Effectiveness of a remote care program in the management of patients with resistant hypertension or multiple medication intolerances

Background

A remote hypertension (HTN) program, designed and implemented at Mass General Brigham (MGB), has demonstrated improved HTN control, reduced need for in-person visits, and increased access to care. The program excluded patients with resistant HTN or multiple intolerances/allergies to guideline-directed therapies, whose blood pressure (BP) is difficult to manage.

Purpose

To develop a more intensive but still remote program (“HTN-Plus”) for patients with resistant HTN or intolerances/allergies to multiple medications, and to assess its effectiveness for BP control.

Methods

From 10/2020 through 11/2021, we identified a subset of hypertensive patients from the total pool of those enrolled in our remote HTN management program, who required more personalized and intensive therapy than the overall remote management program provided. We developed ancillary management for these patients, who included: 1) patients with apparent resistant HTN (ARH), ie with uncontrolled BP despite maximum tolerated doses of at least three anti-HTN medications including a diuretic, and 2) patients with multiple medication intolerances or allergies that precluded appropriate triple therapy or limited dose-optimization. A nurse practitioner provided education and advice on BP measurement technique, lifestyle modifications, and adherence. Evaluation for primary aldosteronism (PA) was undertaken in those with ARH.

Results

We enrolled 3658 patients with uncontrolled HTN, of whom 117 qualified for the HTN-Plus program. The average BP on entry was 143/80 mmHg. 68% had apparent resistant HTN and 32% had multiple medication intolerances/allergies. Among all patients, 30% had incorrect BP-measurement technique upon interview, 10% who were tested for PA had a positive screening test, 56% had a history suggestive of an unmanaged secondary cause, and only 6% admitted imperfect adherence, but urine testing was not done. 74% of patients completed the program meaning they were reachable through the end and did not drop out. Across the program, 72 new medications were started, and 84 medication titrations were made. 50% of patients who enrolled in HTN-plus achieved BP <130/80 mmHg. 22% achieved BP control with education and coaching alone. For patients who completed the program, the average entry and final BPs were 139/78 mmHg and 126/70 mmHg respectively, with an average BP decrease of 13/8 mmHg.

Conclusions

In patients who remain hypertensive despite maximally tolerated guideline-directed medication utilization, our intensified but still entirely remote HTN management program helped patients reach their BP goal through education, coaching, and medication management. Nearly a quarter were able to achieve BP control with education and coaching alone. These results suggest that a significant value of remote care in patients with resistant HTN or medication intolerances/allergies lies in ongoing education and coaching, for which more cost-effective solutions may be considered.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Mass General Brigham as part of quality improvement initiative

The Role of Postural Support in Young Adults' Control of Stationary Kicking

PURPOSE

The requirement for postural stability during the performance of motor skills has been clearly demonstrated in infants, but the necessity for such a postural substrate is not well documented in adults. The present study investigated the role of postural stability during a ballistic ball-kicking task in adults by providing varying degrees of external postural support.

METHOD

In the 1st experiment, 30 participants performed 20 maximal-velocity kicks under each of 3 conditions: grasping a rigid stable handle, light fingertip touch, and grasping a suspended elastic tube. A 2nd experiment with 16 participants varied the position of the stable handle to examine if the handle position in Experiment 1 might simply act as a fulcrum to enhance torque generation.

RESULTS

In Experiment 1, ball velocity was significantly higher in the stable-grasp condition in both men and women with the men showing greater improvement relative to the other conditions. Experiment 2 showed that the position of the stable handle did not significantly affect kicking velocity, indicating that the handle was not simply acting as a fulcrum during the kick.

CONCLUSION

Together, the findings suggest that postural stability may be a rate limiter in the performance of dynamic motor tasks in adults.

Impacts of stage-specific acute pesticide exposure on predicted population structure of the soft-shell clam, Mya arenaria

A combined laboratory and modeling approach was used to assess the impact of selected pesticides on early life stages of the soft-shell clam, Mya arenaria. Clams were exposed for 24h as veligers or pediveligers to the broad-spectrum herbicide hexazinone [3-cyclohexyl-6-(dimethylamino)-1-methyl-1,3,5-triazine-2,4(1h,3h)-dione; Velpar], the phenoxyacetic acid herbicide, 2,4-D (2,4-dichlorophenoxyacetic acid; Agway Super BK 32), or phosmet (Imidan). In addition, juvenile clams were exposed for 24h to 2,4-D and their growth monitored for 21 months. Laboratory experiments indicated veligers were more sensitive to acute pesticide exposure than pediveligers, with 2,4-D exposed veligers exhibiting the lowest survival among all treatments. Relative to controls, juvenile clams exposed to 0.5 ppm 2,4-D had enhanced survival following the initial 3 months of grow out. Juveniles exposed to 0.5, 5 and 10 ppm 2,4-D showed an initial growth delay relative to control clams, but at 21 months post-exposure these clams were significantly larger than control clams. Data from the larval and juvenile exposures were used to generate a stage-specific matrix model to predict the effect of pesticide exposure on clam populations. Impacts on simulated clam populations varied with the pesticide and stage exposed. For example, 2,4-D exposure of veligers and pediveligers significantly reduced predicted recruitment as well as population growth rate compared to controls, but juvenile exposure to 2,4-D did not significantly reduce population growth rate. With the exception of veligers exposed to 10 ppm, hexazinone exposure at the both veliger and pediveliger stages significantly reduced predicted recruitment success compared to 0 ppm controls. Hexazinone exposure also reduced modeled population growth rates, but these reductions were only slight in the pediveliger exposure simulations. Veliger and pediveliger exposure to phosmet reduced modeled population growth rate in a dose-dependent fashion. Changes in modeled population stable stage distributions were also observed when veligers were exposed to any pesticide. These results suggest that both the stage of exposure and the specific toxicant are important in predicting effects of pesticide exposure on soft-shell clam populations, with earlier life stages showing greater sensitivity to the pesticides tested.