Use of Mobile Messaging System for Self-Management of Chemotherapy Symptoms in Patients with Advanced Cancer.

The use of an automated text messaging intervention provided a cost-effective option for symptom management for patients experiencing cancer-related symptoms.

End-of-life care in patients with heart failure.

Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.

Telephone titration of heart failure medications.

BACKGROUND: In clinical practice, heart failure (HF) medications are underused and prescribed at lower than recommended doses. Telephone care is an option that could help to titrate HF medication in a timely manner. We describe our experience of a nurse-run, cardiologist- or nurse practitioner-supervised clinic to up-titrate HF medications via telephone. METHODS: Patients with the diagnosis of HF, New York Heart Association classes I to III, were referred to a registered nurse-run, cardiologist-/nurse practitioner-supervised HF medication titration clinic. Clinical and medication data collected at enrollment to the clinic and at 3 to 6 months after optimization of HF medications in patients who did or did not reach the target doses were compared. Effect on left ventricular (LV) function was also evaluated. RESULTS: There were 79 patients in the evaluation: 64 with HF and LV systolic dysfunction (LVSD) and the remaining 15 with HF and preserved ejection fraction (EF). Seventy-two percent of patients with LVSD were on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), and 61% were on a ß-blocker at baseline, and this increased to 98% and 97%, respectively, after optimization. Target doses was achieved in 50% of patients for ACEI or ARB, and in 41% for ß-blockers. The median time to optimization was 54 days (interquartile range, 20-97 days). The average number of phone calls at the time of optimization were 5.4 (SD, 3.7), and the average number of clinic visits was 1.9 (SD, 1.3). Reasons for not reaching the target doses included hypotension, hyperkalemia, and renal dysfunction for ACEI and bradycardia for ß-blockers. Overall, the EF increased by 10% (SD, 10%) after 6 months, and 35% or greater in 42% of patients whose baseline EF was less than 35%. There were no adverse events related to the dose up-titration. CONCLUSION: Telephonic titration of HF medications was feasible and safe and was achieved in 97% patients on ACEI/ARB and ß-blockers. Medication titration was associated with significant improvement in LV function, avoiding the need for device therapy in many patients.

Correlation of preoperative ankle-brachial index and pulse volume recording with impaired saphenous vein incisional wound healing post coronary artery bypass surgery.

Patients undergoing coronary artery bypass surgery have vascular disease and, subsequently, the risk for impaired healing of their saphenous vein graft site. The purpose of this study was to identify the correlation of the preoperative ankle-brachial index (ABI) and pulse volume recording (PVR) with impaired saphenous vein incisional wound healing post coronary artery bypass grafting. A prospective, correlational research design was used to study 271 male and female adults undergoing coronary artery bypass surgery in which the saphenous vein was used for grafting. Arterial insufficiency was assessed preoperatively using patient history, physical examination, ABI, and PVR. Wound status was assessed postoperatively using the validated ASEPSIS tool for inpatients. A modified ASEPSIS tool, the Wound Healing Self Score, was used for telephone follow-up post discharge. Abnormal ABI and PVR measurements were positively correlated with impaired saphenous vein incisional wound healing (r = 0.72, P < .0001). Both tests also independently predicted impaired healing. Incisional infection correlated with impaired healing (P < .0001). Other clinical variables, including diabetes, hypertension, venous disease, and alcohol and cigarette use, were not found to be statistically significant independent predictors of impaired healing. Routine histories and physical examinations alone are insufficient in predicting risk for impaired saphenous vein incisional wound healing. The addition of noninvasive screening for the presence of arterial insufficiency before coronary artery bypass grafting using ABI and PVR tests is one method of predicting the likelihood of impaired healing.

Coronary-artery revascularization before elective major vascular surgery.

BACKGROUND: The benefit of coronary-artery revascularization before elective major vascular surgery is unclear. METHODS: We randomly assigned patients at increased risk for perioperative cardiac complications and clinically significant coronary artery disease to undergo either revascularization or no revascularization before elective major vascular surgery. The primary end point was long-term mortality. RESULTS: Of 5859 patients scheduled for vascular operations at 18 Veterans Affairs medical centers, 510 (9 percent) were eligible for the study and were randomly assigned to either coronary-artery revascularization before surgery or no revascularization before surgery. The indications for a vascular operation were an expanding abdominal aortic aneurysm (33 percent) or arterial occlusive disease of the legs (67 percent). Among the patients assigned to preoperative coronary-artery revascularization, percutaneous coronary intervention was performed in 59 percent, and bypass surgery was performed in 41 percent. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the group not undergoing revascularization (P<0.001). At 2.7 years after randomization, mortality in the revascularization group was 22 percent and in the no-revascularization group 23 percent (relative risk, 0.98; 95 percent confidence interval, 0.70 to 1.37; P=0.92). Within 30 days after the vascular operation, a postoperative myocardial infarction, defined by elevated troponin levels, occurred in 12 percent of the revascularization group and 14 percent of the no-revascularization group (P=0.37). CONCLUSIONS: Coronary-artery revascularization before elective vascular surgery does not significantly alter the long-term outcome. On the basis of these data, a strategy of coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended.