Remote monitoring data from cardiac implantable electronic devices predicts all-cause mortality.

AIMS: To determine if remotely monitored physiological data from cardiac implantable electronic devices (CIEDs) can be used to identify patients at high risk of mortality. METHODS AND RESULTS: This study evaluated whether a risk score based on CIED physiological data (Triage-Heart Failure Risk Status, 'Triage-HFRS', previously validated to predict heart failure (HF) events) can identify patients at high risk of death. Four hundred and thirty-nine adults with CIEDs were prospectively enrolled. Primary observed outcome was all-cause mortality (median follow-up: 702 days). Several physiological parameters [including heart rate profile, atrial fibrillation/tachycardia (AF/AT) burden, ventricular rate during AT/AF, physical activity, thoracic impedance, therapies for ventricular tachycardia/fibrillation] were continuously monitored by CIEDs and dynamically combined to produce a Triage-HFRS every 24 h. According to transmissions patients were categorized into 'high-risk' or 'never high-risk' groups. During follow-up, 285 patients (65%) had a high-risk episode and 60 patients (14%) died (50 in high-risk group; 10 in never high-risk group). Significantly more cardiovascular deaths were observed in the high-risk group, with mortality rates across groups of high vs. never-high 10.3% vs. <4.0%; P = 0.03. Experiencing any high-risk episode was associated with a substantially increased risk of death [odds ratio (OR): 3.07, 95% confidence interval (CI): 1.57-6.58, P = 0.002]. Furthermore, each high-risk episode ≥14 consecutive days was associated with increased odds of death (OR: 1.26, 95% CI: 1.06-1.48; P = 0.006). CONCLUSION: Remote monitoring data from CIEDs can be used to identify patients at higher risk of all-cause mortality as well as HF events. Distinct from other prognostic scores, this approach is automated and continuously updated.

Assessing life-space mobility for a more holistic view on wellbeing in geriatric research and clinical practice.

Life-space mobility (LSM) is a holistic measure of resilience to physical decline and social isolation in later life. To promote its use as an outcome in geriatric studies and in clinical practice, this review paper explains the concept of LSM; outlines available questionnaires for LSM assessment, provides an overview of associations between LSM and other outcomes, and discusses emerging methods to measure LSM using wearable sensors. Based on performed activity around a central geographical anchor, LSM aims to quantify the observed contraction of daily activities associated with ageing. Several questionnaires are available to assess LSM in different contexts: the University of Alabama Life-Space Assessment and the Life-Space Questionnaire (community settings), the Nursing Home Life-Space Diameter (nursing home settings) and Life Space at Home (for house-bound populations). Some studies using GPS trackers to calculate life-space parameters reported promising results. Although these techniques reduce data collection burden, battery life and older people's willingness to wear a tracker require further improvement before they can be used more widely. Regardless of the assessment method used, LSM was associated with measures of functional and cognitive abilities, nursing home admission and mortality. The current availability of instruments, the ongoing development of less burdensome data collection techniques, and evidence of construct validity support a case for promoting integration of LSM assessments into geriatric research studies and clinical practice. Ultimately, this will provide a more holistic view on older people's health and wellbeing.

Potential prognostic factors for delayed healing of common, non-traumatic skin ulcers: A scoping review.

Healing of non-traumatic skin ulcers is often suboptimal. Prognostic tools that identify people at high risk of delayed healing within the context of routine ulcer assessments may improve this, but robust evidence on which factors to include is lacking. Therefore, we scoped the literature to identify which potentially prognostic factors may warrant future systematic reviews and meta-analyses. We conducted electronic searches in MEDLINE and Embase to identify studies in English published between 1997 and 2017 that tested the association between healing of the three most common non-traumatic skin ulcers encountered by health care professionals (venous leg, diabetic foot, and pressure ulcers) and patient characteristics, ulcer characteristics, and results from clinical investigations. We included 42 studies that investigated factors which may be associated with the healing of venous leg ulcers (n = 17), diabetic foot ulcers (n = 15), and pressure ulcers (n = 10). Across ulcer types, ulcer characteristics were most commonly reported as potential prognostic factors for healing (n = 37), including the size of the ulcer area (n = 29) and ulcer duration at first assessment (n = 16). A total of 35 studies investigated the prognostic value of patient characteristics (n = 35), including age (n = 31), gender (n = 30), diabetes (n = 22), smoking status (n = 15), and history of deep vein thrombosis (DVT) (n = 13). Of these studies, 23 reported results from clinical investigations as potential prognostic factors, with the majority regarding vessel quality. Age, gender, diabetes, smoking status, history of DVT, ulcer area, and ulcer duration at time of first assessment warrant a systematic review and meta-analysis to quantify their prognostic value for delayed ulcer healing.

Association of a device-based remote management heart failure pathway with outcomes: TriageHF Plus real-world evaluation.

AIMS: Clinical pathways have been shown to improve outcomes in patients with heart failure (HF). Although patients with HF often have a cardiac implantable electronic device, few studies have reported the utility of device-derived risk scores to augment and organize care. TriageHF Plus is a device-based HF clinical pathway (DHFP) that uses remote monitoring alerts to trigger structured telephone assessment for HF stability and optimization. We aimed to evaluate the impact of TriageHF Plus on hospitalizations and describe the associated workforce burden. METHODS AND RESULTS: TriageHF Plus was a multi-site, prospective study that compared outcomes for patients recruited between April 2019 and February 2021. All alert-triggered assessments were analysed to determine the appropriateness of the alert and the workload burden. A negative-binomial regression with inverse probability treatment weighting using a time-matched usual care cohort was applied to estimate the effect of TriageHF Plus on non-elective hospitalizations. A post hoc pre-COVID-19 sensitivity analysis was also performed. The TriageHF Plus cohort (n = 443) had a mean age of 68.8 ± 11.2 years, 77% male (usual care cohort: n = 315, mean age of 66.2 ± 14.5 years, 65% male). In the TriageHF Plus cohort, an acute medical issue was identified following an alert in 79/182 (43%) cases. Fifty assessments indicated acute HF, requiring clinical action in 44 cases. At 30 day follow-up, 39/66 (59%) of initially symptomatic patients reported improvement, and 20 (19%) initially asymptomatic patients had developed new symptoms. On average, each assessment took 10 min. The TriageHF Plus group had a 58% lower rate of hospitalizations across full follow-up [incidence relative ratio: 0.42, 95% confidence interval (CI): 0.23-0.76, P = 0.004]. Across the pre-COVID-19 window, hospitalizations were 31% lower (0.69, 95% CI: 0.46-1.04, P = 0.077). CONCLUSIONS: These data represent the largest real-world evaluation of a DHFP based on multi-parametric risk stratification. The TriageHF Plus clinical pathway was associated with an improvement in HF symptoms and reduced all-cause hospitalizations.

Clinical Pathways Guided by Remotely Monitoring Cardiac Device Data: The Future of Device Heart Failure Management?

Research examining the utility of cardiac device data to manage patients with heart failure (HF) is rapidly evolving. COVID-19 has reignited interest in remote monitoring, with manufacturers each developing and testing new ways to detect acute HF episodes, risk stratify patients and support self-care. As standalone diagnostic tools, individual physiological metrics and algorithm-based systems have demonstrated utility in predicting future events, but the integration of remote monitoring data with existing clinical care pathways for device HF patients is not well described. This narrative review provides an overview of device-based HF diagnostics available to care providers in the UK, and describes the current state of play with regard to how these systems fit in with current HF management.

Remotely Monitored Cardiac Implantable Electronic Device Data Predict All-Cause and Cardiovascular Unplanned Hospitalization.

Background Unplanned hospitalizations are common in patients with cardiovascular disease. The "Triage Heart Failure Risk Status" (Triage-HFRS) algorithm in patients with cardiac implantable electronic devices uses data from up to 9 device-derived physiological parameters to stratify patients as low/medium/high risk of 30-day heart failure (HF) hospitalization, but its use to predict all-cause hospitalization has not been explored. We examined the association between Triage-HFRS and risk of all-cause, cardiovascular, or HF hospitalization. Methods and Results A prospective observational study of 435 adults (including patients with and without HF) with a Medtronic Triage-HFRS-enabled cardiac implantable electronic device (cardiac resynchronization therapy device, implantable cardioverter-defibrillator, or pacemaker). Cox proportional hazards models explored association between Triage-HFRS and time to hospitalization; a frailty term at the patient level accounted for repeated measures. A total of 274 of 435 patients (63.0%) transmitted ≥1 high HFRS transmission before or during the study period. The remaining 161 patients never transmitted a high HFRS. A total of 153 (32.9%) patients had ≥1 unplanned hospitalization during the study period, totaling 356 nonelective hospitalizations. A high HFRS conferred a 37.3% sensitivity and an 86.2% specificity for 30-day all-cause hospitalization; and for HF hospitalizations, these numbers were 62.5% and 85.6%, respectively. Compared with a low Triage-HFRS, a high HFRS conferred a 4.2 relative risk of 30-day all-cause hospitalization (8.5% versus 2.0%), a 5.0 relative risk of 30-day cardiovascular hospitalization (3.6% versus 0.7%), and a 7.7 relative risk of 30-day HF hospitalization (2.0% versus 0.3%). Conclusions In patients with cardiac implantable electronic devices, remotely monitored Triage-HFRS data discriminated between patients at high and low risk of all-cause hospitalization (cardiovascular or noncardiovascular) in real time.

Validation of the Infectious Diseases Society of America/American Thoratic Society minor criteria for intensive care unit admission in community-acquired pneumonia patients without major criteria or contraindications to intensive care unit care.

BACKGROUND: The 2007 Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) guidelines for community-acquired pneumonia (CAP) recommended new criteria to guide admission to the intensive care unit (ICU) for patients with this condition. Although the major criteria (requirement for mechanical ventilation or septic shock requiring vasopressor support) are well established, the value of the minor criteria alone have not been fully validated. METHODS: We performed a prospective observational study of consecutive adult patients with CAP admitted to NHS Lothian (Scotland, United Kingdom). Patients meeting the IDSA/ATS major criteria on admission were excluded, along with patients not suitable for ICU care owing to advanced directives or major comorbid illnesses. Performance characteristics for the IDSA/ATS minor criteria were calculated and compared with those for alternative scoring systems identified in the literature. Two definitions of severe CAP were used as primary end points: ICU admission, and subsequent requirement for mechanical ventilation or vasopressor support (MV/VS); 30-day mortality was a secondary outcome. RESULTS: The study included 1062 patients with CAP potentially eligible for ICU admission. Each of the 9 minor criteria was associated with increased risk of MV/VS and 30-day mortality in univariate analysis. Two hundred seven patients had ≥ 3 minor criteria (19.5%). The IDSA/ATS 2007 criteria had an area under the receiver operating characteristic curve of 0.85 (0.82-0.88) for prediction of MV/VS, 0.85 (0.82-0.88) for prediction of ICU admission, and 0.78 (0.74-0.82) for prediction of 30-day mortality. The IDSA/ATS 2007 criteria were at least equivalent to more established scoring systems for prediction of MV/VS and ICU admission and equivalent to alternative scoring systems for predicting 30-day mortality in this patient population. CONCLUSIONS: In a population of patients with CAP without contraindications to ICU care, the IDSA/ATS minor criteria predict subsequent requirement for MV/VS, ICU admission, and 30-day mortality.

Epidemiology, antibiotic therapy, and clinical outcomes in health care-associated pneumonia: a UK cohort study.

BACKGROUND: The recently introduced concept of health care-associated pneumonia (HCAP), referring to patients with frequent healthcare contacts and at higher risk of contracting resistant pathogens, is controversial. METHODS: This prospective observational study recorded the clinical features, microbiology, and outcomes in a UK cohort of hospitalized patients with pneumonia. The primary outcome was 30-day mortality. Logistic regression was used to adjust for confounders when determining the impact of HCAP on clinical outcomes. RESULTS: A total of 20.5% of patients met the HCAP criteria. HCAP patients were older than patients with community-acquired pneumonia (CAP) (median 76 y, IQR 65-83 vs 65 y, IQR 48-77; P < .0001) and more frequently had major comorbidities (62.1% vs 45.2%; P < .0001). Patients with HCAP had higher initial severity compared to CAP patients (Pneumonia Severity Index, mean 3.7 [SD 1.1] vs mean 3.1 [SD 1.3]; P < .0001) but also worse functional status using the Eastern Cooperative Oncology Group scale (mean 2.4 [SD 1.44] vs mean 1.4 [SD 1.13]; P < .0001) and more frequently had treatment restrictions such as do not resuscitate orders (59.9% vs 29.8%; P < .0001). Consequently mortality was increased (odds ratio [OR] 2.15 [1.44-3.22]; P = .002) in HCAP patients on univariate analysis. Multivariate analysis suggested this relationship was primarily due to confounders rather than a higher frequency of treatment failure due to resistant organisms (adjusted OR .97 [.61-1.55]; P = .9). The frequencies of Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and Gram-negative Enterobacteriaceae were low in both cohorts. CONCLUSIONS: HCAP is common in the United Kingdom and is associated with a high mortality. This increased mortality was primarily related to underlying patient-related factors rather than the presence of antibiotic-resistant pathogens. This study did not establish a clear indication to change prescribing practices in a UK cohort.

Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective.

AIMS: This study aims to establish the feasibility, safety, and efficacy of outpatient intravenous (IV) diuretic treatment for the management of decompensated heart failure (HF) for patients enrolled in the HeartFailure@Home service. METHODS AND RESULTS: We retrospectively analysed the clinical episodes of decompensated HF for patients enrolled in the HeartFailure@Home service, managed by ambulatory IV diuretic treatment either at home or on a day-case unit. A control group consisting of HF patients admitted to hospital for IV diuretics (standard-of-care) was also evaluated. In total, 203 episodes of decompensated HF (n = 154 patients) were evaluated. One hundred and fourteen episodes in 79 patients were managed exclusively by the ambulatory IV diuretic service-78 (68.4%) on a day-case unit and 36 (31.6%) domiciliary; 84.1% of patient episodes under the HF@Home service were successfully managed entirely in an out-patient setting without hospitalization. Eleven patients required admission in order to administer higher doses of IV diuretics than could be provided in the ambulatory setting. During follow-up, there were 20 (17.5%) 30 day re-admissions with HF or death in the ambulatory IV group and 29 (32.6%) in the standard-of-care arm (P = 0.02). There was no difference in 30 day HF readmissions between the two groups (14.9% ambulatory vs. 13.5% inpatients, P = 0.8), but 30 day mortality was significantly lower in the ambulatory group (3.5% vs. 21.3% inpatients, P < 0.001). CONCLUSIONS: Outpatient ambulatory management of decompensated HF with IV diuretics given either on a day case unit or in a domiciliary setting is feasible, safe, and effective in selected patients with decompensated HF. This should be explored further as a model in delivering HF services in the outpatient setting during COVID-19.

Triage-HF Plus: a novel device-based remote monitoring pathway to identify worsening heart failure.

AIMS: Remote monitoring of patients with physiological data derived from cardiac implanted electronic devices (CIEDs) offers potential to reconfigure clinical services. The 'Heart Failure Risk Score' (HFRS) uses input from integrated device physiological monitoring to risk-stratify patients as low-risk, medium-risk, or high-risk of a heart failure event in the next 30 days. This study aimed to evaluate a novel clinical pathway utilizing a combination of CIED risk-stratification and telephone triage to identify patients with worsening heart failure (WHF). METHODS AND RESULTS: A prospective, single-centre, real-world evaluation of the 'Triage-HF Plus' clinical pathway (HFRS in combination with telephone triage) over a 27 month period. One hundred and fifty-seven high-risk HFRS transmissions were referred for telephone triage assessment. Interventions were at the discretion of the clinical assessor acting in accordance with clinical guidelines. An additional 3month consecutive sample of low and medium HFRS transmissions (control group) were also contacted for telephone triage assessment (n = 98). Successful telephone contact was made in 127 (81%) of referred high-risk HFRS cases: 71 (55.9%) were confirmed to have WHF requiring intervention; 19 (14.9%) had an alternative acute medical problem; one patient had been recently discharged from hospital with WHF; and 36 (28.0%) had no apparent cause for the high score. In the control group, only one patient had symptoms of WHF. The sensitivity and specificity of CIED-based remote monitoring to identify WHF 98.6% (92.5-100.0%) and 63.4% (55.2-71.0%), respectively. CONCLUSIONS: The Triage-HF Plus clinical pathway is a potentially useful remote monitoring tool for patients with heart failure and in situ CIEDs.

Barriers to the identification of frailty in hospital: a survey of UK clinicians.

Despite numerous national campaigns, frailty remains under-recognised in the hospital setting. We performed a survey of hospital-based clinicians across the UK to identify barriers to the identification and best practice management of frailty in hospital. A total of 402 clinicians were surveyed across a range of grades, specialties and hospitals. Responses highlighted variable awareness and personal understanding of frailty, particularly among junior doctors and clinicians in non-medical specialties. Although 74% of responders agreed frailty assessments should be undertaken for all older people admitted to hospital, only 36% felt this was currently feasible with available resources. Free-text responses highlighted limited education, the perceived subjectivity of frailty assessments, scepticism as to their utility in the hospital setting, and deficiencies in service provision. This was the first survey of UK hospital clinicians regarding frailty assessments. Results highlight multiple areas for improvement and engagement.

Progesterone therapy for the treatment of non-cancer cachexia: a systematic review.

BACKGROUND: Cachexia describes a complex pathological syndrome of muscle wasting, anorexia and weight loss. Progesterone therapies have been shown to improve appetite and promote weight gain in patients with cachexia; however, research has focused heavily on patients with cancer, and its effectiveness in other diseases remains unclear. AIMS: This systematic review aimed to present the evidence available for progesterone therapy as a treatment for non-cancer cachexia. METHOD: Surrogate outcome measures used were weight change, lean body mass (LBM), muscle strength, appetite, health-related quality of life (HRQOL) and serum albumin. Both randomised and non-randomised trials were included. A literature search of clinical trials using the medical subject heading (MeSH) terms 'cachexia' OR 'anorexia' OR 'weight' OR 'frail (truncated)' OR 'appetite' OR 'wasting syndrome' PLUS 'megestrol acetate' OR 'medroxyprogesterone acetate' was performed. RESULTS: Eighteen studies were included in this review; 12 randomised control trials and 6 non-randomised trials. This collated results from 916 patients with HIV/AIDS, end-stage renal failure, chronic obstructive pulmonary disease (COPD) and geriatric cachexia. Meta-analysis comparing progesterone therapy with placebo concluded mean change in weight was not significant (mean difference (MD) 1.56, 95% CI -0.36 to 3.52, p=0.12). There was little evidence to show significant impact on LBM, and no trials looked at muscle strength. There was a paucity of evidence looking at appetite and HRQOL; however, results were generally positive. CONCLUSIONS: Current evidence does not support the use of progesterone therapies for non-cancer cachexia. There may however be a limited role for its use as an appetite stimulant in a palliative context on a case-by-case basis.

Embedding comprehensive geriatric assessment in the emergency assessment unit: the impact of the COPE zone.

We introduced a geographically embedded frailty unit, the comprehensive older person's evaluation 'COPE' zone within our emergency assessment unit (EAU). We collated data for all medical patients over 75 years admitted non-electively for one month before and after this service change. Significantly more patients were seen by a geriatrician on the EAU earlier in their admission in 2014 (33.4 vs 19.3%, p<0.001; 11 vs 20 h, p<0.001). More patients had documented comprehensive geriatric assessment and discussion in a geriatrician multidisciplinary team meeting (relative risk (RR) 3.3, 95% confidence interval (CI) 2.35-4.73, p<0.001; RR 3.6, 95% CI 2.26-5.57, p<0.001, respectively). More patients with markers of frailty were discharged directly from EAU (42.2 vs 29.0%, p = 0.006) without increasing readmissions. Mean length of stay was reduced (9.5 vs 6.8 days, p = 0.02). The introduction of the COPE zone has improved service delivery at the point of access for older people admitted to hospital.

Risk factors for aspiration in community-acquired pneumonia: analysis of a hospitalized UK cohort.

BACKGROUND: There is a move toward finding clinically useful "phenotypes" in community-acquired pneumonia: groups of patients displaying distinct clinical characteristics, microbiology, and prognosis. Aspiration pneumonia is an intuitive clinical phenotype; however, to date there are no recognized diagnostic criteria, and data regarding outcomes in suspected aspiration are limited. METHODS: An observational study of 1348 patients hospitalized with community-acquired pneumonia in the United Kingdom examined both short- and long-term outcomes for patients at risk of aspiration pneumonia. Patients were defined as "at risk" in the presence of chronic neurologic disorders, esophageal disorders and dysphagia, impaired conscious level, vomiting, or witnessed aspiration. The primary outcome was 30-day mortality. Secondary outcomes included 1-year mortality, readmissions, and recurrent pneumonia within 1 year. RESULTS: Some 13.8% of the cohort were classified as "at risk of aspiration." These patients were older (median age, 74 years [interquartile range, 60-84] vs 66 years [interquartile range, 49-77]; P < .0001) and more likely to have comorbidities (chronic liver disease 11.3% vs 3.7%, P < .0001; congestive heart failure 28% vs 17.1%, P = .0004; and stroke 26.9% vs 9.5%, P < .0001). Patients at risk of aspiration pneumonia had a poorer short-term outcome (30-day mortality 17.2% vs 7.7%, P < .0001), but after adjusting for their greater severity of illness and comorbidities this difference was not significant (odds ratio 1.05; 95% confidence interval [CI], 0.63-1.76; P = .8). However, patients with aspiration risk factors were at greater risk of poor long-term outcomes with increased 1-year mortality (hazard ratio [HR], 1.73; 95% CI, 1.15-2.58), increased risk of rehospitalization (HR, 1.52; 95% CI, 1.21-1.91), and a strong association with recurrent admissions with pneumonia (HR, 3.13; 95% CI, 2.05-4.78) after multivariable adjustment. CONCLUSIONS: Using risk factors to identify patients at risk of aspiration pneumonia identifies a distinct clinically useful phenotype of patients with greater severity of disease and poorer long-term outcomes.