Discoveries and impact (February 2022)

Discoveries and Impact highlights selected scientific discoveries by section in the Department of Internal Medicine…

Bringing heart athletes back to the field

Decision making for many young athletes who are diagnosed with inherited or congenital cardiovascular disease and want to continue playing sports can be difficult. A study published in the journal Heartbeat O2 led by Rachel Lampert, MD, presents the experiences of a group of competitive athletes who have returned to play and highlights the need for a shared decision-making approach between physicians, the athlete, and their families, such as the recommend current guidelines.

The researchers conducted an open-label qualitative survey of 15 male and 15 female interscholastic athletes and their parents. During the telephone interview, the research team gathered information about the patient’s experiences with returning to play after diagnosis and areas for improvement.

Athletes and parents often reported being frustrated with their perception of:

  • Difficulty accessing physicians with appropriate expertise
  • Poor communication between doctors, athletes and families, and schools
  • A decision-making process perceived as unilateral and paternalistic
  • Perception that liability concerns, rather than patient welfare, drive decisions
  • The emotional toll this process has had on athletes and families

The authors concluded by recommending open communication between athletes, their physicians, and academic institutions, and shared decision-making regarding return to play for athletes diagnosed with cardiovascular disease.

Disparities found in the treatment of pancreatitis

In the United States, more than 270,000 patients are hospitalized with acute pancreatitis each year. For 40-60% of patients, pancreatitis is caused by the reflux of bile into the pancreatic duct due to gallstones. Due to the prevalent recurrence rate in this disease, it is important that patients undergo gallbladder removal after diagnosis during the same hospital stay. But is this clinical strategy coherent?

Researchers from Yale School of Medicine and Harvard School of Medicine set out to find out. The team, led by Fouad Chouairi of Yale and Thiruvengadam Muniraj, MD, FRCP, reviewed the records of patients who underwent an endoscopic retrograde cholangiopancreatography (ERCP) procedure to diagnose their acute biliary pancreatitis after gallbladder removal. . Of the 205,012 patient records in the US Nationwide Inpatient Sample Database, 42.3% of patients underwent ERCP during the same hospitalization as their gallbladder removal. Fifty-seven percent had ERCP, without undergoing gallbladder removal.

They found that 57.7% of patients did not have their gallbladder removed after ERCP during the same admission. “Large disparities can be observed in the management of acute gallstone pancreatitis, including multiple demographic, socioeconomic, and healthcare-related factors that have influenced management,” they wrote. Learn more.

Dapagliflozin may reduce new onset diabetes in patients with chronic kidney disease and/or heart failure

Type 2 diabetes (T2D) can lead to cardiovascular disease, complications like retinopathy, nephropathy and neuropathy, and even death. Diabetes rates worldwide are expected to soar to 700 million people with the disease. Effective treatment is needed to prevent diabetes and its complications

The new study by The Lancet Diabetes and Endocrinology examined the use of dapagliflozin, an SGLT2 inhibitor, in two multicenter phase 3 trials. 4003 patients with chronic renal failure (DAPA-CKD) and 2605 patients with heart failure (DAPA-HF) who n were not diabetic at baseline were assessed to see if dapagliflozin could reduce new-onset T2D.

After evaluating the results of the two trials, the researchers found that “dapagliflozin reduced the incidence of new cases of T2DM” in these subgroups of patients. Interestingly, the treatment effect (-33%) was comparable to previous studies using metformin, the most commonly prescribed drug in the United States for the prevention of diabetes, but a drug that has neither the benefits HF nor CKD benefits of SGLT2 inhibitors. Learn more in The Lancet.

Harm reduction practices should be considered and used when caring for people who use substances

When treating people with substance use disorders (SUDs) or who use substances, harm reduction should be an approach to implement. Harm reduction “is a patient-centered approach to reducing the negative health, societal, and economic impact of substance use without requiring abstinence,” Yale addiction specialists wrote in their new publication, “Harm Reduction in Health Care Settings”.

Needle exchange programs, fentanyl test strips, low-barrier treatment with drugs for opioid use disorder, and other strategies can reduce harms for people who use drugs. Clinicians should acquire knowledge of harm reduction practices, in order to counsel their patients on various tactics to reduce infections, overdoses and deaths. They should also be aware of the local resources available for these patients.

Learn more on these tactics in the January 2022 issue of North America Medical Clinics.

Train, act on what matters to elderly patients

When training the next generation of healthcare professionals, teaching “evidence-based principles of geriatric medicine is essential,” the authors write in the new publication, “Educational outcomes of multi-site, virtual, interprofessional training in patient-aligned care.” Patient Priorities Care (PPC) assists clinicians in clinical decision-making to provide care aligned with individual patient priorities.

The authors created virtual CPD training for fellows, residents, students, and clinicians at three sites. Of the participants, 60% responded to the post-session survey. Respondents gained CPD skills and recognized the need for practice change. The authors affirm the need to expand this training nationwide and plan to engage educators in a train-the-trainer program.

Lessons learned from virtual training during the COVID-19 pandemic

At the onset of the COVID-19 pandemic, graduate medical education (GME) came to a halt as faculty and trainees took on new clinical duties. To combat these educational challenges, the authors created the Hematology-Oncology Collaborative Videoconferencing Learning Initiative (H/O CO-VID). The virtual learning model was created in collaboration with 13 US institutions.

In the new journal of JCO Oncology Practice, the authors discuss the evaluation of program success. The content of the training was divided into five sessions in total, antiviral and immunological therapies; coagulation disorders and anticoagulation management; pulmonary complications and ventilation management; provider resilience; and ethical decision-making when resources are scarce. Surveys were created to assess the experience. The H/O CO-VID learning initiative was built in six weeks.

In this article, the authors “present a framework for how GME initiatives can rapidly leverage virtual learning to develop multi-institutional collaborations, provide trainees with instructional leadership experiences and access to multidisciplinary experts, and integrate the leadership of the interns in all aspects of the development of initiatives. .” To learn more about this initiative, read “Collaborative Videoconferencing Learning Initiative in Hematology-Oncology (CO-VID) Training: Experiential Lessons Learned from a Novel Trainee-Led Multidisciplinary Virtual Learning Platform.

A winter of dissatisfaction with vaccines

Vaccine hesitancy in the United States, driven by misinformation and political division, is holding the country back from getting the COVID-19 pandemic under control. “Given the high transmissibility of the Delta and Omicron variants, the goal should be to increase vaccine coverage above 80% to 85% for the entire US population. However, this is unlikely to happen without widely implemented mandates, especially by employers and educational institutions,” say the authors from a viewpoint in JAMA.

HLA-A*03 is a predictive biomarker of a poor response to ICI, according to a Lancet Oncology study

Predictive biomarkers could enable more precise use of immune checkpoint inhibitors (ICI) in the treatment of advanced cancers. HLA molecules play a central role in immunity. The purpose of this epidemiological study was to determine the effect of HLA-A*03 as a biomarker to predict response to immunotherapy. Researchers examined clinical outcomes after treatment for advanced cancer in eight patient cohorts.

Survey of prednisone combinations for kidney disease

The full-dose prednisone (FP) regimen in the treatment of patients at high risk for immunoglobulin A (IgAN) nephropathy is still controversial. Pulsed intravenous methylprednisolone plus low-dose alternative prednisone (MCALP) may have a more favorable safety profile, which has not been fully studied. A new study indicates that this combination of prednisone could be one of the choices for IgAN patients at high risk of early stage kidney disease.

The combined effects of obesity and stress on the brain

Obesity is a serious disease that often occurs in people who also suffer from stress-related psychiatric disorders. The brain plays a key role in obesity, but the molecular mechanisms that are altered in obesity have not been fully explained. Yale researchers studied the relationship between obesity and synaptic density using the radioligand [11C]UCB-J (which binds to the synaptic glycoprotein SV2A) and positron emission tomography (PET imaging) in obese people, with or without stress-related psychiatric disorders, with or without comorbid stress-related psychiatric disorders.

Facing the “vicious circle” of a global rheumatology research deficit

A “vicious circle” exists in adult and pediatric rheumatology research. Without a trained rheumatology workforce, the vicious circle develops, resulting in decreased access to care and research, which in turn contributes to missed diagnoses, under-treatment of rheumatic diseases, and bad results. Underreporting of rheumatic diseases leads to underfunding at national and institutional levels, the authors of this editorial report “Notes from the Field” in Arthritis and rheumatology.

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