Readability and Accessibility of Patient-Education Materials for Heart Failure in the United States.

Online education materials are widely used by patients and caregivers to understand the management of complex chronic diseases such as heart failure (HF). Organizations such as the American Medical Association and National Institutes of Health recommend that materials be written at a 6th-grade reading level. The current study examined the readability and accessibility of online education materials for patients with HF. Whole page texts from each included website were entered into an online readability calculator. Five validated readability indices (Flesch-Kincaid Grade Level, Flesch Reading Ease Scale, Gunning Fog Index, Coleman-Liau Index, and Simple Measure of Gobbledygook (SMOG Index)) were used to evaluate each source. Websites were categorized by source (government, public and private). The availability of audiovisual accessibility features and content in non-English languages were assessed for each website. Of the 36 online resources analyzed, the median readability level was 9th-10th grade according to the Flesch-Kincaid Grade Level and college level, according to the Flesch Reading Ease Scale. The Gunning Fog Index and Coleman-Liau Index both showed median readability scores corresponding to a 12th grade reading level, whereas the SMOG Index showed a median score corresponding to that of the 9th grade. Only 10 websites (28%) offered information in languages other than English, and none provided comprehensive accessibility features for users with disabilities. Common online educational materials for patients with HF are characterized by higher readability levels than those recommended by the National Institutes of Health and the American Medical Association, and there were limited multilingual and accessibility options, potentially limiting the accessibility of resources to patients and caregivers.

Breaking Barriers: Advancing the Mission of The Equity in Heart Transplant Project.

The Equity in Heart Transplant Project, Inc (TEHTP), a 501(c)(3) public charity founded in 2022, addresses financial and social barriers impeding access to heart transplantation for patients with end-stage heart failure in the United States. Rooted in the World Health Organization's declaration on health as a fundamental right, TEHTP champions equitable care. Financial impediments disproportionately affect minority populations, perpetuating disparities in heart transplant outcomes. Since its inception in 2022, TEHTP has successfully supported 31 patients. Looking ahead, TEHTP aims to influence health policies surrounding insurance coverage through advocacy efforts and expand assistance to posttransplant care. Past accomplishments and future goals exemplify the organization's commitment to eradicating systemic barriers and ensuring that poverty does not become a death sentence for transplant patients.

Trends in ischemic heart disease among females in low-and middle-income countries from 1990 to 2019.

BACKGROUND: Ischemic heart disease (IHD) is a major contributor to mortality in low-and middle-income-countries (LMICs). However, trends in IHD in females in LMICs are not well described. METHODS: We analyzed the Global Burden of Disease (GBD) Study from 1990 to 2019 for males and females with IHD from the ten most-populous LMICs (India, Indonesia, Pakistan, Nigeria, Ethiopia, Philippines, Egypt, Vietnam, Iran, and Afghanistan). RESULTS: In females, IHD incidence increased from 950,000 cases/year to 1.6 million/year, IHD prevalence increased from 8 million to 22.5 million (181% increase) and IHD mortality from 428,320 to 1,040,817 (143% increase). IHD accounted for 6.2% of all deaths among females in 1990, doubling to 13.2% in 2019. IHD mortality for each country increased with the greatest shift in AAPC seen in the Philippines (5.8%, 95% CI 5.4-6.1) and India (3.7%, 95% CI 3.0-4.4). Notably, reductions in ASMR were greater for males than females in Afghanistan, Iran, Egypt, Ethiopia and Nigeria. (all p < 0.001). CONCLUSIONS: The burden of IHD among females in LMIC has increased considerably in LMICs from 1990 to 2019. While the ASMR from IHD across most countries is declining, this was not uniformly noted. Furthermore, several countries noted lesser improvement in ASMR among females compared to males.

Experiences of Medical Interpreters During Palliative Care Encounters With Limited English Proficiency Patients: A Qualitative Study.

Background: There are many challenges in communication and cultural barriers for patients with limited English proficiency (LEP) who suffer from serious illnesses. Palliative care utilization among this population remains limited and the experiences of medical interpreters during palliative care encounters remain understudied. Methods: We conducted semistructured video interviews with interpreters working at an academic medical center. Interview questions explored interpreters' observations and experiences during palliative care encounters with LEP patients. We performed thematic analysis of the interview contents. Results: Our study included 20 interpreters who interpret in 9 languages with a mean experience of 16.3 years. We identified four themes from the interviews that shed light on the challenges of incorporating palliative care into the care of patients with LEP: (1) lack of a verbatim interpretation for the term "palliative care," (2) poor patient understanding of their treatment goals, (3) suboptimal timing of palliative care involvement, and (4) fears and misconceptions related to palliative care. Owing to challenges in word choice, the timing of palliative care involvement, and poor understanding of palliative care, interpreters observed that many patients with LEP declined palliative care involvement in their treatment plan. Conclusions: In this study, we identified several actionable barriers interpreters noted to incorporating palliative care into care of patients with LEP. Interventions directed toward providing LEP patients with standardized culturally appropriate information on palliative care are needed.

Low Rates of Psychotherapy Referrals in Patients With Heart Failure With Depression.

BACKGROUND: Depression is common among patients with heart failure (HF) and can impact patients' outcomes. In this study, we evaluated the rates of psychotherapy referrals for patients with HF with depression. METHODS AND RESULTS: Using the National Ambulatory Medical Care Survey from 2008 to 2018, we examined visits for patients with depression and concurrent HF or coronary artery disease. We estimated the likelihood of referral for psychotherapy using survey weights to provide nationally representative estimates. Among 1797 visits for patients with HF or coronary artery disease and depression, only 9.4% (95% confidence interval 7.2%-12.2%) were referred for psychotherapy, including mental health counseling and stress management. Rates of referral were lowest among patients with depression and HF at 7.5% (95% confidence interval 4.1%-13.2%). The odds of referral decreased over the years from 2008 to 2018 (odds ratio per additional year 0.87, 95% confidence interval 0.77-0.98, P = .022), with referral rates in 2008 of 12.8% compared with 4.8% in 2018. CONCLUSIONS: In this nationally representative study of ambulatory visits, patients with HF and depression were referred for psychotherapy in only 7.5% of visits and referral rates have decreased over the years. Magnifying the value of psychotherapy and increasing referral rates are essential steps to improve care for patients with HF with depression.

Effect of Widespread Sleep Apnea Screening on Progression of Atrial Fibrillation.

Sleep apnea (SA) is recognized as a predictor of incident atrial fibrillation (AF) and AF recurrence after treatment. However, data on the prevalence of SA phenotypes in patients with AF and the effect of widespread SA screening on AF outcomes are scarce. We conducted a retrospective study of patients with AF referred for SA testing between March 2018 and April 2020. The screening was performed using home sleep testing or polysomnography. AF outcomes were examined by assessment of AF progression as defined by a change from paroxysmal AF to persistent AF, change in antiarrhythmic drug, having an ablation or cardioversion. Of 321 patients evaluated for AF, 251 patients (78%) completed SA testing. A total of 185 patients with complete follow-up data and SA testing were included in our analysis: 172 patients (93%) had SA; 90 of those (49%) had primarily obstructive sleep apnea, 77 patients (42%) had mixed apnea, and 5 patients (3%) had pure central apnea. Time from AF diagnosis to SA testing was associated with AF progression; after 2 years, the risk of AF progression increased (p <0.008). Continuous positive airway pressure treatment did not affect AF progression (p = 0.99). In conclusion, SA is highly prevalent in an unselected population of patients with AF, with mixed apnea being present in over 40% of the population. Early SA testing was associated with decreased rates of AF progression, likely because of earlier and potentially more aggressive pursuit of rhythm control.

Forgotten in the crowd: A qualitative study of medical interpreters' role in medical teams.

BACKGROUND: Patients with limited English proficiency (LEP) experience worse outcomes compared with native English speakers. Communication errors are partly responsible for the disparities among this population. Medical interpreters improve communication and often assume multiple roles during clinical encounters. We sought to explore the perspectives of medical interpreters regarding their role within medical teams and ways to improve communication. METHODS: We conducted a qualitative study using semistructured interviews with inpatient and outpatient medical interpreters at an academic medical center between March and August 2021. Interview questions explored interpreters' perceptions of their roles within the medical team and best practices to improve communication during encounters. Interview transcripts were analyzed using thematic analysis. RESULTS: Our sample consisted of 20 interpreters with a mean age of 48 years (SD: 14.3) and a mean experience of 16.3 years (SD: 10.6). Two main themes emerged from interviews: (1) the full spectrum of medical interpreters' role and (2) factors acting as barriers and facilitators of interpretation. Interpreters described their role as language interpreters, cultural mediators, and patient advocates. They also identified several factors that may enhance encounters, such as utilizing the teach-back method with patients and debriefing with interpreters. CONCLUSIONS: Interpreters view their role as extending beyond interpretation to include cultural mediation and patient advocacy. Addressing commonly encountered challenges and adopting some of the proposed solutions highlighted in this study may facilitate improved communication with LEP patients receiving care in healthcare systems.

Challenges Facing Heart Failure Patients With Limited English Proficiency: A Qualitative Analysis Leveraging Interpreters' Perspectives.

BACKGROUND: Limited English proficiency (LEP) heart failure (HF) patients experience worse HF outcomes, including higher readmission rates and emergency department visits. To elucidate the challenges this population faces, the authors interviewed interpreters to identify gaps in care quality and ways to improve care for LEP HF patients. OBJECTIVES: The authors sought to understand the challenges facing HF patients with LEP using medical interpreters' perspectives. METHODS: The authors conducted a qualitative study using semistructured interviews with interpreters working at an academic medical center. All interpreters employed by the medical center were eligible to participate. Interviews were analyzed using thematic analysis. RESULTS: The authors interviewed 20 interpreters from 9 languages (mean age: 48 ± 14.3 years; mean experience: 16.3 ± 10.6 years). Two themes regarding the challenges of care delivery to LEP HF patients emerged: 1) LEP patients often had a limited understanding of HF etiology, prognosis, and treatment options, and interpreters cited difficulty explaining HF given the complexity of the subject; and 2) practical steps to improve the discharge process for LEP HF patients. Integrating interpreters into both the inpatient and outpatient HF teams was a strongly supported intervention. Additionally, conducting pre-encounter huddles, providing the interpreter service phone number at the time of discharge, involving family members when appropriate, and considering nutrition referrals were all important steps highlighted by interpreters. CONCLUSIONS: This study illuminates challenges that LEP HF patients face and provides potential solutions to improve care for this vulnerable group. Integrating interpreters as part of the HF team and designing practical discharge plans for LEP HF patients could reduce current disparities.

Top Ten Tips Palliative Care Clinicians Should Know About Working with Medical Interpreters.

Medical interpreters are the primary facilitators of effective communication between clinical providers and patients with limited English proficiency. They can assist in managing complex meetings in which patients, families, and clinicians decide on next steps in care. Palliative care (PC) clinicians inherently work in an interdisciplinary manner, which enables them to learn and model the effective integration of medical interpreters into the PC team. Rather than using an interpreter as a language tool, this article encourages PC clinicians to cultivate a partnership with the interpreter as a team member. We describe 10 tips for effective partnering with interpreters: the importance of including the interpreters in preencounter huddles and post-encounter debriefs, agreeing on strategies for interpreting "untranslatable" words and managing the encounters, using the "teach back" method to ensure understanding, acknowledging interpreters as cultural mediators, understanding the potential emotional impact of family meetings on interpreters, and enhancing follow-up with the PC team by providing contact information for PC staff to patients.

Implantable Cardioverter Defibrillators and Chronic Kidney Disease.

Use of implantable cardioverter defibrillators (ICDs) is the treatment of choice for heart failure patients with ejection fraction <35% to prevent sudden cardiac death. Whether this benefit remains among patients with chronic kidney disease (CKD) or end stage renal disease (ESRD) is yet to be elucidated. We conducted a systematic review of studies in PubMed that have investigated the use of ICDs among patients with CKD or ESRD. From the 470 studies identified, we selected 42 for the current review. Patients with CKD/ESRD were more likely to get antitachycardia pacing or shocks and had higher cardiac and/or all-cause mortality compared to patients without CKD/ESRD. These associations had an inverse dose-response effect with worse outcomes with decreasing kidney function. In conclusion, use of ICDs in CKD/ESRD is associated with increased antitachycardia pacing/shocks and mortality suggesting that their routine use in this patient population may be associated with more adverse outcomes than benefits.

Chronic strongyloidiasis: a case of B symptoms and recurrent asthma exacerbations.

Strongyloidiasis is one of the neglected helminths infection that is often underdiagnosed and undertreated. Due to its variable presentation, its diagnosis is often a challenge. We report a case of an immigrant patient with asthma who later developed eosinophilia. After 3 years of unexplained eosinophilia, he developed B symptoms and had frequent asthma exacerbations. He was later diagnosed with strongyloidiasis and treated with ivermectin. His B symptoms resolved, and his asthma exacerbations decreased significantly. Due to the frequent use of corticosteroids in asthma exacerbations, this case illustrates the importance of Strongyloides screening in asthmatics from high-risk regions. It also displays the importance of further investigating patients with asthma who develop eosinophilia and have frequent exacerbations while on optimal asthma treatment. Having a high index of suspicion is essential when making this diagnosis, as clinical presentation is often variable and does not follow a standard time course.

The Impact of Marijuana on the Cardiovascular System: A Review of the Most Common Cardiovascular Events Associated with Marijuana Use.

With the expanded legalization of marijuana, its medical and recreational use have sharply increased over the past decade. A wide array of new forms of cannabis is available on the market today, and the potencies are ten times those of forms previously tested, meaning that the true impact of marijuana on the cardiovascular system remains unclear. Cannabis mainly exerts its effects via the sympathetic and parasympathetic nervous systems, with different doses affecting different cannabinoids receptors. Studies have shown that marijuana plays a role in thrombosis, inflammation, and atherosclerosis. Case reports have linked marijuana use to myocardial infarction, cardiac arrythmias, cardiomyopathies, stroke, and arteritis. Most patients are young, healthy men with no cardiovascular risk factors; however, the patient population is expected to change to include older individuals in the future. The widespread public perception of safety accompanying marijuana use has contributed to its increased use among the elderly, who are the most at risk population for acute cardiovascular events. In this review, we aim to provide a basic understanding of the physiological effects of marijuana on the cardiovascular system and to review the current literature regarding cardiovascular diseases linked to marijuana use in adults.

Aberrant Thyroid Function Tests in a Patient Taking Biotin Supplements.

Biotin is a component of the B-complex vitamins that has been widely used in over-the-counter supplements. The effects of biotin on thyroid function tests (TFTs) have been recently reported by multiple authors. We report here a case of a patient who presented with TFTs consistent with hyperthyroidism and a positive radioactive iodine uptake (RAIU) scan while taking biotin supplements. The TFTs normalized almost a month later and continued to be normal even after resumption of biotin supplements. Interpreting TFTs while patients are taking biotin could pose a diagnostic challenge, so we suggest more frequent monitoring for those patients before starting them on long-term anti-thyroid medications.

Levamisole-induced Vasculitis in a Hepatitis C Patient: A General Medicine Ward Perspective on Diagnosis and Management.

Purpura in hepatitis C patients has a wide range of possible etiologies, some of which include mixed cryoglobulinemia and idiopathic thrombocytopenic purpura. Levamisole is a common chemical used as a lacing agent for cocaine. It is believed to enhance the addictive properties of cocaine, but it has been associated with a vasculitis syndrome that most commonly presents with purpura and leukopenia. We report a case of a patient with hepatitis C and cocaine abuse who presented with vasculitis, thrombocytopenia, and bloody sputum. A punch biopsy was performed, which confirmed the diagnosis of levamisole-induced vasculitis. A comprehensive rheumatology workup could result in variable serology and does not provide a definitive diagnosis. We suggest performing a punch biopsy as part of the initial workup for these patients, as it can provide rapid diagnosis and is associated with a lower cost.