Importance How the COVID-19 pandemic has affected academic medicine faculty's work-life balance is unknown. Objective To assess the association of perceived work-life conflict with academic medicine ...faculty intention to leave, reducing employment to part time, or declining leadership opportunities before and since the COVID-19 pandemic. Design, Settings, and Participants An anonymous online survey of medical, graduate, and health professions school faculty was conducted at a single large, urban academic medical center between September 1 and September 25, 2020. Main Outcomes and Measures Self-assessed intention to leave, reducing employment to part time, or turning down leadership opportunities because of work-life conflict before and since the COVID-19 pandemic. Results Of the 1186 of 3088 (38%) of faculty members who answered the survey, 649 (55%) were women and 682 (58%) were White individuals. Respondents were representative of the overall faculty demographic characteristics except for an overrepresentation of female faculty respondents and underrepresentation of Asian faculty respondents compared with all faculty (female faculty: 649 55% vs 1368 44%; Asian faculty: 259 22% vs 963 31%). After the start of the COVID-19 pandemic, faculty were more likely to consider leaving or reducing employment to part time compared with before the pandemic (leaving: 225 23% vs 133 14%;P < .001; reduce hours: 281 29% vs 206 22%;P < .001). Women were more likely than men to reduce employment to part time before the COVID-19 pandemic (153 28% vs 44 12%;P < .001) and to consider both leaving or reducing employment to part time since the COVID-19 pandemic (leaving: 154 28% vs 56 15%;P < .001; reduce employment: 215 40% vs 49 13%;P < .001). Faculty with children were more likely to consider leaving and reducing employment since the COVID-19 pandemic compared with before the pandemic (leaving: 159 29% vs 93 17%;P < .001; reduce employment: 213 40% vs 130 24%;P < .001). Women with children compared with women without children were also more likely to consider leaving since the COVID-19 pandemic than before (113 35% vs 39 17%;P < .001). Working parent faculty and women were more likely to decline leadership opportunities both before (faculty with children vs without children: 297 32% vs 84 9%;P < .001; women vs men: 206 29% vs 47 13%;P < .001) and since the COVID-19 pandemic (faculty with children vs faculty without children: 316 34% vs 93 10 %;P < .001; women vs men: 148 28% vs 51 14%;P < .001). Conclusions and Relevance In this survey study, the perceived stressors associated with work-life integration were higher in women than men, were highest in women with children, and have been exacerbated by the COVID-19 pandemic. The association of both gender and parenting with increased perceived work-life stress may disproportionately decrease the long-term retention and promotion of junior and midcareer women faculty.
Transthoracic echocardiography (TTE) accounts for almost half of all cardiac imaging services and is a widely available and versatile tool. Appropriate use criteria (AUC) for echocardiography were ...developed to improve patient care and health outcomes. Prior studies have shown that most TTEs are appropriate by AUC. However, the associations among TTE, AUC, and their clinical impact have not been well explored.
To describe the proportion of TTEs that affect clinical care in an academic medical center overall and in subgroups defined as appropriate and inappropriate by AUC.
Retrospective review of medical records from 535 consecutive TTEs at an academic medical center was performed. The TTEs were classified according to 2011 AUC by 2 cardiologists blinded to clinical impact and were assessed for clinical impact by 2 cardiologists blinded to AUC. Clinical impact was assigned to 1 of the following 3 categories: (1) active change in care, (2) continuation of current care, or (3) no change in care.
Five hundred thirty-five patients undergoing TTE.
Transthoracic echocardiography. MAIN OUTCOMES AND MEASURES Prevalence of appropriate, inappropriate, and uncertain TTEs and prevalence of clinical impact subcategories.
Overall, 31.8% of TTEs resulted in an active change in care; 46.9%, continuation of current care; and 21.3%, no change in care. By 2011 AUC, 91.8% of TTEs were appropriate; 4.3%, inappropriate; and 3.9%, uncertain. We detected no statistically significant difference between appropriate and inappropriate TTEs in the proportion of TTEs that led to active change in care (32.2% vs 21.7%; P= .29).
Although 9 in 10 TTEs were appropriate by 2011 AUC, fewer than 1 in 3 TTEs resulted in an active change in care, nearly half resulted in continuation of current care, and slightly more than 1 in 5 resulted in no change in care. The low rate of active change in care (31.8%) among TTEs mostly classified as appropriate (91.8%) highlights the need for a better method to optimize TTE utilization to use limited health care resources efficiently while providing high-quality care.
Aim
Left ventricular (LV) global longitudinal strain (GLS) may detect subtle abnormalities in myocardial contractility among individuals with normal LV ejection fraction (LVEF). However, the ...prognostic implications of GLS among healthy, community‐dwelling adults is not well‐established.
Methods and results
Overall, 2234 community‐dwelling adults (56% women, 47% Black) with LVEF ≥50% without a history of cardiovascular disease (CVD) from the Dallas Heart Study who underwent cardiac magnetic resonance (CMR) with GLS assessed by feature tracking CMR (FT‐CMR) were included. The association of GLS with the risk of incident major adverse cardiovascular events (MACE; composite of incident myocardial infarction, incident heart failure HF, hospitalization for atrial fibrillation, coronary revascularization, and all‐cause death), and incident HF or death were assessed with adjusted Cox proportional hazards models. A total of 309 participants (13.8%) had MACE during a median follow‐up duration of 17 years. Participants with the worst GLS (Q4) were more likely male and of the Black race with a history of tobacco use and diabetes with lower LVEF, higher LV end‐diastolic volume, and higher LV mass index. Cumulative incidence of MACE was higher among participants with worse (Q4 vs. Q1) GLS (20.4% vs. 9.0%). In multivariable‐adjusted Cox models that included clinical characteristics, cardiac biomarkers and baseline LVEF, worse GLS (Q4 vs. Q1) was associated with a significantly higher risk of MACE (hazard ratio HR 1.55, 95% confidence interval CI 1.07–2.24, p = 0.02) and incident HF or death (HR 1.57, 95% CI 1.03–2.38, p = 0.04).
Conclusions
Impaired LV GLS assessed by FT‐CMR among adults free of cardiovascular disease is associated with a higher risk of incident MACE and incident HF or death independent of cardiovascular risk factors, cardiac biomarkers and LVEF.
Left ventricular (LV) global longitudinal strain (GLS) assessed via feature tracking cardiac magnetic resonance imaging is associated with increased risk of major adverse cardiovascular events (MACE). LV GLS is associated with MACE in adults without prevalent cardiovascular disease (CVD). Among participants without pre‐existing CVD, a higher burden of cardiovascular (CV) risk factors was associated with impairment of LV GLS. CI, confidence interval; EDMi, end‐diastolic mass index; HF, heart failure; HR, hazard ratio; LVEF, left ventricular ejection fraction.
•The prevalence of the V122I transthyretin (TTR) variant in individuals with African ancestry is 3.2%.•In mid-life, carriers of the V122I TTR have subtle cardiac structural differences in comparison ...with noncarriers.•Over time, carriers of V122I have a greater increase in amino terminal pro-B-type natriuretic peptide in comparison with noncarriers.•In comparison with noncarriers, carriers of the V122I TTR are at a higher long-term risk of heart failure and death
The V122I variant in transthyretin (TTR) is the most common amyloidogenic mutation worldwide. The aim of this study is to describe the cardiac phenotype and risk for adverse cardiovascular outcomes of young V122I TTR carriers in the general population.
TTR genotypes were extracted from whole-exome sequence data in participants of the Dallas Heart Study. Participants with African ancestry, available V122I TTR genotypes (N = 1818) and either cardiac magnetic resonance imaging (n = 1364) or long-term follow-up (n = 1532) were included. The prevalence of V122I TTR carriers (45 ± 10 years) was 3.2% (n/N = 59/1818). The V122I TTR carriers had higher baseline left ventricular wall thickness (8.52 ± 1.82 vs 8.21 ± 1.62 mm, adjusted P = .038) than noncarriers, but no differences in other cardiac magnetic resonance imaging measures (P > .05 for all). Although carrier status was not associated with amino terminal pro-B-type natriuretic peptide (NT-proBNP) at baseline (P = .79), V122I TTR carriers had a greater increase in NT-proBNP on follow-up than noncarriers (median 28.5 pg/mL, interquartile range 11.4–104.1 pg/mL vs median 15.9 pg/mL, interquartile range 0.0–43.0 pg/mL, adjusted P = .018). V122I TTR carriers were at a higher adjusted risk of heart failure (hazard ratio 3.82, 95% confidence interval 1.80–8.13, P < .001), cardiovascular death (hazard ratio 2.65, 95% confidence interval 1.14–6.15, P = .023), and all-cause mortality (hazard ratio 1.95, 95% confidence interval 1.08–3.51, P = .026) in comparison with noncarriers.
V122I TTR carrier status was associated with a greater increase in NT-proBNP, slightly greater left ventricular wall thickness, and a higher risk for heart failure, cardiovascular death, and all-cause mortality. These findings suggest the need to develop amyloidosis screening strategies for V122I TTR carriers.
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Background It is well known that the maternal cardiovascular system undergoes profound alterations throughout pregnancy. Interest in understanding these changes has led investigators to use evolving ...and increasingly sophisticated techniques to study these changes, most recently with 2-dimensional echocardiography. Despite its clinical utility, echocardiography has limitations, and cardiac magnetic resonance imaging (CMRI) has become increasingly used for evaluation of cardiac structure and function. Objective We used CMRI to evaluate cardiac remodeling according to maternal habitus throughout pregnancy and postpartum. Study Design This was a prospective, observational study of nulliparous women aged 18-30 years, without preexisting medical conditions, conducted from October 2012 through December 2014. Women were classified according to prepregnancy body mass index (BMI) as either normal (BMI 18.5-24.9 kg/m2 ) or overweight (BMI 25-35 kg/m2 ). All women underwent CMRI during 5 epochs throughout gestation: 12-16 weeks, 26-30 weeks, 32-36 weeks, at delivery, and 3 months’ postpartum. Using left ventricular mass (LVM) as a marker of cardiac remodeling, the 2 cohorts were compared. Results There were 14 normal-weight (BMI 22.2 ± 1.3) and 9 overweight (BMI 29.1 ± 2.0) women who participated in the study. Beginning at 26-30 weeks and continuing to delivery, LVM of both normal-weight and overweight women was significantly increased compared with the respective first-trimester studies for each cohort ( P < .001). LVM of both cohorts returned to their index values by 3 months’ postpartum. The geometric ratio of LVM to left ventricular end-diastolic volume was calculated, and both normal-weight and overweight women demonstrated concentric remodeling throughout gestation, however this resolved by 12 weeks’ postpartum. Conclusion There is substantial cardiac remodeling during pregnancy with significant increases in LVM that are proportional to maternal size. Left ventricular geometric remodeling was concentric in both normal-weight and overweight women. All changes in cardiac remodeling resolved by 3 months’ postpartum.
Background
Obesity may increase heart failure risk through cardiac remodeling. Cross‐sectional associations between adiposity and cardiac structure and function have been elucidated, but the impact ...of longitudinal changes in adiposity on cardiac remodeling is less well understood.
Methods and Results
Participants in the Dallas Heart Study without cardiovascular disease or left ventricular dysfunction underwent assessment of body weight, anthropometrics, and cardiac magnetic resonance imaging at baseline and 7 years later. Associations between changes in indices of generalized and central adiposity with changes in left ventricular mass, volume, mass/volume ratio (concentricity), wall thickness, and ejection fraction were assessed using multivariable linear regression. The study cohort (n=1262) mean age was 44 years with 57% women, 44% black, and 36% obese participants. At follow‐up, 41% had ≥5% weight gain, and 15% had ≥5% weight loss. Greater weight gain was associated with younger age, lower risk factor burden, and lower body mass index at baseline. In multivariable models adjusting for age, sex, race, comorbid conditions at baseline and follow‐up, baseline adiposity, and cardiac measurement, increasing weight was associated with increases in left ventricular mass (β=0.10, P<0.0001), wall thickness (β=0.10, P<0.0001), and concentricity (β=0.06, P=0.002), with modest effects on end‐diastolic volume (β=0.04, P=0.044) and ejection fraction (β=0.05, P=0.046). Similar results were seen with other adiposity indices.
Conclusions
Concentric left ventricular remodeling is the predominant phenotype linked to increasing adiposity in middle age. Our findings support the importance of weight management to prevent secular changes in adiposity, concentric remodeling, and eventual heart failure over time.
There has been an increasing interest in use of mineralocorticoid receptor antagonists (MRAs) in patients with heart failure with preserved ejection fraction (HFPEF). However, a comprehensive ...evaluation of MRA effects on left ventricular (LV) structure and function in these patients is lacking. In this meta-analysis, we evaluated the effects of MRAs on LV structure and function among patients with diastolic dysfunction or HFPEF.
Randomized, controlled clinical trials evaluating the efficacy of MRAs in patients with diastolic dysfunction or HFPEF were included. The primary outcome was change in E/e', a specific measure of diastolic function. Secondary outcomes included changes in other measures of diastolic function, LV structure, surrogate markers for myocardial fibrosis (carboxy-terminal peptide of procollagen type I PICP and amino-terminal peptide of pro-collagen type-II PIIINP), blood pressure, and exercise tolerance. In the pooled analysis, MRA use was associated with significant reduction in E/e' (weighted mean difference WMD 95% confidence interval {CI}: -1.68 -2.03 to -1.33; P<0.0001) and deceleration time (WMD 95% CI: -12.0 ms -23.3 to -0.7; P=0.04) as compared with control, suggesting and improvement in diastolic function. Furthermore, blood pressure and levels of PIIINP and PICP were also significantly reduced with MRA therapy with no significant change in LV mass or dimensions.
MRA therapy in patients with asymptomatic diastolic dysfunction or HFPEF is associated with significant improvement in diastolic function and markers of cardiac fibrosis without a significant change in LV mass or dimensions.
Abstract Purpose The purpose of this study is to improve the quality of care and patient outcomes for Staphylococcus aureus bacteremia. Methods A quasi-experimental pre- and postintervention study ...design was used to compare process and clinical endpoints before and after a quality-improvement initiative. All inpatients >18 years of age with a positive blood culture for S. aureus during the specified pre- and postintervention period with clinical information available in the electronic medical record were included. An institutional protocol for the care of patients with S. aureus bacteremia was developed, formalized, and distributed to providers using a pocket card, an electronic order set, and targeted lectures over a 9-month period. Results There were 167 episodes of S. aureus bacteremia (160 patients) identified in the preintervention period, and 127 episodes (123 patients) in the postintervention period. Guideline adherence improved in the postintervention period for usage of transesophageal echocardiogram (43.9% vs 20.2%, P <.01) and adequate duration of intravenous therapy (71% vs 60%, P = .05). In a multivariate Cox proportional hazard model, the variables associated with increased relapse-free survival were postintervention period (hazard ratio HR 0.48; confidence interval CI, 0.24-0.95; P .035) and appropriate source control (HR 0.53; CI, 0.24-0.92; P .027). Regardless of intervention, presence of cancer was associated with an increased risk of relapse or mortality at 90 days (HR 2.88; P <.0001; CI, 1.35-5.01). Conclusion A bundled educational intervention to promote adherence to published guidelines for the treatment of S. aureus bacteremia resulted in a significant improvement in provider adherence to guidelines as well as increased 90-day relapse-free survival.
In the conventional paradigm of the progression of left ventricular hypertrophy, a thick-walled left ventricle (LV) ultimately transitions to a dilated cardiomyopathy. There are scant data in humans ...demonstrating whether this transition occurs commonly without an interval myocardial infarction.
Participants (n=1282) from the Dallas Heart Study underwent serial cardiac magnetic resonance ≈7 years apart. Those with interval cardiovascular events and a dilated LV (increased LV end-diastolic volume EDV indexed to body surface area) at baseline were excluded. Multivariable linear regression models tested the association of concentric hypertrophy (increased LV mass and LV mass/volume
) with change in LVEDV. The study cohort had a median age of 44 years, 57% women, 43% black, and 11% (n=142) baseline concentric hypertrophy. The change in LVEDV in those with versus without concentric hypertrophy was 1 mL (-9 to 12) versus -2 mL (-11 to 7), respectively,
<0.01. In multivariable linear regression models, concentric hypertrophy was associated with larger follow-up LVEDV (
≤0.01). The progression to a dilated LV was uncommon (2%, n=25).
In the absence of interval myocardial infarction, concentric hypertrophy was associated with a small, but significantly greater, increase in LVEDV after 7-year follow-up. However, the degree of LV enlargement was minimal, and few participants developed a dilated LV. These data suggest that if concentric hypertrophy does progress to a dilated cardiomyopathy, such a transition would occur over a much longer timeframe (eg, decades) and perhaps less common than previously thought.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00344903.
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