A pilot study to assess blood-brain barrier permeability in long COVID.

The etiology of brain fog associated with long COVID is not clear. Based on some preliminary work, disruption of the blood-brain barrier has been hypothesized, but has not been tested in patients with long COVID. In this case-control pilot study, we evaluated blood-brain barrier permeability in patients with long COVID and subjective memory loss or brain fog. We used 99 m Technetium diethylenetriaminepentaacetic acid single-photon emission computed tomography (SPECT) to measure blood-brain barrier permeability and a telephone assessment (T-cog) to measure cognitive function. The blood-brain barrier permeability was quantified via SPECT standard uptake value (SUV). We assessed the blood-brain barrier permeability in 14 long COVID patients and 10 control participants without subjective cognitive impairment or brain fog. Participants in the two groups were similar in age. The long COVID group had more comorbidities compared to the control group. There was no difference in the SUVs in the long COVID (0.22 ± 0.12) vs the control (0.17 ± 0.04) group. There was no difference in the T-cog results in the two groups either. We found no evidence of a difference in blood-brain permeability in patients with long COVID when compared to controls without a known history of COVID-19 infection. Larger studies are needed to confirm these findings.

Design of a pragmatic randomized implementation effectiveness trial testing a health system wide hypertension program for older adults.

Hypertension control remains poor. Multiple barriers at the level of patients, providers, and health systems interfere with implementation of hypertension guidelines and effective lowering of BP. Some strategies such as self-measured blood pressure (SMBP) and remote management by pharmacists are safe and effectively lower BP but have not been effectively implemented. In this study, we combine such evidence-based strategies to build a remote hypertension program and test its effectiveness and implementation in large health systems. This randomized, controlled, pragmatic type I hybrid implementation effectiveness trial will examine the virtual collaborative care clinic (vCCC), a hypertension program that integrates automated patient identification, SMBP, remote BP monitoring by trained health system pharmacists, and frequent patient-provider communication. We will randomize 1000 patients with uncontrolled hypertension from two large health systems in a 1:1 ratio to either vCCC or control (usual care with education) groups for a 2-year intervention. Outcome measures including BP measurements, cognitive function, and a symptom checklist will be completed during study visits. Other outcome measures of cardiovascular events, mortality, and health care utilization will be assessed using Medicare data. For the primary outcome of proportion achieving BP control (defined as systolic BP < 130 mmHg) in the two groups, we will use a generalized linear mixed model analysis. Implementation outcomes include acceptability and feasibility of the program. This study will guide implementation of a hypertension program within large health systems to effectively lower BP.

Assessing the Immunization Information System and electronic health record interface accuracy for COVID-19 vaccinations.

Objective: Our objective is to assess the accuracy of the COVID-19 vaccination status within the electronic health record (EHR) for a panel of patients in a primary care practice when manual queries of the state immunization databases are required to access outside immunization records. Materials and Methods: This study evaluated COVID-19 vaccination status of adult primary care patients within a university-based health system EHR by manually querying the Kansas and Missouri Immunization Information Systems. Results: A manual query of the local Immunization Information Systems for 4114 adult patients with "unknown" vaccination status showed 44% of the patients were previously vaccinated. Attempts to assess the comprehensiveness of the Immunization Information Systems were hampered by incomplete documentation in the chart and poor response to patient outreach. Conclusions: When the interface between the patient chart and the local Immunization Information System depends on a manual query for the transfer of data, the COVID-19 vaccination status for a panel of patients is often inaccurate.

Implementing a home-based virtual hypertension programme-a pilot feasibility study.

INTRODUCTION: Implementing a health system-based hypertension programme may lower blood pressure (BP). METHODS: We performed a randomized, controlled pilot study to assess feasibility, acceptability, and safety of a home-based virtual hypertension programme integrating evidence-based strategies to overcome current barriers to BP control. Trained clinical pharmacists staffed the virtual collaborative care clinic (vCCC) to remotely manage hypertension using a BP dashboard and phone "visits" to monitor BP, adherence, side effects of medications, and prescribe anti-hypertensives. Patients with uncontrolled hypertension were identified via electronic health records. Enrolled patients were randomized to either vCCC or usual care for 3 months. We assessed patients' home BP monitoring behaviour, and patients', physicians', and pharmacists' perspectives on feasibility and acceptability of individual programme components. RESULTS: Thirty-one patients (vCCC = 17, usual care = 14) from six physician clinics completed the pilot study. After 3 months, average BP decreased in the vCCC arm (P = 0.01), but not in the control arm (P = 0.45). The vCCC participants measured BP more (9.9 vs. 1.2 per week, P < 0.001). There were no intervention-related adverse events. Participating physicians (n = 6), pharmacists (n = 5), and patients (n = 31) rated all programme components with average scores of >4.0, a pre-specified benchmark. Nine adaptations in vCCC design and delivery were made based on potential barriers to implementing the programme and suggestions. CONCLUSION: A home-based virtual hypertension programme using team-based care, technology, and a logical integration of evidence-based strategies is safe, acceptable, and feasible to intended users. These pilot data support studies to assess the effectiveness of this programme at a larger scale.

ISBARR Huddle: First-Year Medical Students Managing Critical Hypoglycemia as an Interprofessional Team.

Introduction: Recognizing a patient requiring urgent or emergent care and initiating evaluation and management must include elements that support teams working and thinking together. Although team communication strategies exist, a standardized approach for communicating about patients with urgent or emergent conditions is lacking. This simulation was designed to provide first-semester medical students with the opportunity to deliberately practice the foundational teamwork skills required to think as a team while caring for a patient with critical hypoglycemia. Methods: Students were introduced to a team huddle that was structured using ISBARR (identify, situation, background, assessment, recommend, recap) to assist in synthesizing gathered information and arriving at a diagnosis and associated care plan. Students practiced in small groups with faculty coaches and then applied the skills learned to two cases of a patient with critical hypoglycemia followed by debriefing. Results: Two hundred eight first-semester medical students participated in the simulation course across three campuses. We surveyed a single campus subset of 172 students. One hundred thirty-three students completed a postevent survey. The majority felt that the difficulty of the simulation was appropriate for their educational level (94%) and that the training would be applicable to real-life clinical events (76%) and would improve the quality and safety of care (100%). Survey comments highlighted teamwork and the use of the ISBARR huddle communication tool. Discussion: The course provided first-semester medical students with standardized practice of a team-based approach using huddle communication to advance patient care.

Improving patient portal enrolment in an academic resident continuity clinic: quality improvement made simple.

Electronic health record patient portal usage has been associated with improvement in chronic disease parameters, patient functional status and patient satisfaction. Our institution's patient portal is a secure, online health management tool that connects patients to portions of their electronic health record. Our quality improvement project aimed to increase patient portal enrolment significantly in our Internal Medicine resident patient panels. This study was conducted in a large, multisite health system in Kansas City, Kansas that serves a diverse patient population. Our clinic includes 65 resident patient panels. We followed a subset of 16 resident patient panels in this quality improvement project. A baseline audit showed that 35% of the 1628 patients in these panels were enrolled in the patient portal system. A standardised, nurse-initiated portal sign-up process following patient rooming was implemented. Initial results indicated a 9.6% increase in patient portal sign-up at the end of the first 4-week cycle. We then implemented educational sessions for our clinic nurses as well as attending physicians, and achieved a 15.1% increase from baseline to the end of the second 4-week cycle, resulting in 86 patient portal activations (p<0.01). Resident physicians worked with clinic nurse partners in two formats for this project. Nurses assigned to patient rooming for residents during the clinic sessions being studied (rooming nurses) initiated the portal sign-up process. Nurses assigned to partner with the resident for longitudinal patient care management, anchor nurses, worked with residents on items such as phone messages or portal messages. Semi-structured interviews of the four anchor nurses aligned with the 16 residents were conducted at the end of the study and revealed that nursing staff perceived increased patient portal activity to be associated with a decrease in nursing workload and an increase in patient engagement.