Publications

This cross-sectional study characterizes the prevalent use of medications that may raise BP and examine their associations with BP control and antihypertensive use.

This cross-sectional study uses time-series data to evaluate the administration of bamlanivimab-etesevimab and casirivimab-imdevimab monoclonal antibody treatments for SARS-CoV-2 infection after the US Food and Drug Administration deauthorized their use in early 2022.

BACKGROUND: The Trial of Nonpharmacologic Interventions in the Elderly (TONE) demonstrated the efficacy of weight loss and sodium reduction to reduce hypertension medication use in older adults. However, the longer-term effects of drug withdrawal (DW) on blood pressure (BP), adverse events, and orthostatic symptoms were not reported.

METHODS: TONE enrolled adults, ages 60-80 years, receiving treatment with a single antihypertensive and systolic BP (SBP)/diastolic BP <145/<85 mm Hg. Participants were randomized to weight loss, sodium reduction, both, or neither (usual care) and followed up to 36 months;  3 months postrandomization, the antihypertensive was withdrawn and only restored if needed for uncontrolled hypertension. BP and orthostatic symptoms (lightheadedness, feeling faint, imbalance) were assessed at randomization and throughout the study. Two physicians independently adjudicated adverse events, masked to intervention, classifying symptomatic (lightheadedness, dizziness, vertigo), or clinical events (fall, fracture, syncope).

RESULTS: Among the 975 participants (mean age 66 years, 48% women, 24% black), mean (±SD) BP was 128 ± 9/71 ± 7 mm Hg. Independent of assignment, DW increased SBP by 4.59 mm Hg (95% confidence interval [CI]: 3.89, 5.28) compared with baseline. There were 113 adverse events (84 symptomatic, 29 clinical), primarily during DW. Compared with usual care, combined weight loss and sodium reduction mitigated the effects of DW on BP (β = -4.33 mm Hg; 95% CI: -6.48, -2.17) and reduced orthostatic symptoms long term (odds ratio = 0.62; 95% CI: 0.41, 0.92), without affecting adverse events (hazard ratio = 1.81; 95% CI: 0.90, 3.65). In contrast, sodium reduction alone increased risk of adverse events (hazard ratio = 1.75; 95% CI: 1.04, 2.95), mainly during DW.

CONCLUSIONS: In older adults, antihypertensive DW may increase risk of symptomatic adverse events, highlighting the need for caution in withdrawing their antihypertensive medications.

CLINICAL TRIALS REGISTRATION: Trial Number NCT00000535.

Immune checkpoint inhibitors (ICIs) have advanced the field of cancer immunotherapy in patients by sustaining effector immune cell activity within the tumor microenvironment. However, the approach in general is still faced with issues related to ICI response duration/resistance, treatment eligibility, and safety, which indicates a need for further refinements. As immune checkpoint upregulation is inextricably linked to cancer-induced angiogenesis, newer clinical efforts have demonstrated the feasibility of disrupting both tumor-promoting networks to mediate enhanced immune-driven protection. This review focuses on such key evidence stipulating the necessity of co-applying ICI and anti-angiogenic strategies in cancer patients, with particular interest in highlighting newer engineered antibody approaches that may provide theoretically superior multi-pronged and safe therapeutic combinations.

IMPORTANCE: The dramatic rise in use of telehealth accelerated by COVID-19 created new telehealth-specific challenges as patients and clinicians adapted to technical aspects of video visits.

OBJECTIVE: To evaluate a telehealth patient navigator pilot program to assist patients in overcoming barriers to video visit access.

DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study investigated visit attendance outcomes among those who received navigator outreach (intervention group) compared with those who did not (comparator group) at 2 US academic primary care clinics during a 12-week study period from April to July 2021. Eligible participants had a scheduled video visit without previous successful telehealth visits.

INTERVENTIONS: The navigator contacted patients with next-day scheduled video appointments by phone to offer technical assistance and answer questions on accessing the appointment.

MAIN OUTCOMES AND MEASURES: The primary outcome was appointment attendance following the intervention. Return on investment (ROI) accounting for increased clinic adherence and costs of implementation was examined as a secondary outcome.

RESULTS: A total 4066 patients had video appointments scheduled (2553 [62.8%] women; median [IQR] age: intervention, 55 years [38-66 years] vs comparator, 52 years [36-66 years]; P = .02). Patients who received the navigator intervention had significantly increased odds of attending their appointments (odds ratio, 2.0; 95% CI, 1.6-2.6) when compared with the comparator group, with an absolute increase of 9% in appointment attendance for the navigator group (949 of 1035 patients [91.6%] vs 2511 of 3031 patients [82.8%]). The program's ROI was $11 387 over the 12-week period.

CONCLUSIONS AND RELEVANCE: In this quality improvement study, we found that a telehealth navigator program was associated with significant improvement in video visit adherence with a net financial gain. Our findings have relevance for efforts to reduce barriers to telehealth-based health care and increase equity.

BACKGROUND: In 2014, hypertension guidelines for older adults endorsed increased use of fixed-dose combinations, prioritized thiazide diuretics and calcium channel blockers (CCBs) for Black patients, and no longer recommend beta-blockers as first-line therapy.

OBJECTIVE: To evaluate older adults' antihypertensive use following guideline changes.

DESIGN: Time series analysis.

PATIENTS: Twenty percent national sample of Medicare Part D beneficiaries aged 66 years and older with hypertension.

INTERVENTION: Eighth Joint National Committee (JNC8) guidelines MAIN MEASURES: Quarterly trends in prevalent and initial antihypertensive use were examined before (2008 to 2013) and after (2014 to 2017) JNC8. Analyses were conducted among all beneficiaries with hypertension, beneficiaries without chronic conditions that might influence antihypertensive selection (hypertension-only cohort), and among Black patients, given race-based guideline recommendations.

KEY RESULTS: The number of beneficiaries with hypertension increased from 1,978,494 in 2008 to 2,809,680 in 2017, the proportions using antihypertensives increased from 80.3 to 81.2%, and the proportion using multiple classes and fixed-dose combinations declined (60.8 to 58.1% and 20.7 to 15.1%, respectively, all P<.01). Prior to JNC8, the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and CCBs was increasing. Use of CCBs as initial therapy increased more rapidly following JNC8 (relative change in quarterly trend 0.15% [95% CI, 0.13-0.18%), especially among Black beneficiaries (relative change 0.44% [95% CI, 0.21-0.68%]). Contrary to guidelines, the use of thiazides and combinations as initial therapy consistently decreased in the hypertension-only cohort (13.8 to 8.3% and 25.1 to 15.7% respectively). By 2017, 65.9% of Black patients in the hypertension-only cohort were initiated on recommended first-line or combination therapy compared to 80.3% of non-Black patients.

CONCLUSIONS: Many older adults, particularly Black patients, continue to be initiated on antihypertensive classes not recommended as first-line, indicating opportunities to improve the effectiveness and equity of hypertension care and potentially reduce antihypertensive regimen complexity.