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Home blood pressure monitoring for hypertension management during COVID-19 pandemic [Meeting Abstract]

Ding, X; Maheswaran, S; Chodosh, J
Background: Home blood pressure measurement (HBPM) has been a time-honored supplement to periodic in-office measurement to facilitate primary care physician (PCP) diagnosis of hypertension (HTN), its ongoing control and medication management. PCPs, in response to COVID-19, adopted telemedicine as the sole means of care, elevating HBPM as the essential HTN surveillance tool. We assessed the feasibility of this approach in a Veteran Affairs (VA) geriatric clinic.
Method(s): Study subjects included all the Veterans seen by New York Harbor VA geriatrics fellows' clinic between January 1, 2019 and March 1, 2020 and who have HTN listed as an electronic health record (EHR) diagnosis. Those with systolic blood pressure (SBP) > 140 mmHg were prioritized. We called these patients to assess adherence to BP self-care and reconcile medications, to identify reasons for poor adherence and to offer solutions. Patients were called again within two months to re-assess adherence, collect BP measures and adjust medications as needed.
Result(s): Among 102 patients diagnosed with HTN, 41 had not achieved the goal of SBP <140 mmHg prior to this intervention. We reached 78% (n=32) of these 41 patients (requiring 1-3 phone calls). All reported medical adherence, but none were found to consistently check BP at home with any frequency or proper technique. For the 14 patients having no BP monitor at home, we sent a monitor to 10 through prescription and enrolled 4 in a home telehealth (HT) program that uses daily remote measurement. We provided detailed instruction of proper HBPM during the initial interview. At follow-up, 47% (n=15) practiced HBPM and reported BP readings within goal, indicating no need for change in care. Of these 15, 11 had their own BP monitors; 2 achieved control through the HT program. However, only 2 of the 10 patients who received the prescribed BP monitor started HBPM and demonstrated good control.
Conclusion(s): Given our reliance on telemedicine, HBPM is feasible for outpatient HTN management. Close PCP follow-up to encourage consistent HBPM practice may improve and sustain the success of this strategy. The quality of self-reported data should be assessed during office visits
ISSN: 1532-5415
CID: 4870592

Deprescribing inappropriate long-term use of PPI in VA geriatrics clinic [Meeting Abstract]

Maung, P; Lee, J; Maheswaran, S; Shetty, S
Background: Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders. The effectiveness of PPIs has led to overutilization, exposing patients to an increasing number of potential risks. Despite FDA safety warnings regarding the potential adverse effects of long-term PPI use, there has been a failure to re-evaluate the need for continued therapy. The VA Manhattan outpatient Geriatrics clinic, in collaboration with pharmacists and patients, conducted a quality improvement (QI) program using a shared decision-making approach to deprescribe inappropriate PPIs.
Method(s): Patients with PPIs ordered from April, 2017 to April, 2018 were identified using the VA database. Diagnoses were identified using ICD 10 codes. Patients without a clear indication for longterm PPI treatment were identified (long term PPI use is indicated in refractory GERD, Barrett's esophagus, Zollinger-Ellison syndrome, idiopathic chronic peptic ulcer, and bleeding prevention in selected patients). Patients were contacted telephonically by a physician or pharmacist, counseled regarding adverse effects of long-term PPI use and offered titration/discontinuation or change to an alternative agent. If patients consented, they were contacted for follow-up interviews at 1, 3, 6, 12 months after inclusion to assess symptoms and tolerance.
Result(s): Of the1230 patients in the Geriatrics clinic, 74 (6%) were on PPIs. Of these, 41/74 (55%) had no indication for chronic PPI use. 36 of 41 patients consented to participate. We were able to titrate and discontinue or switch to an H2 antagonist in 20 (55%) of the 36 patients but 15 (42%) were restarted on PPI for recurrence of GERD symptoms over the 12 months of follow-up. 1 patient died of natural causes.
Conclusion(s): This QI program successfully deprescribed inappropriate long-term PPIs in some patients without major adverse events by using an interdisciplinary approach and shared decision- making process with patients. However, a sizable proportion of patients required restarting of a PPI for GERD symptoms. Future work is needed to understand if GERD symptom control can be achieved by other means to further decrease PPI use
ISSN: 1532-5415
CID: 4754622

Absolute quantification of circulating tumor cell RNA enables high specificity detection of hepatocellular carcinoma [Meeting Abstract]

Kalinich, M; Bhan, I; Kwan, T T; Miyamoto, D T; Javaid, S; Licausi, J A; Milner, J D; Hong, X; Goyal, L; Sil, S; Choz, M; Kapur, R; Muzikansky, A; Zhang, H; Weitz, D A; Sequist, L V; Ryan, D P; Chung, R; Zhu, A X; Isselbacher, K J; Ting, D T; Toner, M; Maheswaran, S; Haber, D A
Background: Although liver cancer has the second-highest mortality rate among cancers internationally, accurate and scalable assays for the early detection and longitudinal monitoring of hepatocellular carcinoma are lacking. Circulating tumor cells are released from invasive cancers into the blood stream, but the difficulty inherent in isolating, identifying, and characterizing these ultra-rare cells has precluded their widespread implementation as a biomarker. By combining a high-throughput microfluidic negative depletion CTC isolation strategy with the absolute quantification of lineage-specific RNAs, we report the highly specific detection of hepatocellular carcinoma CTCs from patient blood draws. Methods: Blood draws from 48 hepatocellular carcinoma patients, 31 chronic liver disease patients, 25 healthy donors, and 44 patients with primary cancers other than hepatocellular carcinoma were processed through the microfluidic device (CTC-iChip). RNA was extracted, whole-transcriptome amplified, and quantified using droplet digital PCR. Transcript counts were used to fit a logistic regression model to integrate distinct transcript levels into a single CTC-score. The technical feasibility of utilizing RNA sequencing for identification of novel CTC transcripts of interest was also demonstrated with a liver cancer cell line spike-in study. Results: 9 of the 16 untreated HCC patients were successfully detected, while only 1/31 chronic liver disease patients were incorrectly classified. HCC patients undergoing treatment showed a significant decrease in their CTC-score; only 9/32 patients actively receiving treatment were positive. The CTC-score was not correlated with the HCC serum biomarker alpha-fetoprotein, and combining these two orthogonal measures led to estimated positive and negative predictive values of 80% and 86%, respectively, in a high-risk cohort. RNAseq analysis of cell line spike-in data revealed the potential of RNA sequencing for uncovering novel transcripts of interest. Conclusion: Coupling microfluidic depletion with droplet digital PCR allows for the highly specific detection of hepatocellular carcinoma. The CTC-score generated from these data tracks with clinical intervention and is orthogonal to the existing biomarker AFP; combining these two assays has the potential to provide superior detection compared to either individual approach
ISSN: 1538-7445
CID: 2751492

Autoimmune limbic encephalitis [Meeting Abstract]

Younan, M; Maheswaran, S; Chodosh, J
Limbic encephalitis presents as altered mood, memory loss and confusion. Clinical features may include psychiatric symptoms and seizures. In contrast to paraneoplastic disorders, non-paraneoplastic autoimmune encephalitis often responds to immunotherapy and sometimes with marked recovery. However, relapse can occur. An 82-year-old male presented with subacute episodes of memory loss over a few days. The patient was unable to recognize his own home and family members. Physical exam was unremarkable. Neuropsychological assessment revealed deficits in cognitive performance that could be consistent with moderate dementia or a more rapidly progressive encephalopathy. Agitated behavior and anxiety were also noted. Laboratory evaluation included hyponatremia, which was corrected with no symptom improvement. B12, TSH, and HIV were normal. CSF analysis revealed 10 WBCs/muL, Glucose-52 mg/dl, Protein-62 mg/dl and was negative for infectious, neoplastic causes, varicella, VDRL, viral cultures, NMDA receptor antibody, GAD 65 antibody and Anti-Hu antibody. Occult malignancy work up with CT scan of chest and abdomen and colonoscopy was normal. Serum for voltage-gated potassium channel antibodies was positive at 849 pmol/l (>88). EEG showed occasional focal left fronto-temporal slowing without epileptiform activity. MRI revealed focal enhancement of the medial left temporal lobe consistent with limbic encephalitis. The patient started high dose steroids with improvement in memory and complete resolution of focal abnormality within the left hippocampal/parahippocampal region suggestive of resolving encephalitis. At seven months after tapering steroids the patient presented with myoclonus and recurrent memory loss. MRI demonstrated recurrent encephalitis with gyral swelling and FLAIR hyperintensity in the left temporal lobe. The patient was restarted on high dose steroids with addition of Rituximab. This case illustrates that limbic encephalitis can present as a rapidly progressive dementia. Differential diagnosis should include more unusual forms of rapidly progressive dementia such as Jakob-Creutzfeldt disease if myoclonus is present, Lewy body dementia if waxing and waning memory, and Alzheimer's dementia with acute delirium if presenting over a period of months. In this patient, MRI changes were crucial to recognizing a potentially reversible limbic encephalitis. Early recognition and treatment may decrease relapse and reduce functional impairment
ISSN: 0002-8614
CID: 2564962

Decreasing Hypoglycemic Risk in Geriatric Practice: A Quality Improvement Project [Meeting Abstract]

Tall, SOuedraogo; Maheswaran, S; Chodosh, J
ISSN: 1532-5415
CID: 2118752

A Solution to Reduce Hospital Readmission? [Meeting Abstract]

Tall, SOuedraogo; Maheswaran, S; Shetty, S; Han, BH
ISSN: 1532-5415
CID: 2118762

An outpatient quality improvement program increased advance directive discussions that identified a health care proxy or surrogate decision maker [Meeting Abstract]

Singh, S; Quinn, C; Tomskey, R; Han, B; Maheswaran, S
ISSN: 1532-5415
CID: 1565782

A Quality Improvement Program Reduced Fall Rates among High Risk Veterans [Meeting Abstract]

Weinberger, Y.; Ferris, R.; Blaum, C. S.; Han, B.; Shetty, S.; Maheswaran, S.
ISSN: 0002-8614
CID: 953312

Impact of do-not-resuscitate legislation on the use of cardiopulmonary resuscitation in three teaching hospitals [published erratum appears in N Y State J Med 1992 Oct;92(10):450]

Ahronheim JC; Maheswaran S; Rosenberg C
Under New York State's unique do-not-resuscitate law, patients admitted to a hospital are assumed to consent to cardiopulmonary resuscitation unless a do-not-resuscitate order has been written in accordance with specific stipulations. This study was undertaken to determine if the law would significantly change the use of cardiopulmonary resuscitation. The charts of 952 patients who died on the medical services of Bellevue, New York University, and New York Veterans hospitals during the 12-month periods before and after the law went into effect were reviewed. The proportion of patients undergoing cardiopulmonary resuscitation was determined. To take into account the effects of potential confounders (ie, hospital, sex, race or ethnic group, age, diagnosis), a multiple logistic regression analysis was performed. The relative risk for cardiopulmonary resuscitation was found to be 0.81, (95% confidence interval: 0.59-1.10) after the law as compared with before, which was not statistically significant. Although patients with chronic or potentially reversible illness were much more likely than those with hopeless illness to undergo cardiopulmonary resuscitation (relative risk of 7.08 [3.23-15.54] and 12.89 [8.71-19.07], respectively), the data failed to show that the law had an impact on the use of cardiopulmonary resuscitation in any of the disease categories. Total use of formal do-not-resuscitate orders increased from 32.7% to 83.9% (p less than .0001), although at Bellevue, where documentation was high before the law, no further increase occurred.(ABSTRACT TRUNCATED AT 250 WORDS)
PMID: 1614667
ISSN: 0028-7628
CID: 13604