Coronary embolic phenomena (CEP) are difficult to diagnose yet carry potentially devastating clinical consequences. The goal of this chapter is to outline key processes and pathophysiologic mechanisms underlying CEP, primarily in the context of acute coronary syndrome (ACS). Not surprisingly, most reported cases of CEP occur in the left coronary circulation, but some right-sided events have been reported. Overall, causes include thrombotic, septic/infectious, neoplastic, valverelated, and iatrogenic mechanisms such as air embolization. Coronary angiography remains the definitive diagnostic and therapeutic approach, with computed tomography being increasingly utilized. Transthoracic echocardiography (TTE) should be part of a routine work up for patients with suspected CEP. Holter/event monitoring for atrial fibrillation may also be indicated in patients with embolic phenomena. Clinical management includes procedural restoration of coronary blood flow, followed by appropriate anticoagulation or antiplatelet therapy, in conjunction with appropriate treatment of any arrhythmias or other associated cardiac manifestations or conditions. Timely diagnosis, based on a high index of suspicion (especially in high-risk population) may be important in improving morbidity and mortality in affected patients. Since CEPs are often underdiagnosed and may be due to a number of heterogeneous causes, the need arises for increasing provider awareness of these important phenomena, as well as for the implementation of appropriate clinical management guidelines.
The nature of provider-patient relationship (PPR) goes far beyond the simplified paradigm of “chief complaints,” “clinical problems” and corresponding “therapeutic solutions.” In order to more comprehensively explore the scope of PPR in the context of leadership-based partnership (LBP), various factors and their contributions were researched in terms of both the success and optimization of health-care interactions. This is especially relevant to graduate medical education (GME) and advanced practice (AP) training programs. There are numerous nuances to PPR, including various communication, behavioral, ethical and leadership considerations. Body language and tone of voice are essential in establishing rapport, beginning with the so-called ‘first impression,’ which serves as a foundation for developing the PPR. Health-care providers (HCPs) with greater ability to empathize with their patients may achieve higher levels of treatment adherence, better clinical outcomes, and ultimately increased patient satisfaction. The inclusion of a patient as a co-leader and an essential member of their health-care team (HCT) should be a natural step and a top priority for GME and AP trainees. Such collaboration requires an open-minded approach by all stakeholders. Finally, recognizing patient well-being in all domains, including physical, emotional and spiritual, is critical to the holistic approach toward maximizing the benefits of an optimal PPR. Same can be said about the HCP. In this chapter, we will explore key aspects of PPR in the context of both the trainee and the patient being co-leaders within the bounds of the LBP framework.
Climate change (CC) can be defined as a long-term shift in global, continental, and/or local climate patterns. Although many equate CC to the rise in global temperatures, the issue is much more complicated and involves a large number of interconnected factors. Among some of the less discussed considerations of CC are its effects on a broad range of public health issues, including the emergence of novel infectious diseases, the encroachment of infectious disease vectors into previously unaffected geographic distributions, and crop failures resulting in threats of malnutrition and mass migration. This chapter will be devoted to key issues related to CC in the context of international health security (IHS).
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