Cardiologist perceptions of family-centred rounds in cardiovascular clinical care.

Objective: Few data exist regarding physician attitudes and implementation of family-centred rounds (FCR) in cardiovascular care. This study aimed to assess knowledge and attitudes among cardiologists and cardiology fellows regarding barriers and benefits of FCRs. Methods: An electronic, web-based questionnaire was nationally distributed to cardiology fellows and attending cardiologists. Results: In total, 118 subjects were surveyed, comprising cardiologists (n=64, 54%) and cardiology fellows (n=54, 46%). Overall, 61% of providers reported participating in FCRs and 64% felt family participation on rounds benefits the patient. Both fellows and cardiologists agreed that family rounds eased family anxiety (fellows, 63%; cardiologists, 56%; p=0.53), improved communication between the medical team and the patient and family (fellows, 78%; cardiologists, 61%; p=0.18) and improved patient safety (fellows, 59%; cardiologists, 47%; p=0.43). Attitudes regarding enhancement of trainee education were similar (fellows, 69%; cardiologists, 55%; p=0.19). Fellows and cardiologists felt that family increased the duration of rounds (fellows, 78%; cardiologists, 80%; p=0.18) and led to less efficient rounds (fellows, 54%; cardiologists, 58%; p=0.27). Conclusion: The majority of cardiologists and fellows believed that FCRs benefited families, communication and patient safety, but led to reduced efficiency and longer duration of rounds.

Cardiovascular Emergencies in Pregnancy.

Heart disease in pregnancy may manifest as acute coronary syndromes, decompensated valvular disease, and acute heart failure. These disease processes may represent progression of preexisting disease versus newly developed disease resulting from the physiologic changes of pregnancy. Early recognition of clinical presentations, judicious use of diagnostic studies, and multidisciplinary management of patient and fetal considerations can lead to optimal outcomes in this unique patient subset.

Cardiogenic Shock.

Cardiogenic shock (CS) is a physiologic state in which cardiac pump function is inadequate to perfuse the tissues. If CS is not rapidly recognized and treated, tissue hypoperfusion can quickly lead to organ dysfunction and patient death. Evaluation of patients with suspected CS should include an electrocardiogram, chest radiograph, laboratory studies, and bedside echocardiogram. Initial resuscitation is directed toward restoring cardiac output and tissue perfusion. Mechanical circulatory support is indicated for patients with CS who do not respond to pharmacologic therapy. Ultimately, these patients should undergo emergent reperfusion therapy with either percutaneous coronary intervention or coronary artery bypass grafting.

Health Literacy: Readability of ACC/AHA Online Patient Education Material.

OBJECTIVES: To determine whether the online patient education material offered by the American College of Cardiology (ACC) and the American Heart Association (AHA) is written at a higher level than the 6th-7th grade level recommended by the National Institute of Health (NIH). METHODS: Online patient education material from each website was subjected to reading grade level (RGL) analysis using the Readability Studio Professional Edition. One-sample t testing was used to compare the mean RGLs obtained from 8 formulas to the NIH-recommended 6.5 grade level and 8th grade national mean. RESULTS: In total, 372 articles from the ACC website and 82 from the AHA were studied. Mean (±SD) RGLs for the 454 articles were 9.6 ± 2.1, 11.2 ± 2.1, 11.9 ± 1.6, 10.8 ± 1.6, 9.7 ± 2.1, 10.8 ± 0.8, 10.5 ± 2.6, and 11.7 ± 3.5 according to the Flesch-Kincaid grade level (FKGL), Simple Measure of Gobbledygook (SMOG Index), Coleman-Liau Index (CLI), Gunning-Fog Index (GFI), New Dale-Chall reading level formula (NDC), FORCAST, Raygor Readability Estimate (RRE), and Fry Graph (Fry), respectively. All analyzed articles had significantly higher RGLs than both the NIH-recommended grade level of 6.5 and the national mean grade level of 8 (p < 0.00625). CONCLUSIONS: Patient education material provided on the ACC and AHA websites is written above the NIH-recommended 6.5 grade level and 8th grade national mean reading level. Additional studies are required to demonstrate whether lowering the RGL of this material improves outcomes among patients with cardiovascular disease.

Electrocardiogram training for residents: A curriculum based on Facebook and Twitter.

BACKGROUND: We studied whether social media applications can serve as effective educational tools for teaching electrocardiogram (ECG) interpretation to medical residents. METHODS: 39 emergency, family, and internal medicine residents participated in the 33-week "ECG of the Week" curriculum via Facebook and Twitter. ECG skill was assessed before and after the study with a 10-ECG quiz. Outcomes of interest included predictors of participant response rates and post-study quiz performance. RESULTS: ECG quiz scores were 66% and 76% on the pre- and post-study assessments respectively. High-performing participants on the pre-study quiz were more likely to have above-average response rates to ECG challenges (36% vs. 0%, p=0.015). There was no significant difference between pre- and post-study quiz scores. CONCLUSIONS: Our social media-based ECG curriculum elicited the most participation in residents who were already above-average in ECG reading ability. Future designs will need to better reach residents with below-average baseline ECG reading ability.

Longitudinal Assessments of Normal and Perilesional Tissues in Focal Brain Ischemia and Partial Optic Nerve Injury with Manganese-enhanced MRI.

Although manganese (Mn) can enhance brain tissues for improving magnetic resonance imaging (MRI) assessments, the underlying neural mechanisms of Mn detection remain unclear. In this study, we used Mn-enhanced MRI to test the hypothesis that different Mn entry routes and spatiotemporal Mn distributions can reflect different mechanisms of neural circuitry and neurodegeneration in normal and injured brains. Upon systemic administration, exogenous Mn exhibited varying transport rates and continuous redistribution across healthy rodent brain nuclei over a 2-week timeframe, whereas in rodents following photothrombotic cortical injury, transient middle cerebral artery occlusion, or neonatal hypoxic-ischemic brain injury, Mn preferentially accumulated in perilesional tissues expressing gliosis or oxidative stress within days. Intravitreal Mn administration to healthy rodents not only allowed tracing of primary visual pathways, but also enhanced the hippocampus and medial amygdala within a day, whereas partial transection of the optic nerve led to MRI detection of degrading anterograde Mn transport at the primary injury site and the perilesional tissues secondarily over 6 weeks. Taken together, our results indicate the different Mn transport dynamics across widespread projections in normal and diseased brains. Particularly, perilesional brain tissues may attract abnormal Mn accumulation and gradually reduce anterograde Mn transport via specific Mn entry routes.

Frontiers of therapy for patients with heart failure.

This review broadly covers advances in heart failure, which is responsible for significant morbidity, mortality, and cost in the United States. It is a heterogeneous condition, and accurate classification helps ensure appropriate application of evidence-based therapies. Hemodynamics are important in acute heart failure syndromes and may help tailor therapy. Neurohormonal modulation forms the cornerstone of chronic systolic heart failure treatment but does not affect outcomes in diastolic heart failure where management goals emphasize optimization of central volume, blood pressure, and atrial rhythm, as well as the treatment of comorbidities. Frontiers of heart failure therapy range from advances in pharmacology (novel inotropic agents and neurohormonal modulators), to cell biology (nucleic acid-based drugs and cell therapy) to biomedical engineering (devices such as ultrafiltration, biventricular pacemakers, implantable cardiac defibrillators, remote monitoring systems, and left ventricular assist devices), and to health systems (risk stratification and integrated care of comorbidities). The ultimate frontier will be to integrate these data effectively to ensure that patients with heart failure consistently receive the best evidenced-based care possible.

A novel case of transient right ventricular failure in a patient with respiratory distress.

Right ventricular (RV) failure is characterized by an inability to pump blood into the pulmonary circulation and can often lead to hemodynamic instability. Common causes of RV failure include left ventricular (LV) failure, RV infarction, sepsis, cor pulmonale due to acute respiratory distress syndrome, pulmonary emboli, or pulmonary hypertension. We report the case of a 61-year-old woman with no significant pulmonary or cardiac disease who presented with hypoxic respiratory failure in the setting of opioid overdose. She remained obtunded despite naloxone treatment and required endotracheal intubation as well as norepinephrine therapy for persistent hypotension. A transthoracic echocardiogram demonstrated isolated severe RV dysfunction without any LV abnormalities. Cardiac catheterization showed no obstructive coronary artery disease, pulmonary hypertension, or elevated left atrial pressures, and chest imaging only revealed signs of aspiration. Over the next 6 days, the patient's cardiac and respiratory function improved, and a repeat echocardiogram demonstrated complete normalization of RV function. This case demonstrates a novel finding that marked, but transient, RV dysfunction can occur in the setting of acute respiratory failure.

Depression in patients with heart disease: the case for more trials.

Depression is common among patients with heart disease. It is an important comorbidity, both because of its well-known effect on the quality of life and also because it has a significant impact on the ability of patients with heart disease to engage in healthy behaviors and to avoid unhealthy ones. In addition, depression is associated with increased morbidity and mortality in those with established cardiovascular disease. However, no study has demonstrated that treatment of depression improves cardiac outcomes in patients with heart disease. Some have argued that additional trials are not necessary, and that the importance of depression argues for increased recognition and treatment even if it cannot be demonstrated that this improves morbidity and mortality. This article makes the case for more trials in this area, highlighting the importance of using the results of prior trials to generate hypotheses and provide directions for future studies in this area and noting the effect that demonstrating improved survival might have on clinical practice.

Impact of depressive symptoms and their treatment on completing antiviral treatment in patients with chronic hepatitis C.

BACKGROUND/GOALS: Interferon-induced depression affects 20% to 40% of patients treated for chronic hepatitis C virus (HCV). The aim of our study was to examine the influence of antidepressant treatment and whether this improves the likelihood of completing therapy. METHODS: One hundred randomly selected patients with chronic HCV undergoing antiviral therapy at a single center were identified. Patients were categorized as Group 1 (no depressive symptoms during treatment), Group 2 (depressive symptoms without antidepressant therapy), Group 3 (preexisting or prophylactic antidepressants before therapy), and Group 4 (on-demand antidepressant therapy for depressive symptoms). RESULTS: Mean age was 49 years with 72% men. Genotype 1 infection was noted in 65% of patients, and the mean pretreatment HCV RNA level was 1,419,919 IU. Patients without earlier depression receiving on-demand therapy (Group 4) had a significantly higher rate of antiviral treatment completion compared with Group 3 (92% vs. 52%; P=0.01). Patients in groups 1 and 4 with no baseline history of depression had similar treatment completion rates. No significant relationship between the use of antidepressant therapy, SVR or premature cessation of therapy was observed. CONCLUSIONS: Preexisting depression was associated with lower antiviral treatment completion rates despite the use of prophylactic antidepressant therapy. In patients without preexisting depression, however, on-demand antidepressant therapy for depressive symptoms was strongly associated with the highest treatment completion rates in the cohort. Antidepressant therapy for new or worsening depressive symptoms independent of baseline depression status did not affect the probability of achieving SVR or stopping treatment prematurely.