Discoveries & Impact (February 2022)

Discoveries & Impact highlights select scientific discoveries per section across the Department of Internal Medicine...

Athletes with Heart Disease

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

The researchers conducted an open-ended qualitative survey of 15 male and 15 female interscholastic athletes, and their parents. During the phone interview, the research team captured information about the patient’s experiences in returning to play following the diagnosis, and areas for improvement.

Athletes and parents often reported frustration with their perceptions of:

• Difficultly with access to physicians with the appropriate expertise
• Poor communication between physicians, athletes and families, and schools
• A decision-making process perceived as one-sided and paternalistic
• Perception that liability-concerns, rather than patient-well-being, drove decisions
• The emotional toll this process took on athletes and families

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

Shapero, K, Gier, C, Briske, K, Spatz, ES, Wasfy, M, Baggish, AL, Pierce, S, Ackerman, MJ, Lampert, R. Experiences of Athletes with Arrhythmogenic Cardiac Conditions in Returning to Play. Heart Rhythm 02.

Pancreatitis Treatment Disparities

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

Researchers at Yale School of Medicine and Harvard School of Medicine sought to find out. The team, led by Yale’s Fouad Chouairi and Thiruvengadam Muniraj, MD, FRCP, reviewed the records of patients who underwent an endoscopic retrograde cholangiopancreatography (ERCP) procedure to diagnose their acute gallstone pancreatitis after gallbladder removal. From the 205,012 patient records in the U.S. Nationwide Inpatient Sample database, 42.3% of patients had ERCP during the same hospital admission as their gallbladder removal. Fifty-seven percent had ERCP, without undergoing gallbladder removal.

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

Chouairi F, McCarty TR, Hathorn KE, Sharma P, Aslanian HR, Jamidar PA, Thompson CC, Muniraj T. Evaluation of socioeconomic and healthcare disparities on same admission cholecystectomy after endoscopic retrograde cholangiopancreatography among patients with acute gallstone pancreatitis. Surgical Endoscopy 2022, 36(1): 274-281. doi: 10.1007/s00464-020-08272-2. PMID: 33481109.

Dapagliflozin Lessens New-Onset Diabetes

Type 2 diabetes (T2D) can lead to cardiovascular disease, complications like retinopathy, nephropathy, and neuropathy, and even death. Rates of diabetes globally are expected to climb to 700 million people suffering from this ailment. Effective treatment is needed to prevent diabetes and its complications

The new study in The Lancet Diabetes & Endocrinology looked at the use of dapagliflozin, a SGLT2 inhibitor, in two multi-center phase 3 trials. 4003 patients with chronic kidney disease (DAPA-CKD) and 2605 with heart failure (DAPA-HF) who did not have diabetes at baseline were evaluated to see if dapagliflozin could reduce new-onset T2D.

After evaluating results of both trials, researchers found that “dapagliflozin reduced the incidence of new onset T2D” in these subsets of patients. Interestingly, the treatment effect (-33%) was on par with previous studies using metformin, the most commonly prescribed medication in the US for diabetes prevention, but a drug that has neither the HF nor the CKD benefits of the SGLT2 inhibitors. Learn more in The Lancet.

Rossing P, Inzucchi SE, Vart P, Jongs N, Docherty KF, Jhund PS, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Solomon SD, DeMets DL, Bengtsson O, Lindberg M, Langkilde AM, Sjöstrand M, Stefansson BV, Karlsson C, Chertow GM, Hou FF, Correa-Rotter R, Toto RD, Wheeler DC, McMurray JJV, Heerspink HJL. Dapagliflozin and new-onset type 2 diabetes in patients with chronic kidney disease or heart failure: pooled analysis of the DAPA-CKD and DAPA-HF trials. The Lancet. Diabetes & Endocrinology 2022, 10(1): 24-34. doi: 10.1016/S2213-8587(21)00295-3. PMID: 34856173.

Consider Harm Reduction Practices

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

Syringe exchange programs, fentanyl testing strips, low barrier treatment with medications for opioid use disorder, along with other strategies, can reduce harm for persons who use drugs. Clinicians should gain knowledge in harm reduction practices, in order to counsel their patients on various tactics to reduce infection, overdose, and death. They should also be knowledgeable in local resources available to these patients.

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

Chan CA, Canver B, McNeil R, Sue KL. Harm Reduction in Health Care Settings. The Medical Clinics Of North America 2022, 106(1): 201-217. doi: 10.1016/j.mcna.2021.09.002. PMID: 34823731.

Train, Act on What Matters For Older Patients

When training the next generation of healthcare professionals, teaching “evidence-based principles of geriatric medicine is critical,” write the authors in the new publication, “Education outcomes of a multisite, virtual, interprofessional training in patient priorities aligned care.” Patient Priorities Care (PPC) assists clinicians in clinical decision-making to deliver the care aligned with the priorities of each patient.

The authors created a virtual PPC training for fellows, residents, students, and clinicians across three sites. Of the participants, 60% answered the post session survey. The respondents gained skills in PPC, and acknowledged the need for practice change. Authors state the need to expand this training nationally, and plan to engage educators in a train the trainer program.

Ouellet JA, Mecca MC, Tinetti ME, Dindo L, Kiefer L, Nguyen AC, Omer ZB, Naik AD, Catic AG. Education outcomes of a multisite, virtual, interprofessional training in patient priorities aligned care. Journal Of The American Geriatrics Society 2022, 70(1): E5-E7. doi: 10.1111/jgs.17544. PMID: 34741462.

Virtual Training During COVID-19 Pandemic

At the start of the COVID-19 pandemic, graduate medical education (GME) was disrupted as faculty and trainees jumped into new clinical duties. To combat these educational challenges, the authors created the Hematology-Oncology Collaborative Videoconferencing (H/O CO-VID) Learning Initiative. The virtual learning model was created in collaboration across 13 U.S. institutions.

In the new paper from JCO Oncology Practice, the authors discuss evaluating the success of the program. The content of the training was divided into five total sessions, antiviral and immunology therapies; coagulation disorders and anticoagulation management; pulmonary complications and ventilation management; provider resilience; and ethical decision-making during resource scarcity. Surveys were created to assess the experience. The H/O CO-VID Learning Initiative was built in six weeks.

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

Martin RL, Grant MJ, Kimani S, Midha S, May J, Patell R, Collier E, Furfaro D, Bodine C, Reap L, Shah N, DeLaune J, Brusca S, Olazagasti C, Goyal S, Rubinstein S, Hakim N, Qin S, Browning SL, Sena L, Gilbert J, Davidson M, Lovly CM, Seetharamu N, Rangachari D, Murphy M, Chatwal M, Paschal R, Henry E, Collichio F, Green JR. Forming the Hematology-Oncology Collaborative Videoconferencing (CO-VID) Learning Initiative: Experiential Lessons Learned From a Novel Trainee-Led Multidisciplinary Virtual Learning Platform. JCO Oncology Practice 2022, 18(1): e36-e46. doi: 10.1200/OP.20.00960. PMID: 34242082. PMCID: PMC8758064.

A Winter of Vaccine Discontent

Vaccine hesitancy in the U.S., driven by misinformation and political division, is keeping the country from getting the COVID-19 pandemic under control. “Given the high transmissibility of the Delta and Omicron variants, increasing vaccination coverage to more than 80% to 85% for the entire U.S. population should be the goal. However, this is unlikely to happen without widely implemented mandates, especially by employers and educational institutions,” say the authors of a Viewpoint in JAMA.

Del Rio C, Omer SB, Malani PN. Winter of Omicron-The Evolving COVID-19 Pandemic. JAMA 2022, 327(4): 319-320. doi: 10.1001/jama.2021.24315. PMID: 34935863.

HLA-A*03 a Predictive Biomarker of Poor Response to ICI

Predictive biomarkers could allow more precise use of immune checkpoint inhibitors (ICIs) in treating advanced cancers. HLA molecules play a central role in immunity. The aim of this epidemiological study was to determine the effect of HLA-A*03 as a biomarker for predicting response to immunotherapy. Investigators looked at the clinical outcomes after treatment for advanced cancer in eight patient cohorts.

Naranbhai V, Viard M, Dean M, Groha S, Braun DA, Labaki C, Shukla SA, Yuki Y, Shah P, Chin K, Wind-Rotolo M, Mu XJ, Robbins PB, Gusev A, Choueiri TK, Gulley JL, Carrington M. HLA-A*03 and response to immune checkpoint blockade in cancer: an epidemiological biomarker study. The Lancet. Oncology 2022, 23(1): 172-184. doi: 10.1016/S1470-2045(21)00582-9. PMID: 34895481. PMCID: PMC8742225.

Prednisone Combinations for Kidney Disease

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

Li Y, Fu R, Gao J, Wang L, Duan Z, Tian L, Ge H, Ma X, Zhang Y, Li K, Xu P, Tian X, Chen Z. Effect of pulsed intravenous methylprednisolone with alternative low-dose prednisone on high-risk IgA nephropathy: a 18-month prospective clinical trial. Scientific Reports 2022, 12(1): 255. doi: 10.1038/s41598-021-03691-0. PMID: 34996948. PMCID: PMC8742122.

Compounding Effects of Obesity/Stress on the Brain

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

Asch RH, Holmes SE, Jastreboff AM, Potenza MN, Baldassarri SR, Carson RE, Pietrzak RH, Esterlis I. Lower synaptic density is associated with psychiatric and cognitive alterations in obesity. Neuropsychopharmacology : Official Publication Of The American College Of Neuropsychopharmacology 2022, 47(2): 543-552. doi: 10.1038/s41386-021-01111-5. PMID: 34294874. PMCID: PMC8674236.

‘Vicious Circle’ of Global Rheum. Research Gap

A “vicious circle” exists in adult and pediatric rheumatology research. Without a rheumatology-trained workforce, the vicious circle develops, leading to decreased access to care and research, which in turn contributes to missed diagnoses, undertreatment of rheumatic diseases, and poor outcomes. Underreporting of rheumatic diseases drives underfunding at the national and institutional levels, the authors of this “Notes from the Field” editorial report in Arthritis & Rheumatology.

Bilsborrow JB, Peláez-Ballestas I, Pons-Estel B, Scott C, Tian X, Alarcon GS, Bucala R, Lewandowski LB, Hsieh E. Global Rheumatology Research: Frontiers, Challenges, and Opportunities. Arthritis & Rheumatology (Hoboken, N.J.) 2022, 74(1): 1-4. doi: 10.1002/art.41980. PMID: 34535973. PMCID: PMC8712358.