Faculty Bibliography

Mitral regurgitation (MR) has a high prevalence in older patient populations of industrialized nations. Common etiologies are structural, degenerative MR and functional MR secondary to myocardial remodeling. Because of co-morbidities and associated high surgical risk, open surgical mitral repair/replacement is deferred in a significant percentage of patients. For these patients transcatheter repair/replacement are emerging as treatment options. Because of the lack of direct visualization, pre- and intra-procedural imaging is critical for these procedures. In this review, we summarize mitral valve anatomy, trans-catheter mitral valve replacement (TMVR) options, and imaging in the context of TMVR.

BACKGROUND AND AIMS: There are limited data on learning curves and competence in ERCP. By using a standardized data collection tool, we aimed to prospectively define learning curves and measure competence among advanced endoscopy trainees (AETs) by using cumulative sum (CUSUM) analysis. METHODS: AETs were evaluated by attending endoscopists starting with the 26th hands-on ERCP examination and then every ERCP examination during the 12-month training period. A standardized ERCP competency assessment tool (using a 4-point scoring system) was used to grade the examination. CUSUM analysis was applied to produce learning curves for individual technical and cognitive components of ERCP performance (success defined as a score of 1, acceptable and unacceptable failures [p1] of 10% and 20%, respectively). Sensitivity analyses varying p1 and by using a less-stringent definition of success were performed. RESULTS: Five AETs were included with a total of 1049 graded ERCPs (mean +/- SD, 209.8 +/- 91.6/AET). The majority of cases were performed for a biliary indication (80%). The overall and native papilla allowed cannulation times were 3.1 +/- 3.6 and 5.7 +/- 4, respectively. Overall learning curves demonstrated substantial variability for individual technical and cognitive endpoints. Although nearly all AETs achieved competence in overall cannulation, none achieved competence for cannulation in cases with a native papilla. Sensitivity analyses increased the proportion of AETs who achieved competence. CONCLUSION: This study demonstrates that there is substantial variability in ERCP learning curves among AETs. A specific case volume does not ensure competence, especially for native papilla cannulation.

PURPOSE: Correctional settings create unique challenges for patients with special needs, including transgender patients, who have an increased rate of overall discrimination, sexual abuse, healthcare disparities, and improper housing. As part of our correctional health quality improvement process, we sought to review and evaluate the adequacy of care for transgender patients in the New York City jail system. METHODS: Using correctional pharmacy records, transgender patients receiving hormonal treatment were identified. A brief in-person survey was conducted to evaluate their care in the community before incarceration, medical care in jail, and experience in the jail environment. RESULTS: Survey findings and analysis of transgender patient healthcare-related complaints revealed opportunities for improvements in the provision of care and staff understanding of this population. Utilizing these findings, we conducted lesbian, gay, bisexual, and transgender (LGBT) trainings in all 12 jail clinics for medical, nursing, and mental health staff. Three months after LGBT training, patient complaints dropped by over 50%. After the development and implementation of a newly revised transgender healthcare policy, complaints dropped to zero within 6 months. CONCLUSION: Our efforts to assess the quality of care provided to transgender patients revealed significant areas for improvement. Although we have made important gains in providing quality care through the implementation of policies and procedures rooted in community standards and the express wishes of our patients, we continue to engage this patient population to identify other issues that impact their health and well-being in the jail environment.

Transient right bundle branch block following blunt cardiac injury is a known but under-recognized manifestation of cardiac contusion. The first case documented in the medical literature occurred in 1952 in a 22-year-old man who was thrown from a motorcycle. Due to their relatively anterior location, the right ventricle and right bundle branch are at particular risk of injury in contusion. We present here a case in which a 24-year-old man suffered a blunt chest trauma leading to a right bundle branch block and elevated troponin levels, consistent with cardiac contusion. His conduction system abnormalities rapidly resolved and he recovered completely, with no clinical sequelae. <Learning objective: Cardiac contusion is a heterogeneous syndrome with widely variable clinical manifestations and severity. Transient right bundle branch block has been described as a self-limited and benign manifestation of cardiac contusion. This case highlights the need for a better understanding of the natural history and predictors of serious complications of cardiac contusion, which can aid in determining appropriate diagnostic studies, risk stratification, and treatment.>.

Bacterial antimicrobial resistance has been associated with the up regulation of genes encoding efflux pumps and the down regulation of genes encoding outer membrane proteins (OMPs). Gene expression in bacteria is primarily initiated by sigma factors (sigma factors) such as RpoE, which plays an important role in responding to many environmental stresses. Here, we report the first observation that RpoE serves as an antibiotic resistance regulator in Salmonella enteric serovar Typhi (S. Typhi). In this study, we found that the rpoE mutant (DeltarpoE) of S. Typhi GIFU10007 has elevated resistance to several antimicrobial agents, including beta-lactams, quinolones, and aminoglycosides. Genomic DNA microarray analysis was used to investigate the differential gene expression profiles between a wild type and rpoE mutant in response to ampicillin. The results showed that a total of 57 genes displayed differential expression (two-fold increase or decrease) in DeltarpoE versus the wild-type strain. The expressions of two outer membrane protein genes, ompF and ompC, were significantly down-regulated in DeltarpoE (six and seven-fold lower in comparison to wild-type strain) and RamA, a member of the efflux pump AraC/XylS family, was up-regulated about four-fold in the DeltarpoE. Our results suggest RpoE is a potential antimicrobial regulator in S. Typhi, controlling both the down regulation of the OMP genes and up-regulating the efflux system.

Here we report two Enterobacter cloacae ST231 isolates co-producing KPC-3 and NDM-1, causing lethal infections in a tertiary hospital in China. The blaNDM-1-harboring plasmids carry IncA/C2 and IncR replicons, showing a mosaic plasmid structure, and the blaNDM-1 is harbored on a novel class I integron-like element. The blaKPC-3 is located on a Tn3-DeltablaTEM-1-blaKPC-3-DeltaTn1722 element, flanked by two 9-bp direct repeat sequences, and harbored on a novel IncX6 plasmid.

Smoldering multiple myeloma (SMM) is a pre-malignant condition with an inherent risk for progression to multiple myeloma (MM). The 2014 IMWG guidelines define smoldering multiple myeloma as a monoclonal gammopathy disorder with serum monoclonal protein (IgG or IgA) >/=30 g/L or urinary monoclonal protein >/=500 mg per 24 h and/or clonal bone marrow plasma cells 10-60 % without any myeloma-defining events or amyloidosis. The risk for progression of SMM to MM vary based on clinical, laboratory, imaging, and molecular characteristics. Observation, with periodic monitoring is the current standard of care for SMM. Over last few years, research advances in SMM have led to the delineation of newer risk factors for progression and identification of a "high-risk" group that would potentially benefit from early treatment. This review focuses on advances in the SMM risk-stratification model and recent clinical trials in this patient population.