Interventions for Optimization of Guideline-Directed Medical Therapy: A Systematic Review

Importance

Implementation of guideline-directed medical therapy (GDMT) in real-world practice remains suboptimal. It is unclear which interventions are most effective at addressing current barriers to GDMT in patients with heart failure with reduced ejection fraction (HFrEF).

Objective

To perform a systematic review to identify which types of system-level initiatives are most effective at improving GDMT use among patients with HFrEF.

Evidence Review

PubMed, Embase, Cochrane, CINAHL, and Web of Science databases were queried from January 2010 to November 2023 for randomized clinical trials that implemented a quality improvement intervention with GDMT use as a primary or secondary outcome. References from related review articles were also included for screening. Quality of studies and bias assessment were graded based on the Cochrane Risk of Bias tool and Oxford Centre for Evidence-Based Medicine.

Findings

Twenty-eight randomized clinical trials were included with an aggregate sample size of 19 840 patients. Studies were broadly categorized as interdisciplinary interventions (n = 15), clinician education (n = 5), electronic health record initiatives (n = 6), or patient education (n = 2). Overall, interdisciplinary titration clinics were associated with significant increases in the proportion of patients on target doses of GDMT with a 10% to 60% and 2% to 53% greater proportion of patients on target doses of β-blockers and renin-angiotensin-aldosterone system inhibitors, respectively, in intervention groups compared with usual care. Other interventions, such as audits, clinician and patient education, or electronic health record alerts, were also associated with some improvements in GDMT utilization, though these findings were inconsistent across studies.

Conclusions and Relevance

This review summarizes interventions aimed at optimization of GDMT in clinical practice. Initiatives that used interdisciplinary teams, largely comprised of nurses and pharmacists, most consistently led to improvements in GDMT. Additional large, randomized studies are necessary to better understand other types of interventions, as well as their long-term efficacy and sustainability.

Strength and Functional Outcomes Following Achilles Tendon Reconstruction With Hamstring Tendon Autograft Augmentation

BACKGROUND

The proposed advantages of hamstring autograft reconstruction when compared to alternative procedures, such as flexor hallucis longus (FHL) transfer, V-Y lengthening, and allograft reconstruction, are improved healing and reproduction of normal tendon biomechanics and reduced morbidity within the foot and ankle. In this study, we examined the effect of Achilles tendon reconstruction using hamstring autografts on strength and functional outcomes.

METHODS

Patients who underwent Achilles repair with a hamstring autograft for insertional or midsubstance tendinopathy, delayed diagnosis of rupture, or infection after primary repair were evaluated for inclusion. Forty-six patients were identified; 12 further augmented with an FHL transfer are included in the analysis. Isokinetic testing was completed with a Biodex dynamometer under supervision of a physical therapist masked to surgical side. Pre- and postoperative Foot and Ankle Outcome Scores (FAOS, before March 2016) or Patient-Reported Outcomes Measurement Information System (PROMIS, after March 2016) surveys were collected.

RESULTS

For knee flexion, peak torque was not significantly different when comparing operative and nonoperative sides at 180 degrees/second (45.38 Nm vs 45.96 Nm; P = .69) nor at 300 degrees/second (44.2 Nm vs 47.02 Nm; P = .069). Knee extension absolute peak torque was only found to be significantly weaker on the operative side at the faster testing (75.5 Nm vs 79.56 Nm; P < .05). Peak ankle plantarflexion torque was significantly weaker on the operative side at both the slower speed (60 degrees/second: 39.9 Nm vs 48.76 Nm; P < .005) and the faster speed (120 degrees/second: 31.3 Nm vs 40.7 Nm; P < .001). Average power for ankle plantarflexion did not differ significantly from the operative side to the nonoperative side in the slower test (26.46 W vs 27.48 W; P = .60) but did significantly differ on the faster test (32.13 W vs 37.63 W; P = .041). At an average of 19.9 months postoperation, all physical function and pain-related patient-reported outcome scores showed clinically and statistically significant improvement.

CONCLUSION

Achilles reconstruction with a hamstring autograft ± FHL transfer allowed patients with severe Achilles pathology to return to good subjective function, with modest deficits in calf strength compared with the uninjured side. Overall knee flexion strength did not appear impaired. These results suggest that hamstring autograft reconstruction is a viable method to treat these complex cases involving a lack of healthy tissue, allowing patients to return to symptom-free physical function and athletic activity.

LEVEL OF EVIDENCE

Level IV, case series.

Digital Health and the Care of the Patient With Arrhythmia

The field of cardiac electrophysiology has been on the cutting edge of advanced digital technologies for many years. More recently, medical device development through traditional clinical trials has been supplemented by direct to consumer products with advancement of wearables and health care apps. The rapid growth of innovation along with the mega-data generated has created challenges and opportunities. This review summarizes the regulatory landscape, applications to clinical practice, opportunities for virtual clinical trials, the use of artificial intelligence to streamline and interpret data, and integration into the electronic medical records and medical practice. Preparation of the new generation of physicians, guidance and promotion by professional societies, and advancement of research in the interpretation and application of big data and the impact of digital technologies on health outcomes will help to advance the adoption and the future of digital health care.

Implementation of a Telemedicine Clinic in the Covid-19 Era

Background

COVID-19 has drastically altered the delivery of medical care in the United States and beyond. Healthcare providers have been forced to rapidly innovate to mitigate the spread of infection and maintain social distancing. Telemedicine allows for the continuation of vital patient care while decreasing the risk of virus transmission.

Objective

We conducted a survey to assess the satisfaction of both patients and providers with rapid implementation of an electronic medical record (EMR) based video visit system.

Methods

A survey hyperlink was distributed through EMR messages to patients and emails to providers.

Results

74/376 patients (19.7%) and 8/10 (80%) providers completed the survey. The population consisted of advanced heart failure (n = 37, 50%), mechanical circulatory support (n = 4, 5.4%), transplant (n = 19, 25.7%) and general cardiology (n = 14, 18.9%) patients and their respective providers. The patient survey consisted of validated survey questions to assess patient and provider perceptions. Patients were 69.7% male with a mean age of 65. 74% of the patients consider themselves early adopters or innovators with new technology. 85% of surveyed patients believed that telemedicine is simple to use and easy to learn. 77% felt the telemedicine system interface was of good quality, 88% believed it allows for good interaction with the provider, 95% believed it protects both patients and providers by limiting exposure to COVID-19, 83% were overall satisfied with this telemedicine system and would use it again. 75% of providers reported no telemedicine experience prior to COVID-19. Notably, 100% of physicians consider themselves early adopters or innovators with new technology. 87.5% deemed their patients highly complex. 100 % of providers felt that telemedicine is useful for their job and 87.5% felt that their job would be difficult to perform without it, 27.5% believed video visits save and reduce time spent on unproductive activities, and allow accomplishing more work and tasks more quickly, 87.5% believe the system is easy to use overall, 100% agree it enhances providers’ and patients’ safety during COVID-19.

Conclusion

Patients reported high level of satisfaction with video visits and interaction with their providers as well as with the ease of use and convenience of telemedicine appointments. Providers found the telemedicine system easy to use and useful for their job, but many believe there is room for improvement with respect to time saving measures.

MetAP2 inhibition reduces food intake and body weight in a ciliopathy mouse model of obesity

The ciliopathies Bardet-Biedl syndrome and Alström syndrome are genetically inherited pleiotropic disorders with hyperphagia and obesity as primary clinical features. Methionine aminopeptidase 2 inhibitors (MetAP2i) have been shown in preclinical and clinical studies to reduce food intake, body weight, and adiposity. Here, we investigated the effects of MetAP2i administration in a mouse model of ciliopathy produced by conditional deletion of the Thm1 gene in adulthood. Thm1 conditional knockout (cko) mice showed decreased hypothalamic proopiomelanocortin expression as well as hyperphagia, obesity, metabolic disease, and hepatic steatosis. In obese Thm1-cko mice, 2-week administration of MetAP2i reduced daily food intake and reduced body weight 17.1% from baseline (vs. 5% reduction for vehicle). This was accompanied by decreased levels of blood glucose, insulin, and leptin. Further, MetAP2i reduced gonadal adipose depots and adipocyte size and improved liver morphology. This is the first report to our knowledge of MetAP2i reducing hyperphagia and body weight and ameliorating metabolic indices in a mouse model of ciliopathy. These results support further investigation of MetAP2 inhibition as a potential therapeutic strategy for ciliary-mediated forms of obesity.

Stretched arc discharge in produced water

The objective of the present study was to investigate the feasibility of stretching an arc discharge in produced water to increase the volume of produced water treated by plasma. Produced water is the wastewater generated by hydraulic fracturing of shale during the production phase in shale-oil or shale-gas exploration. The electric conductivity of produced water is in the range of 50-200 mS/cm, which provides both a challenge and opportunity for the application of plasmas. Stretching of an arc discharge in produced water was accomplished using a ground electrode and two high-voltage electrodes: one positioned close to the ground electrode and the other positioned farther away from the ground. The benefit of stretching the arc is that the contact between the arc and water is significantly increased, resulting in more efficient plasma treatment in both performance and energy cost.

Electrical control of optical plasmon resonance with graphene

Surface plasmon has the unique capability to concentrate light into subwavelength volume. Active plasmon devices using electrostatic gating can enable flexible control of the plasmon excitations, which has been demonstrated recently in terahertz plasmonic structures. Controlling plasmon resonance at optical frequencies, however, remains a significant challenge because gate-induced free electrons have very weak responses at optical frequencies. Here we achieve efficient control of near-infrared plasmon resonance in a hybrid graphene-gold nanorod system. Exploiting the uniquely strong and gate-tunable optical transitions of graphene, we are able to significantly modulate both the resonance frequency and quality factor of gold nanorod plasmon. Our analysis shows that the plasmon-graphene coupling is remarkably strong: even a single electron in graphene at the plasmonic hotspot could have an observable effect on plasmon scattering intensity. Such hybrid graphene-nanometallic structure provides a powerful way for electrical control of plasmon resonances at optical frequencies and could enable novel plasmonic sensing down to single charge transfer events.

Synthesis of substituted cinnamoyl-tyramine derivatives and their platelet anti-aggregatory activities

Substituted cinnamoyl-tyramine derivatives were synthesized by DCC-coupling of substituted cinnamic acid with tyramine or tyramine methyl-1-ether to evaluate PAF-receptor binding antagonistic activities and inhibitory activities on PAF-induced platelet aggregation with interest on structure-activity relations. The results show that 3,4-dimethoxy-cinnamoyl tyramine-amide or its methyl ether have significant PAF-receptor binding antagonistic activity and platelet anti-aggregatory activities.

Nonlinear responses in optical metamaterials: theory and experiment

We employed both theoretical calculations and experiments to study the nonlinear responses in optical metamaterials. The spectra of second-harmonic generations measured on a fishnet metamaterial are in quantitative agreements with calculations based on full-wave numerical simulations combined with field integrations, both exhibiting ~80 times enhancements at the magnetic resonance frequency. Our calculations explained several interesting features observed experimentally, and suggested an optimal metamaterial structure to yield the strongest nonlinear signals.

Ultrafast modulation of optical metamaterials

We show by pump-probe spectroscopy that the optical response of a fishnet metamaterial can be modulated on the femtosecond time scale. The modulation dynamics is dominated by pump-induced changes in the constituting dielectric medium, but the strength of modulation is dramatically enhanced through the plasmon resonance. The pump-induced spectral responses of the metamaterial provide understanding on how the resonance is modified by pump excitation. Our study suggests that metamaterials can be used as high-speed amplitude/phase modulators with terahertz-bandwidth.

Observation of excitons in one-dimensional metallic single-walled carbon nanotubes

Excitons are generally believed not to exist in metals because of strong screening by free carriers. Here we demonstrate that excitonic states can in fact be produced in metallic systems of a one-dimensional character. Using metallic single-walled carbon nanotubes as a model system, we show both experimentally and theoretically that electron-hole pairs form tightly bound excitons. The exciton binding energy of 50 meV, deduced from optical absorption spectra of individual metallic nanotubes, significantly exceeds that of excitons in most bulk semiconductors and agrees well with ab initio theoretical predictions.

Human amniotic fluid-derived stem cells have characteristics of multipotent stem cells

OBJECTIVES

To characterize mesenchymal stem cell-like cells isolated from human amniotic fluid for a new source of therapeutic cells.

MATERIALS

Fibroblastoid-type cells obtained from amniotic fluid at the time of birth.

METHODS

The ability of ex vivo expansion was investigated until senescence, and stem cell-like characteristics were analyzed by examining differentiation potential, messenger RNA expression and immunophenotypes.

RESULTS AND CONCLUSIONS

A morphologically homogenous population of fibroblastoid-type (HAFFTs) cells, similar to mesenchymal stem cells from bone marrow (BM-MSCs), was obtained at the third passage. The cells became senescent after 27 passages over a period of 8 months while undergoing 66 population doublings. Under appropriate culture conditions, by the 8th passage they differentiated into adipocytes, osteocytes, chondrocytes and neuronal cells, as revealed by oil red O, von Kossa, Alcian blue and anti-NeuN antibody staining, respectively. Immunophenotype analyses at the 17th passage demonstrated the presence of TRA-1-60; SSEA-3 and-4; collagen types I, II, III, IV and XII; fibronectin; alpha-SMA; vimentin; desmin; CK18; CD44; CD54; CD106; FSP; vWF; CD31; and HLA ABC. Reverse transcriptase-polymerase chain reaction analysis of the HAFFTs from passages 6-20 showed consistent expression of Rex-1, SCF, GATA-4, vimentin, CK18, FGF-5 and HLA ABC genes. Oct-4 gene expression was observed up to the 19th passage but not at the 20th passage. HAFFTs showed telomerase activity at the 5th passage with a decreased level by the 21st passage. Interestingly, BMP-4, AFP, nestin and HNF-4alpha genes showed differential gene expression during ex vivo expansion. Taken together, these observations suggest that HAFFTs are pluripotent stem cells that are less differentiated than BM-MSCs, and that their gene expression profiles vary with passage number during ex vivo expansion.

Increased telomerase activity and human telomerase reverse transcriptase mRNA expression in the endometrium of patients with endometriosis

BACKGROUND

Endometriosis is considered a frequent, benign disease with the ability to undergo neoplastic processes. The aim of this study was to evaluate the limitless replication potential of the endometrium in patients with endometriosis by examining human telomerase reverse transcriptase (hTERT) mRNA expression and telomerase activity.

METHODS

Endometrium samples from 30 endometriosis patients and 30 patients without endometriosis were obtained via endometrial biopsy. The expression of hTERT mRNA was determined by real-time RT-PCR assay, and telomerase activity was measured by telomerase repeat amplification protocol (TRAP) assay.

RESULTS

The mean normalized hTERT (N hTERT) mRNA level was significantly higher in the endometriosis than in the control group (P = 0.013). The mean hTERT mRNA levels during the proliferative phase and during the secretory phase were higher in the endometriosis group than in the control group, although the difference was only significant for the secretory phase (P = 0.036). We found a prominent difference in endometrial telomerase activity between moderate-to-severe endometriosis and the control group (P = 0.048). The levels of hTERT mRNA and telomerase activity increased as the disease became more severe (P = 0.038, P = 0.016).

CONCLUSIONS

This study showed the overexpression of hTERT mRNA and telomerase activity in the endometrium of endometriosis patients. These finding suggest that replication potential of endometrial cells may have an important role in the pathogenesis of endometriosis.

A case with balanced chromosome rearrangement involving chromosomes 9, 14, and 13 in a woman with recurrent abortion

A phenotypically normal couple was referred for cytogenetic evaluation due to three consecutive first-trimester spontaneous abortions. Chromosomal analysis from peripheral blood was performed according to standard cytogenetic methods using G-banding technique. The husband's karyotype was normal. The wife's karyotype showed a balanced complex chromosome rearrangement (CCR) involving chromosomes 9, 14, and 13. There were three breakpoints: 9p21.2, 14q21, and 13q12.2. The karyotype was designated as 46, XX, t (9;14;13)(p21.2;q21;q12.2). Fluorescence in situ hybridization (FISH) analysis with chromosome-specific libraries of chromosomes 9, 14, and 13 was performed to confirm this rare chromosome rearrangement. The result of FISH coincided with that obtained by standard cytogenetic techniques.

Triple marker screening for fetal chromosomal abnormalities in Korean women of advanced maternal age

The purpose of this article is to assess the value of maternal serum triple marker screening of alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) for the prenatal diagnosis of fetal chromosomal abnormalities in Korean women of advanced maternal age. Maternal sera were collected from 458 pregnant Korean women aged 35 between 15 and 20 weeks gestation before amniocentesis. A patient- specific second trimester risk for fetal Down's syndrome was calculated using the median values for AFP, hCG, uE3 and maternal age. Twelve fetal chromosomal abnormalities were identified. These included six cases of trisomy 21, one case of 46,XY/47,XY,+21, two cases of trisomy 18, one case of trisomy 13, and two cases of 45, X. A cutoff level of 1:200 detected 85.7% (6/7) of the cases of Down's syndrome and 20% (1/5) of the other aneuploidies, with a 27.3% false positive rate. However, a cutoff level of 1:270 did not result in any gains in detecting Down's syndrome or other aneuploidies at the expense of a false positive rate of 34.3%. Second trimester triple marker testing is an effective screening tool for detecting fetal Down's syndrome in Korean women > or = 35 years old. However, it is not an effective screening tool for non-Down's chromosomal abnormalities.

Development of pulmonary arteriovenous fistulas after bidirectional cavopulmonary shunt

BACKGROUND

A high incidence of pulmonary arteriovenous fistulas (PAVF) has been reported after bidirectional cavopulmonary shunt (BCPS) or total cavopulmonary shunt (TCPS; BCPS in patients with interrupted inferior vena cava). However, the definite diagnostic criteria or standard diagnostic modality of PAVF has not yet been defined. The goal of this study was to evaluate the diagnostic modalities and the prevalence of PAVF.

METHODS

We selected 10 patients with TCPS and 27 patients with BCPS. Lung perfusion scan, contrast echocardiogram, and pulmonary angiogram were performed. The results were compared among groups of patients and among each diagnostic modality.

RESULTS

All 10 patients with TCPS and 16 and 13 patients with BCPS showed positive results on contrast echocardiograms and lung scans, respectively. Six patients with TCPS and 4 patients with BCPS showed positive results on pulmonary angiograms. All patients with TCPS developed subclinical or clinical PAVF and 19 patients with BCPS developed subclinical PAVF and none of them had clinical PAVF during the short-term follow-up.

CONCLUSIONS

Most patients with bidirectional cavopulmonary anastomosis have subclinical evidence of right-to-left intrapulmonary shunting. This problem can be demonstrated with various diagnostic modalities.

Helical CT angiography and three-dimensional reconstruction of total anomalous pulmonary venous connections in neonates and infants

OBJECTIVE

The objective of this study was to investigate the usefulness of helical CT angiography in the evaluation of total anomalous pulmonary venous connections.

MATERIALS AND METHODS

Fourteen patients with total anomalous pulmonary venous connections underwent helical CT angiography and subsequent three-dimensional (3D) reconstruction. They ranged in age from 3 days to 8 months (median age, 2.3 months) and in weight from 2.3 to 7.1 kg (median weight, 4.3 kg). The types of total anomalous pulmonary venous connections and the number of pulmonary veins were evaluated on axial and 3D images. Qualitative evaluations were performed for extent of pulmonary vascular enhancement and contrast- or motion-induced artifacts.

RESULTS

In all patients, helical CT angiography correctly depicted total anomalous pulmonary venous connections. Seven cases were the supracardiac type, four cases were the cardiac type, one case was the infracardiac type, and two cases were the mixed type. The detection rate of the pulmonary vein in 3D reconstruction images (95-98%) was slightly lower than that of the pulmonary vein in the axial images (100%), but the difference between axial and 3D reconstruction images was not statistically significant (p > 0.1). No statistically significant differences were noted among 3D reconstruction images in the detection rates of the pulmonary vein (p > 0.1). The extent of contrast enhancement of the pulmonary vein was good or excellent in all patients. In five patients, there were contrast-induced artifacts that made some surrounding vascular distortion but did not interfere with the pulmonary vein analysis, except in one patient. Motion-induced artifacts were observed in nine patients. One of them had an obstacle in pulmonary vein analysis.

CONCLUSION

The combination of axial and 3D images in helical CT angiography is helpful in the assessment of a total anomalous pulmonary venous connection containing the individual pulmonary vein, and this combination can be a good diagnostic tool in preoperative evaluation of neonates and infants with a total anomalous pulmonary venous connection.

Adverse pregnancy outcome following post-chorionic villus sampling amniocentesis compared to chorionic villus sampling

OBJECTIVE

To assess the adverse pregnancy outcome of post-chorionic villus sampling (CVS) amniocentesis and chorionic villus sampling.

METHODS

Adverse pregnancy outcomes of 32 post-CVS amniocentesis cases and 264 CVS only cases were compared. The base-line characteristics were comparable in the 2 groups.

RESULTS

One (3.1%) chromosomal abnormality was detected in the post-CVS amniocentesis group, compared to 5 (1.8%) in the CVS only group (p > 0.05). The fetal loss rate (spontaneous abortions and stillbirths) among continuing pregnancies was 3.2% in the post-CVS amniocentesis group and 3.5% in the CVS only group (p > 0.05). No statistically significant difference was found in the incidence of neonatal death, preterm delivery, fetal growth restriction, or congenital anomalies between the 2 groups.

CONCLUSION

Adverse pregnancy outcome occurred at a similar frequency in the post-CVS amniocentesis group as in the CVS only group. Therefore, a subsequent amniocentesis after CVS can be considered as a safe procedure that does not introduce any additional adverse pregnancy outcome compared to that of CVS only.

A decrease in circulating levels of immunoreactive insulin-like growth factor binding protein-1 (IGFBP-1) after endometrial ablation using a gynecologic resectoscope

To determine how endometrium alone would contribute to maintaining the circulating levels of Insulin-like growth factor binding protein-1 in vivo, serum immunoreactive IGFBP-1 levels were measured in 19 patients undergoing endometrial ablation using gynecologic resectoscopy. After endometrial ablation there was a significant decrease in the mean levels of circulating IGFBP-1, which was not correlated with the menstrual cycle. This result indicates that the endometrium is one of the sources of the circulating IGFBP-1.

Characteristics of a 128 x 128 liquid-crystal spatial light modulator for wave-front generation

Spatial and temporal characteristics of a 128x128 zero-twist nematic liquid-crystal spatial light modulator are investigated for wave-front generation at a wavelength of 632.8 nm. The modulator is found to have the capability of producing at least eight phase levels between 0 and 2pi , and the rate of arbitrary phase modulation is limited to approximately 4.5 Hz. Wave-front generation of the first 55 Zernike polynomials is demonstrated.

Application of bispectral speckle imaging to near-diffraction-limited imaging in the presence of unknown aberrations

A laboratory experiment that demonstrates near-diffraction-limited imaging of a detailed object in the presence of unknown fixed aberrations in the imaging system is described. A random-phase plate is introduced in a pupil plane of the imaging system to eliminate the effect of fixed aberrations in the system. We employ a bispectral speckle imaging technique to recover the object from speckled images affected by both the random-phase fluctuations induced by the random-phase plate and the fixed aberrations present in the imaging system. For the case where the random phase is assumed to obey Gaussian statistics an approximate form of the bispectral speckle transfer function is obtained with an asymptotic expansion. This approximate form of the transfer function shows the diffraction-limited nature of bispectral speckle imaging when the standard deviation of the random-phase fluctuations is of the order of a wavelength of light. Experimental results are presented for fixed aberrations associated with lens tilt and defocus in the imaging system.

Ovarian transposition with subsequent intrauterine pregnancy

A 28-year-old married, Korean woman was diagnosed with a right unicornuate uterus, a left hypoplastic tube, and a right ovarian necrotic corpus luteal cyst. We performed a right oophorectomy and an excision of the left hypoplastic tube and then transferred the left ovary to the right broad ligament with intact vascular pedicles. Thus the remaining left ovary and right fallopian tube were placed in proximity. The patient conceived 2 months after the operation and delivered a living male infant.