Self-Measured Blood Pressure-Guided Pharmacotherapy: A Systematic Review and Meta-Analysis of United States-Based Telemedicine Trials.

BACKGROUND: The optimal approach to implementing telemedicine hypertension management in the United States is unknown. METHODS: We examined telemedicine hypertension management versus the effect of usual clinic-based care on blood pressure (BP) and patient/clinician-related heterogeneity in a systematic review/meta-analysis. We searched United States-based randomized trials from Medline, Embase, CENTRAL, CINAHL, PsycINFO, Compendex, Web of Science Core Collection, Scopus, and 2 trial registries. We used trial-level differences in BP and its control rate at ≥6 months using random-effects models. We examined heterogeneity in univariable metaregression and in prespecified subgroups (clinicians leading pharmacotherapy [physician/nonphysician], self-management support [pharmacist/nurse], White versus non-White patient predominant trials [>50% patients/trial], diabetes predominant trials [≥25% patients/trial], and White patient predominant but not diabetes predominant trials versus both non-White and diabetes patient predominant trials]. RESULTS: Thirteen, 11, and 7 trials were eligible for systolic and diastolic BP difference and BP control, respectively. Differences in systolic and diastolic BP and BP control rate were -7.3 mm Hg (95% CI, -9.4 to -5.2), -2.7 mm Hg (-4.0 to -1.5), and 10.1% (0.4%-19.9%), respectively, favoring telemedicine. Greater BP reduction occurred in trials where nonphysicians led pharmacotherapy, pharmacists provided self-management support, White patient predominant trials, and White patient predominant but not diabetes predominant trials, with no difference by diabetes predominant trials. CONCLUSIONS: Telemedicine hypertension management is more effective than clinic-based care in the United States, particularly when nonphysicians lead pharmacotherapy and pharmacists provide self-management support. Non-White patient predominant trials achieved less BP reduction. Equity-conscious, locally informed adaptation of telemedicine interventions is needed before wider implementation.

Electrocardiographic Early Repolarization in an Emergency Setting: The Subtleties of Electrocardiography.

The electrocardiographic pattern of early repolarization (ER) is relatively common in the general population. In patients presenting to the emergency room with chest pain, it can be particularly challenging to distinguish ER from life-threatening subtle ST-segment elevation myocardial infarction (STEMI). A 37-year-old male presented to the emergency department with sudden-onset, severe, non-radiating, central chest pain. The ECG showed Q waves in the inferior leads and a widespread end-QRS notch with J-point elevation mimicking ST elevation in the inferior and lateral precordial leads. Initial cardiac biomarkers were within normal limits. Serial cardiac biomarkers were unremarkable. Echocardiography showed no wall motion abnormalities. A review of prior records from a month ago revealed a similar presentation with similar ECG findings when he underwent cardiac catheterization, revealing normal coronary arteries. Since the ECG was unchanged from the prior one with negative cardiac biomarkers and a negative angiographic study a month ago, no further ischemic risk stratification was indicated. Distinguishing ER from subtle STEMI in patients with acute chest pain can be challenging. A good clinical acumen, along with a comparison of prior ECGs, can aid in decision-making.

Heterogeneity of the Effect of Telemedicine Hypertension Management Approach on Blood Pressure: A Systematic Review and Meta-analysis of US-based Clinical Trials.

Background: Telemedicine management of hypertension (TM-HTN) uses home blood pressure (BP) to guide pharmacotherapy and telemedicine-based self-management support (SMS). Optimal approach to implementing TM-HTN in the US is unknown. Methods: We conducted a systematic review and a meta-analysis to examine the effect of TM-HTN vs. usual clinic-based care on BP and assessed heterogeneity by patient- and clinician-related factors. We searched US-based randomized clinical trials among adults from Medline, Embase, CENTRAL, CINAHL, PsycInfo, and Compendex, Web of Science Core Collection, Scopus, and two trial registries to 7/7/2023. Two authors extracted, and a third author confirmed data. We used trial-level differences in systolic BP (SBP), diastolic BP (DBP) and BP control rate at ≥6 months using random-effects models. We examined heterogeneity of effect in univariable meta-regression and in pre-specified subgroups [clinicians leading pharmacotherapy (physician vs. non-physician), SMS (pharmacist vs. nurse), White vs. non-White patient predominant trials (>50% patients/trial), diabetes predominant trials (≥25% patients/trial) and in trials that have majority of both non-White patients and patients with diabetes vs. White patient predominant but not diabetes predominant trials. Results: Thirteen, 11 and 7 trials were eligible for SBP, DBP and BP control, respectively. Differences in SBP, DBP and BP control rate were -7.3 mmHg (95% CI: - 9.4, -5.2), -2.7 mmHg (-4.0, -1.5) and 10.1% (0.4%, 19.9%), respectively, favoring TM-HTN. More BP reduction occurred in trials with non-physician vs. physician led pharmacotherapy (9.3/4.0 mmHg vs. 4.9/1.1 mmHg, P<0.01 for both SBP/DBP), pharmacist vs. nurses provided SMS (9.3/4.1 mmHg vs. 5.6/1.0 mmHg, P=0.01 for SBP, P<0.01 for DBP), and White vs. non-White patient predominant trials (9.3/4.0 mmHg vs. 4.4/1.1 mmHg, P<0.01 for both SBP/DBP), with no difference by diabetes predominant trials. Lower BP reduction occurred in both diabetes and non-White patient predominant trials vs. White patient predominant but not diabetes predominant trials (4.5/0.9 mmHg vs. 9.5/4.2 mmHg, P<0.01 for both SBP/DBP). Conclusions: TM-HTN is more effective than clinic-based care in the US, particularly when non-physician led pharmacotherapy and pharmacist provided SMS. Non-White patient predominant trials seemed to achieve lesser BP reduction. Equity conscious, locally informed adaptation of TM-HTN is needed before wider implementation. Clinical Perspective: What Is New?: In this systematic review and meta-analysis of US-based clinical trials, we found that telemedicine management of hypertension (TM-HTN) was more effective in reducing and controlling blood pressure (BP) compared with clinic based hypertension (HTN) care.The BP reduction was more evident when pharmacotherapy was led by non-physician compared with physicians and HTN self-management support was provided by clinical pharmacists compared with nurses,Non-White patient predominant trials achieved lesser BP reductions than White patient predominant trials.What Are the Clinical Implications?: Before wider implementation of TM-HTN intervention in the US, locally informed adaptation, such as optimizing the team-based HTN care approach, can provide more effective BP control.Without equity focused tailoring, TM-HTN intervention implemented as such can exacerbate inequities in BP control among non-White patients in the US.

Women-centered drug treatment models for pregnant women with opioid use disorder: A scoping review.

BACKGROUND: While there is a high unmet need for drug treatment services tailored to the needs of pregnant women, fewer than half of the opioid use disorder (OUD) treatment programs in the U.S. offer such services. We conducted a scoping review of the literature to identify women-centered drug treatment models that address access, coordination, and quality of care, and their facilitators and barriers. METHODS: We searched PubMed, EMBASE, PsycInfo, Sociology Database, Web of Science, CINAHL, EBSCO Open Dissertations, Health Services Research Projects in Progress, and relevant agency websites from 1990 to 2020. We included studies that evaluated multicomponent models of care that provided medication for OUD (MOUD) to pregnant women in the U.S. RESULTS: Of the 1,578 unduplicated articles screened, 26 articles met the inclusion criteria, which reported on 19 different studies and included 3,193 women. We identified seven different models of care and found that: (1) access was improved by co-locating various services for drug treatment and care, (2) coordination was enhanced by inter-professional collaboration, (3) quality was improved by treating pregnant patients in groups, and (4) stigmatization and criminalization of substance use during pregnancy was a significant barrier to care. CONCLUSIONS: There is an urgent need to bolster patient-provider relationships that are built on trust, are free of stigma, and that empower patients to make their own decisions. Improved policies and regulations to reduce stigma around the use of opioids and MOUD are needed, so that pregnant women with OUD can access high quality care.

Study, Design, and Rationale of Noncommunicable Diseases in Nepal (NCD Nepal) Study: A Community-Based Prospective Epidemiological and Implementation Study in Rural Nepal.

BACKGROUND: Noncommunicable diseases (NCDs) are the leading causes of deaths globally. Currently, there are limited high-quality data on the epidemiology and usefulness of community-based screening and treatment of NCDs in low-to-middle-income countries (LMIC), like Nepal. We describe the protocol of a community-based, longitudinal epidemiological study of screening and management of NCDs in rural Nepal. METHODS: We organize monthly mobile health clinics to screen NCDs among 40- to 75-year-old residents from municipal subdivision wards 3, 4, 6, and 7 of Ghorahi submetropolitan city, Dang, Nepal (approximately 406 km west of the capital, Kathmandu). We estimate a total of 7052 eligible participants. After obtaining informed consent, trained personnel will collect sociodemographic and lifestyle data, medical, medication, and family history using validated questionnaires, plus anthropometric measures and capillary glucose levels. We will screen for hypertension, diabetes, obesity, dyslipidemia, tobacco and alcohol use, self-reported physical activity, dietary habits, cardiovascular disease, stroke, chronic lung disease, cancer, and chronic kidney disease. We will also check hemoglobin A1C, lipid panel, serum creatinine, sodium, potassium, urine dipstick, and urine albumin-to-creatinine ratio in high-risk participants. We will offer lifestyle counseling, pharmacotherapy or refer to higher level care, where appropriate; routinely follow participants with NCDs for continuity of care; and follow individuals without NCDs but with elevated glucose, prehypertension or other risk factors every year, and those without risk factors every 2 years. We will monitor participants in the community to reduce attrition and to track all-cause and disease-specific mortality. DISCUSSION: Understanding the community burden of NCDs in resource-limited setting and testing effectiveness of community-based screening and management of NCDs will provide insights to develop national policy to address NCD burden in LMIC like Nepal.

Clinical profile, complications and outcome of scrub typhus in children: A hospital based observational study in central Nepal.

BACKGROUND: Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children. METHODS: A prospective observational study was carried out in children aged 1-16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA. RESULTS: All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%. CONCLUSIONS: Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome.