The dementia care study (D-CARE): Recruitment strategies and demographic characteristics of participants in a pragmatic randomized trial of dementia care.

INTRODUCTION: Pragmatic research studies that include diverse dyads of persons living with dementia (PLWD) and their family caregivers are rare. METHODS: Community-dwelling dyads were recruited for a pragmatic clinical trial evaluating three approaches to dementia care. Four clinical trial sites used shared and site-specific recruitment strategies to enroll health system patients. RESULTS: Electronic health record (EHR) queries of patients with a diagnosis of dementia and engagement of their clinicians were the main recruitment strategies. A total of 2176 dyads were enrolled, with 80% recruited after the onset of the pandemic. PLWD had a mean age of 80.6 years (SD 8.5), 58.4% were women, and 8.8% were Hispanic/Latino, and 11.9% were Black/African American. Caregivers were mostly children of the PLWD (46.5%) or spouses/partners (45.2%), 75.8% were women, 9.4% were Hispanic/Latino, and 11.6% were Black/African American. DISCUSSION: Health systems can successfully enroll diverse dyads in a pragmatic clinical trial.

The Utility of Peripheral Intravascular Lithotripsy in Calcific Coronary Artery Disease: A Case Series.

BACKGROUND: Coronary intravascular lithotripsy (IVL) is an emerging therapy for the modification of coronary artery calcification (CAC). Data on its use in several clinical and lesion subsets are limited due to their exclusion from preapproval trials. METHODS: We performed a retrospective review of patients who were excluded from preapproval trials of coronary IVL and underwent CAC modification with the off-label use of a peripheral IVL system. The primary outcome was a composite of procedural success, defined as residual stenosis <10%, and no major adverse cardiac event (MACE), ie, cardiac death, myocardial infarction, or target- vessel revascularization, in hospital and at 30 days. RESULTS: Between June 2019 and April 2020, a total of 9 patients who underwent off-label coronary IVL were identified. Exclusion criteria from preapproval trials included a target lesion within an unprotected left main coronary artery (ULMCA; n = 3) and/or ostial location (n = 5), a target lesion involving in-stent restenosis (n = 3), a second target-vessel lesion with >50% stenosis (n = 1), and/or New York Heart Association class III/IV heart failure (n = 5). The primary outcome was achieved in 8 patients. MACE rate was 0% in hospital and at 30 days. For ULMCA lesions (n = 3), residual stenosis was 0% in 2 patients and 10% in 1 patient. For right coronary artery lesions (n = 3), residual stenosis was 0% in 2 patients and 40% in 1 patient. For left anterior descending coronary artery lesions (n = 3), residual stenosis was 0% in all patients. CONCLUSION: Coronary IVL with a peripheral IVL system may be an effective therapy for CAC modification within ULMCA disease, ostial disease, in-stent restenosis, and New York Heart Association class III/IV heart failure.

D-CARE: The Dementia Care Study: Design of a Pragmatic Trial of the Effectiveness and Cost Effectiveness of Health System-Based Versus Community-Based Dementia Care Versus Usual Dementia Care.

BACKGROUND/OBJECTIVES: Although several approaches have been developed to provide comprehensive care for persons living with dementia (PWD) and their family or friend caregivers, the relative effectiveness and cost effectiveness of community-based dementia care (CBDC) versus health system-based dementia care (CBDC) and the effectiveness of both approaches compared with usual care (UC) are unknown. DESIGN: Pragmatic randomized three-arm superiority trial. The unit of randomization is the PWD/caregiver dyad. SETTING: Four clinical trial sites (CTSs) based in academic and clinical health systems. PARTICIPANTS: A total of 2,150 English- or Spanish-speaking PWD who are not receiving hospice or residing in a nursing home and their caregivers. INTERVENTIONS: Eighteen months of (1) HSDC provided by a nurse practitioner or physician's assistant dementia care specialist who works within the health system, or (2) CBDC provided by a social worker or nurse care consultant who works at a community-based organization, or (3) UC with as needed referral to the Alzheimer's Association Helpline. MEASUREMENTS: Primary outcomes: PWD behavioral symptoms and caregiver distress as measured by the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity and Modified Caregiver Strain Index scales. SECONDARY OUTCOMES: NPI-Q Distress, caregiver unmet needs and confidence, and caregiver depressive symptoms. Tertiary outcomes: PWD long-term nursing home placement rates, caregiver-reported PWD functional status, cognition, goal attainment, "time spent at home," Dementia Burden Scale-Caregiver, a composite measure of clinical benefit, Quality of Life of persons with dementia, Positive Aspects of Caregiving, and cost effectiveness using intervention costs and Medicare claims. RESULTS: The results will be reported in the spring of 2024. CONCLUSION: D-CARE will address whether emphasis on clinical support and tighter integration with other medical services has greater benefit than emphasis on social support that is tied more closely to community resources. It will also assess the effectiveness of both interventions compared with UC and will evaluate the cost effectiveness of each intervention.

Multimodality imaging to guide transcatheter treatment of severe degenerative tricuspid regurgitation with tricuspid valve-in-ring implantation and paravalvular leak closure.

Tricuspid valve (TV) degeneration after surgical repair with an annuloplasty ring is problematic as redo operation carries high mortality. This can be addressed with transcatheter therapies to implant a valve within in prior ring (tricuspid valve-in-ring). When an incomplete ring is present, paravalvular leak is commonly encountered after tricuspid valve-in-ring (TViR) implant; however, this can be addressed with paravalvular leak closure devices. Multimodality imaging including cardiac computed tomography and three-dimensional (3D) transesophageal echocardiography (TEE) are important for successful TViR implant. We report a case of tricuspid regurgitation after tricuspid repair with an incomplete annuloplasty ring and subsequent paravalvular leak closure.

Accuracy of Presumptive Gonorrhea Treatment for Gay, Bisexual, and Other Men Who Have Sex with Men: Results from a Large Sexual Health Clinic in Los Angeles, California.

PURPOSE: This study analyzed the accuracy of presumptive gonorrhea treatment in a sexual health clinic serving primarily gay, bisexual, and other men who have sex with men (MSM). Treating suspected gonorrhea before laboratory confirmation can reduce symptoms and transmission; however, this strategy can overtreat uninfected individuals, which may promote antimicrobial resistance. We identified differences in accuracy of gonorrhea presumptive treatment by site of infection and presence of signs or symptoms. METHODS: We conducted a cross-sectional study of gay, bisexual, and other MSM who were treated presumptively for gonorrhea at the Los Angeles LGBT Center between February and July 2015. We calculated positivity of treated patients, proportion of infections treated, and positive predictive value (PPV) of treating gonorrhea presumptively based on signs, symptoms, or exposure at the urethral, rectal, or pharyngeal site. RESULTS: Of 9141 testing visits, presumptive treatment was provided at 1677 (18%). Overall, gonococcal infections were identified at 31% (n = 527) of visits where presumptive treatment was provided, compared to 9% (n = 657) of visits without presumptive treatment (P < 0.01). Forty-five percent of gonococcal infections were treated presumptively, and treatment was provided at 14% of gonorrhea-negative visits. Seventy-eight percent of urethral, 54% of rectal, and 35% of pharyngeal infections were treated presumptively. PPV was highest for genitourinary signs. CONCLUSION: Approximately one-third of gay, bisexual, or other MSM treated presumptively for gonorrhea at a sexual health clinic tested positive for gonorrhea. These findings highlight the potential contribution of point-of-care tests in reducing overtreatment resulting from presumptive treatment.

Interactive Multimodal Curriculum on Use and Interpretation of Inpatient Telemetry.

Introduction: Inpatient telemetry monitoring is a commonly used technology designed to detect and monitor life-threatening arrhythmias. However, residents are rarely educated in the proper use and interpretation of telemetry monitoring. Methods: We developed a training module containing an educational video, PowerPoint presentation, and hands-on interactive learning session with a telemetry expert. The module highlights proper use of telemetry monitoring, recognition of telemetry artifact, and interrogation of telemetry to identify clinically significant arrhythmias. Learners completed pre- and postcurriculum knowledge-based assessments and a postcurriculum survey on their experience with the module. In total, the educational curriculum had three 60-minute sessions. Results: Thirty-two residents participated in the training module. Residents scored higher on the posttest (77% ± 12%) than on the pretest (70% ± 12%), t(31) = -4.3, p < .001. Wilcoxon signed rank tests indicated PGY-3s performed better on the posttest (Mdn = 0.86) than on the pretest (Mdn = 0.72), z = -2.19, p = .031. PGY-2s also performed better on the posttest (Mdn = 0.86) than on the pretest (Mdn = 0.76), z = -2.04, p = .042. There was no difference between pretest (Mdn = 0.66) and posttest (Mdn = 0.71) scores for PGY-1s, z = -1.50, p = .142. The majority of residents reported that the telemetry curriculum boosted their self-confidence, helped prepare them to analyze telemetry on their patients, and should be a required component of the residency. Discussion: This module represents a new paradigm for teaching residents how to successfully and confidently interpret and use inpatient telemetry.

Hypomorphic conditional deletion of E11/Podoplanin reveals a role in osteocyte dendrite elongation.

The transmembrane glycoprotein E11/Podoplanin (Pdpn) has been implicated in the initial stages of osteocyte differentiation. However, its precise function and regulatory mechanisms are still unknown. Due to the known embryonic lethality induced by global Pdpn deletion, we have herein explored the effect of bone-specific Pdpn knockdown on osteocyte form and function in the post-natal mouse. Extensive skeletal phenotyping of male and female 6-week-old Oc-cre;Pdpnflox/flox (cKO) mice and their Pdpnflox/flox controls (fl/fl) has revealed that Pdpn deletion significantly compromises tibial cortical bone microarchitecture in both sexes, albeit to different extents (p < 0.05). Consistent with this, we observed an increase in stiffness in female cKO mice in comparison to fl/fl mice (p < 0.01). Moreover, analysis of the osteocyte phenotype by phalloidin staining revealed a significant decrease in the dendrite volume (p < 0.001) and length (p < 0.001) in cKO mice in which deletion of Pdpn also modifies the bone anabolic loading response (p < 0.05) in comparison to age-matched fl/fl mice. Together, these data confirm a regulatory role for Pdpn in osteocyte dendrite formation and as such, in the control of osteocyte function. As the osteocyte dendritic network is known to play vital roles in regulating bone modeling/remodeling, this highlights an essential role for Pdpn in bone homeostasis.

Association of chronic kidney disease with abnormal cardiac mechanics and adverse outcomes in patients with heart failure and preserved ejection fraction.

AIMS: Chronic kidney disease (CKD) is associated with worse outcomes in heart failure with preserved ejection fraction (HFpEF). Whether this association is due the effect of CKD on intrinsic abnormalities in cardiac function is unknown. We hypothesized that CKD is independently associated with worse cardiac mechanics in HFpEF. METHODS AND RESULTS: We prospectively studied 299 patients enrolled in the Northwestern University HFpEF Program. Using the creatinine-based CKD-Epi equation to calculate estimated glomerular filtration rate (eGFR), study participants were analysed by CKD status (using eGFR <60 mL/min/1.73 m(2) to denote CKD). Indices of cardiac mechanics (longitudinal strain parameters) were measured using speckle-tracking echocardiography. Using multivariable-adjusted linear and Cox regression analyses, we determined the association between CKD and echocardiographic parameters and clinical outcomes (cardiovascular hospitalization or death). Of 299 study participants, 48% had CKD. CKD (dichotomous variable) and reduced eGFR (continuous variable) were both associated with worse cardiac mechanics indices including left atrial (LA) reservoir strain, LV longitudinal strain, and right ventricular free wall strain even after adjusting for potential confounders, including co-morbidities, EF, and volume status. For example, for each 1-SD decrease in eGFR, LA reservoir strain was 3.52% units lower (P < 0.0001) after multivariable adjustment. Reduced eGFR was also associated with worse outcomes [adjusted hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.01-1.61 per 1-SD decrease in eGFR; P = 0.039]. The association was attenuated after adjustment for indices of cardiac mechanics (P = 0.064). CONCLUSION: In HFpEF, CKD is independently associated with worse cardiac mechanics, which may explain why HFpEF patients with CKD have worse outcomes. TRIAL REGISTRATION: NCT01030991.

Association of neighborhood characteristics with cardiovascular health in the multi-ethnic study of atherosclerosis.

BACKGROUND: The concept of cardiovascular health (CVH) was introduced as a global measure of one's burden of cardiovsacular risk factors. Previous studies established the relationship between neighborhood characteristics and individual cardiovascular risk factors. However, the relationship between neighborhood environment and overall CVH remains unknown. METHODS AND RESULTS: We analyzed data from the Multi-Ethnic Study of Atherosclerosis baseline examination (2000­2002). Mean age was 61.6 years, and 52% were women. Ideal, intermediate, and poor categories of cholesterol, body mass index, diet, physical activity, fasting glucose, blood pressure, and smoking were defined according to the American Heart Association 2020 Strategic Goals, assigned an individual score, and summed to create an overall score. CVH scores were categorized into ideal (11­14 points), intermediate (9­10), and poor (0­8). Neighborhood exposures included favorable food store and physical activity resources densities (by 1-mile buffer), reported healthy food availability,walking/physical activity environment, safety, and social cohesion (by census tract). Multinomial logistic regression was used to determine the association of each characteristic with ideal and intermediate CVH, adjusted for demographics and neighborhood socioeconomic status. Over 20% of Multi-Ethnic Study of Atherosclerosis participants had an ideal CVH score at baseline. In fully adjusted models, favorable food stores (odds ratio=1.22; 1.06­1.40), physical activity resources(odds ratio=1.19; 1.08­1.31), walking/physical activity environment (odds ratio=1.20; 1.05­1.37), and neighborhood socioeconomic status (odds ratio=1.22; 1.11­1.33) were associated with higher odds of having an ideal CVH score. CONCLUSIONS: Neighborhood environment including favorable food stores, physical activity resources, walking/physical activity environment, and neighborhood socioeconomic status are associated with ideal CVH. Further research is needed to investigate the longitudinal associations between neighborhood environment and CVH.

Patterns and predictors of follow-up in patients with mild traumatic brain injury.

BACKGROUND: This study was undertaken to identify factors that influence follow-up for patients with mild traumatic brain injury (MTBI). METHODS: One hundred and ninety-nine consecutive inpatients diagnosed with MTBI at a Trauma Centre (or TC) were monitored for establishment of care with a brain injury specialist after discharge. Bivariate statistics were calculated to determine subject characteristics impacting the decision to pursue TBI-related specialty care. RESULTS: One hundred and nineteen patients (59.8%) followed up with the TC for routine post-injury care. Patients who followed up were older (age >40: OR = 2.48, p = 0.01, 95% CI = 1.03-8.96) and had longer hospital lengths of stay (LOS > 3 days: OR = 2.99, p < 0.001, 95% CI = 1.33-7.67). Upon follow-up, providers identified 20 patients (16.8%) with persistent neurologic symptoms, seven (3.5%) of whom saw a brain injury specialist. Lack of insurance significantly decreased the likelihood of follow-up with the TC and/or establishment of care with a TBI specialist. (OR = 0.76, p = 0.01, 95% CI = 0.62-0.95). CONCLUSIONS: Being insured was strongly predictive for follow-up at the TC and for establishing with a brain injury specialist post-MTBI. The TC post-injury visit identified MTBI patients with persistent symptoms, suggesting post-acute TC follow-up is an important venue for MTBI sequelae screening and referral.

Educating future physicians to track health care quality: feasibility and perceived impact of a health care quality report card for medical students.

PURPOSE: Quality improvement (QI) requires measurement, but medical schools rarely provide opportunities for students to measure their patient outcomes. The authors tested the feasibility and perceived impact of a quality metric report card as part of an Education-Centered Medical Home longitudinal curriculum. METHOD: Student teams were embedded into faculty practices and assigned a panel of patients to follow longitudinally. Students performed retrospective chart reviews and reported deidentified data on 30 nationally endorsed QI metrics for their assigned patients. Scorecards were created for each clinic team. Students completed pre/post surveys on self-perceived QI skills. RESULTS: A total of 405 of their patients' charts were abstracted by 149 students (76% response rate; mean 2.7 charts/student). Median abstraction time was 21.8 (range: 13.1-37.1) minutes. Abstracted data confirmed that the students had successfully recruited a "high-risk" patient panel. Initial performance on abstracted quality measures ranged from 100% adherence on the use of beta-blockers in postmyocardial infarction patients to 24% on documentation of dilated diabetic eye exams. After the chart abstraction assignment, grand rounds, and background readings, student self-assessment of their perceived QI skills significantly increased for all metrics, though it remained low. CONCLUSIONS: Creation of an actionable health care quality report card as part of an ambulatory longitudinal experience is feasible, and it improves student perception of QI skills. Future research will aim to use statistical process control methods to track health care quality prospectively as our students use their scorecards to drive clinic-level improvement efforts.

Trauma deserts: distance from a trauma center, transport times, and mortality from gunshot wounds in Chicago.

OBJECTIVES: We examined whether urban patients who suffered gunshot wounds (GSWs) farther from a trauma center would have longer transport times and higher mortality. METHODS: We used the Illinois State Trauma Registry (1999-2009). Scene address data for Chicago-area GSWs was geocoded to calculate distance to the nearest trauma center and compare prehospital transport times. We used multivariate regression to calculate the effect on mortality of being shot more than 5 miles from a trauma center. RESULTS: Of 11,744 GSW patients during the study period, 4782 were shot more than 5 miles from a trauma center. Mean transport time and unadjusted mortality were higher for these patients (P < .001 for both). In a multivariate model, suffering a GSW more than 5 miles from a trauma center was associated with an increased risk of death (odds ratio = 1.23; 95% confidence interval = 1.02, 1.47; P = .03). CONCLUSIONS: Relative "trauma deserts" with decreased access to immediate care were found in certain areas of Chicago and adversely affected mortality from GSWs. These results may inform decisions about trauma systems planning and funding.