Taking Stock: Disruption in the Life of a Professional Organization.

The purpose of this paper is to describe the journey of the National Hartford Center for Gerontological Nursing Excellence, a 501(c)(3) organization, during the COVID-19 pandemic. Using the RISE (resilience, intention, sustain, and endurance) model, the organization's response is detailed. The COVID-19 pandemic pushed us to think about the way we operate and proactively develop and implement strategies for the organization. For example, changing to a virtual format for our leadership conference was a very successful change that has influenced our planning for future conferences. We are emerging as a stronger organization due to our initial and sustained responses to this crisis.

Multiple Sites of Arterial Thrombosis in A 35-Year Old Patient after ChAdOx1 (AstraZeneca) Vaccination, Requiring Emergent Femoral and Carotid Surgical Thrombectomy.

BACKGROUND: Vaccine Induced Thrombotic Thrombocytopenia (VITT) is a rare complication following ChAdOx1 (AstraZeneca) vaccination. Venous thrombosis in unusual sites such as splachnic or intracranial thrombosis, is the commonest manifestation. CASE REPORT: We report a 35-year-old male patient who presented with acute left leg ischemia and thrombocytopenia 11-days after vaccination requiring emergent thrombectomy. During work-up, a localized thrombus was detected in the left carotid bifurcation mandating carotid thrombectomy. Localized right iliac thrombus causing a non-limiting flow stenosis was treated conservatively. The platelet aggregating capacity of patient's plasma was confirmed in a functional assay, thereby establishing VITT. CONCLUSION: To the best of our knowledge this is the first case presenting multiple arterial thromboses requiring surgical treatment after ChAdOx1 vaccination.

The effectiveness of excimer laser angioplasty to treat coronary in-stent restenosis with peri-stent calcium as assessed by optical coherence tomography.

AIMS: We aimed to evaluate the effectiveness of excimer laser coronary angioplasty (ELCA) to treat in-stent restenosis (ISR) due to peri-stent calcium-related stent underexpansion as assessed by optical coherence tomography (OCT). METHODS AND RESULTS: We studied 81 patients (81 lesions with ISR, stent underexpansion, and peri-stent calcium >90°) who underwent OCT imaging both pre and post percutaneous coronary intervention and compared lesions treated with ELCA (n=23) vs. without ELCA (n=58). ELCA use was associated with more calcium fracture (ELCA: 61%, non-ELCA: 12%, p<0.01), larger final minimum lumen area (ELCA: 4.76 mm2 [3.25, 5.57], non-ELCA: 3.46 mm2 [2.80, 4.13], p<0.01), and a larger previously implanted stent area (ELCA: 6.15 mm2 [4.83, 7.09], non-ELCA: 4.65 mm2 [3.84, 5.40], p<0.01). In the multivariable model, ELCA use was associated with peri-stent calcium fracture (odds ratio 46.5, 95% confidence interval: 6.8, 315.9, p<0.001) that, in turn, was associated with final larger lumen and stent dimensions. Finally, contrast injection during ELCA was associated with multiple calcium fractures and fractures even in thicker calcium. CONCLUSIONS: ELCA is effective for treating ISR with underexpansion by disrupting peri-stent calcium, facilitating better expansion of the previously implanted stent.

Safety of Same-Day Discharge after Percutaneous Coronary Intervention with Orbital Atherectomy.

BACKGROUND: Severely calcified lesions present many challenges to percutaneous coronary intervention (PCI). Orbital atherectomy (OA) aids vessel preparation and treatment of severely calcified coronary lesions. Same-day discharge (SDD) after PCI has numerous advantages including cost savings and improved patient satisfaction. The aim of this study is to evaluate the safety of SDD among patients treated with OA in a real-world setting. METHODS: This was a single-center retrospective analysis of patients undergoing OA. In-hospital and 30-day outcomes were assessed for major adverse cardiac events (MACE), device-related events and hospital readmissions. RESULTS: There were 309 patients treated with OA of whom 94 had SDD (30.4%). Among SDD patients, there were no acute procedural complications and all patients were safely discharged on the day of the procedure. MACE at 30 days occurred in 1 patient (1.06%) due to major bleeding in the setting of a gastric arteriovenous malformation. There were 8 patients with unplanned 30-day readmissions (8.5%). CONCLUSION: SDD after OA in patients with heavily calcified lesions appears to be safe, with low rates of adverse events and readmissions in select patients. In patients with SDD treated with OA, unplanned readmission occurred at a similar rate to the statewide average 30-day PCI readmission rate. Larger studies are needed to confirm the safety of this treatment paradigm and the potential cost savings.

The impact of previous revascularization on clinical outcomes in patients undergoing primary percutaneous coronary intervention.

While the impact of prior coronary artery bypass graft surgery (CABG) on in-hospital outcomes in patients with ST-elevation myocardial infarction (STEMI) has been described, data are limited on patients with prior percutaneous coronary intervention (PCI) undergoing primary PCI in the setting of an STEMI. The aim of the present study was to assess the effect of previous revascularization on in-hospital outcomes in STEMI patients undergoing primary PCI. Between January 2004 and December 2007, a total of 1649 patients underwent primary PCI for STEMI at four New York State hospitals. Baseline clinical and angiographic characteristics and in-hospital outcomes were prospectively collected as part of the New York State PCI Reporting System (PCIRS). Patients with prior surgical or percutaneous coronary revascularization were compared to those without prior coronary revascularization. Of the 1649 patients presenting with STEMI, a total of 93 (5.6%) had prior CABG, 258 (15.7%) had prior PCI, and 1298 (78.7%) had no history of prior coronary revascularization. Patients with prior CABG were significantly older and had higher rates of peripheral vascular disease, diabetes mellitus, congestive heart failure, and prior stroke. Additionally, compared with those patients with a history of prior PCI as well as those without prior coronary revascularization, patients with previous CABG had more left main interventions (24% vs 2% and 2%; P<.001), but were less often treated with drug-eluting stents (47% vs 61% and 72%; P<.001). Despite a low incidence of adverse in-hospital events, prior CABG was associated with higher all-cause in-hospital mortality (6.5% vs 2.2%; P=.012), and as a result, higher overall MACE (6.5% vs 2.7%; P=.039). By multivariate analysis, prior CABG (odds ratio, 3.40; 95% confidence interval, 1.15-10.00) was independently associated with in-hospital mortality. In contrast, patients with prior PCI had similar rates of MACE (4.3% vs 2.7%; P=.18) and in-hospital mortality (3.1% vs 2.2%; P=.4) when compared to the de novo population. Patients with a prior history of CABG, but not prior PCI, undergoing primary PCI in the setting of STEMI have significantly worse in-hospital outcomes when compared with patients who had no prior history of coronary artery revascularization. Thus, only prior surgical - and not percutaneous - revascularization should be considered a significant risk factor in the setting of primary PCI.

Determinants of bare-metal stent use in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Bare-metal stent (BMS) use in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has been associated with higher rates of adverse cardiac events, including target lesion and target vessel revascularization. The purpose of the present study was to determine which clinical characteristics predict BMS use in patients with STEMI undergoing primary PCI. Data were prospectively collected from all patients who underwent primary PCI for STEMI between January 1, 2004 and December 31, 2007 at four New York State academic medical centers. Demographics, baseline medical history, procedural characteristics, and in-hospital outcomes were compared in patients receiving DESs versus BMSs. Of the 1394 patients studied, a total of 290 (20.8%) patients received a BMS while 1104 (79.2%) received a DES. Patients receiving a BMS were more likely to have higher rates of prior coronary artery bypass graft surgery, prior PCI, peripheral vascular disease, and diabetes mellitus, and were more likely to be Hispanic and uninsured. They were also more likely to present with stent thrombosis and worse left ventricular ejection fraction (LVEF). Patients receiving a BMS had significantly longer hospital length of stay and a trend toward higher all-cause in-hospital mortality. In multivariate analysis, independent predictors of BMS use included uninsured status (versus private insurance) (odds ratio [OR], 2.81; 95% confidence interval [CI], 1.70-4.67), peripheral vascular disease (OR, 1.96; 95% CI, 1.08- 3.56), and LVEF (OR, 0.98; 95% CI, 0.97-0.99). In conclusion, in this analysis of a contemporary cohort of patients undergoing primary PCI, lack of health insurance, peripheral vascular disease, and worse LVEF were independently associated with higher rates of BMS implantation in patients with STEMI undergoing primary PCI.

Impact of severity of renal dysfunction on determinants of in-hospital mortality among patients undergoing percutaneous coronary intervention.

BACKGROUND: Chronic kidney disease (CKD) is a known prognostic indicator of poor outcomes following percutaneous coronary intervention (PCI) for coronary artery disease. However, it is unclear whether other predictors of mortality differ among patients with varying degrees of renal impairment. Thus, we aimed to identify determinants of in-hospital mortality which are specific to patients with preserved renal function, moderate CKD, or end stage renal disease (ESRD) on dialysis, undergoing PCI. METHODS: The study population included 25,018 patients who underwent PCI between January 1, 2004, and December 31, 2007, at four New York State hospitals. The primary endpoint of the study was in-hospital mortality. RESULTS: A total of 474 (1.9%) patients had ESRD on dialysis, 6,596 (26.4%) had moderate CKD (GFR<60 ml/min/1.73 m(2) ), and 17,948 (71.7%) had preserved renal function (GFR>60 ml/min/1.73 m(2) ). Patients with ESRD and moderate CKD were older, more often male, and had higher rates of prior coronary revascularization, peripheral vascular disease, congestive heart failure, prior stroke, and diabetes than those with preserved function. All-cause in-hospital mortality rates were significantly higher in patients with ESRD and moderate CKD compared to patients with GFR >60 ml/min/1.73 m(2) (2.1% and 1.3%, respectively vs. 0.3%, p < 0.001). In multivariable analysis, ESRD (OR: 3.68, 95% CI 1.62-8.36) and moderate CKD (OR: 2.92, 95% CI 1.91-4.46) were independently associated with higher rates of in-hospital mortality. Independent predictors of mortality were markedly distinct in each group and included female gender and myocardial infarction within the past 72 hr in the ESRD group, versus left ventricular ejection fraction, peripheral vascular disease, congestive heart failure, emergency PCI, and absence of prior PCI in the moderate CKD group and age, prior bypass graft surgery, congestive heart failure, emergency PCI, and absence of prior myocardial infarction in patients with preserved renal function. CONCLUSIONS: Patients with moderate CKD or ESRD undergoing PCI have an approximately threefold increase in the risk of in-hospital mortality compared with patients with preserved renal function, with radically different mortality predictors existing for varying levels of renal function.

Association of health insurance status with presentation and outcomes of coronary artery disease among nonelderly adults undergoing percutaneous coronary intervention.

OBJECTIVE: The aim of this study was to determine if insurance status is associated with adverse outcomes in patients with coronary artery disease. METHODS: A cohort of 13,456 patients who underwent percutaneous coronary intervention (PCI) between January 1, 2004, and December 31, 2007, at 4 New York State teaching hospitals was retrospectively studied. The primary outcome of interest was in-hospital mortality from any cause. RESULTS: Of the 13,456 patients studied, 11,927 (88.6%) were insured by private carriers, 1,036 (7.7%) patients were covered by Medicaid, and 493 (3.7%) were uninsured. Uninsured and Medicaid patients tended to be younger and more often nonwhite and Hispanic. They had a higher prevalence of congestive heart failure and worse left ventricular function. Compared with privately insured patients, uninsured and Medicaid patients had increased all-cause mortality (1.2% and 0.9%, respectively, vs 0.3%; P < .001). For all patients, lack of insurance (OR 3.02, 95% CI 1.10-8.28) and Medicaid (OR 4.39, 95% CI 1.93-9.99) were independently associated with mortality. Lack of insurance (OR 5.02, 95% CI 1.58-15.93) and Medicaid (OR 4.55, 95% CI 1.19-17.45) were also independently associated with increased mortality in patients undergoing emergent PCI. CONCLUSION: Lack of insurance and Medicaid insurance are both independently associated with an increased risk of in-hospital mortality after PCI for coronary artery disease.

Effect of gender and race on outcomes in dialysis-dependent patients undergoing percutaneous coronary intervention.

We aimed to determine whether gender and race are independently associated with in-hospital major adverse cardiac and cerebrovascular events (MACCE) and hospital length of stay in chronic dialysis patients undergoing percutaneous coronary intervention (PCI). Cardiovascular disease is the leading cause of mortality in patients with end-stage renal disease requiring dialysis. Whether gender or race independently influences the outcomes in patients undergoing PCI is not fully understood. The study population included 474 chronic dialysis patients who underwent PCI at 4 New York State teaching hospitals from January 1, 2004 to December 31, 2007. The primary end point of the study was the composite of in-hospital MACCE, defined as all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke. The secondary end points included in-hospital all-cause mortality and hospital length of stay. Of the 474 chronic dialysis patients, 172 (36.3%) were women. The women undergoing PCI were more likely to be black or Hispanic and had a greater left ventricular ejection fraction. The women had significantly greater rates of in-hospital MACCE (5.8% vs 1.7%, p=0.013) and mortality (4.7% vs 0.7%, p=0.006). No significant difference in the MACCE rates was found between the black and white patients (4.9% vs 2.2%, respectively, p=0.125), although black patients showed a trend toward greater in-hospital mortality (4.1% vs 1.2%, p=0.069). After adjustment for the baseline clinical and procedural characteristics, female gender was an independent predictor of MACCE (odds ratio 7.41, 95% confidence interval 1.81 to 30.27) and all-cause mortality (odds ratio 13.23, 95% confidence interval 1.55 to 113.25), but race was not. No significant difference in the hospital length of stay was observed by either gender or race. In conclusion, in this study, female gender was independently associated with a greater risk of MACCE and all-cause mortality in dialysis-dependent patients undergoing PCI. Although being a black woman was an independent predictor of mortality, race per se was not an independent predictor of in-hospital mortality.

The presence, characterization and prognosis of coronary plaques among patients with zero coronary calcium scores.

Patients with coronary artery calcium (CAC) scores of zero are generally considered not to have atherosclerosis. Recent studies involving computed tomography coronary angiography (CTCA) challenge this assumption. This goal of the present study is to assess the frequency, morphology, location, and the prognosis of patients with plaque detected on CTCA and zero CAC. 1,119 patients (51 ± 12 years, 52% male) with a zero CAC score during CTCA study were retrospectively identified. The CTCA studies were assessed for the presence, morphology, location and severity of all coronary plaques. All-cause mortality was assessed. The prevalence of coronary plaque was 13% (147 patients). Among the 212 plaques identified 154 (73%) were non-calcified, 28 (13%) were calcified, and 30 (14%) were of mixed morphology. Notably, ≥70% stenosis was noted among only 0.4% of all patients. ROC analysis revealed that coronary artery disease risk factors did not add to the prediction of plaque among our patients. Over a mean follow-up of 2.5 ± 0.6 years there were 4 deaths (0.4%), all in patients without coronary plaque on CTCA. The presence of coronary plaque is not uncommon among patients with zero CAC scores. These plaques were rarely associated with hemodynamically significant stenoses and were associated with an excellent prognosis. Clinical factors do not appear to be useful in predicting which patients with zero CAC scores have undetected coronary plaque.

Programmed inappropriate ICD ventricular defibrillation for cardioversion of persistent atrial fibrillation.

In this report we briefly describe a patient with a dual chamber implantable cardioverter defibrillator in the context of severe ischemic cardiomyopathy who developed persistent atrial fibrillation. After appropriate anticoagulation and under mild sedation the patient was successfully cardioverted to sinus rhythm after a programmed ventricular synchronized defibrillation using his defibrillator. Programmed internal cardioversion of persistent atrial fibrillation in patients who have an implantable cardioverter defibillator without atrial defibrillation capabilities could be an effective and safe therapeutic option. Unlike external electrical cardioversion, this strategy does not interfere with the implantable cardioverter defibrillator, is more effective, and obviates the need of general anesthesia. This strategy should be further evaluated in clinical trials.

Prevalence of hepatitis B and C markers among refugees in Athens.

AIM: To assess the prevalence of hepatitis B and C serological markers in a population of refugees living in Athens. METHODS: One hundred and thirty refugees (81 males and 49 females, mean age +/-SD: 31.7+/-8 years) were included in the study. The hepatitis B virus surface antigen (HBsAg), the hepatitis B virus core antibody (anti-HBc) and the hepatitis C virus antibody (anti-HCV) were detected using a third-generation immunoassay. RESULTS: Twenty individuals (15.4 %) were HBsAg positive and 69 (53.1 %) were anti-HBc positive. The prevalence of HBsAg and anti-HBc was higher among refugees from Albania and Asia (statistical significant difference, P<0.008 and P<0.001 respectively). The prevalence of these markers was found irrelevant to age or sex. Anti-HCV was detected in the serum of 3 individuals (2.3 %). No differences among age, sex or ethnicity regarding anti-HCV prevalence were found. CONCLUSION: It can be concluded that refugees living in Athens are an immigrant population characterized by a high incidence of HBV infection. The prevalence of HBV markers is higher among refugees from Albania and Asia. It is therefore believed that the adherence to general precautions and the initiation of HBV vaccination programs will be necessary in the future, especially in these communities. Although the prevalence of HCV infection seems to be relatively low, extended epidemiological surveys are needed to provide valid results.