Use of High-Flow Nasal Cannula in Patients With Pneumonia and Hypoxemic Respiratory Failure at Altitudes Above 2600 m: What Is the Best Predictor of Success?

Introduction: The use of high-flow nasal cannulas (HFNC) in patients with hypoxemic ventilatory failure reduces the need for mechanical ventilation and does not increase mortality when intubation is promptly applied. The aim of the study is to describe the behavior of HFNC in patients who live at high altitudes, and the performance of predictors of success/failure of this strategy. Methods: Prospective multicenter cohort study, with patients aged over 18 years recruited for 12 months in 2020 to 21. All had a diagnosis of hypoxemic respiratory failure secondary to pneumonia, were admitted to intensive care units, and were receiving initial management with a high-flow nasal cannula. The variables assessed included need for intubation, mortality in ICU, and the validation of SaO2, respiratory rate (RR) and ROX index (IROX) as predictors of HFNC success / failure. Results: One hundred and six patients were recruited, with a mean age of 59 years and a success rate of 74.5%. Patients with treatment failure were more likely to be obese (BMI 27.2 vs 25.5; OR: 1.03; 95% CI: .95-1.1) and had higher severity scores at admission (APACHE II 12 vs 20; OR 1.15; 95% CI: 1.06-1.24). Respiratory rates after 12 (AUC .81 CI: .70-.92) and 18 h (AUC .85 CI: .72-0.90) of HFNC use were the best predictors of failure, performing better than those that included oxygenation. ICU mortality was higher in the failure group (6% vs 29%; OR 8.8; 95% CI:1.75-44.7). Conclusions: High-flow oxygen cannula therapy in patients with hypoxemic respiratory failure living at altitudes above 2600 m is associated with low rates of therapy failure and a reduced need for mechanical ventilation in the ICU. The geographical conditions and secondary physiological changes influence the performance of the traditionally validated predictors of therapy success. Respiratory rate <30 proved to be the best indicator of early success of the device at 12 h of use.

Providers' Perspectives on Adherence to Hormonal Therapy in Breast Cancer Survivors. Is there a Role for the Digital Health Feedback System?

OBJECTIVE: Despite the benefits of hormonal therapy (HT) adherence remains suboptimal in ER positive breast cancer patients. Medication adherence is challenging to assess and tends to be overestimated. The Digital Health Feedback System (DHFS) consists of an ingestible sensor attached to a pill that sends intake date and time to a smart phone or computer. Patients can share this information with health care providers and other persons. The DHFS can also send reminders. This mixed methods study examined providers' perceptions of HT medication adherence. The potential role of the DHFS in enhancing medication tracking and adherence was also explored. METHODS: We conducted semi-structured interviews with key informants (N=10). Questions examined perceptions about adherence barriers and facilitators, challenges tracking adherence, and views on the DHFS. Findings informed the development of a survey that was administered online (N=19). RESULTS: Providers emphasized the importance of fostering open and trustful communication around adherence. The most mentioned challenges to assessing adherence were the patient not disclosing discontinuation immediately (78.9%) and over-reporting adherence (57.9%). The perceived potential benefits of DHFS were the ability to track adherence better (94.7%) and reminders to take the medication (68.4%). Safety to ingest a sensor was as a major perceived barrier (8 4.2%). CONCLUSION: Interventions that target providers and doctor-patient communication are warranted to enhance adherence and reduce communication delays around HT discontinuation. PRACTICE IMPLICATIONS: DHFS has the potential to enhance HT adherence by directly targeting barriers. Future studies should also examine the feasibility of adopting the DHFS with cancer patients.

Initiation of Adjuvant Endocrine Therapy in Black and White Women With Breast Cancer.

BACKGROUND: Adjuvant endocrine therapy reduces risk of recurrence and mortality in women with hormone receptor-positive breast cancer, yet many women never initiate it. We examined the influence of race, sociocultural factors, and process-of-care factors on initiation of adjuvant endocrine therapy in a racially diverse sample. PATIENTS AND METHODS: Eligible women were originally recruited for the Narrowing the Gaps in Adjuvant Therapy Study (2006-2011). Sociocultural and process-of-care factors were collected via telephone surveys before adjuvant therapy. Clinical factors were abstracted from charts. Penalized LASSO (least absolute shrinkage and selection operator) logistic regression model was used to identify variables associated with initiation. RESULTS: Of the 270 women, 55.6% were black and the rest were white. Most women (74.8%) initiated therapy. A significant interaction (P = .008) was found between race and age. Black women aged ≤ 50 years had the lowest initiation (59.7%) compared to black women > 50 years (87.1%), white women ≤ 50 years (73.7%), or white women > 50 years (72.0%). Multivariate analysis found that younger black women exhibited a marginally higher risk of noninitiation compared to older black women. Additionally, ratings of financial access, presence of comorbidities, and levels of communication were all associated with endocrine therapy initiation. CONCLUSION: Black women ≤ 50 years of age and women with financial constraints may be important subgroups for interventions. Patient-provider communication appears to be an important leverage point to foster therapy uptake.