Andra Leah Blomkalns

All Publications

• Assessment of Sensitivity and Specificity of Patient-Collected Lower Nasal Specimens for Sudden Acute Respiratory Syndrome Coronavirus 2 Testing. JAMA network open Altamirano, J., Govindarajan, P., Blomkalns, A. L., Kushner, L. E., Stevens, B. A., Pinsky, B. A., Maldonado, Y. 2020; 3 (6): e2012005

  View details for DOI 10.1001/jamanetworkopen.2020.12005

  View details for PubMedID 32530469

• The AAMC Standardized Video Interview: Lessons Learned From the Residency Selection Process. Academic medicine : journal of the Association of American Medical Colleges Gallahue, F. E., Deiorio, N. M., Blomkalns, A., Bird, S. B., Dunleavy, D., Fraser, R., Overton, B. R. 2020; 95 (11): 1639–42

  Abstract

  Calls to change the residency selection process have increased in recent years, with many focusing on the need for holistic review and alternatives to academic metrics. One aspect of applicant performance to consider in holistic review is proficiency in behavioral competencies. The Association of American Medical Colleges (AAMC) developed the AAMC Standardized Video Interview (SVI), an online, asynchronous video interview that assesses applicants' knowledge of professionalism and their interpersonal and communication skills. The AAMC worked with the emergency medicine community to pilot the SVI. Data from 4 years of research (Electronic Residency Application Service [ERAS] 2017-2020 cycles) show the SVI is a reliable, valid assessment of these behavioral competencies. It provides information not available in the ERAS application packet, and it does not disadvantage individuals or groups. Yet despite the SVI's psychometric properties, the AAMC elected not to renew or expand the pilot in residency selection.In this Invited Commentary, the authors share lessons learned from the AAMC SVI project about introducing a new tool for use in residency selection. They recommend that future projects endeavoring to find ways to support holistic review engage all stakeholders from the start; communicate the value of the new tool early and often; make direct comparisons with existing tools; give new tools time and space to succeed; strike a balance between early adopters and broad participation; help stakeholders understand the limitations of what a tool can do; and set clear expectations about both stakeholder input and pricing. They encourage the medical education community to learn from the SVI project and to consider future partnerships with the AAMC or other specialty organizations to develop new tools and approaches that prioritize the community's needs. Finding solutions to the challenges facing residency selection should be a priority for all stakeholders.

  View details for DOI 10.1097/ACM.0000000000003573

  View details for PubMedID 33112586

• So the Doctor Is Burned Out: What Does It Mean for Patient Care? ACADEMIC EMERGENCY MEDICINE Lu, D. W., Blomkalns, A. L. 2019; 26 (7): 835–36

  View details for DOI 10.1111/acem.13714

  View details for Web of Science ID 000475970700015

• So the doctor is burned out: What does it mean for patient care? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Lu, D. W., Blomkalns, A. L. 2019

  Abstract

  The current state of physician burnout has become an increasingly popular topic of discussion and concern. Depending on how it is defined and measured by researchers, the prevalence of physician burnout ranges anywhere from 0 to 80%.1 Emergency medicine is often cited as the specialty with some of the highest reported levels of physician burnout.2 Regardless of what the "true" prevalence of physician burnout may be, most of these studies suggest the presence of a crisis. The detrimental impact of burnout on physicians is certainly of interest to physicians. What is missing from these discussions is the impact of burnout on patients, their families, and objective clinical outcomes. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30768823

• Making Promotion Count: The Gender Perspective On Behalf of the Society for Academic Emergency Medicine Equity Research Taskforce. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Madsen, T. E., Heron, S. L., Rounds, K., Kass, D., Lall, M., Sethuraman, K. N., Arbelaez, C., Blomkalns, A., Safdar, B. 2019

  Abstract

  Women in academic emergency medicine (EM) experience disparities in both compensation and advancement.1-3 Some hypothesized causes of gender disparities include lack of mentorship and resources,4-5 unequal distribution of opportunity,6-7 sexism8 and implicit bias.9-10 Gender differences in academic rank in EM may also be driven by differences in scholarly productivity, slower ascent to leadership among women, attrition from academic medicine, and potentially a lack of adequate support for faculty that have family obligations competing with work,4 though these factors are largely speculative. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30628138

• Computed tomographic quantification of periaortic adipose tissue volume as a correlate of cardiovascular disease. Cardiology journal Robbins, N., Hooker, E. A., Hart, K. W., Kapur, S., Blomkalns, A. 2019; 26 (6): 802–4

  View details for DOI 10.5603/CJ.2019.0119

  View details for PubMedID 31970740

• Research Priorities for Physician Wellness in Academic Emergency Medicine: Consensus from the Society of Academic Emergency Medicine Wellness Committee. AEM education and training Chung, A. S., Wong, M. L., Sanchez, L. D., Lu, D. W., Manfredi, R. A., Mishkin, H., Heron, S., Blomkalns, A. L. 2018; 2 (Suppl Suppl 1): S40–S47

  Abstract

  Background: Physicians and trainees in academic health care settings face unique challenges to maintaining and enhancing their well-being compared to their community practice counterparts.Objective: Our objective was to develop a research agenda focused on well-being, resilience, and career longevity issues specific to practicing emergency medicine in an academic setting.Methods: We convened an expert group of academic emergency physicians prior to the 2018 annual meeting of the Society for Academic Emergency Medicine to determine a set of uniformly accepted research priorities in the field by consensus.Results: Three themes emerged as components of a comprehensive research agenda: 1) origins and natural history of burnout, resilience, well-being and other related concepts; 2) influence of early training and the learning environment; and 3) impact of burnout, attrition, and lack of organizational or system support for wellness on operations.Conclusion: We believe that this agenda will inform future research and effective interventions to support physician and trainee well-being.

  View details for PubMedID 30607378

• Echocardiographic assessment of insulin-like growth factor binding protein-7 and early identification of acute heart failure. ESC heart failure Kalayci, A., Peacock, W. F., Nagurney, J. T., Hollander, J. E., Levy, P. D., Singer, A. J., Shapiro, N. I., Cheng, R. K., Cannon, C. M., Blomkalns, A. L., Walters, E. L., Christenson, R. H., Chen-Tournoux, A., Nowak, R. M., Lurie, M. D., Pang, P. S., Kastner, P., Masson, S., Gibson, C. M., Gaggin, H. K., Januzzi, J. L. 2020

  Abstract

  AIMS: Concentrations of insulin-like growth factor binding protein-7 (IGFBP7) have been linked to abnormal cardiac structure and function in patients with chronic heart failure (HF), but cardiovascular correlates of the biomarker in patients with more acute presentations are lacking. We aimed to determine the relationship between IGFBP7 concentrations and cardiac structure and to evaluate the impact of IGFBP7 on the diagnosis of acute HF among patients with acute dyspnoea.METHODS AND RESULTS: In this pre-specified subgroup analysis of the International Collaborative of N-terminal pro-B-type Natriuretic Peptide Re-evaluation of Acute Diagnostic Cut-Offs in the Emergency Department (ICON-RELOADED) study, we included 271 patients with and without acute HF. All patients presented to an emergency department with acute dyspnoea, had blood samples for IGFBP7 measurement, and detailed echocardiographic evaluation. Higher IGFBP7 concentrations were associated with numerous cardiac abnormalities, including increased left atrial volume index (LAVi; r=0.49, P<0.001), lower left ventricular ejection fraction (r=-0.27, P<0.001), lower right ventricular fractional area change (r=-0.31, P<0.001), and higher tissue Doppler E/e' ratio (r=0.44, P<0.001). In multivariable linear regression analyses, increased LAVi (P=0.01), lower estimated glomerular filtration rate (P=0.008), higher body mass index (P=0.001), diabetes (P=0.009), and higher concentrations of amino-terminal pro-B-type natriuretic peptide (NT-proBNP, P=0.02) were independently associated with higher IGFBP7 concentrations regardless of other variables. Furthermore, IGFBP7 (odds ratio=12.08, 95% confidence interval 2.42-60.15, P=0.02) was found to be independently associated with the diagnosis of acute HF in the multivariable logistic regression analysis.CONCLUSIONS: Among acute dyspnoeic patients with and without acute HF, increased IGFBP7 concentrations are associated with a range of cardiac structure and function abnormalities. Independent association with increased LAVi suggests elevated left ventricular filling pressure is an important trigger for IGFBP7 expression and release. IGFBP7 may enhance the diagnosis of acute HF.

  View details for DOI 10.1002/ehf2.12722

  View details for PubMedID 32406612

• Characteristics of Emergency Department Patients With COVID-19 at a Single Site in Northern California: Clinical Observations and Public Health Implications. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Duanmu, Y., Brown, I. P., Gibb, W. R., Singh, J., Matheson, L. W., Blomkalns, A. L., Govindarajan, P. 2020

  Abstract

  In December 2019, a novel coronavirus disease (COVID-19) emerged in Wuhan, China and spread globally, resulting in the first World Health Organization (WHO) classified pandemic in over a decade.1 As of April 2020, the United States (US) has the most confirmed COVID-19 cases worldwide, but public health interventions and testing availability have varied across the country. 2.

  View details for DOI 10.1111/acem.14003

  View details for PubMedID 32344458

• Innovation in Residency Selection: The AAMC Standardized Video Interview ACADEMIC MEDICINE Bird, S. B., Hern, H., Blomkalns, A., Deiorio, N. M., Haywood, Y., Hiller, K. M., Dunleavy, D., Dowd, K. 2019; 94 (10): 1489–97

  View details for DOI 10.1097/ACM.0000000000002705

  View details for Web of Science ID 000509244700024

• Innovation in Residency Selection: The AAMC Standardized Video Interview. Academic medicine : journal of the Association of American Medical Colleges Bird, S. B., Hern, H. G., Blomkalns, A., Deiorio, N. M., Haywood, Y., Hiller, K. M., Dunleavy, D., Dowd, K. 2019

  Abstract

  PURPOSE: Innovative tools are needed to help shift residency selection toward a more holistic process that balances academic achievement with other knowledge and skills important for success in residency. The authors evaluated the feasibility of the AAMC Standardized Video Interview (SVI) and evidence of the validity of SVI total scores.METHOD: The SVI, developed by the Association of American Medical Colleges, consists of six questions designed to assess applicants' interpersonal and communication skills and knowledge of professionalism. Study 1 was conducted in 2016 for research purposes. Study 2 was an operational pilot administration in 2017; SVI data were available for residency selection use by emergency medicine residency programs for the 2018 application cycle. Descriptive statistics, correlations, and standardized mean differences were used to examine data.RESULTS: Study 1 included 855 applicants; Study 2 included 3,532 applicants. SVI total scores were relatively normally distributed. There were small correlations between SVI total scores and United States Medical Licensing Examination Step exam scores, Alpha Omega Alpha Honor Medical Society membership, and Gold Humanism Honor Society membership. There were no-to-small group differences in SVI total scores by gender and race/ethnicity, and small-to-medium differences by applicant type.CONCLUSIONS: Findings provide initial evidence of the validity of SVI total scores and suggest these scores provide different information than academic metrics. Use of the SVI, as part of a holistic screening process, may help program directors widen the pool of applicants invited to in-person interviews and may signal that programs value interpersonal and communication skills and professionalism.

  View details for PubMedID 30870151

• Making Promotion Count: The Gender Perspective ACADEMIC EMERGENCY MEDICINE Madsen, T. E., Heron, S. L., Rounds, K., Kass, D., Lall, M., Sethuraman, K. N., Arbelaez, C., Blomkalns, A., Safdar, B., Soc Acad Emergency Med Equity Res 2019; 26 (3): 335–38

  View details for DOI 10.1111/acem.13680

  View details for Web of Science ID 000461220000009

• Beyond Test Scores and Medical Knowledge: The Standardized Video Interview, an Innovative and Ethical Approach for Holistic Assessment of Applicants. Academic medicine : journal of the Association of American Medical Colleges Bird, S. B., Blomkalns, A., Deiorio, N. M., Gallahue, F. E. 2018; 93 (2): 151

  View details for PubMedID 29377856

• Role of myeloperoxidase in abdominal aortic aneurysm formation: mitigation by taurine. American journal of physiology. Heart and circulatory physiology Kim, H. W., Blomkalns, A. L., Ogbi, M., Thomas, M., Gavrila, D., Neltner, B. S., Cassis, L. A., Thompson, R. W., Weiss, R. M., Lindower, P. D., Blanco, V. M., McCormick, M. L., Daugherty, A., Fu, X., Hazen, S. L., Stansfield, B. K., Huo, Y., Fulton, D. J., Chatterjee, T., Weintraub, N. L. 2017; 313 (6): H1168–H1179

  Abstract

  Oxidative stress plays a fundamental role in abdominal aortic aneurysm (AAA) formation. Activated polymorphonuclear leukocytes (or neutrophils) are associated with AAA and express myeloperoxidase (MPO), which promotes inflammation, matrix degradation, and other pathological features of AAA, including enhanced oxidative stress through generation of reactive oxygen species. Both plasma and aortic MPO levels are elevated in patients with AAA, but the role of MPO in AAA pathogenesis has, heretofore, never been investigated. Here, we show that MPO gene deletion attenuates AAA formation in two animal models: ANG II infusion in apolipoprotein E-deficient mice and elastase perfusion in C57BL/6 mice. Oral administration of taurine [1% or 4% (wt/vol) in drinking water], an amino acid known to react rapidly with MPO-generated oxidants like hypochlorous acid, also prevented AAA formation in the ANG II and elastase models as well as the CaCl2 application model of AAA formation while reducing aortic peroxidase activity and aortic protein-bound dityrosine levels, an oxidative cross link formed by MPO. Both MPO gene deletion and taurine supplementation blunted aortic macrophage accumulation, elastin fragmentation, and matrix metalloproteinase activation, key features of AAA pathogenesis. Moreover, MPO gene deletion and taurine administration significantly attenuated the induction of serum amyloid A, which promotes ANG II-induced AAAs. These data implicate MPO in AAA pathogenesis and suggest that studies exploring whether taurine can serve as a potential therapeutic for the prevention or treatment of AAA in patients merit consideration.NEW & NOTEWORTHY Neutrophils are abundant in abdominal aortic aneurysm (AAA), and myeloperoxidase (MPO), prominently expressed in neutrophils, is associated with AAA in humans. This study demonstrates that MPO gene deletion or supplementation with the natural product taurine, which can scavenge MPO-generated oxidants, can prevent AAA formation, suggesting an attractive potential therapeutic strategy for AAA.

  View details for DOI 10.1152/ajpheart.00296.2017

  View details for PubMedID 28971841

  View details for PubMedCentralID PMC5814655

• Red Blood Cell Dysfunction Induced by High-Fat Diet: Potential Implications for Obesity-Related Atherosclerosis. Circulation Unruh, D., Srinivasan, R., Benson, T., Haigh, S., Coyle, D., Batra, N., Keil, R., Sturm, R., Blanco, V., Palascak, M., Franco, R. S., Tong, W., Chatterjee, T., Hui, D. Y., Davidson, W. S., Aronow, B. J., Kalfa, T., Manka, D., Peairs, A., Blomkalns, A., Fulton, D. J., Brittain, J. E., Weintraub, N. L., Bogdanov, V. Y. 2015; 132 (20): 1898–1908

  Abstract

  High-fat diet (HFD) promotes endothelial dysfunction and proinflammatory monocyte activation, which contribute to atherosclerosis in obesity. We investigated whether HFD also induces the dysfunction of red blood cells (RBCs), which serve as a reservoir for chemokines via binding to Duffy antigen receptor for chemokines (DARC).A 60% HFD for 12 weeks, which produced only minor changes in lipid profile in C57/BL6 mice, markedly augmented the levels of monocyte chemoattractant protein-1 bound to RBCs, which in turn stimulated macrophage migration through an endothelial monolayer. Levels of RBC-bound KC were also increased by HFD. These effects of HFD were abolished in DARC(-/-) mice. In RBCs from HFD-fed wild-type and DARC(-/-) mice, levels of membrane cholesterol and phosphatidylserine externalization were increased, fostering RBC-macrophage inflammatory interactions and promoting macrophage phagocytosis in vitro. When labeled ex vivo and injected into wild-type mice, RBCs from HFD-fed mice exhibited ≈3-fold increase in splenic uptake. Finally, RBCs from HFD-fed mice induced increased macrophage adhesion to the endothelium when they were incubated with isolated aortic segments, indicating endothelial activation.RBC dysfunction, analogous to endothelial dysfunction, occurs early during diet-induced obesity and may serve as a mediator of atherosclerosis. These findings may have implications for the pathogenesis of atherosclerosis in obesity, a worldwide epidemic.

  View details for PubMedID 26467254

• Unstable Angina and Non ST-Segment Elevation ACS Scientific American Emergency Medicine edited by Brown, D. 2015
• Localization, identification, and excision of murine adipose depots. Journal of visualized experiments : JoVE Mann, A., Thompson, A., Robbins, N., Blomkalns, A. L. 2014

  Abstract

  Obesity has increased dramatically in the last few decades and affects over one third of the adult US population. The economic effect of obesity in 2005 reached a staggering sum of $190.2 billion in direct medical costs alone. Obesity is a major risk factor for a wide host of diseases. Historically, little was known regarding adipose and its major and essential functions in the body. Brown and white adipose are the two main types of adipose but current literature has identified a new type of fat called brite or beige adipose. Research has shown that adipose depots have specific metabolic profiles and certain depots allow for a propensity for obesity and other related disorders. The goal of this protocol is to provide researchers the capacity to identify and excise adipose depots that will allow for the analysis of different factorial effects on adipose; as well as the beneficial or detrimental role adipose plays in disease and overall health. Isolation and excision of adipose depots allows investigators to look at gross morphological changes as well as histological changes. The adipose isolated can also be used for molecular studies to evaluate transcriptional and translational change or for in vitro experimentation to discover targets of interest and mechanisms of action. This technique is superior to other published techniques due to the design allowing for isolation of multiple depots with simplicity and minimal contamination.

  View details for DOI 10.3791/52174

  View details for PubMedID 25549006

  View details for PubMedCentralID PMC4396874

• Isolation and excision of murine aorta; a versatile technique in the study of cardiovascular disease. Journal of visualized experiments : JoVE Robbins, N., Thompson, A., Mann, A., Blomkalns, A. L. 2014: e52172

  Abstract

  Cardiovascular disease is a broad term describing disease of the heart and/or blood vessels. The main blood vessel supplying the body with oxygenated blood is the aorta. The aorta may become affected in diseases such as atherosclerosis and aneurysm. Researchers investigating these diseases would benefit from direct observation of the aorta to characterize disease progression as well as to evaluate efficacy of potential therapeutics. The goal of this protocol is to describe proper isolation and excision of the aorta to aid investigators researching cardiovascular disease. Isolation and excision of the aorta allows investigators to look at gross morphometric changes as wells as allowing them to preserve and stain the tissue to look at histologic changes if desired. The aorta may be used for molecular studies to evaluate protein and gene expression to discover targets of interest and mechanisms of action. This technique is superior to imaging modalities as they have inherent limitations in technology and cost. Additionally, primary isolated cells from a freshly isolated and excised aorta can allowing researchers to perform further in situ and in vitro assays. The isolation and excision of the aorta has the limitation of having to sacrifice the animal however, in this case the benefits outweigh the harm as it is the most versatile technique in the study of aortic disease.

  View details for DOI 10.3791/52172

  View details for PubMedID 25490214

  View details for PubMedCentralID PMC4354289

• Transplanted perivascular adipose tissue accelerates injury-induced neointimal hyperplasia: role of monocyte chemoattractant protein-1. Arteriosclerosis, thrombosis, and vascular biology Manka, D., Chatterjee, T. K., Stoll, L. L., Basford, J. E., Konaniah, E. S., Srinivasan, R., Bogdanov, V. Y., Tang, Y., Blomkalns, A. L., Hui, D. Y., Weintraub, N. L. 2014; 34 (8): 1723–30

  Abstract

  Perivascular adipose tissue (PVAT) expands during obesity, is highly inflamed, and correlates with coronary plaque burden and increased cardiovascular risk. We tested the hypothesis that PVAT contributes to the vascular response to wire injury and investigated the underlying mechanisms.We transplanted thoracic aortic PVAT from donor mice fed a high-fat diet to the carotid arteries of recipient high-fat diet-fed low-density lipoprotein receptor knockout mice. Two weeks after transplantation, wire injury was performed, and animals were euthanized 2 weeks later. Immunohistochemistry was performed to quantify adventitial macrophage infiltration and neovascularization and neointimal lesion composition and size. Transplanted PVAT accelerated neointimal hyperplasia, adventitial macrophage infiltration, and adventitial angiogenesis. The majority of neointimal cells in PVAT-transplanted animals expressed α-smooth muscle actin, consistent with smooth muscle phenotype. Deletion of monocyte chemoattractant protein-1 in PVAT substantially attenuated the effects of fat transplantation on neointimal hyperplasia and adventitial angiogenesis, but not adventitial macrophage infiltration. Conditioned medium from perivascular adipocytes induced potent monocyte chemotaxis in vitro and angiogenic responses in cultured endothelial cells.These findings indicate that PVAT contributes to the vascular response to wire injury, in part through monocyte chemoattractant protein-1-dependent mechanisms.

  View details for DOI 10.1161/ATVBAHA.114.303983

  View details for PubMedID 24947528

  View details for PubMedCentralID PMC4103955

• HDAC9 knockout mice are protected from adipose tissue dysfunction and systemic metabolic disease during high-fat feeding. Diabetes Chatterjee, T. K., Basford, J. E., Knoll, E., Tong, W. S., Blanco, V., Blomkalns, A. L., Rudich, S., Lentsch, A. B., Hui, D. Y., Weintraub, N. L. 2014; 63 (1): 176–87

  Abstract

  During chronic caloric excess, adipose tissue expands primarily by enlargement of individual adipocytes, which become stressed with lipid overloading, thereby contributing to obesity-related disease. Although adipose tissue contains numerous preadipocytes, differentiation into functionally competent adipocytes is insufficient to accommodate the chronic caloric excess and prevent adipocyte overloading. We report for the first time that a chronic high-fat diet (HFD) impairs adipogenic differentiation, leading to accumulation of inefficiently differentiated adipocytes with blunted expression of adipogenic differentiation-specific genes. Preadipocytes from these mice likewise exhibit impaired adipogenic differentiation, and this phenotype persists during in vitro cell culture. HFD-induced impaired adipogenic differentiation is associated with elevated expression of histone deacetylase 9 (HDAC9), an endogenous negative regulator of adipogenic differentiation. Genetic ablation of HDAC9 improves adipogenic differentiation and systemic metabolic state during an HFD, resulting in diminished weight gain, improved glucose tolerance and insulin sensitivity, and reduced hepatosteatosis. Moreover, compared with wild-type mice, HDAC9 knockout mice exhibit upregulated expression of beige adipocyte marker genes, particularly during an HFD, in association with increased energy expenditure and adaptive thermogenesis. These results suggest that targeting HDAC9 may be an effective strategy for combating obesity-related metabolic disease.

  View details for DOI 10.2337/db13-1148

  View details for PubMedID 24101673

  View details for PubMedCentralID PMC3868044

• CD14 directs adventitial macrophage precursor recruitment: role in early abdominal aortic aneurysm formation. Journal of the American Heart Association Blomkalns, A. L., Gavrila, D., Thomas, M., Neltner, B. S., Blanco, V. M., Benjamin, S. B., McCormick, M. L., Stoll, L. L., Denning, G. M., Collins, S. P., Qin, Z., Daugherty, A., Cassis, L. A., Thompson, R. W., Weiss, R. M., Lindower, P. D., Pinney, S. M., Chatterjee, T., Weintraub, N. L. 2013; 2 (2): e000065

  Abstract

  Recruitment of macrophage precursors to the adventitia plays a key role in the pathogenesis of abdominal aortic aneurysms (AAAs), but molecular mechanisms remain undefined. The innate immune signaling molecule CD14 was reported to be upregulated in adventitial macrophages in a murine model of AAA and in monocytes cocultured with aortic adventitial fibroblasts (AoAf) in vitro, concurrent with increased interleukin-6 (IL-6) expression. We hypothesized that CD14 plays a crucial role in adventitial macrophage precursor recruitment early during AAA formation.CD14(-/-) mice were resistant to AAA formation induced by 2 different AAA induction models: aortic elastase infusion and systemic angiotensin II (AngII) infusion. CD14 gene deletion led to reduced aortic macrophage infiltration and diminished elastin degradation. Adventitial monocyte binding to AngII-infused aorta in vitro was dependent on CD14, and incubation of human acute monocytic leukemia cell line-1 (THP-1) monocytes with IL-6 or conditioned medium from perivascular adipose tissue (PVAT) upregulated CD14 expression. Conditioned medium from AoAf and PVAT induced CD14-dependent monocyte chemotaxis, which was potentiated by IL-6. CD14 expression in aorta and plasma CD14 levels were increased in AAA patients compared with controls.These findings link CD14 innate immune signaling via a novel IL-6 amplification loop to adventitial macrophage precursor recruitment in the pathogenesis of AAA.

  View details for DOI 10.1161/JAHA.112.000065

  View details for PubMedID 23537804

  View details for PubMedCentralID PMC3647288

• Human coronary artery perivascular adipocytes overexpress genes responsible for regulating vascular morphology, inflammation, and hemostasis. Physiological genomics Chatterjee, T. K., Aronow, B. J., Tong, W. S., Manka, D., Tang, Y., Bogdanov, V. Y., Unruh, D., Blomkalns, A. L., Piegore, M. G., Weintraub, D. S., Rudich, S. M., Kuhel, D. G., Hui, D. Y., Weintraub, N. L. 2013; 45 (16): 697–709

  Abstract

  Inflammatory cross talk between perivascular adipose tissue and the blood vessel wall has been proposed to contribute to the pathogenesis of atherosclerosis. We previously reported that human perivascular (PV) adipocytes exhibit a proinflammatory phenotype and less adipogenic differentiation than do subcutaneous (SQ) adipocytes. To gain a global view of the genomic basis of biologic differences between PV and SQ adipocytes, we performed genome-wide expression analyses to identify differentially expressed genes between adipocytes derived from human SQ vs. PV adipose tissues. Although >90% of well-expressed genes were similarly regulated, we identified a signature of 307 differentially expressed genes that were highly enriched for functions associated with the regulation of angiogenesis, vascular morphology, inflammation, and blood clotting. Of the 156 PV upregulated genes, 59 associate with angiogenesis, vascular biology, or inflammation, noteworthy of which include TNFRSF11B (osteoprotegerin), PLAT, TGFB1, THBS2, HIF1A, GATA6, and SERPINE1. Of 166 PV downregulated genes, 21 associated with vascular biology and inflammation, including ANGPT1, ANGPTL1, and VEGFC. Consistent with the emergent hypothesis that PV adipocytes differentially regulate angiogenesis and inflammation, cell culture-derived adipocyte-conditioned media from PV adipocytes strongly enhanced endothelial cell tubulogenesis and monocyte migration compared with media from SQ adipocytes. These findings demonstrate that PV adipocytes have the potential to significantly modulate vascular inflammatory crosstalk in the setting of atherosclerosis by their ability to signal to both endothelial and inflammatory cells.

  View details for DOI 10.1152/physiolgenomics.00042.2013

  View details for PubMedID 23737535

  View details for PubMedCentralID PMC3742916

• Cardiac Imaging and Stress Testing, 2e Emergency Medicine Executive edited by Adams, J. 2012
• Low level bacterial endotoxin activates two distinct signaling pathways in human peripheral blood mononuclear cells. Journal of inflammation (London, England) Blomkalns, A. L., Stoll, L. L., Shaheen, W., Romig-Martin, S. A., Dickson, E. W., Weintraub, N. L., Denning, G. M. 2011; 8: 4

  Abstract

  Bacterial endotoxin, long recognized as a potent pro-inflammatory mediator in acute infectious processes, has more recently been identified as a risk factor for atherosclerosis and other cardiovascular diseases. When endotoxin enters the bloodstream, one of the first cells activated is the circulating monocyte, which exhibits a wide range of pro-inflammatory responses.We studied the effect of low doses of E. coli LPS on IL-8 release and superoxide formation by freshly isolated human peripheral blood mononuclear cells (PBMC).IL-8 release was consistently detectable at 10 pg/ml of endotoxin, reaching a maximum at 1 ng/ml, and was exclusively produced by monocytes; the lymphocytes neither produced IL-8, nor affected monocyte IL-8 release. Superoxide production was detectable at 30 pg/ml of endotoxin, reaching a maximum at 3 ng/ml. Peak respiratory burst activity was seen at 15-20 min, and superoxide levels returned to baseline by 1 h. IL-8 release was dependent on both membrane-associated CD14 (mCD14) and Toll-like receptor 4 (TLR4. Superoxide production was dependent on the presence of LBP, but was not significantly affected by a blocking antibody to TLR4. Moreover, treatment with lovastatin inhibited LPS-dependent IL-8 release and superoxide production.These findings suggest that IL-8 release and the respiratory burst are regulated by distinct endotoxin-dependent signaling pathways in PBMC in low level of endotoxin exposure. Selectively modulating these pathways could lead to new approaches to treat chronic inflammatory diseases, such as atherosclerosis, while preserving the capacity of monocytes to respond to acute bacterial infections.

  View details for DOI 10.1186/1476-9255-8-4

  View details for PubMedID 21352551

  View details for PubMedCentralID PMC3056742

• Obesity Challenging and Emerging Conditions in Emergency Medicine edited by Venkat, A. 2011
• The time dependence of antithrombin initiation in patients with non-ST-segment elevation acute coronary syndromes: subgroup analysis from the ACUITY trial. Annals of emergency medicine Diercks, D. B., Pollack, C. V., Hollander, J. E., Blomkalns, A. L., Emerman, C. L., Rokos, I. C., Larson, D. M., Hoekstra, J. W., Mehran, R., Stone, G. W. 2011; 57 (3): 204–12.e1–6

  Abstract

  Antithrombins are among standard treatment agents for patients with non-ST-segment elevation acute coronary syndromes. We aimed to determine the association between time from emergency department (ED) presentation to treatment with an antithrombin and adverse cardiac events.The study cohort was a subgroup of the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial, enrolled from March 1, 2005, to December 5, 2005. The ACUITY trial enrolled patients with moderate- and high-risk non-ST-segment elevation acute coronary syndromes and who were undergoing an early invasive strategy (<72 hours from randomization). All patients received an antithrombin (unfractionated heparin, low-molecular-weight heparin, or bivalirudin), in addition to other agents. A formal ED case report form was introduced in March 2005. Time from presentation to antithrombin initiation was evaluated as a continuous variable in hours. The endpoints were defined as major ischemic events (death, myocardial infarction, unplanned revascularization) or major bleeding within 30 days, or inhospital major bleeding. Logistic regression was used to adjust for demographics, severity of disease, comorbidities, and treatment differences.Of the 2,722 patients enrolled with an ED case report form, complete time data were available in 2,632 (96%). Median time to antithrombin administration was 4.87 hours (interquartile range 2.67 to 9.83). After multivariable analysis, there was no association of major ischemic events with log time (hours) to antithrombin treatment (adjusted odds ratio [OR] 0.99; 95% confidence interval [CI] 0.97 to 1.01). There was an increase in major bleeding at 30 days and inhospital major bleeding complications with longer log time (hours) to antithrombin initiation (adjusted OR 1.44, 95% CI 1.15 to 1.80; OR 1.43, 95% CI 1.13 to 1.83, respectively).In this study of patients with non-ST-segment elevation acute coronary syndromes who were undergoing an early invasive management strategy, we were unable to demonstrate an association between adverse ischemic outcomes with the timing of antithrombin administration. However, there was an increase in bleeding outcomes as time to antithrombin administration increased.

  View details for DOI 10.1016/j.annemergmed.2010.06.567

  View details for PubMedID 20952100

• Turning ACS outside in: linking perivascular adipose tissue to acute coronary syndromes AMERICAN JOURNAL OF PHYSIOLOGY-HEART AND CIRCULATORY PHYSIOLOGY Blomkalns, A. L., Chatterjee, T., Weintraub, N. L. 2010; 298 (3): H734–H735

  View details for DOI 10.1152/ajpheart.00058.2010

  View details for Web of Science ID 000274931500002

  View details for PubMedID 20097767

• Gender differences in time to presentation for myocardial infarction before and after a national women's cardiovascular awareness campaign: a temporal analysis from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation (CRUSADE) and the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network-Get with the Guidelines (NCDR ACTION Registry-GWTG). American heart journal Diercks, D. B., Owen, K. P., Kontos, M. C., Blomkalns, A., Chen, A. Y., Miller, C., Wiviott, S., Peterson, E. D. 2010; 160 (1): 80–87.e3

  Abstract

  In 2001-2002, the American Heart Association and National Heart, Lung, and Blood Institute initiated national campaigns with the aim of increasing women's awareness of their risk of heart disease, with particular focus on women aged 40 to 60 years. Our aim is to determine if these women's awareness campaigns were associated with a reduction in the time to hospital presentation for myocardial infarction in women.The study population comprised patients who presented with a non-ST-segment elevation myocardial infarction in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines Registry and the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network-Get with the Guidelines registry. Analysis was done based on the introduction of the educational intervention: preintervention 2002-2003, intermediate 2004-2005, and post 2006-2007.Of 125,161 patients, 50,162 (40.1%) are women. The median time from symptom onset to presentation was significantly longer in women than men: 3 hours (interquartile range 1.4-7.6) versus 2.8 hours (interquartile range 1.3-7.2, P < .0001), a difference that remained significant after adjusting for clinical characteristics. There was no measurable reduction in the time from symptom onset to presentation over the period of the awareness campaigns: post- versus preintervention period (-0.18%, 95% CI -3.02% to 2.74%). After adjustment for covariates, women aged 40 to 60 years had a 3.46% longer time to presentation than men (95% CI 1.06-5.92, P = .005).There was no reduction in time from symptom onset to hospital presentation for myocardial infarction patients since national awareness campaigns in women were initiated, and a significant gender gap remains.

  View details for DOI 10.1016/j.ahj.2010.04.017

  View details for PubMedID 20598976

• The association between money and opinion in academic emergency medicine. The western journal of emergency medicine Birkhahn, R. H., Blomkalns, A., Klausner, H., Nowak, R., Raja, A. S., Summers, R., Weber, J. E., Briggs, W. M., Arkun, A., Diercks, D. 2010; 11 (2): 126–32

  Abstract

  Financial conflicts of interest have come under increasing scrutiny in medicine, but their impact has not been quantified. Our objective was to use the results of a national survey of academic emergency medicine (EM) faculty to determine if an association between money and personal opinion exists.We conducted a web-based survey of EM faculty. Opinion questions were analyzed with regard to whether the respondent had either 1) received research grant money or 2) received money from industry as a speaker, consultant, or advisor. Responses were unweighted, and tests of differences in proportions were made using Chi-squared tests, with p<0.05 set for significance.We received responses from 430 members; 98 (23%) received research grants from industry, while 145 (34%) reported fee-for-service money. Respondents with research money were more likely to be comfortable accepting gifts (40% vs. 29%) and acting as paid consultants (50% vs. 37%). They had a more favorable attitude with regard to societal interactions with industry and felt that industry-sponsored lectures could be fair and unbiased (52% vs. 29%). Faculty with fee-for-service money mirrored those with research money. They were also more likely to believe that industry-sponsored research produces fair and unbiased results (61% vs. 45%) and less likely to believe that honoraria biased speakers (49% vs. 69%).Accepting money for either service or research identified a distinct population defined by their opinions. Faculty engaged in industry-sponsored research benefitted socially (collaborations), academically (publications), and financially from the relationship.

  View details for PubMedID 20823958

  View details for PubMedCentralID PMC2908643

• The usage patterns of cardiac bedside markers employing point-of-care testing for troponin in non-ST-segment elevation acute coronary syndrome: results from CRUSADE. Clinical cardiology Takakuwa, K. M., Ou, F. S., Peterson, E. D., Pollack, C. V., Peacock, W. F., Hoekstra, J. W., Ohman, E. M., Gibler, W. B., Blomkalns, A. L., Roe, M. T. 2009; 32 (9): 498–505

  Abstract

  Point-of-care (POC) testing may expedite the care of emergency department (ED) patients suspected of having acute coronary syndromes (ACS). We evaluated the use patterns of cardiac bedside markers or POC testing for troponin in patients with non-ST-segment elevation (NSTE) ACS.NSTE ACS data were collected from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines (CRUSADE) registry. We compared hospital and patient characteristics, in-hospital events, and process-of-care variables between hospitals to those that did not use POC testing in > or = 50% of enrolled patients. We examined characteristics, in-hospital events, and process-of-care differences between patients with negative vs positive troponin POC testing results.Of 568 hospitals, 74 (16,276 patients) had high POC usage compared with 197 hospitals (50,782 patients) with no troponin POC usage. From the high POC usage hospitals, 12,604 patients had recorded troponin POC test results. Hospitals with high POC usage had a shorter ED length of stay and were less likely to administer aspirin, beta-blockers, and heparin during the first 24 hours of care. Patients with positive troponin POC results were more often older, minority, female, Medicare-insured, diabetic, and renally impaired. They had fewer electrocardiograms within 10 minutes but were more likely to get aspirin, beta-blockers, glycoprotein IIb/IIIa inhibitors, and heparin within 24 hours of arrival. They also had longer ED lengths of stay, received fewer in-hospital and interventional procedures, and had more adverse clinical events.Differences existed in how hospitals used POC testing and the care given based on those results. Positive POC results are associated with expedited and higher use of anti-ischemic therapies.

  View details for DOI 10.1002/clc.20626

  View details for PubMedID 19743496

• Serial venous point-of-care lactate measurements for the evaluation and triage of undifferentiated patients with blunt trauma Point Care Blomkalns, A. 2009
• Safety and efficacy of bivalirudin in high-risk patients admitted through the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Miller, C. D., Blomkalns, A. L., Gersh, B. J., Pollack, C. V., Brogan, G. X., Diercks, D. B., Peacock, W. F., Stone, G. W., Hollander, J. E., Manoukian, S. V., Hoekstra, J. W. 2009; 16 (8): 717–25

  Abstract

  The objective was to assess the safety and efficacy of bivalirudin monotherapy in patients with high-risk acute coronary syndrome (ACS) presenting to the emergency department (ED).Data from the Acute Catheterization and Urgent Intervention Triage StrategY (ACUITY) trial were used to conduct a post hoc subgroup analysis of high-risk ACS patients (cardiac biomarker elevation or ST-segment deviation) who initially presented to the ED. The ACUITY trial randomized patients to receive heparin (unfractionated [UFH] or enoxaparin) plus glycoprotein IIb/IIIa inhibition (GPI), bivalirudin plus GPI, or bivalirudin monotherapy. Endpoints included composite ischemia, major bleeding (not coronary artery bypass graft (CABG) related), and net clinical outcome (major bleeding plus composite ischemia).Of 13,819 participants in the ACUITY trial, 6,441 presented initially to the ED, met high-risk criteria, and were included in the primary analysis. Bivalirudin alone when compared to heparin plus GPI, after adjusting for covariates, was associated with an improvement in net clinical outcome (12.3% vs. 14.3%, adjusted odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.66 to 0.99), similar composite ischemia (9.3% vs. 9.1%, adjusted OR = 0.98, 95% CI = 0.77 to 1.24), and less major bleeding (4.0% vs. 6.8%, adjusted OR = 0.57, 95% CI = 0.42 to 0.75). Bivalirudin plus GPI when compared to heparin plus GPI had similar net clinical outcome (13.8% vs. 14.3%, adjusted OR = 0.91, 95% CI = 0.75 to 1.11), composite ischemia (8.8% vs. 9.1%, adjusted OR = 0.87, 95% CI = 0.69 to 1.11), and major bleeding (6.8% vs. 6.8%, adjusted OR = 1.01, 95% CI = 0.79 to 1.30).Bivalirudin monotherapy decreases major bleeding while providing similar protection from ischemic events compared to heparin plus GPI in patients with high-risk ACS admitted through the ED.

  View details for DOI 10.1111/j.1553-2712.2009.00417.x

  View details for PubMedID 19673711

• Academic emergency medicine faculty and industry relationships. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Birkhahn, R. H., Blomkalns, A. L., Klausner, H. A., Nowak, R. M., Raja, A. S., Summers, R. L., Weber, J. E., Briggs, W. M., Arkun, A., Diercks, D. 2008; 15 (9): 819–24

  Abstract

  The authors surveyed the membership of the Society for Academic Emergency Medicine (SAEM) about their associations with industry and predictors of those associations.A national Web-based survey inviting faculty from the active member list of SAEM was conducted. Follow-up requests for participation were sent weekly for 3 weeks. Information was collected on respondents' personal and practice characteristics, industry interactions, and personal opinions regarding these interactions. Raw response rates were reported and a logistic regression was used to generate descriptive statistics.Responses were received from 430 members, representing 14% of the 3,183 active members. Respondents were 83% male and 86% white, with 96% holding an MD degree (24% with an additional postdoctoral degree). Most were at the assistant (37%) or associate (25%) professor rank, with 51% holding at least one leadership position. Most respondents (82%) reported some type of industry interaction, most commonly the acceptance of food or beverages (67%). Respondents at the associate professor rank or higher were more likely to receive payments from industry (51% vs. 22%, odds ratio [OR] = 3.7).This survey suggests that interactions between industry and academic EM faculty are common and increase with academic rank, but not with years in practice or leadership influence. The number and type of interactions are consistent with those reported by a national sampling of other physician specialties.

  View details for PubMedID 19244632

• Society for Academic Emergency Medicine Industry Relations Committee Academic Emergency Medicine Birkahn, R. 2008
• Cardiac Imaging and Stress Testing Emergency Medicine edited by Adams, J. 2007
• Emergency Department education improves patient knowledge of coronary artery disease risk factors but not the accuracy of their own risk perception. Preventive medicine Williams, A., Lindsell, C., Rue, L., Blomkalns, A. 2007; 44 (6): 520–25

  Abstract

  Coronary artery disease (CAD) is the single largest killer of both males and females in the United States. The Emergency Department (ED) represents a unique environment in which patient education may improve coronary artery disease risk factor knowledge and relative risk perception. ED patients' understanding of CAD risk factors is often limited. Patients' perception of their own risk is often not a reflection of their true risk. We hypothesized that an American Heart Association educational video intervention would improve patients' knowledge of coronary artery disease risk factors and personal risk awareness in the ED setting.IRB approval was obtained for this prospective observational cohort study. Our trial included 100 adult patients (age 18 and over), both male and female, using the ED population at an inner city tertiary care Level I trauma center hospital as our source of participants. Recruitment of patients began in January 2002 and ended in May 2004.Patients who watched the educational video did improve their knowledge of cardiac risk factors significantly when compared to patients who received no educational video intervention. In our study, this information was not retained at 30-day follow-up. However, there was still significant improvement in their knowledge when compared to baseline scores pre-intervention. Patients overestimated their risk when compared to an objective measure of risk. In both the study and control groups, patients significantly overestimated their risk pre-educational intervention, immediately post-educational intervention, and at 30-day follow-up when compared to an objective measure of risk.Simple educational intervention at a teachable moment (i.e. when a patient is experiencing chest pain in the ED) significantly improves patient's knowledge of CAD risk factors immediately post-intervention. This improvement in knowledge is not fully retained at 30-day follow-up, which suggests that patients may benefit from further educational intervention prior to 1 month follow-up. Patients overestimate their risk when compared to an objective measure of risk, regardless of whether they receive an educational intervention or not.

  View details for DOI 10.1016/j.ypmed.2007.01.011

  View details for PubMedID 17336373

• Guideline implementation research: exploring the gap between evidence and practice in the CRUSADE Quality Improvement Initiative. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Blomkalns, A. L., Roe, M. T., Peterson, E. D., Ohman, E. M., Fraulo, E. S., Gibler, W. B. 2007; 14 (11): 949–54

  Abstract

  Translating research results into routine clinical practice remains difficult. Guidelines, such as the 2002 American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina and non-ST-segment elevation myocardial infarction, have been developed to provide a streamlined, evidence-based approach to patient care that is of high quality and is reproducible. The Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation (CRUSADE) Quality Improvement Initiative was developed as a registry for non-ST-segment elevation acute coronary syndromes to track the use of guideline-based acute and discharge treatments for hospitalized patients, as well as outcomes associated with the use of these treatments. Care for more than 200,000 patients at more than 400 high-volume acute care hospitals in the United States was tracked in CRUSADE, with feedback provided to participating physicians and hospitals regarding their performance over time and compared with similar institutions. Such access to data has proved important in stimulating improvements in non-ST-segment elevation acute coronary syndromes care at participating hospitals for delivery of acute and discharge guideline-based therapy, as well as improving outcomes for patients. Providing quality improvement methods such as protocol order sets, continuing education programs, and a CRUSADE Quality Improvement Initiative toolbox serve to actively stimulate physician providers and institutions to improve care. The CRUSADE Initiative has also proven to be a fertile source of research in translation of treatment guidelines into routine care, resulting in more than 52 published articles and 86 abstracts presented at major emergency medicine and cardiology meetings. The cycle for research of guideline implementation demonstrated by CRUSADE includes four major steps--observation, intervention, investigation, and publication--that serve as the basis for evaluating the impact of any evidence-based guideline on patient care. Due to the success of CRUSADE, the American College of Cardiology combined the CRUSADE Initiative with the National Registry for Myocardial Infarction ST-segment elevation myocardial infarction program to form the National Cardiovascular Data Registry-Acute Coronary Treatment & Intervention Outcomes Network Registry beginning in January 2007.

  View details for DOI 10.1197/j.aem.2007.06.017

  View details for PubMedID 17967956

• Evaluation of dyslipidemia in the emergency department: Impact of cholesterol testing on subsequent therapy AMERICAN HEART JOURNAL Blomkalns, A. L., O'Connell, E. M., Eady, C. E., Lindsell, C. J., Gibler, W. 2006; 152 (6): 1182–86

  Abstract

  Dyslipidemia is not routinely evaluated in emergency department (ED) patients. We hypothesized that many ED patients would qualify for lipid therapy and that methods of follow-up for patients would not achieve adequate treatment goals.We performed an observational study of ED patients with symptoms consistent with acute coronary syndrome (ACS). Lipid profiles and data about coronary heart disease risk factors were obtained. The National Institutes of Health/National Cholesterol Education Program guidelines were used to determine whether patients qualified for drug therapy. Six-week and 6-month follow-ups were performed.Three hundred ninety-four patients presenting to the ED with possible ACS were enrolled in the study; 47 patients were subsequently excluded. The remaining 347 included patients who were 63.7% African American and 53.6% female. Proportions of patients with low-density lipoprotein > or = 130 and > or = 160 were 30.8% and 10.1%, respectively. Fifty-seven (16.4%, 95% CI 12.9%-20.7%) qualified for immediate drug therapy. Of the 44 patients meeting treatment criteria for whom follow-up was obtained, only 1 (2.3%) had received lipid-lowering medications with outpatient referral within 6 weeks. At 6 months, 4 (9.5%) of 42 patients with follow-up had received lipid-lowering therapies.Dyslipidemia meeting criteria for therapy is present in a significant proportion of ED patients. Most of these patients do not get appropriately treated on medical follow-up. Our study suggests that lipid screening and subsequent appropriate lipid-lowering therapy could be considered for ED patients with possible ACS.

  View details for DOI 10.1016/j.ahj.2006.07.015

  View details for Web of Science ID 000243110400032

  View details for PubMedID 17161073

• Emergency Department Multimarker Point-of-care Testing Reduces Time to Cardiac Marker Results Without Loss of Diagnostic Accuracy POINT OF CARE Storrow, A. B., Lindsell, C. J., Collins, S. P., Fermann, G. J., Blomkalns, A. L., Williams, J. M., Goldsmith, B., Gibler, W. 2006; 5 (3): 132–36

  View details for DOI 10.1097/01.poc.0000232334.13428.7a

  View details for Web of Science ID 000218039400007

• Frequency and consequences of recording and electrocardiogram > 10 minutes after arrival in an emergency room in non-ST-segment elevation acute coronary syndromes (from the CRUSADE initiative) AMERICAN JOURNAL OF CARDIOLOGY Diercks, D. B., Peacock, W. F., Hiestand, B. C., Chen, A. Y., Pollack, C. V., Kirk, J. D., Blomkalns, A. L., Newby, L. K., Hochman, J. S., Peterson, E. D., Roe, M. T. 2006; 97 (4): 437–42

  Abstract

  We sought to determine the frequency of electrocardiographic (ECG) acquisition within 10 minutes of hospital arrival, factors associated with delayed ECG acquisition, and any relation among delayed ECG acquisition, treatment patterns, and clinical outcomes. We therefore analyzed data from 63,478 patients (26,615 women, 42%) with high-risk non-ST-segment elevation acute coronary syndromes (designated by positive cardiac markers and/or ischemic ST-segment changes) who were enrolled in the CRUSADE Quality Improvement Initiative from February 2001 to March 2004. Patients were categorized based on time to electrocardiography as delayed (>10 minutes from hospital arrival) or nondelayed (<10 minutes). Multivariable predictors of delayed ECG acquisition were determined. Overall, median time to electrocardiography was 15 minutes (25th to 75th percentile 7 to 32). ECG acquisition was delayed (median 25 minutes, 25th to 75th percentile 16 to 50) in 41,397 patients (65.2%). In the remaining 34.8%, time to electrocardiography was <10 minutes (median 5 minutes, 25th to 75th percentile 3 to 8). Women were more likely than men to have delayed ECG acquisition (69% vs 62%), and female gender was the most significant predictor of delayed ECG acquisition (odds ratio 1.29, 95% confidence interval 1.25 to 1.34). In conclusion, only 33% of high-risk patients with non-ST-segment elevation acute coronary syndrome had an initial electrocardiogram obtained <10 minutes of arrival as recommended. Women were significantly more likely than men to have delayed ECG acquisition. Emergency departments should focus on decreasing the time to initial ECG acquisition to improve treatment of acute coronary syndrome in this group.

  View details for DOI 10.1016/j.amjcard.2005.09.073

  View details for Web of Science ID 000235479200001

  View details for PubMedID 16461033

• Cyanosis; Rheumatology Emergency Medicine Handbook edited by Roppolo, L. 2006
• Chest pain unit concept: Rationale and diagnostic strategies CARDIOLOGY CLINICS Blomkalns, A. L., Gibler, W. B. 2005; 23 (4): 411-+

  Abstract

  Each year in the United States, over 8 million patients present to the emergency department(ED) with complaints of chest discomfort or other symptoms consistent with possible acute coronary syndrome (ACS). While over half of these patients are typically admitted for further diagnostic evaluation, fewer than 20% are diagnosed with ACS. With hospital beds and inpatient resources scarce, these admissions can be avoided by evaluating low- to moderate-risk patients in chest pain units. This large, undifferentiated patient population represents a potential high-risk group for emergency physicians requiring a systematic approach and specific ED resources. This evaluation is required to appropriately determine if a patient is safe to be discharged home with outpatient follow-up versus requiring admission to the hospital for monitoring and further testing.

  View details for DOI 10.1016/j.ccl.2005.08.011

  View details for Web of Science ID 000233769800004

  View details for PubMedID 16278115

• Practical implementation of the guidelines for unstable angina/non-ST-segment elevation myocardial infarction in the emergency department ANNALS OF EMERGENCY MEDICINE Gibler, W. B., Cannon, C. P., Blomkalns, A. L., Char, D. M., Drew, B. J., Hollander, J. E., Jaffe, A. S., Jesse, R. L., Newby, L. K., Ohman, E. M., Peterson, E. D., Pollack, C. V. 2005; 46 (2): 185–97

  Abstract

  In the United States each year, >5.3 million patients present to emergency departments with chest discomfort and related symptoms. Ultimately, >1.4 million individuals are hospitalized for unstable angina and non-ST-segment elevation myocardial infarction. For emergency physicians and cardiologists alike, these patients represent an enormous challenge to accurately diagnose and appropriately treat. This update of the 2002 American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction (UA/NSTEMI) provides an evidence-based approach to the diagnosis and treatment of these patients in the emergency department, in-hospital, and after hospital discharge. Despite publication of the guidelines several years ago, many patients with UA/NSTEMI still do not receive guidelines-indicated therapy.

  View details for DOI 10.1016/j.annemergmed.2005.04.022

  View details for Web of Science ID 000230855100016

  View details for PubMedID 16046952

• Practical implementation of the guidelines for unstable angina/non-ST-segment elevation myocardial infarction in the emergency department - A Scientific Statement from the American Heart Association Council on Clinical Cardiology (Subcommittee on Acute Cardiac Care), Council on Cardiovascular Nursing, and Quality of Care and Outcomes Research Interdisciplinary Working Group, in Collaboration with the Society of Chest Pain Centers CIRCULATION Gibler, W. B., Cannon, C. P., Blomkalns, A. L., Char, D. M., Drew, B. J., Hollander, J. E., Jaffe, A. S., Jesse, R. L., Newby, L. K., Ohman, E. M., Peterson, E. D., Pollack, C. V. 2005; 111 (20): 2699–2710

  Abstract

  In the United States each year, >5.3 million patients present to emergency departments with chest discomfort and related symptoms. Ultimately, >1.4 million individuals are hospitalized for unstable angina and non-ST-segment elevation myocardial infarction. For emergency physicians and cardiologists alike, these patients represent an enormous challenge to accurately diagnose and appropriately treat. This update of the 2002 American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction (UA/NSTEMI) provides an evidence-based approach to the diagnosis and treatment of these patients in the emergency department, in-hospital, and after hospital discharge. Despite publication of the guidelines several years ago, many patients with UA/NSTEMI still do not receive guidelines-indicated therapy.

  View details for DOI 10.1161/01.CIR.0000165556.44271.BE

  View details for Web of Science ID 000229313000021

  View details for PubMedID 15911720

• Gender disparities in the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Blomkalns, A. L., Chen, A. Y., Hochman, J. S., Peterson, E. D., Trynosky, K., Diercks, D. B., Brogan, G. X., Boden, W. E., Roe, M. T., Ohman, E. M., Gibler, W. B., Newby, L. K., CRUSADE Invest 2005; 45 (6): 832–37

  Abstract

  We hypothesized that significant disparities in gender exist in the management of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS).Gender-related differences in the diagnosis and treatment of ACS have important healthcare implications. No large-scale examination of these disparities has been completed since the publication of the revised American College of Cardiology/American Heart Association guidelines for management of patients with NSTE ACS.Using data from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative, we examined differences of gender in treatment and outcomes among patients with NSTE ACS.Women (41% of 35,875 patients) were older (median age 73 vs. 65 years) and more often had diabetes and hypertension. Women were less likely to receive acute heparin, angiotensin-converting enzyme inhibitors, and glycoprotein IIb/IIIa inhibitors and less commonly received aspirin, angiotensin-converting enzyme inhibitors, and statins at discharge. The use of cardiac catheterization and revascularization was higher in men, but among patients with significant coronary disease, percutaneous revascularization was performed in a similar proportion of women and men. Women were at higher risk for unadjusted in-hospital death (5.6% vs. 4.3%), reinfarction (4.0% vs. 3.5%), heart failure (12.1% vs. 8.8%), stroke (1.1% vs. 0.8%), and red blood cell transfusion (17.2% vs. 13.2%), but after adjustment, only transfusion was higher in women.Despite presenting with higher risk characteristics and having higher in-hospital risk, women with NSTE ACS are treated less aggressively than men.

  View details for DOI 10.1016/j.jacc.2004.11.055

  View details for Web of Science ID 000227586600003

  View details for PubMedID 15766815

• Chest Pain Unit Concept: Rationale and Diagnostic Strategies Cardiology Clinics edited by Amsterdam, E. 2005
• Diagnosis of Acute Coronary Syndromes in the Emergency Department: Evolution of Chest Pain Centers In Acute Coronary Syndromes, Third Edition edited by Dekker, M. 2005
• Standardized reporting guidelines for studies evaluating risk stratification of emergency department patients with potential acute coronary syndromes ANNALS OF EMERGENCY MEDICINE Hollander, J. E., Blomkains, A. L., Brogan, G. X., Diercks, D. B., Field, J. M., Garvey, J. L., Gibler, W. B., Henry, T. D., Hoekstra, J. W., Holroyd, B. R., Hong, Y. L., Kirk, J. D., O'Neil, B. J., Jackson, R. E., Hollander, J. E., Aufderheide, T., Blomkalns, A. L., Brogan, G. X., Christenson, J., Collins, S., Diercks, D. B., Fesmire, F. M., Garvey, J. L., Gibler, W. B., Green, G. B., Hoekstra, J. W., Holroyd, B. R., Kirk, J. D., Lindsell, C. J., Peacock, W. F., Pollack, C. V., Zalenski, R., Jackson, R. E. 2004; 44 (6): 589-598

  View details for DOI 10.1016/j.annemergmed.2004.08.009

  View details for Web of Science ID 000225503900005

  View details for PubMedID 15573034

• Achieving standardization in clinical research: Changing cacophony into harmony ANNALS OF EMERGENCY MEDICINE Gibler, W. B., Blomkalns, A. L. 2004; 44 (3): 213–14

  View details for DOI 10.1016/j.annemergmed.2004.03.032

  View details for Web of Science ID 000223647200003

  View details for PubMedID 15332060

• Development of the chest pain center: Rationale, implementation, efficacy, and cost-effectiveness PROGRESS IN CARDIOVASCULAR DISEASES Blomkalns, A. L., Gibler, W. B. 2004; 46 (5): 393–403

  View details for DOI 10.1016/j.pcad.2003.12.005

  View details for Web of Science ID 000221990300003

  View details for PubMedID 15179628

• Residency training in emergency medicine: the challenges of the 21st century. The Keio journal of medicine Williams, A. L., Blomkalns, A. L., Gibler, W. B. 2004; 53 (4): 203–9

  Abstract

  Emergency Medicine is a relatively young specialty in the United States as well as in other parts of the world. It was only 36 years ago, in 1968, that the American College of Emergency Physicians was founded. Two years later, the University of Cincinnati in Cincinnati, Ohio, USA launched the first Emergency Medicine Residency Training Program. Until the inception of this program, staffing of "Emergency Rooms" consisted largely of physicians who were not trained in the specialty of Emergency Medicine. Emergency Medicine Residency training programs fulfill the need to have Emergency Medicine trained physicians staffing Emergency Departments. There are three and four year training formats for Emergency Medicine in the United States. The University of Cincinnati program is a full four-year program, which teaches residents to master the many diagnostic, procedural, and interpersonal skills required of Emergency Medicine physicians. Diagnostic skills must encompass the pathology affecting all organ systems in all age groups and both sexes. Procedural skills include airway management, vascular access, cavity access, and wound repair. Interpersonal skills are demanding as well, requiring leadership/management of the Emergency Department care team, immediate patient rapport, and dealing with patient/family grief. The Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) ensures that all programs have a structured curriculum complete with both didactic and bedside teaching, as well as structured methods for evaluation of both residents and faculty. According to manpower studies, a great need still exists for Emergency Physicians in many United States hospitals, particularly in rural communities.

  View details for PubMedID 15647626

• The Chest Pain Center Concept Cardiovascular Emergencies edited by Peacock, F. 2004
• Basic MI Therapy Cardiovascular Emergencies edited by Peacock, F. 2004
• Emergency department crowding: Emergency physicians and cardiac risk stratification as part of the solution ANNALS OF EMERGENCY MEDICINE Blomkalns, A. L., Gibler, W. B. 2004; 43 (1): 77–78

  View details for DOI 10.1016/j.annemergmed.2003.10.033

  View details for Web of Science ID 000187852900015

  View details for PubMedID 14707945

• Selecting safe psychotropics for patients after a myocardial infarction. Current Psychiatry Deewan, N., Suresh, D., Blomkalns, A., Jenkins, W. 2003
• Evaluation of Acute Chest Pain in Women. In Coronary Disease in Women edited by Shaw, L. 2003
• Evaluation of chest pain and heart failure in the emergency department: impact of multimarker strategies and B-type natriuretic peptide. Reviews in cardiovascular medicine Gibler, W. B., Blomkalns, A. L., Collins, S. P. 2003; 4 Suppl 4: S47–55

  Abstract

  In the emergency setting, acute chest pain and shortness of breath represent common patient presentations. Cardiac biomarkers including myoglobin, creatine kinase (CK)-MB, troponin, and b-type natriuretic peptide provide diagnostic and prognostic information for patients with chest pain and shortness of breath. This article reviews the use of cardiac biomarkers in the emergency department to evaluate acute coronary syndrome and congestive heart failure.

  View details for PubMedID 14564228

• Can electrocardiographic criteria predict adverse cardiac events and positive cardiac markers? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Blomkalns, A. L., Lindsell, C. J., Chandra, A., Osterlund, M. E., Gibler, W. B., Pollack, C. V., Tiffany, B. R., Hollander, J. E., Hoekstra, J. W. 2003; 10 (3): 205–10

  Abstract

  To determine electrocardiogram (ECG) predictors of positive cardiac markers and short-term adverse cardiac events in an undifferentiated chest pain population presenting to emergency departments (EDs). The authors hypothesized that specific ECG findings, other than those previously identified in higher-risk populations, would be predictive of cardiac outcomes and positive cardiac markers.This study used data from a prospectively collected, retrospectively analyzed Internet-based data registry of undifferentiated chest pain patients (i*trACS). Logistic regression modeling was performed to determine the ECG findings that were predictive of 1) positive cardiac markers and 2) short-term adverse cardiac events.ST-segment elevation (STE), ST-segment depression (STD), pathological Q-waves (PQW), and T-wave inversion were associated with increased odds of percutaneous coronary intervention or catheterization, myocardial infarction, or coronary artery bypass grafting. The odds of creatine kinase-MB (CK-MB) measuring positive were increased if STE, STD, or PQW were present [odds ratio (OR) 2.495, 2.582, and 1.295, respectively]. A right bundle branch block tended to decrease the odds of CK-MB measuring positive (OR 0.658). A similar pattern of results was observed for troponin I (OR 3.608 for STE, 3.72 for STD, 1.538 for PQW). Troponin T showed an increased odds of measuring positive if any of STE, STD, left bundle branch block, or T-wave inversion were evident (OR 2.313, 2.816, 1.80, and 1.449, respectively).Initial ECG criteria can be used to predict short-term cardiac outcomes and positive cardiac markers. These findings can be important aids in the risk-stratification and aggressive treatment regimens of chest pain patients presenting to EDs.

  View details for PubMedID 12615583

• Markers and the initial triage and treatment of patients with chest pain. Cardiovascular toxicology Blomkalns, A. L., Gibler, W. B. 2001; 1 (2): 111–15

  Abstract

  Emergency departments evaluate nearly 8 million patients with chest pain per year. Nearly 4 million of these individuals are admitted to inpatient units for further evaluation and treatment, but only 30% of these admitted patients ultimately have the diagnosis of acute coronary syndrome (ACS). Previously, the initial evaluation of patients with chest discomfort presenting to the emergency department (ED) involved the triad of history, physical, and ECG. Current evidence demonstrates that a fourth element, cardiac markers, serves as a valuable aid in not only determining initial diagnosis but also providing risk stratification and dictating initial patient treatment. Chest pain units (CPUs) using serial marker determinations have been successful in identifying patients with or at risk for adverse cardiac events in a timely and cost- efficient manner. New point-of-care-testing (POCT) of cardiac markers at the patient's bedside allows for even more timely determination. This article will review the use of cardiac markers in heterogeneous patients presenting to EDs with chest discomfort. We will focus on the use of markers in the risk stratification and initial treatment of the ED chest pain population and emphasize the role of CPUs and POCT.

  View details for PubMedID 12213982

• Venomous Animal Injuries In Emergency Medicine: Concepts and Clinical Practice, 5th edition edited by Rosen, P. 2001
• Diagnosis of Acute Coronary Syndromes in the Emergency Department – The Evolution of Chest Pain Centers Acute Coronary Syndromes: Second edition, Revised and Expanded edited by Topol, E. 2001
• The Diagnosis of Acute Coronary Syndromes in the Emergency Department In Acute Coronary Syndromes edited by Bassan, R. 2000
• The Diagnosis of Acute Cornoary Syndromes in the Emergency Department: The Evolution of Chest Pain Centers. In Acute Coronary Syndromes edited by Topol, E. 2000
• Catfish spine envenomation: a case report and literature review WILDERNESS & ENVIRONMENTAL MEDICINE Blomkalns, A. L., Otten, E. J. 1999; 10 (4): 242–46

  Abstract

  Catfish spine envenomations are common injuries, reported in both freshwater and saltwater. Such injuries are complex puncture wounds, often complicated by severe infection. Signs and symptoms range from simple local pain and bleeding to systemic manifestations with hemodynamic compromise. Care and treatment involve aggressive pain management, judicious wound cleansing, prophylactic antibiotics, and close follow-up. A case of catfish spine envenomation from a freshwater catfish is presented here.

  View details for DOI 10.1580/1080-6032(1999)010[0242:CSEACR]2.3.CO;2

  View details for Web of Science ID 000084397600006

  View details for PubMedID 10628284

• Purification of bovine alpha-lactalbumin by immobilized metal ion affinity chromatography PREPARATIVE BIOCHEMISTRY & BIOTECHNOLOGY Blomkalns, A. L., Gomez, M. R. 1997; 27 (4): 219–26

  Abstract

  The milk protein alpha-lactalbumin was isolated from bovine whey protein concentrate solution by immobilized metal ion affinity chromatography (IMAC) using Cu(II)-Chelating Sepharose Fast Flow. Stepwise pH (5.5-3.8) changes in sodium acetate buffer were used to elute the protein selectively, at which time it was concentrated and reapplied to an uncharged Chelating Sepharose Fast Flow column to remove the contaminating Cu(II) ions. A purity of 90% and recovery of 80% was achieved. The described method appears to be suitable for isolation of alpha-lactalbumin in a form adequate for milk formula engineering.

  View details for DOI 10.1080/10826069708001280

  View details for Web of Science ID A1997YK08800002

  View details for PubMedID 9413555