Cardiology professionals' views of social robots in augmenting heart failure patient care

Aims

Social robots are arriving to the modern healthcare system. Whether patients with heart failure, a prevalent chronic disease with high health and human costs would derive benefit from a social robot intervention has not been investigated empirically. Diverse healthcare provider's perspectives are needed to develop an acceptable and feasible social robot intervention to be adopted for the clinical benefit of patients with heart failure. Using a qualitative research design, this study investigated healthcare providers' perspectives of social robot use in heart failure patient care.

Methods and results

Interdisciplinary healthcare providers from a tertiary care cardiac hospital completed a structured individual interview and a supplemental questionnaire. The framework method was used to analyse the qualitative data. Respondents (n = 22; saturation was reached with this sample; 77% female; 52% physicians) were open to using social robots to augment their practice, particularly with collecting pertinent data and providing patient and family education and self-management prompts, but with limited responsibility for direct patient care. Prior to implementation, providers required robust evidence of: value-added beyond current remote patient monitoring devices, patient and healthcare provider partnerships, streamlined integration into existing practice, and capability of supporting precision medicine goals. Respondents were concerned that social robots did not address and masked broader systemic issues of healthcare access and equity.

Conclusion

The adoption of social robots is a viable option to assist in the care of patients with heart failure, albeit in a restricted capacity. The results inform the development of a social robotic intervention for patients with heart failure, including improving social robot efficiencies and increasing their uptake, while protecting patients' and providers' best interest.

Cardiac PET Myocardial Blood Flow Quantification Assessment of Early Cardiac Allograft Vasculopathy

BACKGROUND

Positron emission tomography (PET) has demonstrated utility for diagnostic and prognostic assessment of cardiac allograft vasculopathy (CAV) but has not been evaluated in the first year after transplant.

OBJECTIVES

The authors sought to evaluate CAV at 1 year by PET myocardial blood flow (MBF) quantification.

METHODS

Adults at 2 institutions enrolled between January 2018 and March 2021 underwent prospective 3-month (baseline) and 12-month (follow-up) post-transplant PET, endomyocardial biopsy, and intravascular ultrasound examination. Epicardial CAV was assessed by intravascular ultrasound percent intimal volume (PIV) and microvascular CAV by endomyocardial biopsy.

RESULTS

A total of 136 PET studies from 74 patients were analyzed. At 12 months, median PIV increased 5.6% (95% CI: 3.6%-7.1%) with no change in microvascular CAV incidence (baseline: 31% vs follow-up: 38%; P = 0.406) and persistent microvascular disease in 13% of patients. Median capillary density increased 30 capillaries/mm2 (95% CI: -6 to 79 capillaries/mm2). PET myocardial flow reserve (2.5 ± 0.7 vs 2.9 ± 0.8; P = 0.001) and stress MBF (2.7 ± 0.6 vs 2.9 ± 0.6; P = 0.008) increased, and coronary vascular resistance (CVR) (49 ± 13 vs 47 ± 11; P = 0.214) was unchanged. At 12 months, PET and PIV had modest correlation (stress MBF: r = -0.35; CVR: r = 0.33), with lower stress MBF and higher CVR across increasing PIV tertiles (all P < 0.05). Receiver-operating characteristic curves for CAV defined by upper-tertile PIV showed areas under the curve of 0.74 for stress MBF and 0.73 for CVR.

CONCLUSIONS

The 1-year post-transplant PET MBF is associated with epicardial CAV, supporting potential use for early noninvasive CAV assessment. (Early Post Transplant Cardiac Allograft Vasculopahty [ECAV]; NCT03217786).

Influence of preoperative frailty on quality of life after cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Frailty has emerged as an important prognostic marker of increased mortality after cardiac surgery, but its association with quality of life (QoL) and patient-centered outcomes is not fully understood. We sought to evaluate the association between frailty and such outcomes in older patients undergoing cardiac surgery.

METHODS

This systematic review included studies evaluating the effect of preoperative frailty on QoL outcomes after cardiac surgery amongst patients 65 years and older. The primary outcome was patient's perceived change in QoL following cardiac surgery. Secondary outcomes included residing in a long-term care facility for 1 year, readmission in the year following the intervention, and discharge destination. Screening, inclusion, data extraction, and quality assessment were performed independently by two reviewers. Meta-analyses based on the random-effects model were conducted. The evidential quality of findings was assessed with the GRADE profiler.

RESULTS

After the identification of 3105 studies, 10 observational studies were included (1580 patients) in the analysis. Two studies reported on the change in QoL following cardiac surgery, which was higher for patients with frailty than for patients without. Preoperative frailty was associated with both hospital readmission (pooled odds ratio [OR] 1.48 [0.80-2.74], low GRADE level) as well as non-home discharge (pooled OR 3.02 [1.57-5.82], moderate GRADE level).

CONCLUSION

While evidence in this field is limited by heterogeneity of frailty assessment and non-randomized data, we demonstrated that baseline frailty may possibly be associated with improved QoL, but with increased readmission as well as discharge to a non-home destination following cardiac surgery. These patient-centered outcomes are important factors when considering interventional options for older patients.

STUDY REGISTRATION

OSF registries (https://osf.io/vm2p8).

Impact of baseline beta-blocker use on inotrope response and clinical outcomes in cardiogenic shock: a subgroup analysis of the DOREMI trial

Background

Cardiogenic shock (CS) is associated with significant morbidity and mortality. The impact of beta-blocker (BB) use on patients who develop CS remains unknown. We sought to evaluate the clinical outcomes and hemodynamic response profiles in patients treated with BB in the 24 h prior to the development of CS.

Methods

Patients with CS enrolled in the DObutamine compaREd to MIlrinone trial were analyzed. The primary outcome was a composite of all-cause mortality, resuscitated cardiac arrest, need for cardiac transplant or mechanical circulatory support, non-fatal myocardial infarction, transient ischemic attack or stroke, or initiation of renal replacement therapy. Secondary outcomes included the individual components of the primary composite and hemodynamic response profiles derived from pulmonary artery catheters.

Results

Among 192 participants, 93 patients (48%) had received BB therapy. The primary outcome occurred in 47 patients (51%) in the BB group and in 52 (53%) in the no BB group (RR 0.96; 95% CI 0.73–1.27; P = 0.78) throughout the in-hospital period. There were fewer early deaths in the BB group (RR 0.41; 95% CI 0.18–0.95; P = 0.03). There were no differences in other individual components of the primary outcome or in hemodynamic response between the two groups throughout the remainder of the hospitalization.

Conclusions

BB therapy in the 24 h preceding the development of CS did not negatively influence clinical outcomes or hemodynamic parameters. On the contrary, BB use was associated with fewer deaths in the early resuscitation period, suggesting a paradoxically protective effect in patients with CS.

Trial registration ClinicalTrials.gov Identifier: NCT03207165

Shared Decision Making and Effective Communication in Heart Failure-Moving from "Code Status" to Decisional Readiness

Despite advances in treatment options, heart failure (HF) remains a progressive, symptomatic, and terminal disease for a large number of patients. The need for enhanced discussions regarding prognosis and goals of care has been recognised by multiple professional societies and public health policy, yet these conversations rarely occur in a timely manner. Shared decision making (SDM) is the process through which clinicians and patients work toward treatment decisions that are aligned with the patients' values, goals, and preferences. SDM is especially appropriate when treatments carry an uncertain benefit and potential risk, and it emphasises the fact that neither medical evidence nor patient values alone can determine the best treatment for a patient. The foundation of these discussions should focus on a general understanding of disease trajectory and prognosis, with a clear acknowledgment of prognostic uncertainty. These discussions should include not only the risks of death but also the potential burden of worsening symptoms and decreased quality of life. The goal of these discussions should not be to rule in or rule out specific therapies in a future hypothetical scenario, but instead to prepare our patients and their loved ones to make "in-the-moment" treatment decisions when faced with an acute decompensation, taking into context the state of their illness at that time.

Heart Failure: A Palliative Medicine Review of Disease, Therapies, and Medications With a Focus on Symptoms, Function, and Quality of Life

Despite significant advances in heart failure (HF) treatment, HF remains a progressive, extremely symptomatic, and terminal disease with a median survival of 2.1 years after diagnosis. HF often leads to a constellation of symptoms, including dyspnea, fatigue, depression, anxiety, insomnia, pain, and worsened cognitive function. Palliative care is an approach that improves the quality of life of patients and their caregivers facing the problems associated with life-threatening illness and therefore is well suited to support these patients. However, historically, palliative care has often focused on supporting patients with malignant disease, rather than a progressive chronic disease such as HF. Predicting mortality in patients with HF is challenging. The lack of obvious transition points in disease progression also raises challenges to primary care providers and specialists to know at what point to integrate palliative care during a patient's disease trajectory. Although therapies for HF often result in functional and symptomatic improvements including health-related quality of life (HRQL), some patients with HF do not demonstrate these benefits, including those patients with a preserved ejection fraction. Provision of palliative care for patients with HF requires an understanding of HF pathogenesis and common medications used for these patients, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes HF and current targeted therapies and their effects on symptoms, hospital admission rates, exercise performance, HRQL, and survival. Pharmacological interactions with and precautions related to commonly used palliative care medications are reviewed. The goal of this review is to equip palliative care clinicians with information to make evidence-based decisions while managing the balance between optimal disease management and patient quality of life.

Wanted: role models--medical students' perceptions of professionalism

BACKGROUND

Transformation of medical students to become medical professionals is a core competency required for physicians in the 21st century. Role modeling was traditionally the key method of transmitting this skill. Medical schools are developing medical curricula which are explicit in ensuring students develop the professional competency and understand the values and attributes of this role. The purpose of this study was to determine student perception of professionalism at the University of Ottawa and gain insights for improvement in promotion of professionalism in undergraduate medical education.

METHODS

Survey on student perception of professionalism in general, the curriculum and learning environment at the University of Ottawa, and the perception of student behaviors, was developed by faculty and students and sent electronically to all University of Ottawa medical students. The survey included both quantitative items including an adapted Pritzker list and qualitative responses to eight open ended questions on professionalism at the Faculty of Medicine, University of Ottawa. All analyses were performed using SAS version 9.1 (SAS Institute Inc. Cary, NC, USA). Chi-square and Fischer's exact test (for cell count less than 5) were used to derive p-values for categorical variables by level of student learning.

RESULTS

The response rate was 45.6% (255 of 559 students) for all four years of the curriculum. 63% of the responses were from students in years 1 and 2 (preclerkship). Students identified role modeling as the single most important aspect of professionalism. The strongest curricular recommendations included faculty-led case scenario sessions, enhancing interprofessional interactions and the creation of special awards to staff and students to "celebrate" professionalism. Current evaluation systems were considered least effective. The importance of role modeling and information on how to report lapses and breaches was highlighted in the answers to the open ended questions.

CONCLUSIONS

Students identify the need for strong positive role models in their learning environment, and for effective evaluation of the professionalism of students and teachers. Medical school leaders must facilitate development of these components within the MD education and faculty development programs as well as in clinical milieus where student learning occurs.