Podcasts about patients hospitalized

Episode Notes Join DASON Liaison Jeannette Bouchard as she hosts Dr. Dan Ilges and Dr. Ryan Stevens to discuss the recent article published in Infection Control & Hospital Epidemiology titled: “Real-world Utility of Procalcitonin in Patients Hospitalized with Community-Acquired Pneumonia: A Matched Cohort Study.” Together, they unpack how this study challenges the utility of procalcitonin in guiding antibiotic use for CAP, explores implications for diagnostic stewardship, and reflects on strategies to optimize antimicrobial decision-making in inpatient care. The articles reviewed in this episode can be found here: https://pubmed.ncbi.nlm.nih.gov/40017121/ and here: https://www.fda.gov/media/100879/download For more information about DASON, please visit: https://dason.medicine.duke.edu/

In his weekly clinical update, Dr. Griffin with Vincent Racaniello debate the changes in FDA vaccine approval policy especially how it is applied to COVID-19 vaccines and restricts vaccine availability/usage and Novavax's vaccine, mpox on surfaces and in the air, “bird flu”, the ongoing measles outbreak globally before Dr. Griffin reviews recent statistics on RSV, benefits of vaccination for infants, influenza and SARS-CoV-2 infections, the Wasterwater Scan dashboard, the high number of childhood deaths during this “flu” season, the May 22 VRBPAC COVID-19 vaccine meeting, where to find PEMGARDA, prolonged steroid and antibiotic therapies, provides information for Columbia University Irving Medical Center's long COVID treatment center, where to go for answers to your long COVID questions, cognitive impairment in long COVID and contacting your federal government representative to stop the assault on science and biomedical research. Subscribe (free): Apple Podcasts, RSS, email Become a patron of TWiV! Links for this episode FDA to issue new vaccine approval guidance amid questions over coronavirus shots (Washington Post) FDA vaccine committee meeting(Reuters) Evidence-based approach to COVID-19 vaccination (NEJM) FDA CBER townhall: new COVID019 vaccination approval mechanism (YouTube) FDA poised to restrict access to COVID vaccines, our own Dr. Griffin is cited! (NY Times) Novavax approval letter (FDA) We giveth and taketh away: Novavax approved but restricted use (AP News) FDA approves Novavax COVID vaccine with stricter new conditions (NY Times) History behind public health falsehoods– vaccine and autism (NPR) Making vaccines less accessible-RFK Jr making MAHA! (PBS News Hour) Kenneday says DO NOT to take medical advice from him, the HHS secretary…hummmm (NY Times) Staying up to date with COVID-19 vaccines (CDC: COVID-19) How science lost America's trust and surrendered health policy to skeptics (WSJ) HHS stops recommendation of COVID-19 shots for children and pregnant women (Reuters) No more routine COVID-19 vaccines for children and pregnant women (WSJ) House to investigate Pfizer for allegedly delaying COVID-19 vaccines (Reuters) Statement on the antigen composition of COVID-19 vaccines (WHO) WHO advisers say current strains OK for COVID vaccine production (CIDRAP) We can't remain indifferent to suffering: Catholic Church now champions HPV vaccination (DailyNation) Air and surface sampling for mpox in UK (Eurosurveillance) Researchers report mpox DNA, live virus on surfaces and in air from patients' rooms(CIDRAP) USDA reported H5N1 bird flu detection in wild birds (CDC: Avian Influenza) USDA reported H5N1 in poultry (CDC: Avian Influenza) HPAI Confirmed Cases in Livestock(USDA Animal and Plant Health Inspections Service) H5 bird flu: current situation (CDC: Avian Influenza) Bird flu (CDC: Avian Influenza) Measles cases and outbreaks (CDC Rubeola) Measles and rubella weekly monitoring report: (Government of Canada) Measles vaccine recommendations from NYP (jpg)  Get the FACTS about measles (NY State Department of Health) Measles (CDC Measles (Rubeola) Measles vaccine (CDC Measles (Rubeola) Presumptive evidence of measles immunity (CDC) Contraindications and precautions to measles vaccination (CDC) Adverse events associated with childhood vaccines: evidence bearing on causality (NLM) Measles Vaccination: Know the Facts(ISDA: Infectious Diseases Society of America) Deaths following vaccination: what does the evidence show (Vaccine) Influenza: Waste water scan for 11 pathogens (WastewaterSCan) US respiratory virus activity (CDC Respiratory Illnesses) Weekly surveillance report: clift notes (CDC FluView) Respiratory virus activity levels (CDC Respiratory Illnesses) Weekly surveillance report: clift notes (CDC FluView) FDA-CDC-DOD: 2025-2046 influenza vaccine composition (FDA) RSV: Waste water scan for 11 pathogens (WastewaterSCan) US respiratory virus activity (CDC Respiratory Illnesses) RSV-Network (CDC Respiratory Syncytial virus Infection) Waste water scan for 11 pathogens (WastewaterSCan) COVID-19 deaths (CDC) COVID-19 national and regional trends (CDC) COVID-19 variant tracker (CDC) SARS-CoV-2 genomes galore (Nextstrain) Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States (CDC: COVID-19) COVID-19 vaccine VRBPAC May 22 (FDA) Where to get pemgarda (Pemgarda) EUA for the pre-exposure prophylaxis of COVID-19 (INVIYD) Infusion center (Prime Fusions) CDC Quarantine guidelines (CDC) NIH COVID-19 treatment guidelines (NIH) Drug interaction checker (University of Liverpool) Infectious Disease Society guidelines for treatment and management (ID Society) Molnupiravir safety and efficacy (JMV) Convalescent plasma recommendation for immunocompromised (ID Society) What to do when sick with a respiratory virus (CDC) When your healthcare provider is infected/exposed with SARS-CoV-2 (CDC) Managing healthcare staffing shortages (CDC) Steroids,dexamethasone at the right time (OFID) The clinical impact of prolonged steroid therapy in severe COVID-19 patients (BMC Pulmonary Medicine) Anticoagulation guidelines (hematology.org) Antibiotic Treatment in Patients Hospitalized for Nonsevere COVID-19 (JAMA Network Open) Daniel Griffin's evidence based medical practices for long COVID (OFID) Long COVID hotline (Columbia : Columbia University Irving Medical Center) The answers: Long COVID Self-reported health, neuropsychological tests and biomarkers in fully recovered COVID-19 patients vs patients with post-COVID cognitivesymptoms (PLoS One) Vortioxetine for Cognitive Impairment in Major Depressive Disorder During Post-COVID Syndrome (Journal of Clincial Psychiatrist) Reaching out to US house representative Letters read on TWiV 1220 Dr. Griffin's COVID treatment summary (pdf) Timestamps by Jolene Ramsey. Thanks! Intro music is by Ronald Jenkees Send your questions for Dr. Griffin to daniel@microbe.tv Content in this podcast should not be construed as medical advice.

In the September 24, 2024, JACC issue, Dr. Valentin Fuster presents the latest expert consensus on heart failure management, updating the 2019 guidelines with ten key changes. Highlights include a strong emphasis on SGLT inhibitors throughout hospitalization and a refined approach to managing heart failure patients, ensuring timely adjustments in therapy and improved patient care strategies.

Howie and Harlan are joined by Chima Ndumele of the Yale School of Public Health to discuss his research on structural changes to Medicaid that could keep vulnerable populations healthier. Harlan reports on the remarkable abilities of Google's latest medicine-focused AI; Howie reflects on a study showing the impact of race-neutral measures of lung function.  Links: AI and Medicine “Capabilities of Gemini Models in Medicine” Medicaid Medicaid.gov “10 Things to Know About Medicaid” Supplemental Nutrition Assistance Program (SNAP) “Long-Term Stability of Coverage Among Michigan Medicaid Beneficiaries: A Cohort Study” “Unwinding And The Medicaid Undercount: Millions Enrolled In Medicaid During The Pandemic Thought They Were Uninsured” Chima Ndumele: “Variation in Health Outcomes: The Role of Spending on Social Services, Public Health, and Health Care, 2000–09” Chima Ndumele: “In Medicaid Managed Care Networks, Care Is Highly Concentrated Among A Small Percentage Of Physicians” “N.C. developing plan to improve Medicaid participants' job prospects” “Yale School of Public Health Graduates Urged to Adopt a “Healthy Disregard for the Impossible” Race and Lung Function “Implications of Race Adjustment in Lung-Function Equations” Harlan Krumholz: “Association of Racial and Socioeconomic Disparities with Outcomes among Patients Hospitalized with Acute Myocardial Infarction, Heart Failure, and Pneumonia. An Analysis of Within- and Between-Hospital Variation” “Q&A: Harlan Krumholz on hospital readmissions” Health & Veritas Live on May 30 Join Howie and Harlan in person at the Yale Innovation Summit. Watch live on YouTube. Learn more about the MBA for Executives program at Yale SOM. Email Howie and Harlan comments or questions.

Howie and Harlan are joined by Chima Ndumele of the Yale School of Public Health to discuss his research on structural changes to Medicaid that could keep vulnerable populations healthier. Harlan reports on the remarkable abilities of Google's latest medicine-focused AI; Howie reflects on a study showing the impact of race-neutral measures of lung function.  Links: AI and Medicine “Capabilities of Gemini Models in Medicine” Medicaid Medicaid.gov “10 Things to Know About Medicaid” Supplemental Nutrition Assistance Program (SNAP) “Long-Term Stability of Coverage Among Michigan Medicaid Beneficiaries: A Cohort Study” “Unwinding And The Medicaid Undercount: Millions Enrolled In Medicaid During The Pandemic Thought They Were Uninsured” Chima Ndumele: “Variation in Health Outcomes: The Role of Spending on Social Services, Public Health, and Health Care, 2000–09” Chima Ndumele: “In Medicaid Managed Care Networks, Care Is Highly Concentrated Among A Small Percentage Of Physicians” “N.C. developing plan to improve Medicaid participants' job prospects” “Yale School of Public Health Graduates Urged to Adopt a “Healthy Disregard for the Impossible” Race and Lung Function “Implications of Race Adjustment in Lung-Function Equations” Harlan Krumholz: “Association of Racial and Socioeconomic Disparities with Outcomes among Patients Hospitalized with Acute Myocardial Infarction, Heart Failure, and Pneumonia. An Analysis of Within- and Between-Hospital Variation” “Q&A: Harlan Krumholz on hospital readmissions” Health & Veritas Live on May 30 Join Howie and Harlan in person at the Yale Innovation Summit. Watch live on YouTube. Learn more about the MBA for Executives program at Yale SOM. Email Howie and Harlan comments or questions.

Commentary by Dr. Candice Silversides

Commentary by Dr. Valentin Fuster

News

The Filtrate:Joel TopfNayan AroraSophia AmbrusoWith Special Guest:Boback Ziaeian @boback Assistant Professor of Medicine David Geffen School of Medicine at UCLA. His Google Schoolar page is better than yours. And returning for her fourth time (why do we keep inviting her back?)Sadiya Khan @heartDocSadiya Assistant Professor of Medicine (Cardiology) and Preventative Medicine at Northwestern Feinberg School of Medicine. LinkEditor:Priya YenebereShow Notes:Diuretic Therapy review by. Craig Brater NEJMThe manuscript in JAMA | NephJCMetoprolol vs Carvedilol: Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial (Lancet)EMPULSE: The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial (Nature Medicine)Effect of Aliskiren on Postdischarge Mortality and Heart Failure Readmissions Among Patients Hospitalized for Heart Failure The ASTRONAUT Randomized TrialEffects of Oral Tolvaptan in Patients Hospitalized for Worsening Heart Failure The EVEREST Outcome TrialSophia ended up placing fifth in NephMadness 2023. (Link)Joel finished 697thAfter winning in the opening round, Northwestern lost to UCLA, in the second round of the March Madness tournament, 68-63.Torsemide to furosemide equivalents CardioMems positive trial: Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure therapy: complete follow-up results from the CHAMPION randomised trial (The Lancet)CardioMems negative trial: Haemodynamic-guided management of heart failure (GUIDE-HF): a randomised controlled trial (The Lancet)Estimation of the Absolute Risk of Cardiovascular Disease and Other Events: Issues With the Use of Multiple Fine-Gray Subdistribution Hazard Models (Circulation)Torasemide in chronic heart failure: results of the TORIC study (PubMed)Tubular SecretionsNayan: Louise Penny A World of Curiosities: A Novel (Amazon)Sadiya: Ted Lasso season threeSophia:The Last of Us on HBO and SNL skit Mario Cart as Prestige DramaBoback: Duolingo for Japanese

If there's one physician I listen and trust it's Dr David Brownstein. I have followed his guidance and introduced protocols into my own practice like hydrogen peroxide to game-changing effect. So I wanted to talk to him again a year later and discuss where his thinking is and what novel ideas and therapies he is working with now that could again make a game-changing effect in my life and my work. Dr. David Brownstein, M.D., is a board-certified family physician who utilizes the best of conventional and alternative therapies. He is the Medical Director for the Center for Holistic Medicine in West Bloomfield, Michigan. He is a graduate of the University of Michigan and Wayne State University School of Medicine.Dr. Brownstein is a member of the American Academy of Family Physicians and serves on the board for the International College of Integrative Medicine. Dr. Brownstein has lectured internationally about his success using natural therapies. He has also authored sixteen books including Iodine: Why You Need It, Why You Can't Live Without It, and his newest book A Holistic Approach to Viruses.Join us as we explore:What unique lessons Dr Brownstein has learnt over the past 3 years about the immune system, including the need to move as well as keeping sweets in the cupboard.Fibrinogen - what it is and why we need to pay more attention to it.The big problem with ocean derived supplements and products, and why there is less of what we need and more of what we don't want!The biological mechanism of iodine, and why we need more than ever yet there is less than ever in nature.Ferritin, iron, zinc and copper – Dr Brownstein's view on ferritin and iron, the relationship between iron, zinc and copper, what are healthy levels and why birth control is an unknown part of the biological copper crisis.Robert F. Kennedy Jr's  presidential candidacy.Mentions:Study – Randomized Trial of Molnupiravir or Placebo in Patients Hospitalized with Covid-19, https://evidence.nejm.org/doi/full/10.1056/EVIDoa2100044Support the showSupport the show on Patreon:As much as we love doing it, there are costs involved and any contribution will allow us to keep going and keep finding the best guests in the world to share their health expertise with you. I'd be grateful and feel so blessed by your support: https://www.patreon.com/MadeToThriveShowSend me a WhatsApp to +27 64 871 0308. Disclaimer: Please see the link for our disclaimer policy for all of our content: https://madetothrive.co.za/terms-and-conditions-and-privacy-policy/

Show notes at pharmacyjoe.com/episode824. In this episode, I'll discuss torsemide vs furosemide for symptoms and quality of life among patients hospitalized for heart failure. The post 824: Torsemide vs Furosemide – Which Is Better For Symptoms and Quality of Life Among Patients Hospitalized for Heart Failure? appeared first on Pharmacy Joe.

Show notes at pharmacyjoe.com/episode824. In this episode, I ll discuss torsemide vs furosemide for symptoms and quality of life among patients hospitalized for heart failure. The post 824: Torsemide vs Furosemide – Which Is Better For Symptoms and Quality of Life Among Patients Hospitalized for Heart Failure? appeared first on Pharmacy Joe.

I en nylig publisert studie har forskerne sammenlignet dødeligheten ved covid-19 og sesonginfluensa. Covid-19-infeksjon gir en kjent økt risiko for facialisparese – men gir også covid-19-vaksinasjon økt risiko? BCG-vaksinen er kjent for å gi såkalt «off target»-effekter, altså at den beskytter mot flere infeksjonssykdommer enn tuberkulose. Nå er det forsket på om den også kan beskytte mot covid-19. Under pandemien tok likestillingen mellom kjønnene innen forskning et stort steg tilbake, da bare 11 % av de mest aktive forskerne i det første pandemiåret var kvinner. Hvorfor var det slik? Og har du hørt om Rosalind Franklin, kvinnen som var helt instrumentell for oppdagelsen av DNA-ets heliksstruktur? Ikke det? Sjefredaktør Are Brean forteller blant annet også om ny forskning på prostatakreft hos transkvinner, på om det er bedre å operere eller ikke operere pasienter med isjias, og om den dødelige hetebølgen i Europa i fjor.Tilbakemeldinger kan sendes til stetoskopet@tidsskriftet.no.    Stetoskopet produseres av Synne Muggerud Sørensen, Are Brean og Julie Didriksen ved Tidsskrift for Den norske legeforening. Ansvarlig redaktør er Are Brean.    Jingle og lydteknikk: Håkon Braaten / Moderne media Coverillustrasjon: Stephen Lee Artikler nevnt:Risk of Death in Patients Hospitalized for COVID-19 vs Seasonal Influenza in Fall-Winter 2022-2023 Association of SARS-CoV-2 Vaccination or Infection With Bell Palsy: A Systematic Review and Meta-analysis Randomized Trial of BCG Vaccine to Protect against Covid-19 in Health Care Workers Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from Jan 1, 2020, to July 31, 2022: an observational analysis Seven days in medicine: 19-25 April 2023 The State of the World's Children 2023 How pandemic publishing struck a blow to the visibility of women's expertise How Rosalind Franklin was let down by DNA's dysfunctional team Prostate Cancer in Transgender Women in the Veterans Affairs Health System, 2000-2022 Prenatal Exposure to Antiseizure Medication and Incidence of Childhood- and Adolescence-Onset Psychiatric Disorders Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials Early surgery for sciatica Europe's record heatwave in 2022 caused many health harms, report finds

Commentary by Dr. Valentin Fuster

Episode 9! In this episode we step a little out of our comfort zone to talk about a couple of analyses which caught our interest recently: 1) "Comparative Effectiveness of Fludrocortisone and Hydrocortisone vs Hydrocortisone Alone Among Patients With Septic Shock" published  by Bosch et al March 2023 in JAMA Internal Medicine2) "Osmotic Demyelination Syndrome in Patients Hospitalized with Hyponatremia" published by MacMillan et al March 2023 in NEJM EvidenceFludrocortisone: https://pubmed.ncbi.nlm.nih.gov/36972033/COIITSS: https://pubmed.ncbi.nlm.nih.gov/20103758/ODM: https://evidence.nejm.org/doi/full/10.1056/EVIDoa2200215ODM Editorial: https://evidence.nejm.org/doi/full/10.1056/EVIDe2300014If you enjoy the podcast please share on social media or by word of mouth! Thank you!Be sure to follow us on the social @icucast for the associated figures, comments, and other content not available in the audio format! Email us at icuedandtoddcast@gmail.com with any questions or suggestions! Thank you Mike Gannon for the intro and exit music!

Editor's Summary by Linda Brubaker, MD, MS, Senior Editor of JAMA, the Journal of the American Medical Association, for the April 4, 2023, issue. Related Content: Audio Highlights

The Journal of Rheumatology's Editor-in-Chief Earl Silverman discusses this month's selection of articles that are most relevant to the clinical rheumatologist. Sex-Specific Differences in Patients With Psoriatic Arthritis: A Systematic Review - doi.org/10.3899/jrheum.220386 Evaluating the Threshold Score for Classification of Systemic Lupus Erythematosus Using the EULAR/ACR Criteria - doi.org/10.3899/jrheum.220100 The Association Between Quadriceps Strength and Synovitis in Knee Osteoarthritis: An Exploratory Study From the Osteoarthritis Initiative - doi.org/10.3899/jrheum.220538 Prevalence, Risk Factors, and Outcomes of Gout Flare in Patients Hospitalized for PCR-Confirmed COVID-19: A Multicenter Retrospective Cohort Study - doi.org/10.3899/jrheum.220762d Etanercept Withdrawal and Retreatment in Nonradiographic Axial Spondyloarthritis: Results of RE-EMBARK, an Open-Label Phase IV Trial - doi.org/10.3899/jrheum.220353

CME credits: 1.25 Valid until: 27-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/applicability-of-the-galactic-hf-trial-and-omecamtiv-mecarbil-to-patients-hospitalized-for-heart-failure-in-the-us-the-gwtg-hf-registry/15290/ In this program, expert faculty discuss data presented at the 2023 ACC Congress in a concise, informative, on-demand format. This format extends the congress analysis to a broader audience with greater detail than what is available in abstracts. Rapid advances from the meeting require well-planned educational programming to bridge knowledge, competence, and performance gaps.

Commentary by Dr. Akshay Desai

CME credits: 1.25 Valid until: 23-11-2023 Claim your CME credit at https://reachmd.com/programs/cme/generalizability-of-the-victoria-trial-and-the-us-fda-label-for-vericiguat-to-patients-hospitalized-for-heart-failure-in-the-united-states/14369/ In this program, expert faculty review and discuss real-world applications of the latest, practice-changing data across different therapeutic areas within cardiovascular medicine presented at the American Heart Association Scientific Session 2022.

Welcome to the NeurologyLive® Mind Moments® podcast. Tune in to hear leaders in neurology sound off on topics that impact your clinical practice. In this episode, we spoke with Ambereen Mehta, MD, MPH, palliative care physician, and assistant professor of medicine, Johns Hopkins Bayview Medical Center. She joined the show to discuss palliative care and its evolving role in the care paradigm for patients with chronic neurologic disease, as well as its history in the United States, how it differs from hospice care, and more. To learn more about neuropalliative care, head to our International Neuropalliative Care Society (INPCS) partner page, or click here to learn more about the INPCS 2022 Annual Meeting. Episode Breakdown: 1:15 – Overview of palliative care and its purpose 5:40 – Differences between hospice and palliative care 7:55 – History of palliative care in the United States 12:25 – Palliative care's fit in neurologic care 15:10 – Neurology News Minute 17:10 – Benefits of care for caregivers 21:15 – Palliative care resources and societies 22:30 – Neuropalliative care and its current goals 26:30 – Benefits for clinicians of implementing neuropalliative care 30:20 – Recommendations for physicians 36:00 – Tips for trying palliative care practices and findings resources This episode is brought to you by the Medical World News streaming service. Check out new content and shows every day, only at medicalworldnews.com The stories featured in this week's Neurology News Minute, which will give you quick updates on the following developments in neurology, are further detailed here: FDA Accepts Application for Trofinetide in Rett Syndrome LIFT-AD Study Amended to Assess Alzheimer Disease Agent Fosgonimeton as Monotherapy Tolerizing MS Vaccine Displays Efficacy in Model of Relapsing-Remitting Multiple Sclerosis Thanks for listening to the NeurologyLive® Mind Moments® podcast. To support the show, be sure to rate, review, and subscribe wherever you listen to podcasts. For more neurology news and expert-driven content, visit neurologylive.com. REFERENCES 1. Shemme AJ, Phillips JN, Bloise R, Koehler TJ, Gorelick PB, Francis BA. The Impact of a Neurocritical Care and Neuropalliative Collaboration on Intensive Care Unit Outcomes. Am J Hosp Palliat Care. 2022;39(6):687-694. doi:10.1177/10499091211060055 2. Mehta AK, Wright SM, Wu DS, Harris CM. Palliative Care Involvement in Patients Hospitalized in the United States with Aneurysmal Subarachnoid Hemorrhage. J Palliat Med. 2021;24(10):1555-1560. doi:10.1089/jpm.2021.0116 3. Williamson TL, Adil SM, Shalita C, et al. Palliative Care Consultations in Patients with Severe Traumatic Brain Injury: Who Receives Palliative Care Consultations and What Does that Mean for Utilization? Neurocrit Care. 2022;36(3):781-790. doi:10.1007/s12028-021-01366-2 4. Bužgová R, Kozáková R, Bar M. The effect of neuropalliative care on quality of life and satisfaction with quality of care in patients with progressive neurological disease and their family caregivers: an interventional control study. BMC Palliat Care. 2020;19(1):143. doi:10.1186/s12904-020-00651-9 5. Mehta AK, Jackson NJ, Wiedau-Pazos M. Palliative Care Consults in an Inpatient Setting for Patients With Amyotrophic Lateral Sclerosis. Am J Hosp Palliat Care. 2021;38(9):1091-1098. doi:10.1177/1049909120969959 6. Lou W, Granstein JH, Wabl R, Singh A, Wahlster S, Creutzfeldt CJ. Taking a Chance to Recover: Families Look Back on the Decision to Pursue Tracheostomy After Severe Acute Brain Injury. Neurocrit Care. 2022;36(2):504-510. doi:10.1007/s12028-021-01335-9. 7. Miyasaki JM, Kluger BM (ed). Handbook of Clinical Neurology. Neuropalliative Care - Part I. 2022;190:2-243 8. Lou W, Granstein JH, Wabl R, Singh A, Wahlster S, Creutzfeldt CJ. Taking a Chance to Recover: Families Look Back on the Decision to Pursue Tracheostomy After Severe Acute Brain Injury. Neurocrit Care. 2022;36(2):504-510. doi:10.1007/s12028-021-01335-9 9. Phillips JN, Besbris J, Foster LA, Kramer NM, Maiser S, Mehta AK. Models of outpatient neuropalliative care for patients with amyotrophic lateral sclerosis. Neurology. 2020;95(17):782-788. doi:10.1212/WNL.0000000000010831

Interview with Tariq Ahmad, MD, MPH, author of Alerting Clinicians to 1-Year Mortality Risk in Patients Hospitalized With Heart Failure: The REVEAL-HF Randomized Clinical Trial, and Rishi K. Wadhera, MD, MPP, MPhil, author of Improving Quality Improvement—From Aspiration Toward Empiricism. Hosted by Gregg C. Fonarow, MD. Related Content: Alerting Clinicians to 1-Year Mortality Risk in Patients Hospitalized With Heart Failure Improving Quality Improvement—From Aspiration Toward Empiricism

Interview with Tariq Ahmad, MD, MPH, author of Alerting Clinicians to 1-Year Mortality Risk in Patients Hospitalized With Heart Failure: The REVEAL-HF Randomized Clinical Trial, and Rishi K. Wadhera, MD, MPP, MPhil, author of Improving Quality Improvement—From Aspiration Toward Empiricism. Hosted by Gregg C. Fonarow, MD. Related Content: Alerting Clinicians to 1-Year Mortality Risk in Patients Hospitalized With Heart Failure Improving Quality Improvement—From Aspiration Toward Empiricism

This week, please join authors Mikhail Kosiborod and Christian Schulze and Editorialist Stefan Anker as they discuss the original articles "Effects of Empagliflozin on Symptoms, Physical Limitations and Quality of Life in Patients Hospitalized for Acute Heart Failure: Results From the EMPULSE Trial" and "Effects of Early Empagliflozin Initiation on Diuresis and Kidney Function in Patients With Acute Decompensated Heart Failure (EMPAG-HF)" and the editorial "SGLT2 Inhibitors: From Antihyperglycemic Agents to All-Around Heart Failure Therapy." Dr. Carolyn Lam:             Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley:           And I'm Dr. Greg Hundley, associate editor, director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam:             I'm so excited about the feature discussion this week. It is a paired feature along with their editorial and it's all focused on SGLT2 inhibitors. The first, results from the EMPULSE trial, Effects of Empagliflozin on Symptoms, Physical Limitations and Quality of Life in Patients Hospitalized for Acute Heart Failure; and the second, the EMPAG-heart failure trial, The Effects of Early Empagliflozin Initiation on Diuresis and Kidney Function in Patients with Acute Heart Failure. Incredibly important topics, incredibly important discussion. Wait up for it. We're just going to tell you a little bit more about two other original papers in today's issue, and I'm going to go first, Greg. Is that okay? Dr. Greg Hundley:           You bet. Dr. Carolyn Lam:             Now, really interesting topic here. We have strong evidence supporting the effective blood pressure and cardiovascular disease risk lowering properties of healthy diet such as the DASH diet, Mediterranean diet, and so on and so on. But what about the diet consumed by a fifth of the entire world's population? The Chinese cuisine. Interestingly, today's paper addresses just that. This is from authors, Dr. Wu, from Peking University Clinical Research Institute and colleagues who performed a multicenter patient and outcome assessor blind randomized feeding trial among 265 participants with baseline systolic blood pressure of 130 to 159 in four major Chinese cuisines. And these are the Shandong, Huaiyang, Cantonese, and Szechuan cuisines, and here's how they did it. After a seven day run in period on a control diet matching the usual local diets, participants were randomized to continue with the control diet or the cuisine based Chinese heart healthy diet for another 28 days. The primary outcome was systolic blood pressure. The study developed the first heart healthy Chinese diet that fits Chinese food culture and emphasizes its palatability by involving master shifts in developing the recipes. Dr. Greg Hundley:           Oh wow. Carolyn, this is really interesting, especially one fifth of the world's population in studying a heart healthy diet. So did it work? I can't wait to hear the results. Dr. Carolyn Lam:             Well, the change in systolic and diastolic blood pressure from baseline to the end of the study in the control group was five millimeters mercury and 2.8 millimeters mercury reduction, respectively. The net difference of change between the two groups in systolic and diastolic blood pressure were a reduction of 10 and almost four millimeters mercury, respectively. The effect size did not differ among cuisines, and so in summary, with a patient and assessor blind randomized feeding trial, this study really demonstrated that the blood pressure lowering effect of the Chinese heart health diet could indeed be substantial, and importantly, be compatible with medications while palatable and affordable in Chinese adults with high blood pressure, and so these results support the idea that food is medicine and will give many patients with high blood pressure the confidence to adopt heart healthy diets in their lifestyle treatment. Dr. Greg Hundley:           Wow, Carolyn, that is really an interesting article. So many of these articles today could all be features in and of themselves. That was just outstanding. Well, my next paper comes to us from the world of preclinical science, and it's from Dr. Sean Wu from Stanford University School of Medicine. So Carolyn, immune checkpoint inhibitors are monoclonal antibodies that are used to activate the immune system against tumor cells. Now, despite their therapeutic benefits, immune checkpoint inhibitors have the potential to cause immune mediated adverse events such as myocarditis, a rare but serious side effect with up to 50% mortality in affected patients. Now histologically, patients with immune checkpoint inhibitor of myocarditis have lymphocytic infiltrates in the heart implicating T-cell mediated mechanisms. However, the precise pathologic immune subsets and molecular changes in immune checkpoint inhibitor myocarditis are unknown. Dr. Carolyn Lam:             Wow. So insights into the etiology of these immune checkpoint associated myocarditis cases must be very important. So what did they find? Dr. Greg Hundley:           Right, Carolyn? So clonal cytotoxic, TEMRA CD8+ cells were found to be significantly increased in the blood of patients with immune checkpoint inhibitor myocarditis corresponding with an analogous increase in effector cytotoxic CD8+ cells in the blood and hearts of PD-1 deficient mice with myocarditis. These expanded effector CD8+ cells had unique transcriptional changes, including upregulation of the chemokines CCL5, CCL4, and CCL4L2, and they may serve as attractive diagnostic therapeutic targets for reducing life threatening cardiac immune related adverse events in immune checkpoint inhibitor treated cancer patients, and Carolyn, just like so many of our articles, there's a very nice accompanying editorial by Professor Gianluigi Condorelli that also offers an update on current research pertaining to non-systemic steroid therapy to treat immune mediated myocarditis. Well, Carolyn, how about we jump to some of the other articles in the issue? Dr. Carolyn Lam:             Oh, you bet, Greg. There's an exchange of letters between Drs. Madias and Knops regarding the article “Efficacy and Safety of Appropriate Shocks and Antitachycardia Pacing in Transvenous and Subcutaneous Implantable Defibrillators: The Analysis of All Appropriate Therapy in the PRAETORIAN Trial.” Dr. Greg Hundley:           And also in the mail bag, Professor Mark has a Research Letter entitled “Effect of Empagliflozin on Kidney Biochemical and Imaging Outcomes in Patients with Type 2 Diabetes, or Prediabetes, and Heart Failure with Reduced Ejection Fraction, The SUGAR-DM-HF Study,” and our own Tracy Hampton has several synopses from articles published elsewhere in our piece on cardiovascular news. Well, how about we get onto that feature forum discussion, two papers, two editorialists. I can't wait. Dr. Carolyn Lam:             Me too. Let's go, Greg. Dr. Greg Hundley:           Welcome, listeners to this July 26th feature forum discussion. So remember, listeners, for forum discussions, we have several manuscripts that focus on a singular topic and we bring together the authors, our associate editors, and also an editorialist, and today, I want to introduce, we have with us Dr. Mikhail Kosiborod from Mid America Heart Institute in Kansas City, Missouri, Dr. Christian Shults from University Hospital Jena in Germany, Stefan Anker from Charité in Berlin, Germany, and our Associate Editors, Brendan Everett from Brigham and Women's Hospital in Boston, Massachusetts, and Justin Grodin from University of Texas Southwestern Medical Center in Dallas, Texas. Welcome, gentleman, and we'll start with you, Mikhail. Could you describe for us the background information that went into the preparation of your study and what was the hypothesis that you wanted to address? Dr. Mikhail Kosiborod:   Well, thanks very much, Greg. The background for the study, which was the secondary analysis of the EMPULSE trial was patients that are hospitalized with acute decompensated heart failure represent a very high risk group. We know that they have high risk of death and hospitalizations, and we also know that they have very poor health status that's very high burden of symptoms, physical limitations, and poor quality of life, and so addressing those treatment goals, trying to reduce the risk of clinical events like death and hospitalizations and improve the symptoms and physical limitations in this patient population are very important treatment goals. Now we previously demonstrated in the main results of the EMPULSE trials that using empagliflozin initiating empagliflozin SGLT2 inhibitor in this patient population as compared with placebo provided a significant total clinical benefit, which was a composite of total death, repeat hospitalizations for heart failure, or a change in a Kansas City cardiomyopathy questionnaire, which is a kind of a gold standard measure of patient's health status. What we tried to do in a much more granular fashion in this study is to understand the effects of empagliflozin as compared with placebo on this very important outcome, the Kansas City cardiomyopathy questionnaire, and we actually evaluate all of the key domains and composite symptoms, physical limitations, as well as quality of life. Dr. Greg Hundley:           Very nice, and Mikhail, can you describe for us what study population specifically, and then what was your study design? Dr. Mikhail Kosiborod:   Well, this was a population of patients that were hospitalized with heart failure and that EMPULSE was unique in its design because first of all, previous SGLT2 inhibitor trials mostly focused on patients with chronic heart failures that were in an outpatient setting, including prior trials of empagliflozin, and EMPULSE really focused on acutely hospitalized patient population, but it included patients regardless of ejection fraction. So as they were hospitalized with decompensated heart failure and reduced or preserved ejection fraction. They were enrolled regardless of if they had type 2 diabetes, they were enrolled essentially, regardless of kidney function, only patients with EGFR of less than 20 were excluded, and also importantly, was this study and a unique feature of the study in particular was that we enrolled patients whether they had acute de novo heart failure. That means that was a new diagnosis of heart failure that was bad enough for them to be hospitalized or worsening chronic heart failure requiring hospitalization. So it was really an all-comer trial for patients acutely hospitalized for heart failure. So we had just over 500 patients and they were randomized in the hospital. After a brief period of stabilization, we use empagliflozin, 10 milligrams daily or placebo and treated for 90 days, and the primary outcome at 90 days was a total clinical benefit that I described that was a composite, hierarchical composite of total death hospitalizations, repeat hospitalizations for heart failure and changing KCCQ. In this study, again, we focused predominantly on KCCQ, trying to understand the effects on health status, again, symptoms, physical limitations, and quality of life. Dr. Greg Hundley:           Excellent. And Mikhail, what were your study results? Dr. Mikhail Kosiborod:   Well, what we observed, a couple of things. One is we first examined the effects of empagliflozin on the primary endpoint across the range of KCCQ and baseline, and what we found was that regardless of the degree of symptomatic impairment and baseline, empagliflozin was consistent in providing them total clinical benefits that I described previously, and then kind of shifting to what I think is the most interesting findings, the effects of empagliflozin versus placebo on KCCQ, what we found was that as you would imagine in this population of patients that were acutely hospitalized with heart failures, that had very poor health status, very low KCCQ at baseline, and within the first 90 days, which was observation period, both groups of patients had substantial improvements in KCCQs. As one would expect after acutely decompensated episode of heart failure and treatment in a hospital, everyone got better. But patients treated with empagliflozin had significantly greater improvement in KCCQs than those that were treated with placebo, and that was first of all, a very substantial difference between the two groups. It was more than five points in favor of empagliflozin already at 15 days and was highly statistically significant, and it was maintained throughout the 90 day treatment period. So the fact that we saw both a clinical meaningful and statistically significant improvement in just 15 days, I think is a very important clinical message, and then finally, I guess what I will mention is these benefits of empagliflozin while main outcome we looked at was KCCQ total symptoms, we're focusing on the symptoms, but it was consistent when we looked at physical limitations as well as quality of life. So really, all key domains of KCCQ were impacted in a similar way. Dr. Greg Hundley:           Very nice. So in acute heart failure, marked symptomatic improvement after the administration of the SGLT2 inhibitor empagliflozin at 10 milligrams per day. Well, now listeners, we're going to turn to our associate editor, Dr. Brendan Everett, and Brendan, again, you have many papers come across your desk. What attracted you to this particular manuscript? Dr. Brendan Everett:      Well, thanks, Greg, and I think this manuscript caught my eye because of the importance of the clinical question, and Mikhail outlined why I think that was really relevant. So we understand that this class of medications or SGLT2 inhibitors have important effects on outcomes like re-hospitalization in patients with heart failure, and what was particularly striking about this paper is that it took patients rather than those with chronic heart failure, but as Mikhail mentioned, enrolled a patient population that was actually in the hospital, and I think this was an important frontier for this particular question about when to start the SGLT2 inhibitor and what kind of benefits there might be. Furthermore, I think the fact that they did not select the population based on ejection fraction was particularly striking, and of course, I think is remarkable, but now old news, they did not select on the presence or absence of diabetes as well. And so those three components really attracted me to the paper. I also think the outcome is one that really is valuable and worth exploring, and specifically, I'm talking about how patients feel on the medication after a hospitalization for heart failure. Appropriately, we focused on re-hospitalization for heart failure and cardiovascular death in prior trials in this space, and I think we need to embellish those findings or further deepen those findings with a perspective on how patients actually feel when they get the medication, and of course, it goes without saying that what's particularly important here also is that it was a randomized placebo controlled trial, and so the results have some element of internal validity that I think is really important. So those were the things, Greg, that really attracted my attention as I read the paper for the first time. Dr. Greg Hundley:           Thank you so much, Brendan. Well, listeners, we've got a second paper today and we're next going to hear from Dr. Christian Shults, and he also is focusing on really another aspect of the administration of empagliflozin in patients with acute heart failure and that pertains to the renal function of the patients. So Christian, could you describe for us the background pertaining to your study and what was the hypothesis that you were intending to address? Dr. Christian Schulze:     Thanks, Greg. Well, it's great to introduce all study here in this running. So our study impacted those in acute decompensated heart failure. The impact HF trial was a study based on the hypothesis that we wanted to test, whether empagliflozin has effects in acute decompensated heart failure, and we focused on the patient population that was not addressed in EMPULSE, patients that came to the ER and needed to be treated right away, and we wanted to know and this was our main hypothesis, but are the diuretic and [inaudible 00:17:11] effects of the SGLT2 inhibitor on this case, empagliflozin, actually had an impact on diuretic regimens and kidney functions since this is one of the main end points that limits treatment, and also is one of the outcomes of patients with acute decompensated heart failure in the hospital. Dr. Greg Hundley:           Very nice. And so Christian, what study design did you implement and who was included in your study population? Dr. Christian Schulze:     So we also used the randomized two arm study design. We included patients with acute decompensated heart failure independent of left ventricular ejection fraction. Patients needed to have an NT-proBNP of more than 500. The average NT-proBNP in fact was 4,300 in our entire patient population, and we included patients within 12 hours of presentation. So many of these patients have been recruited in the ER, they presented two hour cardiology heart failure service, and then were immediately randomized to the trial in the two arms, and we tested not 10 milligrams of empagliflozin. We actually tested 25 milligrams of empagliflozin based on in-house data that 25 milligrams potentially had a stronger diuretic effect compared to 10 milligrams. Dr. Greg Hundley:           And what did you find? Dr. Christian Schulze:     So we followed patients for five days. It was a relatively short period of time. It was designed to address the in-house phase of patients with acute decompensated heart failure. The mean duration of stay was 6.3 days in the hospital so this was exactly the time that we wanted to test. We had a 30 day endpoint for safety issues, and what we could see is that patients on 25 milligrams on empagliflozin on top of standard diuretic regimens and medical care had 25% higher diuretic outputs compared to patients in the placebo group. We also found no differences in markers of renal injury dysfunction, and could in fact confirm that after 30 days, patients in the empagliflozin group had a better EGFR compared to patients in the placebo group. On top, we saw a more rapid decrease in body weight and also a more profound decrease in NT-proBNT values. Dr. Greg Hundley:           And Christian, just for our listeners to put a little bit of this in perspective, what was the range of serum creatinine for the patients that were enrolled in your study? Dr. Christian Schulze:     So the main EGFR in the entire population was around 60 and the creatinine values were around 107 on average in the entire cohort. So this is a very typical population. We had around 30% of the population with de Novo heart failure, around 20 to 30% of the population was pre-treated for preexisting heart failure. So very typical population of patients with heart failure presenting to the emergency room. Dr. Greg Hundley:           And did you have any kind of lower level EGFR cutoff, I mean, for enrollment into this study? Dr. Christian Schulze:     So when we designed the trial, we actually still had the sub classification of diabetes or impaired glucose or homeostasis as an inclusion criteria. We dropped it before we started the trial because the data came out that this is actually, in fact, not a critical issue for patients with heart failure. So diabetes was not a subgroup in our trial and the lower limit of EGFR was actually a thoroughly defined protocol. Dr. Greg Hundley:           Very nice. Well, listeners, now we're going to turn to our second associate editor, Dr. Justin Grodin from University of Texas Southwestern Medical Center in Dallas, Texas, and Justin, similar to Brendan, and you see many papers come across your desk and so what attracted you to this particular paper by Christian and his colleagues? Dr. Justin Grodin:            Well, Greg, I think first and foremost, and I think very similar to Brendan, but I think what's always striking is if I may just take a step back, decompensated heart failure in the United States is the number one cause for hospitalization among Medicare beneficiaries. So I think really, the brunt and really the truly public health message of the disease is very important in the applicability, and even though that decompensated heart failures is one of the most common things that we ever encounter when we practice, internists, cardiologists, et cetera, we have very, very little clinical trial guidance that tells us how to decongest individuals when they're hospitalized with swelling and heart failure and a lot of these individuals can be quite ill, and we have some clinical trial data, but largely, we have a lot of negative studies or inconclusive studies in this space. So certainly, what drew me to this trial was definitely that context, and obviously, based on the mechanistic data with SGLT2 inhibitors, I think one of the natural questions, which Christian addresses, is that we know that up front, they do augment natriuresis. So I think it's very compelling to marry those two together because this is what many of us that use these medications regularly have been asking is whether or not they would have some efficacy in that regard, and then another thing that caught my eye and me as a cardiorenal investigator was, just as Christian highlighted, was we have a clinical trial that randomly assigned individuals, really that were ill and many of whom were not stabilized within 12 hours of presentation, and we're talking about patients that are coming into the hospital at all times during the day in and I think that's very remarkable that we have something with standard... We have a study with standardized assessments where we're really trying to ask a very practical, pragmatic question, which is do these therapies lower the sodium balance in individuals with decompensated heart failure, and I think what's important is largely, we've got a lot of medications that supplement loop diuretics, which are the class of drugs that the majority of us use, and we have a lot of other therapies that we use that really have very little data or poor data that guide us such as thiazide diuretics, carbonic and hydrase inhibitors, mineralocorticoid receptor antagonists, and so here, we have a clinical trial that asks a question that's on many people's minds. And then we do have very compelling, at least short term pragmatic and mechanistic data that does tell us that these individuals do have a greater natriuretic effect when empagliflozin is used as an adjunct to standardized loop diuretic therapy. So it's a very practical clinical question, and I think what's very important, and we could debate probably all day about the implications of GFR change and kidney function change while we're decongesting somebody with diuretics, but I think what's reassuring to all the clinicians is we really didn't see an effect on kidney function despite a greater natriuretic effect or enhanced diuretic effect, if you will, with the use of empagliflozin. Dr. Greg Hundley:           Very nice. Well, thank you, Justin. Listeners, now we have an editorialist and as you know, editorialists really help us put the scientific presentation of an original manuscript into the perspective of really the global theme of a topic, and we have Stefan Anker from Berlin, and Stefan, can you describe for us how do we put these two manuscripts and results that we've heard about really in the context now of moving forward with the use of SGLT2 inhibitors in the management of patients with acute decompensated heart failure? Dr. Stefan Anker:            Thank you so much. Really, I think these two papers, on the one hand, enhance our certainty about early use, and on the other hand, possibly show us that there might be even more to achieve by, on the one hand, moving even earlier with the application of SGLT2 inhibitors or possibly consider the higher dose. Now let's take one step back. These drugs were developed in type two diabetes and the first successful trial was the [inaudible 00:25:42] outcome trial. Many people have forgotten that this trial tested two doses and not only one, the 10 and the 25 milligram dose, and of course, with the success for improving kidney outcomes and heart failure hospitalization outcomes, we move forward into these two specialist areas, on the one hand, broadening it to the non-diabetic communities, but on the other end, narrowing it by focusing on the 10 milligram dose regardless of whether there is [inaudible 00:26:12]. And we basically now learn A, to use these drugs even earlier than we did in the big trials and we can now be sure to start their use in the hospital, and if you take the average change in quality of life results seen, you actually get a better result for the patient on quality of life when you start earlier than when you start late in the ambulatory studies where basically, in the chronic setting, maybe you have one and a half to two points difference. Here, you now have four and a half points in the study shown by Mikhail, and of course, it's also good to know that you can start this in any type of patient, regardless of their quality of life. The impact study from Christian, they basically moved it now even earlier, moving into the hospital space is possible based on EMPULSE. Moving it into the acute admission space is at least a consideration now based on what Christian here has shown. And he is actually addressing the one question I hear very often in my presentations about SGLT2 inhibitors, what about this 25 milligram dose? Is there a place for this in cardiology as well, and a possible place is shown here, not only that this is a safe thing to do, but also you get urinary output. Of course, we may in the future, want to see this compared, directly compared to the 10 milligram dose, but of course, the world is not created in one day, but needs more than one and so really, I think these two studies, on the one hand, address an important issue, when to start using them. On the other hand, show us a little bit of a glimpse to the future. Dr. Greg Hundley:           Very nice, Stefan, and listeners, we get to take advantage of having these authors, editors, and editorialists together and ask them what they see as the next study to be performed in this sort of sphere of research. So Mikhail, we'll start with you. In 30 seconds or less, what do you see as the next study to be performed in this arena of research? Dr. Mikhail Kosiborod:   I think, Greg, what we've learned recently, including from the EMPULSE trial, we have this population of patients in a hospital with heart failure's a huge issue as Justin mentioned, and until recently, we had very little [inaudible 00:28:31] for them beyond the usual kind of decongestion with loop diuretics and trying to make them feel better, but you look at outcome data. It really was a dearth of effective therapies that have meaningful impact on important outcomes. Now that's changing, SGLT2 inhibitors is one example. There are some other recent examples in this patient population, like a firm HF and iron deficient patients with heart failure. But the bottom line is it's no longer kind of a desert, if you will, of positive trials. We now have something we can do and I think what this proves is that we need to actually invest more, both in terms of resources and time to really do what we we're being able to do in other areas of heart failure and those patients with chronic, half and half where we can start developing pillars of therapy that can actually truly improve outcomes with this patient population and there is a lot going on that makes me optimistic that's going to be the case in the coming years. Dr. Greg Hundley:           Very nice. And Brendan? Dr. Brendan Everett:      Well, I think both trials mentioned today really pushed our understanding of this population forward. I think the biggest clinical question that I face when I'm caring for these patients is that we have four, at least, guideline directed therapies, right? We have beta blockers, we have ARBs, ACE inhibitors and ARNIs. We have mineral receptor antagonists and we have SGLT2 inhibitors. So which do we use in what order and how do we start them, and what kind of parameters do we use to guide us if we're limited either by renal function or by blood pressure or by some other factor. And we often, if not always, have one of those constraints that we're dealing with and so I would say the next step for me is trying to sort out which of these therapies and what order ought to be our highest priority for patients with acute decompensated heart failure as we move quickly from the acute decongestion stage towards discharge and a chronic therapy that will then be followed as an outpatient over the ensuing days and months. Dr. Greg Hundley:           Very nice. And Christian. Dr. Christian Schulze:     Thank you again, and Brandon pointed out very nicely. I mean, we have good evidence now for chronic heart failure treatment. We have the four columns of heart failure medical therapy. Questions that remain open is what do we do with all these patients that are now guideline medicated, come to the hospital with an acute decompensation? Should we carry on with the medication? Should we terminate and in particular, should be carry on with full dose, 50% dose of SGLT2 inhibitors, and the next question is, what dose should we use, in fact, for SGLT2 inhibitors? Is it in group effects or is sotagliflozin comparable to empagliflozin, and then is there a role for a step by scheme that we initially have in high dose therapy that we then downgrade to 10 milligrams on the chronic heart failure treatments, and then of course, quality of life is very important. We should ask this question also in this patient population that is early on treated, do we see benefits that carry on in the outpatient setting and do we see an effect of early treatment on long term benefits? Dr. Greg Hundley:           Justin? Dr. Justin Grodin:            Well, I would have to agree with all of my colleagues here on this call. I think all have raised really good points, but I think one very simple, and I'll echo some of Brendan's statements, but one very simple question is we know that when we decongest people and initiate a negative salt balance in the hospital for decompensated heart failure, we cause neurohormonal activation and there are a lot of downstream untoward effects from chronic decongestive therapies, and I think one of the more compelling things is we still yet have defined what is the best way to decongest individuals with swelling or volume overload in the hospital. Here, we have compelling studies with SGLT2 inhibitors for quality of life and really, the way patients feel. And this is really what's important to them, and then something very pragmatic to clinicians and let's make people pee more, but I think one of the compelling questions, and I don't know if it will be answered, is we have a lot of choices for supplemental therapies and different diuretic strategies when patients come in the hospital for decompensated heart failure, and I do think that these studies do move the needle with SGLT2 inhibitors. I think that's abundantly clear, but we still don't know what is the best way to dry out my patient or make my patient pee so that they feel better, but I do think that these studies do at least set the stage that there's some compelling advantages to SGLT2 inhibitors. Dr. Greg Hundley:           And then lastly, Stefan. Dr. Stefan Anker:            Thank you. Besides the detailed points mentioned by many, and Christian, totally support 25 versus 10 milligram, how long 25 milligram, if at all in the future. Besides this, I'm interested in the big picture question. So what about the post myocardial infarct congestion/heart failure situation, and there will be two trials in the next 18 to 24 months that report on this, and my pet kind of area is actually to treat heart failure where nobody thinks it is heart failure, and what I mean is for instance, advanced cancer patients, cardiac wasting cardiomyopathy. So the heart failure in sick cancer patients, and indeed, we are planning to do exactly that now in a study focusing on hospice care patients to really improve the quality of life, the very thing focus here on the EMPULSE trial. Dr. Greg Hundley:           Well, listeners, we want to thank our authors, Dr. Mikhail Kosiborod from Mid America Heart Institute in University of Missouri, and Christian Shults from the University Hospital in Jena, Germany. Also, our associate editors, Dr. Brendan Everett from Brigham and Women's Hospital in Boston, and Dr. Justin Grodin from University of Texas Southwestern in Dallas, Texas, and also, our editorialist, Dr. Stefan Anker from Charité in Berlin, Germany for bringing us these two manuscripts pertaining to two randomized clinical trials regarding the administration of the SGLT2 inhibitor, empagliflozin in acute heart failure, demonstrating first, marked improvement in heart failure symptoms and health related quality of life. And second, in those with estimated GFRs greater than 30 mls per minute, an augmentation of natriuresis in the setting of the co-administration of diuretics without deterioration in renal function. Well, on behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week on the run. This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

Commentary by Dr. Valentin Fuster

Moderator Alice Gallo de Moraes, MD, and journal CHEST® authors Mohammad Alrawashdeh, PhD, MSN, and Chanu Rhee, MD, MPH, discuss the article, "Prevalence and Outcomes of Previously Healthy Adults Among Patients Hospitalized with Community-Onset Sepsis," which was published in the July issue. DOI: https://doi.org/10.1016/j.chest.2022.01.016

CME credits: 1.00 Valid until: 30-06-2023 Claim your CME credit at https://reachmd.com/programs/cme/what-are-the-keys-to-post-discharge-care-for-patients-hospitalized-for-hfref/14084/ TBD

Managing Complex Patients Hospitalized Due to COVID-19: Cases in Practice

Managing Complex Patients Hospitalized Due to COVID-19: Cases in Practice

Managing Complex Patients Hospitalized Due to COVID-19: Cases in Practice

Managing Complex Patients Hospitalized Due to COVID-19: Cases in Practice

Managing Complex Patients Hospitalized Due to COVID-19: Cases in Practice

Managing Complex Patients Hospitalized Due to COVID-19: Cases in Practice

Managing Complex Patients Hospitalized Due to COVID-19: Cases in Practice

Managing Complex Patients Hospitalized Due to COVID-19: Cases in Practice

Dr. Ebell and Dr. Wilkes discuss the POEM titled ' Thromboprophylaxis after discharge improves clinical outcomes for certain high-risk patients hospitalized with COVID-19 (MICHELLE) '

CME credits: 1.50 Valid until: 25-04-2023 Claim your CME credit at https://reachmd.com/programs/cme/results-from-the-empulse-trial-effects-of-empagliflozin-on-symptoms-physical-limitations-and-quality-of-life-in-patients-hospitalized-for-acute-heart-failure/14058/ tbd

Writing Group for the CODA Collaborative. Patient factors associated with appendectomy within 30 days of initiating antibiotic treatment for appendicitis. JAMA Surg 2022 Jan 12; [e-pub]. Now, investigators have explored in a secondary analysis of  The CODA Collaborative. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med 2020 Oct 5; [e-pub]. (data from a previous randomized antibiotics-versus-surgery trial (NEJM JW Gen Med Dec 1 2020 and N Engl J Med 2020; 383:1907). Have looke at the data to see could we predict factors that make you more likely to appendectomy and fail antibiotic therapy.  They identified 735 patients who had been randomized to antibiotic treatment; 154 (21%) of these patients underwent appendectomy within 30 days. Overall, 29% of patients in the antibiotics group underwent appendectomy within 90 days (41% of those with appendicolith vs. 25% without). The authors suggest hey maybe this appendicolith is the magic answer of who will fail therapy—maybe!! BUT remember this is secondary analysis so this is only hypothesis generating even a secondary analysis of a rct is just hypothesis. You need a new RCT to actually show causation.  Also as stated in the editorialists note that in subsequent analyses of this same data set, nearly 50% of patients underwent appendectomy within 2 years, regardless of the presence of an appendicolith, so an initial nonsurgical approach might only delay surgery. Some say 50% still going to surgery is terrible but I say even if 50% prevented from having surgery that is still 50% of people are being prevented from a surgery      Acetazolamide to Prevent Adverse Altitude Effects in COPD and Healthy Adults | NEJM Evidence Trial 1 was a randomized, double-blind, parallel-design trial in which 176 patients with COPD were treated with acetazolamide capsules (375 mg/day) or placebo- COPD patients had oxygen saturation measured by pulse oximetry of 92% or greater  primary outcome in trial 1 was the incidence of the composite end point of altitude-related adverse health effects (ARAHE)== Criteria for ARAHE included acute mountain sickness (AMS) and symptoms or findings relevant to well-being and safety, such as severe hypoxemia, requiring intervention. In trial 1 of patients with COPD, 68 of 90 (76%) receiving placebo and 42 of 86 (49%) receiving acetazolamide experienced ARAHEThe number needed to treat (NNT) to prevent one case of ARAHE was 4EVEN at NNT of 4 you  have to realize that still 50% of those with COPD required intervention to go back down to lower level.   Trial 2 comprised 345 healthy lowlanders.The primary outcome in trial 2 was the incidence of acute mountain sickness AMS assessed at 3100 m by the Lake Louise questionnaire score (the scale of self-assessed symptoms ranges from 0 to 15 points, indicating absent to severe, with 3 or more points including headache, indicating acute mountain sickness AMS).In trial 2 of healthy individuals, 54 of 170 (32%) receiving placebo and 38 of 175 (22%) receiving acetazolamide experienced acute mountain sickness AMS  The NNT to prevent one case of acute mountain sickness AMS was 10 (95% CI, 5 to 141).So use the acetazolamide still 1 in 5 individuals experience acute mountain sickness    Annals for Hospitalists Inpatient Notes - Clinical Pearls—Stopping, Starting, and Optimizing Guideline-Directed Medical Therapy in Patients Hospitalized for Heart Failure With Reduced Ejection Fraction | Annals of Internal Medicine (acpjournals.org) Treat with??Foundational medical therapy for HFrEF consists of comprehensive disease-modifying quadruple medical therapy, including angiotensin receptor–neprilysin inhibitors (ARNIs), β-blockers, mineralocorticoid receptor antagonists, and sodium–glucose cotransporter-2 inhibitors (1). Quadruple medical therapy is estimated to cumulatively reduce the relative risk for death by 73% over 2 years, with a number needed to treat of 3.9 to save 1 life  compared with traditional therapy using an ACEI and a β-blocker, treating a 55-year-old patient with comprehensive disease-modifying quadruple therapy projects to increase life expectancy by more than 6 years Approximately 1 in 4 patients hospitalized for worsening HFrEF die or are rehospitalized within 30 days of discharge --- Deferring in-hospital initiation is consistently associated with medications never being initiated in the outpatient setting, or initiated after substantial delaySTART THEM IN THE HOSPITAL-- There is no evidence to suggest that “go slow,” “one medication change at a time,” or “defer to outpatient” approaches improve medication tolerance or accomplish anything beneficial  If you mix a bunch of moon pies in a trash can you get what sounds like a great time but if you mix a bunch of cow pies in a trash can you just get poop Clearly seen in this next article Vitamin D supplementation for the treatment of migraine: A meta-analysis of randomized controlled studies - ClinicalKey  meta-analysis aims to explore the efficacy of vitamin D for migraine patients. Six RCTs and 301 patients were included in the meta-analysis. On average these people were having around 7 migraines per months and compared to control the vit d group decrease headache days by about 1.5 per month compared to placebo or UC So you say vit d works for something!!Not so fast Remember I would like a 25 yr old cut my hair by not 5 five year olds…. Sadly these studies were 5 yr olds UC could be nothing. Well vit d beating nothing isn't hard, we know placebo is real Even beating placebo isn't hard when it is open label or you are not blinded to the active arm. If I say, yes you are getting this drug vit d that will help your headaches you are going to believe it much more than if I just give you a pamphlet.  The authors in the discussion state “Higher vitamin D levels is associated with lower risk of migraine “ Well ya that is true but having a higher vitamin d level is also associated with going outside more. And going outside more is associated with no having a migraine.  High vit d level is amazing!! I love it but replacing it still seems to do nothing however if you want a high level and want to go outside and get a high level then I think that is a great idea and speaking of great ideas—    Here is a sad but enlightening article— Home pregnancy test use and timing of pregnancy confirmation among people seeking health care - ClinicalKey The researchers found that 74% of survey respondents took a home pregnancy test as the first step in confirming a suspected pregnancy;  Respondents who took home pregnancy tests confirmed pregnancy 10 days earlier than those who first tested at a clinic. (duh statements- if you test at home you find out sooner, this is so obvious an a no brainer--- BUT Confirmation of pregnancy at greater than 7 weeks' gestational age was higher among adolescents, Latina versus white women, food-insecure versus -secure women, and people with unplanned pregnancies. Those that did not test at home cited concerns about test accuracy (42%) and difficulties accessing one (26%). While overall 1/5 21% confirmed pregnancy at ≥7 weeks gestation, confirmation at ≥7 weeks was higher among adolescents versus young adults (47%!! vs 13%, p = 0.001), Latina versus white women (28% vs 11%, p = 0.02), food insecure versus secure women (28% vs 17%, p = 0.06), and people with unplanned versus planned/mistimed pregnancies (25% vs 13%, p = 0.07). Latina and food insecure women discover their pregnancy at the same time or rate as individuals with unplanned pregnancy!!! one in 5 confirm pregnancy at 7 weeks gestation or later and in those Latina, poor, or unplanned It is ¼ at >7weeks this obviously effects prenatal care and Gestational bans in the first trimester will disproportionately prevent young people, people of color, and those living with food insecurity from being able to access abortion.This is tough but it is this data that reminds me and should remind us that life is not equal and healthcare is not equal and certain populations and groups do need our help more than others.

Commentary by Dr. Usha Tedrow

In this week's View, guest host Deepak Bhatt, MD, MPH, FACC, offers a preview of some of the hottest trials at the European Society of Cardiology Congress 2021, taking place virtually August 27-30, including IAMI, EMPEROR-Preserved, EMPEROR-Pooled, MASTER DAPT, ENVISAGE-TAVI AF, FIGARO-DKD, FIDELITY, Colchicine in Patients Hospitalized with COVID-19, PREPARE-IT, The Michelle trial, GUIDE-HF, QUARTET, TWILIGHT-HBR, PRONOUNCE, and Amulet IDE.

Covid patients hospitalized, on ventilators at new highs; UA trustees direct campuses to implement mask rules; No verdict yet in Baker trial; Crystal Bridges announces donation

Pedro, Joanne e Fred discutem as novidades sobre COVID-19, em especial sobre a variante delta, os novos tratamentos aprovados e os efeitos colaterais de vacina. Esse episódio foi em parceria com o Whitebook! Acesse o aplicativo que te ajuda de forma rápida com informação de confiança na hora que você mais precisa! Clique no link para descobrir mais https://tinyurl.com/TdC-Whitebook e use o cupom CLINICAGEM para 30 dias grátis! Minutagem (2:10) Parceria com Whitebook (3:45) Variantes do covid (7:30) Variante delta (8:40) Sintomas da variante (10:45) Transmissibilidade (12:15) Vacina e a variante (16:20) Novos tratamentos (23:59) Inibidores da JAK (25:20) Corticoides (29:40) Anticorpos monoclonais (32:40) Reações vacinais (43:23) Resposta do desafio da semana anterior (44:23) Desafio da semana (45:16) Salves Referências em breve. Referências: Pinzón, Miguel Alejandro, et al. "Dexamethasone vs methylprednisolone high dose for Covid-19 pneumonia." PloS one 16.5 (2021): e0252057. Ranjbar, Keivan, et al. "Methylprednisolone or dexamethasone, which one is superior corticosteroid in the treatment of hospitalized COVID-19 patients: a triple-blinded randomized controlled trial." BMC infectious diseases 21.1 (2021): 1-8. Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe Acute Respiratory Distress Syndrome and COVID-19. Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19. Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial. Guimarães, Patrícia O., et al. "Tofacitinib in Patients Hospitalized with Covid-19 Pneumonia." New England Journal of Medicine (2021). Kalil, Andre C., et al. "Baricitinib plus remdesivir for hospitalized adults with Covid-19." New England Journal of Medicine 384.9 (2021): 795-807. ALLEN, Hester et al. Increased household transmission of COVID-19 cases associated with SARS-CoV-2 Variant of Concern B. 1.617. 2: a national casecontrol study. Public Health England, 2021. https://www.who.int/en/activities/tracking-SARS-CoV-2-variants/ https://covid.joinzoe.com/post/new-top-5-covid-symptoms

More Information: ATS COVID-19 Resource Center

Commentary by Dr. Valentin Fuster

This week's show features a panel discussion between authors Adrian Wells and Hyeon Chang Kim as they discuss their articles "Improving the Effectiveness of Psychological Interventions for Depression and Anxiety in Cardiac Rehabilitation PATHWAY—A Single-Blind, Parallel, Randomized, Controlled Trial of Group Metacognitive Therapy" and "Associations of Ideal Cardiovascular Health and Its Change During Young Adulthood With Premature Cardiovascular Events: A Nationwide Cohort Study." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, also your co-host. And Associate Editor, Director of the Pauley Heart Center, VCU Health in Richmond, Virginia. Dr. Carolyn Lam: Greg, we're starting off the month with double features, and these are just so interesting. The first paper talks about psychological interventions for depression and anxiety in cardiac rehabilitation. And the next talks about ideal cardiovascular health and its change during young adulthood and how that relates to premature cardiovascular events. Cool, huh? Dr. Greg Hundley: Absolutely. Well, Carolyn. How about we grab a cup of coffee and start discussing some of the other articles in the issue? And I could go first. Carolyn, the first article that I've got is from Mrs. Elizabeth Jordan from Ohio State University Wexner Medical Center. And it really pertains to cardiomyopathies. And remember, Carolyn, classically, we categorize hypertrophic, dilated, and arrhythmogenic right ventricular cardiomyopathy. And each has a signature genetic theme. Hypertrophic cardiomyopathy and ARVC are largely understood as genetic diseases of sarcomere or desmosome proteins. But in contrast, there are over 250 genes spanning more than 10 gene ontologies that have been implicated in dilated cardiomyopathy. And therefore, it really represents a very complex and diverse genetic architecture. So to clarify this, a systematic curation of evidence to establish the relationship of genes with dilated cardiomyopathy was conducted by an international panel with clinical and scientific expertise in dilated cardiomyopathy genetics. And they evaluated evidence supporting monogenic relationships of genes with idiopathic dilated cardiomyopathy. Dr. Carolyn Lam: Oh, wow. That sounds like a lot of work. And what did they find, Greg? Dr. Greg Hundley: Right, Carolyn. So in the curation of 51 genes, 19 had high evidence. 12 are definitive strong, and seven moderate. And notably, these 19 genes only explain the minority of cases, leaving the remainder of dilated cardiomyopathy genetic architecture really incompletely addressed. And clinical genetic testing panels include most high evidence genes. However also, the panel noted that genes lacking robust evidence are very commonly observed clinically. Dr. Greg Hundley: So Carolyn, the take home message from this international panel is that while dilated cardiomyopathy genetic testing panels include an average of about 60 genes, when curating published evidence for dilated cardiomyopathy, only 19 have really emerged as high levels of evidence. And then in this study, 51 genes were evaluated. And the 19 genes appraised as high evidence were recommended to be routinely used in the genetic evaluation of dilated cardiomyopathy. And one more point. Rare variants from genes without moderate, strong, or definitive evidence should not be used in clinical practice to predict dilated cardiomyopathy risk most importantly when also you're screening at risk family members. Dr. Carolyn Lam: Wow. Very nice. Stunning numbers. Well, my paper is identifying a novel therapeutic target in pulmonary arterial hypertension. Do you want to know what that is? Dr. Greg Hundley: Ah, yes, Carolyn. Very interesting. So what is it? Dr. Carolyn Lam: It's switch-independent 3A. Which is an epigenetic modifier, which is drastically down-regulated in pulmonary arterial hypertension patients and rodent models of pulmonary arterial hypertension. And strongly associated with decreased bone morphogenic protein receptor type two, or BMPR2 expression. So this switch-independent 3A overexpression up-regulated BMPR2 expression by modulating critical epigenetic pathways and decreasing a specific transcription factor binding to the BMPR2 promoter in pulmonary vascular smooth muscle cells. Furthermore, aerosolized lung-targeted gene transfer of adeno-associated virus zero type one and containing switch-independent 3A reversed and prevented pulmonary arterial hypertension phenotype in preclinical animal models. So this beautiful study, from Dr. Hadri from Icahn School of Medicine at Mount Sinai in New York and colleagues, really suggests that switch-independent 3A can be a clinically relevant molecule for the treatment of pulmonary arterial hypertension. Dr. Greg Hundley: Wow, Carolyn. Really nice. Very intricate science for the study of pulmonary hypertension. Well, my next paper actually comes to us from Dr. Joe Hill and colleagues at UT Southwestern Medical Center. And Carolyn, as we know, cardiac hypertrophy is an independent risk factor for heart failure. Of course, the leading cause of morbidity and mortality globally. And the calcineurin NFAT, or nuclear factor of activated T-cells pathway, and the MAP kinase ERK, or extra cellular signal regulated kinase pathway, contributes to the pathogenesis of cardiac hypertrophy as an interdependent network of signaling cascades. However, Carolyn, how these pathways interact really remains unclear. And so Dr. Hill and colleagues engineered a cardiomyocyte-specific ETS2, a member of the E26 transformation specific sequence or ETS domain family knockout mouse, and investigated the role of ETS2 in cardiac hypertrophy. Primary cardiomyocytes were also used to evaluate ETS2 function in cell growth. Dr. Carolyn Lam: Wow. Okay. So what were the results, Greg? Dr. Greg Hundley: Right, Carolyn. Three main findings. First, ETS2 is activated by ERK1/2, or extracellular signal-regulated kinase 1/2, in both hypertrophied murine hearts and in human dilated cardiomyopathy. Second, ETS2 is required for both pressure overload, and calcineurin induced cardiac hypertrophy responses involving signaling cascades distinct from, but interdependent with ERK1/2 signaling. And third, this group discovered that ETS2 synergizes with NFAT to transactivate RCAN1-4, an established downstream target of NFAT, or nuclear factor of activated T-cells. And they identified an MIR-223 as a novel transcriptional target of NFAT ETS2 in cardiomyocytes. Dr. Carolyn Lam: Wow. Wow. That sounds like a lot of detailed work. Could you tell us what the clinical implications are, Greg? Dr. Greg Hundley: You bet, Carolyn. So in aggregate, these findings unveil a previously unrecognized molecular interaction between two conical hypertrophic signaling pathways, MAP kinase-driven hypertrophy, and calcineurin driven hypertrophy. And therefore, as pathological cardiac hypertrophy is an established risk factor for heart failure development, this unveiling of novel signaling mechanisms really is of potential clinical relevance. Dr. Carolyn Lam: Thanks, Greg. Well, let's round up with what else there is in this week's issue. There's a Frontiers paper by Dr. Chris Granger. And it's a big call to action to the cardiology community, to incorporate SGLT2 inhibitors and GLP-1 receptor agonists for cardiovascular and kidney disease risk reduction. There's a Joint Opinion piece from the American Heart Association, World Heart Federation, American College of Cardiology, and European Society of Cardiology on, “The Tobacco Endgame: Eradicating a Worsening Epidemic,” by Dr. Elkind. Dr. Greg Hundley: Oh great, Carolyn. Well, I've got an On My Mind piece from Professor Bhatt. And it's entitled, “Does SGLT1 inhibition Add Benefit to SGLT2 Inhibition in Type 2 Diabetes Mellitus?” And next, Dr. Viskin has an ECG Challenge entitled, “Long QT Syndrome and Torsade de Pointes Ultimately Treated With Quinidine, The Concept of Pseudo Torsade de Pointes.” And then finally, there's a Letter to the Editor by Dr. Lu regarding the article, “Association of Body Mass Index and Age with Morbidity and Mortality in Patients Hospitalized with COVID-19, Results from the American Heart Association COVID-19 Cardiovascular Disease Registry.” Well, Carolyn, I can't wait to get on to this double feature. Dr. Carolyn Lam: Me too. Let's go. Dr. Greg Hundley: Welcome, listeners, to our feature discussion today. And again, we're going to create today a forum, because we have two very interesting papers to present during this timeframe. Our first is going to come to us from Dr. Adrian Wells from University of Manchester. And our second paper will come to us from Dr. Hyeon Chang Kim from Yonsei University. I want to welcome you both, gentlemen. And Adrian, I would like to start with you. Tell us a little bit about the background related to your study. And then what was the hypothesis that you wanted to address? Dr. Adrian Wells: Okay, well thank you for inviting me to take part in this podcast. Following cardiac events, around one in three individuals will develop significant anxiety and depression symptoms. And we know that anxiety and depression can have an impact on prognosis, quality of life, future outcomes. Psychological treatment isn't routinely offered in cardiac rehabilitation for anxiety and depression, despite the fact that we identified that many of our patients felt that they would benefit from a psychological intervention to address these issues. And they felt that their needs were not really being met. So our primary question was, can we improve psychological outcomes in patients with cardiovascular disease? Dr. Greg Hundley: Very nice. And Adrian, what was your study population? And also, what was your study design? Dr. Adrian Wells: So we selected patients who entered cardiac rehabilitation in the UK. So these are patients with acute coronary syndrome, revascularization, stable heart failure, heart transplantation, and so on. And so, a wide group of individuals. We recruited 332 patients, all of whom had had anxiety and depression scores of eight or more. So these were people showing mild to severe levels of psychological distress. We conducted a two arm single blind randomized controlled trial, with 332 patients who were randomly allocated to one of these two conditions. And we assessed anxiety and depression symptoms before treatment at four months and at 12 months. Dr. Greg Hundley: Describe a little bit some of the specifics of your intervention. And then what did you find? Dr. Adrian Wells: We use relatively recent new treatment called metacognitive therapy. And this was delivered in a group format over six sessions. And we trained cardiac rehabilitation staff, nurse consultants, physiotherapists, in the delivery of this intervention. Metacognitive therapy works on helping patients discover unhelpful patterns of thinking, such as worrying and ruminating ,and excessive threat monitoring. And to reduce those patterns of thinking that contribute to anxiety, depression, and poor adaptation following stressful life experiences. Dr. Greg Hundley: And what did you find? Dr. Adrian Wells: Well, what we found was that the addition of metacognitive therapy to treatment to usual cardiac rehabilitation, significantly improved outcomes at four months and 12 months. What was striking about this was that our effect sizes were modest and moderate to large. They seem to be larger than those obtained in other studies or psychological treatments. And of note, the treatment seemed to impact well on both anxiety and depression symptoms. Whereas other types of intervention evaluated in the past have tended to treat the depression, but not so much the anxiety. Dr. Greg Hundley: Very good. So it sounds like a group-based intervention. And I'm assuming maybe participants interacted not only with your staff, but with one another. How would you put your results really in the context with other research that's going on in this space? Dr. Adrian Wells: Well, there have been a number of studies in the past that have looked at individual and group-based treatments, and patient preference for different types of intervention. I think this is the first study to use a clear manualized intervention that's based on the psychological theory of mechanisms that contribute to the maintenance of psychological problems. Obviously, this tended to use more prescriptive interventions like anxiety management, stress management, taking techniques from a range of different sources. So I think there's a difference of conceptual basis to this kind of intervention. And it's something that is highly manualized and structured, and in fact can be delivered by a range of different healthcare professionals. Dr. Greg Hundley: Very nice. And also during cardiovascular rehab. Correct? Dr. Adrian Wells: Absolutely, yeah. During cardiac rehab. One interesting finding... And we were a little concerned that this might adversely affect attendance at cardiac rehab. But we found that the treatment was well tolerated, and it didn't have any negative impact on attendance at these other sessions. Dr. Greg Hundley: Excellent. Well, congratulations on this new finding. Well, listeners, we're next going to turn to Dr. Hyeon Chang Kim from Yonsei University in Korea. And Yong-Chan, could you describe for us also the background related to your study, and the hypothesis that your research wanted to test? Dr. Hyeon Chang Kim: Thank you for inviting me to this wonderful discussion. South Korea is among the countries with the lowest cardiovascular mortality in the world. And the rate is even decreasing. However, cardiovascular risk factor is worsening. Especially in younger generation in Korea. So these young people may not have a very high cardiovascular risk, but I wanted to know the potential impact of worsening cardiovascular risk profile in this younger Korean generation. And furthermore, I wanted to know how much we can lead youth cardiovascular risk by improving their cardiovascular health profile. Dr. Greg Hundley: Very nice. And so tell us about your study design and what was the study population, related to your study? Dr. Hyeon Chang Kim: My study is basically based on the national health checkup program and national health insurance claim database. In Korea, adults over the age of 20 and employed workers of all ages are required to take general health checkup every two years. The participation rate is between 70 and 80%. So we identified three and a half million adults, age 20 to 39 years, who complete the health checkup. And cardiovascular health scores was calculated as the number of ideal cardiovascular health component, which include non-smoking, moderate physical activity three times a week, body mass index below 2030, normal blood pressure, normal cholesterol and normal fasting glucose. So the score can range from zero to six. And higher score meaning better cardiovascular health. Our outcomes were myocardial infarction, stroke, heart failure, and cardiovascular deaths in about 16 years. In addition, we also evaluate the risk of cardiovascular disease. According to two year change in how the vascular health score using repeated health checkup data. Dr. Greg Hundley: Very nice. So evaluating a set of behavioral patterns and risk factors in younger individuals, and then predicting what their longer term adverse cardiovascular outcomes would be. So what did you find? Dr. Hyeon Chang Kim: So even in this relatively low risk population, better cardiovascular health score was associated with significantly lower cardiovascular risk. About 20% reduction per one point higher score. And more importantly, people with improving cardiovascular score over two years showed leading toward cardiovascular risk. Even if their baseline cardiovascular health score was very low. Dr. Greg Hundley: Really unique findings. Tell us about the impact of your results relative to other studies published in this space. And was this also.... This was unique, because it's an Asian population, Dr. Hyeon Chang Kim: Asian population. And we are among the very low risk population. And even in this low risk population, cardiovascular health score was... Fear can be a good predictor of cardiovascular risk. And compared to many Western countries, we have very low cardiovascular risk. And our population was younger than most other studies. So we can provide some evidence that even in the higher risk population, they can do much better, based on our study. Another important thing, we can check the impact of a changing cardiovascular score, even in the younger generation. Dr. Greg Hundley: Very good. And just as a frame of reference for our listeners. Give us some characteristics, if you wouldn't mind, on what really constitutes practically a low risk score, versus what would constitute a high risk score Dr. Hyeon Chang Kim: In this younger Korean population, their cigarette smoking, and their obesity, and physical inactivity are the most common causes of worsening cardiovascular profile. And the behavioral risk factor also can attack the blood glucose and cholesterol blood pressure. So in this younger generation, they're keeping the good behavior. Past behavior is very important and it's beneficial in the very long-term. Dr. Greg Hundley: Very nice, well listeners. We're going to turn to our experts here. Two very interesting studies. And ask them both, what do they think is the next study that needs to be performed in their respective areas of research? So Yong-Chan, we'll start with you. Since we just discussed your paper. What do you think is the next study to be performed really in this sphere of research. Dr. Hyeon Chang Kim: Korea is a relatively low cardiovascular risk, has a very small size, and no racial diversity. But even in this country, disparity and inequality in cardiovascular health is becoming an important issue. So I want to identify subcultural relatively poor cardiovascular health among younger population. And also I want to find ways to improve their cardiovascular score. The conventional approaches, such as education and mass campaign, are less effective oppose this younger adults have a poor socioeconomic status. So, we may need to develop newer target-specific strategies to improve their cardiovascular health. Dr. Greg Hundley: Good. And Dr. Wells, our agent will turn next to you. What do you see is the next area of investigation or research study that needs to be performed in your sphere of interests? Dr. Adrian Wells: Well, I think the next step is to look at rollout of this intervention. Is that feasible, and how acceptable is this to cardiac services? In fact, the National Institute of Health Research have just awarded us some funding to examine feasibility and barriers to implementation in the healthcare system. In addition to that, we're beginning to examine the effects of metacognitive therapy with other health conditions, such as cancer in children and adolescents. Dr. Greg Hundley: Nice. Well listeners, we have had just a wonderful discussion today from both Dr. Adrian Wells from University of Manchester. Who brought to us combining a group-mediated, psychological stress-reducing, anxiety-reducing, intervention to the cardiac rehab sphere. And how impactful that was in reducing both anxiety, and overall depressive symptoms. And then also exciting research from Dr. Hyeon Chang Kim from South Korea. Identifying for us that in Asian population, as well as what we know in other races, those individuals in their twenties to thirties with favorable lifestyle habits, have reduced cardiovascular risk much later in life. Dr. Greg Hundley: Well, on behalf of both Carolyn and myself, we want to wish you a great week. And we'll catch you next week on the run. Dr. Greg Hundley: This program is copyright of the American Heart Association, 2021. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors, or of the American Heart Association. For more, visit ahajournals.org.  

Covax, altså samarbeidet for rettferdig vaksinefordeling globalt, er en vakker idé, men fungerer det i praksis? Nei, mener noen. Nå er vi dessuten vant til å omtale virusvarianter som «den britiske varianten», og «den indiske varianten», men WHO kom i juni med forslag til hvordan vi skal navngi variantene. Valgte de det beste systemet? I tillegg får vi høre mer om hvordan covid-19-vaksiner påvirker spermiekvalitet, hvordan covid-19 påvirker hjernen, bruk av tofacitinib mot covid-19 og den kontroversielle FDA-godkjenningen av et nytt legemiddel mot Alzheimers sykdom. Sjefredaktør Are Brean forteller om dette og mer i dagens episode.Tilbakemeldinger kan sendes til stetoskopet@tidsskriftet.no.          Stetoskopet produseres av Irene Rønold, Are Brean og Julie Didriksen ved Tidsskrift for Den norske legeforening. Ansvarlig redaktør er Are Brean.                Lydtekniker: Håkon Braaten / Moderne Media         Coverillustrasjon: Stephen Lee  Artikler nevnt:A beautiful idea: how COVAX has fallen shortSARS-CoV-2 Variants of Interest and Concern naming scheme conducive for global discourseSuspend intellectual property rights for covid-19 vaccinesEmbrace the WHO's new naming system for coronavirus variantsCOVID has shown the power of science–industry collaborationSperm Parameters Before and After COVID-19 mRNA VaccinationCovid-19: Failures of leadership, national and globalExplaining covid-19 performance: what factors might predict national responses?Brain imaging before and after COVID-19 in UK BiobankTofacitinib in Patients Hospitalized with Covid-19 PneumoniaThe Problem of Aducanumab for the Treatment of Alzheimer DiseaseThree FDA advisory panel members resign over approval of Alzheimer's drugLandmark Alzheimer's drug approval confounds research community

Meet Rochelle Perry PMHNP (rdperry05241@gmail.com) to learn about how she's worked with her son on his use of Long-Acting Injectables (LAIs) and how she uses them in her outpatient settings. There is a lot of strong clinical evidence that this patient care pathway helps and it's very easy, with low barriers to us providing it right in our office. Learn more about that... listen and enjoy. References: Greene, M., Yan, T., Chang, E., Hartry, A., Touya, M., & Broder, M. S. (2018). Medication adherence and discontinuation of long-acting injectable versus oral antipsychotics in patients with schizophrenia or bipolar disorder. Journal of Medical Economics, 21(2), 127–134. https://doi.org/10.1080/13696998.2017.1379412 (https://doi.org/10.1080/13696998.2017.1379412) Kishimoto, T., Hagi, K., Nitta, M., Leucht, S., Olfson, M., Kane, J. M., & Correll, C. U. (2018). Effectiveness of Long-Acting Injectable vs Oral Antipsychotics in Patients With Schizophrenia: A Meta-analysis of Prospective and Retrospective Cohort Studies. Schizophrenia Bulletin, 44(3), 603–619. https://doi.org/10.1093/schbul/sbx090 (https://doi.org/10.1093/schbul/sbx090) Oliver, D., Davies, C., Crossland, G., Lim, S., Gifford, G., McGuire, P., & Fusar-Poli, P. (2018). Can We Reduce the Duration of Untreated Psychosis? A Systematic Review and Meta-Analysis of Controlled Interventional Studies. Schizophrenia Bulletin, 44(6), 1362–1372. https://doi.org/10.1093/schbul/sbx166  Subotnik, K., Casaus, L., Ventura, J., Luo, J., Hellemann, G., Gretchen-Doorly, D., Marder, S., & Nuechterlein, K. (2015). Long-Acting Injectable Risperidone for Relapse Prevention and Control of Breakthrough Symptoms After a Recent First Episode of Schizophrenia : A Randomized Clinical Trial. JAMA Psychiatry (Chicago, Ill.), 72(8), 822–829. https://doi.org/10.1001/jamapsychiatry.2015.0270 Titus-Lay, E. N., Ansara, E. D., Isaacs, A. N., & Ott, C. A. (2018). Evaluation of adherence and persistence with oral versus long-acting injectable antipsychotics in patients with early psychosis. The Mental Health Clinician, 8(2), 56–62. https://doi.org/10.9740/mhc.2018.03.056 (https://doi.org/10.9740/mhc.2018.03.056) Velligan, D. I., Maples, N. J., Pokorny, J. J., & Wright, C. (2020). Assessment of adherence to oral antipsychotic medications: What has changed over the past decade?. Schizophrenia Research, 215, 17–24. https://doi.org/10.1016/j.schres.2019.11.022 (https://doi.org/10.1016/j.schres.2019.11.022) Weiden, P. J., Claxton, A., Kunovac, J., Walling, D. P., Du, Y., Yao, B., Yagoda, S., Bidollari, I., Keane, E., & Cash, E. (2020). Efficacy and Safety of a 2-Month Formulation of Aripiprazole Lauroxil With 1-Day Initiation in Patients Hospitalized for Acute Schizophrenia Transitioned to Outpatient Care: Phase 3, Randomized, Double-Blind, Active-Control ALPINE Study. The Journal of Clinical Psychiatry, 81(3), 19m13207. https://doi.org/10.4088/JCP.19m13207 Contact PsychNP CastWant to be a guest? Fill this form out: https://forms.gle/tTQ8nChFaV4tKEj38 (https://forms.gle/tTQ8nChFaV4tKEj38) Email us Email: PsychNPcast@gmail.com

In this podcast, Meredith Sloan, MD, talks about the ways that statins have improved clinical outcomes for patients with community-acquired pneumonia (CAP), including what's next for research on statins in patients with CAP.

Commentary by Dr. Valentin Fuster

Dr. Jennifer Frontera discusses her paper, "A Prospective Study of Neurologic Disorders in Hospitalized COVID-19 Patients in New York City". Show references: https://n.neurology.org/content/early/2020/10/05/WNL.0000000000010979

Can C-reactive protein levels predict respiratory decline in patients with COVID-19? Find out about this and more in today’s PV Roundup podcast.

Commentary by Dr. Valentin Fuster

A randomized, double-blind, placebo-controlled trial conducted to assess if early intervention with interleukin-6 receptor blockade might limit COVID-19 progression to hypoxemic respiratory failure or death, reduce the risk of clinical worsening, and decrease the duration of supplemental oxygen use. 

A cohort study published in JAMA looks at the evidence regarding race and mortality in hospitalized patients affected by COVID-19.

Commentary by Dr. Valentin Fuster

New York City has been at the epicenter of COVID-19, and one leading organization there met the pandemic onslaught head-on. On this episode, we’ll hear how that organization sparked innovations in care, staff support and even a key construction project to create a new dynamic and pace for the future. Guest speaker:Robert J. Cerfolio, MD, MBAExecutive Vice PresidentVice Dean, Medical SchoolChief of Hospital OperationsNYU Langone Health Moderator:Tomas Villanueva, DO, MBA, FACPE, SFHMAssociate Vice PresidentClinical ResourcesVizient Show Notes:[02:08] Nimbleness: dealing with the unknown[02:40] Ramping up number of executive meetings[03:40] Innovation: accelerating the graduation of fourth-year medical students[03:48] Innovation: accelerating an ER expansion to months instead of years[04:10] Continuing to operate at “warp speed” and not going back[04:27] Ramping up ICUs[05:20] Innovations in clinical care[06:20] Innovations in taking care of staff[07:22] Takeaways in dealing with a COVID upsurge[08:55] Not just a microangiopathic disease, a hypercoagulable state—use of IV heparin[09:47] Use of low-molecular-weight heparin Links | Resources:Early Heparin therapy improves hypoxia in COVID-19 patients Click hereHealth System in Pandemic Epicenter Identifies Outcomes & New Risk Factors of Patients Hospitalized with COVID-19 Click here9 ways Covid-19 may forever upend the U.S. health care industry Click hereCare for Critically Ill Patients with COVID-19 (JAMA, March 2020) Click here Subscribe Today!Apple PodcastsSpotifyAndroidStitcherRSS Feed 

On this episode, we continue the story of a health care organization in New York City, at the flashpoint of the COVID-19 outbreak, and the breakthrough innovations it made to enable continued care during the first wave. Our discussion focuses on the importance of staff resilience, reaching out to patient families, the use of medical students on the frontlines and dealing with the staggering costs of the pandemic. Guest speaker:Robert J. Cerfolio, MD, MBAExecutive Vice PresidentVice Dean, Medical SchoolChief of Hospital OperationsNYU Langone Health Moderator:Tomas Villanueva, DO, MBA, FACPE, SFHMAssociate Vice PresidentClinical ResourcesVizient Show Notes:[00:25] Biggest surprise in past four months[01:15] Improving communication with patient families[04:16] Long-term costs to the organization[04:40] Reaching pre-COVID volumes in elective procedures[05:02] Innovations to mitigate the financial toll[05:34] No staff layoffs, furloughs or pay cuts[05:50] Regaining patient trust; need to care for patients with non-COVID conditions[07:01] Convincing staff that facility is safe; eliminating unnecessary precautions[08:21] Message for leaders Links | Resources:Health System in Pandemic Epicenter Identifies Outcomes & New Risk Factors of Patients Hospitalized with COVID-19 Click here9 ways Covid-19 may forever upend the U.S. health care industry Click hereCare for Critically Ill Patients with COVID-19 (JAMA, March 2020) Click here Subscribe Today!Apple PodcastsSpotifyAndroidStitcherRSS Feed 

Commentary by Dr. Valentin Fuster

The current antibody test results may bring hope due to the mortality rate much lower than expected worldwide based on the date, but if you look closer at the numbers, they revealed a personal health crisis. The conditions put people at the most at risk to contract Covid-19 include hypertension, obesity, and diabetes. These are primarily lifestyle diseases, mostly preventable and manageable with better choices with diet and exercise.    Learn more in today's episode!    Questions? You can email your questions to zane@zanegriggs.com. Connect with me at zanegriggs.com or on Instagram @zanegriggsfitness     LINKS: JAMA Study April 22, 2020: Presenting Characteristics, Comorbidities and Outcomes Among 5700 Patients Hospitalized with Covid-19 in the New York City Area TIME Magazine: Almost Every Hospitalized Corona Virus Patient Has Another Underlying Health Issue According To A Study Of New York Patients Covid-19 is an emergent case of aging   Quick Episode Summary: Covid-19 statistics Underlying health problems and Covid-19 Diseases of lifestyle choices Normal is not optimal The cost of lifestyle choice diseases Time for change

It's been a while! We took a short hiatus while our lives were upended by the pandemic. But we couldn't stay away forever. Today we review some of the big trials published in the last month on Covid-19. We look at the large case series on New York patients published in JAMA, three hydroxychloroquine studies, the lopinavir-ritonavir study and the compassionate use of remdesivir study. Buckle up! 5700 Patients Hospitalized with COVID-19 in New York CityLopinavir-Ritonavir in Severe COVID-19Hydroxychloroquine in FranceHydroxychloroquine in China Hydroxychloroquine in Veterans Compassionate Use of Remdesivir Music from https://filmmusic.io"Sneaky Snitch" by Kevin MacLeod (https://incompetech.com)License: CC BY (http://creativecommons.org/licenses/by/4.0/)

Ref: Glycemic Characteristics and Clinical Outcomes of COVID-19 Patients Hospitalized in the United States. J Diabetes Sci Technol. 2020; In press

Welcome to the first episode of PERTCast, the official podcast of the PERT Consortium! Episode 1: Oren Friedman interviews Vic Tapson about risk stratification of the pulmonary embolism patient. Oren Friedman MD Associate Director, Cardiac Surgery ICU  Pulmonary Critical Care  Cedars-Sinai Medical Center Victor Tapson MDProfessor of MedicineDirector, Venous Thromboembolism and Pulmonary Vascular Disease Research ProgramAssociate Director, Pulmonary and Critical Care SectionCedars-Sinai Medical Center PE risk stratification Pearls: history and classifications. Patient’s appearance and vitals (initial and trend) are most important parts of risk stratification algorithm. Syncope can have a wide differential. Syncope in setting of PE can have significant consequences. Patient resting comfortably can be reassuring, but at the same time ask- what happens on exertion, to gauge the severity of symptoms (i.e. dizziness, near syncope etc.) Profound hypoxemia is under recognized in PE classification. European Society of Cardiology (ESC) integrates PESI, and sPESI score that is much more practical way of PE classification. ESC classification divide PE into Intermediate PE (Submassive PE) in to two categories- Intermediate high risk (positive sPESI score, RV dysfunction and biomarker positivity) or Intermediate low risk (Positive sPESI score, and RV dysfunction or biomarker positivity). PE classification is heterogeneous, patient’s hemodynamics can evolve, so will be their risk stratification score. Biomarkers in PE risk stratification: Troponin more sensitive than BNP. Be careful for false positives (elevated BNP in chronic heart failure) Lactic acid can provide prognostic information in setting of PE. CTA based risk stratification: Contrast reflux into IVC/Liver RV/LV ratio >0.9 Clot burden, 40% occlusion of pulmonary circulation can be associated with high PE related mortality.  Echo based risk stratification: Normal RV can’t generate systolic pressure in the excess of 50-60 mm Hg. Elevated PA systolic pressure >70-80 mm HG suggest chronic component of RV failure RV need to have good systolic function to generate high PA pressure TAPSE is not the holy grail of RV dysfunction, interpret with caution. Residual DVT Extensive DVT (above knee) with higher risk PE have worse outcomes. Patient activity (few days to weeks) should be restricted. IVC filter should not be considered in every case of PE with DVT.  Treatment Pearls: Every patient with acute PE should be promptly anticoagulated. Change in vital trends or persistently abnormal vital signs may help in consideration of advance reperfusion strategies in same PE category.  Take home message: Look at patient’s appearance + Vitals (HR, RR) and add other objective measures (sPESI, Biomarkers, imaging) + Residual clot burden in risk stratification. Activate the multidisciplinary PERT to leverage input from local experts. References: Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033-69, 3069a-3069k. Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-9. Van der meer RW, Pattynama PM, Van strijen MJ, et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology. 2005;235(3):798-803. Prandoni P, Lensing AW, Prins MH, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016;375(16):1524-1531. Becattini C, Cohen AT, Agnelli G, et al. Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT: Systematic Review and Meta-analysis. Chest. 2016;149(1):192-200. Grau E, Tenías JM, Soto MJ, et al. D-dimer levels correlate with mortality in patients with acute pulmonary embolism: Findings from the RIETE registry. Crit Care Med. 2007;35(8):1937-41.

This podcast is taken from a talk I gave at Grand Rounds at The Bristol Royal Infirmary on the Top 10 Papers in EM over the last 12 months. Many of these have been covered in previous podcasts, but running through them gives a good opportunity for further recap and reflection. Papers Covered; Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV1. Injury. 2015 Dec 13. pii: S0020-1383(15)00768-8. doi: 10.1016/j.injury.2015.11.045. [Epub ahead of print] (more in February'sPapers of the month) Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Baharoglu MI. Lancet.2016 May 9. pii: S0140-6736(16)30392-0. doi: 10.1016/S0140-6736(16)30392-0. [Epub ahead of print] (more in July's Papers of the month) Causes of Elevated Cardiac Troponins in the Emergency Department and Their Associated Mortality. Meigher S. Acad Emerg Med. 2016 (more in our Troponins podcast) Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. Ferguson I, et al. Ann Emerg Med. 2016. (more in September's Paper's of the month) Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P. N Engl J Med. 2016 (more in our podcast PE The Controversy) Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Andersen LW. JAMA. 2017 (more in March's Papers of the month) Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Donaldson L. Emerg Med Australas. 2016 Aug 25 (more in our Stroke Thrombolysis podcast) Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Nijssen EC. Lancet. 2017 (more in April's Papers podcast) Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Sierink JC. Lancet. 2016 Jun 28 (more in August's Papers podcast) Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017  (more coming up in May's Papers podcast!) Enjoy and we'll be back with our papers of the month next week! Simon  

Dans cette troisième baladodiffusion, les Drs Luc Lanthier et Geneviève LeTemplier discutent de l’étude PESIT sur la prévalence de l’embolie pulmonaire chez les sujets avec une première syncope, en plus de réviser la littérature médicale d’octobre 2016. Référence principale : Prandoni P, Lensing AWA, Prins MH et coll. Prevalence of Pulmonary Embolism among Patients Hospitalized for … Continuer la lecture de « BC 003 – Prévalence d’embolie pulmonaire chez les sujets hospitalisés pour une syncope (étude PESIT) »

It's never long before the topic of pulmonary embolism makes it back into the controversial lime light and a recent paper on the association of PE with syncope is the lastest reason. The PESIT trial, just published in the New England Journal of Medicine certainly grabs your attention when you read the abstract, with the implication that PE's are a major and hugely missed cause of the presentation of syncope. It also highlights a diagnostic work up that consists of blanket Well's scoring +/- d-dimer to decide who should be worked up further for the potential diagnosis, for every single patient presenting with syncope, including those with no appropriate symptoms or signs! As always to read the abstract and draw a conclusion is to fall at the first hurdle, so take a listen to the podcast as we dive a bit deeper into the paper and topic, and of course make sure you take a look at the paper yourself and see what you make of the headline grabbing article Enjoy! References and Further Reading Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P. N Engl J Med. 2016 Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. Schultz DJ.J Trauma. 2004 Apr  Prospective evaluation of unsuspected pulmonary embolism on contrast enhanced multidetector CT (MDCT) scanning. Ritchie G. Thorax. 2007 Jun. EM Nerd-The Case of the Incidental Bystander JC: Prevalence of PE in patients with syncope. St.Emlyn’s

Hey guys! This podcast, Dr. Wheatley and Dr. Osborne discuss some of the newest literature as it pertains to obs. Instead of butchering these innocent people's names, we put the info here! First we discussed this hot hot article from NEJM. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016 Oct 20;375(16):1524-1531. Prandoni P Then we talked about this correlating study. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk: Results from the IRiS (Intermediate-Risk Syncope) Study. Acad Emerg Med. 2016 Aug;23(8):941-8. doi: 10.1111/acem.13013. Epub 2016 Aug 1. Numeroso F Then we talked about this interesting abstract. This is from the forum at ACEP and you can click the link to the PDF. It's abstract 76. Effect of a Sickle Cell Vaso-occlusive Crisis Observation Unit Pathway on the Admission Rate for Frequent Emergency Department Users Loeffler P, Sturgis L, Muelller T, Gibson R, Lyon M/Augusta University, Augusta, GA Then we finished with AHRQ study. It's also free can be found here! We hope you enjoy!

Dr Areej El-Jawahri speaks with ecancertv at ASCO 2016 about integrated palliative care, for the benefit of patients and their families. She found that, among 160 patients hospitalised for HCT, those randomised to the palliative care intervention (vs. control) reported less decline in QOL (-14.7 vs. -21.5, P = 0.04), and less increase in depression symptoms (HADS-Depression: 2.4 vs. 3.9, P = 0.02), and symptom burden (ESAS: 30.3 vs. 38.3, P = 0.007) from baseline to week-2. Intervention participants also reported a decline in anxiety symptoms compared to control patients who reported an increase in anxiety from baseline to week-2 (HADS-Anxiety: -0.80 vs. 1.1, P = 0.0006) Based on these findings, Dr El-Jawahri advocates incorporated palliative care become part of wider practice.

Interview with Eric M. Mortensen, MD, MSc, author of Association of Azithromycin With Mortality and Cardiovascular Events Among Older Patients Hospitalized With Pneumonia

Background: Management of community-acquired pneumonia (CAP) places a considerable burden on hospital resources. REACH was a retrospective, observational study (NCT01293435) involving adults >= 18 years old hospitalized with CAP and requiring in-hospital treatment with intravenous antibiotics conducted to collect data on current clinical management patterns and resource use for CAP in hospitals in ten European countries. Methods: Data were collected via electronic Case Report Forms detailing patient and disease characteristics, microbiological diagnosis, treatments before and during hospitalization, clinical outcomes and health resource consumption. Results: Patients with initial antibiotic treatment modification (n = 589; 28.9%) had a longer mean hospital stay than those without (16.1 [SD: 13.1; median 12.0] versus 11.1 {SD: 8.9; median: 9.0] days) and higher ICU admission rate (18.0% versus 11.9%). Septic shock (6.8% versus 3.0%), mechanical ventilation (22.2% versus 9.7%), blood pressure support (fluid resuscitation: 19.4% versus 11.4%), parenteral nutrition (6.5% versus 3.9%) and renal replacement therapy (4.2% versus 1.4%) were all more common in patients with treatment modification than in those without. Hospital stay was longer in patients with comorbidities than in those without (mean 13.3 [SD: 11.1; median: 10.0] versus 10.0 [SD: 7.5; median: 8.0] days). Conclusions: Initial antibiotic treatment modification in patients with CAP is common and is associated with considerable additional resource use. Reassessment of optimal management paradigms for patients hospitalized with CAP may be warranted.

Background: Data describing real-life management and treatment of community-acquired pneumonia (CAP) in Europe are limited. REACH (NCT01293435) was a retrospective, observational study collecting data on the management of EU patients hospitalized with CAP. The purpose of this study was to understand patient and disease characteristics in patients hospitalized with CAP and to review current clinical practices and outcomes. Methods: Patients were aged >= 18 years, hospitalized with CAP between March 2010 and February 2011, and requiring in-hospital treatment with intravenous antibiotics. An electronic Case Report Form was used to collect patient, disease and treatment variables, including type of CAP, medical history, treatment setting, antibiotics administered and clinical outcomes. Results: Patients (N = 2,039) were recruited from 128 centres in ten EU countries (Belgium, France, Germany, Greece, Italy, the Netherlands, Portugal, Spain, Turkey, UK). The majority of patients were aged >= 65 years (56.4%) and had CAP only (78.8%). Initial antibiotic treatment modification occurred in 28.9% of patients and was more likely in certain groups (patients with comorbidities; more severely ill patients; patients with healthcare-associated pneumonia, immunosuppression or recurrent episodes of CAP). Streamlining (de-escalation) of therapy occurred in 5.1% of patients. Mean length of hospital stay was 12.6 days and overall mortality was 7.2%. Conclusion: These data provide a current overview of clinical practice in patients with CAP in EU hospitals, revealing high rates of initial antibiotic treatment modification. The findings may precipitate reassessment of optimal management regimens for hospitalized CAP patients.

Interview with Mihai Gheorghiade, MD, author of Improving Postdischarge Outcomes in Patients Hospitalized for Acute Heart Failure Syndromes

Can C-reactive protein levels predict respiratory decline in patients with COVID-19? Find out about this and more in today's PV Roundup podcast.