Adding access blood flow surveillance reduces thrombosis and improves arteriovenous fistula patency: a randomized controlled trial

Purpose Stenosis is the main cause of arteriovenous fistula (AVF) failure. It is still unclear whether surveillance based on vascular access blood flow (QA) enhances AVF function and longevity. Methods We conducted a three-year follow-up randomized, controlled, multicenter, open-label trial to compare QA-based surveillance and pre-emptive repair of subclinical stenosis with standard monitoring/surveillance techniques in prevalent mature AVFs. AVFs were randomized to either the control group (surveillance based on classic alarm criteria; n = 104) or to the QA group (QA measured quarterly using Doppler ultrasound [ M-Turbo®] and ultrasound dilution [Transonic®] added to classic surveillance; n = 103). The criteria for intervention in the QA group were: 25% reduction in QA, QA<500 mL/min or significant stenosis with hemodynamic repercussion (peak systolic velocity [PSV] more than 400 cm/sc or PSV pre-stenosis/stenosis higher than 3). Results At the end of follow-up we observed a significant reduction in the thrombosis rate in the QA group (0.025 thrombosis/patient/year in the QA group vs. 0.086 thrombosis/patient/year in the control group [p = 0.007]). There was a significant improvement in the thrombosis-free patency rate (HR, 0.30; 95% CI, 0.11-0.82; p = 0.011) and in the secondary patency rate in the QA group (HR, 0.49; 95% CI, 0.26-0.93; p = 0.030), with no differences in the primary patency rate between the groups (HR, 0.98; 95% CI, 0.57-1.61; p = 0.935). There was greater need for a central venous catheter and more hospitalizations associated with vascular access in the control group (p = 0.034/p = 0.029). Total vascular access-related costs were higher in the control group (€227.194 vs. €133.807; p = 0.029). Conclusions QA-based surveillance combining Doppler ultrasound and ultrasound dilution reduces the frequency of thrombosis, is cost effective, and improves thrombosis free and secondary patency in autologous AVF.

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Hemodynamic impact of VASQ device in vascular access creation

The Journal of Vascular Access ◽

10.1177/1129729820983153 ◽

2020 ◽

pp. 112972982098315

Author(s):

Roberto Palumbo ◽

Sara Dominijanni ◽

Alessia Centi ◽

Gabriele D’Urso ◽

Paola Tatangelo ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Vascular Access ◽

Complication Rate ◽

Neointimal Hyperplasia ◽

Arterial Flow ◽

Control Group ◽

Secondary Patency ◽

Arteriovenous Fistulae ◽

The Mean ◽

The Impact

Background: Native arteriovenous fistula is the preferred vascular access in term of functionality, efficiency and complication rate. Nevertheless, research continues to seek strategies to reduce the risk of neointimal hyperplasia and hemodynamic modification. The aim of the study was to evaluate the impact on hemodynamic of the VasQ device in arteriovenous fistulae creation. Methods: The analysis included patients who underwent to fistula creation with or without implantation of the VasQ device between May and September 2019. The hemodynamic parameters were evaluated pre-operatively and at a follow-up of 1, 3, 6 months. The patency and complication rate were evaluated. Results: Fifteen VasQ devices were implanted during 30 arteriovenous fistula surgery. The baseline patients features were similar between groups (VasQ treated/control). At baseline, preoperative arterial flow was similar; radial artery diameter at surgical site was 3.4 ± 0.8 mm in treated and 2.8 ± 0.5 mm in the control group. The mean arterial flow at 1 month was 480 ± 210 mL/min in treated and 561 ± 27 mL/min in the control group. At 3 months the mean arterial flow in treated was 645 ± 143 mL/min versus 824 ± 211 mL/min ( p = 0.02) in the control group; at 6 months the arterial flow was 714 ± 146 mL/min versus 810 ± 194 mL/min ( p = 0.05) in control group. The cardiac output flow at 6 months in the treated group was 4458 ± 928 mL/min versus 5599 ± 1355 mL/min ( p = 0.05) in the control group. At 6 months the primary patency was 73% and 80% and the secondary patency 80% and 86% in treated compared to the control group, respectively. No VASQ device complications were recorded. Conclusion: The analysis of these data suggested that using VasQ device could be protective against the hemodynamic modification that occur during arteriovenous fistulae creation.

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Evaluation of portal pressure by doppler ultrasound in patients with cirrhosis before and after simvastatin administration – a randomized controlled trial

F1000Research ◽

10.12688/f1000research.13915.1 ◽

2018 ◽

Vol 7 ◽

pp. 256 ◽

Cited By ~ 1

Author(s):

Nadia Elwan ◽

Raafat Salah ◽

Manal Hamisa ◽

Ebtsam Shady ◽

Nehad Hawash ◽

...

Keyword(s):

Blood Flow ◽

Portal Hypertension ◽

Portal Vein ◽

Hepatic Artery ◽

Doppler Ultrasound ◽

Resistance Index ◽

Control Group ◽

Randomized Controlled ◽

Group I ◽

Before And After

Background: Portal hypertension is one of the most frequent complications of cirrhosis. β-adrenergic blockers, with or without organic nitrates, are currently used as hypotensive agents. Statins such as simvastatin seem to be safe for patients with chronic liver diseases and exert multiple pleiotropic actions. This study aimed to assess PTH using Doppler ultrasound in patients with cirrhosis before and after simvastatin administration. Methods: This randomized controlled clinical trial was conducted on 40 patients with cirrhosis who were randomized into 2 groups: group I included 20 patients with cirrhosis who were administered 20 mg of simvastatin daily for 2 weeks and then 40 mg daily for another 2 weeks, and group II included 20 patients with cirrhosis who did not receive simvastatin as a control group. All patients underwent full clinical examination, laboratory investigations, and abdominal Doppler ultrasound at baseline and after 30 days to evaluate portal vein diameter, blood flow volume, direction and velocity of portal vein blood flow, hepatic artery resistance and pulsatility indices, splenic artery resistance index, portal hypertension index (PHI), liver vascular index, and modified liver vascular index (MLVI). Results: There was a highly significant decrease in the hepatic artery resistance index in group I, from 0.785 ± 0.088 to 0.717 ± 0.086 (P < 0.001). There was a significant decrease in the PHI in group I , from 3.915 ± 0.973 m/sec to 3.605 ± 1.168 m/sec (P = 0.024). Additionally, there was a significant increase in the MLVI in group I from 11.540 ± 3.266 cm/sec to 13.305 ± 3.222 cm/sec, an increase of 15.3% from baseline (P = 0.009). No significant adverse effects were detected. Conclusions: Simvastatin is safe and effective in lowering portal hypertension. [ClinicalTrials.gov Identifier: NCT02994485]

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Comprehensive Comparison of the Performance of Autogenous Brachial-Basilic Transposition Arteriovenous Fistula and Prosthetic Forearm Loop Arteriovenous Graft in a Multiethnic Asian Hemodialysis Population

BioMed Research International ◽

10.1155/2016/8693278 ◽

2016 ◽

Vol 2016 ◽

pp. 1-7 ◽

Cited By ~ 7

Author(s):

Koy Min Chue ◽

Kyi Zin Thant ◽

Hai Dong Luo ◽

Yu Hang Rodney Soh ◽

Pei Ho

Keyword(s):

Arteriovenous Fistula ◽

Vascular Access ◽

Secondary Patency ◽

Arteriovenous Graft ◽

Central Venous ◽

Maturation Time ◽

Limited Life Expectancy ◽

Limited Life ◽

Comprehensive Comparison

Aim.For patients who have exhausted cephalic vein arteriovenous fistula (AVF) options, controversy exists on whether brachial-basilic AVF with transposition (BBTAVF) or a forearm arteriovenous graft (AVG) should be the next vascular access of choice. This study compared the outcomes of these two modalities.Methods.A retrospective study of 122 Asian multiethnic patients who underwent either a BBTAVF (81) or an AVG (41). Maturation time and intervention rates were analyzed. Functional primary, secondary, and overall patency rates were evaluated.Results.The maturation time for BBTAVFs was significantly longer than AVGs. There was also a longer deliberation time before surgeons abandon a failing BBTAVF compared to an AVG. Both functional primary and secondary patency rates were significantly higher in the BBTAVF group at 1-year follow-up: 73.2% versus 34.1% (p<0.001) and 71.8% versus 54.3% (p=0.022), respectively. AVGs also required more interventions to maintain patency. When maturation rates were considered, the overall patency of AVGs was initially superior in the first 25 weeks after creation and then became inferior afterwards.Conclusion.BBTAVFs had superior primary and functional patency and required less salvage interventions. The forearm AVG might have a role in patients who require early vascular access due to complications from central venous catheters or with limited life expectancy.

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P1337ENDOVASCULAR REVISION OF ARTERIOVENOUS ANASTOMOSIS BY DOUBLE GUIDE TECHNIQUE

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1337 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Nicola Pirozzi ◽

Jacopo Scrivano ◽

Loredana Fazzari ◽

Roberto Pirozzi

Keyword(s):

Blood Flow ◽

Endovascular Treatment ◽

Arteriovenous Fistula ◽

De Novo ◽

Guide Wire ◽

Target Lesion ◽

Anastomotic Stenosis ◽

Secondary Patency ◽

Arteriovenous Anastomosis

Abstract Background and Aims Juxta-anastomotic stenosis is the most frequent complication of arteriovenous fistula (AVF) for haemodialysis (HD). Treatment options are surgical bypass by creating a more proximal anastomosis or endovascular treatment by angioplasty. The available literature data show equal outcomes in term of secondary patency, but a significantly higher rate of recurrent stenosis for endovascular treatment (0.5 procedure/AVF/year). We describe the results of endovascular treatment by “double guide technique” (DGT) as to Turmel Rodrigues original description, in a series of patients referred to our centre. Method We describe all consecutive patients treated by DGT in the first semester of 2018 because of a de novo occurring juxta-anastomotic stenosis of the arteriovenous fistula for haemodialysis. The procedure was carried out as described by Turmell Rodrigues. In short: by means of a single retrograde access through the outflow vein by a 6 french valved introducer, two guide wire are navigated into both proximal and distal artery. Two consecutive dilatation of the anastomosis area are then performed including first the juxta-anastomotic vein at 6 to 7 mm (mean 6.7mm, ds 0.55), followed by the juxta-anastomotic artery at 4mm (mean 4.1mm, ds 0.33), as show in figures. Follow up was carried out at 1, 3, 6 12 month by clinical examination and ultrasound examination. Prospectively collected data was analyzed retrospectively. Results 25 patients were treated during the first 6 month of 2018 by a single operator. Patients data (mean): age 71years, HD vintage 31month, AVF vintage 31month. AVF distribution were: distal radio-cephalic 32%, proximal radio-cephalic 52%, distal ulnar-basilic 8%, humero-basilic 8%. Mean preoperative AVF blood flow - as measured by duplex ultrasound (US) - was 540ml/min. 32% of AVF have preoperative blood flow >600ml/min but a critical stenosis (<1.9mm of diameter). Mean juxta-anastomotic vein and juxta-anastomotic artery ballon diameter were 6.7mm (ds 0.55) and 4.1mm (ds 0.33) respectively. Overall mean blood flow at 12 month was 830ml/min. During follow up 3 patients required endovascular treatment of some new occurring stenosis, 3 patients were lost to follow up at 12 month, 1 patient died from unrelated reasons. In 52% of patients any other revision was required, while 32% required 1 further angioplasty, 4% 2 further angioplasty and 4% 4 further angioplasty of the target lesion during the following 12 month (recurrence rate: 0.28 procedure/patients/year). Assisted functional patency at 12month was 95%. Conclusion Endovascular treatment of juxta-anastomotic AVF stenosis by the DGT performed quite satisfactorily in our series and showed a low recurrence on the target lesion compared to data from literature. At 12 month the average AVF blood flow was below 1000ml/min. The technical advantage of the DGT consist in the single, small caliber percutaneous access, needed to complete the procedure. A larger series would confirm how this refinement of the technique compares with the improved results we preliminary observed.

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Effectiveness of Text Messaging as an Incentive to Maintain Physical Activity after Cardiac Rehabilitation: A Randomized Controlled Pilot Study

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18126645 ◽

2021 ◽

Vol 18 (12) ◽

pp. 6645

Author(s):

Giulia Foccardi ◽

Marco Vecchiato ◽

Daniel Neunhaeuserer ◽

Michele Mezzaro ◽

Giulia Quinto ◽

...

Keyword(s):

Physical Activity ◽

Cardiac Rehabilitation ◽

Exercise Testing ◽

Text Messages ◽

Control Group ◽

Stand Test ◽

Randomized Controlled ◽

Sit To Stand ◽

Significant Difference

Although the efficacy of cardiac rehabilitation (CR) is proven, the need to improve patients’ adherence has emerged. There are only a few studies that have investigated the effect of sending text messages after a CR period to stimulate subjects’ ongoing engagement in regular physical activity (PA). A randomized controlled pilot trial was conducted after CR, sending a daily PA text message reminder to an intervention group (IG), which was compared with a usual care control group (CG) during three months of follow-up. Thirty-two subjects were assessed pre- and post-study intervention with GPAQ, submaximal iso-watt exercise testing, a 30 s sit-to-stand test, a bilateral arm curl test, and a final survey on a seven-point Likert scale. A statistically significant difference in the increase of moderate PA time (Δ 244.7 (95% CI 189.1, 300.4) minutes, p < 0.001) and in the reduction of sedentary behavior time (Δ −77.5 (95% CI 104.9, −50.1) minutes, p = 0.004) was shown when the IG was compared with the CG. This was associated with an improvement in heart rate, blood pressure, and patients’ Borg rating on the category ratio scale 10 (CR10) in iso-watt exercise testing (all p < 0.05). Furthermore, only the IG did not show a worsening of the strength parameters in the follow-up leading to a change of the 30 s sit-to-stand test with a difference of +2.2 (95% CI 1.23, 3.17) repetitions compared to CG (p = 0.03). The telemedical intervention has been appreciated by the IG, whose willingness to continue with regular PA emerged to be superior compared to the CG. Text messages are an effective and inexpensive adjuvant after phase 2 CR that improves adherence to regular PA. Further studies are needed to confirm these results in a larger patient population and in the long term.

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Effectiveness of Abdominal and Gluteus Medius Training in Lumbo-Pelvic Stability and Adductor Strength in Female Soccer Players. A Randomized Controlled Study

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18041528 ◽

2021 ◽

Vol 18 (4) ◽

pp. 1528

Author(s):

Héctor Guerrero-Tapia ◽

Rodrigo Martín-Baeza ◽

Rubén Cuesta-Barriuso

Keyword(s):

Repeated Measures ◽

Gluteus Medius ◽

Soccer Players ◽

Controlled Study ◽

Control Group ◽

Extrinsic Factors ◽

Randomized Controlled ◽

Limb Injuries ◽

Experimental Group

Background. Abdominal and lumbo-pelvic stability alterations may be the origin of lower limb injuries, such as adductor pathology in soccer players. Imbalance can be caused by both intrinsic and extrinsic factors. Methods: In this randomized controlled trial over 8 weeks, 25 female footballers were randomly allocated to an experimental group (isometric abdominal training and gluteus medius-specific training) or a control group (isometric abdominal training). Evaluations were performed at baseline, at the end of the intervention and after a 4-week follow-up period. The exercise protocol in common for both groups included three exercises: Plank, Lateral plank and Bird dog. Specific exercises for the gluteus medius were: Pelvic drop and Stabilization of the gluteus medius in knee valgus. Outcome measures were lumbar-pelvic stability and adductor strength. Results: After the intervention, there was an increase in lumbo-pelvic stability in both groups, being greater in the control group than in the experimental group (mean differences [MD]: 4.84 vs. MD: 9.58; p < 0.01) with differences in the analysis of repeated measures (p < 0.001), but not in group interaction (p = 0.26). Changes were found in adductor strength in the experimental group (MD: −2.48; p < 0.001 in the left adductor; MD: −1.48; p < 0.01 in right adductor) and control group (MD: −1.68; p < 0.001 in the left adductor; MD: −2.05; p < 0.001 in the right adductor) after the intervention, with differences in the analysis of repeated measures in left (p < 0.001) and right (p < 0.001) adductor strength. Conclusions: An abdominal and gluteal training protocol shows no advantage over a protocol of abdominal training alone for lumbo-pelvic stability and adductor strength, while improvements in both variables are maintained at four weeks follow-up.

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Efficacy of Mobile phone use on adherence to Nevirapine prophylaxis and retention in care among the HIV-exposed infants in prevention of mother to child transmission of HIV: a randomized controlled trial

BMC Pediatrics ◽

10.1186/s12887-021-02660-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Lilian M. N. Kebaya ◽

Dalton Wamalwa ◽

Nyambura Kariuki ◽

Bashir Admani ◽

Philip Ayieko ◽

...

Keyword(s):

Mobile Phone ◽

Infant Feeding ◽

Retention In Care ◽

Control Group ◽

Hiv Exposed Infants ◽

Randomized Controlled ◽

Phone Calls ◽

Hiv Exposed ◽

To Receive

Abstract Background HIV is a major contributor to infant mortality. A significant gap remains between the uptake of infant and maternal antiretroviral regimens and only a minority of HIV-exposed infants receives prophylaxis and safe infant feeding. Losses to follow-up of HIV-exposed infants are associated with shortcomings of facility-based PMTCT models with weak community support of linkages. Use of mobile phones offers an opportunity for improving care and promoting retention assessed by timely attendance of scheduled appointments for the mother-baby pairs and achievement of an HIV-free generation. The objective of this study was to compare self-reported adherence to infant Nevirapine (NVP) prophylaxis and retention in care assessed by timely attendance of scheduled appointments over 10 weeks in HIV exposed infants randomized to 2-weekly mobile phone calls (intervention) versus no phone calls (control). Methods In this open label randomized controlled study, one hundred and fifty HIV infected women drawn from 3 health facilities in Western Kenya and their infants were randomly assigned to receive either phone-based reminders on PMTCT messages or standard health care messages (no calls) within 24 h of delivery. Women in the intervention arm continued to receive fortnightly phone calls. At 6- and 10-weeks following randomization we collected data on infant adherence to Nevirapine, mode of infant feeding, early HIV testing and retention in care in both study arms. All analyses were intention to treat. Results At 6 weeks follow-up, 90.7% (n = 68) of participants receiving phone calls reported adherence to infant NVP prophylaxis, compared with 72% (n = 54) of participants in the control group (p = 0.005). Participants in the intervention arm were also significantly more likely to remain in care than participants in the control group [78.7% (n = 59) vs. 58.7% (n = 44), p = 0.009 at 6 weeks and 69.3% (n = 52) vs. 37.3% (n = 28), p < 0.001 at 10 weeks]. Conclusions These results suggest that phone calls are potentially an important tool to improve adherence to infant NVP prophylaxis and retention in care for HIV-exposed infants. Trial registration PACTR202007654729602. Registered 6 June 2018 - Retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=3449

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Short-term balance training and acute effects on postural sway in balance-deficient older adults: a randomized controlled trial

BMC Sports Science Medicine and Rehabilitation ◽

10.1186/s13102-021-00251-x ◽

2021 ◽

Vol 13 (1) ◽

Author(s):

Niklas Sörlén ◽

Andreas Hult ◽

Peter Nordström ◽

Anna Nordström ◽

Jonas Johansson

Keyword(s):

Older Adults ◽

Postural Sway ◽

Intervention Group ◽

Community Dwelling ◽

Control Group ◽

Positive Effects ◽

Randomized Controlled ◽

Eyes Closed ◽

Balance Exercise

Abstract Background We aimed to determine the effectiveness of 4 weeks of balance exercise compared with no intervention on objectively measured postural sway. Methods This was a single-center parallel randomized controlled, open label, trial. A six-sided dice was used for allocation at a 1:1-ratio between exercise and control. The trial was performed at a university hospital clinic in Sweden and recruited community-dwelling older adults with documented postural instability. The intervention consisted of progressively challenging balance exercise three times per week, during 4 weeks, with follow-up at week five. Main outcome measures were objective postural sway length during eyes open and eyes closed conditions. Results Sixty-five participants aged 70 years (balance exercise n = 32; no intervention n = 33) were randomized. 14 participants were excluded from analysis because of early dropout before follow-up at week five, leaving 51 (n = 22; n = 29) participants for analysis. No significant differences were detected between the groups in any of the postural sway outcomes. Within-group analyses showed significant improvements in hand grip strength for the intervention group, while Timed Up & Go improvements were comparable between groups but only statistically significant in the control group. Conclusions Performing balance exercise over a four-week intervention period did not acutely improve postural sway in balance-deficient older adults. The lower limit in duration and frequency to achieve positive effects remains unclear. Trial registration Clinical trials NCT03227666, July 24, 2017, retrospectively registered.

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Effects of Aerobic, Resistance, or Combined Exercise Training Among Older Adults with Subjective Memory Complaints: A Randomized Controlled Trial

Journal of Alzheimer s Disease ◽

10.3233/jad-210047 ◽

2021 ◽

pp. 1-17

Author(s):

Taeko Makino ◽

Hiroyuki Umegaki ◽

Masahiko Ando ◽

Xian Wu Cheng ◽

Koji Ishida ◽

...

Keyword(s):

Older Adults ◽

Exercise Training ◽

Controlled Trial ◽

Community Dwelling ◽

Control Group ◽

Subjective Memory ◽

Logical Memory ◽

Randomized Controlled ◽

Community Dwelling Older Adults

Background: Physical exercise is suggested to be effective for preventing cognitive decline in older adults, but the relative efficacy of different types of exercise have yet to be clarified. Objective: This single-blinded randomized controlled trial was designed to investigate the differential effects of aerobic exercise training (AT), resistance exercise training (RT), and combined exercise training (CT) on cognition in older adults with subjective memory complaints (SMC). Methods: Community-dwelling older adults with SMC (n = 415; mean age = 72.3 years old) were randomly assigned to one of the four groups: AT, RT, CT, or control group. The study consisted of two phases: a 26-week intervention and a 26-week follow-up. The participants were evaluated at baseline, 26 weeks (postintervention), and 52 weeks (follow-up). The primary outcome of this study was memory function, which was assessed using the Logical Memory II subtest of the Wechsler Memory Scale-Revised (WMS-R) score. The secondary outcomes included global cognitive function, verbal fluency, working memory, processing speed, and executive functions. Results: Intention-to-treat analysis by a mixed-effect model repeated measure showed that the AT group had significantly improved performance on the WMS-R Logical Memory II test (2.74 [1.82–3.66] points) than the control group (1.36 [0.44–2.28] points) at the postintervention assessment (p = 0.037). The effect was more pronounced in those without amnesia than those with amnesia. No significant improvement was observed in the RT and CT groups. Conclusion: This study suggests that AT intervention can improve delayed memory in community-dwelling older adults, particularly in individuals without objective memory decline.

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Effect of physician prescribed information on hospital readmission and death after discharge among patients with health failure: A randomized controlled trial

Health Informatics Journal ◽

10.1177/1460458221996409 ◽

2021 ◽

Vol 27 (1) ◽

pp. 146045822199640

Author(s):

Faranak Kazemi Majd ◽

Vahideh Zarea Gavgani ◽

Ali Golmohammadi ◽

Ali Jafari-Khounigh

Keyword(s):

Randomized Controlled Trial ◽

Hospital Readmission ◽

Medical Information ◽

Controlled Trial ◽

Intervention Group ◽

Control Group ◽

Randomized Controlled ◽

Long Term Follow Up ◽

Oral Information

In order to understand if a physician prescribed medical information changes, the number of hospital readmission, and death among the heart failure patients. A 12-month randomized controlled trial was conducted (December 2013–2014). Totally, 120 patients were randomly allocated into two groups of intervention ( n = 60) and control ( n = 60). Accordingly, the control group was given the routine oral information by the nurse or physician, and the intervention group received the Information Prescription (IP) prescribed by the physician as well as the routine oral information. The data was collected via telephone interviews with the follow-up intervals of 6 and 12 months, and also for 1 year after the discharge. The patients with the median age of (IQR) 69.5 years old (19.8) death upon adjusting a Cox survival model, [RR = 0.67, 95%CI: 0.46–0.97]. Few patients died during 1 year in the intervention group compared to the controls (7 vs 15) [RR = 0.47, 95%CI: 0.20–1.06]. During a period of 6-month follow-up there was not statistically significant on death and readmission between two groups. Physician prescribed information was clinically and statistically effective on the reduction of death and hospital readmission rates among the HF patients in long term follow-up.

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