Reaching Ambulatory Older Adults with Educational Tools: Comparative Efficacy and Cost of Varied Outreach Modalities in Primary Care

BACKGROUND

Providing patients with access to health information that can be obtained outside of an office visit is an important part of education, yet little is known about the effectiveness of outreach modalities to connect older adults to online educational tools. The objective was to identify the effectiveness and cost of outreach modalities providing online information about advance care planning (ACP) for older adults.

METHODS

Six different outreach modalities were utilized to connect patients to online educational tools (ACP video decision aids). Participants were 13,582 patients aged 65 and older of 185 primary care providers with appointments over a 30-month period within a large health system in the greater New York City area. Main outcome measures were number of online video views and costs per outreach for each modality.

KEY RESULTS

There were 1150 video views for 21,407 remote outreach events. Text messages, sent to the largest volume of patients (8869), had the highest outcome rate (9.6%) and were the most economical ($0.09). Characterization of phone calls demonstrated 21.7% engagement in the topic of ACP but resulted in minimal video views (<1%) and incurred the highest cost per outreach ($2.88). In-office handouts had negligible results (<1%).

CONCLUSIONS

Text was the most cost-effective modality to connect older adults to an online educational tool in this pragmatic trial, though overall efficacy of all modalities was low.

Atenolol is not effective in reducing ventricular arrhythmia severity on exercise stress test in patients with catecholaminergic polymorphic ventricular tachycardia

 

Patients with catecholaminergic polymorphic ventricular tachycardia (CPVT) are at risk for malignant ventricular arrhythmias during exercise and emotions which may lead to sudden cardiac death. Beta-blockers (BB) are the mainstay of therapy in patients with CPVT, but studies comparing the efficacy of different types of BB are scarce. Our objective was to determine the efficacy of different types of BB in reducing the ventricular arrhythmia (VA) severity on exercise stress test (EST) in patients with CPVT.

Data was derived from the International CPVT Registry, a large retrospective cohort study. We included patients who had an EST before (pre-EST) and after start of BB (post-EST). We divided the cohort into five groups based on the first prescribed BB and compared pre-EST and post-EST.

We included 428 patients (median age 18.5 [11.7–39.6] years, 240 (56.%) female), 155 (36.2%) probands) of whom 38 (8.9%) used atenolol, 131 (30.6%) bisoprolol, 82 (19.2%) metoprolol, 124 (29.0%) nadolol and 53 (12.4%) propranolol. Sex and history of aborted cardiac arrest were similar in all groups. The age at start of BB differed (p&lt;0,001): patients using bisoprolol were oldest (35.0 [15.7–35.3]) while patients using propranolol were youngest (12.3 [8.8–24.9]). Median daily BB dose in mg/kg was: 1.0 [0.8–2.3] for atenolol, 0.06 [0.05–0.10] for bisoprolol, 0.9 [0.6–1.5] for metoprolol, 1.1 [0.9–1.6] for nadolol and 1.5 [1.1–2.8] for propranolol. Resting heart rate on pre-EST and post-EST was similar in all groups. Patients using metoprolol had a significantly higher maximum heart rate post-EST compared to nadolol and propranolol (161±18 vs 136±19 and 130±22 bpm, p=0,002 and p=0,001, respectively). The VA severity decreased significantly after BB (147 (37.9%) (non-sustained) ventricular tachycardia ((NS)VT) and 120 (30.9%) no or isolated ventricular premature beat (iVPB) pre-EST vs 46 (11.4%) (NS)VT and 184 (45.7%) iVPB post-EST, p&lt;0,001). Examining the different groups, the VA severity decreased significantly after BB in all but atenolol (13 (40.6%) (NS)VT and 8 (25.0%) iVPB pre-EST vs 9 (25.0%) (NS)VT and 15 (41.7%) iVPB post-EST, p=0,103).

Based on these results we conclude that all beta-blockers except atenolol are effective in reducing the VA severity on EST in patients with CPVT.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): E-Rare Joint Transnational Call for Proposals 2015 “Improving Diagnosis and Treatment of Catecholaminergic Polymorphic Ventricular Tachycardia: Integrating Clinical and Basic Science”

An impedance-guided intra arterial catheter

Under certain circumstances, the placement of arterial catheters can be difficult. In these instances, a form of guidance is preferred to avoid repeated insertions of the arterial catheter. Ultrasonic guidance is generally used in these instances, but the equipment required is expensive and cumbersome. This study produced an arterial catheter that is guided by the impedance of biological tissue encountered between the patient's skin and the lumen of the artery, with the aim of producing a cheaper and manageable alternative to ultrasonic guidance. Additionally, this study has inspected the impedance of human tissue in order to determine whether or not a sufficient and discernable difference between the impedance of the different tissue types could be identified and thus be used to guide an arterial catheter based on said impedance differences. The results indicate that the difference between subcutaneous tissue, fat tissue and skeletal muscle tissue are not clear enough to make accurate discrimination between tissue types. However, the study shows a clear difference between the impedance of arterial blood and the aforementioned tissue, allowing for the device to determine when accurate placement has been achieved. From the results obtained in the studies, the discrimination between blood and other intermediary tissue can be made with 99,4% confidence.

Comparison of 4 proliferation markers and their significance for evaluation of tumor dignity in intracranial tumors

The proliferation indices of immunohistochemically detected bromodeoxyuridine, Ki-67 antigen (antibodies Ki-67 and MIB 1), and proliferating cell nuclear antigen were determined manually and with computer assisted morphometry in 38 gliomas, 29 meningeomas, 9 metastases, and 16 other tumors. Comparing the markers among one another the highest correlation coefficient was found for bromodeoxyuridine and MIB 1 (0.9). The proliferation indices of all markers correlated significantly with the tumor grading. The highest correlation coefficient for proliferation index and grading (0.7) was calculated for the MIB 1 index determined in one high power field (0.0153 mm(2)) in the tissue area with the highest proliferative activity. Concerning applicability and correlation with tumor dignity MIB 1 was superior to the other three antibodies investigated.

[Current diagnostic and treatment options in thyroid carcinoma]

Authors evaluated a set of 1182 patients who underwent a surgery for thyroid disease at two workplaces--1st Surgery Clinic of L. Pasteur Teaching Hospital of Kosice and ENT Department of East-Slovak Oncology Institute, a. s. of Kosice during 5 year period from the point of view of Medullary Thyroid Carcinoma. Of the given number, 9 suffered a confirmed diagnosis of Medullary Thyroid Carcinoma. Incidence and treatment results conform to available publications. The most important elements for successful treatment are considered the early diagnosis and sufficient surgical treatment. The early diagnosis is in hands of GPs and endocrinologists and is the most important regarding the success of treatment. It is useful to direct the surgical treatment into Centres where--regarding rare occurrence, seriousness of disease and specific treatment--the optimum result may be achieved.

A phase II trial of the mTOR inhibitor AP23573 as a single agent in advanced endometrial cancer

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Background: There are few effective therapies for women with advanced or recurrent endometrial cancer. Targeted therapies such as AP23573, a novel mTOR inhibitor, may result in clinical benefit with fewer side effects. Preliminary results of a trial of single agent AP23573 in patients with progressive endometrial cancer who may have had up to 2 prior regimens of cytotoxic chemotherapy are reported. Methods: The trial is an open-label, Simon 2-stage, single-arm study enrolling patients who have advanced endometrial cancer with documented progression in the 3 months prior to entry. Patients receive 12.5mg AP23573 QDx5 as a 30-min. intravenous infusion every other week for 28-day cycles. The primary efficacy endpoint is Clinical Benefit Response (CBR), defined as a complete or partial response or prolonged stable disease (= 16 weeks) by modified RECIST guidelines. Results: Seven of the first 19 patients achieved CBR, allowing expansion to the second stage. Enrollment is now complete (45 patients). Demographic data are available for 35 (median 66 yrs.; range 46–89) patients who received treatment: 23 adenocarcinomas, 5 carcinosarcomas, 6 papillary serous carcinomas (UPSC) and 1 clear cell carcinoma. Thirty-four patients had prior chemotherapy including doxorubicin, taxanes or platinum agents. Fourteen of the 26 patients with available history had prior pelvic radiotherapy. Nine of 27 (33%) patients evaluable for response had CBRs, including 2 partial responses (PRs). One CBR had UPSC, the remaining patients, including the PRs, had adenocarcinomas. Seven of the patients achieving CBR are still on treatment. Eighteen of the 27 patients discontinued treatment before 4 cycles because of progressive disease (14), consent withdrawal (1) or unrelated adverse events (3). Adverse event data are available for 27 patients. The most common adverse events are fatigue, anemia (33% each), mouth sores and nausea/vomiting (30% each). There have been 16 grade 3/ 4 treatment related adverse events (2 hyperglycemia, 14 separate events similar to those reported in other AP23573 trials). Conclusions: AP23573 shows encouraging single-agent activity in pretreated patients with advanced, progressive endometrial cancer and is well tolerated.

No significant financial relationships to disclose.

[The Jervell and Lange-Nielsen syndrome. Natural history, molecular basis and clinical outcome]

Data on the Jervell and Lange-Nielsen syndrome (JLN), the long QT syndrome (LQTS) variant associated with deafness and caused by homozygous or compound heterozygous mutations on the KCNQ1 or on the KCNE1 genes encoding the IKs current, are still largely based on case reports. We analyzed data from 186 JLN patients obtained from the literature (31%) and from individual physicians (69%). Most patients (86%) had cardiac events and 50% were symptomatic already by age 3. Their QTc was markedly prolonged (557 +/- 65 ms). Most of the arrhythmic events (95%) were triggered by emotions or exercise. Females are at lower risk for cardiac arrest and sudden death (CA/SD). A QTc>550 ms and history of syncope during the first year of life are independent predictors of subsequent CA/SD. Most mutations (90.5%) are on the KCNQ1 gene; mutations on the KCNE1 gene are associated with a more benign course. beta-blockers have only partial efficacy as 51% of the patients had events despite therapy and 29% had CA/SD.

CONCLUSIONS

JLN syndrome is a most severe variant of LQTS, with a very early onset, major QTc prolongation, and is not well responsive to beta-blockers. Subgroups at relatively lower risk for CA/SD are identifiable and include females, patients with a QTc pound550 ms, without events in the first year of life, and with mutations on KCNE1. Early therapy with ICDs has to be considered.

Achsenanomalien der Vena cava inferior mit paracavalem venösen Aneurysma und renalem Kollateralkreislauf

Venöse Aneurysmata der großen Gefäße stellen anatomische Raritäten dar. Die meisten bisher publizierten Malformationen des venösen Systems betreffen hauptsächlich die Vena cava inferior und treten in unterschiedlichen Formen auf. Aussackungen der infradiaphragmalen Vena cava inferior werden bei routinemäßig durchgeführten abdominellen Sonographien nur selten beobachtet und stellen dann häufig Zufallsbefunde dar. Berichte hierüber beschränken sich auf einzelne Kasuistiken und bereiten den Klinikern nicht selten diagnostische und therapeutische Schwierigkeiten. In der vorliegenden Arbeit wird eine asymptomatische, ausgeprägte venöse trunkuläre Missbildung der Vena cava inferior mit suprarenaler Abflussstörung beschrieben. Der hier vorgestellte Fall stellt einen bislang nicht beschriebenen Befund dar. Unter Berücksichtigung der gesamten Befundkonstellation entschlossen wir uns zu einer konservativen Behandlung des Patienten.

Air-flow simulation in realistic models of the trachea

In this article we present preliminary results from a new technique for flow simulation in realistic anatomical airways. The airways are extracted by means of Level-Sets methods that accurately model the complex and varying surfaces of anatomical objects. The surfaces obtained are defined at the sub-pixel level where they intersect the Cartesian grid of the image domain. It is therefore straightforward to construct embedded boundary representations of these objects on the same grid, for which recent work has enabled discretization of the Navier-Stokes equations for incompressible fluids. While most classical techniques require construction of a structured mesh that approximates the surface in order to extrapolate a 3D finite-element griding of the whole volume, our method directly simulates the air-flow inside the extracted surface without losing any complicated details and without building additional grids.

Breath biomarkers and non-alcoholic fatty liver disease: preliminary observations

Breath biomarkers have the potential to offer information that is similar to conventional clinical tests or they are entirely unique. Preliminary data support the use of breath biomarkers in the study of liver disease, in particular non-alcoholic fatty liver disease (NAFLD). It was evaluated whether breath ethanol, ethane, sulfur compounds and acetone would be associated with hepatic histopathology amongst morbidly obese patients presenting for bariatric surgery. Breath samples were collected during a preoperative visit and compared with liver biopsies obtained during the surgery. A Student's two-tailed t-test was used to compare differences between the two groups. Linear regression was used to analyse associations between the concentrations of breath molecules and independent predictor variables. It was found that breath ethanol, ethane and acetone can be useful biomarkers in patients with NAFLD. In particular, breath ethanol can be associated with hepatic steatosis, and breath acetone can be associated with non-alcoholic steatohepatitis.

Structural, biochemical and functional aspects of sperm-oocyte interactions in pigs

Polyspermic fertilization is still a major issue in porcine IVF systems. New information is available to characterize the zona pellucida (ZP) at different developmental stages by scanning electron microscopy (SEM) and by confocal microscopy to show the distribution of ZP glycoproteins. SEM images indicated no differences between in vivo and in vitro matured oocytes; however a change in the surface structure between immature and matured oocytes, as well as between mature oocytes and preimplantation embryos was obvious. In addition, spermatozoa were more tightly fixed in the ZP of in vivo produced compared to the ZP of in vitro produced embryos. The ZP undergoes biochemical changes during maturation prior to fertilization. The acidity of the ZP increases during maturation as indicated by a shift of 1.3 pl units for ZPB/ZPC and 0.8 pl units for ZPA in 2D gel electrophoresis, which is based on increasing sulfation of the oligosaccharides during maturation. Mass spectrometry in combination with in-gel deglycosylation allowed the mapping of new glycosylation sites. Functionality of the ZP also depends on its maturation status. Induction of the acrosome reaction was delayed when capacitated spermatozoa were exposed to immature oocytes.

Hernienchirurgie: Wachstumsverhalten humaner Fibroblasten auf alloplastischen Kunststoffnetzen

BACKGROUND

The biocompatibility of meshes in hernia surgery seems to be influenced markedly by the amount of the selected material and its structure. Fibroblasts play a major key role during the process of mesh incorporation. This study was performed to investigate differences in cell morphology and proliferation of human fibroblasts cultured on different polypropylene meshes.

METHODS

In the present in vitro study the cellular response of human fibroblasts was investigated by scanning electron microscopy (SEM), comparing three different polypropylene meshes: a newly constructed low-weight and microporous mesh (NK1), a low-weight and macroporous mesh with absorbable polyglactin filaments (Vypro), and a heavy-weight and microporous mesh (BiomeshP1). Human fibroblasts (1,5.10(5) cells) were incubated with the meshes (each 12 mm(2)) for 6 hours, 5 days, 2, 4, 6, and 12 weeks. Computer-assisted morphometry of the fibroblast/mesh surface ratio served to reflect the biological cell response.

RESULTS

The Vypro mesh showed the significantly highest fibroblast density during the first 6 weeks, but cell growth was nearly exclusively limited to the polyglactin filaments. At 3 months, after reabsorption of the polyglactin, the fibroblast-coated polypropylene mesh surface was only 50% compared to NK1 and BiomeshP1. The morphologic aspect of the fibroblasts on the BiomeshP1 mesh was much more degenerative and unphysiological, compared to NK1 and Vypro, with isolated, single cells instead of a broad, connective growth. The BiomeshP1 showed a significantly higher fibroblast proliferation around the nodes of the mesh compared to the straight filaments. On the NK1 mesh fibroblasts exclusively proliferated on the filaments but not on the pressed mesh surface.

CONCLUSIONS

The polymer surface and structure appears to be of major importance for the biocompatibility of meshes: human fibroblasts preferably grow on low-weight meshes, thin filaments, and mesh nodes. Heavy-weight meshes induce degenerative cell reactions. Polyglactin seems to further improve cell proliferation whereas a pressed mesh surface without pores hinders fibroblast growth.