Virtual healthcare solutions in heart failure: a literature review.

The widespread adoption of mobile technologies offers an opportunity for a new approach to post-discharge care for patients with heart failure (HF). By enabling non-invasive remote monitoring and two-way, real-time communication between the clinic and home-based patients, as well as a host of other capabilities, mobile technologies have a potential to significantly improve remote patient care. This literature review summarizes clinical evidence related to virtual healthcare (VHC), defined as a care team + connected devices + a digital solution in post-release care of patients with HF. Searches were conducted on Embase (06/12/2020). A total of 171 studies were included for data extraction and evidence synthesis: 96 studies related to VHC efficacy, and 75 studies related to AI in HF. In addition, 15 publications were included from the search on studies scaling up VHC solutions in HF within the real-world setting. The most successful VHC interventions, as measured by the number of reported significant results, were those targeting reduction in rehospitalization rates. In terms of relative success rate, the two most effective interventions targeted patient self-care and all-cause hospital visits in their primary endpoint. Among the three categories of VHC identified in this review (telemonitoring, remote patient management, and patient self-empowerment) the integrated approach in remote patient management solutions performs the best in decreasing HF patients' re-admission rates and overall hospital visits. Given the increased amount of data generated by VHC technologies, artificial intelligence (AI) is being investigated as a tool to aid decision making in the context of primary diagnostics, identifying disease phenotypes, and predicting treatment outcomes. Currently, most AI algorithms are developed using data gathered in clinic and only a few studies deploy AI in the context of VHC. Most successes have been reported in predicting HF outcomes. Since the field of VHC in HF is relatively new and still in flux, this is not a typical systematic review capturing all published studies within this domain. Although the standard methodology for this type of reviews was followed, the nature of this review is qualitative. The main objective was to summarize the most promising results and identify potential research directions.

Virtual healthcare solutions for cardiac rehabilitation: a literature review.

Graphical AbstractAdherence to cardiac rehabilitation following a primary event has been demonstrated to improve quality of life, increase functional capacity, and decrease hospitalizations and mortality. Mobile technologies offer an opportunity to improve both the quality and utilization of cardiac rehabilitation, and recent clinical studies investigated this technology. This literature review summarizes the current use of mobile health, wearable activity monitors (WAMs), and other multi-component technologies deployed to support home-based virtual cardiac rehabilitation. The methodology was adapted from the Cochrane Handbook for Systematic Reviews of Interventions. We identified 2094 records, of which 113 were eligible for qualitative analysis. Different virtual cardiac rehabilitation solutions were implemented in the studies: (i) multi-component interventions in 48 studies (42.5%), (ii) WAMs in 27 studies (23.9%), (iii) web-based communications solutions, and (iv) mobile apps, both in 19 studies (16.4%). Functional capacity was the most frequently reported primary outcome (k = 37, 32.7%), followed by user adherence/compliance (k = 35, 31.0%), physical activity (k = 27, 23.9%), and quality of life (k = 14, 12.4%). Studies provided a mixed assessment of the efficacy of virtual cardiac rehabilitation in attaining either significant improvements over baseline or significant improvements in outcomes compared with conventional rehabilitation. Efficacy outcomes with virtual cardiac rehabilitation sometimes improve on the centre-based outcomes; however, superior clinical efficacy may not necessarily be the only outcome of interest. The promise of virtual cardiac rehabilitation includes the potential for increased user adherence and longer-term patient engagement. If these outcomes can be improved, that would be a significant justification for using this technology.

Cardiovascular Disease in Rheumatoid Arthritis: Risk Factors, Autoantibodies, and the Effect of Antirheumatic Therapies.

OBJECTIVE: To scope the current published evidence on cardiovascular risk factors in rheumatoid arthritis (RA) focusing on the role of autoantibodies and the effect of antirheumatic agents. METHODS: Two reviews were conducted in parallel: A targeted literature review (TLR) describing the risk factors associated with cardiovascular disease (CVD) in RA patients; and a systematic literature review (SLR) identifying and characterizing the association between autoantibody status and CVD risk in RA. A narrative synthesis of the evidence was carried out. RESULTS: A total of 69 publications (49 in the TLR and 20 in the SLR) were included in the qualitative evidence synthesis. The most prevalent topic related to CVD risks in RA was inflammation as a shared mechanism behind both RA morbidity and atherosclerotic processes. Published evidence indicated that most of RA patients already had significant CV pathologies at the time of diagnosis, suggesting subclinical CVD may be developing before patients become symptomatic. Four types of autoantibodies (rheumatoid factor, anti-citrullinated peptide antibodies, anti-phospholipid autoantibodies, anti-lipoprotein autoantibodies) showed increased risk of specific cardiovascular events, such as higher risk of cardiovascular death in rheumatoid factor positive patients and higher risk of thrombosis in anti-phospholipid autoantibody positive patients. CONCLUSION: Autoantibodies appear to increase CVD risk; however, the magnitude of the increase and the types of CVD outcomes affected are still unclear. Prospective studies with larger populations are required to further understand and quantify the association, including the causal pathway, between specific risk factors and CVD outcomes in RA patients.

A neural representation of sequential states within an instructed task.

In the study of the neural basis of sensorimotor transformations, it has become clear that the brain does not always wait to sense external events and afterward select the appropriate responses. If there are predictable regularities in the environment, the brain begins to anticipate the timing of instructional cues and the signals to execute a response, revealing an internal representation of the sequential behavioral states of the task being performed. To investigate neural mechanisms that could represent the sequential states of a task, we recorded neural activity from two oculomotor structures implicated in behavioral timing--the supplementary eye fields (SEF) and the lateral intraparietal area (LIP)--while rhesus monkeys performed a memory-guided saccade task. The neurons of the SEF were found to collectively encode the progression of the task with individual neurons predicting and/or detecting states or transitions between states. LIP neurons, while also encoding information about the current temporal interval, were limited with respect to SEF neurons in two ways. First, LIP neurons tended to be active when the monkey was planning a saccade but not in the precue or intertrial intervals, whereas SEF neurons tended to have activity modulation in all intervals. Second, the LIP neurons were more likely to be spatially tuned than SEF neurons. SEF neurons also show anticipatory activity. The state-selective and anticipatory responses of SEF neurons support two complementary models of behavioral timing, state dependent and accumulator models, and suggest that each model describes a contribution SEF makes to timing at different temporal resolutions.

Separate representations of target and timing cue locations in the supplementary eye fields.

When different stimuli indicate where and when to make an eye movement, the brain areas involved in oculomotor control must selectively plan an eye movement to the stimulus that encodes the target position and also encode the information available from the timing cue. This could pose a challenge to the oculomotor system since the representation of the timing stimulus location in one brain area might be interpreted by downstream neurons as a competing motor plan. Evidence from diverse sources has suggested that the supplementary eye fields (SEF) play an important role in behavioral timing, so we recorded single-unit activity from SEF to characterize how target and timing cues are encoded in this region. Two monkeys performed a variant of the memory-guided saccade task, in which a timing stimulus was presented at a randomly chosen eccentric location. Many spatially tuned SEF neurons encoded only the location of the target and not the timing stimulus, whereas several other SEF neurons encoded the location of the timing stimulus and not the target. The SEF population therefore encoded the location of each stimulus with largely distinct neuronal subpopulations. For comparison, we recorded a small population of lateral intraparietal (LIP) neurons in the same task. We found that most LIP neurons that encoded the location of the target also encoded the location of the timing stimulus after its presentation, but selectively encoded the intended eye movement plan in advance of saccade initiation. These results suggest that SEF, by conditionally encoding the location of instructional stimuli depending on their meaning, can help identify which movement plan represented in other oculomotor structures, such as LIP, should be selected for the next eye movement.

Parietal representation of object-based saccades.

When monkeys make saccadic eye movements to simple visual targets, neurons in the lateral intraparietal area (LIP) display a retinotopic, or eye-centered, coding of the target location. However natural saccadic eye movements are often directed at objects or parts of objects in the visual scene. In this paper we investigate whether LIP represents saccadic eye movements differently when the target is specified as part of a visually displayed object. Monkeys were trained to perform an object-based saccade task that required them to make saccades to previously cued parts of an abstract object after the object reappeared in a new orientation. We recorded single neurons in area LIP of two macaque monkeys and analyzed their activity in the object-based saccade task, as well as two control tasks: a standard memory saccade task and a fixation task with passive object viewing. The majority of LIP neurons that were tuned in the memory saccade task were also tuned in the object-based saccade task. Using a hierarchical generalized linear model analysis, we compared the effects of three different spatial variables on the firing rate: the retinotopic location of the target, the object-fixed location of the target, and the orientation of the object in space. There was no evidence of an explicit object-fixed representation in the activity in LIP during either of the object-based tasks. In other words, no cells had receptive fields that rotated with the object. While some cells showed a modulation of activity due to the location of the target on the object, these variations were small compared to the retinotopic effects. For most cells, firing rates were best accounted for by either the retinotopic direction of the movement, the orientation of the object, or both spatial variables. The preferred direction of these retinotopic and object orientation effects were found to be invariant across tasks. On average, the object orientation effects were consistent with the retinotopic coding of potential target locations on the object. This interpretation is supported by the fact that the magnitude of these two effects were roughly equal in the early portions of the trial, but around the time of the motor response, the retinotopic effects dominated. We conclude that LIP uses the same retinotopic coding of saccade target whether the target is specified as an absolute point in space or as a location on a moving object.