Depression and Clinical Inertia in Patients With Uncontrolled Hypertension

Depression is a known risk factor for poor prognosis among patients with cardiovascular disease.1 Numerous biological and behavioral mechanisms have been proposed.2 However, few studies have investigated the association between depression and “clinical inertia,” or lack of treatment intensification in individuals not at evidence-based goals for care.3 To address this gap, we assessed whether a diagnosis of depression is associated with clinical inertia in patients with uncontrolled hypertension

Behavioral economics implementation: Regret lottery improves mHealth patient study adherence.

Background: Nonadherence to study protocols reduces the generalizability, validity, and statistical power of longitudinal studies. Purpose: To determine whether an automated electronically-delivered regret lottery would improve adherence to an intensive mHealth self-monitoring protocol as part of a longitudinal observational study. Methods: We enrolled 77 adults into a 52-week study requiring five daily ecologic momentary assessments (EMA) of stress and daily accelerometer use. We performed a pre/post single-arm study to evaluate the efficacy of a lottery intervention in improving adherence to this protocol. Midway through the study, participants were invited to enter a weekly regret lottery ($50 prize, expected value Results: 62 participants consented to lottery participation. In the 12 weeks prior to lottery initiation, weekly adherence was declining (slope -1.4%/week). The weekly per-participant probability of adherence was higher after lottery initiation when comparing the 4-week (32% pre-lottery vs 50% post-lottery, p \u3c 0.001), 8-week (37% vs 49%, p \u3c 0.001), and 12-week periods (39% vs 45%, p = 0.001) before and after lottery initiation. However, the rate of decline in adherence over time was unchanged. Conclusion: The implementation of an automated, electronically-delivered weekly regret lottery improved adherence with an intensive self-monitoring study protocol. Regret lotteries may represent a cost-effective tool to improve adherence and reduce bias caused by dropout or nonadherence

Definitions and Standardization of a New Grading Scheme for Eyelid Contour Abnormalities after Trichiasis Surgery

Approximately 8 million individuals worldwide suffer from trichiasis, a condition characterized by in-turned lashes that rub against the eye. Trichiasis is caused by repeated or prolonged ocular infection with Chlamydia trachomatis. Surgery is available to correct in-turned lashes. In most programmatic and research settings, the primary determinant of surgical success is whether or not lashes are touching the globe post-operatively. However, other surgical outcomes such as the contour of the eyelid are also important. Yet, no standard method for evaluating and reporting this outcome has been defined. In this study, we developed and tested a grading system for evaluating the severity of eyelid contour abnormalities after surgery using photographs of eyelids six weeks post-operatively. We found good agreement across photograph graders and also between field and photograph grades. This system should be useful in helping to standardize reporting of this outcome

Modulation of epithelial sodium channel (ENaC) expression in mouse lung infected with Pseudomonas aeruginosa

BACKGROUND: The intratracheal instillation of Pseudomonas aeruginosa entrapped in agar beads in the mouse lung leads to chronic lung infection in susceptible mouse strains. As the infection generates a strong inflammatory response with some lung edema, we tested if it could modulate the expression of genes involved in lung liquid clearance, such as the α, β and γ subunits of the epithelial sodium channel (ENaC) and the catalytic subunit of Na(+)-K(+)-ATPase. METHODS: Pseudomonas aeruginosa entrapped in agar beads were instilled in the lung of resistant (BalB/c) and susceptible (DBA/2, C57BL/6 and A/J) mouse strains. The mRNA expression of ENaC and Na(+)-K(+)-ATPase subunits was tested in the lung by Northern blot following a 3 hours to 14 days infection. RESULTS: The infection of the different mouse strains evoked regulation of α and β ENaC mRNA. Following Pseudomonas instillation, the expression of αENaC mRNA decreased to a median of 43% on days 3 and 7 after infection and was still decreased to a median of 45% 14 days after infection (p < 0.05). The relative expression of βENaC mRNA was transiently increased to a median of 241%, 24 h post-infection before decreasing to a median of 43% and 54% of control on days 3 and 7 post-infection (p < 0.05). No significant modulation of γENaC mRNA was detected although the general pattern of expression of the subunit was similar to α and β subunits. No modulation of α(1)Na(+)-K(+)-ATPase mRNA, the catalytic subunit of the sodium pump, was recorded. The distinctive expression profiles of the three subunits were not different, between the susceptible and resistant mouse strains. CONCLUSIONS: These results show that Pseudomonas infection, by modulating ENaC subunit expression, could influence edema formation and clearance in infected lungs

Vertically oriented upper eyelid nerve fibers. A clinical, anatomical and immunohistochemical study

Vertically oriented suborbicular nerve fibers are frequently encountered during upper eyelid surgery. It has not been well established whether these fibers are terminal motor branches of the facial nerve (VII) or sensory branches of the ophthalmic nerve (V-1). To investigate the origin of these nerve fibers, three different techniques were used: (1) intraoperative nerve stimulation; (2) cadaver dissection; and (3) immunohistochemical analysis. The results of all three investigative methods are in agreement and conclusively demonstrate that these fibers represent sensory branches of the ophthalmic nerve (V-1) and not motor branches of the facial nerve (VII). Anatomical dissection showed that the sensory fibers to the upper eyelid do not travel solely within the suborbicular fascial plane, but also course in the preorbicular plane and within the orbicularis muscle itself. The terminal branches of the facial nerve to the upper eyelid innervate the orbicularis oculi from the undersurface and in a horizontal orientation. Clinical correlation of these findings is discussed

Increasing the Precision of Hypertension Treatment Through Personalized Trials: a Pilot Study

© 2019, Society of General Internal Medicine. Background: There are substantial differences in the effects of blood pressure (BP) medications in individual patients. Yet, the current standard approach to prescribing BP medications is not personalized. Objective: To determine the feasibility of individualizing the selection of BP medications through pragmatic personalized (i.e., N-of-1) trials. Design: Series of N-of-1 trials. Setting: Outpatient. Patients: Hypertensive adults prescribed none or one BP medication. Intervention: Participation in a flexible, open-label personalized trial of two to three BP medications (NCT02744456). Measurements: BP was measured twice per day with a validated home BP device. Frequency and severity of side effects were assessed at the end of the day via an electronic questionnaire. Patients’ BP medication preference was assessed after reviewing BP lowering and side effect results with a study clinician. Feasibility was assessed by determining the proportion of patients who adhered to self-assessments. Benefit was assessed by asking patients to rate the helpfulness of participation and whether they would recommend personalized trials to other hypertensive patients. Key Results: Of ten patients enrolled, two dropped out prior to initiation, one discovered white coat hypertension through ambulatory BP monitoring, and seven (mean age 58 years, 71% of women) completed personalized trials. All seven were compliant with home BP monitoring and side effect tracking. All seven recommended personalized trials of BP medications to others. Thiazides were preferred by three patients, renin-angiotensin system–blocking agents by two patients, a combination of thiazide and beta-blocker by one patient, and any of three classes by one patient. Conclusions: Personalized trials of BP medications were feasible and led to improved treatment precision. Heterogeneity of patient preferences and of therapeutic BP response for first-line BP medications can be determined through a personalized trial approach