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.

Use of a device-based remote management heart failure care pathway is associated with reduced hospitalization and improved patient outcomes: TriageHF Plus real-world evaluation

Background

Heart failure (HF) is a leading cause of hospital admission. However, prompt identification of worsening HF using implantable device data and proactive intervention may reduce hospitalizations.

The validated TriageHF algorithm in enabled ICD/CRT devices uses sensor data to risk stratify patients for HF hospitalization in the next 30 days. TriageHF Plus is a novel device-based HF care pathway (DHFP) that uses “high” risk status as the trigger for remote intervention (see Figure 1 for pathway overview). Outcomes after DHFP implementation in a clinical setting have not been examined.

Purpose

To evaluate the impact of TriageHF Plus clinical pathway on hospitalisation rates.

Methods

A prospective, multi-center evaluation comparing monthly hospitalization rates for patients enrolled in a DHFP with a concurrent standard of care (SoC) cohort and characterizing staffing resources necessary to implement the DHFP. The DHFP cohort received telephonic assessment and guideline-directed clinical care upon transition to high-risk status. Propensity scores (PS) were applied to DHFP and SoC cohorts to allow unbiased comparison. A negative binomial model was fitted to the monthly number of all-cause hospitalizations with treatment group (DHFP vs. SoC) as a covariate, using PS as weights.

Results

Between 09/11/2019 and 06/24/2021, 758 patients were included in the study (443 DHFP, 315 SoC). Proportion CRT 76%/ 89% and LVEF <50% 78%/ 66% for DHFP/ SoC, respectively.

196 high risk transmissions prompted telephone assessment, with successful contact in 182; of which, 79 (43%) identified an explanatory acute medical issue. A secondary intervention was undertaken in 44/79 (56%). High risk transmissions took on average 19 minutes per clinical assessment (initial telephone triage and 30 day follow up). The rate of hospitalizations was 58% lower in the DHFP group, compared with SoC, after PS adjustment (IRR 0.42, 95% CI: 0.23, 0.76, p=0.004), see Figure 2. Sensitivity analyses showed Covid-19 had little effect on results.

Conclusions

This is the first prospective, real-world evaluation of a device-based HF care pathway to report a reduction in hospitalizations and does so with minimal staffing time. Integrated into existing HF services, device-based remote monitoring of HF patients can improve outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic

Medically managed prosthetic valve endocarditis caused by Salmonella enteritidis

Infective endocarditis is associated with morbidity and mortality even when appropriately treated. It can be more complicated to treat when prosthetic material is present, often necessitating surgical revision as well as antimicrobial therapy. Endocarditis caused by gram-negative bacilli is a rare occurrence, with some literature and expert opinion suggesting superior outcomes with combined surgery and antibiotics when a prosthetic valve is involved. In cases where the prosthetic valve is well-functioning and undamaged, or cardiothoracic surgery represents a significant operative risk, it can be unclear how best to proceed. This report documents a case of Salmonella enterica subspecies enterica serovar enteritidis endocarditis of a mechanical mitral valve. The patient was managed with 6 weeks of intravenous antibiotics followed by suppressive oral antibiotic therapy. They remain in good health at 24 months.

Deep learning for screening of interstitial lung disease patterns in high-resolution CT images

AIM

To develop a screening tool for the detection of interstitial lung disease (ILD) patterns using a deep-learning method.

MATERIALS AND METHODS

A fully convolutional network was used for semantic segmentation of several ILD patterns. Improved segmentation of ILD patterns was achieved using multi-scale feature extraction. Dilated convolution was used to maintain the resolution of feature maps and to enlarge the receptive field. The proposed method was evaluated on a publicly available ILD database (MedGIFT) and a private clinical research database. Several metrics, such as success rate, sensitivity, and false positives per section were used for quantitative evaluation of the proposed method.

RESULTS

Sections with fibrosis and emphysema were detected with a similar success rate and sensitivity for both databases but the performance of detection was lower for consolidation compared to fibrosis and emphysema.

CONCLUSION

Automatic identification of ILD patterns in a high-resolution computed tomography (CT) image was implemented using a deep-learning framework. Creation of a pre-trained model with natural images and subsequent transfer learning using a particular database gives acceptable results.

Reactive angioendotheliomatosis as a presenting cutaneous manifestation of Hughes syndrome

Background

Antiphospholipid antibody syndrome is an autoimmune disorder associated with pregnancy complications, venous and/or arterial thrombosis and the presence of antiphospholipid antibodies. This syndrome is known to present with various cutaneous features, but association with reactive angioendotheliomatosis has been described rarely in the literature.

Results

A woman in her thirties with a past history of three consecutive abortions developed purpuric, ulcerative plaque over the plantar aspect of the foot. Her biopsy showed marked expansion of dermal vasculature due to intravascular cellular proliferation suggestive of reactive angioendotheliomatosis. The intravascular cells stained positive for CD31. Her blood investigations showed positive lupus anticoagulant, antiphospholipid antibodies and anticardiolipin antibodies, leading to a diagnosis of antiphospholipid syndrome also known as Hughes syndrome.

Conclusion

We suggest that a hypercoagulable state caused the formation of intravascular thrombi leading to reactive angioendotheliomatosis. We report a case of Hughes syndrome with reactive angioendotheliomatosis as the first clinical cutaneous manifestation and treated satisfactorily with anticoagulants and immunomodulators.

Opposing effects of pro- and anti-inflammatory cytokine gene polymorphisms on the risk for breast cancer in western Indian women: a pilot study

In an earlier study, the genotypes associated with higher level of transforming growth factor-β1 (TGF-β1) were found to reduce the risk for breast cancer in western Indian women. This observation implied that gene polymorphisms affecting the levels of pro- and anti-inflammatory cytokines may influence the risk for breast cancer in this population. Hence, we performed genotyping for three more functional single-nucleotide polymorphisms (SNPs) responsible for variations in the levels of cytokines associated with inflammation. To that effect, polymorphisms in genes coding for IL-4 (IL-4 C-590T; rs2243250), IFN-γ (IFN-G A + 874T; rs2430561) and MCP-1 (MCP-1 A-2578G; rs1024611) were examined in premenopausal, healthy women (N = 239) and patients with breast cancer (N = 182) from western India. In carriers of the IL-4*590T allele, a reduced risk for the disease (dominant model; OR = 0.61, 95% CI 0.37-0.98) was seen similar to that seen in TGF-B1*10C carriers. An opposite trend was observed with respect to the alleles associated with higher expression of MCP-1 or IFN-γ. In individuals positive for three or more alleles associated with higher levels of either pro- or anti-inflammatory cytokines, an additive effect on the modulation of risk for the disease was evident (for TGF-B1 & IL-4, OR = 0.33, 95% CI 0.12-0.87; for IFN-G & MCP-1, OR = 2.29, 95% CI 0.95-5.51). In the context of contrasting observations in other populations, these results indicate a significant contribution of anti-inflammatory genotypes in the modulation of risk for breast cancer in western Indian women.

Effects of subclinical bovine leukemia virus infection on some production parameters in a dairy farm in southern Turkey

Some production parameters of seropositive cows (age, first calving age, 305 day mature equivalent last milk yield production, lifetime mature equivalent milk yield production, lifetime total milk production, lifetime total milking period, lifetime monthly milk production, lifetime daily milk production, lifetime total days of milking, number of inseminations per pregnancy (for last pregnancy), number of calves and calving interval (for last pregnancy)) were analysed in the current study. The study population was clinically healthy Holstein cows from a commercial dairy herd in southern Turkey. Of 109 animals, 65 cows were seropositive by ELISA and the prevalence of bovine leukemia virus (BLV) infection was 59.6%. The prevalence of seropositive cows in 2nd (62.8%), 3rd (64.7%), 4th (61.5%), and 5th (66.6 %) lactations was slightly higher than that of cows in 1st (52.6%) lactations. No statistical differences were observed between BLV seronegative and seropositive cows for production and reproduction parameters analysed in this study (P > 0.05).

An investigation of equine infectious anaemia infection in the central Anatolia region of Turkey

In this study, 162 horses, 80 donkeys and 51 mule serum samples were collected in Konya city. Additionally, 64 horse serum samples from Ankara and 49 samples from Kayseri city were included in the study. A total of 406 serum samples were examined by agar gel immunodiffusion (AGID) and enzyme-linked immunosorbent assay (ELISA) for antibody to equine infectious anaemia virus (EIAV) and no positive result was detected.

A clinical trial of the efficacy and safety of montelukast as monotherapy in patients with chronic stable bronchial asthma

This study is aimed to evaluate the efficacy and safety of montelukast, as monotherapy, in the treatment of chronic stable bronchial asthma in adults. This was a multicentre, open label, non-comparative, prospective, 4-week study. Eligible patients discontinued all anti-inflammatory medication (steroids, chromoglycate sodium) 2 weeks prior to starting therapy with montelukast (10 mg daily). The primary efficacy criteria were improvements in forced expiratory volume in one second (FEV1), peak exploratory flow rate (PEFR) after 4 weeks of therapy. Secondary efficacy criteria were improvement in the patients' symptoms (assessed on an ordinal scale), decrease in discomfort levels (scored on a scale of 0-100), change in peripheral eosinophil counts, decrease in total daily dose of inhaled beta2 agonist (salbutamol). A total of 148 patients, mean age (+/- SD) 40.21 +/- 13.70 years, were enrolled into the study. At the end of the study there were significant improvements in FEV1 and PEFR (29% and 28% increase respectively from baseline values, p<0.000001). The mean total daily dose of inhaled salbutamol decreased significantly from prestudy values of 461 +/- 332 microg/day to 161 +/- 207 microg/day (p<0.000001). The mean eosinophil counts fell from 5.80 +/- 4.90% (+/- SD) to 4.84 +/- 4.42% (+/- SD) (p=0.02). Symptom scores improved significantly as did subjective assessment of discomfort. A total of 29 (19.6%) adverse events were reported, all of which were of mild to moderate intensity. Monotherapy with montelukast significantly improved parameters of asthma control. It was well tolerated with no reports of serious or severe adverse events.

Pacemaker prevention therapies for the control of drug-refractory paroxysmal atrial fibrillation

AIMS

Atrial septal pacing has been shown to prevent paroxysmal atrial fibrillation (PAF) refractory to drugs in patients without inappropriate bradycardia. This study assesses the effects of atrial septal pacing using new pacing algorithms designed to prevent the initiation or maintenance of PAF.

METHODS AND RESULTS

Eleven Medtronic AT500 and 6 Guidant Pulsar Max pacemakers were implanted. The incremental benefit of prevention pacing therapies was compared with DDDR pacing by analysis of pacemaker-stored electrograms, ambulatory electrocardiography, symptoms and quality of life questionnaires.

RESULTS

Atrial septal pacing reduced AF burden by >50% in 13/17 patients (76.5%). Activation of a combined pacing algorithm (atrial pacing preference; atrial rate stabilization; and post mode-switch overdrive pacing) in patients with AT500 pacemakers produced a marginal reduction in AF burden (mean %AF 0.61 ON, 0.73 OFF, P=0.53 ns). Conversely in the Pulsar Max group when atrial pacing preference was activated, AF burden was slightly increased (mean %AF 5.84 ON, 3.73 OFF,P =0.13). Symptoms improved with atrial septal pacing but did not change when prevention algorithms were activated.

CONCLUSION

Atrial septal pacing resulted in a marked improvement in AF burden and symptoms. Activation of specific prevention pacing algorithms provided more continuous atrial pacing but had limited and heterogeneous effects on AF burden.

Atrial septal pacing in the prevention of paroxysmal atrial fibrillation refractory to antiarrhythmic drugs

BACKGROUND

Early reports have shown that pacing the atria at a site or sites other than the right atrial appendage may prevent atrial fibrillation. Our centre has shown that pacing the atrial septum reduces the duration of atrial activation which is an important determinant of predisposition to paroxysmal atrial fibrillation. Ablation of the atrioventricular (AV) node together with implantation of a pacemaker can control symptoms due to paroxysmal atrial fibrillation in patients in whom antiarrhythmic drugs have failed. The aim of this study was to investigate the effect of atrial septal pacing on patients who were candidates for AV node ablation.

METHODS

Atrial septal pacemakers were implanted in 28 patients with symptomatic, paroxysmal atrial fibrillation that had been unresponsive to two or more antiarrhythmic drugs. Pacing was not indicated for any reason other than the anticipated need to proceed to AV node ablation. Change in symptoms was assessed by quality of life questionnaires and recurrence of atrial fibrillation was measured objectively by pacemaker interrogation and ambulatory electrocardiographic monitoring.

RESULTS

Atrial septal pacing in combination with an antiarrhythmic agent resulted in a substantial subjective improvement in 19 patients (68%). Objective data confirmed similar findings; atrial fibrillation was completely or markedly reduced in 17 patients (60%). Six patients experienced a modest improvement in symptoms; in only four patients was it necessary to proceed to AV node ablation.

CONCLUSIONS

Atrial septal pacing together with continuance of previously ineffective antiarrhythmic therapy may prevent or markedly reduce the frequency of paroxysmal atrial fibrillation and obviate the need to ablate the AV node.

Protective effect of vitamin E in dimethoate and malathion induced oxidative stress in rat erythrocytes

Organophosphate (OP) pesticides such as dimethoate and malathion intoxication has been shown to produce oxidative stress due to the generation of free radicals and alter the antioxidant defense system in erythrocytes. It is possible that vitamin E being present at the cell membrane site may prevent OP-induced oxidative damage. In the present study, rats were pretreated orally with vitamin E (250 mg/kg body wt, twice a week for 6 weeks) prior to oral administration of a single low dose of dimethoate and/or malathion (0.01% LD(50)). The result showed that treatment with OP increased lipid peroxidation (LPO) in erythrocytes, however, vitamin E pretreated rats administered OP's showed decreased LPO in erythrocytes. The increase in the activities of superoxide dismutase (SOD) and catalase (CAT) and total-SH content in erythrocytes from dimethoate and/or malathion treated rats as compared to control appears to be a response towards increased oxidative stress. Vitamin E pretreated animals administered OP's showed a lowering in these parameters as compared to OP treated rats which indicates that vitamin E provide protection against OP-induced oxidative stress. The glutathione-S-transferase (GST) activity in erythrocytes was inhibited in OP intoxicated rats which partially recovered in vitamin E pretreated animals administered OP's. Inhibition in erythrocyte and serum acetylcholinesterase (AChE) activity was not relieved in vitamin E pretreated rats administered OP's probably due to the competitive nature of enzyme inhibition by OP's. The results show that vitamin E may amelierate OP-induced oxidative stress by decreasing LPO and altering antioxidant defense system in erthrocytes.

Lipid peroxidation and antioxidant enzymes in isoproterenol induced oxidative stress in rat erythrocytes

Isoproterenol, upon oxidation, produces quinones which react with oxygen to produce superoxide anions (O2.-) and H2O2. In the present study, isoproterenol was administered to rats in two doses so as to evaluate its beta adrenergic and toxicological action in terms of lipid peroxidation (LPO) and antioxidant enzymes in erythrocytes. Isoproterenol (30 mg/100 g body wt.) was administered to rats and the animals were followed up to 7 days after administration. Some of these animals were treated with a second dose of isoproterenol 24 h after the first dose and the animals were followed up to 12 h. The result showed increased lipid peroxidation (LPO) and superoxide dismutase (SOD) activity in erythrocytes in response to isoproterenol. Catalase (CAT) activity in erythrocytes decreased with isoproterenol between day 2-7 as compared to control. The second injection of isoproterenol showed increased CAT activity in erythrocytes which decreased at 12 h as compared to control. The erythrocyte GSH content and glutathione-S-transferase (GST) activity decreased with isoproterenol treatment as compared to control. However, erythrocyte GSH content as well as GST activity both recovered towards control with time. Elevated serum lactate dehydrogenase (LDH), creatine phosphokinase (CPK) and glutamate oxaloacetate transaminase (GOT) activity was observed after isoproterenol treatment. The results show increased LPO and altered antioxidant system in erythrocytes in response to isoproterenol induced oxidative stress.

Lipid peroxidative damage on pyrethroid exposure and alterations in antioxidant status in rat erythrocytes: a possible involvement of reactive oxygen species

Pyrethroid pesticides are used preferably over organochlorines and organophosphates due to their high effectiveness, low toxicity to non-target organisms and easy biodegradibility. However, it is possible that during the pyrethroid metabolism, there is generation of reactive oxygen species (ROS) and pyrethroids may produce oxidative stress in intoxicated rats. The present study was therefore, undertaken to determine pyrethroid-induced lipid peroxidation (LPO) and to show whether pyrethroid intoxication alters the antioxidant system in erythrocytes. A single dose of cypermethrin and/or fenvalerate (0.001% LD50) was administered orally to rats and the animals were sacrificed at 0, 1, 3, 7 and 14 days of treatment. The results showed that lipid peroxidation (LPO) in erythrocytes increased within 3 days of pyrethroid treatment. The increased oxidative stress resulted in an increase in the activity of antioxidant enzymes such as superoxide dismutase (SOD) and catalase (CAT). The increase in reduced glutathione (GSH) content in erythrocytes may probably be an initial adaptive response to increased oxidative stress in pyrethroid intoxicated rats. Erythrocytes and serum acetylcholinesterase (AChE) activity was measured in pyrethroid-induced oxidative stress as it may mimic inhibition in target tissues such as muscle and brain. The inhibition in erythrocytes and serum AChE activity was partially relieved over a period of time indicating recovery from pyrethroid intoxication. The increase in erythrocyte LPO correlated with the inhibition in erythrocyte AChE activity and so erythrocyte AChE can be a marker enzyme in pyrethroid toxicity. The results show oxidative stress and alteration in antioxidant enzymes in erythrocytes of pyrethroid intoxicated rats.

Lipid peroxidation and antioxidant enzymes in isoproterenol induced oxidative stress in rat tissues

The oxidative metabolism of catecholamines produce quinones which react with oxygen to produce superoxide anions (O2-.) and H2O2. The catecholamines, however, are important under stress conditions but may have damaging effects due to the generation of reactive oxygen species (ROS) and formation of oxidation products. ROS are involved as causative factors in many diseases, therefore, the generation of ROS by catecholamines may also contribute to this process. Isoproterenol (ISO) was administered to rats in two doses so as to evaluate their beta-adrenergic and toxicological actions in terms of lipid peroxidation (LPO) and the changes in the antioxidant enzymes such as superoxide dismutase (SOD), catalase (CAT), glutathione-S-transferase (GST) and glutathione (GSH) content in heart, liver and kidney. ISO treatment caused LPO in tissues, however, the heart initially showed decreased LPO. This is attributed to the condition of hypertrophy by which the heart can protect itself to a limited extent against oxidative stress. The second dose of ISO, administered 24 h after the first treatment, showed toxic effects resulting in a higher increase in LPO. The increased SOD activity in tissues 3 days after a dose of ISO suggests that the ROS may induce SOD activity to dismutate O2-. However, increased amounts of O2-., inhibited SOD activity at 3 and 6 h with recovery towards control values at 12 h of a second dose of ISO treatment. CAT activity in tissues increased at 6 h of a second dose of ISO treatment. The elevated SOD and CAT enzymes in tissues indicate a response due to increased ROS. The increase in GSH content in the heart, liver and kidney at day 2 of ISO treatment and 12 h after the second dose of ISO may also neutralise oxidative stress. The inhibition in GST activity in tissues was observed probably due to increased ROS generation, however, GST activity partially recovered by 12 h after the second dose of ISO, in an attempt to counteract oxidative stress. The result shows that ISO induced oxidative stress and the increase of the antioxidant system in tissues may attenuate oxidative stress. It is suggested that ROS generation in the oxidation of catecholamines may be partially counteracted by the antioxidant system in tissues.

Erythrocyte sedimentation rates in patients with renal cell carcinoma

The importance of erythrocyte sedimentation rate (ESR) in patients with renal cell carcinomas (RCCa) is still controversial. ESR levels increased in over half of these patients. In this study, ESR levels of 19 patients with RCCa were investigated (85.368 +/- 5.914). In 11 patients in whom carcinomas were only localized in the kidney, the ESR levels were detected as 78.182 +/- 8.686. In 8 patients who had metastasis, the ESR levels were found as 95.250 +/- 6.427. ESR levels were also estimated in 15 healthy adult persons as control group (18.133 +/- 2.180). Mean ESR values were significantly higher in the tumor group than in the control group (p less than 0.01). There was no statistical difference of the ESR levels between the patients who had local RCCa and advanced RCCa (p greater than 0.05, NS). The removal of the tumoral mass caused the ESR levels to diminish. In conclusion, the ESR levels were not a good criteria in patients with RCCa for evaluating either prognosis or metastasis.

Antibody-based enzyme-linked immunosorbent assay for determination of immune complexes in clinical tuberculosis

Immune complexes were isolated from sera of tuberculosis patients by precipitation with 2.5% polyethylene glycol. The precipitates were characterized by quantitative determination of different immunoglobulin classes by single radioimmunodiffusion, sodium dodecyl sulfate polyacrylamide gel electrophoresis for presence of serum components, Ouchterlony's double diffusion method for detection of complement components C3 and C4, and immuno-dot assay for detection of Mycobacterium tuberculosis antigens. The results showed that polyethylene glycol precipitates of patients' sera were indeed immune complexes, as they contained immunoglobulins, albumin, complement components, and mycobacterial antigens, whereas precipitates from control sera contained mainly albumin. The antibodies present in immune complexes were specific to M. tuberculosis antigen and showed no binding to Escherichia coli antigens. Immune complex levels, as determined by the ability to bind M. tuberculosis antigens in an enzyme-linked immunosorbent assay, were significantly higher in tuberculosis patients (n = 22) than in healthy control subjects (n = 18). Thus, immune complex level could be a useful parameter in the diagnosis of active tuberculosis.