Scheduled Visits Research Articles

Screening for undiagnosed atrial fibrillation using an electronic health record‒based clinical prediction model: clinical pilot implementation initiative

BackgroundAtrial fibrillation (AF) is a major risk factor for ischemic stroke, and early AF diagnosis may reduce associated morbidity and mortality. A 10-variable predictive model (UNAFIED) was previously developed to estimate patients’ 2-year AF risk. This study evaluated a clinical workflow incorporating UNAFIED for screening, education, and follow-up evaluation of patients visiting a cardiology clinic who may be at an elevated risk of developing AF within 2 years.MethodsPatients were included if they were aged ≥ 40 years with a scheduled in-person visit at the Eskenazi Health Cardiology Clinic between October 25, 2021, and August 10, 2022. Clinical decision support identified patients with an elevated AF risk. Initial screening with 1-lead electrocardiogram devices was offered, and routine clinical practice for diagnosis and management was followed. Physicians were surveyed on their use of the workflow, attitudes toward implementation, and perceived impact on patient care.ResultsA total of 2827 patients had a clinic visit during the study period, of whom 1395 were eligible to be screened because they were classified as “elevated risk” by the UNAFIED predictive model. AF or atrial flutter diagnosis was newly documented for 29 patients during the study period. Of the newly diagnosed patients, 13 began anticoagulant therapy to mitigate stroke risk. Physicians (n = 13) who used the workflow most clinic days were more likely to indicate that it was easy to use, was not time-consuming, and improved patient care compared with physicians who only used the workflow occasionally.ConclusionsTo our knowledge, this study is the first of its kind to demonstrate clinical application of an electronic health record-based AF predictive model. The newly documented diagnoses, however, did not solely result from implementation of UNAFIED. This non-invasive, inexpensive approach could be adopted by other sites wishing to proactively screen patients at elevated risk for AF. Other sites should verify the model’s performance in their own settings and ensure compliance with evolving regulatory requirements where applicable.

Open versus arthroscopic fusion of the subtalar joint: a randomized controlled trial.

Our primary aim was to compare the early complication rate (< 6 weeks postoperatively) after open or arthroscopic fusion of the subtalar joint. Secondary outcomes included late complications (> 6 weeks postoperatively), function, pain, and patient satisfaction. In this prospective randomized controlled trial, patients listed for subtalar joint fusion were included and randomized for open or arthroscopic fusion. Complications were assessed at scheduled visits at 2 and 6 weeks, 3, 6, and 12 months postoperatively. Functional scores, pain scores, and patient satisfaction were assessed at 3, 6, and 12 months postoperatively, and PROMS at baseline (preoperatively), 3, 6, and 12 months postoperatively. The scores were compared over time between the groups using Fisher's exact test and linear mixed models. 51 patients were included between 2013 and 2020, of whom 25 were allocated to open and 26 to arthroscopic fusion. 3 early complications (2 sural nerve lesions, 1 infection) occurred in the open fusion group (12%; 95% confidence interval [CI] 3-32) and 3 (2 wound healing problems, 1 screw exchange) in the arthroscopic group (12%; CI 3-31). Late complications included screw removal (n = 5) in the open fusion group versus screw removal (n = 5), non-union (n = 2), bony prominence/calcification removal (n = 1), sural nerve lesion (n = 1), lesion of the calcaneal branch of the tibial nerve (n = 1), complex regional pain syndrome type II (n = 1), and secondary plantar fasciitis (n = 1) in the arthroscopic fusion group. No superiority of arthroscopic over open fusion was found regarding early (P = 1.0) and late complications (P = 0.2), function and pain scores, and patient satisfaction over 12 months Conclusion:Arthroscopic fusion did not result in fewer early complications compared with open fusion. Secondary outcomes did not differ significantly between the approaches.

Gross motor delays in infants and young boys with Duchenne muscular dystrophy

Background Duchenne muscular dystrophy (DMD), an X-linked progressive neurodegenerative disorder, is being added to required universal screening programs for newborns in the United States. It is estimated that this will result in around 880 patients presenting at clinics in infancy. Very little is known about the early gross motor abilities in infants and young boys with DMD. Objective Describe the early gross motor skill acquisition in boys in our clinic with DMD. Methods Between the years 2016 and 2024, 90 boys with DMD under the age of 6 years (2 months – 5 years 10 months at their first visit) were evaluated as part of their standard of care during regularly scheduled clinic visits using the using the Bayley Scales of Infant &amp; Toddler Development, Third Edition (Bayley-III). Forty-seven boys were seen in clinic longitudinally with two to six follow up visits for a total of 129 assessments. Results Ninety four percent of the boys with DMD seen in our clinic demonstrated delays in gross motor skills across the age span when compared with normative controls. None of the boys reached a ceiling on the Bayley-III despite being older than the intended age range of the test. Conclusions Our clinic data showed an almost universal gross motor delay in infants and toddlers that did not diminish over time.

Long-term outcomes of active surveillance for low-risk papillary thyroid carcinoma: Progression patterns and tumor calcification.

Active surveillance (AS) for low-risk papillary thyroid carcinoma (PTC) is acknowledged as a valid management strategy. While older age is identified as a favorable factor for progression, long-term evidence is scarce and lifelong monitoring has been deemed essential. This study investigated progression patterns and tumor calcification under long-term AS and explored the possibility of ending follow-up. A total of 650 patients with low-risk PTC who chose AS were enrolled. Progression was defined as either tumor enlargement (≥3mm from initiation) or development of clinically apparent lymph node metastasis. The median observation period was 8years; 45.2% were under surveillance for ≥10years. Overall, 80 patients (12.3%) exhibited progression. Median age and observation period at the time of progression were 55 and 4years, respectively. Only 2 patients showed progression after 15years of follow-up and 5 patients showed progression after reaching 80years old. Among 71 patients experiencing tumor enlargement, surgery was performed immediately in 32 patients. The remaining 39 patients continued surveillance, but only 5 demonstrated ongoing enlargement thereafter. Of 40 surgeries due to progression, 36 were conducted within the first 10years. The degree of calcification correlated with age and observation periods. No progression occurred after the development of rim calcification. Progression during AS was extremely rare in older patients with long-term surveillance and in tumors with rim calcification. It may be feasible to consider ending scheduled surveillance visits for these patients. Instances of progression halting after enlargement are not uncommon.

The effect of antidepressant treatment on viral suppression among people with HIV diagnosed with depression in an urban clinic, 2012-2023.

To estimate the effect of antidepressant initiation on viral non-suppression among people with HIV (PWH) with clinically recognized, untreated depression. Retrospective, observational cohort study. We included clinical diagnoses of depression from January 2012-June 2022 among PWH in the Johns Hopkins HIV Clinical Cohort without another serious psychiatric illness who had initiated antiretroviral therapy. We excluded diagnoses less than 90 days from a prior diagnosis, antidepressant prescription, or >1 mental health visits. We estimated the association between initiating an antidepressant within 1 month of the index depression diagnosis and viral load non-suppression (>200 copies/mL) on the first viral load 3-12 months subsequent. We adjusted for a comprehensive set of demographic and clinical confounders. We included 2,346 depression diagnoses among 946 patients; patients initiated an antidepressant following 16%. The risk of viral non-suppression in the absence of antidepressant treatment was 15.6% (95% confidence interval [CI]: 13.1, 18.4). Antidepressant initiation was not associated with viral non-suppression (risk difference: 0.5%; 95% CI: -3.7, 4.8) or secondary outcomes: improvement or resolution of depressive symptoms or adherence to scheduled clinic visits. In this sample of patients with as-yet-untreated depression, in a setting with co-located, low-barrier psychiatric services, antidepressant treatment was not associated with improved viral suppression. Pharmacologic management of depression has documented benefits in other studies. However, there may be a subset of PWH with depression who have been previously unsuccessfully treated with antidepressants who are less likely to respond to approved pharmacologic options and who require different interventions to improve their viral suppression.

Evaluation of an HIV-related Education Intervention Scale-up: A Hybrid Type 3 Effectiveness-implementation Study in the Dominican Republic.

We developed an infographic intervention to augment HIV-related education in the Dominican Republic (DR), which demonstrated preliminary success in pilot studies. We then partnered with the United States Agency for International Development's (USAID) HIV Services and Systems Strengthening program in the DR to scale up the intervention. We used a two-tier Training-of-Trainer (TOT) method to teach intervention administration. N = 12 program leaders completed the tier-1 training and subsequently taught N ~ 102 clinical staff to use infographics with people with HIV (PWH) (tier-2 trainings). Study Aim 1 was to assess implementation outcomes; Aim 2 was to explore infographic influences on program-level health outcomes. We conducted a hybrid type 3 effectiveness-implementation study with three data components: (1) Surveys bookending tier-1 and tier-2 trainings; (2) Focus groups with tier-1 and tier-2 trainees; and (3) program-level data. We designed surveys according to Kirkpatrick's Training Evaluation Model and analyzed responses with descriptive statistics and/or Fisher's exact tests. We led four focus groups with a theory-driven guide and analyzed transcripts with conventional qualitative content analysis. We analyzed program-level data by comparing outcomes before and after infographic use with advanced statistical modeling. All 12 program leaders completed tier-1, and 36 staff completed tier-2 surveys; focus groups comprised eight tier-1 and 27 tier-2 trainees; program-level data pertained to 4,318 PWH. Surveys and focus groups indicated the TOT method is feasible, acceptable, and sustainable. Program-level findings showed PWH were more likely to attend scheduled visits and be virally suppressed following infographic implementation. Results indicate our intervention can likely enhance HIV education at large scale.

Efficacy of Terpinen-4-ol Combined With Eyelid Deep Cleaning for the Treatment of Demodex Blepharitis: A Randomized, Open-Label Trial.

We aimed to evaluate the clinical efficacy of a combined treatment regimen involving terpinen-4-ol (T4O) and eyelid deep cleaning for managing Demodex blepharitis. In this randomized, open-label trial, 40 patients diagnosed with Demodex blepharitis at the Cornea Specialty Clinic of Hankou Aier Eye Hospital were enrolled. Participants were randomly assigned to either a T4O or a combination treatment group. The T4O group used T4O cleaning wipes exclusively for two months. The combination group used T4O cleaning wipes and underwent deep eyelid cleaning at three scheduled visits (initial, first-, and second-month time points). A final follow-up was conducted one month after completion of treatment (three months after the beginning of treatment). At each visit, we assessed the number of Demodex mites, the ocular surface disease index (OSDI), eyelid margin sign scores, and corneal fluorescein staining scores. After two months of treatment, both the T4O and combination groups exhibited significant reductions in Demodex mite counts of 5.65 ± 6.03 and 7.75 ± 6.91, respectively. The T4O group, however, showed an increase in mite counts one month after ceasing treatment. Conversely, the combination group maintained and enhanced the reduction in mite counts post-treatment, with a significant difference at the third-month follow-up (8.70 ± 6.81 vs. 4.15 ± 6.91, P = 0.043). Although both groups demonstrated overall declines in OSDI scores post-treatment, only the combination group showed significant improvements at the second- and third-month follow-ups. No adverse events were reported in either group. Treatment with T4O wipes for two months significantly reduces Demodex mite counts, although there is a notable risk of mite rebound when treatment is ceased. Combining T4O wipes and eyelid deep cleaning offers a more effective reduction in Demodex mite counts and improvement in ocular symptoms compared to T4O treatment alone. The study finds that T4O combined with eyelid deep cleaning is more effective in treating Demodex blepharitis, highlighting the need for appropriate treatment duration and adjunctive therapies.

Bimekizumab 4-year Maintenance of Responses in Week 16 Responders with Moderate to Severe Plaque Psoriasis: Results from the BE BRIGHT Open-label Extension Phase 3 Trial

Introduction: Psoriasis is a chronic disease where loss of response to biologic therapies over time is commonly observed; studying long-term efficacy of new treatments is important.1 Maintenance of high responses to bimekizumab (BKZ) has been reported through 3 years (yrs) in patients with moderate to severe plaque psoriasis.2 This study evaluates the maintenance of clinical responses over 4 years among patients with moderate to severe plaque psoriasis who achieved complete or near-complete skin clearance after 16 weeks (wks) of BKZ treatment and entered the BE BRIGHT open-label extension. Responses were compared over 4 years between all patients who were randomized to BKZ and continued to receive bimekizumab (320 mg every 4 wks [Q4W] or Q8W) in the open-label extension, and those who received the BKZ dosing regimen that is approved for most patients: BKZ 320 mg Q4W to Wk 16 followed by 320 mg Q8W. Methods: Patients completing the 52-wk BE VIVID or 56-wk BE SURE/BE READY phase 3 trials could enter the BE BRIGHT open-label extension (OLE).2–5 Maintenance of PASI90/PASI100 (≥90%/100% improvements from baseline in Psoriasis Area and Severity Index) to Yr4 (OLE Wk144) was assessed in Wk16 responders. Analyzed patients were randomized to BKZ 320 mg Q4W to Wk16, received BKZ Q4W or Q8W until OLE entry, then BKZ Q4W or Q8W dependent on PASI response/prior dose (BKZ Total); the subset who received BKZ Q4W/Q8W/Q8W (initial/maintenance/OLE) were also analyzed. All received BKZ Q8W from OLE Wk48 or at their next scheduled visit. Patients who discontinued due to lack of efficacy/treatment-related adverse events were considered non-responders; multiple imputation was used for all other missing data (modified non-responder imputation). Results: Of 989 BKZ-randomized patients, 87.5% achieved PASI90 and 62.7% PASI100 at Wk16 (non-responder imputation). 693 Wk16 PASI90 and 503 PASI100 responders entered the OLE (BKZ Total); 186 and 147, respectively, received BKZ Q4W/Q8W/Q8W. 87.7%/73.3% of Wk16 PASI90/PASI100 responders maintained their responses to Yr4 (BKZ Total). In the Q4W/Q8W/Q8W subset, 89.0%/76.7% maintained their responses to Yr4. Conclusions: Among Wk16 responders, high efficacy responses were sustained through 4 yrs of BKZ treatment, including patients who received the approved Q4W/Q8W/Q8W dosing regimen.

Impact of encounters on patient app use: results of a tethered mobile personal health record usage pattern analysis.

The adoption of tethered mobile personal health records provides not only medical information to patients but also various convenience functions related to hospital use, thereby increasing accessibility to healthcare services and promoting patient engagement. We analyse the tethered mobile personal health records app's usage logs to determine how it can contribute to improving medical service accessibility and patient engagement. Log data, that comprised menu type, log time, and date, were collected from the mobile personal health records app of a tertiary referral hospital. Clinical information, including patients' demographics and visit type, was collected from the clinical research warehouse system. The usage log was analysed in terms of the type of visit, service function, and time period. Outpatients accounted for 34% of the total app usage and was the most app-accessed visit type. The most utilized menu functions were lab test and visit schedule for visits or non-visits. For Inpatient and Health check-ups, menu usage patterns showed a focus on lab test results. While investigations and other menu usage showed double peaks in the morning and afternoon, peak usage of lab test results correlated with inpatient blood sampling times, which was around 9 am. App menus to access health information, particularly blood tests, emerged as the most accessed menu. Hence, when compared with blood sampling times and hospital information system usage patterns, encounters occurring in the hospital majorly impacted patient app use. For improved patient engagement, improving lab test function should be the priority.

A reinforcement learning approach for the online dynamic home health care scheduling problem.

Over recent years, home health care has gained significant attention as an efficient solution to the increasing demand for healthcare services. Home health care scheduling is a challenging problem involving multiple complicated assignments and routing decisions subject to various constraints. The problem becomes even more challenging when considered on a rolling horizon with stochastic patient requests. This paper discusses the Online Dynamic Home Health Care Scheduling Problem (ODHHCSP), in which a home health care agency has to decide whether to accept or reject a patient request and determine the visit schedule and routes in case of acceptance. The objective of the problem is to maximize the number of patients served, given the limited resources. When the agency receives a patient's request, a decision must be made on the spot, which poses many challenges, such as stochastic future requests or a limited time budget for decision-making. In this paper, we model the problem as a Markov decision process and propose a reinforcement learning (RL) approach. The experimental results show that the proposed approach outperforms other algorithms in the literature in terms of solution quality. In addition, a constant runtime of less than 0.001 seconds for each decision makes the approach especially suitable for an online setting like our problem.

Implementing Screening for Eating Disorders in Adolescents and Young Adults with a History of Cancer.

Eating disorders are prevalent in the adolescent and young adult (AYA) population, with 2.7% of adolescents effected. AYAs with cancer possess several risk factors for eating disorders that may place them at an even higher risk. Since these patients see their oncology team frequently, oncology clinics are opportune settings for eating disorder screening. Here, we describe a study to implement screening for eating disorders in AYA patients in an oncology clinic. During regularly scheduled oncology visits, eligible patients were given the SCOFF questionnaire. A total of 163 eligible patients filled out the SCOFF questionnaire with 11 positive results (6.75%). Eating disorder screening was successfully implemented in our pediatric oncology clinic. With a rate more than double than the general population, we observed that AYA patients with a history of cancer are at a higher risk for eating disorders and should undergo routine screening in oncology clinics.

Culturally Tailored Messages and Trial Registry Enrollment

Marginalized populations have lower levels of clinical trial representation than other populations. Tailoring recruitment materials and providing incentives may improve representation. To determine whether culturally tailored video improves parents' decision to enroll (DTE) Black children in a research registry. A randomized clinical trial, using mixed methods and consecutive sampling, was conducted in an urban primary care pediatric clinic. A post hoc study assessed the association of a monetary incentive with DTE. Ninety-three parents were recruited before their child's scheduled clinic visit. Participants completed a survey during which they were randomly assigned to review a paragraph (control group), generic video, or tailored video and received a gift card. Video watchers completed questions about its effectiveness. All participants were invited to join the registry. In the post hoc study, consenting participants followed the control group protocol and the coordinator promised them an ink pen for participating. The study was conducted between November 15, 2022, and August 29, 2023. A survey regarding the importance of being included in research studies was administered after participants watched a culturally tailored video. The primary outcome was DTE. Covariates were message effectiveness, clinical trial knowledge, and trust. Intention-to-treat analysis was performed. A total of 125 individuals were included. All groups had similar mean (SD) parent age (overall, 32.6 [7.35] years), gender (110 [88.0%] women), and race (116 [92.8%] Black or African American). There was no significant difference in the odds of DTE between the appeal video and control (odds ratio [OR], 1.19; 95% CI, 0.38-3.72) or between the generic video and control (OR, 1.91; 95% CI, 0.54-6.71). However, DTE was higher for all 3 gift card groups vs the ink pen incentive group (eg, control vs ink pen incentive: OR, 5.01; 95% CI, 1.68-14.95). After adjusting for trust, monetary incentives were associated with higher odds of DTE (adjusted OR, 5.92; 95% CI, 2.44-14.39). In this randomized clinical trial, targeted messaging was not associated with a higher decision to enroll in a pediatric clinical trial registry. There may be a role for combining holistic messaging with monetary incentives to improve enrollment. ClinicalTrials.gov Identifier: NCT06138145.

QLTI-16. QUALITY IMPROVEMENT PROJECT (QIPR) FOR IMPLEMENTATION OF PSYCHOSOCIAL ASSESSMENTS FOR ONCOLOGY CLINICAL CARE

Abstract BACKGROUND Patient-reported outcomes (PROs) have been used to assess individuals’ quality of life (QoL) throughout cancer treatment. Individuals with cancer often experience physical, psychological, and social challenges. It is crucial to evaluate their QoL to provide supportive care services to improve survival and treatment outcomes in real-world cancer clinical settings. Patients’ ability to engage with completing PROs is critical to ensuring PRO implementation efficacy. This QIPR (UF: 2216) examined these completion rates in coordinated medical-behavioral cancer care. METHODS Questionnaires delivered to neuro-oncology and psycho-oncology patients through the electronic health record (EHR) prior to scheduled office visits were: PROMIS – Anxiety, Depression, Pain Interference, Ability to Participate in Social Roles, and Cognitive and Physical Function. Data collection occurred from July 2023-January 2024. Descriptive statistics were calculated to assess battery completion rates. Information from the first 3 encounters following initiation of the battery into clinical practice were analyzed. RESULTS Of 906 scheduled encounters, 491 (54.2%) were attended by 280 unique patients. The battery was completed at least once by 106 (37.9%) patients. 72.6% (N=77) of these patients completed the battery at the first scheduled visit at which it was assigned. Of patients with 2 scheduled visits (N=25, 23.6%); 24.0% (N=6) completed the battery at both visits. Of patients that had 3 scheduled visits (N=12, 11.3%); 16.7% (N=2) completed it at all 3 visits. CONCLUSION Only approximately 38% of patients completed the battery at least once across 3 consecutive visits. The highest battery completion rate was at the first visit at which it was assigned. Completion rates were lower across additional visits. Future work will seek to understand barriers and facilitators of these completion rates to optimize implementation of PROs in coordinated medical-behavioral oncology care.

Efficiency of Primary Health Services in the Greek Public Sector: Evidence from Bootstrapped DEA/FDH Estimators.

Strengthening primary healthcare (PHC) is vital for enhancing efficiency and improving access, clinical outcomes, and population well-being. The World Health Organization emphasizes the role of effective PHC in reducing healthcare costs and boosting productivity. With growing healthcare demands and limited resources, efficient management is critical. Background/Objectives: Building on this point, this study aimed to evaluate the efficiency of PHC units across Greece, focusing on Health Centers (HCs) and Local Health Units (ToMYs). The objective was to assess their efficiency levels and identify factors contributing to observed inefficiencies. This study explores a novel research area by being the first to assess the efficiency of restructured primary healthcare facilities in Greece, utilizing 2019 data-the first year operational data became available for the newly established ToMY facilities following recent healthcare reforms. Methods: We applied a comprehensive suite of non-parametric methods, including Data Envelopment Analysis (DEA) under variable, constant, increasing, and decreasing returns to scale (VRS, CRS, IRS/NDRS, DRS/NIRS) assumptions, along with the Free Disposal Hull (FDH) model, all oriented toward output maximization. Efficiency scores were refined using bootstrapping to calculate 95% confidence intervals, and efficient units were ranked via the super-efficiency model. Outliers were identified and removed through the data cloud algorithm. For the first time at this scale, the final sample included the vast majority of PHC facilities in Greece-234 Health Centers and 94 Local Health Units-with inputs categorized into three human resource types: medical, nursing/paramedical, and administrative/other staff. Outputs encompassed scheduled visits, emergency visits, and pharmaceutical prescription visits. This diverse and comprehensive application of DEA methods represents a novel approach to evaluating PHC efficiency in Greece, with potential relevance to broader healthcare contexts. Results: The analysis revealed significant inefficiencies and differences in technical efficiency between HCs and ToMYs. HCs could nearly double their outputs (VRS score: 1.92), while ToMYs could increase theirs by 58% (VRS score: 1.58). Scale efficiency scores were closer, with HCs slightly more aligned with their optimal scale (1.17 vs. 1.20 for ToMYs). Conclusions: There is significant potential to improve efficiency in PHC, with variations depending on unit characteristics and regional differences. This evaluation provides a foundation for policymakers to identify areas for improvement and enhance the overall performance of healthcare services in Greece.

Multimedia-Based Education Led to Improvement in Disease Knowledge Among Patients with Cirrhosis.

Current evidence shows limited patient understanding of liver disease, coupled with no standard guidelines or methods to offer patient education in a busy clinical environment. We developed multimedia-based education (MBE) for those with cirrhosis & tested its effectiveness in improving patient knowledge from baseline to 1 month. This prospective study enrolled cirrhotic patients who had a scheduled visit with a hepatologist at an ambulatory academic practice or were admitted to the liver inpatient service. Once consented, patients completed a baseline knowledge questionnaire, and were given a link to watch the videos (text or email). Four videos were developed by the study team with input from clinicians and patients (liver function, symptoms and complications, medical management and preventive actions & nutrition). At month 1, the study coordinator confirmed with the patient that they had watched the videos at least once, and patients completed the same knowledge questionnaire. The scores between pre- and post-intervention were compared using the Wilcoxon signed rank test. Of the 120 enrolled, 113 completed baseline and 75 completed follow-up. 48% had alcohol-related liver disease as the underlying cause of cirrhosis. Mean MELD score at enrollment was 14.7 ± 8.14. There was a statistically significant improvement in knowledge scores across all domains from baseline to month 1 (p < 0.05). The overall knowledge score improved from 65 to 83% (p < 0.001), with highest improvement by 40% in the domain of liver function and causes of cirrhosis. MBE can help improve patients' knowledge about liver function, management, and prevention and can be used in both ambulatory and inpatient hepatology practice.

Effects of gestational age on blood cortisol and prolactin levels during pregnancy in malaria endemic area.

The hormonal shift occurring in pregnant women is crucial for the outcome of pregnancy. We conducted a study in pregnant women living in a malaria endemic area to determine the potential effect of gestational age on the modulation of the endocrine system by cortisol and prolactin production during pregnancy. Primigravidae and multigravidae with a gestational age between 16-20 weeks were included in the study and followed up to delivery and 6-7 weeks thereafter. Venous blood was collected at scheduled visit: Visit 1 (V1; 16-20 weeks of amenorrhea), Visit 2 (V2; 28 ±1 weeks of pregnancy), Visit 3 (V3; 32 ±1 weeks of pregnancy), Visit4 (V4; delivery) and Visit5 (V5; 6-7 weeks after delivery). In addition, a cord blood sample was also collected during labour at delivery. Nulliparous and primiparous/multiparous non-pregnant women were enrolled in the control group. Cortisol and prolactin plasma concentrations were measured using ichroma II and i-chamber apparatus. Light microscopy was used to detect Plasmodium falciparum infections. A linear mixed-effects regression (LMER) model was used to assess the association between the variation of cortisol titres and prolactin levels during the pregnancy and the post-partum. Results showed that cortisol and prolactin levels in the peripheral blood were globally up-regulated during pregnancy. Concentrations of cortisol during follow-up was significantly higher in primigravidae than in multigravidae during the whole pregnancy (p<0.024). Moreover, the level of prolactin which was higher before delivery in primigravidae reversed at delivery and postpartum visit, but the difference was not statistically significant during the follow-up (V1 to V5) (p = 0.60). The cortisol level in peripheral blood at delivery was higher than that in the cord blood, and conversely for prolactin. Cortisol and prolactin levels decreased after delivery, though the level of prolactin was still higher than that at enrolment. An increase of one unit of prolactin was associated with the decrease of the average concentration of cortisol by 0.04 ng/ml (p = 0.009). However, when cortisol increases with one unit, the average concentration of prolactin decreases by 1.16 ng/ml (p = 0.013). These results showed that the up-regulation effects of cortisol and prolactin are related to gestational age. A The downward regulation effect that both hormones have on each other during the pregnancy when each increase to 1 unit (1.0 ng/ml) was also reported.

Older Adults Benefit From Virtual Support for Continuous Glucose Monitor Use But Require Longer Visits.

Older adults may be less comfortable with continuous glucose monitoring (CGM) technology or require additional education to support use. The Virtual Diabetes Specialty Clinic study provided the opportunity to understand glycemic outcomes and support needed for older versus younger adults living with diabetes and using CGM. Prospective, virtual study of adults with type 1 diabetes (T1D, N = 160) or type 2 diabetes (T2D, N = 74) using basal-bolus insulin injections or insulin pump therapy. Remote CGM diabetes education (3 scheduled visits over 1 month) was provided by Certified Diabetes Care and Education Specialists with additional visits as needed. CGM-measured glycemic metrics, HbA1c and visit duration were evaluated by age (<40, 40-64 and ≥65 years). Median CGM use was ≥95% in all age groups. From baseline to 6 months, time 70 to 180 mg/dL improved from 45% ± 22 to 57% ± 16%; 50 ± 25 to 65 ± 18%; and 60 ± 28 to 69% ± 18% in the <40, 40-64, and ≥65-year groups, respectively (<40 vs 40-64 years P = 0.006). Corresponding values for HbA1c were 8.0% ± 1.6 to 7.3% ± 1.0%; 7.9 ± 1.6 to 7.0 ± 1.0%; and 7.4 ± 1.4 to 7.1% ± 0.9% (all P > 0.05). Visit duration was 41 min longer for ages ≥65 versus <40 years (P = 0.001). Adults with diabetes experience glycemic benefit after remote CGM use training, but training time for those >65 years is longer compared with younger adults. Addressing individual training-related needs, including needs that may vary by age, should be considered.

Patient-initiated follow-up supported by asynchronous telemedicine versus usual care in spondyloarthritis (TeleSpA-study): a randomised controlled trial of clinical and cost-effectiveness

With rising health-care expenditures and workforce shortages, sustainable alternatives to traditional outpatient follow-up strategies are required to optimise care efficiency. We aimed to investigate the cost-effectiveness and clinical effectiveness of patient-initiated follow-up (PIFU) supported by asynchronous telemedicine for patients with spondyloarthritis compared with usual care in daily practice. TeleSpA was a multicentre, pragmatic, open-label, randomised controlled trial. Patients with spondyloarthritis and stable disease were randomly assigned (1:1) to either the PIFU and asynchronous telemedicine group or usual care group. All patients received a scheduled outpatient visit at baseline and after 1 year. Patients were monitored remotely at 6 months (PIFU and asynchronous telemedicine) or at the discretion of the treating rheumatologist (usual care). The primary outcome was the number of rheumatology visits within a 1-year period. A trial-based 1-year health-economic evaluation from a Dutch health-care perspective (only including health-care costs) and societal perspective (also including travel costs and work productivity losses), per the Dutch guidelines was used to estimate cost-effectiveness. The safety analysis was done in the intention-to-treat population and was based on spontaneous reports of adverse events and serious adverse events or as observed by the research team. The primary analysis was in the intention-to-treat population. Individuals with relevant lived experience were involved in the study design. This trial was registered with the Dutch National Trial Register (NL71041.068.19) and ClinicalTrials.gov (NCT04673825) and is completed. Between Dec 2, 2020, and June 20, 2022, 200 patients were randomly assigned to PIFU and asynchronous telemedicine (n=100) or usual care (n=100). 79 (40%) of 200 participants were women, 121 (60%) were men, and the mean age was 55·0 years (SD 11·9). After 1 year, the mean number of rheumatology visits was 1·9 (SD 1·5) for the PIFU and asynchronous telemedicine group and 2·6 (1·3) in the usual care group (mean difference -0·7 [95% CI -1·0 to -0·3]; 25·4% reduction; p<0·0001). PIFU and asynchronous telemedicine was cost-effective from a health-care perspective, saving health-care costs (-€180 [95% CI -921 to 560]) without a loss in quality-adjusted life-years (0·004 [95 % CI -0·022 to 0·030]). Seven non-trial-related adverse events occurred in the PIFU and asynchronous telemedicine group and eight in usual care group (including one death). PIFU and asynchronous telemedicine resulted in significant and clinically meaningful reductions in rheumatology visits. This was not at the expense of health outcomes and saved health-care costs. Dutch Arthritis Society.

Real-time Technical Support Using a Remote Technology During Cardiac Implantable Electronic Device Follow-up: A Preliminary Multicenter Experience in Clinical Practice.

Industry-employed allied professionals (IEAPs) provide technical assistance to physicians during cardiac implantable electronic device (CIED) implantation, programming, troubleshooting, and follow-up. The Heart Connect™ application (Boston Scientific Inc., Marlborough, MA, USA) is a data-sharing system that enables remote access and display sharing of the CIED Programmer. This report aims to describe the preliminary experience of remote IEAP support through the application during CIED follow-up in clinical practice. The application was downloaded on the programmer, and network connections were established and tested at six Italian centers. Staff members were trained and online meetings were scheduled with IEAPs during consecutive CIED follow-up visits. Data and user feedback were collected. A total of 20 operators received training, and online meetings were conducted during 208 patient visits. Of these, 202 (97%) visits were successfully completed with remote support, without the need for additional medical or technical assistance. The connection quality, audio, and video were rated as good or excellent in ≥95% of sessions. The average duration of online meetings ranged from 6-16 min, depending on the supported session type. Comprehensive CIED checks and tests were performed during the visits, leading to the identification of relevant conditions or programming changes in 29% of visits. All operators found the application to be user-friendly and effective. Overall, satisfaction with the remote support service was rated high in 80% of responses, particularly for managing unscheduled CIED follow-up visits. In conclusion, remote support during CIED follow-up appears to be feasible, effective, and well accepted. It offers a viable alternative to traditional on-site IEAP support for both scheduled and unscheduled follow-up visits.

Development, Acceptability, and Initial Implementation of an Interactive Text-Messaging Program for Fathers with Low Income.

This study describes the development, acceptability, and implementation of an interactive text messaging program to engage fathers enrolled in home visitation programs. We used an iterative development approach that integrated rapid testing of intervention content with acceptability feedback from program participants to examine the processes of implementation. In Study 1, we describe the rapid testing framework and present data from 171 men who provided feedback on Text4Dad content via three online surveys. In Study 2, a case study, we use administrative data from 108 fathers with whom we pilot-tested Text4Dad in three community-based home visiting programs, with the program implemented by fatherhood program community health workers (F-CHWs). Content analysis of exchanges between F-CHWs and fathers describes the specific use of Text4Dad. Across all three online surveys, fathers reported positive reviews of the Text4Dad content. The F-CHWs used Text4Dad mainly to push out information, especially that related to home visit scheduling and local events, instead of engaging in bidirectional interactions with fathers. We conclude with a set of recommendations for social service and maternal and child health providers regarding the feasibility of implementing text messaging to support home visiting in community-based settings.