Implementing a remote self-screening programme for atrial fibrillation using digital health technology among community-dwellers aged 75 years and older: a qualitative evaluation.

OBJECTIVE: To examine the feasibility of implementing remote atrial fibrillation (AF) self-screening among older people supported by a remote central monitoring system. DESIGN: Process evaluation of the Mass AF randomised clinical trial (ACTRN12621000184875) with one-to-one semistructured interviews using interview guides underpinned by the Critical Realism approach and coded using the UK Medical Research Council Guidance of Process Evaluation Framework. SETTING AND PARTICIPANTS: Community-dwelling people aged ≥75 years from both genders (ratio 1:1) and urban/rural (ratio 2:1) in Australia. INTERVENTIONS: Participants were provided handheld single-lead electrocardiogram (ECG) devices and trained to self-record ECGs once daily on weekdays for at least 6 months. A remote central team notified participants and general practitioners (GPs) of AF. PRIMARY FEASIBILITY OUTCOMES: The strengths, weaknesses, opportunities and threats (SWOT) analysis examined enablers (ie, strengths and opportunities) and barriers (ie, weaknesses and threats). RESULTS: Overall, 200 participants; 98.5% completed the 6-month programme, 96% reported being satisfied with screening and 48 were interviewed: mean age 79 years, 54% male and 71% urban. 11 GPs were interviewed: 55% female and 64% urban. Programme participants trusted the remote monitoring system that supported the screening programme and provided follow-up pathways where required. GPs saw opportunities to introduce this self-screening programme to at-risk patients and improve patients' risk profiles. Programme participants reported that after being trained to use the device, they felt empowered to do self-screening and found it convenient. GPs saw empowerment could enhance the doctor-patient relationship. Participants and GPs valued screening in diagnosing AF that would otherwise be missed in usual care, but the uncertainty of effective screening duration could be a barrier. CONCLUSIONS: This screening programme was feasible with the reinforcement of the underpinning enablers. Several implementation strategies were identified using SWOT analysis, including leveraging the opportunity for GPs to introduce this screening programme to at-risk patients. TRIAL REGISTRATION NUMBER: ACTRN12621000184875.

A randomised controlled implementation study integrating patient self-screening with a remote central monitoring system to screen community-dwellers aged 75 years and older for atrial fibrillation.

AIMS: Diagnosis of atrial fibrillation (AF) provides opportunities to reduce stroke risk. This study aimed to compare AF diagnosis rates, participant satisfaction and feasibility of an electrocardiogram (ECG) self-screening virtual care system with usual care. METHODS: This randomised controlled implementation study involving community-dwelling people aged ≥75 years was conducted from May 2021 to June 2023. Participants were given a handheld single-lead ECG device and trained to self-record ECGs once daily on weekdays for 12 months. The control group received usual care with their general practitioners in the first 6 months and participated in the subsequent 6 months. AF diagnosis and participant satisfaction were assessed at 6 months. RESULTS: 200 participants (mean age 79.0±3.4 years; 54.0% female; 72.5% urban). AF was diagnosed in 10/97 (10.3%) intervention participants and 2/100 (2.0%) in the control group (Odds Ratio 5.6, 95% CI 1.4-37.3, p=0.03). In the intervention, 80% of AF cases were diagnosed within 3 months. 91/93 (97.9%) intervention participants and 55/93 (59.1%) control-waitlisted participants (p<0.001) were satisfied with AF screening. Of the expected 20 days per month, the overall monthly median number of days participants self-recorded ECGs was 20 (interquartile range 17-22). Participants were confident using the device (93%), reported it was easy to use (98%) and found screening efficient (96%). CONCLUSIONS: Patient-led AF self-screening using single-lead ECG devices with a remote central monitoring system was feasible, acceptable, and effective in diagnosing AF among older people. This screening model could be adapted for implementation, interfacing with integrated care models within existing health systems.

Our screening model involves virtual enrolment and training participants aged ≥75 years to use handheld single-lead ECG devices. With a remote central support system, older people are empowered to use handheld devices to self-screen atrial fibrillation (AF) at home or elsewhere in the community. This innovative screening model was feasible and acceptable, with high adherence to self-screening among older participants (mean age of 79 years). It yielded a 5-fold higher rate of AF diagnosis at 6 months compared to standard usual care and needed 12 participants screened to find one additional AF. This screening model can be implemented, interfacing with (i.e., communicating, connecting and supporting) the existing healthcare systems. If implemented at scale, it could provide better access and quality of AF screening and care to remote and high-risk populations.

Yolk sac tumours of the orbit and sinonasal tract.

PURPOSE: The aim of this study is to report two cases of paediatric Yolk sac tumours (YST) of the orbit and sinonasal tract, with a major review on the subject. METHODS: Two case reports along with a comprehensive retrospective literature review of all English language publications between 1974 and 2021 is presented. Literature review examined the demographics, clinical presentation and diagnostic and prognostic factors of extragonadal YSTs of the orbit and sinonasal tract. RESULTS: Orbit and sinuses are rare sites for YST, with only 25 paediatric cases reported in the literature. Extragonadal yolk sac tumours carry a significantly worse outcome than those localised to the gonads, with the 5-year survival of 66% and 81-89%, respectively. Our review found the median age of presentation to be 18 months (18 months for males and 24 months for females), and females are more commonly affected. The most common presentations were proptosis, facial swelling and ophthalmoplegia. Treatments and therefore outcomes varied in the cases due to the large time period. Of the cases reported in the last 10 years, all patients with data provided were alive and disease-free at follow-up. CONCLUSION: Sino-orbital yolk sac tumours are rare and have variable presentations, dependent on the extent of local invasion. Early diagnosis and treatment with multimodal therapy are paramount in having improved overall survival.

The Relationship between Metabolic Syndrome and Frailty in Older People: A Systematic Review and Meta-Analysis.

AIMS: Both metabolic syndrome (MetS) and frailty are associated with increased all-cause mortality, yet the complex interplay between these two conditions has not adequately been elucidated. We aim to analyse the relationship between MetS and frailty through a systematic review of the literature with meta-analyses. METHODS: A literature search was conducted via MEDLINE and EMBASE. Studies were included if validated frameworks for defining frailty and MetS (presence of at least 3 out of the five constitutive components: abdominal obesity, high fasting blood glucose, hypertension, hypertriglyceridaemia, and low high-density lipoprotein level) were utilised, in addition to the inclusion of participants aged 60 or older. RESULTS: Eleven studies were included, all observational. All were in community-dwelling older people, 9 cross-sectional and 2 longitudinal. Most of the studies used Fried's frailty phenotype. The prevalence of frailty ranged from 0.9% to 14.8% in population-based studies and 35.6% in the outpatient clinic setting. The prevalence of MetS was also higher in the outpatient clinic setting at 47.5%, compared to 17.5-41.0% in the community-dwelling populations. The meta-analysis of 11 studies showed that MetS was associated with an increased risk of frailty (pooled OR 1.73, 95% CI, 1.41-2.13). CONCLUSION: This systematic review and meta-analysis suggest that frailty was more prevalent in older people with MetS compared to older people without MetS. The study findings suggest the importance of frailty screening in older people with MetS and a distinct role of managing MetS in preventing frailty in older people.

Patient-Led Mass Screening for Atrial Fibrillation in the Older Population Using Handheld Electrocardiographic Devices Integrated With a Clinician-Coordinated Remote Central Monitoring System: Protocol for a Randomized Controlled Trial and Process Evaluation.

BACKGROUND: Atrial fibrillation (AF) is common in older people and increases the risk of stroke. The feasibility and effectiveness of the implementation of a patient-led AF screening program for older people are unknown. OBJECTIVE: This study aims to examine the feasibility and effectiveness of an AF screening program comprising patient-led monitoring of single-lead electrocardiograms (ECGs) with clinician-coordinated central monitoring to diagnose AF among community-dwelling people aged ≥75 years in Australia. METHODS: This is a nationwide randomized controlled implementation trial conducted via the internet and remotely among 200 community-dwelling adults aged ≥75 years with no known AF. Randomization will be performed in a 1:1 allocation ratio for the intervention versus control. Intervention group participants will be enrolled in the monitoring program at randomization. They will receive a handheld single-lead ECG device and training on the self-recording of ECGs on weekdays and submit their ECGs via their smartphones. The control group participants will receive usual care from their general practitioners for the initial 6 months and then commence the 6-month monitoring program. The ECGs will be reviewed centrally by trained personnel. Participants and their general practitioners will be notified of AF and other clinically significant ECG abnormalities. RESULTS: This study will establish the feasibility and effectiveness of implementing the intervention in this patient population. The primary clinical outcome is the AF detection rate, and the primary feasibility outcome is the patient satisfaction score. Other outcomes include appropriate use of anticoagulant therapy, participant recruitment rate, program engagement (eg, frequency of ECG transmission), agreement in ECG interpretation between the device automatic algorithm and clinicians, the proportion of participants who complete the trial and number of dropouts, and the impact of frailty on feasibility and outcomes. We will conduct a qualitative evaluation to examine the barriers to and acceptability and enablers of implementation. Ethics approval was obtained from the human research ethics committee at the University of Sydney (project number 2020/680). The results will be disseminated via conventional scientific forums, including peer-reviewed publications and presentations at national and international conferences. CONCLUSIONS: By incorporating an integrated health care approach involving patient empowerment, centralized clinician-coordinated ECG monitoring, and facilitation of primary care and specialist services, it is possible to diagnose and treat AF early to reduce stroke risk. This study will provide new information on how to implement AF screening using digital health technology practicably and feasibly for older and frail populations residing in the community. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621000184875; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380877. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34778.

Impairment in activities of daily living and readmission in older patients with heart failure: a cohort study.

OBJECTIVES: This study aims to investigate the prevalence of impairment of activities of daily living (ADLs) in older patients with heart failure (HF), and to examine the impact of ADL impairment on readmission after discharge. DESIGN AND SETTINGS: A prospective cohort study was conducted in patients aged ≥65 years with HF admitted to a tertiary hospital in Vietnam from August 2016 to June 2017. Difficulties with six ADLs were assessed by a questionnaire. Participants were classified into two categories (with and without ADL impairment). The associations of ADL impairment with 3-month readmission were examined using logistic regression models. RESULTS: There were 180 participants (mean age 80.6±8.2, 50% female) and 26.1% were classified as having ADL impairment. The most common impaired activity was bathing (21.1%), followed by transferring (20.0%), toileting (12.2%), dressing (8.9%), eating (3.3%), and continence (2.8%). During 3-month follow-up, 32.8% of the participants were readmitted to hospitals (55.3% in participants with ADL impairment, 24.8% in those without ADL impairment, p<0.001). ADL impairment significantly increased the risk of 3-month readmission (adjusted OR 2.75, 95% CI 1.25 to 6.05, p=0.01). CONCLUSIONS: In summary, ADL impairment was common in older hospitalised patients with HF and was associated with increased readmission. These findings suggest further studies on ADL assessment and intervention during transition care for older patients with HF after discharge to prevent readmission.