Risultati per: Linee Guida per le cure post-parto

Objectives
The interim Foundation Year 1 (FiY1) post was created in response to the COVID-19 pandemic to help bolster the workforce and manage increased clinical pressures. This study aimed to assess the impact of the FiY1 post on medical graduates’ self-reported confidence in common tasks, core skills, competencies and procedures prior to starting FY1, as a measure of increasing preparedness for practice.

Setting
A longitudinal survey was performed at a tertiary teaching hospital in the South East of England. FiY1 posts ran from June to July 2020.

Participants
Questionnaires were sent to 122 medical graduates from a single medical school (recipients included FiY1s and non-FiY1s) and to 69 FiY1s at a single Teaching Hospital NHS Trust, irrespective of medical school attended. Initial and follow-up questionnaires had 86 and 62 respondents, respectively. Of these, 39 graduates were matched; 26 were FiY1s and 13 non-FiY1s. The 39 matched results were analysed.

Primary outcome measures
Confidence levels in common FY1 tasks, core procedures and competencies were gathered before and after the FiY1 post through online questionnaires. Change in confidence comparing FiY1s and non-FiY1s was measured and analysed using linear regression.

Results
On a 5-point scale, the FiY1 post increased overall confidence in starting FY1 by 0.62 (95% CI 0.072 to 1.167, p=0.028). The FiY1 post increased confidence in performing venepuncture by 0.32 (95% CI 0.011 to 0.920, p=0.045), performing intravenous cannulation by 0.48 (95% CI 0.030 to 1.294, p=0.041) and recognising, assessing and initiating the management of the acutely ill patient by 0.32 (95% CI 0.030 to 1.301, p=0.041).

Conclusions
The COVID-19 pandemic FiY1 post improved confidence in core skills and competencies. These findings may help guide future educational interventions in conjunction with further larger scale studies, ultimately aiding to bridge the transition gap between being a medical student and a doctor.

Annals of Internal Medicine, Ahead of Print.

This Viewpoint proposes a solution to better safeguard reproductive health information in patient records that are now more complete owing to the interoperability of health information exchange networks.

This cohort study analyzes self-reported data from 3 large ongoing studies to determine whether high levels of psychological distress before SARS-CoV-2 infection are associated with increased risk of developing post–COVID-19 conditions, sometimes called long COVID.

Circulation, Volume 146, Issue Suppl_1, Page A15841-A15841, November 8, 2022. Introduction:COVID-19 acutely affects the cardiovascular system leading to various cardiac complications. Major concerns are on the less understood long-term cardiovascular consequences of COVID-19.Hypothesis: Post COVID-19 cardiac dysfunctions could be long lasting and vary by severity of initial infection.Methods:This is an on-going prospective observational study from a multidisciplinary Post COVID-19 Research Clinic. Inclusion criteria included both RT-PCR confirmed and recovered COVID-19 patients and control subjects. After IRB approval and informed consents, 83 participants received serial transthoracic echocardiography at 3, 6 or >12 months after initial infection. Pearson’s correlation coefficients, Fisher’s exact test and one-way ANOVA was conducted to examine the association between variables, across follow-up time and severity of initial infection.Results:Proximal RVOT diastolic diameter was significantly larger at >12 months’ compared to earlier time points post COVID-19 (2.92±0.55 cm at 3 months, 2.81±0.57 cm at 6 months and 3.15±0.52 cm at >12 months). The posterior wall was significantly thicker in post COVID-19 patients with moderate or severe infection compared to patients with mild infection. The left atrium diameter was significantly larger as the initial infection severity increased. Pulmonary artery acceleration time was significantly shorter as initial infection severity increased indicating higher pulmonary arterial pressure although no significant relationship was found with follow-up time. There were no left ventricular ejection fraction, E/E’ (index of diastolic function) or valvular abnormality differences by either follow-up time or severity. Furthermore, 77% patients with severe infection had grade 1 diastolic dysfunction compared to mild (28.57%) or moderate (33.33%) patients.Conclusions:Long-term echocardiographic follow-up showed increased RV size after COVID-19 over time. Posterior wall thickness, left atrium size and pulmonary artery acceleration time, and diastolic dysfunction were correlated with initial infection severity in long-term post COVID-19 patients suggestive of possible structural changes in recovered patients from COVID-19.

Circulation, Volume 146, Issue Suppl_1, Page A13481-A13481, November 8, 2022. Introduction:Cardiac procedures and surgeries can cause injury to the pericardium and result in pericarditis, termed post-cardiotomy syndrome or post-cardiac injury syndrome (PCIS). The incidence of PCIS after transcatheter aortic valve replacement (TAVR) is unknown, and the aim of the current study is to compare the incidence of PCIS in surgical versus transcatheter aortic valve replacement (SAVR, TAVR).Methods:In a single-center retrospective cohort study of randomly selected patients who had TAVR or SAVR in 2019, the primary outcome was PCIS, defined according to ESC guidelines. Pericarditis recurrence was also defined according to ESC guidelines. Due to baseline differences in SAVR and TAVR patients, propensity score matching was performed using calipers of width equal to 0.2 of the standard deviation of the logit of the propensity score.Results:Patients undergoing TAVR (n=103) were older, had higher STS-PROM scores, and generally more co-morbidities compared to patients undergoing SAVR (n=100), with the exception of atrial fibrillation (Table). Overall, 17 patients (17%) with SAVR had PCIS compared to 1 patient (1%) with TAVR (p

Circulation, Volume 146, Issue Suppl_1, Page A13291-A13291, November 8, 2022. Introduction:Successful management of Heart Failure (HF) patients post-discharge requires a multi-faceted approach including close medication management to decrease preventable readmissions.Methods:We conducted a one-year single center, single-blinded randomized trial of HF patients post-discharge comparing standard of care vs. intensive virtual care on HF readmission rates. The intensive virtual care included comprehensive medication management by a Virtual Clinical Pharmacist (VCP).Results:Among the 591 participants, the median age was 73.2 years, 52.5% male, and 56.2% white. There were 308 patients randomized into the intervention group of which 165 (53.5%) enrolled. During VCP visits, 155 patient concerns were identified including active symptoms (45.2%), lack of clarity of medication regimen (40.6%), concurrent uncontrolled hyperglycemia or hypertension (9%) and non-adherence with provider follow up appointments (5.2%). There were 625 VCP interventions in 165 HF patients. Of these patients, VCPs increased access to medical care (33.9%), optimized guideline directed medical therapy (17.6%), addressed symptoms of HF exacerbations (7.9%), and other impactful interventions (Table). VCP recommendations had a 59% acceptance rate into the patient’s treatment plan when clinicians were contacted directly. A 6.9% decrease in 30-day readmission rates was demonstrated (p=0.03) in the intervention group, in addition to a decrease from 24.4% to 19.2% in emergency department visits (p=0.15). For patients readmitted, the intervention arm had a shorter length of stay, 5.6 days, when compared to control, 6.8 days (p=0.14).Conclusion:This single center randomized trial demonstrated that Virtual Clinical Pharmacist-led comprehensive medication management identified key interventions with high-level clinician engagement for post-discharge HF patients that resulted in a 6.9% reduction in HF readmissions.

Circulation, Volume 146, Issue Suppl_1, Page A12100-A12100, November 8, 2022. Case Presentation:49-year-old male without known cardiovascular history presented with three days of atypical chest discomfort. 12-lead EKG revealed ST-segment elevations in II-III-aVF and depression in V1 suggestive of an acute infero-posterior MI (A), Troponin T at 6.85 ng/mL. Following administration of DAPT and heparinization, emergent coronary angiography proved a dominant RCA with proximal 60% and middle 100% occlusion (B), 80% focal stenosis at mid-LAD and 70% focal stenosis at prox-LCx (C). PCI with intra-aortic balloon pump support was performed, with two DES deployed in the RCA, use of a trans-venous pacemaker was required for complete AV block, and two defibrillations required for ventricular fibrillation. Following further hemodynamic compromise unexplained by his hemodynamic parameters, TEE was performed, demonstrating a large mid/distal infero-septum ventricular septal defect with left to right shunt (D, E and F), as well as a basal/mid infero-septum large pseudo-aneurysm (PSA) cavity (contained rupture) (G: low velocity Doppler flow from LV to PSA cavity, H and I show intact septum). The patient continued to decompensate requiring escalation to temporary mechanical circulatory support with VA-ECMO. Heart transplantation was initially considered, family decided to withdraw care due to multi-organ failure and poor prognosisDiscussion:Due to widespread availability of primary percutaneous coronary intervention with early reperfusion, mechanical complications post MI are less common in current days. Following transmural MI, persistent hypotension and cardiogenic shock should alert for complications such as VSD or PSA. While VSD may be amenable to percutaneous or surgical closure, PSA is associated with very high mortality even if surgery is attempted. Given the presence of both a VSD and PSA, mechanical support with VA-ECMO allowed us to support the patient for several days as a bridge to decision regarding heart transplantation

Circulation, Volume 146, Issue Suppl_1, Page A12866-A12866, November 8, 2022. Introduction:Myeloproliferative neoplasms (MPNs) are clonal stem cell neoplasms associated with increased thrombotic risk. However, long-term outcomes after acute coronary syndrome (ACS) and identification of MPN-specific risk factors have not been characterized.Methods:Single-center, retrospective cohort of patients with MPN admitted for ACS from 2000 to 2020 (n = 41). Primary outcomes were major adverse cardiac events (MACE) and bleeding. MACE was composite of cardiovascular (CV) death, myocardial infarction, ischemic stroke, and heart failure (HF) hospitalization. Patients with and without MACE and bleeding were compared to identify risk factors; univariable and multivariable Cox proportional hazards and competing-risk regression models were used.Results:Patient characteristics described in Table 1. After a median follow-up of 80 months, 28 patients had MACE and 14 experienced bleeding. Patients with MACE had shorter median time to index ACS event (35 mos vs 76) and higher rates of JAK2 mutation (82% vs 54%), history of HF (46% vs 15%), and median white blood cell count (WBC, 13 vs 8) at index event compared with patients without MACE. Patients with bleeding had higher rates of JAK2 mutation (93% vs 63%) and WBC (17 vs 10), and lower hydroxyurea use (50% vs 85%) compared with patients without bleeding. Cox and competing-risk regression results in Table 2.Conclusions:Patients with MPN and ACS are at high risk of MACE and bleeding. JAK2 mutation and elevated WBC count (≥ 20 K/μL) at time of index ACS were associated with MACE and bleeding. ACS event occurring within 12 months of MPN diagnosis was associated with MACE. Larger studies are needed to confirm our results.

Circulation, Volume 146, Issue Suppl_1, Page A11489-A11489, November 8, 2022. Introduction:The hemodynamic demands on the heart during normal pregnancy induce physiological cardiac hypertrophy. Together with exercise induced cardiac hypertrophy and cardiac enlargement during post-natal growth, these physiological cardiac adaptations are distinct from pathological hypertrophy caused by heart diseases including volume/pressure overload. Exercise-induced cardiac hypertrophy can induce a protective phenotype that leads to resistance from ischemic injury or pressure overload induced pathological remodeling. Whether pregnancy induced cardiac hypertrophy can also protect the heart from post-partum (PP) pathological stimuli remains unknown and is the focus of this study.Methods:We challenged both post-partum and age matched non-pregnant female C57BL/6 mice with 7-day osmotic minipump infusion of Angiotensin II/phenylephrine (AngII/PE) and determined the cardiac alterations.Results:PP mice had more severe cardiac pathological remodeling after AngII/PE infusion compared with non-pregnant counterparts, with greater increases in heart weight, cardiomyocyte hypertrophy and fibrosis. Echocardiography showed both left and right ventricular hypertrophy without overt systolic dysfunction. PP mice had greater elevations in expression levels of fetal genes and fibrotic genes compared with non-pregnant mice after AngII/PE infusion. RNA-sequencing analysis suggested a more robust change in gene expression level in PP mice after AngII/PE treatment compared to non-pregnant counterparts, with a substantial role for extracellular matrix organization genes. We also found a significant alteration of gene expression levels for enriched extracellular structural organization at 1-day PP, which underlies ongoing structural re-organization in the myocardium shortly after deliver. These PP changes may predispose the heart to adverse remodeling when simultaneously challenged with pathological stimuli.Conclusions:Pregnancy induced cardiac remodeling does not protect the heart against PP pathological stimuli. In fact, the rapid remodeling in the PP heart may predispose it to exacerbation of pathological remodeling.

Circulation, Volume 146, Issue Suppl_1, Page A15083-A15083, November 8, 2022. Introduction:Among patients hospitalized for HF, patients hospitalized with worsening chronic heart failure (WCHF) are at increased risk for morbidity and mortality compared with those who are recently diagnosed with HF. Whether there are differences in clinical course during hospitalization for HF is unclear.Methods:We pooled 735 participants hospitalized for HF in the DOSE, CARRESS, and ROSE trials. We grouped participants by whether HF was recently diagnosed (≤12 months) or WHCF ( >12 months). We compared changes in congestion, kidney function, and symptoms during hospitalization, as well as early post-discharge kidney and mortality outcomes.Results:Overall, 132 (18%) had recently diagnosed HF and 603 (82%) had WCHF. Compared with WCHF, patients with recently diagnosed HF tended to have lower serum creatinine and higher systolic blood pressure, ejection fraction, and serum NT-proBNP (all p0.15) (Figure). Recently diagnosed HF showed improved dyspnea at 72 hours (p=0.03). There was no difference in change in serum creatinine from baseline to 60 days (p=0.75). There was a trend toward significantly increased odds of mortality during study follow-up (adjusted odds ratio 1.96 [95% confidence interval 0.97-3.94], p=0.06).Conclusion:Patients hospitalized for recently diagnosed and WCHF have generally similar in-hospital clinical trajectories, and similar changes in kidney function early post-discharge. Despite these similarities and adjustment for other clinical factors, patients with WCHF remain at increased risk for post-discharge mortality as compared with patients who are more recently diagnosed.

Circulation, Volume 146, Issue Suppl_1, Page A13431-A13431, November 8, 2022. Introduction:Mitral valve (MV) leaflet morphology plays an important role insuring efficient, unidirectional blood flow from the left atrium (LA) to ventricle (LV). When treating severe mitral regurgitation (MR), surgical repair, valve replacement, or transcatheter edge-to-edge (E-2-E) repair all provide valid options depending on anatomy and clinical circumstances. These interventions alter the MV morphology, impacting LV filling dynamics. We used fluid-structure interactions (FSI) to evaluate LV filling dynamics after MV interventions, taking into consideration full left-heart (LH) dynamics.Methods:3-D MV model of a patient suffering from severe MR was reconstructed from echocardiographic data. A LH wall motion algorithm was developed and applied to CT-derived LA and LV walls to realistically represent LH dynamics. LH wall motion, MV dynamics and blood flow in LA and LV during MV function was simulated using a strongly coupled fluid structure interaction approach. Virtual interventions using a surgical 33mm bioprosthetic valve (BPV) and transcatheter E-2-E repair were performed and evaluated.Results:Our FSI model predicted a physiological vortex ring developing in the LV for the pre-op MV during early diastole. BPV produced complex asymmetrical vortices. Due to its double orifice, the E-2-E clip produced two separate vortex rings with the largest velocity magnitude. Of all the three treatments, BPV had the greatest leaflet deformation rate.Conclusion:This model provides realistic quantitative insights into post-op filling dynamics that can be used to personalize and optimize valve intervention. These methodologies may help clinicians to realistically predict and evaluate patient-specific LV filling dynamics to tailor MV interventions.

Circulation, Volume 146, Issue Suppl_1, Page A12837-A12837, November 8, 2022. Introduction:Morbidity of the left atrioventricular valve (LAVV) remains the leading indication for reoperation on atrioventricular septal defects (AVSDs). While qualitative 2D and quantitative 3D risk factors have been identified, no quantitative 2D measurement yet exists to predict poor postoperative outcomes. The aim of this study was to evaluate objective measurements of the LAVV and subvalvar apparatus in relation to postoperative outcomes.Methods:A retrospective review was performed on 2D echocardiograms of patients undergoing surgical repair of an AVSD from January 1, 2014 to December 31, 2021. Demographic and perioperative data were collected from the electronic medical record. The hingepoint-to-hingepoint length of the superior, mural and inferior bridging leaflets in early diastole, as well as LAVV chordal length at end-diastole were measured and indexed to body surface area. A poor outcome was defined by significant LAVV regurgitation (moderate or greater), LAVV stenosis (5mmHg or greater), need for second cardiopulmonary bypass run, postoperative ECMO, reoperation, or death. LAVV measurements were compared to composite outcome by Wilcoxon rank sum test.Results:Of 120 patients with adequate perioperative imaging, 47 (39.2%) had a poor outcome. Indexed LAVV chordal length was significantly different between those who experienced a poor outcome and those who did not, with shorter chordal length predictive of a poor outcome. Interestingly, mural leaflet size was not associated with a poor outcome.Conclusions:Indexed LAVV chordal length is a novel measurement shown to predict a poor postoperative outcome in AVSD. Additional analysis is necessary to assess whether short chords are more predictive of LAVV regurgitation or stenosis, and to determine a numeric cut-off of indexed chordal length for predicting poor outcome.

Circulation, Volume 146, Issue Suppl_1, Page A12848-A12848, November 8, 2022. Introduction:Immunosuppression of heart transplant (txp) recipients increases risk of infection. This study will identify the most common pathogens and characterize the most at-risk patients.Methods:We performed a single center retrospective cohort study at the University of Rochester. Demographics, pretransplant characteristics, and infections requiring rehospitalization were obtained (table 1) from electronic records of patients who received a txp from January 1, 2011 through July 1, 2020. Chi-square, t-test, and Wilcoxon rank-sum test assessed association between mortality, infection risk and other variables.Results:We identified 132 patients who received txp but excluded 4 due to incomplete data, 10 (7.6%) patients died during index admission while 12 (9.4%) more patients died in the year following their txp. Infections occurring 1 month post txp were associated with mortality (p-adj 0.026). Prior sternotomies (n=65, 50.8%) were associated with both mortality and bacterial infection (p-adj

Circulation, Volume 146, Issue Suppl_1, Page A12896-A12896, November 8, 2022. Introduction: Takotsubo’s Cardiomyopathy (TCM) is a diagnosis of exclusion recognized by regional left ventricle (LV) dysfunction and absent coronary artery disease. There are isolated reports of patients with autoimmune conditions developing TCM post intravenous immunoglobulin (IVIG). IVIG is a plasma product which inactivates microbial antigens and downregulates certain cytokines, but its cardiac effects are varied. Our case describes a female with progressive neuromyopathy who developed cardiomyopathy post IVIG infusion.  Case: A 68 year old female, with type 2 diabetes, hypertension, stroke, and neuromyopathy presented with worsening dysarthria and gait issues for 2 years. Examination revealed multiple neurological deficits, and vital signs showed pulse of 105 with blood pressure of 101/75 mmHg. Initial electrocardiogram (EKG) showed sinus tachycardia and CT angiogram of head was unremarkable. She had a negative cardiac catheterization 2 years ago and a normal echocardiogram 6 months ago. IVIG 400 mg/kg daily for 5 days was started for neuromyopathy flare. She had chest pain on infusion day 4. EKG showed ST elevation in leads V2-V4, and labs revealed troponin I of 0.96 ng/ml with proBNP of 7583 pg/mL. Echo showed LV akinesis with preserved basal segmental function suggestive of TCM. Carvedilol and losartan were started. Further ischemic work up was not done as she died from respiratory failure.  Discussion: IVIG is linked to thromboembolic events including strokes and myocardial infarction (MI), but TCM is rare. Risk factors include high dose therapy ( >1g/kg), coronary artery disease, prior MI, smoking, diabetes, hypertension, autoimmune conditions, or hyperviscosity states. Our patient had multiple risk factors for MI post infusion including age, gender, and comorbidities. Her assessment is limited by incomplete ischemic workup. IVIG may have negative cardiac effects secondary to vasoconstrictive cytokines, arterial spasm, or increased blood viscosity, but is confounded by other factors in this case.  Conclusions:IVIG has poorly described cardiac effects including possible induction of TCM. Further trials monitoring cardiac outcomes post IVIG stratified by dosage and risk would improve patient selection and education.  

Circulation, Volume 146, Issue Suppl_1, Page A12809-A12809, November 8, 2022. Background:Major adverse cardiac events (MACE) are a leading cause of morbidity and mortality after orthotopic liver transplantation (OLT). Cirrhotic cardiomyopathy (CCM) is relatively common and a source of MACE in patients after OLT. Initial diagnostic criteria based on transthoracic echocardiogram (TTE) were described in 2005 and revised in 2019 with echocardiographic advancements (Table 1). We sought to identify CCM related predictors of MACE at 13 months post-OLT.Methods:This is a retrospective study of adult patients who underwent OLT between 2009-2019. All patients had TTE’s within one year pre-OLT and one month to 13 months post-OLT. We excluded TTE’s within one-month post-OLT to reduce contributions from stress cardiomyopathy. Patients with a left ventricular ejection fraction less than 50% pre-OLT were excluded. MACE was defined as death, MI, CHF hospitalization, or cardiac arrest. Multivariable Cox regression was used to identify independent predictors of MACE.Results:Of 568 OLT patients screened, 131 met inclusion criteria for this study. There were 103 and 23 patients who met 2005 and 2019 criteria, respectively. During the 13 month follow up period, 42 patients had MACE. Compared to those without MACE, patients with MACE had more ascites (93 vs 70%, p 0.003), hepatorenal syndrome (HRS) (17 vs 4%, p 0.019), delayed OLT >10 days after admission (19 vs 7%, p 0.033), pre-OLT CCM per 2005 criteria (90% vs 73%, p 0.023), and lower diastolic blood pressure (60.81 vs 66.88, p 0.014). There was no difference in pre-OLT CCM per 2019 criteria (19 vs 17%, p 0.758) or MELD-Na score (21.24 vs 19.40, p 0.166). In multi-variable cox regression analysis adjusted for diastolic blood pressure, HRS, ascites, and OLT timing during admission, CCM per 2005 criteria remained significant as seen in Figure 1 (Hazard Ratio = 3, p 0.038).Conclusion:CCM per 2005 criteria is an independent predictor of MACE at 13 months post-OLT while CCM per 2019 criteria is not.