STAT+: Top health officials highlight efforts to make medical records more portable

Zac Jiwa, a federal Medicare official, delivered a eulogy of sorts at a Thursday Medicare event highlighting the successes of the Health Tech Ecosystem initiative

The eulogy’s subject? The clipboard. 

For the past eight months, hundreds of health tech companies have been working to meet goals set out by the federal government to make patient records more portable, create systems that import patients’ data into providers’ electronic health records systems, and stand up various patient apps. The idea is to make filling out a stack of paperwork at every doctor’s visit, on that ubiquitous clipboard, a thing of the past.

Continue to STAT+ to read the full story…

A Text Messaging–Based Program to Transition From Basal Insulin to Glucagon-Like Peptide-1 Receptor Agonists in Safety-Net Diabetes Care: Pilot Quality Improvement Intervention Study

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and basal insulin both lower blood sugar, but while insulin puts people at risk of hypoglycemia and weight gain, GLP-1 RAs do not. In addition, GLP-1 RAs have added cardiometabolic and renal benefits. For these reasons, when possible, many primary care providers prefer their patients with type 2 diabetes to be from basal insulin to a GLP-1 RA. This transition process can be labor intensive, requiring multiple dosing adjustments and a watchful eye for hypoglycemia and hyperglycemia. The Mobile Insulin Titration Intervention (MITI)–GLP1 program uses SMS text messaging–based technology to support a streamlined and supervised transition process from basal insulin to a GLP-1 RA. This program takes place at a multilingual safety-net clinic. Objective: Our objectives were to assess program feasibility and acceptability to determine whether the intervention was doable, practical, and worthy of further investigation via a larger controlled trial. Preliminary clinical outcomes are also discussed in this paper. Methods: Patients were enrolled on a secure web platform that sent them a daily SMS text message asking the following: “What was your fasting blood sugar this morning?” Each weekday, texted responses containing patients’ fasting blood sugar levels were checked for alarm values, and once weekly, patients were called and advised on whether and how to lower their basal insulin and increase their GLP-1 RA dose. The program was co-run by general internal medicine physicians and nurses and continued until the patient had their insulin stopped completely and/or their GLP-1 RA dose reached the maximum, or 16 weeks elapsed. All enrolled patients were included in the analyses. Results: A total of 72 patients completed the pilot program. Feasibility and acceptability were high. Of 3671 SMS text messages sent by the program, 3520 (95.89%) received a response from patients. Of 719 cumulative weeks in which Thursday titration phone calls were attempted, successful connections with patients were made in 649 (90.26%) instances. Preliminary clinical outcomes were promising. Insulin doses were meaningfully reduced (55/72, 76.39% had their basal insulin reduced by at least 50%; 45/72, 62.5% had their insulin stopped completely). GLP-1 RA doses were meaningfully increased (64/72, 88.89% had their GLP-1 RA dose increased by ≥1 level; 45/72, 62.5% were discharged on the maximum dose of their GLP-1 RA). There was minimal hypoglycemia (5/3520, 0.14% of the SMS text messages reported a value of <80 mg/dL) and hyperglycemia (1/3520, 0.03% of the SMS text messages reported a value of >400 mg/dL). Conclusions: A general internal medicine–run MITI-GLP1 pilot program using SMS text messaging and interdisciplinary teamwork between internists and nurses is a feasible and acceptable intervention for safely and effectively transitioning people with well-controlled type 2 diabetes away from basal insulin and toward a GLP-1 RA.

BBB Access Route via Proteomic Vascular Mapping

A limiting feature of many neurological therapies is the ability of molecules to cross the blood-brain barrier (BBB) from the circulatory system. Since the BBB prevents simple diffusion of materials across the divide, identifying the proteins responsible for transport is necessary for effective design of BBB-crossing therapies.

“So basically, everything in the circulating blood, if they want to have an exchange with the organ, they need to pass through this interface,” says senior author Jiefu Li, PhD, Janelia Research Campus Group Leader at the Howard Hughes Medical Institute.

Identification of the structures within blood vessels involved with the processes of molecular movement across the BBB has been somewhat elusive. However, Li and his team have developed a technique that not only identifies proteins within the luminal surface—the inner lining—of the vasculature, but also works in vivo, allowing them to track how these features change across the aging brain.

“Understanding how the blood-brain barrier works, particularly figuring out the molecular targets that you can play with to open and close the barrier, will provide new possibilities for drug delivery,” Li says.

Their work is published in Science in a paper entitled, “Luminal surface proteome of the brain vasculature uncovers blood-brain barrier regulators.”

Using mice, the team developed a proteomic profiling method that can be used not only in brain vasculature, but throughout the body. “Briefly, a lectin-conjugated peroxidase is perfused and anchored to the luminal surface of blood vessels to catalyze the biotinylation of adjacent proteins, thereby enabling subsequent protein enrichment and mass spectrometry analysis,” wrote the authors.

They tested the method in the brain, kidney and intestine, in both mice and northern tree shrew, showing functionality and applicability across organs and species.

“This will allow us to say: we know that the vasculature system is doing different things in different organs and it relies on this luminal surface, but how does that happen? What are the molecular players there?” Li says.

Using quantitative proteomics of the luminal surface—from early development through adulthood and aging—they found that over time there was a decrease in angiogenic and transport proteins. They also found an increase in proteins that increased stiffness in the vasculature.

In addition to developing this in vivo technique, the team identified two proteins that are temporally distinct in their expression while both playing a role in modulating BBB permeability. Knockouts of nitric oxide synthase Nos3 and arginine transporter Slc7a1 resulted in BBB leakage in neonates, but not adults, while genetic screens identified hyaluronidase HYAL2 as being required for maintaining BBB integrity throughout the lifespan of mice.

“What we know now is that we have two new pathways, potentially, to open the blood-brain barrier and to inform some therapeutic developments,” says Li.

Utilization of this proteomic based method in vivo both opens up new avenues of functional research across the cardiovascular system, and also provides data and a methodology for novel therapeutic targets for crossing the BBB.

“This method solves an important need but it’s also a very easy-to-use method, so everyone can use it,” Li says.

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