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

Microbiological and faunal soil attributes of coffee cultivation under different management systems in Brazil

Brazil is the biggest coffee producer in the world and different plantation management systems have been applied to improve sustainability and soil quality. Little is known about the environmental effects of these different management systems, therefore, the goal of this study was to use soil biological parameters as indicators of changes. Soils from plantations in Southeastern Brazil with conventional (CC), organic (OC) and integrated management systems containing intercropping of Brachiaria decumbens (IB) or Arachis pintoi (IA) were sampled. Total organic carbon (TOC), microbial biomass carbon (MBC) and nitrogen (MBN), microbial activity (C-CO2), metabolic quotient (qCO2), the enzymes dehydrogenase, urease, acid phosphatase and arylsulphatase, arbuscular mycorrhizal fungi (AMF) colonization and number of spores and soil fauna were evaluated. The greatest difference between the management systems was seen in soil organic matter content. The largest quantity of TOC was found in the OC, and the smallest was found in IA. TOC content influenced soil biological parameters. The use of all combined attributes was necessary to distinguish the four systems. Each management presented distinct faunal structure, and the data obtained with the trap method was more reliable than the TSBF (Tropical Soils) method. A canonic correlation analysis showed that Isopoda was correlated with TOC and the most abundant order with OC. Isoptera was the most abundant faunal order in IA and correlated with MBC. Overall, OC had higher values for most of the biological measurements and higher populations of Oligochaeta and Isopoda, corroborating with the concept that the OC is a more sustainable system.

Genetic diversity of polysporic isolates of Moniliophthora perniciosa (Tricholomataceae)

The causal agent of witches' broom disease, Moniliophthora perniciosa is a hemibiotrophic and endemic fungus of the Amazon basin and the most important cocoa disease in Brazil. The purpose of this study was to analyze the genetic diversity of polysporic isolates of M. perniciosa to evaluate the adaptation of the pathogen from different Brazilian regions and its association with different hosts. Polysporic isolates obtained previously in potato dextrose agar cultures of M. perniciosa from different Brazilian states and different hosts (Theobroma cacao, Solanum cernuum, S. paniculatum, S. lycocarpum, Solanum sp, and others) were analyzed by somatic compatibility grouping where the mycelium interactions were distinguished after 4-8 weeks of confrontation between the different isolates of M. perniciosa based on the precipitation line in the transition zone and by protein electrophoresis through SDS-PAGE. The diversity of polysporic isolates of M. perniciosa was grouped according to geographic proximity and respective hosts. The great genetic diversity of M. perniciosa strains from different Brazilian states and hosts favored adaptation in unusual environments and dissemination at long distances generating new biotypes.

Platelet-activating factor and human meningiomas

Meningiomas are common primary intracranial tumours. Platelet-activating factor (PAF) is an inflammatory and angiogenic lipid mediator involved in several types of cancer. The presence of PAF receptor (PAF-R) transcripts, the levels of PAF, the phospholipase A2 activity (PLA2, the enzymatic activity implicated in PAF formation) and the PAF acetylhydrolase activity (AHA, the PAF degrading enzyme) were investigated in 49 human meningiomas. PAF-R transcripts, PAF, PLA2 and AHA were detected in meningiomas. However, their levels did not correlate with biological parameters such as the tumour grade, the presence of associated oedema, necrosis, mitotic index as well as intensity of the neovascularization and chronic inflammatory response. In conclusion, PAF is present in meningiomas where it might act on tumour growth by altering the local angiogenic and/or cytokine networks as previously suggested for human breast and colorectal cancer.

Demyelinating peripheral neuropathy associated with hemophagocytic lymphohistiocytosis. An immuno-electron microscopic study

We report the case of an 11-year-old male who developed subacute diffuse polyradiculoneuropathy, associated with digestive symptoms and Epstein-Barr virus infection. Parental consanguinity was present. The laboratory findings including bone marrow smear were consistent with hemophagocytic lymphohistiocytosis (HLH). Electrophysiological study of peripheral nerves revealed an intense and diffuse demyelinating process. The histological nerve lesions were severe and purely demyelinating. Most axons were intact. There was a diffuse infiltration of the nerve parenchyma by mononuclear cells. Immuno-electron microscopic study evidenced entry of macrophages into Schwann cell cytoplasm with dissociation of myelin sheaths. This boy died several months after the onset of the neuropathic symptoms. HLH is a rare genetic or acquired disorder in childhood characterized by abnormal immune activation, which induces an uncontrolled inflammatory response with sustained hyperactivation of T lymphocytes and macrophages. Only very rare cases of peripheral nerve involvement have been described in HLH. This is the first case showing that peripheral nerves, as other viscera, may be destroyed by the macrophagic infiltration, which characterizes HLH.

Effects of 2,3-butanedione monoxime on excitation-contraction coupling in frog twitch fibres

10 and 30 mM 2,3-butanedione monoxime (BDM) applied extracellularly to voltage-clamped frog skeletal muscle twitch fibres suppressed both Ca2+ release flux and intramembranous charge movement. Both effects could be clearly separated. The early peak of the Ca2+ release flux was suppressed at every test voltage. The steady level attained at the end of a 100 ms clamp depolarization was relatively spared for lower depolarizing pulses, but was as suppressed as the peak at voltages above -20 mV. The intramembranous charge movement was affected mainly in the I gamma component. The drug had a distinct effect on the kinetics of the intramembranous charge movement current around the threshold for Ca2+ release. The three kinetic components of I gamma were simultaneously affected. For more positive depolarizations where the kinetic effect was not evident, the oxime had no significant effect on the charge moved. Under conditions in which I gamma was absent (i.e. stretched fibres, intracellular solutions containing 6 to 10 mM BAPTA), treatment with 10 mM BDM had a small, not significant suppressive effect on the maximum charge moved (Qmax), while it affected Ca2+ release significantly. When 10 mM BDM was applied in the presence of 0.2 mM tetracaine, the local anaesthetic-resistant Ca2+ release flux was not further suppressed by the oxime.