The health and economic burden of breathlessness, Australia, 2019: a national survey.

29 August 2024: This article published in Early View in error. The article is under embargo and will republish on 16th September 2024.

Comparing performance of primary care clinicians in the interpretation of SPIROmetry with or without Artificial Intelligence Decision support software (SPIRO-AID): a protocol for a randomised controlled trial.

INTRODUCTION: Spirometry is a point-of-care lung function test that helps support the diagnosis and monitoring of chronic lung disease. The quality and interpretation accuracy of spirometry is variable in primary care. This study aims to evaluate whether artificial intelligence (AI) decision support software improves the performance of primary care clinicians in the interpretation of spirometry, against reference standard (expert interpretation). METHODS AND ANALYSIS: A parallel, two-group, statistician-blinded, randomised controlled trial of primary care clinicians in the UK, who refer for, or interpret, spirometry. People with specialist training in respiratory medicine to consultant level were excluded. A minimum target of 228 primary care clinician participants will be randomised with a 1:1 allocation to assess fifty de-identified, real-world patient spirometry sessions through an online platform either with (intervention group) or without (control group) AI decision support software report. Outcomes will cover primary care clinicians' spirometry interpretation performance including measures of technical quality assessment, spirometry pattern recognition and diagnostic prediction, compared with reference standard. Clinicians' self-rated confidence in spirometry interpretation will also be evaluated. The primary outcome is the proportion of the 50 spirometry sessions where the participant's preferred diagnosis matches the reference diagnosis. Unpaired t-tests and analysis of covariance will be used to estimate the difference in primary outcome between intervention and control groups. ETHICS AND DISSEMINATION: This study has been reviewed and given favourable opinion by Health Research Authority Wales (reference: 22/HRA/5023). Results will be submitted for publication in peer-reviewed journals, presented at relevant national and international conferences, disseminated through social media, patient and public routes and directly shared with stakeholders. TRIAL REGISTRATION NUMBER: NCT05933694.

Clinical, technical, and implementation characteristics of real-world health applications using FHIR.

Objective: Understanding the current state of real-world Fast Healthcare Interoperability Resources (FHIR) applications (apps) will benefit biomedical research and clinical care and facilitate advancement of the standard. This study aimed to provide a preliminary assessment of these apps' clinical, technical, and implementation characteristics. Materials and Methods: We searched public repositories for potentially eligible FHIR apps and surveyed app implementers and other stakeholders. Results: Of the 112 apps surveyed, most focused on clinical care (74) or research (45); were implemented across multiple sites (56); and used SMART-on-FHIR (55) and FHIR version R4 (69). Apps were primarily stand-alone web-based (67) or electronic health record (EHR)-embedded (51), although 49 were not listed in an EHR app gallery. Discussion: Though limited in scope, our results show FHIR apps encompass various domains and characteristics. Conclusion: As FHIR use expands, this study-one of the first to characterize FHIR apps at large-highlights the need for systematic, comprehensive methods to assess their characteristics.

A systematic review on the effectiveness and impact of clinical decision support systems for breathlessness.

Breathlessness is a common presenting symptom in practice. This systematic review aimed to evaluate the impact of CDSS on breathlessness and associated diseases in real-world clinical settings. Studies published between 1 January 2000 to 10 September 2021 were systematically obtained from 14 electronic research databases including CENTRAL, Embase, Pubmed, and clinical trial registries. Main outcomes of interest were patient health outcomes, provider use, diagnostic concordance, economic evaluation, and unintended consequences. The review protocol was prospectively registered in PROSPERO (CRD42020163141). A total of 4294 records were screened and 37 studies included of which 30 were RCTs. Twenty studies were in primary care, 13 in hospital outpatient/emergency department (ED), and the remainder mixed. Study duration ranged from 2 weeks to 5 years. Most were adults (58%). Five CDSS were focused on assessment, one on assessment and management, and the rest on disease-specific management. Most studies were disease-specific, predominantly focused on asthma (17 studies), COPD (2 studies), or asthma and COPD (3 studies). CDSS for COPD, heart failure, and asthma in adults reported clinical benefits such as reduced exacerbations, improved quality of life, improved patient-reported outcomes or reduced mortality. Studies identified low usage as the main barrier to effectiveness. Clinicians identified dissonance between CDSS recommendations and real-world practice as a major barrier. This review identified potential benefits of CDSS implementation in primary care and outpatient services for adults with heart failure, COPD, and asthma in improving diagnosis, compliance with guideline recommendations, promotion of non-pharmacological interventions, and improved clinical outcomes including mortality.

Asthma and risk of infection, hospitalization, ICU admission and mortality from COVID-19: Systematic review and meta-analysis.

OBJECTIVE: As COVID-19 spreads across the world, there are concerns that people with asthma are at a higher risk of acquiring the disease, or of poorer outcomes. This systematic review aimed to summarize evidence on the risk of infection, severe illness and death from COVID-19 in people with asthma. DATA SOURCES AND STUDY SELECTION: A comprehensive search of electronic databases including preprint repositories and WHO COVID-19 database was conducted (until 26 May 2020). Studies reporting COVID-19 in people with asthma were included. For binary outcomes, we performed Sidik-Jonkman random effects meta-analysis. We explored quantitative heterogeneity by subgroup analyses, meta regression and evaluating the I2 statistic. RESULTS: Fifty-seven studies with an overall sample size of 587 280 were included. The prevalence of asthma among those infected with COVID-19 was 7.46% (95% CI = 6.25-8.67). Non-severe asthma was more common than severe asthma (9.61% vs. 4.13%). Pooled analysis showed a 14% risk ratio reduction in acquiring COVID-19 (95% CI = 0.80-0.94; p < 0.0001) and 13% reduction in hospitalization with COVID-19 (95% CI = 0.77-0.99, p = 0.03) for people with asthma compared with those without. There was no significant difference in the combined risk of requiring admission to ICU and/or receiving mechanical ventilation for people with asthma (RR = 0.87 95% CI = 0.94-1.37; p = 0.19) and risk of death from COVID-19 (RR = 0.87; 95% CI = 0.68-1.10; p = 0.25). CONCLUSION: The findings from this study suggest that the prevalence of people with asthma among COVID-19 patients is similar to the global prevalence of asthma. The overall findings suggest that people with asthma have a lower risk than those without asthma for acquiring COVID-19 and have similar clinical outcomes.

Asthma and COVID-19 risk: a systematic review and meta-analysis.

BACKGROUND: Individual case series and cohort studies have reported conflicting results in people with asthma on the vulnerability to and risk of mortality from coronavirus disease 2019 (COVID-19). RESEARCH QUESTION: Are people with asthma at a higher risk of being infected or hospitalised or poorer clinical outcomes from COVID-19? METHODS: A systematic review and meta-analysis based on five main databases including the World Health Organization COVID-19 database between 1 December 2019 and 11 July 2021 on studies with a control (non-asthma) group was conducted. Prevalence and risk ratios were pooled using Sidik-Jonkman random-effects meta-analyses. FINDINGS: 51 studies with an 8.08% (95% CI 6.87-9.30%) pooled prevalence of people with asthma among COVID-19 positive cases. The risk ratios were 0.83 (95% CI 0.73-0.95, p=0.01) for acquiring COVID-19; 1.18 (95% CI 0.98-1.42, p=0.08) for hospitalisation; 1.21 (95% CI 0.97-1.51, p=0.09) for intensive care unit (ICU) admission; 1.06 (95% CI 0.82-1.36, p=0.65) for ventilator use; and 0.94 (95% CI 0.76-1.17, p=0.58) for mortality for people with asthma. Subgroup analyses by continent revealed a significant difference in risk of acquiring COVID-19, ICU admission, ventilator use and death between the continents. INTERPRETATION: The risk of being infected with severe acute respiratory syndrome coronavirus 2 was reduced compared to the non-asthma group. No statistically significant differences in hospitalisation, ICU admission and ventilator use were found between groups. Subgroup analyses showed significant differences in outcomes from COVID-19 between America, Europe and Asia. Additional studies are required to confirm this risk profile, particularly in Africa and South America, where few studies originate.

Targeting ageing and preventing organ degeneration with metformin.

BACKGROUND: Ageing is characterized by a decline in cognitive and bodily functions. Metformin, the most commonly prescribed antidiabetic agent today, has proved to be able to modulate oxidative stress, several inflammatory pathways and cellular senescence to promote anti-ageing. This review aims to explore and summarize the effects of metformin on ageing. RESULTS: Metformin, a longstanding treatment for diabetes, has been shown to increase lifespan in both vertebrate and mammalian models. This pleiotropic effect is hypothesized to mimic calorie restriction, a currently proven means of slowing ageing, by decreasing insulin and insulin-like growth factor (IGF)-1 levels and improving insulin sensitivity. However, studies have shown that metformin is also able to target several other ageing pathways, thereby inhibiting mammalian target of rapamycin (mTOR), increasing AMPK activity and improving DNA repair. Clinical studies, such as those supported by the UK Clinical Practice Research Datalink service, have reported that diabetes patients treated with metformin live longer than patients without diabetes. Metformin use can also reduce type 2 diabetes mellitus (T2DM) incidence among those at risk, lower cancer incidence, and improve cognitive function, cardiovascular disease (CVD) risk factors and atherosclerosis. CONCLUSION: Various studies have found that metformin can target several nutrient-sensing, anti-ageing and immune pathways, leading to reductions in oxidative stress, inflammation and DNA damage as well as providing effects similar to those of calorie restriction. However, further trials are still needed to confirm these findings.

Apela/Elabela/Toddler: New perspectives in molecular mechanism of heart failure.

Background. Despite significant therapeutic advances, heart failure (HF) remains unacceptably high in morbidity and mortality. Additionally, its high-care and costs make HF a deadly and costly disease. First reported independently by two group of researchers, Apela/Elabela/Toddler (ELA) is the second endogenous apelin-receptor ligand discovered which is encoded from a previously classified non-coding gene, and has emerged as a key signalling-pathway in the cardiovascular system. Aims. To explore and summarise the biological effects and diagnostic potential of ELA as a new biomarker for heart failure. Results. ELA (prepro-ELA 54 AA) is a molecule with three isoforms (ELA 11,16 and 32), recently identified as the second endogenous ligand to APJ-receptor and functions to mediate early cardiac development during zebrafish embryogenesis by inducing cardiogenesis, vasculogenesis and bone formation. In adults, it enhances cardiac contractility, promotes vasodilatory effects, mediates fluid homeostasis, reduces food intake, limits kidney dysfunction and exerts anti-atherosclerotic as well as anti-oxidative properties. Conclusion. These results show that ELA, an endogenous agonist of the APJ-receptor exerts cardiovascular effects comparable and potentially more potent than apelin and is found to be downregulated in experimental models and humans with heart failure.

Comparing outcomes of nutrition therapy, insulin and oral anti-diabetics in managing diabetes mellitus in Pregnancy: Retrospective study and review of current guidelines.

AIMS: This study aims to evaluate the glycemic profile and outcomes of Indonesian diabetic pregnant mothers based on their methods of therapy and review current international as well as national guidelines on management of diabetes in pregnancy. MATERIALS AND METHODS: Data was obtained from medical records of Hermina-Podomoro Hospital. Subjects were grouped based on therapy - nutrition therapy only, insulin and oral anti-diabetics group. RESULTS: Forty-five subjects were obtained with an average age of 31-years. Around thirty-five percent of patients were given nutrition therapy only, 55.6% were using insulin and 8.8% were using oral anti-diabetics. Oral anti-diabetics users showed worse glycemic profile among the three groups. Six-patients suffered from IUFD with the highest proportion found in oral anti-diabetics users. CONCLUSION: The above results show the negative impacts of DM on pregnant mothers and the unborn. Caution is advised on the use of oral anti-diabetics as it may increase the risk of infant mortality. Increased monitoring and prenatal services for DM patients are essential in achieving blood glucose targets.

Diabetes in pregnancy and infant mortality: Link with glycemic control.

AIMS: To compare the clinical and glycemic profile as well as pregnancy complications and infant mortality among diabetic mothers in Indonesia. MATERIALS AND METHODS: Data was obtained from medical records of Internal-Medicine Clinic in Hermina Podomoro General Hospital during the period January-December 2015. Subjects were grouped into good and poor outcome groups based on infant mortality. RESULTS: Forty-five subjects were obtained with an average age of 31 years, 41 had gestational diabetes mellitus while 4 had pregestational diabetes. Twenty-one patients had high-risk pregnancies (age >30 years or <20 years). No maternal mortalities were reported, only 6 pregnancies were complicated with infant death. Comorbidities mainly found were preeclampsia, anemia and urinary tract infection. Most patients delivered through caesarian section. Almost all of them were treated with insulin. Comparison between both groups showed that those with poor outcomes have a significantly higher body mass index prior to pregnancy, higher body weight prior and after pregnancy as well as worse glycemic profile. CONCLUSION: Diabetes in pregnancy has been found to increase rates of infant mortality. This study showed that patients with poor glycemic control are at a greater risk of infant mortality. Therefore increased monitoring and prenatal care as well as optimal glycemic control for patients with diabetes in pregnancy is recommended. Optimal glycemic control will lead to diabetic mothers with pregnancies of equal risk and similar outcomes to those of normal patients.

Glycated hemoglobin targets and glycemic control: Link with lipid, uric acid and kidney profile.

AIMS: To compare uric acid, lipid, and kidney profile along with management and complications of Indonesian diabetic patients with good and poor glycemic control based on glycated hemoglobin profile. MATERIALS AND METHODS: Data was obtained from medical records of Internal Medicine Clinic in Hermina Podomoro General Hospital for the period January-December 2015. Subjects were grouped into good and poor glycemic control groups based on their glycated hemoglobin (HbA1c) levels. RESULTS: Fifty-five subjects were obtained with an average age of 54 years, 29 with good glycemic control and 26 with poor glycemic control. All glycemic parameters were worse in poor compared to good glycemic control group (p < 0.05). Similar averages of urea, creatinine, uric acid, low-density lipoprotein (LDL) and a lower average of high-density lipoprotein (HDL) were found between both groups with statistically non-significant differences (p > 0.05). Main comorbidities were dyslipidemia, hypertension, and nephropathy. Fatty liver disease, urinary tract infection and neuropathy was also reported. Most patients were prescribed with oral anti-diabetics. CONCLUSION: Diabetic patients regardless of glycemic control according to current guidelines have a greater average lipid and kidney profile than the optimum target. Therefore both are equally at greater risk for cardiovascular diseases, nephropathy, and other diabetic complications. Greater patient monitoring of these parameters is recommended to lower the risk of comorbidities and complications.