POAG) and central corneal thickness (CCT)-matched control subjects and their effect on intraocular pressure (IOP) measurement. METHODS: Thirteen eyes of 13 POAG subjects and 15 eyes of 15 normal subjects underwent corneal topography; IOP using Goldmann applanation tonometry (GAT), dynamic contour tonometry (DCT), and corneal compensated IOP (IOPcc) using the Reichert ocular response analyzer (ORA); corneal hysteresis; and CCT. Results from POAG and control eyes were then compared using t tests. RESULTS: Ages in the POAG group were slightly greater than that in the control group. CCT was closely matched between groups. Significant differences were found between GAT versus DCT and GAT versus IOPcc within both groups: Mean GAT IOP was not significantly different between POAG and controls, whereas mean DCT IOP did show a significant difference between groups as did mean IOPcc. The delta differences, GATΔDCT and GATΔIOPcc, were of greater magnitude in POAG subjects when compared with controls. Corneal hysteresis was significantly lower in POAG subjects. CONCLUSIONS: The delta differences between GAT and newer measures of IOP are greater in magnitude in patients with POAG than in the normal controls, independent of CCT. This is likely due to differences in the corneal biomechanical properties with POAG corneas being softer than healthy corneas, which causes greater underestimation of IOP by GAT in POAG than controls. Underestimation of IOP could affect treatment decisions and outcomes in POAG.

Soil stabilisation using AMD sludge, compost and lignite: TCLP leachability and continuous acid leaching.

Utilising locally available industrial by-products for in situ metal stabilisation presents a low-cost remediation approach for contaminated soil. This study explored the potential use of inorganic (acid mine drainage (AMD) sludge and zero-valent iron) and carbonaceous materials (green waste compost, manure compost, and lignite) for minimising the environmental risks of As and Cu at a timber treatment site. After 9-month soil incubation, significant sequestration of As and Cu in soil solution was accomplished by AMD sludge, on which adsorption and co-precipitation could take place. The efficacy of AMD sludge was comparable to that of zero-valent iron. There was marginal benefit of adding carbonaceous materials. However, in a moderately aggressive environment (Toxicity Characteristic Leaching Procedure), AMD sludge only suppressed the leachability of As but not Cu. Therefore, the provision of compost and lignite augmented the simultaneous reduction of Cu leachability, probably via surface complexation with oxygen-containing functional groups. Under continuous acid leaching in column experiments, combined application of AMD sludge with compost proved more effective than AMD sludge with lignite. This was possibly attributed to the larger amount of dissolved organic matter with aromatic moieties from lignite, which may enhance Cu and As mobility. Nevertheless, care should be taken to mitigate ecological impact associated with short-term substantial Ca release and continuous release of Al at a moderate level under acid leaching. This study also articulated the engineering implications and provided recommendations for field deployment, material processing, and assessment framework to ensure an environmentally sound application of reactive materials.