Use of a Pulmonary Artery Pressure Sensor to Manage Patients With Left Ventricular Assist Devices

Background: Hemodynamic-guided management with a pulmonary artery pressure (PAP) sensor (CardioMEMS^TM) is effective in reducing heart failure hospitalization (HFH) in patients with chronic heart failure (HF). This study aims to determine the feasibility and clinical utility of the CardioMEMS HF system to manage patients supported with LVADs. Methods: In this multi-center prospective study, we followed patients with HeartMate II^TM (n=52) or HeartMate 3^TM (n=49) LVADs and with CardioMEMS PA Sensors, and measured PAP, 6-minute walk distance (6MWD), quality of life (EQ-5D-5L scores), and HFH rates through 6 months. Patients were stratified as responders (R) and non-responders (NR) to reductions in PA diastolic pressure (PAD). Results: There were significant reductions in PAD from baseline to 6 months in R (21.5 to 16.5 mmHg, p<0.001), compared to an increase in NR (18.0 to 20.3, p=0.002). and there was a significant increase in 6MWD among R (266 vs 322 meters, p=0.025) compared to no change in NR. Patients who maintained PAD < 20 compared with PAD ≥ 20 mmHg for more than half the time throughout the study (averaging 15.6 vs 23.3 mmHg) had a statistically significant lower rate of HFH (12.0% vs 38.9%, p=0.005). Conclusions: LVAD patients managed with CardioMEMS with a significant reduction in PAD at 6 months showed improvements in 6MWD. Maintaining PAD < 20 mmHg was associated with fewer HF hospitalizations. Hemodynamic-guided management of LVAD patients with CardioMEMS is feasible and may result in functional and clinical benefits. Prospective evaluation of ambulatory hemodynamic management in LVAD patients is warranted. Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT03247829.

The Impact of Angiotensin Receptor-Neprilysin Inhibitors on Arrhythmias in Patients with Heart Failure: A Systematic Review and Meta-analysis

Angiotensin receptor-neprilysin inhibitor (ARNI) use has become increasingly popular. Current guidelines recommend using ARNI therapy for heart failure with reduced (HFrEF) and preserved ejection fraction (HFpEF). As therapies become more widely available, heart failure-associated burdens such as ventricular arrhythmias and sudden cardiac death (SCD) will become increasingly prevalent. We conducted a systematic review and meta-analysis to assess the impact of ARNI therapy on HFrEF and HFpEF pertaining to arrhythmogenesis and SCD. We performed a search of MEDLINE (PubMed), the Cochrane Library, and ClinicalTrials.gov for relevant studies. The odds ratios (ORs) of SCD, ventricular tachycardia (VT), ventricular fibrillation (VF), atrial fibrillation/flutter (AF), supraventricular tachycardia (SVT), and implantable cardioverter-defibrillator (ICD) shocks were calculated. A total of 10 studies, including 6 randomized controlled trials and 4 observational studies, were included in the analysis. A total of 18,548 patients from all studies were included, with 9,328 patients in the ARNI arm and 9,220 patients in the angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB) arm, with a median follow-up time of 15 months. There was a significant reduction in the composite outcomes of SCD and ventricular arrhythmias in patients treated with ARNIs compared to those treated with ACEIs/ARBs (OR, 0.71; 95% confidence interval, 0.54-0.93; P = .01; I² = 17%; P = .29). ARNI therapy was also associated with a significant reduction in ICD shocks. There was no significant reduction in the VT, VF, AF, or SVT incidence rate in the ARNI group compared to the ACEI/ARB group. In conclusion, the use of ARNIs confers a reduction in composite outcomes of SCD and ventricular arrhythmias among patients with heart failure. These outcomes were mainly driven by SCD reduction in patients treated with ARNIs.

Resident Engagement in a Wellness Program in a Large Academic Residency: A Follow-Up After Two Years of Wellness

INTRODUCTION

The rate of burnout among residents has reached an alarming level and negatively impacts learning, attrition, and patient care. We implemented a comprehensive Surgery Resident Wellness Program in a large academic program and aimed to assess the degree this initiative improved resident burnout based on validated burnout and well-being models utilizing voluntary surveys.

MATERIALS AND METHODS

A voluntary survey was sent to surgical residents and included the Maslach Burnout Inventory and The Psychological General Well-Being Index. These were graded according to the respective validated scale for each test. The survey was administered prior to establishing a wellness program, and at 6 month- and 24 month-intervals following its establishment. These data were analyzed using univariate analysis based on survey data from each of the time points.

RESULTS

The survey had a 51% response rate. The baseline, 6-month, and 24-month mean scores for MBI personal accomplishment were 32.80, 32.91, and 35.57, emotional exhaustion was 23.48, 23.0, and 24.42, and depersonalization were 10.94, 9.54, and 11.11. Resident burnout was present in 16 of 31 (51.61%), 14 of 33 (42.42%), and 12 of 27 (44.44%) residents at each time point. The rate of change in resident burnout was -17.8% at 6 months and -13.9% at 24 months. The averaged PGWBI global scores were 66, 73, and 83 among the participants who took the survey at each time interval.

CONCLUSIONS

Conclusion Implementation of a structured wellness program was associated with a decrease in resident burnout and an increase in overall resident wellness.

Faculty Emotional Intelligence Matters for Resident Education

OBJECTIVE

This study aimed to determine the emotional intelligence (EI) of surgical faculty and evaluate its relationship with resident evaluations of faculty behaviors.

DESIGN

This study retrospectively collected faculty EI scores as well as general surgery resident evaluations of faculty. Parametric and nonparametric tests were used for statistical analysis.

SETTING

The study was conducted at the University of Texas Southwestern in the Department of Surgery in Dallas, Texas. This is an academic, tertiary care center.

PARTICIPANTS

Surgical faculty members at a single institution in 2018 completed the Emotional Intelligence Appraisal, a 28-item, electronic assessment with possible scores ranging from zero to 100. Aggregate, anonymous resident evaluations of faculty members were collected from the program director's office. Faculty with fewer than 8 resident evaluations were excluded.

RESULTS

In total, 59 faculty members participated (89%). The sample was mostly white (69.2%), male (63.5%), with an average of 47 ± 10 years of age, 12.2 ± 10 years in practice, and 44 ± 24 evaluations per faculty member. The group's mean EI score was 76 ± 7.7. Faculty EI scores were found to have a moderate, positive correlation with resident rotational evaluations of faculty (r(51) = 0.52, p < 0.001). Faculty EI scores did not significantly correlate with resident evaluations of faculty intraoperative behaviors.

CONCLUSIONS

The results of this study suggest that a majority of our faculty are competent with regard to EI. Furthermore, faculty EI is an important factor in the clinical learning environment and correlates with resident rotational evaluations of teaching behaviors.

Comparing Measures to Assess Health-Related Quality of Life in Heart Failure With Preserved Ejection Fraction

OBJECTIVES

This study sought to compare the performance of 2 health-related quality of life (HRQOL) questionnaires in patients with heart failure with preserved ejection fraction (HFpEF).

BACKGROUND

The ability to accurately assess HRQOL over time is important in the care of patients with heart failure. The validity and reliability of HRQOL tools including the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Questionnaire (KCCQ) has not been fully determined or compared in patients with HFpEF.

METHODS

Among patients with stable chronic HFpEF enrolled in the NEAT (Nitrate Effect on Activity Tolerance in Heart Failure) trial (n = 110), the study evaluated and compared reliability, validity, and responsiveness to change of the MLHFQ and KCCQ at baseline, 6 weeks, and 12 weeks.

RESULTS

Internal consistency was good and comparable for MLHFQ and KCCQ domains measuring similar aspects of HRQOL at baseline including the MLHFQ physical (Cronbach's α = 0.93) compared with the KCCQ clinical summary (α = 0.91), and the MLHFQ emotional (α = 0.92) compared with the KCCQ quality of life (α = 0.87). Correlations with New York Heart Association functional class (Spearman rho; r_s= -0.37 vs. 0.30) and 6-min walk test (6MWT) (r_s = 0.38 vs. -0.23) at baseline were slightly stronger for the KCCQ overall summary score than for the MLHFQ total score. The MLHFQ was more responsive to change in 6MWT based on responsiveness statistics.

CONCLUSIONS

These data suggest that both the MLHFQ and KCCQ are reliable and valid tools to assess HRQOL in HFpEF. The KCCQ was more strongly correlated with baseline functional status parameters, while the MLHFQ was more responsive to improvement in 6MWT.

Immunocytochemical evidence of calreticulin-like protein in pollen tubes and styles of Petunia hybrida Hort

With a polyclonal antibody raised against calreticulin (CRT) the locations where the protein occurs in unpollinated and pollinated styles of Petunia hybrida were localized. The epitopes binding the CRT antibody were immunolocalized preferentially in pollen tubes. In transmitting tract cells, both before and after pollination, the level of CRT was low. The protein was mainly localized in the cytosol and around dictyosomes of transmitting-tract cells. In pollen tubes, a high level of CRT was found at their tips rich in endoplasmatic reticulum, cisternae piles of reticular and/or dictyosomal origin, and vesicles. Binding sites of the CRT antibody were also found in the internal callosic cell wall of the pollen tube. These results indicate a role of CRT in cells directly participating in pollen-pistil interaction.

Novel auxin transport inhibitors phenocopy the auxin influx carrier mutation aux1

The hormone auxin is transported in plants through the combined actions of diffusion and specific auxin influx and efflux carriers. In contrast to auxin efflux, for which there are well documented inhibitors, understanding the developmental roles of carrier-mediated auxin influx has been hampered by the absence of specific competitive inhibitors. However, several molecules that inhibit auxin influx in cultured cells have been described recently. The physiological effects of two of these novel influx carrier inhibitors, 1-naphthoxyacetic acid (1-NOA) and 3-chloro-4-hydroxyphenylacetic acid (CHPAA), have been investigated in intact seedlings and tissue segments using classical and new auxin transport bioassays. Both molecules do disrupt root gravitropism, which is a developmental process requiring rapid auxin redistribution. Furthermore, the auxin-insensitive and agravitropic root-growth characteristics of aux1 plants were phenocopied by 1-NOA and CHPAA. Similarly, the agravitropic phenotype of inhibitor-treated seedlings was rescued by the auxin 1-naphthaleneacetic acid, but not by 2,4-dichlorophenoxyacetic acid, again resembling the relative abilities of these two auxins to rescue the phenotype of aux1. Further investigations have shown that none of these compounds block polar auxin transport, and that CHPAA exhibits some auxin-like activity at high concentrations. Whilst results indicate that 1-NOA and CHPAA represent useful tools for physiological studies addressing the role of auxin influx in planta, 1-NOA is likely to prove the more useful of the two compounds.

Crystallization and preliminary X-ray analysis of the auxin receptor ABP1

Auxin-binding protein (ABP1) is an important receptor for the plant hormone auxin that is involved with many growth and developmental responses in plants. The maize ABP1 gene has been expressed in insect cells, purified and crystallized. Type II crystals are monoclinic, with two glycosylated homodimers in the asymmetric unit, and diffract to 1.9 A using synchrotron radiation.

Maize calreticulin localizes preferentially to plasmodesmata in root apex

Using a polyclonal antibody raised against calreticulin purified and sequenced from maize, we performed an immunocytological study to characterize putative domain-specific subcellular distributions of endoplasmic reticulum (ER)-resident calreticulin in meristematic cells of maize root tip. At the light microscopy level, calreticulin was immunolocalized preferentially at cellular peripheries, in addition to nuclear envelopes and cytoplasmic structures. Punctate labelling at the longitudinal walls and continuous labelling at the transverse walls was characteristic. Immunogold electron microscopy revealed plasmodesmata as the most prominently labelled cell periphery structure. In order to further probe the ER-domain-specific distribution of maize calreticulin at plasmodesmata, root apices were exposed to mannitol-induced osmotic stress. Plasmolysis was associated with prominent accumulations of calreticulin at callose-enriched plasmodesmata and pit fields while the contracting protoplasts were depleted of calreticulin. In contrast, other ER-resident proteins recognized by HDEL peptide and BiP antibodies localized exclusively to contracted protoplasts. This finding reveals that, in plasmolysed cells, calreticulin enriched ER domains at plasmodesmata and pit fields are depleted of other ER-resident proteins containing the HDEL retention peptide.