Public Health

Aulivola, B., Mitchell, E.L., Rowe, V.L., Smeds, M.R., Abramowitz, S., Amankwah, K.S., Chen, H.T., Dittman, J.M., Erben, Y., Humphries, M.D., Lahiri, J.A., Pascarella, L., Quiroga, E., Singh, T.M., Wang, L.J. and Eidt, J.F. (2020). “Ensuring Equity, Diversity and Inclusion in the Society for Vascular Surgery A Report of the Society for Vascular Surgery Task Force on Equity, Diversity and Inclusion.” J Vasc Surg Dec 14;S0741-5214(20)32602-1. [Epub ahead of print].

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Diversity, equity, and inclusion represent interconnected goals meant to ensure that all individuals, regardless of their innate identity characteristics, feel welcomed and valued amongst their peers. Equity is achieved when all individuals have equal access to leadership and career advancement opportunities as well as fair compensation for their work. It is well known that the unique backgrounds and perspectives contributed by a diverse workforce strengthen and improve medical organizations overall. The Society for Vascular Surgery (SVS) is committed to supporting the highest quality leadership, patient care, surgical education, and societal recommendations through promoting diversity, equity, and inclusion within the SVS. The overarching goal of this document is to provide specific context and guidance for enhancing diversity, equity, and inclusion within the SVS as well as setting the tone for conduct and processes beyond the SVS, within other national and regional vascular surgery organizations and practice settings.

Carey, S.A., Afzal, A., Jamil, A., Williams, S. and Gottlieb, R.L. (2020). “Outpatient COVID-19 surveillance testing in orthotopic heart transplant recipients.” Clin Transplant Sep 25;e14105. [Epub ahead of print.]. e14105.

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COVID-19 case fatality rate in the United States is currently reported at 4.8% based on the confirmed cases of COVID-19. However, there are conflicting reports of estimated deaths in the post-cardiac transplantation patient population associated with COVID-19. METHODS: Observational, retrospective analysis of a large cohort of post Orthotopic Heart Transplantation (OHT) patients in a high volume heart transplantation program in Dallas, Texas underwent outpatient COVID-19 screening and testing for both SARS-CoV-2 nasopharyngeal RT-PCR and anti-SARS-CoV2 IgG serology as a result of a clinic protocol to facilitate re-opening of face-to-face outpatient clinical visits. RESULTS: The full outpatient cohort tested at time of their clinic visit tested negative for COVID-19 by nasopharyngeal RT-PCR. Only 2 patients tested seropositive for anti-SARS-COV2 IgG. Five positive inpatient cases were also identified and all, but one recovered. CONCLUSION: A COVID-19 surveillance protocol can be easily instituted in this high-risk population and facilitate safe transplant clinic operation. As the cases and prevalence increase across the United States, further strategies will need to be developed to determine the best course of action to help manage this select population while minimizing their exposure to the ongoing pandemic.

Spinner, C.D., Gottlieb, R.L., Criner, G.J., Arribas López, J.R., Cattelan, A.M., Soriano Viladomiu, A., Ogbuagu, O., Malhotra, P., Mullane, K.M., Castagna, A., Chai, L.Y.A., Roestenberg, M., Tsang, O.T.Y., Bernasconi, E., Le Turnier, P., Chang, S.C., SenGupta, D., Hyland, R.H., Osinusi, A.O., Cao, H., Blair, C., Wang, H., Gaggar, A., Brainard, D.M., McPhail, M.J., Bhagani, S., Ahn, M.Y., Sanyal, A.J., Huhn, G. and Marty, F.M. (2020). “Effect of Remdesivir vs Standard Care on Clinical Status at 11 Days in Patients With Moderate COVID-19: A Randomized Clinical Trial.” Jama 324(11): 1048-1057.

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IMPORTANCE: Remdesivir demonstrated clinical benefit in a placebo-controlled trial in patients with severe coronavirus disease 2019 (COVID-19), but its effect in patients with moderate disease is unknown. OBJECTIVE: To determine the efficacy of 5 or 10 days of remdesivir treatment compared with standard care on clinical status on day 11 after initiation of treatment. DESIGN, SETTING, AND PARTICIPANTS: Randomized, open-label trial of hospitalized patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and moderate COVID-19 pneumonia (pulmonary infiltrates and room-air oxygen saturation >94%) enrolled from March 15 through April 18, 2020, at 105 hospitals in the United States, Europe, and Asia. The date of final follow-up was May 20, 2020. INTERVENTIONS: Patients were randomized in a 1:1:1 ratio to receive a 10-day course of remdesivir (n = 197), a 5-day course of remdesivir (n = 199), or standard care (n = 200). Remdesivir was dosed intravenously at 200 mg on day 1 followed by 100 mg/d. MAIN OUTCOMES AND MEASURES: The primary end point was clinical status on day 11 on a 7-point ordinal scale ranging from death (category 1) to discharged (category 7). Differences between remdesivir treatment groups and standard care were calculated using proportional odds models and expressed as odds ratios. An odds ratio greater than 1 indicates difference in clinical status distribution toward category 7 for the remdesivir group vs the standard care group. RESULTS: Among 596 patients who were randomized, 584 began the study and received remdesivir or continued standard care (median age, 57 [interquartile range, 46-66] years; 227 [39%] women; 56% had cardiovascular disease, 42% hypertension, and 40% diabetes), and 533 (91%) completed the trial. Median length of treatment was 5 days for patients in the 5-day remdesivir group and 6 days for patients in the 10-day remdesivir group. On day 11, patients in the 5-day remdesivir group had statistically significantly higher odds of a better clinical status distribution than those receiving standard care (odds ratio, 1.65; 95% CI, 1.09-2.48; P = .02). The clinical status distribution on day 11 between the 10-day remdesivir and standard care groups was not significantly different (P = .18 by Wilcoxon rank sum test). By day 28, 9 patients had died: 2 (1%) in the 5-day remdesivir group, 3 (2%) in the 10-day remdesivir group, and 4 (2%) in the standard care group. Nausea (10% vs 3%), hypokalemia (6% vs 2%), and headache (5% vs 3%) were more frequent among remdesivir-treated patients compared with standard care. CONCLUSIONS AND RELEVANCE: Among patients with moderate COVID-19, those randomized to a 10-day course of remdesivir did not have a statistically significant difference in clinical status compared with standard care at 11 days after initiation of treatment. Patients randomized to a 5-day course of remdesivir had a statistically significant difference in clinical status compared with standard care, but the difference was of uncertain clinical importance. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04292730.

Shah, S., Castro-Dominguez, Y., Gupta, T., Attaran, R., Byrum, G.V., 3rd, Taleb, A., Pettyjohn, A., Bartel, R.C., Szerlip, M., Henry, T.D., Mahmud, E. and Applegate, R.J. (2020). “Impact of the COVID-19 pandemic on interventional cardiology training in the United States.” Catheter Cardiovasc Interv Aug 7;10.1002/ccd.29198. [Epub ahead of print.].

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OBJECTIVES: We sought to determine the effect of COVID-19 related reduction in elective cardiac procedures and acute coronary syndrome presentations on interventional cardiology (IC) training. BACKGROUND: The COVID-19 pandemic has significantly disrupted healthcare in the United States, including cardiovascular services. The impact of COVID-19 on IC fellow training in the United States has not been assessed. METHODS: The Society for Cardiovascular Angiography and Interventions (SCAI) surveyed IC fellows training in both accredited and advanced non-accredited programs, as well as their program directors (PD). RESULTS: Responses were received from 135 IC fellows and 152 PD. All respondents noted reductions in procedural volumes beginning in March 2020. At that time, only 43% of IC fellows had performed >250 PCI. If restrictions were lifted by May 15, 2020 78% of IC fellows believed they would perform >250 PCI, but fell to only 70% if restrictions persisted until the end of the academic year. 49% of IC fellows felt that their procedural competency was impaired by COVID-19, while 97% of PD believed that IC fellows would be procedurally competent at the end of their training. Most IC fellows (65%) noted increased stress at work and at home, and many felt that job searches and/or existing offers were adversely affected by the pandemic. CONCLUSION: The COVID-19 pandemic has substantially affected IC training in the United States, with many fellows at risk of not satisfying current program procedural requirements. These observations support a move to review current IC program requirements and develop mitigation strategies to supplement gaps in education related to reduced procedural volume.

Nayak, A., Hicks, A.J. and Morris, A.A. (2020). “Understanding the Complexity of Heart Failure Risk and Treatment in Black Patients.” Circ Heart Fail 13(8): e007264.

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Although care of patients with heart failure (HF) has improved in the past decade, important disparities in HF outcomes persist based on race/ethnicity. Age-adjusted HF-related cardiovascular disease death rates are higher for Black patients, particularly among young Black men and women whose rates of death are 2.6- and 2.97-fold higher, respectively, than White men and women. Similarly, the rate of HF hospitalization for Black men and women is nearly 2.5-fold higher when compared with Whites, with costs that are significantly higher in the first year after HF hospitalization. While the relative rate of HF hospitalization has improved for other race/ethnic minorities, the disparity in HF hospitalization between Black and White patients has not decreased during the last decade. Although access to care and socioeconomic status have been traditional explanations for the observed racial disparities in HF outcomes, contemporary data suggest that novel factors including genetic susceptibility as well as social determinants of health and implicit bias may play a larger role in health outcomes than previously appreciated. The purpose of this review is to describe the complex interplay of factors that influence racial disparities in HF incidence, prevalence, and disease severity, with a highlight on evolving knowledge that will impact the clinical care and address future research needs to improve HF disparities in Blacks.