Post-COVID-19 Syndrome Clinical Pathway for the US Veterans Health Administration.

The Department of Veterans Health Affairs (VHA) has launched 22 multispecialty post-COVID-19 clinics across the US for the growing number of veterans experiencing long-term sequelae after acute COVID-19 infection. While evidence-based treatments for this syndrome are under investigation, there is a critical need to establish and disseminate clinical pathways (CPWs) based on knowledge and experience gained in those clinics. This VHA CPW is intended to guide primary care clinicians who care for patients experiencing dyspnea and/or cough during post-COVID-19 syndrome (PCS), which includes symptoms and abnormalities persisting or present beyond 12 weeks of the onset of acute COVID-19. This effort will help guide and standardize the care of veterans across the VHA, improve health outcomes, and effectively utilize health care resources. This article summarizes our stepwise diagnostic approach for patients presenting with PCS dyspnea and/or cough in primary care; it also highlights teleconsultation and telerehabilitation as opportunities to reach those in rural areas or with transportation barriers and improve reach for specialized services.

Vitamin D Supplementation and Muscle Power, Strength and Physical Performance in Older Adults: A Randomized Controlled Trial.

BACKGROUND: Low 25-hydroxyvitamin D (25[OH]D) concentrations (<30 ng/mL [<50 nmol/L]) have been associated with muscle weakness and impaired physical performance in observational studies. However, the effect of vitamin D supplementation on changes in muscle strength and physical performance in randomized controlled trials has been mixed. OBJECTIVES: To determine the effect of daily vitamin D supplementation on leg power, strength, and physical performance in low-functioning older adults with 25(OH)D concentrations of 18 to <30 ng/mL. METHODS: In this double-blind, randomized controlled trial, 136 low-functioning [Short Physical Performance Battery (SPPB) scores ≤10] adults aged 65-89 y with 25(OH)D concentrations of 18 to <30 ng/mL were randomly assigned to 2000 IU/d vitamin D3 or placebo for 12 mo. Lower-extremity leg power (primary outcome), leg and grip strength, SPPB, timed up and go (TUG), postural sway, and gait velocity and spatiotemporal parameters (secondary outcomes) were assessed at baseline, 4 and 12 mo. A subset (n = 37) also underwent a muscle biopsy at baseline and 4 mo and muscle fiber composition and contractile properties were assessed. RESULTS: Participants' mean ± SD age and SPPB scores at baseline were 73.4 ± 6.3 y and 7.8 ± 1.8, respectively. Mean ± SD 25(OH)D concentrations at baseline and 12 mo were 19.4 ± 4.2 ng/mL and 28.6 ± 6.7 ng/mL in the vitamin D group and 19.9 ± 4.9 ng/mL and 20.2 ± 5.0 ng/mL in the placebo group for a mean ± SE difference of 9.1 ± 1.1 ng/mL (P < 0.0001). However, there were no differences in change in leg power, leg or grip strength, SPPB score, TUG, postural sway, or gait velocity and spatiotemporal parameters by intervention group over 12 mo or muscle fiber composition and contractile properties over 4 mo. CONCLUSIONS: In low-functioning older adults with 25(OH)D concentrations of 18 to <30 ng/mL, randomization to 2000 IU/d vitamin D3 did not result in improvements in leg power, strength, or physical performance or muscle fiber composition and contractile properties. This trial was registered at clinicaltrials.gov as NCT02015611.

Preliminary evidence on cigarette nicotine reduction with concurrent access to an e-cigarette: Manipulating cigarette nicotine content, e-liquid nicotine content, and e-liquid flavor availability.

The reinforcing characteristics of e-cigarettes could moderate the impact of reducing cigarette nicotine content. In this study, people who smoke daily were recruited from North Carolina and Pennsylvania (US) in 2018 and 2019. Within a randomized 2 × 2 × 2 factorial design, participants received investigational cigarettes and an e-cigarette for 12 weeks. Cigarette nicotine content was very low (0.4 mg/g of tobacco; VLNC) or normal (15.8 mg/g; NNC). E-liquids were 0.3% ("low") or 1.8% ("moderate") freebase nicotine, and available in tobacco flavors or tobacco, fruit, dessert and mint flavors. Study recruitment concluded before reaching the planned sample size (N = 480). Fifty participants were randomized and 32 completed the study. We found that randomization to VLNC, relative to NNC cigarettes, reduced self-reported cigarettes per day (CPD; mean difference: -12.96; 95% CI: -21.51, -4.41; p = 0.005); whereas e-liquid nicotine content and flavor availability did not have significant effects. The effect of cigarette nicotine content was larger in the moderate vs. low nicotine e-liquid groups and in the all flavors versus tobacco flavors e-liquid groups; tests of the interaction between e-liquid characteristics and cigarette nicotine content were not significant. Biomarkers of smoke exposure at Week 12 did not differ across conditions, which may reflect variability in adherence to only using VLNC cigarettes. In conclusion this study offers preliminary evidence that the extent to which cigarette nicotine reduction decreases smoking may depend on the reinforcing characteristics of alternative products, including the available nicotine contents and flavors of e-cigarettes.

Text Messaging and Home Blood Pressure Monitoring for Patients with Uncontrolled Hypertension: Proposal for a Feasibility Pilot Randomized Controlled Trial.

BACKGROUND: A decrease in blood pressure, even modestly (ie, 2 mmHg), lowers cardiovascular morbidity and mortality. Low patient adherence to antihypertensive medication is the most significant modifiable patient-related barrier to achieving controlled blood pressure. Preliminary studies have shown that SMS text messaging and home blood pressure monitoring (HBPM) can be effective in promoting medication adherence and blood pressure control. The best strategy to engage with older patients of low socioeconomic status who are low adopters of technology and disproportionally affected by uncontrolled hypertension is still unknown. OBJECTIVE: The objective of this study is to improve blood pressure control in the older, low socioeconomic status population. The study will test two aims: First, we aim to evaluate the feasibility of conducting a randomized controlled trial by using an SMS-based approach among nonadherent, older patients of low socioeconomic status who have uncontrolled hypertension. Feasibility will be assessed in terms of recruitment rates per month (primary outcome); patient acceptability will be evaluated by monitoring retention rates and SMS response rates and using the validated Systems Usability Scale (secondary outcomes). Second, we aim to estimate the effects of the SMS approach on lowering blood pressure and adherence to antihypertensive medications. METHODS: We will recruit 24 patients of low socioeconomic status with uncontrolled hypertension (systolic BP>140 mmHg or diastolic BP>90 mmHg) showing low medication adherence and taking at least two antihypertensives, who have presented to two outpatient clinics of Wake Forest Baptist Health (Winston Salem, North Carolina, USA). Participants will be randomly assigned to either SMS and HBPM (n=12) or usual care and HBPM (n=12) intervention. Clinicians adjusting the patients' medications will be blinded to the study assignment. Text messages will be sent from a secure platform to assess medication adherence and HBPM on a weekly basis. The content and delivery frequency of the proposed SMS intervention are based on input from three focus groups conducted in Spring 2019. Participants in both study arms will receive education on HBPM and using an HBPM device. We hypothesize that we will successfully recruit 24 participants and the intervention will be acceptable to the participants. It will also improve medication adherence (assessed by question Medication Adherence Questionnaire scores) and blood pressure control. RESULTS: Our study was funded in July 2020. As of May 2021, we have enrolled 6 participants. CONCLUSIONS: Our findings will help design a larger efficacy trial to advance the field of eHealth delivery systems particularly for older adults of low socioeconomic status. This study addresses a highly significant topic and targets a population of high morbidity and mortality that has been traditionally underrepresented in clinical trials. TRIAL REGISTRATION: ClinicalTrials.gov NCT03596242; https://clinicaltrials.gov/ct2/show/NCT03596242. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/18984.

High blood pressure in Hispanics in the United States: a review.

PURPOSE OF REVIEW: To provide an overview of the available data on the prevalence of hypertension (HTN) in various groups and segments of the Hispanic population; prevalence of awareness, treatment and control of HTN among Hispanics; and HTN-related disparities, through disproportionate effects on the Hispanic elderly, women, and young adults. RECENT FINDINGS: Data on HTN in Hispanics has been lacking or aggregated and frequently not inclusive of certain groups of Hispanics but the available data do show a pattern of more prevalent HTN and HTN disparities among Hispanics compared with non-Hispanic whites. Hispanic adults have some of the highest prevalence of poorly controlled blood pressure compared with any other race-ethnic group in the United States. Further, the impact of the most recent iteration of the HTN guidelines among all segments of the Hispanic population has not been well studied. SUMMARY: The most recent HTN guidelines will likely only further illuminate worsening HTN-related disparities among Hispanics. These findings suggest significant screening and treatment disparities must be addressed to reduce HTN risk among the Hispanic population.

Echogenicity Is Related to Skeletal Muscle Strength in Patients With Acute Respiratory Failure.

PURPOSE: Patients with acute respiratory failure (ARF) show changes in skeletal muscle structure and strength. The purpose of this study was to examine the relationship between muscle thickness, echogenicity, and strength in patients with ARF. METHODS: Thirteen (6 females, 7 males) patients with ARF participated in the study. Knee extensor strength was measured via a handheld dynamometer and quadriceps images were obtained via ultrasonography at hospital discharge. The ultrasonograms were used to obtain muscle thickness and both mean ± SD echogenicity of the rectus femoris, vastus lateralis, and vastus medialis. Partial correlations, controlling for age, body mass index, and fluid intake were used to describe the relationships among knee extensor strength and echogenicity and muscle thickness. RESULTS: Knee extensor strength and vastus lateralis SD echogenicity were significantly correlated when controlling for age, body mass index, and fluid intake (r = 0.69, P = .029). Knee extensor strength and vastus lateralis echogenicity were 19.1 ± 8.0 kg and 19.8 ± 5.4 units, respectively. No other correlations between strength and ultrasound measures were found to be significant. CONCLUSION: These results show skeletal muscle echogenicity to be significantly correlated with skeletal muscle strength in patients with ARF. As such, it may be useful in identifying muscle weakness in these patients when they are unable or unwilling to perform voluntary strength testing.

Dietary Approaches to Stop Hypertension Diet Concordance and Incident Heart Failure: The Multi-Ethnic Study of Atherosclerosis.

INTRODUCTION: In observational studies, the association between the Dietary Approaches to Stop Hypertension (DASH) diet and incident heart failure has been inconsistent. It was hypothesized that higher DASH diet concordance has a protective effect on heart failure in a multi-ethnic cohort. METHODS: The Multi-Ethnic Study of Atherosclerosis cohort includes men and women of multiple ethnicities who were aged 45-84 years and free of clinical cardiovascular disease at baseline. Participants were recruited between 2000 and 2002 from six U.S. communities and followed for incident cardiovascular health events through 2015 for the purpose of this data set. Diet was measured using food-frequency questionnaires. Cox proportional hazards analysis was used to investigate the associations of the DASH diet concordance with incident heart failure in 2017-2018. RESULTS: During a median 13 years of follow-up, 179 of 4,478 participants developed heart failure, corresponding to a rate of 3.4 per 1,000 person years. Heart failure incidence rates did not vary significantly by DASH quintile for the population as a whole. In participants younger than 75 years, highest DASH concordance was associated with a lower risk of incident heart failure compared with those in the lowest quintile (hazard ratio=0.4, 95% CI=0.2, 0.9 vs all participants hazard ratio=1.0, 95% CI=0.2, 0.9) after adjusting for demographics, energy consumption, and known cardiovascular confounders. CONCLUSIONS: This study supports the hypothesis that DASH is beneficial in heart failure prevention within the individuals aged less than 75 years subgroup, an idea that to date was substantiated only by much smaller studies or in less diverse patient populations.

The Effects of Yoga on Patients with Mild Cognitive Impairment and Dementia: A Scoping Review.

Yoga is an ancient mind body practice. Although yoga has been used as a complementary health approach for enhancing wellness and addressing a variety of health issues, little is known about the impact of yoga on cognitive functioning in adults with mild cognitive impairment (MCI) and dementia. We conducted a literature review to examine the impact of yoga on persons with MCI and dementia. Eight studies were identified that reported on yoga as either the primary intervention or one component of a multi-component intervention in samples of persons with MCI or dementia. Results suggest that yoga may have beneficial effects on cognitive functioning, particularly on attention and verbal memory. Further, yoga may affect cognitive functioning through improved sleep, mood, and neural connectivity. There are a number of limitations of the existing studies, including a lack of intervention details, as well as variability in the frequency/duration and components of the yoga interventions. A further complicating issue is the role of various underlying etiologies of cognitive impairment. Despite these limitations, providers may consider recommending yoga to persons with MCI or dementia as a safe and potentially beneficial complementary health approach.

Pharmacologic Treatment of Hypertensive Urgency in the Outpatient Setting: A Systematic Review.

BACKGROUND: Hypertensive urgency (HU), defined as acute severe uncontrolled hypertension without end-organ damage, is a common condition. Despite its association with long-term morbidity and mortality, guidance regarding immediate management is sparse. Our objective was to summarize the evidence examining the effects of antihypertensive medications to treat. METHODS: We searched the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Reviews, Web of Science, Google Scholar, and Embase through May 2016. STUDY SELECTION: We evaluated prospective controlled clinical trials, case-control studies, and cohort studies of HU in emergency room (ER) or clinic settings. We initially identified 11,223 published articles. We reviewed 10,748 titles and abstracts and identified 538 eligible articles. We assessed the full text for eligibility and included 31 articles written in English that were clinical trials or cohort studies and provided blood pressure data within 48 h of treatment. Studies were appraised for risk of bias using components recommended by the Cochrane Collaboration. The main outcome measured was blood pressure change with antihypertensive medications. Since studies were too diverse both clinically and methodologically to combine in a meta-analysis, tabular data and a narrative synthesis of studies are presented. RESULTS: We identified only 20 double-blind randomized controlled trials and 12 cohort studies, with 262 participants in prospective controlled trials. However, we could not pool the results of studies. In addition, comorbidities and their potential contribution to long-term treatment of these subjects were not adequately addressed in any of the reviewed studies. CONCLUSIONS: Longitudinal studies are still needed to determine how best to lower blood pressure in patients with HU. Longer-term management of individuals who have experienced HU continues to be an area requiring further study, especially as applicable to care from the generalist.

Real-time patient survey data during routine clinical activities for rapid-cycle quality improvement.

BACKGROUND: Surveying patients is increasingly important for evaluating and improving health care delivery, but practical survey strategies during routine care activities have not been available. OBJECTIVE: We examined the feasibility of conducting routine patient surveys in a primary care clinic using commercially available technology (Web-based survey creation, deployment on tablet computers, cloud-based management of survey data) to expedite and enhance several steps in data collection and management for rapid quality improvement cycles. METHODS: We used a Web-based data management tool (survey creation, deployment on tablet computers, real-time data accumulation and display of survey results) to conduct four patient surveys during routine clinic sessions over a one-month period. Each survey consisted of three questions and focused on a specific patient care domain (dental care, waiting room experience, care access/continuity, Internet connectivity). RESULTS: Of the 727 available patients during clinic survey days, 316 patients (43.4%) attempted the survey, and 293 (40.3%) completed the survey. For the four 3-question surveys, the average time per survey was overall 40.4 seconds, with a range of 5.4 to 20.3 seconds for individual questions. Yes/No questions took less time than multiple choice questions (average 9.6 seconds versus 14.0). Average response time showed no clear pattern by order of questions or by proctor strategy, but monotonically increased with number of words in the question (<20 words, 21-30 words, >30 words)-8.0, 11.8, 16.8, seconds, respectively. CONCLUSIONS: This technology-enabled data management system helped capture patient opinions, accelerate turnaround of survey data, with minimal impact on a busy primary care clinic. This new model of patient survey data management is feasible and sustainable in a busy office setting, supports and engages clinicians in the quality improvement process, and harmonizes with the vision of a learning health care system.

Providing a Spanish interpreter using low-cost videoconferencing in a community health centre: a pilot study using tablet computers.

BACKGROUND: The advent of more mobile, more reliable, and more affordable videoconferencing technology finally makes it realistic to offer remote foreign language interpretation in the office setting. Still, such technologies deserve proof of acceptability to clinicians and patients before there is widespread acceptance and routine use. OBJECTIVE: We sought to examine: (1) the audio and video technical fidelity of iPad/Facetime(TM) software, (2) the acceptability of videoconferencing to patients and clinicians. METHODS: The convenience sample included Spanish-speaking adult patients at a community health care medicine clinic in 2011. Videoconferencing was conducted using two iPads(TM) connecting patient/physician located in the clinic examination room, and the interpreter in a remote/separate office in the same building. A five-item survey was used to solicit opinions on overall quality of the videoconferencing device, audio/video integrity/fidelity, perception of encounter duration, and attitude toward future use. RESULTS: Twenty-five patients, 18 clinicians and 5 interpreters participated in the project. Most patients (24/25) rated overall quality of videoconferencing as good/excellent with only 1 'fair' rating. Eleven patients rated the amount of time as no longer than in-person, and nine reported it as shorter than inperson. Most patients, 94.0% (24/25), favoured using videoconferencing during future visits. For the 18 clinicians, the results were similar. CONCLUSIONS: Based on our experience at a singlesite community health centre, the videoconferencing technology appeared to be flawless, and both patients and clinicians were satisfied. Expansion of videoconferencing to other off-site healthcare professionals should be considered in the search for more cost-effective healthcare.