Remote monitoring and behavioral economics in the management of heart failure in patients discharged from the hospital
1. Remote monitoring with medication incentives did not significantly reduce the risk of hospitalization for all causes or death in patients with heart failure.
Level of evidence evaluation: 1 (excellent)
Treatment of chronic heart failure requires significant patient involvement and lifestyle changes to reduce the risk of decompensation. In the recent literature, behavioral economics has been proposed as an area of interest in increasing patient participation and preventing hospital admission. The randomized controlled two-arm EMPOWER study included 552 patients with heart failure from 3 centers into two groups, intervention (n = 272) and routine care (n = 280). Exclusion criteria included renal failure, inotropic therapy, and transplant or ventricular assist facilities. The intervention part consisted of remote monitoring, digital scales, electronic pill bottles and lottery incentives conditional on adherence to a daily weighing plan and diuretics. The primary outcome was time to death or readmission for all reasons within 12 months. There were 423 readmissions and 26 deaths in the control group, compared with 377 readmissions and 23 deaths in the intervention group. Overall, there was no significant difference in hospitalization or death between the control and intervention groups (unadjusted risk ratio, 0.91; 95% CI, 0.74-1.13; p = 0.40).
Occurrence and prognostic consequences of readmission caused by thrombotic events after hospitalization with heart failure
1. Thromboembolic events were associated with a 2-3-fold higher risk of mortality in patients with heart failure after admission to the hospital.
Level of evidence evaluation: 2 (good)
Thrombotic events are a common cause of morbidity in hospitalized patients with heart failure. Although the risk factors for venous thromboembolic events (VTE) and arterial thromboembolic events (ATE) significantly overlap, the incidence of rehospitalizations caused by these events in patients with heart failure is not well described. This cohort study included 585,353 Medicare recipients with 3 to 10 days of hospitalization for heart failure followed by discharge home. The primary outcome was the incidence of ATE and VTE 90 days after discharge, while secondary outcomes included length of hospital stay, 30 days, 90 days, and long-term mortality from VTE or ATE. Heart failure remained the most common cause of re-admission (13.2%), followed by ATE (3.4%) and VTE (0.5%). At a median follow-up of 25.6 months, re-admissions for ATE and VTE were associated with a higher risk of mortality in the study cohort [(hazard ratio, 2.76; 95% CI 2.71-2.81); (hazard ratio 2.17; 95% CI 2.08-2.27) respectively] than patients without re-admission. More evidence is needed to determine the benefit of routine post-admission thromboembolic event screening.
Apatinib in patients with recurrent or metastatic thymic epithelial tumor: a single-arm, multicenter, open-label phase II study
1. Apatinib showed an objective response rate of 40% and a disease control rate of 84% in patients with epithelial tumors.
Level of evidence evaluation: 3 (average)
Thyroid epithelial tumors (TETs) are rare malignancies in adults and there are currently few treatment options after failure of first-line platinum-based combination chemotherapy. Vascular endothelial growth factors (VEGFs) are often aberrantly elevated in TET. There is growing evidence to suggest that apatinib, an angiogenesis inhibitor targeting VEGF receptor 2, may have antitumor activity in advanced thymic carcinoma (TC), aggressive and distant metastatic carcinoma. This open-label, single-arm study involved 25 patients in three centers in China. Patients were adults with progressive TC or thymoma following a single platinum-based chemotherapy line and ECOG 0-2 performance status. Patients received apatinib 500 mg orally until disease progression, toxicity, or withdrawal. After two cycles of apatinib, CT or MRI was completed to evaluate the tumor response. The primary endpoints were objective response rate (proportion of patients with complete or partial response), while the secondary endpoints were progression-free survival, overall survival, disease control rate, and safety. At the end of phase II, one patient achieved a complete response, while 9 achieved a partial response, an objective response rate of 40% (95% CI 21-61%) and a disease control rate of 84% (95% CI 64-95%). Progression-free survival was 9.0 months (95% CI 5.4-12.6), while median overall survival was 24.0 months (95% CI 8.2-39.8). Grade 3 treatment-related adverse reactions occurred in 15 patients. Although this study has shown meaningful results, stronger evidence is needed to demonstrate the overall efficacy and toxicity of apatinib for TET.
Anticoagulants with or without a proton pump inhibitor and the risk of colorectal cancer: a case-control population study
1. Clopidogrel monotherapy was associated with a 30% lower risk of colorectal cancer.
Level of evidence evaluation: 3 (average)
Proton pump inhibitors are commonly indicated for gastroesophageal reflux due to their irreversible blockade of gastric acid secretion. Concerns have been raised about systemic hypergastrinemia and potential colorectal carcinogenesis through epithelial cell proliferation, but the evidence to date is inconclusive. The aim of this study was to investigate the potential relationship between colorectal cancer and low-dose therapy with aspirin, clopidogrel, direct oral anticoagulants (DOAC) and proton pump inhibitors in Taiwan. A retrospective case-control study included 10,481 colorectal cancer patients and 41,924 colorectal cancer patients who underwent colonoscopy or abdominal CT. Known confusing factors were adjusted using conditional logistic regression. In this cohort, clopidogrel monotherapy was found to reduce the risk of colorectal cancer by 30% (AOR 0.70; 95% CI 0.60-0.83, p <0.001). Furthermore, treatment with proton pump inhibitors increased the risk of colorectal cancer by 38% (AOR 1.38; 95% CI 1.28-1.49, p <0.001). This risk was found to increase with combination therapy using proton pump inhibitors and DOAC (OR 3.91; 95% CI 1.49-10.27, p = 0.006).
Left atrial decompression in pediatric patients with extracorporeal membrane oxygenation support for cardiopulmonary bypass withdrawal failure: slope-weighted analysis
1. Left atrial decompression reduced composite hospitalization outcomes in pediatric patients receiving ECMO.
Level of evidence evaluation: 2 (good)
Left atrial (LA) decompression in pediatric heart failure patients has been shown to reduce left ventricular wall tension and promote recovery. However, the benefits of this approach in patients receiving extracorporeal membrane oxygenation (ECMO) have not been well established. This retrospective multicenter cohort study included 1508 children at ECMO for cardiopulmonary bypass withdrawal failure, 18% of whom underwent LA decompression. The aim of the study was to describe the benefit of this procedure for hospital outcomes using weighted propensity score analysis to accommodate differences in baseline. Primary composite hospitalization outcome was defined as any of hospitalization mortality, transplantation, or conversion to ventricular assist devices during ECMO. In this cohort, LA decompression was found to reduce the risk of hospitalization adverse events (adjusted odds ratio, 0.775; 95% CI 0.644-0.932). Importantly, there was limited data on the timing of LA decompression and the specific interventions used that would affect hospital outcomes. Overall, these preliminary findings suggest a protective benefit of LA decompression in pediatric patients with ECMO, but higher quality evidence is needed to guide treatment.
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