Self-Measured Blood Pressure-Guided Pharmacotherapy: A Systematic Review and Meta-Analysis of United States-Based Telemedicine Trials

BACKGROUND

The optimal approach to implementing telemedicine hypertension management in the United States is unknown.

METHODS

We examined telemedicine hypertension management versus the effect of usual clinic-based care on blood pressure (BP) and patient/clinician-related heterogeneity in a systematic review/meta-analysis. We searched United States-based randomized trials from Medline, Embase, CENTRAL, CINAHL, PsycINFO, Compendex, Web of Science Core Collection, Scopus, and 2 trial registries. We used trial-level differences in BP and its control rate at ≥6 months using random-effects models. We examined heterogeneity in univariable metaregression and in prespecified subgroups (clinicians leading pharmacotherapy [physician/nonphysician], self-management support [pharmacist/nurse], White versus non-White patient predominant trials [>50% patients/trial], diabetes predominant trials [≥25% patients/trial], and White patient predominant but not diabetes predominant trials versus both non-White and diabetes patient predominant trials].

RESULTS

Thirteen, 11, and 7 trials were eligible for systolic and diastolic BP difference and BP control, respectively. Differences in systolic and diastolic BP and BP control rate were -7.3 mm Hg (95% CI, -9.4 to -5.2), -2.7 mm Hg (-4.0 to -1.5), and 10.1% (0.4%-19.9%), respectively, favoring telemedicine. Greater BP reduction occurred in trials where nonphysicians led pharmacotherapy, pharmacists provided self-management support, White patient predominant trials, and White patient predominant but not diabetes predominant trials, with no difference by diabetes predominant trials.

CONCLUSIONS

Telemedicine hypertension management is more effective than clinic-based care in the United States, particularly when nonphysicians lead pharmacotherapy and pharmacists provide self-management support. Non-White patient predominant trials achieved less BP reduction. Equity-conscious, locally informed adaptation of telemedicine interventions is needed before wider implementation.

Trends in new and persistent opioid use in older adults with and without cancer

BACKGROUND

The impact of ongoing efforts to decrease opioid use on patients with cancer remains undefined. Our objective was to determine trends in new and additional opioid use in patients with and without cancer.

METHODS

This retrospective cohort study used data from Surveillance, Epidemiology, and End Results program-Medicare for opioid-naive patients with solid tumor malignancies diagnosed from 2012 through 2017 and a random sample of patients without cancer. We identified 238 470 eligible patients with cancer and further focused on 4 clinical strata: patients without cancer, patients with metastatic cancer, patients with nonmetastatic cancer treated with surgery alone ("surgery alone"), and patients with nonmetastatic cancer treated with surgery plus chemotherapy or radiation therapy ("surgery+"). We identified new, early additional, and long-term additional opioid use and calculated the change in predicted probability of these outcomes from 2012 to 2017.

RESULTS

New opioid use was higher in patients with cancer (46.4%) than in those without (6.9%) (P < .001). From 2012 to 2017, the predicted probability of new opioid use was more stable in the cancer strata (relative declines: 0.1% surgery alone; 2.4% surgery+; 8.8% metastatic cancer), than in the noncancer stratum (20.0%) (P < .001 for each cancer to noncancer comparison). Early additional use declined among surgery patients (‒14.9% and ‒17.5% for surgery alone and surgery+, respectively) but was stable among patients with metastatic disease (‒2.8%, P = .50).

CONCLUSIONS

Opioid prescribing declined over time at a slower rate in patients with cancer than in patients without cancer. Our study suggests important but tempered effects of the changing opioid climate on patients with cancer.

Differential Impact of Consolidative Thoracic Radiotherapy in Extensive-Stage Small Cell Lung Cancer Based on Systemic Therapy Type and Sex

PURPOSE/OBJECTIVE(S)

Consolidative thoracic radiotherapy (cTRT) has been shown in phase III RCTs to improve overall (OS) and progression-free survival (PFS) after initial chemotherapy (chemo) in extensive-stage small cell lung cancer (ES-SCLC). This benefit was particularly pronounced in women compared to men in the 2015 CREST trial (hazard ratio [HR] 0.68 vs. 1.01, respectively). However, it is unknown whether similar findings would apply after chemoimmunotherapy (chemo-IO) became standard of care first-line treatment in 2018. In this analysis, we report national practice patterns and survival outcomes of cTRT versus no cTRT following chemo or chemo-IO, stratified by sex.

MATERIALS/METHODS

Patients from the nationwide Flatiron Health de-identified electronic health record-derived database were included if they completed 4-6 cycles of first-line systemic therapy (platinum-doublet chemo or chemo-IO) for stage IV SCLC diagnosed between 2014 and 2021. Patients who progressed or started cTRT within 14 days or died within 90 days of completing systemic therapy were excluded to account for immortal time bias. We evaluated OS and PFS using multivariable Cox proportional hazards regression with receipt of cTRT as an independent covariate and last date of chemo as index date. As a sensitivity analysis to address potential selection bias, we weighted the models by the inverse probability of receiving cTRT. All OS and PFS analyses were stratified by systemic therapy type and sex.

RESULTS

A total of 1,227 patients were included (850 chemo, 377 chemo-IO). The proportion of patients who received cTRT increased from 11.7% in 2014 to 20.7% in 2017, and then decreased to 16.4% in 2021. There were no statistically significant differences in baseline characteristics between patients who did and did not receive cTRT. In adjusted analyses among women receiving chemo, cTRT was associated with superior OS (HR 0.68; 95% confidence interval [CI] 0.51-0.91) and PFS (HR 0.64; 95% CI 0.47-0.86) [Table 1]. There was a non-statistically significant trend towards improved OS (HR 0.57; 95% CI 0.32-1.02) and PFS (HR 0.59; 95% CI 0.34-1.02) among women receiving chemo-IO. No OS or PFS benefit with cTRT was observed in men receiving either chemo or chemo-IO. Findings were similar in weighted analyses.

CONCLUSION

The survival impact of cTRT may be differentially impacted by sex, with female patients appearing more likely to benefit than male patients regardless of systemic therapy type. While the underpinnings of this association need to be elucidated, stratification by sex should be considered for RCTs studying cTRT in ES-SCLC.

Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic.

DESIGN, SETTING AND PARTICIPANTS

This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021.

OUTCOMES AND ANALYSIS

We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts.

RESULTS

We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity.

CONCLUSIONS

Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

Prostate cancer aggressiveness and financial toxicity among prostate cancer patients

INTRODUCTION

Financial toxicity (FT) is a growing concern among cancer survivors that adversely affects the quality of life and survival. Individuals diagnosed with aggressive cancers are often at a greater risk of experiencing FT. The objectives of this study were to estimate FT among prostate cancer (PCa) survivors after 10-15 years of diagnosis, assess the relationship between PCa aggressiveness at diagnosis and FT, and examine whether current cancer treatment status mediates the relationship between PCa aggressiveness and FT.

METHODS

PCa patients enrolled in the North Carolina-Louisiana Prostate Cancer Project (PCaP) were recontacted for long-term follow-up. The prevalence of FT in the PCaP cohort was estimated. FT was estimated using the COmprehensive Score for Financial Toxicity, a validated measure of FT. The direct effect of PCa aggressiveness and an indirect effect through current cancer treatment on FT was examined using causal mediation analysis.

RESULTS

More than one-third of PCa patients reported experiencing FT. PCa aggressiveness was significantly independently associated with high FT; high aggressive PCa at diagnosis had more than twice the risk of experiencing FT than those with low or intermediate aggressive PCa (adjusted odds ratio [aOR] = 2.13, 95% CI = 1.14-3.96). The proportion of the effect of PCa aggressiveness on FT, mediated by treatment status, was 10%, however, the adjusted odds ratio did not indicate significant evidence of mediation by treatment status (aOR = 1.05, 95% CI = 0.95-1.20).

CONCLUSIONS

Aggressive PCa was associated with high FT. Future studies should collect more information about the characteristics of men with high FT and identify additional risk factors of FT.

Racial identification represents significant risk factor for healthcare disparity among patients with severe bronchopulmonary dysplasia treated with tracheostomy

OBJECTIVES

To characterize the patient population with severe bronchopulmonary dysplasia (BPD) requiring tracheostomy in a large tertiary level 4 neonatal intensive care unit (NICU) and to identify potential targets for improvement in the delivery of high-quality healthcare.

METHODS

An IRB-exempt but IRB-registered retrospective review of medical records. Study inclusion criteria: patients treated for severe BPD with tracheostomy under 2 years of age in our tertiary referral center NICU. Control group criteria: 4-year aggregate NICU patient demographics. Basic demographics, maternal history, clinical data points, and outcomes variables were collected.

RESULTS

There was a statistically significant difference between the two groups in only one variable: racial identification (p-value = 0.036). All data points were then analyzed against racial identification, and statistically significant differences appeared in 4 categories: 1) illicit drug use, 2) birth head circumference and length, 3) days to readmission, and 4) child opportunity index scores. There was not a statistically significant difference in any other maternal characteristics or medical comorbidities, NICU length of stay, age at tracheostomy, or decannulation status.

CONCLUSION

The incidence of our tracheostomy in infants with severe BPD was significantly higher (p = 0.036) in the subjects whose families identified as racially African American or Black, a marked contrast to our general NICU population and our overall tracheostomy population. The timing of the first readmission to the hospital was shorter for Caucasian or White infants compared to African American or Black infants. COI demonstrated statistically significantly poorer resources for African American or Black infants compared to White infants with tracheostomy. All other perinatal and outcome measurements did not differ significantly between the two racial groups. This suggests that this racial disparity is present and needs further investigation to better assess its impact on risk and outcomes as we develop pathways for high-quality healthcare delivery.

Timing of steroid initiation and response rates to immune checkpoint inhibitors in metastatic cancer

Background

Corticosteroids (CS) are the mainstay of immune-related adverse effect (irAE) management, as well as for other indications in cancer treatment. Previous studies evaluating whether CS affect immune checkpoint inhibitor (CPI) efficacy compared patients receiving CS versus no CS. However, there is a paucity of clinical data evaluating the timing of concomitant CS and CPI efficacy.

Methods

We retrospectively collected data from patients who received CS during CPI treatment at a single institution. Patients were in two cohorts based on timing of initiation of CS (≥2 months vs <2 months after initiating CPI). Patient characteristics, irAEs, cancer type, treatment type, treatment response/progression per RECIST V.1.1, and survival data were collected. Kaplan-Meier and Cox proportional hazard regression methods estimated HRs for the primary endpoint of progression-free survival (PFS) along with overall survival (OS).

Results

We identified 247 patients with metastatic cancer who received CS concurrently with CPIs. The median time on CS was 1.8 months. After adjusting for treatment type, tumor type, brain metastases, and irAEs, those treated with CS ≥2 months after starting CPI had a statistically significant longer PFS (HR=0.30, p<0.001), and OS (HR 0.34, p<0.0001) than those who received CS <2 months after starting CPI. Objective response rate (ORR) for patients on CS ≥2 months was 39.8%, versus ORR for patients <2 months was 14.7% (p value =<0.001)

Conclusion

Our results suggest that early use of CS during CPI treatment significantly hinders CPI efficacy. This data needs to be validated prospectively. Future studies should focus on the immune mechanisms by which CSs affect T-cell function early in the CPI treatment course.

Rural-urban disparities in the distribution of dental caries among children in south-eastern Louisiana: a cross-sectional study

INTRODUCTION

The purpose of this cross-sectional study was to assess the prevalence of dental caries among elementary school-aged children in rural compared to urban communities within south-eastern Louisiana that have participated in a school-based dental screening and sealant program.

METHODS

The authors utilized de-identified Sealant Efficiency Assessment for Locals and States screening data for 2007-2014 provided by The Health Enrichment Network oral health program. The screening was conducted throughout 46 elementary schools in Louisiana. Screening forms recorded decayed, missing, and filled permanent teeth (DMFT). Descriptive statistics including demographic characteristics and oral health conditions were calculated. Univariate and multivariable logistic regression analyses were performed to assess the burden of caries in schools.

RESULTS

Of 963 children screened, 32% had dental caries. There was an increased risk of having any DMFT among children who attended rural schools as compared to those who attended urban schools (prevalence odds ratio (POR)=2.17, 95% confidence interval (CI)=1.61-2.93). This study found that non-Hispanic black children had reduced odds of DMFT as compared to the children from other reported ethnicities (POR=0.695, 95%CI=0.503-0.960).

CONCLUSION

A higher prevalence of dental caries was found in rural compared to urban communities. Further research is needed to assess the extent of geographic differences to improve oral health outcomes.

Serum urea, creatinine and electrolyte status in patients presenting with acute gastroenteritis

The present study was undertaken to estimate the serum urea, creatinine and electrolyte status of patients presenting with acute gastroenteritis. Sixty patients who presented to Kathmandu Medical College and Teaching hospital from 15 June to 15 July 2005 with acute diarrhea with or without associated vomiting, causing dehydration severe enough to require hospital admission were investigated for serum urea, creatinine and electrolyte level. Out of 60 patients investigated, serum sodium and potassium level were available for 34 patients. Only one (2.9%) patients had sodium level below 135mEq/l, thirty two (94.11%) had sodium level between 135-146 mEq/l and one (2.9%) had sodium level above 146mEq/l. Similarly 9 (26.47%) patients had potassium level below 3.5mEq/l, 22 (64.70%) patients had potassium level between 3.5-5 mEq/l and 3 (8.82%) patients had level above 5 mEq/l. Serum urea and creatinine level were available for 47 patients. 36 (76.59%) patients had serum urea level between 15-45mg/dl and 11 (23.40%) patients had urea level above 45 mg/dl. 35 (74.46%) patients had serum creatinine level between 0.5-1.4 mg/dl and 12 (25.53%) had serum creatinine level above 1.4 mg/dl. In this study hypokalaemia was noticed more than hyponatremia and significant number of patients also showed increased level of serum urea and creatinine. Therefore, serum urea, creatinine and electrolytes should be closely monitored in patients with acute gastroenteritis.