Use of percutaneous mechanical circulatory support for right ventricular failure.

BACKGROUND: Utilization of right ventricular mechanical circulatory support (RV-MCS) devices has been limited by a lack of recognition of RV failure as well as a lack of availability and experience with RV-MCS. AIMS: We report a single-center experience with the use of percutaneous RV-MCS and report predictors of adverse outcomes. METHODS: This was a single-center retrospective cohort study. Data from consecutive patients who received RV-MCS for any indication between June 2015 and January 2022 were included. Data on baseline comorbidities, hemodynamics, and laboratory values were collected. The primary outcome was in-hospital mortality analyzed as a logistic outcome in a multivariable model. These variables were further ranked by their predictive value. RESULTS: Among 58 consecutive patients enrolled, the median age was 66 years, 31% were female and 53% were white. The majority of the patients (48%) were hospitalized for acute on chronic heart failure. The majority of the patients were SCAI SHOCK Stage D (67%) and 34 (64%) patients had MCS placed within 24 h of the onset of shock. Before placement of RV-MCS, median central venous pressure (CVP) and RV stroke work index were 20 mmHg and 8.9 g m/m2, respectively. Median serum lactate was 3.5 (1.6, 6.2) mmol/L. Impella RP was implanted in 50% and ProtekDuo in the remaining 50%. Left ventricular MCS was concomitantly used in 66% of patients. Twenty-eight patients (48.3%) died. In these patients, median serum lactate was significantly higher (4.1 [2.3, 13.0] vs. 2.2 [1.4, 4.0] mmol/L, p = 0.007) and a trend toward higher median CVP (24 [18, 31] vs. 19 [14, 24] mmHg, p = 0.052). In the multivariable logistic model, both serum lactate and CVP before RV-MCS placement were independent predictors of in-hospital mortality. Serum lactate had the highest predictive value. CONCLUSION: In our real-world cohort, 52% of patients treated with RV-MCS survived their index hospitalization. Serum lactate at presentation and CVP were the strongest predictors of in-hospital mortality.

Acute infusion-related reactions in pediatric patients receiving etoposide at a tertiary cancer center.

INTRODUCTION: Etoposide is a key component of many pediatric chemotherapy regimens for both hematologic and solid tumors. It is well documented that patients receiving etoposide may experience infusion-related reactions. METHODS: In this study, total doses of etoposide and etoposide phosphate were identified, and infusion-related reactions were retrospectively evaluated at a large pediatric oncology ambulatory clinic. The primary outcome was to determine the rate of acute infusion-related reactions to etoposide. A secondary objective was to identify potential risk factors associated with such reactions. RESULTS: Overall, 1463 doses of etoposide were dispensed to 150 unique patients and 15 patients (10%) experienced etoposide infusion-related reactions. Of the 15 patients that experienced etoposide infusion-related reaction, two were successfully able to tolerate subsequent infusions with a slower etoposide infusion rate and pre-medications. The remaining patients changed drug formulation to etoposide phosphate (n = 12) or continued therapy without any formulation of etoposide (n = 1). Patients with classical Hodgkin's lymphoma experienced a higher incidence of infusion-related reactions compared to the overall patient population (30.5% vs. 10%) and made up 73.3% of all infusion-related reactions during the study period. CONCLUSIONS: During the examined study period, 10% of patients experienced an acute infusion-related reaction to etoposide. This review builds on previous literature concluding that additional monitoring may be warranted in patients with classical Hodgkin's lymphoma receiving etoposide.

Assessing Unwanted Variations in Rheumatology Clinic Previsit Rooming.

BACKGROUND: Rheumatologists face time pressures similar to primary care but have not generally benefitted from optimized team-based rooming during the time from the waiting room until the rheumatologist enters the room. OBJECTIVE: The aim of this study was to assess current capacity for population management in rheumatology clinics; we aimed to measure the tasks performed by rheumatology clinic staff (medical assistants or nurses) during rooming. METHODS: We performed a cross-sectional time-study and work-system analysis to measure rooming workflows at 3 rheumatology clinics in an academic multispecialty practice during 2014-2015. We calculated descriptive statistics and compared frequencies and durations using Fisher exact test and analysis of variance. RESULTS: Observing 190 rheumatology clinic previsit rooming sequences (1419 minutes), we found many significant variations. Total rooming duration varied by clinic (median, 6.75-8.25 minutes; p < 0.001). Vital sign measurement and medication reconciliation accounted for more than half of rooming duration. Among 3 clinics, two of 15 tasks varied significantly in duration, and 9 varied in frequency. Findings led clinic leaders to modify policies and procedures regarding 6 high-variation tasks streamlining assessment of weight, height, pain scores, tobacco use, disease activity, and refill needs. CONCLUSIONS: Assessing rheumatology rooming tasks identified key opportunities to improve quality and efficiency without burdening providers. This project demonstrated user-friendly methods to identify opportunities to standardize rooming and support data-driven decisions regarding rheumatology clinic practice changes to improve population management in rheumatology.

Frequency and Predictors of Communication About High Blood Pressure in Rheumatoid Arthritis Visits.

BACKGROUND/OBJECTIVE: Given heightened cardiovascular disease (CVD) risk in rheumatoid arthritis (RA) and that higher blood pressure (BP) represents greater CVD risk, we hypothesized that higher BP would predict more BP-related communication in rheumatology visits. We examined predictors of documented BP communication during RA clinic visits. METHODS: This was a retrospective cohort study of RA patients identified in electronic health record records with uncontrolled hypertension (HTN) receiving both primary and rheumatology care. Trained abstractors reviewed RA visit notes for "BP communication" using a standardized tool to elicit documentation about BP or HTN beyond recording vital signs. We used multivariate logistic regression to examine the impact of BP category (American Heart Association: ideal normotension, pre-HTN, and stages I and II HTN) on odds ratios (95% confidence intervals) of BP communication. RESULTS: Among 1267 RA patients, 40% experienced BP elevations meeting the definition of uncontrolled HTN. Of 2677 eligible RA visits, 22% contained any documented BP communication. After adjustment, models predicted only 31% of visits with markedly high BPs 160/100 mm Hg or greater would contain BP communication. Compared with stage I, stage II elevation did not significantly increase communication (odds ratio, 2.0 [95% confidence interval, 1.4-2.8] vs. 1.5 [1.2-2.2]), although both groups' odds exceeded pre-HTN and normotension. Less than 10% of eligible visits resulted in documented action steps recommending follow-up of high BP. CONCLUSIONS: Regardless of BP magnitude, most RA clinic visits lacked documented communication about BP despite compounded CVD risk. Future work should study how rheumatology clinics can facilitate follow-up of high BPs to address HTN as the most common and reversible CVD risk factor.

Call to Action on Making Physical Activity Assessment and Prescription a Medical Standard of Care.

The U.S. population is plagued by physical inactivity, lack of cardiorespiratory fitness, and sedentary lifestyles, all of which are strongly associated with the emerging epidemic of chronic disease. The time is right to incorporate physical activity assessment and promotion into health care in a manner that engages clinicians and patients. In April 2015, the American College of Sports Medicine and Kaiser Permanente convened a joint consensus meeting of subject matter experts from stakeholder organizations to discuss the development and implementation of a physical activity vital sign (PAVS) to be obtained and recorded at every medical visit for every patient. This statement represents a summary of the discussion, recommendations, and next steps developed during the consensus meeting. Foremost, it is a "call to action" for current and future clinicians and the health care community to implement a PAVS in daily practice with every patient.

Measurements of wall shear stress and aortic pulse wave velocity in swine with familial hypercholesterolemia.

PURPOSE: To assess measurements of pulse wave velocity (PWV) and wall shear stress (WSS) in a swine model of atherosclerosis. MATERIALS AND METHODS: Nine familial hypercholesterolemic (FH) swine with angioplasty balloon catheter-induced atherosclerotic lesions to the abdominal aorta (injured group) and 10 uninjured FH swine were evaluated with a 4D phase contrast (PC) magnetic resonance imaging (MRI) acquisition, as well as with radial and Cartesian 2D PC acquisitions, on a 3T MR scanner. PWV values were computed from the 2D and 4D PC techniques, compared between the injured and uninjured swine, and validated against reference standard pressure probe-based PWV measurements. WSS values were also computed from the 4D PC MRI technique and compared between injured and uninjured groups. RESULTS: PWV values were significantly greater in the injured than in the uninjured groups with the 4D PC MRI technique (P = 0.03) and pressure probes (P = 0.02). No significant differences were found in PWV between groups using the 2D PC techniques (P = 0.75-0.83). No significant differences were found for WSS values between the injured and uninjured groups. CONCLUSION: The 4D PC MRI technique provides a promising means of evaluating PWV and WSS in a swine model of atherosclerosis, providing a potential platform for developing the technique for the early detection of atherosclerosis.

Physical activity counselling in sports medicine: a call to action.

Physical activity (PA) is a key component of healthy lifestyle and disease prevention. In contrast, physical inactivity accounts for a significant proportion of premature deaths worldwide. Physicians are in a critical position to help patients develop healthy lifestyles by actively counseling on PA. Sports medicine physicians, with their focus on sports and exercise medicine are uniquely trained to provide such expertise to patients, learners and colleagues. To succeed, physicians need clinical tools and processes that support PA assessment and counseling. Linking patients to community resources, and specifically to health and fitness professionals is a key strategy. Efforts should be made to expand provider education during medical school, residency and fellowship training, and continuing medical education. Lastly, physically active physicians are more likely to counsel patients to be active. A key message for the sports medicine community is the importance of serving as a positive PA role model.

Effect of a Telephone Health Coaching Intervention on Hypertension Control in Young Adults: The MyHEART Randomized Clinical Trial.

Importance: Uncontrolled hypertension (ie, a 24-hour ambulatory systolic blood pressure of ≥130 mm Hg and diastolic blood pressure of ≥80 mm Hg or clinic systolic blood pressure of ≥140 mm Hg and diastolic blood pressure of ≥90 mm Hg) in young adults is a US public health burden. Objective: To evaluate the effect of a telephone coaching and blood pressure self-monitoring intervention compared with usual care on changes in systolic and diastolic blood pressures and behaviors at 6 and 12 months. Design, Setting, and Participants: This randomized clinical trial included male and female participants aged 18 to 39 years with uncontrolled hypertension confirmed by 24-hour ambulatory blood pressure testing. This was a geographically diverse, multicentered study within 2 large, Midwestern health care systems. Data were collected from October 2017 to February 2022 and analyzed from February to June 2022. Interventions: The My Hypertension Education and Reaching Target (MyHEART) intervention consisted of telephone coaching every 2 weeks for 6 months, with home blood pressure monitoring. Control participants received routine hypertension care. Main Outcomes and Measures: The co-primary clinical outcomes were changes in 24-hour ambulatory and clinic systolic and diastolic blood pressure at 6 and 12 months. The secondary outcomes were hypertension control (defined as ambulatory systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg or clinic systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg) and changes in hypertension self-management behavior. Results: A total of 316 participants were randomized (159 to the control group and 157 to the intervention group) from October 2017 to December 2020. The median (IQR) age was 35 (31-37) years, 145 of 311 participants (46.6%) were female, and 166 (53.4%) were male; 72 (22.8%) were Black, and 222 (70.3%) were White. There were no differences in baseline characteristics between groups. There was no significant difference between control and intervention groups for mean 24-hour ambulatory systolic or diastolic blood pressure or clinic systolic or diastolic blood pressure at 6 or 12 months. However, there was appreciable clinical reduction in blood pressures in both study groups (eg, mean [SD] change in systolic blood pressure in intervention group at 6 months, -4.19 [9.77] mm Hg; P < .001). Hypertension control did not differ between study groups. Participants in the intervention group demonstrated a significant increase in home blood pressure monitoring at 6 and 12 months (eg, 13 of 152 participants [8.6%] checked blood pressure at home at least once a week at baseline vs 30 of 86 [34.9%] at 12 months; P < .001). There was a significant increase in physical activity, defined as active by the Godin-Shephard Leisure-Time Physical Activity Questionnaire, in the intervention group at 6 months (69 of 100 [69.0%] vs 51 of 104 [49.0%]; P = .004) but not at 12 months (49 of 86 [57.0%] vs 49 of 90 [54.4%]; P = .76). There was a significant reduction in mean (SD) sodium intake among intervention participants at 6 months (3968.20 [1725.17] mg vs 3354.72 [1365.75] mg; P = .003) but not 12 months. There were no significant differences in other dietary measures. Conclusions and Relevance: The MyHEART intervention did not demonstrate a significant change in systolic or diastolic blood pressures at 6 or 12 months between study groups; however, both study groups had an appreciable reduction in blood pressure. Intervention participants had a significant reduction in dietary sodium intake, increased physical activity, and increased home blood pressure monitoring compared with control participants. These findings suggest that the MyHEART intervention could support behavioral changes in young adults with uncontrolled hypertension. Trial Registration: ClinicalTrials.gov Identifier: NCT03158051.

Dual-emitting quantum dot/quantum rod-based nanothermometers with enhanced response and sensitivity in live cells.

Temperature is a key parameter in physiological processes, and probes able to detect small changes in local temperature are necessary for accurate and quantitative physical descriptions of cellular events. Several have recently emerged that offer excellent temperature sensitivity, spatial resolution, or cellular compatibility, but it has been challenging to realize all of these properties in a single construct. Here, we introduce a luminescent nanocrystal-based sensor that achieves this with a 2.4% change/°C ratiometric response over physiological temperatures in aqueous buffers, with a precision of at least 0.2 °C. Thermoresponsive dual emission is conferred by a Förster resonant energy transfer (FRET) process between CdSe-CdS quantum dot-quantum rods (QD-QRs) as donors and cyanine dyes as acceptors, which are conjugated to QD-QRs using an amphiphilic polymer coating. The nanothermometers were delivered to live cells using a pH-responsive cationic polymer colloid, which served to both improve uptake and release nanocrystals from endosomal confinement. Within cells, they showed an unexpected enhancement in their temperature response and sensitivity, highlighting the need to calibrate these and similar probes within the cell.

Long-term effects of smoking and smoking cessation on exercise stress testing: three-year outcomes from a randomized clinical trial.

BACKGROUND: The long-term effects of smoking and smoking cessation on markers of cardiovascular disease (CVD) prognosis obtained during treadmill stress testing (TST) are unknown. The purpose of this study was to evaluate the long-term effects of smoking cessation and continued smoking on TST parameters that predict CVD risk. METHODS: In a prospective, double-blind, randomized, placebo-controlled trial of 5 smoking cessation pharmacotherapies, symptom-limited TST was performed to determine peak METs, rate-pressure product (RPP), heart rate (HR) increase, HR reserve, and 60-second HR recovery, before and 3 years after the target smoking cessation date. Relationships between TST parameters and treatments among successful abstainers and continuing smokers were evaluated using multivariable analyses. RESULTS: At baseline, the 600 current smokers (61% women) had a mean age of 43.4 (SD 11.5) years and smoked 20.7 (8.4) cigarettes per day. Their exercise capacity was 8.7 (2.3) METs, HR reserve was 86.6 (9.6)%, HR increase was 81.1 (20.9) beats/min, and HR recovery was 22.3 (11.3) beats. Cigarettes per day and pack-years were independently and inversely associated with baseline peak METs (P < .001), RPP (P < .01, pack-years only), HR increase (P < .05), and HR reserve (P < .01). After 3 years, 168 (28%) had quit smoking. Abstainers had greater improvements than continuing smokers (all P < .001) in RPP (2,055 mm Hg beats/min), HR increase (5.9 beats/min), and HR reserve (3.7%), even after statistical adjustment (all P < .001). CONCLUSIONS: Smokers with a higher smoking burden have lower exercise capacity, lower HR reserve, and a blunted exercise HR response. After 3 years, TST improvements suggestive of improved CVD prognosis were observed among successful abstainers.

Low frequency of primary lipid screening among medicare patients with rheumatoid arthritis.

OBJECTIVE: Although studies have demonstrated suboptimal preventive care in RA patients, performance of primary lipid screening (i.e., testing before cardiovascular disease [CVD], CVD risk equivalents, or hyperlipidemia is evident) has not been systematically examined. The purpose of this study was to examine associations between primary lipid screening and visits to primary care providers (PCPs) and rheumatologists among a national sample of older RA patients. METHODS: This retrospective cohort study examined a 5% Medicare sample that included 3,298 RA patients without baseline CVD, diabetes mellitus, or hyperlipidemia, who were considered eligible for primary lipid screening during the years 2004-2006. The outcome was probability of lipid screening by the relative frequency of primary care and rheumatology visits, or seeing a PCP at least once each year. RESULTS: Primary lipid screening was performed in only 45% of RA patients. Overall, 65% of patients received both primary and rheumatology care, and 50% saw a rheumatologist as often as a PCP. Any primary care predicted more lipid screening than lone rheumatology care (26% [95% confidence interval (95% CI) 21-32]). As long as a PCP was involved, performance of lipid screening was similar regardless of the balance between primary and rheumatology visits (44-48% [95% CI 41-51]). Not seeing a PCP at least annually decreased screening by 22% (adjusted risk ratio 0.78 [95% CI 0.71-0.84]). CONCLUSION: Primary lipid screening was performed in fewer than half of eligible RA patients, highlighting a key target for CVD risk reduction efforts. Annual visits to a PCP improved lipid screening, although performance remained poor (51%). Half of RA patients saw their rheumatologist as often or more often than they saw a PCP, illustrating the need to study optimal partnerships between PCPs and rheumatologists for screening patients for CVD risks.

A review of guidelines for dyslipidemia in children and adolescents.

The recent publication of new pediatric lipid screening guidelines represents a change in recommendations regarding lipid screening and management for pediatric patients that will affect all health care professionals who care for children and adolescents. The guidelines differ from the selective screening recommended by the 2007 US Preventive Services Task Force, instead recommending routine lipid screening for children and adolescents at ages 9-11 years and again at 17-21 years. Studies have shown that limiting lipid screening to patients with risk factors fails to identify many patients with genetic or acquired dyslipidemias. Without universal screening, many at-risk children will not be identified.

Impact of a Rheumatology Clinic Protocol on Tobacco Cessation Quit Line Referrals.

OBJECTIVE: Smoking increases cardiopulmonary and rheumatic disease risk, yet tobacco cessation intervention is rare in rheumatology clinics. This study aimed to implement a rheumatology staff-driven protocol, Quit Connect, to increase the rate of electronic referrals (e-referrals) to free, state-run tobacco quit lines. METHODS: We conducted a quasi-experimental cohort study of Quit Connect at 3 rheumatology clinics comparing tobacco quit line referrals from 4 baseline years to referrals during a 6-month intervention period. Nurses and medical assistants were trained to use 2 standardized electronic health record (EHR) prompts to check readiness to quit smoking within 30 days, advise cessation, and connect patients using tobacco quit line e-referral orders. Our objective was to use EHR data to examine the primary outcome of tobacco quit line referrals using pre/post design. RESULTS: Across 54,090 pre- and post-protocol rheumatology clinic visits, 4,601 were with current smokers. We compared outcomes between 4,078 eligible pre-implementation visits and 523 intervention period visits. Post-implementation, the odds of tobacco quit line referral were 26-fold higher compared to our pre-implementation rate (unadjusted odds ratio [OR] 26 [95% confidence interval (95% CI) 6-106]). Adjusted odds of checking readiness to quit in the next 30 days increased over 100-fold compared to pre-implementation (adjusted OR 132 [95% CI 99-177]). Intervention led to e-referrals for 71% of quit-ready patients in <90 seconds; 24% of referred patients reported a quit attempt. CONCLUSION: Implementing Quit Connect in rheumatology clinics was feasible and improved referrals to a state-run tobacco quit line. Given the importance of smoking cessation to reduce cardiopulmonary and rheumatic disease risk, future studies should investigate disseminating cessation protocols like Quit Connect that leverage tobacco quit lines.

Non-high-density lipoprotein cholesterol concentration is associated with the metabolic syndrome among US youth aged 12-19 years.

OBJECTIVE: To test the hypothesis that the concentration of non-high-density lipoprotein cholesterol (non-HDL-C) is associated with the metabolic syndrome (MetS) in youth. STUDY DESIGN: Data on children and adolescents aged 12-19 years (n = 2734) from the cross-sectional National Health and Nutrition Examination Survey 1999-2004 were analyzed. RESULTS: Depending on the definition of MetS used, the mean non-HDL-C concentration among youth with MetS ranged from 144.2 to 155.8 mg/dL, compared with 108.8-109.1 mg/dL in those without MetS (all P < .001). The MetS prevalence ranged from 6.9% to 11.7% in youth with a non-HDL-C concentration of 120-144 mg/dL and from 21.5% to 23.4% in those with a concentration ≥ 145 mg/dL-both significantly higher than the prevalence of 1.9%-3.4% in youth with a concentration <120 mg/dL (all P < .001). After adjustment for potential confounders, youth with a non-HDL-C concentration ≥ 120 mg/dL or ≥ 145 mg/dL were about 3 or 4 times more likely to have MetS compared with those with a non-HDL-C <120 mg/dL or <145 mg/dL (all P < .001). CONCLUSIONS: Fasting non-HDL-C concentration was strongly associated with MetS in US youth. Our results support the use of non-HDL-C thresholds of 120 mg/dL and 145 mg/dL to indicate borderline and high MetS risk, respectively.

Medical student exposure to and attitudes about pharmaceutical companies.

PURPOSE: Medical students are at-risk to the influence of pharmaceutical company (Pharma) marketing. As interactions with the industry come under increasing scrutiny and regulation, previous studies on student-Pharma relations no longer may be accurate. This study assessed students' attitudes toward and interactions with Pharmas at the University of Wisconsin School of Medicine and Public Health (UWSMPH). METHOD: A modified questionnaire based on a previously administered national survey was completed by students in April and May 2009. The survey was analyzed to disclose the frequency of student-Pharma interactions, where interactions took place, and differences between preclinical and clinical students. RESULTS: The overall response rate was 53.6% (348/649). Most student-Pharma interactions took place at locations remote from the main campus, with free lunches (70.2%), snacks (66.9%), and small, non-educational items (55.8%) representing the most common gifts. Many clinical students had discussed medical personnel-Pharma interactions with a physician or friend. Of those surveyed, 78% felt they had received limited instruction from the school on how to interact with Pharma representatives. Preclinical students expressed greater uncertainty about using Pharmas as educational resources and were more reluctant to accept Pharma gifts than clinical students. DISCUSSION: Student attitudes toward interactions with Pharmas reveal the need for further education and guidance-particularly on the risks of using Pharmas as educational resources. Pharma exposures remote from the main campus account for a high proportion of all interactions, which further highlights the need to educate students on conflicts of interest during their preclinical training.