Providence Health & Services

Novel treatments are needed for the primary and secondary prevention of heart failure in patients with type 2 diabetes, including individuals with and those without a history of heart failure. Conflicting trial evidence exists on whether glucagon-like peptide-1 receptor agonists (GLP-1RAs) reduce the risk of hospitalization for heart failure (HHF) in this broad population and whether this is a class effect or varies by specific agent. Furthermore, their comparative effectiveness against sodium-glucose cotransporter-2 inhibitors (SGLT-2is) is unknown. We emulated 2 target trials using population-based health care data from Stockholm, Sweden (2010-2021). Target trial 1 included adult patients with type 2 diabetes who newly initiated GLP-1RA versus dipeptidyl peptidase-4 inhibitors (DPP-4is), and target trial 2 compared GLP-1RA with SGLT-2i. The primary outcome was HHF. Cox regression was used to estimate intention-to-treat hazard ratios, with inverse probability of treatment weighting used to balance 72 confounders. Major adverse cardiovascular events were used as the positive control outcome. Analyses were conducted for the GLP-1RA class overall and for individual agents, including liraglutide and semaglutide. Target trial 1 included 32 979 patients (42% GLP-1RA and 58% DPP-4i) with a mean age of 64 years and 40% female; and target trial 2 included 30 104 patients (49% GLP-1RA and 51% SGLT-2i) with a mean age of 63 years and 38% female. Starting a GLP-1RA was associated with a lower 3-year absolute risk of HHF than starting a DPP-4i (3.4% versus 4.3%), corresponding to a weighted hazard ratio of 0.77 (95% CI, 0.66-0.91). Absolute 3-year risks for GLP-1RA compared with SGLT-2i on HHF were 3.6% and 3.3% with a weighted hazard ratio of 1.02 (95% CI, 0.85-1.18). The absolute risk difference was largest for patients with higher predicted risk of heart failure at baseline. Results were consistent for single agents, in per-protocol analyses, and in the majority of subgroups. In positive control outcome analyses, GLP-1RA use was associated with a lower rate of major adverse cardiovascular events than DPP-4i use (weighted hazard ratio, 0.85 [95% CI, 0.74-0.99]), consistent with trial findings. GLP-1RA use is associated with a lower risk of HHF compared with DPP-4i and similar risks compared with SGLT-2i in routine clinical care for patients with type 2 diabetes.

The Targeted Agent and Profiling Utilization Registry Study is a phase II basket trial evaluating the antitumor activity of targeted agents in patients with advanced cancer and genomic alterations. Results of four cohorts of patients with ATM-altered tumors treated with olaparib are reported: colorectal cancer (CRC), lung cancer (LC), pancreatic cancer (PC), and other solid tumors (histology-pooled, HP). Eligible patients had advanced solid tumors, measurable disease (RECIST), Eastern Cooperative Oncology Group performance status 0-2, adequate organ function, and no standard treatment options. The primary end point was disease control (DC), defined as objective response (OR) or stable disease (SD) of at least 16 weeks duration. For histology-specific cohorts, Simon's two-stage design was based on a null DC rate of 15% versus 35% (power = 0.85; α = .10). For the HP cohort, the hypothesized null DC rate of 15% was rejected if the lower limit of a one-sided 90% CI was >15%. Secondary end points were OR, progression-free survival, overall survival, duration of response or SD, and safety. Patients with CRC (n = 30), LC (n = 20), PC (n = 28), or other advanced cancers (n = 38) with ATM alterations were enrolled. The DC rates were 23% (one-sided 90% CI, 8 to 100; P = .38), 45% (one-sided 90% CI, 32 to 100; P = .0004), 28% (one-sided 90% CI, 14 to 100; P = .14), and 25% (one-sided 90% CI, 16 to 100), respectively. The null hypothesized 15% DC rate was rejected for the LC and HP cohorts but not the CRC and PC cohorts. Twenty of 116 patients (17%) experienced treatment-related grade 3 adverse events (AE) or serious AEs. Olaparib met the prespecified criteria to declare a signal of activity in patients with ATM-altered cancer within the LC and HP cohorts but not the CRC or PC cohorts.

The early and precise identification of neuro-cardiac conditions is one of the greatest clinical problems as the interactions between cardiovascular and the nervous systems are intricate. The paper introduces an AI-Enhanced Multimodal Framework, which combines electrocardiogram (ECG), electroencephalogram (EEG), and clinical textual information, to help to diagnose neuro-cardiac abnormalities in the early stages. The suggested system uses deep multimodal learning to derive discriminative representation of heterogeneous biomedical signals and textual metadata and then a fusion mechanism is used to infer inter-modal correlation with disease progression. High-level preprocessing and signal improvement algorithms are used to process noise and variability of bio signals, and contextual embeddings are generated based on clinical narratives by transformer-based language models. The experimental findings on benchmark data sets indicate that multimodal fusion model performs significantly better as compared to unimodal baselines in accuracy and sensitivity in identifying comorbid neuro-cardiac conditions. The framework offers the basis to smart, data-driven health care systems, which can produce diagnostic information in real time and in interpretable forms, which will potentially result in better patient outcomes because of proactive clinical decision support.

The e antigen is the highest prevalence antigen commonly encountered in the Rh blood system, while Dib has a prevalence of nearly 100% in most populations studied. The immune response to these antigens is clinically significant with respect to hemolysis (hemolytic disease of the fetus/newborn and hemolytic transfusion reactions). A 33-year-old G6P4 pregnant woman presented for an initial prenatal visit. Anti-e was detected at the time of delivery of her 5th baby. Initial blood bank testing for her 6th pregnancy revealed strong pan-reactivity that proved to be anti-e and anti-Dib. A combined antibody titer of 16 led to pregnancy monitoring using serial fetal middle cerebral artery Doppler sonography. All results were in the normal range, indicating a low risk for severe fetal anemia. The patient donated 3 units of blood for autologous and/or neonatal transfusion. She ultimately had a vaginal delivery at ~37 weeks gestational age with minimal blood loss. Her neonate had a normal hemoglobin/hematocrit at delivery and no clinical evidence of jaundice even though he had a strongly reactive DAT, typed positive for both e and Dib, and had both antibodies eluted from his red cells. On close follow-up, he developed mild jaundice but did not require treatment. Though this pregnant patient had 2 clinically significant antibodies to high prevalence blood group antigens, they did not affect the neonate adversely. This case demonstrates that close collaboration between obstetricians, neonatologists, and transfusion medicine specialists is essential for positive patient outcomes in cases like this.

Latinos/as comprise nearly 20% of the U.S. population; 25% report past-month binge drinking, and disparities in care persist. Culturally adapted interventions may improve outcomes and access. We tested the efficacy of a culturally adapted behavioral intervention to reduce unhealthy alcohol use, delivered in Spanish to Latino/a adults. We conducted a parallel, two-group, randomized controlled trial with 12- and 26-week follow-ups to test a three-session intervention delivered by community health workers (CHWs) from a community-based agency in Los Angeles, California. The intervention combined culturally adapted Motivational Enhancement Therapy and Strengths-Based Case Management (CA-MET/SBCM) and was compared to the Rethinking Drinking booklet. Participants were 236 non-treatment-seeking Latino/a adults who exceeded National Institute on Alcohol Abuse and Alcoholism low-risk drinking limits. The primary outcome was the percentage of heavy drinking days (≥5 drinks for men, ≥4 drinks for women) in the past 90 days at 26 weeks. Secondary outcomes were the average number of drinks per week and alcohol-related problems. The CA-MET/SBCM group had greater reductions in heavy drinking days and average drinks per week at Week 26 compared with the Rethinking Drinking group (-21.7 vs. -12.9 for percent heavy drinking days; -15.9 vs. -9.8 for average drinks per week). At Week 12, heavy drinking days were also significantly reduced in the CA-MET/SBCM group (-18.5 vs. -10.3). A culturally adapted behavioral intervention, combining MET and SBCM, delivered by Spanish-speaking CHWs significantly reduced unhealthy alcohol use among Latinos/as. These results are promising in addressing health disparities, although continued research is essential to further reduce unhealthy drinking and advance health equity for Latinos/as.

In today's health care landscape-marked by rapid advancement of medical technology, application of artificial intelligence, strains on workforce supply and demand, and significant changes in organizational structure-nursing professional development specialists find themselves at a pivotal intersection. They carry the responsibility of nurturing individual nursing competence and organizational resilience. To that end, they must meet formidable leadership challenges.

Iron deficiency is the most common cause of anemia in pregnancy. Iron requirements increase to meet the demands of maternal red cell expansion and fetal development. As part of a quality-improvement project, ferritin levels were obtained in all patients (N=1,858) presenting in the first trimester to identify iron deficiency. Anemia (hemoglobin less than 11 g/dL) was present in 75 patients (4.0%, 95% CI, 3.2–5.0) and iron deficiency (ferritin level less than 30 ng/mL) in 757 (40.7%, 95% CI, 38.5–43.0). Hemoglobin was 11 g/dL or higher in 707 (93.4%) patients with iron deficiency. Anemia was present in 25 of 1,101 (2.3%, 95% CI, 1.5–3.3) patients with normal ferritin levels. Additional research is required to determine whether earlier supplementation decreases the incidence of anemia later in pregnancy and improves outcomes.