Is it time for Heart-Brain clinics? A clinical survey and proposition to improve current care for cognitive problems in heart failure.

BACKGROUND: Cognitive impairment is highly prevalent among patients with heart failure (HF). International guidelines on the management of HF recommend screening for cognitive impairment and tailored care for patients with cognitive impairment. However, practical guidance is lacking. In this study, we explore cardiologists' perspective on screening and care for cognitive impairment in patients with HF. We give an example of a multidisciplinary Heart-Brain care pathway that facilitates screening for cognitive impairment in patients with HF. METHODS: We distributed an online survey to cardiologists from the Dutch working groups on Geriatric Cardiology and Heart Failure. It covered questions about current clinical practice, impact of cognitive impairment on clinical decision-making, and their knowledge and skills to recognize cognitive impairment. RESULTS: Thirty-six out of 55 invited cardiologists responded. Only 3% performed structured cognitive screening, while 83% stated that not enough attention is paid to cognitive impairment. More than half of the cardiologists desired more training in recognizing cognitive impairment and three-quarters indicated that knowing about cognitive impairment would change their treatment plan. Eighty percent agreed that systematic cognitive screening would benefit their patients and 74% wished to implement a Heart-Brain clinic. Time and expertise were addressed as the major barriers to screening for cognitive impairment. CONCLUSION: Although cardiologists are aware of the clinical relevance of screening for cognitive impairment in cardiology patients, such clinical conduct is not yet commonly practiced due to lack of time and expertise. The Heart-Brain care pathway could facilitate this screening, thus improving personalized care in cardiology.

Funduscopy: Yes or no? Hypertensive emergencies and retinopathy in the emergency care setting; a retrospective cohort study.

According to international guidelines, patients with a suspected hypertensive emergency (HE) admitted to the emergency department (ED) should undergo comprehensive evaluation including funduscopic examination. However, funduscopy is not always readily available and little is known about the prevalence of retinopathy among these patients in the ED setting. In order to characterize patients who should undergo funduscopy, we studied the prevalence, characteristics and clinical outcome in patients with a suspected HE and retinopathy grade III/IV. We conducted a retrospective cohort study of consecutive patients with severe elevation of blood pressure (BP) admitted to the ED between 2012 and 2015. Patients with a systolic blood pressure (SBP) ≥180 mm Hg or diastolic blood pressure (DBP) ≥120 mm Hg at time of presentation were included. A total of 271 patients were included, of whom 18 (6.6%; 95%CI 3.9-10.5) had a HE. In 121 patients (44.6%; 95%CI 37.1-53.3), funduscopy was performed, of whom 17 (14.0%; 95%CI 8.2-22.5) had retinopathy grade III/IV. Mean SBP and DBP were significantly higher in patients with retinopathy (P < .001). However, retinopathy was also seen in patients with lower BP (SBP < 200 mm Hg and DBP < 120 mm Hg). No differences in other clinical characteristics, including visual disturbances, were found. One patient with retinopathy suffered an ischemic stroke after taking oral medication. The prevalence of retinopathy is high among examined patients. Except for higher BP, no clinical signs or symptoms are associated with the presence of retinopathy grade III/IV. We therefore conclude that funduscopic examination should be performed in every patient with a suspected HE.

Hepatitis E virus genotype 3 infection in a tertiary referral center in the Netherlands: Clinical relevance and impact on patient morbidity.

BACKGROUND: Hepatitis E virus (HEV) genotype 3 infections can have important clinical consequences. OBJECTIVES: To evaluate patients at risk and the effect of treatment strategies, we studied the clinical course and treatment outcome in patients diagnosed with HEV viremia in our hospital. STUDY DESIGN: Between January 2008 and March 2015 we included all patients with HEV genotype 3 (HEV-3) infections diagnosed by means of quantitative real-time reverse transcription-polymerase chain reaction test (RT-PCR). Clinical data were evaluated retrospectively. RESULTS: In total 79 patients were included. Forty-nine patients (62%) were male, median age of all patients was 52 years (range 13-79). Sixty-one (77%) patients were immunocompromised. Three patients (3.8%) had only transient viremia, forty-three (54.5%) cleared the infection within six months and twenty-six (32.9%) developed chronic infection. Five patients (6.3%) were lost to follow-up. All patients developing chronic infection were immunocompromised. Overall, thirteen (16%) patients within this cohort died. Three patients had pre-existent liver diseases and died of liver-related causes. Time between diagnosis and death was shorter for patients with pre-existent liver diseases (p=0.03). Twenty-eight percent of patients on immunosuppressive medication achieved viral clearance after reducing the dose of immunosuppressive therapy. Thirty patients (38.0%) were treated with off-label ribavirin in which 25 (83.3%) a sustained viral response has been documented. CONCLUSION: HEV genotype 3 viremia mainly presents in patients with underlying chronic liver diseases or an impaired immune system. Patients with pre-existent liver diseases are at high risk for complications and even death. The off-label use of ribavirin can cure HEV infection.