In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02–2.56) and frailty (HR 2.77, 95% CI 1.38–5.58) were significantly associated with the development of major bleeding. In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.

Background: Geriatric conditions are common among patients with atrial fibrillation (AF) and relate to complications of oral anticoagulation (OAC). Objective: To examine the prevalence of geriatric conditions among older patients with AF on OAC and relate type of OAC to geriatric conditions. Methods: Participants had a diagnosis of AF, were aged ≥65 years, CHA2DS2VASC ≥ 2, and had no OAC contraindications. Participants completed a 6-component geriatric assessment that included validated measures of frailty (CHS Frailty Scale), cognitive function (MoCA), social support (MOS), depressive symptoms (PHQ9), vision, and hearing. Type of OAC prescribed was documented in medical records. Results: 86% of participants were prescribed an OAC. These participants were on average aged 75.7 (SD: 7.1) years, 49% were women, two thirds were frail or pre-frail, and 44% received a DOAC. DOAC users were younger, had lower CHA2DS2VASC and HAS-BLED scores, and were less likely to be frail. In Massachusetts, pre-frailty was associated with a significantly lower odds of DOAC vs. VKA use (OR = 0.64, 95%CI 0.45, 0.91). Pre-frailty (OR = 0.33, 95%CI 0.18-0.59) and social isolation (OR = 0.38, 95%CI 0.14-0.99) were associated with lower odds of DOAC receipt in patients aged 75 years or older. Social isolation was associated with higher odds of DOAC use (OR = 2.13, 95%CI 1.05-4.29) in patients aged 65-74 years. Conclusions: Geriatric conditions were common and related to type of OAC prescribed, differentially by age group. Research is needed to evaluate whether a geriatric examination can be used clinically to better inform OAC decision-making in older patients with AF.

Stroke prevention is a cornerstone of atrial fibrillation (AF) treatment. Whereas vitamin K antagonists (VKA) were the sole oral anticoagulant (OAC), direct oral anticoagulants (DOAC) use is increasing. Although aging-specific risk factors, are known to influence OAC outcomes, few studies have

OBJECTIVESOral anticoagulants are the cornerstone of stroke prevention in high‐risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing.DESIGNCross‐sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE‐AF) prospective cohort study.SETTINGMulticenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018.PARTICIPANTSParticipants with AF age 65 years or older, CHA2DS2‐VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65‐74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244).MEASUREMENTSA six‐component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record.RESULTSA total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre‐frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51‐1.09; frail OR = .69; 95% CI = .35‐1.36; social isolation OR = .90; 95% CI = .52‐1.54; depression OR = .79; 95% CI = .49‐1.27; visual impairment OR = .98; 95% CI = .65‐1.48; and hearing impairment OR = 1.05; 95% CI = .71‐1.54).CONCLUSIONGeriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147–154, 2019

Background: Data from previous studies that examined sex differences in the characteristics, clinical presentation, and management of patients with atrial fibrillation (AF) have been inconsistent. Objective: To use data from a large contemporary cohort of older patients with AF to examine sex specific differences in baseline characteristics, symptoms, and management practices. Methods: We used data from baseline interviews and the review of medical records of participants in the Systematic Assessment of Geriatric Elements in AF (SAGE-AF) study. Participants were ≥ 65 years old with AF and a CHA2DS2-VASc≥ 2. Results: Of the 1244 participants, 49% were female. Women on average were slightly older (76.3 (7.4) vs. 74.8 (6.7) years, p<0.01), and less often had a history of coronary heart disease, diabetes, renal disease, dyslipidemia, smoking, or alcohol abuse, in comparison with men. Women reported higher rates of anxiety, depression, and frailty (27% vs. 20%, 34% vs. 23%, and 18% vs. 10%, respectively, p<0.01) when compared with men. Women had higher average CHA2DS2-VASc (4.9 (1.6) vs. 4.0 (1.5), p<0.01) but lower HAS-BLED (2.7 (1.0) vs. 3.0 (1.0), p<0.01) scores compared with men. Women more frequently reported AF-related symptoms of palpitations, irregular heartbeat, pause in heart activity, and dizziness (29% vs. 16%, 22% vs. 15%, 11% vs. 6%, and 25% vs. 19%, respectively, p<0.05) than men. Women were more likely to have paroxysmal AF (54% vs. 65%, p<0.01) than persistent AF (30% vs. 20%, p<0.01) than men. Approximately 85% of study participants received oral anticoagulants (OACs). There were no significant differences in either the rates of prescription of OACs or their classes between men and women. There were no sex differences in the choice of rate or rhythm control treatments by sex. Multivariable adjusted models showed that women were less frequently treated with cardioversion (OR=0.69, 95% CI: 0.54-0.90), pacemaker (OR= 0.73, 95% CI: 0.56-0.96), or an implanted defibrillator (OR= 0.32, 95% CI: 0.21-0.50) compared with men. Conclusion: Women with AF were older, had more psychosocial but less comorbidities, and were more symptomatic than men. While no differences in the receipt of OACs were detected, women continue to be treated more conservatively with lower rates of receipt of interventions than men.

We read with a great interest the article by Dr. Peters [ [1] Peters S. Rare form of basal ballooning without reduction of left ventricular function in takotsubo cardiomyopathy. Int. J. Cardiol. Jan 1, 2016; 202: 514 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ] recently published in the International Journal of Cardiology. In this article, the author presents a rare case of basal ballooning also known as reverse-takotsubo cardiomyopathy which is a variant of takotsubo cardiomyopathy (TCM). It is well known that takotsubo cardiomyopathy is an acute condition which occurs most commonly in patients who have suffered extreme physical/biochemical or psychosocial stress. However, in this correspondence, author did not identify a specific stressful event which could have precipitated this condition in the patient. Rather this patient had a past history of multiple stressful events. Reply to a comment concerning “Rare form of basal ballooning without reduction of left ventricular function in takotsubo cardiomyopathy”International Journal of CardiologyVol. 207PreviewIn my presentation published in the International Journal of Cardiology entitled Rare form of basal ballooning without reduction of left ventricular function in takotsubo cardiomyopathy several episodes of stress-related events were mentioned in the text. Full-Text PDF

Takotsubo cardiomyopathy (TCM) is stress induced cardiac dysfunction which is being increasingly recognized [ [1] Minhas A.S. Hughey A.B. Kolias T.J. Nationwide trends in reported incidence of Takotsubo cardiomyopathy from 2006 to 2012. Am. J. Cardiol. 2015 Oct 1; 116: 1128-1131 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar ] in patients with physical or neuropsychological stress. This cardiomyopathy receives its name from a Japanese word 'takotsubo' which means an "octopus pot" resembling the shape of the left ventricle during systole on imaging studies of the heart. TCM is a transient systolic dysfunction of the apical and/or midsegments of the heart, which mimics myocardial infarction, but in the absence of obstructive coronary artery disease. Its diagnosis should be suspected in postmenopausal women who present with symptoms of acute coronary syndrome (ACS) after intense psychological stress in whom the clinical manifestations and electrocardiogram abnormalities are out of proportion to the degree of elevation in cardiac biomarkers [ 2 Lyon A.R. Bossone E. Schneider B. Sechtem U. Citro R. Underwood S.R. Sheppard M.N. Figtree G.A. Parodi G. Akashi Y.J. Ruschitzka F. Filippatos G. Mebazaa A. Omerovic E. Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. Eur. J. Heart Fail. 2016 Jan; 18: 8-27 Crossref PubMed Scopus (633) Google Scholar , 3 Templin C. Ghadri J.R. Diekmann J. Napp L.C. Bataiosu D.R. Jaguszewski M. Clinical features and outcomes of Takotsubo (Stress) cardiomyopathy. N. Engl. J. Med. 2015 Sep 3; 373: 929-938 Crossref PubMed Scopus (1326) Google Scholar ]. Here, we present a case of TCM occurring in a patient after MRI which is a first reported case of its kind in literature.

We read with much interest the Alliance for Academic Internal Medicine perspective “The New Internal Medicine Fellowship Match Timeline: A Change in the Right Direction,” published in the November 2014 issue of The American Journal of Medicine.1Angus S. Adams M. Willett L.L. et al.The new internal medicine fellowship match timeline: a change in the right direction.Am J Med. 2014; 127: 1132-1136Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In this survey, the Association of Program Directors in Internal Medicine survey committee showed that the changes in the internal medicine fellowship timeline were perceived as beneficial by internal medicine residency program directors for both residency and fellowship programs, as well as for fellowship applicants. According to the program directors, these changes in the timeline give more time to the applicants to help in making informed decisions for the subspecialty of their choice and more time to complete research project(s). It was no surprise that 65% of program directors perceived that these changes in the timeline put unmatched applicants in a position of uncertainty and caused difficulty in planning for their postgraduation plans. This is true especially for applicants on J1 visas (exchange visitors). We know that the employment process is cumbersome and time-consuming for physicians seeking employment on J1 visas, because they must search for employment in a Health Professional Shortage Area and obtain visa waiver approval from their home country, employment sponsoring state, and US Citizenship and Immigration Services.2Available at: http://www.uscis.gov/working-united-states/students-and-exchange-visitors/conrad-30-waiver-program. Accessed March 1, 2015.Google Scholar Some of these states, such as Arizona and Florida, have an application deadline for filing for J1 waiver spots under the Conrad 30 program as early as November of the previous federal year.3Available at: http://www.conrad30.com/application_deadlines.html. Accessed March 1, 2015. Updated application deadlines for all the State can be found on each of the respective state's Department of Health website.Google Scholar We requested data from the Association of American Medical Colleges data warehouse about the Electronic Residency Application Service applicants who applied in internal medicine subspecialties under the J1 visa and those who were US citizens. We found that the number of fellowship applicants on the J1 visa, which was steadily increasing before the change, started to decrease after the change in fellowship timeline. This suggests that these changes are not favorable for J1 visa applicants (Figure 1). The numbers of applicants who were US citizens continued to decrease with the exception of a minimal increase in applicants in 2011 and 2013 (Figure 2).Figure 2Number of US citizen applicants.∗ ∗Please note that some subspecialties did not recruit through the match for the 2012 season because the recruitment cycle changed from 18 months to 12 months, so the Association of American Medical Colleges could not provide us the exact number of the nonmatch applicants for year 2012. The year 2012 is not included because the change resulted in few applications through the match in this year, although the change in application had no effect on the number of fellowship enrollments.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We suggest that the Association of Program Directors in Internal Medicine committee surveys both matched and unmatched fellowship applicants to have firsthand knowledge of the impact of these changes. The New Internal Medicine Fellowship Match Timeline: A Change in the Right DirectionThe American Journal of MedicineVol. 127Issue 11PreviewFor approximately 2 decades, there has been debate and concern regarding the fellowship recruitment process. In 1999, the Alliance for Academic Internal Medicine (AAIM) convened a task force to address these concerns. This task force developed a set of principles aimed at improving the fellowship recruitment process.1 The principles stressed that residents should have adequate exposure to all career options before being required to decide on a single career choice and that delaying the time of application for fellowship would allow residents to make more informed decisions regarding their career choices. Full-Text PDF The ReplyThe American Journal of MedicineVol. 128Issue 11PreviewWe appreciate the letter written in response to our publication1 by Goyal et al highlighting the importance of the fellowship match for many of our Internal Medicine trainees. A change in any process may generate unintended consequences, and we agree that further study of how the move in the fellowship timeline impacts all trainees over time is warranted. Full-Text PDF

Pancreatectomy with autologous islet transplantation has slowly been proving to be an effective way of treating chronic pancreatitis while lessening the effects of the concomitant surgical diabetes of pancreatectomy alone. Assessing patient quality of life and pain after the procedure is particularly important as intractable pain is the main complaint for which patients undergo total pancreatectomy.We used the Rand SF-36 and McGill pain questionnaires, and Visual Analogue Scale to assess patients preoperatively for quality of life and pain resulting from life with chronic pancreatitis. After undergoing total pancreatectomy with autologous islet transplantation (TPAIT), patients were followed with surveys administered at 1 month, 6 months, and 1 year to evaluate changes in their quality of life and pain experienced.Significant improvement was reported in all components of every questionnaire within a year after surgery. Furthermore, patient reported mean scores on quality of life were found to fall within the range of the general population.From our experience with 53 patients at the University of Arizona, after pancreatectomy with autologous islet transplantation patients reported a higher quality of life when compared to preoperative values, as well as reduced levels of pain.

Background: Cognitive impairment (CI) during hospitalization is associated with poor long-term outcomes but little is known about changes in cognitive status soon after discharge. Methods: Adults (n=1,545) without dementia or delirium were interviewed during hospitalization for an Acute Coronary Syndrome (ACS) and at 1-month post-discharge as part of the ongoing Transitions, Risks and Actions in Coronary Events - Center for Cardiovascular Outcomes Research and Education (TRACE-CORE) study. CI was indicated by a score ≤28 on the Telephone Interview of Cognitive Status (TICS; range: 0-41). Patients reported demographic characteristics, anxiety (GAD7), depression (PHQ9), and stress (PSS4). Factors associated with cognitive change categories (consistently impaired, transiently impaired, newly impaired versus not impaired) were examined using adjusted multinomial logistic regression (Table). Results: Participants were 66% male, 83% non-Hispanic white, and aged 62±11 years. Of those with CI during hospitalization (16%; n=245), 53% remediated by 1-month. Among the remaining 1300 patients, with normal cognitive function during hospitalization, 5% (n=67) had developed cognitive impairment by 1-month post discharge. Women had higher odds of becoming newly impaired (Table). Low education, health literacy, and numeracy were associated with persistent, transient, and new impairment. Compared to those who lived with a spouse, patients who lived alone were more likely to be transiently impaired, and those who lived with others were more like to become newly impaired. High stress and low social support were associated with persistent impairment. Conclusions: For many patients with ACS, cognitive status changes during the transition from hospital to home; thus, assessing cognition both in-hospital and post-discharge is important for detecting patients who could benefit from tailored transitional care, because they are at high risk for decline, or early follow-up for booster discharge instructions and secondary prevention, because there is a good chance of their improving.

Purpose: Underlying Metabolic Syndrome (MS) has many different manifestations such as Type 2 Diabetes, hyperlipidemia, obesity or NAFLD, but there is no means of tracking progression of MS in patient populations that may have any or all of these conditions to varying degree. It was our hypothesis that improved risk scoring could be accomplished via an index that considered a composite of MS system components. Methods: The FS index (Fayad/Schentag) of MS considered the following: Fasting Blood Glucose, Fasting Insulin, HBA1c, BMI, AST, Triglycerides, Glucose Supply-Demand (S/D) index, and Proinsulin. Each parameter was mathematically arranged to increase as MS worsened, and weighted approximately equally in the prediction of MS progression and risk for CV events. The FS index was then applied to well-studied patient populations already in our databases, using a neural net model. The database included previously published 45 patients with T2D having AMIs, 45 precisely matched T2D controls without AMIs, 41 patients with RYGB surgery and reversal of MS, 300 patients with COPD and T2D, and 18 patients given Brake therapy for Hepatitis C, NAFLD, or prediabetes. FS index values were calculated from serial laboratory and clinical data over timeframes ranging 2-10 years. In these patient populations, a normal FS index value is 20-50. Patients with two or more manifestations of MS are above 200. Maximum values are above 500, typical when nearly every MS component is abnormal. Results: High FS index values predicted CV risk in this patient population, regardless of the specific components of MS that were abnormal. Abnormal and rising FS index values predicted AMI. When MS is studied as the equal weight of its components using the FS index, it is apparent why clinical strategies treating only one component of MS do not remove all risk of CV events. The index also explains why drug therapies that improve one aspect of MS but worsen others may not mitigate CV risk or remove events. Abnormal FS index values subsequently normalized, indicated resolution of each component of MS syndrome, raising the possibility that specific treatments of MS might halt progression or reverse MS entirely. For example, changes in FS index in patients with RYGB surgery were dramatic, taking scores of these patients from above 250 to values below 20 in most cases. Responses to oral Brake were similar to RYGB, even though Brake treated patients did not lose as much weight. Conclusion: Overall, the FS (Fayad/Schentag) index, which is composed of mostly readily available laboratory and clinical measures, is a promising tool describing progression or amelioration of MS in routine practice.

The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require “all-payer” support.