Increased Opportunities for Transplantation for Women in the New Heart Allocation System.

BACKGROUND: Historically, women have had less access to advanced heart failure therapies, including temporary and permanent mechanical circulatory support and heart transplantation (HT), with worse waitlist and post-transplant survival compared with men. This study evaluated for improvement in sex differences across all phases of HT in the 2018 allocation system. METHODS AND RESULTS: The United Network for Organ Sharing registry was queried to identify adult patients (≥18 years) listed for HT from October 18, 2016, to October 17, 2018 (old allocation), and from October 18, 2018, to October 18, 2020 (new allocation). The outcomes of interest included waitlist survival, pretransplant use of temporary and durable mechanical circulatory support, rates of HT, and post-transplant survival. There were 15,629 patients who were listed for HT and included in this analysis; 7745 (2039 women, 26.3%) in the new and 7875 patients (2074 women, 26.3%) in the old allocation system. When compared with men in the new allocation system, women were more likely to have lower priority United Network for Organ Sharing status at time of transplant, and less likely to be supported by an intra-aortic balloon pump (27.1% vs 32.2%, P < .001), with no difference in the use of venoarterial extracorporeal membrane oxygenation (5.5% vs 6.3%, P = .28). Despite these findings, when transplantation was viewed in the context of risk for death or delisting, the cumulative incidence of transplant within 6 months of listing was higher in women than men in the new allocation system (62.4% vs 54.9%, P < .001) with no differences in post-transplant survival. When comparing women in the old with the new allocation system, the distance traveled for organ procurement was 187.5 ± 207.0 miles vs 272.8 ± 233.7 miles (P < .001). CONCLUSIONS: Although the use of temporary mechanical circulatory support in women remains lower than in men in the new allocation system, more women are being transplanted with comparable waitlist and post-transplant outcomes as men. Broader sharing may be making its greatest impact on improving transplant opportunities for women.

Twitter as a Tool for Health Research: A Systematic Review.

BACKGROUND: Researchers have used traditional databases to study public health for decades. Less is known about the use of social media data sources, such as Twitter, for this purpose. OBJECTIVES: To systematically review the use of Twitter in health research, define a taxonomy to describe Twitter use, and characterize the current state of Twitter in health research. SEARCH METHODS: We performed a literature search in PubMed, Embase, Web of Science, Google Scholar, and CINAHL through September 2015. SELECTION CRITERIA: We searched for peer-reviewed original research studies that primarily used Twitter for health research. DATA COLLECTION AND ANALYSIS: Two authors independently screened studies and abstracted data related to the approach to analysis of Twitter data, methodology used to study Twitter, and current state of Twitter research by evaluating time of publication, research topic, discussion of ethical concerns, and study funding source. MAIN RESULTS: Of 1110 unique health-related articles mentioning Twitter, 137 met eligibility criteria. The primary approaches for using Twitter in health research that constitute a new taxonomy were content analysis (56%; n = 77), surveillance (26%; n = 36), engagement (14%; n = 19), recruitment (7%; n = 9), intervention (7%; n = 9), and network analysis (4%; n = 5). These studies collectively analyzed more than 5 billion tweets primarily by using the Twitter application program interface. Of 38 potential data features describing tweets and Twitter users, 23 were reported in fewer than 4% of the articles. The Twitter-based studies in this review focused on a small subset of data elements including content analysis, geotags, and language. Most studies were published recently (33% in 2015). Public health (23%; n = 31) and infectious disease (20%; n = 28) were the research fields most commonly represented in the included studies. Approximately one third of the studies mentioned ethical board approval in their articles. Primary funding sources included federal (63%), university (13%), and foundation (6%). CONCLUSIONS: We identified a new taxonomy to describe Twitter use in health research with 6 categories. Many data elements discernible from a user's Twitter profile, especially demographics, have been underreported in the literature and can provide new opportunities to characterize the users whose data are analyzed in these studies. Twitter-based health research is a growing field funded by a diversity of organizations. Public health implications. Future work should develop standardized reporting guidelines for health researchers who use Twitter and policies that address privacy and ethical concerns in social media research.

A Randomized Trial Testing the Effect of Narrative Vignettes Versus Guideline Summaries on Provider Response to a Professional Organization Clinical Policy for Safe Opioid Prescribing.

STUDY OBJECTIVE: Clinical guidelines are known to be underused by practitioners. In response to the challenges of treating pain amid a prescription opioid epidemic, the American College of Emergency Physicians (ACEP) published an evidence-based clinical policy for opioid prescribing in 2012. Evidence-based narratives, an effective method of communicating health information in a variety of settings, offer a novel strategy for disseminating guidelines to physicians and engaging providers with clinical evidence. We compare whether narrative vignettes embedded in the ACEP daily e-newsletter improved dissemination of the clinical policy to ACEP members, and engagement of members with the clinical policy, compared with traditional summary text. METHODS: A prospective randomized controlled study, titled Stories to Promote Information Using Narrative trial, was performed. Derived from qualitative interviews with 61 ACEP physicians, 4 narrative vignettes were selected and refined, using a consensus panel of clinical and implementation experts. All ACEP members were then block randomized by state of residence to receive alternative versions of a daily e-mailed newsletter for a total of 24 days during a 9-week period. Narrative newsletters contained a selection of vignettes that referenced opioid prescription dilemmas. Control newsletters contained a selection of descriptive text about the clinical policy, using length and appearance similar to that of the narrative vignettes. Embedded in the newsletters were Web links to the complete vignette or traditional summary text, as well as additional links to the full ACEP clinical policy and a Web site providing assistance with prescription drug monitoring program enrollment. The newsletters were otherwise identical. Outcomes measured were the percentage of subjects who visited any of the Web pages that contained additional guideline-related information and the odds of any unique physician visiting these Web pages during the study. RESULTS: There were 27,592 physicians randomized, and 21,226 received the newsletter during the study period. When each physician was counted once during the study period, there were 509 unique visitors in the narrative group and 173 unique visitors in the control group (4.8% versus 1.6%; difference 3.2%; 95% confidence interval [CI] 2.7% to 3.7%). There were 744 gross visits from the e-newsletter to any of the 3 Web pages in the narrative group compared with 248 in the control group (7.0% versus 2.3%; odds ratio 3.2; 95% CI 2.7 to 3.6). During the study, the odds ratio of any physician in the narrative group visiting one of the 3 informational Web sites compared with the control group was 3.1 (95% CI 2.6 to 3.6). CONCLUSION: Among a national sample of emergency physicians, narrative vignettes outperformed traditional guideline text in promoting engagement with an evidence-based clinical guideline related to opioid prescriptions.

Bridging strategies and cardiac replacement outcomes in patients with acute decompensated heart failure-related cardiogenic shock.

AIMS: To describe outcomes associated with bridging strategies in patients with acute decompensated heart failure-related cardiogenic shock (ADHF-CS) bridged to durable left ventricular assist device (LVAD) or heart transplantation (HTx). METHODS AND RESULTS: Durable LVAD or HTx recipients from 2014 to 2019 with pre-operative ADHF-CS were identified in the Society of Thoracic Surgeons Adult Cardiac Surgery Database and stratified by bridging strategy. The primary outcome was operative or 30-day post-operative mortality. Secondary outcomes included post-operative major bleeding. Exploratory comparisons between bridging strategies and outcomes were performed using overlap weighting with and without covariate adjustment. Among 9783 patients with pre-operative CS, 8777 (89.7%) had ADHF-CS. Medical therapy (n = 5013) was the most common bridging strategy, followed by intra-aortic balloon pump (IABP; n = 2816), catheter-based temporary mechanical circulatory support (TMCS; n = 417), and veno-arterial extracorporeal membrane oxygenation (VA-ECMO; n = 465). Mortality was highest in patients bridged with VA-ECMO (22%), followed by catheter-based TMCS (10%), IABP (9%), and medical therapy (7%). Adverse post-operative outcomes were more frequent in LVAD recipients compared with HTx recipients. CONCLUSION: Among patients with ADHF-CS bridged to HTx or durable LVAD, the highest rates of death and adverse events during index hospitalization were observed in those bridged with VA-ECMO, followed by catheter-based TMCS, IABP, and medical therapy. Patients who received durable LVAD had higher rates of post-operative complications compared with HTx recipients. Prospective trials are needed to define optimal bridging strategies in patients with ADHF-CS.

Management of Type 2 Diabetes in Stage C Heart Failure with Reduced Ejection Fraction.

Type 2 diabetes is an increasingly common comorbidity of stage C heart failure with reduced ejection fraction (HFrEF). The two diseases are risk factors for each other and can bidirectionally independently worsen outcomes. The regulatory requirement of cardiovascular outcomes trials for antidiabetic agents has led to an emergence of novel therapies with robust benefits in heart failure, and clinicians must now ensure they are familiar with the management of patients with concurrent diabetes and stage C HFrEF. This review summarises the current evidence for the management of type 2 diabetes in stage C HFrEF, recapitulating data from landmark heart failure trials regarding the use of guideline-directed medical therapy for heart failure in patients with diabetes. It also provides a preview of upcoming clinical trials in these populations.

Communicating Guideline Recommendations Using Graphic Narrative Versus Text-Based Broadcast Screensavers: Design and Implementation Study.

BACKGROUND: The use of graphic narratives, defined as stories that use images for narration, is growing in health communication. OBJECTIVE: The aim of this study was to describe the design and implementation of a graphic narrative screensaver (GNS) to communicate a guideline recommendation (ie, avoiding low-value acid suppressive therapy [AST] use in hospital inpatients) and examine the comparative effectiveness of the GNS versus a text-based screensaver (TBS) on clinical practice (ie, low-value AST prescriptions) and clinician recall. METHODS: During a 2-year period, the GNS and the TBS were displayed on inpatient clinical workstations. The numbers of new AST prescriptions were examined in the four quarters before, the three quarters during, and the one quarter after screensavers were implemented. Additionally, an electronic survey was sent to resident physicians 1 year after the intervention to assess screensaver recall. RESULTS: Designing an aesthetically engaging graphic that could be rapidly understood was critical in the development of the GNS. The odds of receiving an AST prescription on medicine and medicine subspecialty services after the screensavers were implemented were lower for all four quarters (ie, GNS and TBS broadcast together, only TBS broadcast, only GNS broadcast, and no AST screensavers broadcast) compared to the quarter prior to implementation (odds ratio [OR] 0.85, 95% CI 0.78-0.92; OR 0.89, 95% CI 0.82-0.97; OR 0.87, 95% CI 0.80-0.95; and OR 0.81, 95% CI 0.75-0.89, respectively; P<.001 for all comparisons). There were no statistically significant decreases for other high-volume services, such as the surgical services. These declines appear to have begun prior to screensaver implementation. When surveyed about the screensaver content 1 year later, resident physicians recalled both the GNS and TBS (43/70, 61%, vs 54/70, 77%; P=.07) and those who recalled the screensaver were more likely to recall the main message of the GNS compared to the TBS (30/43, 70%, vs 1/54, 2%; P<.001). CONCLUSIONS: It is feasible to use a graphic narrative embedded in a broadcast screensaver to communicate a guideline recommendation, but further study is needed to determine the impact of graphic narratives on clinical practice.

Gender Differences in Publication Authorship During COVID-19: A Bibliometric Analysis of High-Impact Cardiology Journals.

Background The purpose of this study was to examine gender differences in authorship of manuscripts in select high-impact cardiology journals during the early coronavirus disease 2019 (COVID-19) pandemic. Methods and Results All manuscripts published between March 1, 2019 to June 1, 2019 and March 1, 2020 to June 1, 2020 in 4 high-impact cardiology journals (Journal of the American College of Cardiology, Circulation, JAMA Cardiology, and European Heart Journal) were identified using bibliometric data. Authors' genders were determined by matching first name with predicted gender using a validated multinational database (Genderize.io) and manual adjudication. Proportions of women and men first, co-first, senior, and co-senior authors, manuscript types, and whether the manuscript was COVID-19 related were recorded. In 2019, women were first authors of 176 (22.3%) manuscripts and senior authors of 99 (15.0%) manuscripts. In 2020, women first authored 230 (27.4%) manuscripts and senior authored 138 (19.3%) manuscripts. Proportions of woman first and senior authors were significantly higher in 2020 compared with 2019. Women were more likely to be first authors if the manuscript's senior author was a woman (33.8% for woman first/woman senior versus 23.4% for woman first/man senior; P<0.001). Women were less likely to be first authors of COVID-19-related original research manuscripts (P=0.04). Conclusions Representation of women as key authors of manuscripts published in major cardiovascular journals increased during the early COVID-19 pandemic compared with similar months in 2019. However, women were significantly less likely to be first authors of COVID-19-related original research manuscripts. Future investigation into the gender-disparate impacts of COVID-19 on academic careers is critical.

Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT-HF pilot study.

AIMS: Implementation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains incomplete. Non-cardiovascular hospitalization may present opportunities for GDMT optimization. We assessed the efficacy and durability of a virtual, multidisciplinary 'GDMT Team' on medical therapy prescription for HFrEF. METHODS AND RESULTS: Consecutive hospitalizations in patients with HFrEF (ejection fraction ≤40%) were prospectively identified from 3 February to 1 March 2020 (usual care group) and 2 March to 28 August 2020 (intervention group). Patients with critical illness, de novo heart failure, and systolic blood pressure <90 mmHg in the preceeding 24 hs prior to enrollment were excluded. In the intervention group, a pharmacist-physician GDMT Team provided optimization suggestions to treating teams based on an evidence-based algorithm. The primary outcome was a GDMT optimization score, the sum of positive (+1 for new initiations or up-titrations) and negative therapeutic changes (-1 for discontinuations or down-titrations) at hospital discharge. Serious in-hospital safety events were assessed. Among 278 consecutive encounters with HFrEF, 118 met eligibility criteria; 29 (25%) received usual care and 89 (75%) received the GDMT Team intervention. Among usual care encounters, there were no changes in GDMT prescription during hospitalization. In the intervention group, ß-blocker (72% to 88%; P = 0.01), angiotensin receptor-neprilysin inhibitor (6% to 17%; P = 0.03), mineralocorticoid receptor antagonist (16% to 29%; P = 0.05), and triple therapy (9% to 26%; P < 0.01) prescriptions increased during hospitalization. After adjustment for clinically relevant covariates, the GDMT Team was associated with an increase in GDMT optimization score (+0.58; 95% confidence interval +0.09 to +1.07; P = 0.02). There were no serious in-hospital adverse events. CONCLUSIONS: Non-cardiovascular hospitalizations are a potentially safe and effective setting for GDMT optimization. A virtual GDMT Team was associated with improved heart failure therapeutic optimization. This implementation strategy warrants testing in a prospective randomized controlled trial.

Acute heart failure.

Acute heart failure (AHF) is one of the most common causes for hospital admission and is associated with a high risk of mortality. Compared to chronic heart failure, there is less robust evidence to guide diagnosis, risk stratification and management of AHF. This state-of-the art review aims to summarize new developments in this field. We also highlight areas of ongoing work including novel vasoactive agents, alternative models to traditional hospital admission and strategies to improve patient engagement.

Trends in US Heart Transplant Waitlist Activity and Volume During the Coronavirus Disease 2019 (COVID-19) Pandemic.

IMPORTANCE: Solid organ transplants have declined significantly during the coronavirus disease (COVID-19) pandemic in the US. Limited data exist regarding changes in heart transplant (HT). OBJECTIVE: To describe national and regional trends in waitlist inactivations, waitlist additions, donor recovery, and HT volume during COVID-19. DESIGN, SETTING, AND PARTICIPANTS: This descriptive cross-sectional study used publicly available data from the United Network for Organ Sharing and US Centers for Disease Control and Prevention, using 8 prespecified United Network for Organ Sharing regions. Adult (18 years or older) HT candidates listed and deceased donors recovered between January 19 to May 9, 2020. EXPOSURES: COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: Changes in waitlist inactivations, waitlist additions, deceased donor recovery, and transplant volumes from the pre-COVID-19 (January 19-March 15, 2020) to the COVID-19 era (March 15-May 9, 2020). Density mapping and linear regression with interrupted time series analysis were used to characterize changes over time and changes by region. RESULTS: During the COVID-19 era, there were 600 waitlist inactivations compared with 343 during the pre-COVID era (75% increase). Waitlist additions decreased from 637 to 395 (37% reduction). These changes were most profound in the Northeast and Great Lakes regions with high rates of COVID-19. Deceased donor recovery decreased by 26% from 1878 to 1395; the most significant decrease occurred in the North Midwest despite low COVID-19 prevalence. Heart transplant volumes were significantly reduced across all regions except the Northwest. The largest decrease was seen in the Northeast where COVID-19 case rates were highest. From the pre-COVID-19 era to the COVID-19 era, there was significant regional variation in waitlist additions (eg, 69% decrease in the Northeast vs 8.5% increase in the South Midwest; P < .001) and deceased donor recovery (eg, 41% decrease in North Midwest vs 16% decrease in South Midwest; P = .02). CONCLUSIONS AND RELEVANCE: Heart transplant volumes have been significantly reduced in recent months, even in regions with a lower prevalence of COVID-19 cases. This has been accompanied by increased waitlist inactivations, decreased waitlist additions, and decreased donor recovery. Future studies are needed to determine if the COVID-19 pandemic is associated with changes in waitlist mortality.

Nine contemporary therapeutic directions in heart failure.

The global burden of heart failure has continued to increase dramatically with 26 million people affected and an estimated health expenditure of $31 billion worldwide. Several practice-influencing studies were reported recently, bringing advances along many frontiers in heart failure, particularly heart failure with reduced ejection fraction. In this article, we discuss nine distinct therapeutic areas that were significantly influenced by this scientific progress. These distinct areas include the emergence of sodium-glucose cotransporter-2 inhibitors, broadening the application of angiotensin-neprilysin inhibition, clinical considerations in therapy withdrawal in those patients with heart failure that 'recover' myocardial function, benefits of low-dose direct oral anticoagulants in sinus rhythm, targeted therapy for treating cardiac amyloidosis, usefulness of mitral valve repair in heart failure, the advent of newer left ventricular assist devices for advanced heart failure, the role of ablation in atrial fibrillation in heart failure, and finally the use of wearable defibrillators to address sudden death.

Content Analysis of Metaphors About Hypertension and Diabetes on Twitter: Exploratory Mixed-Methods Study.

BACKGROUND: Widespread metaphors contribute to the public's understanding of health. Prior work has characterized the metaphors used to describe cancer and AIDS. Less is known about the metaphors characterizing cardiovascular disease. OBJECTIVE: The objective of our study was to characterize the metaphors that Twitter users employ in discussing hypertension and diabetes. METHODS: We filtered approximately 10 billion tweets for keywords related to diabetes and hypertension. We coded a random subset of 5000 tweets for the presence of metaphor and the type of metaphor employed. RESULTS: Among the 5000 tweets, we identified 797 (15.9%) about hypertension or diabetes that employed metaphors. When discussing the development of heart disease, Twitter users described the disease as a journey (n=202), as transmittable (n=116), as an object (n=49), or as being person-like (n=15). In discussing the experience of these diseases, some Twitter users employed war metaphors (n=101). Other users described the challenge to control their disease (n=34), the disease as an agent (n=58), or their bodies as machines (n=205). CONCLUSIONS: Metaphors are used frequently by Twitter users in their discussion of hypertension and diabetes. These metaphors can help to guide communication between patients and providers to improve public health.

What Factors Affect Physicians' Decisions to Prescribe Opioids in Emergency Departments?

Objective: With 42% of all emergency department visits in the United States related to pain, physicians who work in this setting are tasked with providing adequate pain management to patients with varying primary complaints and medical histories. Complicating this, the United States is in the midst of an opioid overdose epidemic. State governments and national organizations have developed guidelines and legislation to curtail opioid prescriptions in acute care settings, while also incentivizing providers for patient satisfaction and completeness of pain control. In order to inform future policies that focus on provider pain medication prescribing, we sought to characterize the factors physicians weigh when considering treating pain with opioids in the emergency department. Methods: We conducted and transcribed open-ended, semistructured qualitative interviews with 52 physicians at a national emergency medicine conference. Results: Participants reported a wide range of factors contributing to their opioid prescribing patterns related to three domains: 1) provider assessment of pain characteristics, 2) patient-based considerations, and 3) practice environment. Pain characteristics include the characteristics of various acute and chronic pain syndromes, including physicians' empathy due to their own experiences with pain. Patient characteristics include "trustworthiness," race and ethnicity, and the concern for risk of misuse. Factors related to the practice environment include hospital policy, legislation/regulation, and guidelines. Conclusion: The decision to prescribe opioids to patients in the emergency department is complex and nuanced. Physicians are interested in guidance and are concerned about the competing pressures placed on their opioid prescribing due to incentives related to patient satisfaction scores on one hand and inflexible policies that do not allow for individualized, patient-centered decisions on the other.

Twitter as a Potential Data Source for Cardiovascular Disease Research.

IMPORTANCE: As society is increasingly becoming more networked, researchers are beginning to explore how social media can be used to study person-to-person communication about health and health care use. Twitter is an online messaging platform used by more than 300 million people who have generated several billion Tweets, yet little work has focused on the potential applications of these data for studying public attitudes and behaviors associated with cardiovascular health. OBJECTIVE: To describe the volume and content of Tweets associated with cardiovascular disease as well as the characteristics of Twitter users. DESIGN, SETTING, AND PARTICIPANTS: We used Twitter to access a random sample of approximately 10 billion English-language Tweets originating from US counties from July 23, 2009, to February 5, 2015, associated with cardiovascular disease. We characterized each Tweet relative to estimated user demographics. A random subset of 2500 Tweets was hand-coded for content and modifiers. MAIN OUTCOMES AND MEASURES: The volume of Tweets about cardiovascular disease and the content of these Tweets. RESULTS: Of 550 338 Tweets associated with cardiovascular disease, the terms diabetes (n = 239 989) and myocardial infarction (n = 269 907) were used more frequently than heart failure (n = 9414). Users who Tweeted about cardiovascular disease were more likely to be older than the general population of Twitter users (mean age, 28.7 vs 25.4 years; P < .01) and less likely to be male (59 082 of 124 896 [47.3%] vs 8433 of 17 270 [48.8%]; P < .01). Most Tweets (2338 of 2500 [93.5%]) were associated with a health topic; common themes of Tweets included risk factors (1048 of 2500 [41.9%]), awareness (585 of 2500 [23.4%]), and management (541 of 2500 [21.6%]) of cardiovascular disease. CONCLUSIONS AND RELEVANCE: Twitter offers promise for studying public communication about cardiovascular disease.