1. Remote monitoring with incentives for medication adherence did not significantly reduce the risk of all-cause inpatient readmission or death in heart failure patients.
Evidence Rating Level: 1 (Excellent)
Chronic heart failure management requires significant patient participation and lifestyle changes to reduce the risk of decompensation. In recent literature, behavioural economics has been proposed as an area of interest in increasing patient participation and preventing hospital readmissions. The 2-arm EMPOWER randomized controlled trial recruited 552 heart failure patients from 3 centers to two groups, intervention (n=272) and usual care (n=280). Exclusion criteria included kidney failure, inotrope therapy and transplant or ventricular assist devices. The intervention arm consisted of remote monitoring, digital scales, electronic pill bottles and lottery incentives conditional to adherence with a daily weighing schedule and diuretic medication. The primary outcome was time to death or all-cause readmission within 12 months. In the control group, 423 readmissions and 26 deaths occurred, compared with 377 readmissions and 23 deaths in the intervention group. Overall, there was no significant difference between the control and intervention groups for inpatient admission or death (unadjusted hazard ratio, 0.91; 95% CI, 0.74-1.13; p=.40).
1. Thromboembolic events were associated with a 2-3x greater risk of mortality in heart failure patients following hospital admissions.
Evidence Rating Level: 2 (Good)
Thrombotic events are a common cause of morbidity in hospitalized heart failure patients. Although risk factors for venous thromboembolic events (VTEs) and arterial thromboembolic events (ATEs) overlap significantly, 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 a 3 to 10-day hospital admission for heart failure followed by discharge home. The primary outcome was ATE and VTE incidence 90 days after discharge from hospital, while secondary outcomes included length of hospital stay, 30-day, 90-day and long-term mortality from VTE or ATE. Heart failure remained the most common cause for readmission (13.2%), followed by ATE (3.4%) and VTE (0.5%). At median follow-up of 25.6 months, readmissions for ATE and VTE were linked 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 with no readmissions. More evidence is required to determine the benefit of routine screening for thromboembolic events post-admission.
1. Apatinib demonstrated objective response rates of 40% and disease control rates of 84% in patients with thymic epithelial tumors.
Evidence Rating Level: 3 (Average)
Thymic epithelial tumors (TETs) are rare malignancies in adults and few treatment options presently exist following failure of first-line, platinum-based combination chemotherapy. Vascular endothelial growth factors (VEGF) are often aberrantly elevated in TETs. Increasing evidence suggests that apatinib, an angiogenesis inhibitor targeting VEGF receptor 2, may have anti-tumor activity in advanced thymic carcinoma (TC), an aggressive and distantly metastatic cancer. This open-label single-arm trial enrolled 25 patients at three centers in China. Patients were adults with progressive TC or thymoma following one line of platinum-based chemotherapy and ECOG performance status of 0-2. Patients received apatinib 500 mg orally until disease progression, toxicity or withdrawal of consent. Following two cycles of apatinib, a CT or MRI was completed to evaluate tumor response. The primary endpoint was objective response rate (proportion of patients with complete or partial response) while secondary endpoints were progression-free survival, overall survival, disease control rate and safety. By the end of phase II, one patient achieved complete response while 9 achieved partial response, objective response rate 40% (95% CI 21-61%) and disease control rate of 84% (95% CI 64-95%). The 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 events occurred in 15 patients. While this trial showed meaningful results, stronger evidence is needed to demonstrate the overall efficacy and toxicities of apatinib for TETs.
1. Clopidogrel monotherapy was associated with a 30% lower risk of colorectal cancer risk.
Evidence Rating Level: 3 (Average)
Proton pump inhibitors are commonly indicated for gastroesophageal reflux due to their irreversible blockage of gastric acid secretion. Concerns have been raised regarding systemic hypergastrinemia and potential colorectal carcinogenesis via epithelial cell proliferation, but evidence to date is inconclusive. This study aimed to investigate the potential relationship between colorectal cancer and low-dose aspirin, clopidogrel, direct oral anticoagulant (DOAC) and proton pump inhibitor therapy in Taiwan. The retrospective case-control study included 10,481 patients with colorectal cancer and 41,924 patients without colorectal cancer who underwent colonoscopy or abdominal CT scan. Known confounders were adjusted using conditional logistic regression. Within this cohort, monotherapy with clopidogrel was found to decrease the risk of colorectal cancer by 30% (AOR 0.70; 95% CI 0.60-0.83, p < 0.001). Furthermore, proton pump inhibitor therapy 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).
1. Left atrial decompression reduced composite in-hospital outcomes in pediatric patients receiving ECMO.
Evidence Rating Level: 2 (Good)
Left atrial (LA) decompression for pediatric heart failure patients has been demonstrated to decrease left ventricular wall stress and promote recovery. However, the benefits of this procedure in patients receiving extracorporeal membrane oxygenation (ECMO) are not well established. This retrospective multicenter cohort study included 1508 children on ECMO for failure to wean from cardiopulmonary bypass, 18% of whom underwent LA decompression. The aim of the study was to describe the benefit of this procedure for in-hospital outcomes utilizing a propensity score weighed analysis to adjust for baseline differences. The primary composite in-hospital outcome was defined as any of in-hospital mortality, transplant or conversion to ventricular assist devices while on ECMO. Within this cohort, LA decompression was found to reduce risk of in-hospital adverse outcomes (adjusted odds ratio, 0.775; 95% CI 0.644-0.932). Importantly, limited data was available in terms of the timing of LA decompression and specific interventions used which would affect in-hospital outcomes. Overall, these preliminary findings suggest a protective benefit of LA decompression in pediatric ECMO patients, but higher quality evidence is necessary to guide management.
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