Diagnostic and treatment concordance in primary care participants and dermatologists utilizing Extension for Community Health Outcomes (ECHO)

INTRODUCTION

Suboptimal access to dermatologic care is dependent on patient location and insurance type. Although there have been attempts to address access issues, barriers to providing excellent dermatologic care to all patients at the right time still exist. The objective of this study was to investigate the clinical impact of Dermatology Extension for Community Healthcare Outcomes (ECHO) project participation on primary care providers' diagnostic and treatment tendencies and accuracy.

METHODS

This was a retrospective cohort study constructed using Dermatology Extension for Community Healthcare Outcomes case and recommendation data from November 2015 to June 2021. The University of Missouri-based Dermatology Extension for Community Healthcare Outcomes specialty hub team offers regularly scheduled live interactive tele-mentoring sessions for primary care providers who practice in rural and underserved areas. 524 patient cases presented by 25 primary care providers were included in the analysis. Of those, 449 cases were included in diagnostic concordance, and 451 in treatment concordance analysis.

RESULTS

Less than 40% of all diagnoses were fully concordant with an expert panel. Over 33% of patients were misdiagnosed, and over 26% received partially correct diagnosis. Only 16% of all treatment recommendations were fully concordant with an expert panel.

DISCUSSION

Diagnostic and treatment accuracy of participants is low, and Dermatology Extension for Community Healthcare Outcomes platform ensured patients received correct diagnosis and treatment quickly. Although tele-dermatology models are effective, they continue to be underutilized. Dermatologists in practice and training should be encouraged to adopt innovative clinical educational models, like Dermatology ECHO, to expand access to dermatologic expertise for the most marginalized populations.

Jupiter's X-Ray and UV Dark Polar Region

We present 14 simultaneous Chandra X-ray Observatory (CXO)-Hubble Space Telescope (HST) observations of Jupiter's Northern X-ray and ultraviolet (UV) aurorae from 2016 to 2019. Despite the variety of dynamic UV and X-ray auroral structures, one region is conspicuous by its persistent absence of emission: the dark polar region (DPR). Previous HST observations have shown that very little UV emission is produced by the DPR. We find that the DPR also produces very few X-ray photons. For all 14 observations, the low level of X-ray emission from the DPR is consistent (within 2-standard deviations) with scattered solar emission and/or photons spread by Chandra's Point Spread Function from known X-ray-bright regions. We therefore conclude that for these 14 observations the DPR produced no statistically significant detectable X-ray signature.

Reducing long acting antipsychotic injection dosage frequency: A pilot study in a community mental health team

BACKGROUND

Antipsychotic long acting injections (LAI) allow a range of dosage intervals to be administered. Short intervals can be inconvenient for patients and staff. There are few clinical reasons for using them yet this is common practice.

AIMS

This study aimed to examine the feasibility of reducing LAI frequency with service user consent.

METHODS

The study took place in a community mental health team in the north of England. A specialist mental health pharmacist reviewed records of all service users on LAI and drew up an action plan. Each service user then met with the consultant psychiatrist for medication review.

RESULT

Nineteen out of thirty service users on LAI had intervals less than the maximum licensed. The frequency was reduced in eight cases. After 6 months follow-up, there was no deterioration in symptoms. In nine cases, antipsychotic doses were also reduced as a result of the review.

CONCLUSION

Where a service user is prescribed a LAI with a short dosage interval consideration should be given to increase the interval. This can free up service user and staff time. A medication focused review can also lead to other benefits such as dosage reduction.

Dermatology ECHO - an innovative solution to address limited access to dermatology expertise

INTRODUCTION

The present maldistribution of dermatologists in the USA may make it difficult for patients to access timely and quality care. Access to specialty care may be even more challenging for rural and underserved patients due to geographical limitations and other socioeconomic hardships. With over one-third of primary care patients seeking care for at least one skin problem, it is important to follow the American Academy of Dermatology Special Positioning Workgroup\'s core areas of impact regarding treatment of conditions that affect millions of patients by using a team-based approach and telemedicine technologies. The objective of this study was to demonstrate the Dermatology Extension for Community Healthcare Outcomes (ECHO) project approach in multidisciplinary telementoring and education of primary care providers (PCPs) in treatment and management of complex, costly, and common skin diseases via live interactive video technologies.

METHODS

Dermatology ECHO is a distance education telementoring platform that uses a multidisciplinary case-based approach in a non-judgemental environment. A team of specialists, including general dermatologists, pediatric dermatologists, a dermatopathologist, a clinical psychologist, and a nurse practitioner, meets via video with a number of PCPs from isolated, rural, or underserved areas to discuss de-identified patient cases and present dermatology-specific continuing medical education (CME)-approved didactic presentations. The University of Missouri, Department of Dermatology, leads the first Dermatology ECHO in the USA. They partner with various primary care clinics across Missouri to provide mentoring in the treatment of skin conditions. Missouri Telehealth Network provides operational support through the Show-Me ECHO project. The network also assists with provider recruitment activities.

RESULTS

The authors describe a patient case to illustrate the effect of ECHO on provider distance learning and patient outcomes. A 69-year-old woman from rural Missouri was spurred by a rooster. She presented to her primary care clinic six times over a 2-month period. She was prescribed several different medications and underwent tests and one procedure, including vaccination. After the patient\'s case was presented during the Dermatology ECHO session, she was correctly diagnosed with a Mycobacterium skin infection, and new recommendations were made. The patient improved significantly within 2 weeks.

CONCLUSIONS

As specialty medical evidence-based recommendations continue to increase, providers practicing in isolated rural and underserved areas may find it challenging to keep up with the new knowledge. Dermatology ECHO creates a community of practice that allows participating providers to discuss complex cases, receive specific guidance and mentoring, and participate in CME presentations. The case presented here supports the authors\' observations that Dermatology ECHO is an appropriate platform for learning evidence-based medical knowledge via videoconferencing technology.

Reliability of Drug Users' Self-Reported HIV Risk Behaviors and Validity of Self-Reported Recent Drug Use

This study examined the reliability and validity of the Risk Behavior Assessment, a structured interview questionnaire designed to evaluate drug use and sexual HIV risk behaviors. Participants were 218 drug users currently not in treatment who completed the RBA two times over a 48-hour period and gave urine samples on both occasions. We examined internal consistency and test-retest reliability and found that, overall, drug users reliably report drug use and sexual behavior, although the reliability of reports of specific needle practice and sexual behavior items was somewhat lower. Validity results indicated that drug users' accurately report use of cocaine and opiates. These findings indicate that this self-report questionnaire, when administered by trained interviewers, reliably measures HIV risk behaviors in a drug-using population and provides a valid assessment of recent drug use.

Host Responses to Biofilm

From birth to death the human host immune system interacts with bacterial cells. Biofilms are communities of microbes embedded in matrices composed of extracellular polymeric substance (EPS), and have been implicated in both the healthy microbiome and disease states. The immune system recognizes many different bacterial patterns, molecules, and antigens, but these components can be camouflaged in the biofilm mode of growth. Instead, immune cells come into contact with components of the EPS matrix, a diverse, hydrated mixture of extracellular DNA (bacterial and host), proteins, polysaccharides, and lipids. As bacterial cells transition from planktonic to biofilm-associated they produce small molecules, which can increase inflammation, induce cell death, and even cause necrosis. To survive, invading bacteria must overcome the epithelial barrier, host microbiome, complement, and a variety of leukocytes. If bacteria can evade these initial cell populations they have an increased chance at surviving and causing ongoing disease in the host. Planktonic cells are readily cleared, but biofilms reduce the effectiveness of both polymorphonuclear neutrophils and macrophages. In addition, in the presence of these cells, biofilm formation is actively enhanced, and components of host immune cells are assimilated into the EPS matrix. While pathogenic biofilms contribute to states of chronic inflammation, probiotic Lactobacillus biofilms cause a negligible immune response and, in states of inflammation, exhibit robust antiinflammatory properties. These probiotic biofilms colonize and protect the gut and vagina, and have been implicated in improved healing of damaged skin. Overall, biofilms stimulate a unique immune response that we are only beginning to understand.

The human voice areas: Spatial organization and inter-individual variability in temporal and extra-temporal cortices

fMRI studies increasingly examine functions and properties of non-primary areas of human auditory cortex. However there is currently no standardized localization procedure to reliably identify specific areas across individuals such as the standard ‘localizers’ available in the visual domain. Here we present an fMRI ‘voice localizer’ scan allowing rapid and reliable localization of the voice-sensitive ‘temporal voice areas’ (TVA) of human auditory cortex. We describe results obtained using this standardized localizer scan in a large cohort of normal adult subjects. Most participants (94%) showed bilateral patches of significantly greater response to vocal than non-vocal sounds along the superior temporal sulcus/gyrus (STS/STG). Individual activation patterns, although reproducible, showed high inter-individual variability in precise anatomical location. Cluster analysis of individual peaks from the large cohort highlighted three bilateral clusters of voice-sensitivity, or “voice patches” along posterior (TVAp), mid (TVAm) and anterior (TVAa) STS/STG, respectively. A series of extra-temporal areas including bilateral inferior prefrontal cortex and amygdalae showed small, but reliable voice-sensitivity as part of a large-scale cerebral voice network. Stimuli for the voice localizer scan and probabilistic maps in MNI space are available for download.

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Three “voice patches” along human superior temporal gyrus/sulcus.

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Anatomical location reproducible within- but variable between-individuals.

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Extended voice processing network includes amygdala and prefrontal cortex.

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Stimulus material for “voice localizer” scan available for download.

Big Data Usage Patterns in the Health Care Domain: A Use Case Driven Approach Applied to the Assessment of Vaccination Benefits and Risks. Contribution of the IMIA Primary Healthcare Working Group

BACKGROUND

Generally benefits and risks of vaccines can be determined from studies carried out as part of regulatory compliance, followed by surveillance of routine data; however there are some rarer and more long term events that require new methods. Big data generated by increasingly affordable personalised computing, and from pervasive computing devices is rapidly growing and low cost, high volume, cloud computing makes the processing of these data inexpensive.

OBJECTIVE

To describe how big data and related analytical methods might be applied to assess the benefits and risks of vaccines.

METHOD

We reviewed the literature on the use of big data to improve health, applied to generic vaccine use cases, that illustrate benefits and risks of vaccination. We defined a use case as the interaction between a user and an information system to achieve a goal. We used flu vaccination and pre-school childhood immunisation as exemplars.

RESULTS

We reviewed three big data use cases relevant to assessing vaccine benefits and risks: (i) Big data processing using crowdsourcing, distributed big data processing, and predictive analytics, (ii) Data integration from heterogeneous big data sources, e.g. the increasing range of devices in the "internet of things", and (iii) Real-time monitoring for the direct monitoring of epidemics as well as vaccine effects via social media and other data sources.

CONCLUSIONS

Big data raises new ethical dilemmas, though its analysis methods can bring complementary real-time capabilities for monitoring epidemics and assessing vaccine benefit-risk balance.

Effectiveness of trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2012/13 end of season results

The effectiveness of the 2012/13 trivalent seasonal influenza vaccine (TIV) was assessed using a test-negative case-control study of patients consulting primary care with influenza-like illness in the United Kingdom. Strain characterisation was undertaken on selected isolates. Vaccine effectiveness (VE) against confirmed influenza A(H3N2), A(H1N1) and B virus infection, adjusted for age, sex, surveillance scheme (i.e. setting) and month of sample collection was 26% (95% confidence interval (CI): -4 to 48), 73% (95% CI: 37 to 89) and 51% (95% CI: 34 to 63) respectively. There was an indication, although not significant, that VE declined by time since vaccination for influenza A(H3N2) (VE 50% within three months, 2% after three months, p=0.25). For influenza A(H3N2) this is the second season of low VE, contributing to the World Health Organization (WHO) recommendation that the 2013/14 influenza vaccine strain composition be changed to an A(H3N2) virus antigenically like cell-propagated prototype 2012/13 vaccine strain (A/Victoria/361/2011). The lower VE seen for type B is consistent with antigenic drift away from the 2012/13 vaccine strain. The majority of influenza B viruses analysed belong to the genetic clade 2 and were antigenically distinguishable from the 2012/13 vaccine virus B/Wisconsin/1/2010 clade 3. These findings supported the change to the WHO recommended influenza B vaccine component for 2013/14.

Effectiveness of trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2012/13 end of season results

Binary file ES_Abstracts_Final_ECDC.txt matches

Long-term 4-year safety of saxagliptin in drug-naive and metformin-treated patients with Type 2 diabetes

AIMS

To evaluate the safety of saxagliptin ± metformin over 4 years in patients with Type 2 diabetes mellitus.

METHODS

Drug-naive (n = 401; study 11) or metformin-treated (n = 743; study 14) adults with HbA(1c) of 53-86 mmol/mol (7.0-10%) were enrolled in two randomized, placebo-controlled, double-blind trials of saxagliptin 2.5, 5 or 10 mg/day. Patients rescued during or completing 24 weeks of treatment could continue in a 42-month long-term blinded phase, for which the primary goal was assessment of safety and tolerability. Between-group efficacy was not evaluated in the long-term phase of study 11. Time to rescue or discontinuation because of inadequate glycaemic control, change from baseline in HbA(1c) and percentages of patients achieving HbA(1c) < 53 mmol/mol (< 7.0%) were assessed in study 14.

RESULTS

No new safety findings were noted during the long-term phase. Most adverse events were mild or moderate, with slightly greater frequency of upper respiratory infections with saxagliptin. Hypoglycaemic event rates were similar with saxagliptin and placebo. In study 14, time to rescue or discontinuation because of inadequate glycaemic control was longer with saxagliptin plus metformin than for placebo plus metformin. From baseline to week 154, HbA(1c) decreased with saxagliptin but increased with placebo.

CONCLUSION

Saxagliptin monotherapy or add-on to metformin is generally safe and well tolerated, with no increased risk of hypoglycaemia, for up to 4 years.

Bacillus-calmette-guerin (bcg) organisms directly alter the growth of bladder-tumor cells

Studies in recent years have shown various effects of bacillus Calmette Guerin organisms on the human immune system. In the present study, the direct effects of bacillus Calmette Guerin (BCG) (as used for the clinical management of superficial bladder cancer) on bladder tumour cells were investigated. Using a proliferation assay, changes in the growth rates of tumour cells were studied following direct exposure to BCG. The effects of variations in the BCG dose, and in the viability of BCG organisms were investigated and our initial observations concerning the antiproliferative effects of interferon-garnma were extended. The main finding of these studies is the direct immuno-modulatory effects of BCG organisms on the proliferative capacity of human tumour cells. Previously these alterations in the growth rate of bladder cancer cells, which are observed following patient therapy, were attributed to the production of various cytokines. However, after exposure to BCG the growth of tumour cell lines was suppressed in a dose and time dependent manner. Furthermore, both viable and nonviable bacilli can exert this action although heat killed BCG may be less effective in doing so. In concordance with our earlier study, interferon-gamma exerted marked antiproliferative effects against eight tumour cell lines. Furthermore, a 12 hour pulse of cytokine was sufficient to suppress the growth of tumour cells. This is an important finding as cytokine is not detected in patient's urine later than 12 hours after immunotherapy. No consistent pattern of growth altering effect was observed with any of the other cytokines tested (IL-1-alpha, IL-2, IL-3, IL-4, IL-6, IL-7, IL-8, GM-CSF). Our study suggests that BCG organisms per se may exert direct effects upon tumour cells in vivo and thus ease the load on the immune responses leading to the eventual eradication of tumour.

Skin conditions are the commonest new reason people present to general practitioners in England and Wales

BACKGROUND

Knowledge of the prevalence and incidence of skin conditions is a prerequisite for designing clinical services and providing appropriate training for primary health care professionals. In the U.K. the general practitioner and practice nurse are the first point of medical contact for persons with skin conditions.

OBJECTIVES

We aimed to obtain contemporary data in age-, gender- and diagnosis-specific detail on persons presenting to primary care with skin problems. Comparisons were made with similar data for other major disease groups and with similar data from other recent years.

METHODS

We used surveillance data collected in the Weekly Returns Service (WRS) of the Royal College of General Practitioners during 2006 and trend data for subsequent years. The WRS sentinel practices monitor all consultations by clinical diagnosis in a representative population of 950,000 in England and Wales.

RESULTS

For conditions included in chapter XII of the International Classification of Diseases Ninth Revision (ICD9), 15% of the population consulted; a further 9% presented with skin problems classified elsewhere in the ICD9, making a total of 24%. There was no evidence of increasing or decreasing trend since 2006. Skin infections were the commonest diagnostic group, while 20% of children < 12 months were diagnosed with atopic eczema. Considered collectively, the incidence of new episodes of skin disorders (including diagnoses outside chapter XII) exceeded incidences for all other major disease groupings.

CONCLUSIONS

Compared with other major disease groups, skin conditions are the most frequent reason for consultation in general practice. This result emphasizes the need for appropriate education and training for all medical students and particularly for continuing education in dermatology for all primary health care professionals.

Increased incidence of Mycoplasma pneumoniae infection in England and Wales in 2010: multiocus variable number tandem repeat analysis typing and macrolide susceptibility

An epidemic of Mycoplasma pneumoniae infection began in Denmark in late 2010. A similar increase in M. pneumoniae infections was noted in England and Wales in the same period, with a decline in early 2011. Multiocus variable number tandem repeat analysis typing and analysis of macrolide resistance markers indicate that at least nine known and two novel strain types were circulating in England and Wales during October 2010 to January 2011. There was no evidence of macrolide resistance.

E-mail communication with patients: a survey of the American College of Physicians, Missouri Chapter

Numerous surveys have found patients expressing strong interest in e-mail communication with their physicians. However, currently very limited literature is available on physician interest. A survey was e-mailed to the members of the Missouri Chapter of the American College of Physicians to ascertain their specific concerns. Very few physicians use electronic mail with patients. Even fewer use it on a frequent basis and most do not give any written policy guidelines to patients.

Mycoplasma pneumoniae infection in primary care investigated by real-time PCR in England and Wales

Real-time PCR was employed to detect a conserved region of the P1 cytadhesin gene of Mycoplasma pneumoniae in combined nose and throat swabs collected from patients attending GP surgeries during 2005-2009 with symptoms of respiratory tract infection (RTI). Samples were collected as part of an annual winter epidemiological and virological linked study in England and Wales. A total of 3,987 samples were tested, 65 (1.7%, 95%CI 1.3-2.1) had detectable M. pneumoniae DNA. Positive patients were detected of both gender, aged from 9 months to 78 years, who had clinical signs of upper RTI, fever and/or myalgia, an influenza-like illness to lower RTI. Mixed infections were identified in four cases, two with influenza A H1, one with H3 and one with influenza B. Children aged 5-14 years were more likely to have detectable M. pneumoniae in samples than all other age groups (Fishers p = 0.03), attributed to the 2005-2006 season in which 6.0% (12/200, 95%CI 3.4-10.3) of 5-14 year olds had detectable M. pneumoniae in comparison to 2.2% in 2006-2007 (3/141 95%CI 0.5-6.4), 2.2% in 2007-2008 (2/89 95%CI 0.1-8.3) and 0% in 2008-2009 (0/151 95%CI 0-2.9).

Ethical concerns in the use of electronic medical records

The use of electronic medical record systems raises important ethical concerns about patient privacy and confidentiality, medical errors, expectations of structured data entry by clinicians, documentation integrity, and provider-patient interaction. Clinicians and health care organizations need to define best practices and policies in the use of EMR systems to improve quality and maintain clinician efficiency without compromising patient welfare and safety.

Acute hepatic failure in an infant caused by acetaminophen (paracetamol) toxicity

A 7-month-old infant developed acute fatal hepatic failure owing to inadvertent duplication of paracetamol prescriptions. Paracetamol toxicity should be considered in the differential diagnosis of infants presenting with acute hepatic failure.

Controversies in skin resurfacing: the role of erbium

Carbon dioxide laser resurfacing has been a valuable procedure for facial skin rejuvenation since the early 1990s, largely replacing medium and deep chemical peels and dermabrasion. The introduction of the erbium:YAG laser for resurfacing has caused confusion about its role. Because of its ability to resurface very superficially it has been limited by many laser surgeons to treating only superficial rhytides and sun damage. However, it is the equal of CO2 in improving deep rhytides but with quicker healing and fewer side-effects.

Addressing ethical issues in the nursing home

Ethical dilemmas are encountered frequently in long term facilities, encompassing a myriad of concerns related to end of life care, rehospitalization, artificial hydration and nutrition, capacity for decision making, use of sedation, and dealing with conflict that may arise amongst those caring for and about the patient. Having a formalized means of sorting through difficult cases is often not readily available in long term care facilities that have limited staffing and are often a remote distance from tertiary care centers where clinical ethicists tend to live professionally. A method is proposed to provide patients, families, and staff a means by which to systematically work through ethical dilemmas when formal ethics consultation is not available.

Seasonal influenza activity in Europe: declining in most countries in the West but increasing in the North-East

This winter, the consultation rates for influenza like illness (ILI) and/or acute respiratory infection (ARI) started to increase firstly in Scotland, Greece and Spain in December 2006 [1], where they have already returned to levels just above or at the baseline.

Seasonal influenza beginning in Europe: report from EISS

Increased influenza activity was reported in six countries in the second week of 2007: Greece, the Netherlands, United Kingdom (Northern Ireland), Scotland, Spain and Switzerland. Based on trends of previous years, influenza activity is expected to increase in many more European countries in the weeks ahead. The influenza activity reported so far has mainly been associated with influenza A viruses.

Modern surgical and interventional options for the management of heart failure

Current standard drug therapy provides only palliative and symptomatic relief for patients with severe heart failure, but there is now a wide array of device applications that holds great promise for reducing the mortality and disability that result from heart failure. Patients with severe chronic and refractory heart failure should be considered for heart transplantation or mechanical circulatory supportwith a ventricular assist device. Newer surgical and interventional treatments are in continuous evolution.

Array comparative genomic hybridisation (aCGH) analysis of premenopausal breast cancers from a nuclear fallout area and matched cases from Western New York

High-resolution array comparative genomic hybridisation (aCGH) analysis of DNA copy number aberrations (CNAs) was performed on breast carcinomas in premenopausal women from Western New York (WNY) and from Gomel, Belarus, an area exposed to fallout from the 1986 Chernobyl nuclear accident. Genomic DNA was isolated from 47 frozen tumour specimens from 42 patients and hybridised to arrays spotted with more than 3000 BAC clones. In all, 20 samples were from WNY and 27 were from Belarus. In total, 34 samples were primary tumours and 13 were lymph node metastases, including five matched pairs from Gomel. The average number of total CNAs per sample was 76 (range 35–134). We identified 152 CNAs (92 gains and 60 losses) occurring in more than 10% of the samples. The most common amplifications included gains at 8q13.2 (49%), at 1p21.1 (36%), and at 8q24.21 (36%). The most common deletions were at 1p36.22 (26%), at 17p13.2 (26%), and at 8p23.3 (23%). Belarussian tumours had more amplifications and fewer deletions than WNY breast cancers. HER2/neu negativity and younger age were also associated with a higher number of gains and fewer losses. In the five paired samples, we observed more discordant than concordant DNA changes. Unsupervised hierarchical cluster analysis revealed two distinct groups of tumours: one comprised predominantly of Belarussian carcinomas and the other largely consisting of WNY cases. In total, 50 CNAs occurred significantly more commonly in one cohort vs the other, and these included some candidate signature amplifications in the breast cancers in women exposed to significant radiation. In conclusion, our high-density aCGH study has revealed a large number of genetic aberrations in individual premenopausal breast cancer specimens, some of which had not been reported before. We identified a distinct CNA profile for carcinomas from a nuclear fallout area, suggesting a possible molecular fingerprint of radiation-associated breast cancer.

Evidence-based drug treatment of heart failure

Modern management strategies have revolutionized the treatment of patients with acute and chronic heart failure (HF). Physicians should identify the risks and benefits of each drug or interventional option being considered for the treatment of HF. Inhibition of the neurohormonal axis with angiotensin converting enzyme (ACE) inhibitors and beta-blockers has significantly improved morbidity and mortality of patients with chronic HF. An aggressive approach targeted at improving hemodynamics and end-organ function is warranted during acute exacerbations or decompensated heart failure. Immediate recognition and management of potentially reversible causes and simultaneous initiation of supportive therapy to augment the cardiac output are key elements to the successful treatment of acute heart failure.

Pathology, prognosis, and prevention of heart failure

Optimal management of patients with heart failure (HF) should be guided by thorough evaluation and use of functional classification and disease staging systems. Though the understanding of precise underlying pathophysiological mechanisms has increased dramatically in recent years, it is essential to continue the search for greater efficacy in preventing, controlling, and reversing this pathological state. Recent developments in the diagnosis and treatment of heart failure have improved prognosis in terms of both survival and morbidity due to re-hospitalization. The underutilization of medical and preventive therapies in patients with heart failure is a major public health issue, despite the recommendations of various evidence-based guide lines. Patient education and disease management programs have been shown to optimize HF-management by bridging the gap between evidence-based medicine and clinical practice, thereby, reducing hospitalization rate. This paper, the first in a series of three papers, will identify the pathology, prognosis and prevention of heart failure, while the paper to follow will discuss modern methods of interventional management.