The feasibility of text reminders to improve medication adherence in adolescents with asthma.

OBJECTIVE: Personal health applications have the potential to help patients with chronic disease by improving medication adherence, self-efficacy, and quality of life. The goal of this study was to assess the impact of MyMediHealth (MMH) - a website and a short messaging service (SMS)-based reminder system - on medication adherence and perceived self-efficacy in adolescents with asthma. METHODS: We conducted a block-randomized controlled study in academic pediatric outpatient settings. There were 98 adolescents enrolled. Subjects who were randomized to use MMH were asked to create a medication schedule and receive SMS reminders at designated medication administration times for 3 weeks. Control subjects received action lists as a part of their usual care. Primary outcome measures included MMH usage patterns and self-reports of system usability, medication adherence, asthma control, self-efficacy, and quality of life. RESULTS: Eighty-nine subjects completed the study, of whom 46 were randomized to the intervention arm. Compared to controls, we found improvements in self-reported medication adherence (P = .011), quality of life (P = .037), and self-efficacy (P = .016). Subjects reported high satisfaction with MMH; however, the level of system usage varied widely, with lower use among African American patients. CONCLUSIONS: MMH was associated with improved medication adherence, perceived quality of life, and self-efficacy.Trial Registration This project was registered under http://clinicaltrials.gov/ identifier NCT01730235.

Takotsubo cardiomyopathy: real life management in the intensive coronary care unit.

AIM: Takotsubo cardiomyopathy is a cardiac syndrome characterized by reversible left ventricular dysfunction, ischemic changes on electrocardiogram, elevation of cardiac biomarkers, absence of obstructive coronary artery disease in the setting of various stressing conditions. To date, little is known on best clinical management of this syndrome in coronary care units. Whe thus aimed to present our experience in a real life takotsubo population. METHODS: We identified all patients with Takotsubo cardiomyopathy at our center Maria Vittoria Hospital, Turin, between October 2006 and February 2012. Patients where considered to have Takotsubo syndrome if they presented chest pain on admission, new elettrocardiographic changes suggestive of myocardial ischemia, evidence of apical balloning with hyperkinesis of basal segments on echocardiography, rise in troponin I and, after coronary angiography, no coronary artery disease. We adjudicated the following clinical events: death and recurrence of ischemic events; we also made a detailed analysis of the stressing conditions leading to clinical syndrome. RESULTS: A total of 26 patients were included, 4 (15%) males and 22 (85%) females; mean age was 71±13. After more than 1 year median follow-up the incidence of death was 7.7% (2 deaths), with all deaths, due to cardiogenic shock, occurring in the first 10 days of hospitalization; 2 patients (8%) experienced recurrence of ischemic event. Leading cause of Takostubo was major depressive episode (16%), followed by mourning (12%), falling down with difficulties in standing up (12%), vomiting (8%) and pulmonary infection (8%). In the coronary care unit major complications of patients with Takotsubo syndrome were acute hearth failure (62%), cardiogenic shock (27%), sepsis (31%), pulmonary aedema (27%) and anemia (12%). Two patients needed non-invasive ventilation support and one intra-aortic balloon conterpulasation. In addition one patient developed rabdomyolysis and one left heart thrombus. Cornerstone drug therapy was as follows: 96% of patients took aspirin, 58% beta blockers, 54% nitroglicerine, 46% intravenous heparin, 27% dopamine. CONCLUSION: Takotsubo syndrome is an important safety issue occurring predominantly in post-menopausal women undergoing specific stressing condition. Heart failure and cardiogenic shock are the most serious clinical complication and leading cause of death in the short period, good prognosis is seen thereafter.

The financial impact of health information exchange on emergency department care.

OBJECTIVE: To examine the financial impact health information exchange (HIE) in emergency departments (EDs). MATERIALS AND METHODS: We studied all ED encounters over a 13-month period in which HIE data were accessed in all major emergency departments Memphis, Tennessee. HIE access encounter records were matched with similar encounter records without HIE access. Outcomes studied were ED-originated hospital admissions, admissions for observation, laboratory testing, head CT, body CT, ankle radiographs, chest radiographs, and echocardiograms. Our estimates employed generalized estimating equations for logistic regression models adjusted for admission type, length of stay, and Charlson co-morbidity index. Marginal probabilities were used to calculate changes in outcome variables and their financial consequences. RESULTS: HIE data were accessed in approximately 6.8% of ED visits across 12 EDs studied. In 11 EDs directly accessing HIE data only through a secure Web browser, access was associated with a decrease in hospital admissions (adjusted odds ratio (OR)=0.27; p<0001). In a 12th ED relying more on print summaries, HIE access was associated with a decrease in hospital admissions (OR=0.48; p<0001) and statistically significant decreases in head CT use, body CT use, and laboratory test ordering. DISCUSSION: Applied only to the study population, HIE access was associated with an annual cost savings of $1.9 million. Net of annual operating costs, HIE access reduced overall costs by $1.07 million. Hospital admission reductions accounted for 97.6% of total cost reductions. CONCLUSION: Access to additional clinical data through HIE in emergency department settings is associated with net societal saving.

Automated dose-rounding recommendations for pediatric medications.

BACKGROUND: Although pediatric electronic prescribing systems are increasingly being used in pediatric care, many of these systems lack the clinical decision-support infrastructure needed to calculate a safe and effective rounded medication dose. This infrastructure is required to facilitate tailoring of established dosing guidance while maintaining the medication's therapeutic intent. OBJECTIVE: The goal of this project was to establish best practices for generating an appropriate medication dose and to create an interoperable rounding knowledge base combining best practices and dose-rounding information. METHODS: We interviewed 19 pediatric health care and pediatric pharmacy experts and conducted a literature review. After using these data to construct initial rounding tolerances, we used a Delphi process to achieve consensus about the rounding tolerance for each commonly prescribed medication. RESULTS: Three categories for medication-rounding philosophy emerged from our literature review: (1) medications for which rounding is used judiciously to retain the intended effect; (2) medications that are rounded with attention to potential unintended effects; and (3) medications that are rarely rounded because of the potential for toxicity. We assigned a small subset of medications to a fourth category-inadequate data-for which there was insufficient information to provide rounding recommendations. For all 102 medications, we were able to arrive at a consensus recommendation for rounding a given calculated dose. CONCLUSIONS: Results of this study provide the pediatric information technology community with a primary set of recommended rounding tolerances for commonly prescribed drugs. The interoperable knowledge base developed here can be integrated with existing and developing electronic prescribing systems, potentially improving prescribing safety and reducing cognitive workload.

MyMediHealth - designing a next generation system for child-centered medication management.

BACKGROUND: The last mile of the medication use system requires tools to help patients comply with medication administration rules and monitor for side effects. Personal health records (PHR) and emerging user-adopted communication tools promise to change the landscape of medication management; however, no research has been done to demonstrate how these tools might be constructed to support children with special healthcare needs. The overarching goal of the MyMediHealth project was to investigate ways in which PHRs and supported applications can improve the safety and quality of medication delivery in this population. DESIGN APPROACH: This project employed user-centered design to identify requirements for a child-centered medication management system. We collected information through site visits, facilitated group discussions, and iterative design sessions with adult caregivers. Once design requirements were articulated and validated, we constructed an initial prototype medication scheduler, which was evaluated by 202 parents using scripted activities completed using an online interactive prototype. The results of this analysis informed the development of a working prototype. STATUS: We have completed a working prototype of a scheduling system, a text-message-based alert and reminder system, and a medication administration record based on web-entered patient data. IMPLICATIONS: Pilot testing of the working prototype by stakeholders yielded strong endorsement and helpful feedback for future modifications, which are now underway as a part of an expanded project to test this system in a real-world environment.

Different patterns of atrial activation in idiopathic atrial fibrillation: simultaneous multisite atrial mapping in patients with paroxysmal and chronic atrial fibrillation.

OBJECTIVES: We aimed to evaluate: 1) the behavior of electrical activity simultaneously in different atrial regions during atrial fibrillation (AF); 2) the difference of atrial activation between paroxysmal and chronic AF; 3) the atrial refractoriness dispersion; and 4) the correlation between the effective refractory periods (ERPs) and the FF intervals. BACKGROUND: Little data exist on the electrophysiologic characteristics of the different atrial regions in patients with AF. A more detailed knowledge of the electrical activity during AF may provide further insights to improve treatment of AF. METHODS: Right and left atria were extensively mapped in 30 patients with idiopathic AF (18 paroxysmal and 12 chronic). In different atrial locations, we analyzed 1) the FF interval duration; and 2) the grade of organization and, in case of organized electrical activity, the direction of atrial activation. Furthermore, in patients with paroxysmal AF, we determined the atrial ERP, evaluated the ERP dispersion and assessed the presence of a correlation between the ERPs and the FF intervals. RESULTS: In patients with chronic AF, we observed a shortening of the FF intervals and a greater prevalence of disorganized activity in all the atrial sites examined. In patients with paroxysmal AF, a significant dispersion of refractoriness was observed. The right lateral wall showed longer FF intervals and more organized atrial activity and, unexpectedly, the shortest mean ERPs. In contrast, the septal area showed shorter FF intervals, greater disorganization and the longest mean ERPs. CONCLUSIONS: Electrical activity during AF showed a significant spatial inhomogeneity, which was more evident in patients with paroxysmal AF. The mean FF intervals did not correlate with the mean ERPs.

Typical atrial flutter ablation: conduction across the posterior region of the inferior vena cava orifice may mimic unidirectional isthmus block.

INTRODUCTION: The aim of this study was to map the low right atrium before and after radiofrequency ablation of the inferior vena cava-tricuspid annulus (IVC-TA) isthmus in patients with typical atrial flutter (AFI) to better understand the electrophysiologic meaning of incomplete or unidirectional block following the ablation procedure and its relationship with AFI recurrence. METHODS AND RESULTS: We performed atrial mapping in 12 patients using a "basket" catheter in the IVC orifice, Halo catheter in the right atrium, and multipolar catheters in the coronary sinus (CS) and His region. In patients in sinus rhythm, atrial activation was analyzed during pacing from the CS and low lateral right atrium (LLRA) before and after ablation. Atrial activation propagated across the isthmus and posterior region of the IVC orifice simultaneously before ablation. Mapping during AF1 in four patients showed that the crista terminalis was a site of functional block. After ablation, evaluation of Halo catheter recordings in three patients showed apparent unidirectional counterclockwise block, whereas analysis of basket catheter recordings demonstrated complete bidirectional block. The apparent conduction over the isthmus during pacing from proximal CS was due to conduction along the posterior part of the IVC orifice, which activated the LLRA despite complete isthmus block. CONCLUSION: Our results demonstrate that limited endocardial mapping may yield a pattern compatible with unidirectional block in the IVC-TA isthmus, although bidirectional block is present at this anatomic level.

Recognition specificity of individual EH domains of mammals and yeast.

The Eps homology (EH) domain is a recently described protein binding module that is found, in multiple or single copies, in several proteins in species as diverse as human and yeast. In this work, we have investigated the molecular details of recognition specificity mediated by this domain family by characterizing the peptide-binding preference of 11 different EH domains from mammal and yeast proteins. Ten of the eleven EH domains could bind at least some peptides containing an Asn-Pro-Phe (NPF) motif. By contrast, the first EH domain of End3p preferentially binds peptides containing an His-Thr/Ser-Phe (HT/SF) motif. Domains that have a low affinity for the majority of NPF peptides reveal some affinity for a third class of peptides that contains two consecutive amino acids with aromatic side chains (FW or WW). This is the case for the third EH domain of Eps15 and for the two N-terminal domains of YBL47c. The consensus sequences derived from the peptides selected from phage-displayed peptide libraries allows for grouping of EH domains into families that are characterized by different NPF-context preference. Finally, comparison of the primary sequence of EH domains with similar or divergent specificity identifies a residue at position +3 following a conserved tryptophan, whose chemical characteristics modulate binding preference.

Eps15R is a tyrosine kinase substrate with characteristics of a docking protein possibly involved in coated pits-mediated internalization.

eps15R was identified because of its relatedness to eps15, a gene encoding a tyrosine kinase substrate bearing a novel protein-protein interaction domain, called EH. In this paper, we report a biochemical characterization of the eps15R gene product(s). In NIH-3T3 cells, three proteins of 125, 108, and 76 kDa were specifically recognized by anti-eps15R sera. The 125-kDa species is a bona fide product of the eps15R gene, whereas p108 and p76 are most likely products of alternative splicing events. Eps15R protein(s) are tyrosine-phosphorylated following epidermal growth factor receptor activation in NIH-3T3 cells overexpressing the receptor, even at low levels of receptor occupancy, thus behaving as physiological substrates. A role for eps15R in clathrin-mediated endocytosis is suggested by its localization in plasma membrane-coated pits and in vivo association to the coated pits' adapter protein AP-2. Finally, we demonstrate that a sizable fraction of eps15R exists in the cell as a complex with eps15 and that its EH domains exhibit binding specificities that are partially distinct from those of eps15. We propose that eps15 and eps15R are multifunctional binding proteins that serve pleiotropic functions within the cell.

Differential Response in Left Ventricular Mass and Arterial Resistive Index following Fosinopril Therapy.

The aim of this study was to assess the differential response in left ventricular mass and resistive index (RI) of renal and carotid arteries in mild to moderate essential hypertensive patients after 1 year of ACE inhibitor therapy. Twenty-six patients (mean age 42.9 +/- 10.9 years) underwent 24-hour ambulatory blood pressure monitoring, echocardiography and renal and carotid echo-Doppler (by measuring RI, as an expression of arterial impedance) after a placebo period and 12 months of fosinopril treatment (20 mg/day). Our study showed a significant decrease in 24-hour BP (p < 0.05), left cardiac mass (p < 0.05) and RI of common carotid and hilum renal arteries (p < 0.05). In contrast, there were no significant reductions in the interlobar renal RI (as an expression of unchanged intrarenal resistance) and in the internal carotid artery RI. While the 24-hour BP decrease was strongly correlated with the left cardiac mass modifications (r = 0.73, p < 0.005), no significant relationship was observed with the renal and carotid artery parameters. In conclusion, the present study demonstrated that long-term treatment with fosinopril produced a differential response in left ventricular mass and arterial RI in patients with mild to moderate essential hypertension. In addition, the arterial impedance modifications of common carotid and hilum renal artery were largely unrelated to the 24-hour BP reduction.

[Mitral valve bioprosthesis from bovine pericardium. Color Doppler echographic study and long-term follow up]. / Bioprotesi valvolari mitraliche di pericardio bovino. Studio ecocardiografico e color Doppler e follow-up a lungo termine.

Pericardial heart valve bioprostheses have been utilized for 20 years. In spite of encouraging initial results, long-term follow-up showed a higher incidence of structural failures and primary tissue failures than porcine bioprostheses. Pericarbon represents the newest generation of bovine pericardial bioprostheses. Aim of this study is the long-term evaluation with echocardiographic and color Doppler technique of an innovative bioprostheses, in particular, its morfological and functional characteristics. From 1985 to 1989, 78 consecutive patients (21 males, 57 females, mean age 56.5 +/- 8.16 years) underwent mitral valve replacement with Pericarbon 29, by the same operator, who preserved the mitral posterior leaflet. One month after operation, 21 of these patients underwent echo-color Doppler evaluation, in normalized hemodynamic conditions (normality ranges). In 1995, at the end of the followup, 30 of the remaining 54 patients underwent new echo-color Doppler evaluation and these data were compared with normality ranges values. Leaflets' thickness increased from 0.98 +/- 0.09 to 2.87 +/- 0.73 mm (anterior leaflet; p < 0.0001) and from 1.02 +/- 0.08 to 2.71 +/- 0.45 mm (posterior leaflet; p < 0.0001) 43.3% of anterior leaflet and 53.3% of posterior leaflet showed fibrocalcic lesions. Mean transvalvular gradient increased from 3.4 +/- 0.2 to 6.6 +/- 3.4 mmHg (p < 0.0001); also functional area decreased (p < 0.0001). We have found no paraprosthetic regurgitation and a very low number of central prosthetic regurgitation. Left ventricular function, evaluated by ejection fraction and regional kinesis, remained substantially preserved.

Asymmetric alignment-stabilized external-cavity semiconductor laser.

We have demonstrated an alignment-stabilized asymmetric cavity configuration for a grating-tuned externalcavity semiconductor laser. The grating in the asymmetric cavity has a 16-fold greater angular misalignment tolerance than in a conventional symmetric external-cavity semiconductor laser. The tuning ranges are nearly the same for both cavities (approximately 30 nm).