Comparison of Sodium-Glucose Cotransporter-2 Inhibitor and Glucagon-Like Peptide-1 Receptor Agonist Prescribing in Patients With Diabetes Mellitus With and Without Cardiovascular Disease.

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP1-RAs) reduce cardiovascular events and mortality in patients with type 2 diabetes mellitus (T2DM). We sought to describe trends in prescribing for SGLT2is and GLP1-RAs in diverse care settings, including (1) the outpatient clinics of a midwestern integrated health system and (2) small- and medium-sized community-based primary care practices and health centers in 3 midwestern states. We included adults with T2DM and ≥1 outpatient clinic visit. The outcomes of interest were annual active prescription rates for SGLT2is and GLP1-RAs (separately). In the integrated health system, 22,672 patients met the case definition of T2DM. From 2013 to 2019, the overall prescription rate for SGLT2is increased from 1% to 15% (absolute difference [AD] 14%, 95% confidence interval [CI] 13% to 15%, p <0.01). The GLP1-RA prescription rate was stable at 10% (AD 0%, 95% CI -1% to 1%, p = 0.9). In community-based primary care practices, 43,340 patients met the case definition of T2DM. From 2013 to 2017, the SGLT2i prescription rate increased from 3% to 7% (AD 4%, 95% CI 3% to 6%, p <0.01), whereas the GLP1-RA prescription rate was stable at 2% to 3% (AD 1%, 95% CI -1 to 1%, p = 0.40). In a fully adjusted regression model, non-Hispanic Black patients had lower odds of SGLT2i or GLP1-RA prescription (odds ratio 0.56, 95% CI 0.34 to 0.89, p = 0.016). In conclusion, the increase in prescription rates was greater for SGLT2is than for GLP1-RAs in patients with T2DM in a large integrated medical center and community primary care practices. Overall, prescription rates for eligible patients were low, and racial disparities were observed.

Fulminant myocarditis in a patient with coronavirus disease 2019 and rapid myocardial recovery following treatment.

Coronavirus disease 2019 (COVID-19) is a global pandemic increasingly encountered in the clinical setting. It typically manifests as a respiratory illness, although cardiac involvement is common and portends a worse prognosis. We present the case of a 56-year-old male admitted with COVID-19 fulminant myocarditis and cardiogenic shock. We discuss important aspects of the multidisciplinary and interventional care involved in treating cardiogenic shock as well as the likely mechanisms of, and potential treatment for, COVID-19 myocarditis. The various pathways of myocardial injury, including direct viral damage, macrophage activation, and lymphocytic infiltration, are outlined in detail in addition to associated pathology such as cytokine release syndrome. COVID-19 is a complex and multisystem disease process; in addition to supportive care, specific consideration should be given to the underlying mechanism of injury for each patient.

Development of a Portable Tool to Identify Patients With Atrial Fibrillation Using Clinical Notes From the Electronic Medical Record.

BACKGROUND: The electronic medical record contains a wealth of information buried in free text. We created a natural language processing algorithm to identify patients with atrial fibrillation (AF) using text alone. METHODS AND RESULTS: We created 3 data sets from patients with at least one AF billing code from 2010 to 2017: a training set (n=886), an internal validation set from site no. 1 (n=285), and an external validation set from site no. 2 (n=276). A team of clinicians reviewed and adjudicated patients as AF present or absent, which served as the reference standard. We trained 54 algorithms to classify each patient, varying the model, number of features, number of stop words, and the method used to create the feature set. The algorithm with the highest F-score (the harmonic mean of sensitivity and positive predictive value) in the training set was applied to the validation sets. F-scores and area under the receiver operating characteristic curves were compared between site no. 1 and site no. 2 using bootstrapping. Adjudicated AF prevalence was 75.1% at site no. 1 and 86.2% at site no. 2. Among 54 algorithms, the best performing model was logistic regression, using 1000 features, 100 stop words, and term frequency-inverse document frequency method to create the feature set, with sensitivity 92.8%, specificity 93.9%, and an area under the receiver operating characteristic curve of 0.93 in the training set. The performance at site no. 1 was sensitivity 92.5%, specificity 88.7%, with an area under the receiver operating characteristic curve of 0.91. The performance at site no. 2 was sensitivity 89.5%, specificity 71.1%, with an area under the receiver operating characteristic curve of 0.80. The F-score was lower at site no. 2 compared with site no. 1 (92.5% [SD, 1.1%] versus 94.2% [SD, 1.1%]; P<0.001). CONCLUSIONS: We developed a natural language processing algorithm to identify patients with AF using text alone, with >90% F-score at 2 separate sites. This approach allows better use of the clinical narrative and creates an opportunity for precise, high-throughput cohort identification.

Factors Associated With Excess Myocardial Infarction Risk in HIV-Infected Adults: A Systematic Review and Meta-analysis.

OBJECTIVES: To estimate the pooled relative risk (RR) of incident acute myocardial infarction (AMI) among HIV-infected adults compared with HIV-uninfected controls and explore the contribution of traditional and HIV-related risk factors. BACKGROUND: Understanding AMI risk and associated risk factors in HIV-infected populations has the potential to inform clinical management and prevention strategies. METHODS: We systematically identified cohort studies of HIV-infected or HIV-infected and matched uninfected adults reporting AMI incidence rates published up to January 1, 2017. Random-effects meta-analysis models were used to estimate the aggregate RR of AMI by HIV status. Subgroup analysis and meta-regression were used to explore factors affecting risk. RESULTS: Sixteen studies (N = 1,619,690, median age 38.5 years, 78.9% male, mean follow-up of 6.5 years) were included. In pooled analyses of HIV-infected and matched uninfected cohorts (n = 5), HIV-infected individuals had higher AMI incidence rates (absolute risk difference = 2.2 cases per 1000 persons per year) and twice the risk of AMI [RR = 1.96 (1.5-2.6)] compared with matched HIV-uninfected controls. In a multivariate meta-regression, each additional percentage point in the proportion of male participants [odds ratio (OR) = 1.20 (1.14-1.27)] and each additional percentage point in the prevalence of hypertension [OR = 1.19 (1.12-1.27)], dyslipidemia [OR = 1.09 (1.07-1.11)], and smoking [OR = 1.09 (1.05-1.13)] were independently associated with increased AMI risk in HIV-infected adults. CONCLUSIONS AND RELEVANCE: Chronic HIV infection is associated with a 2-fold higher AMI risk. Traditional risk factors such as hypertension, dyslipidemia, and smoking are significant contributors to AMI risk among HIV-infected adults and should be aggressively targeted in routine HIV care.

Acquired Methemoglobinemia Associated with Topical Lidocaine Administration: A Case Report.

A 55-year-old male was admitted to the hospital with pneumonia. During an intubation procedure, the patient received an application of endobronchial lidocaine (4% gel). Within 2 h of intubation, the patient developed worsening hypoxia, and investigation of arterial blood gasses revealed a pH of 7.21, carbon dioxide partial pressure (PaCO2) of 3.3 kPa, oxygen partial pressure (PaO2) of 55.1 kPa, and measured oxygen saturation of 49%. Co-oximetry of this sample returned a methemoglobin level of 53%. Intravenous methylthioninium chloride (1% solution at 1 mg/kg) was delivered, and subsequent arterial blood gasses, at 30 min and 1 h post administration, showed methemoglobin levels of 12 and 9%, respectively, with return of oxygen saturation to > 90%.

Feasibility, Process, and Outcomes of Cardiovascular Clinical Trial Data Sharing: A Reproduction Analysis of the SMART-AF Trial.

Importance: Data sharing is as an expanding initiative for enhancing trust in the clinical research enterprise. Objective: To evaluate the feasibility, process, and outcomes of a reproduction analysis of the THERMOCOOL SMARTTOUCH Catheter for the Treatment of Symptomatic Paroxysmal Atrial Fibrillation (SMART-AF) trial using shared clinical trial data. Design, Setting, and Participants: A reproduction analysis of the SMART-AF trial was performed using the data sets, data dictionary, case report file, and statistical analysis plan from the original trial accessed through the Yale Open Data Access Project using the SAS Clinical Trials Data Transparency platform. SMART-AF was a multicenter, single-arm trial evaluating the effectiveness and safety of an irrigated, contact force-sensing catheter for ablation of drug refractory, symptomatic paroxysmal atrial fibrillation in 172 participants recruited from 21 sites between June 2011 and December 2011. Analysis of the data was conducted between December 2016 and April 2017. Main Outcomes and Measures: Effectiveness outcomes included freedom from atrial arrhythmias after ablation and proportion of participants without any arrhythmia recurrence over the 12 months of follow-up after a 3-month blanking period. Safety outcomes included major adverse device- or procedure-related events. Results: The SMART AF trial participants' mean age was 58.7 (10.8) years, and 72% were men. The time from initial proposal submission to final analysis was 11 months. Freedom from atrial arrhythmias at 12 months postprocedure was similar compared with the primary study report (74.0%; 95% CI, 66.0-82.0 vs 76.4%; 95% CI, 68.7-84.1). The reproduction analysis success rate was higher than the primary study report (65.8%; 95% CI 56.5-74.2 vs 75.6%; 95% CI, 67.2-82.5). Adverse events were minimal and similar between the 2 analyses, but contact force range or regression models could not be reproduced. Conclusions and Relevance: The feasibility of a reproduction analysis of the SMART-AF trial was demonstrated through an academic data-sharing platform. Data sharing can be facilitated through incentivizing collaboration, sharing statistical code, and creating more decentralized data sharing platforms with fewer restrictions to data access.

Effects of Different Dietary Interventions on Blood Pressure: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Previous studies have shown beneficial effects of individual dietary approaches for blood pressure (BP) control, but their relative effectiveness is not well established. We performed a systematic review of published dietary pattern interventions and estimated the aggregate BP effects through meta-analysis. PubMed, EMBASE, and Web of Science databases were searched to identify studies published between January 1, 1990 and March 1, 2015. Studies meeting specific inclusion and exclusion criteria were selected. Data were pooled using random effects meta-analysis models. Twenty-four trials with 23 858 total participants were included. The overall pooled net effect of dietary intervention on systolic BP and diastolic BP was -3.07 mm Hg (95% confidence interval, -3.85 to -2.30) and -1.81 mm Hg (95% confidence interval, -2.24 to -1.38), respectively. The Dietary Approaches to Stop Hypertension diet had the largest net effect (systolic BP, -7.62 mm Hg [95% confidence interval, -9.95 to -5.29] and diastolic BP, -4.22 mm Hg [95% confidence interval, -5.87 to -2.57]). Low-sodium; low-sodium, high-potassium; low-sodium, low-calorie; and low-calorie diets also led to significant systolic and diastolic BP reductions, whereas Mediterranean diet participants experienced a significant incremental reduction in diastolic but not systolic BP. Subgroup analysis also showed important variations in effectiveness based on duration, size, and participant demographics. In conclusion, dietary modifications are associated with clinically meaningful, though variable, reductions in BP. Some diets are more effective than others and under different circumstances, which has important implications from both clinical and public health perspectives.