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1.
Am J Kidney Dis ; 2021 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-33421456

RESUMO

RATIONALE AND OBJECTIVE: An important component of hemodialysis management involves delivery of complex dietary recommendations. The aim of this study was to determine the feasibility of a mobile phone text message intervention to improve dietary behavior in people on hemodialysis. STUDY DESIGN: Six-month randomized feasibility study. SETTING: and participants: Patients receiving maintenance hemodialysis across two health districts in Sydney, Australia. INTERVENTIONS: Participants randomized to the intervention received three text messages per week, in addition to standard dietary care, for six months. The usual care group received standard dietary care. OUTCOMES: The primary outcomes were feasibility, measured using recruitment and retention rates, acceptability of the intervention, and adherence to dietary recommendations. Secondary exploratory outcomes included information on certain clinical parameters related to dietary management of patients receiving maintenance hemodialysis. RESULTS: 130 people were recruited. 48% (130/272) of eligible patients consented to participate and 88% (115/130) completed the study. Semi-structured interviews evaluating acceptability identified five themes: clear and comprehensive, engaging with consistent and relevant content, maintaining attention with timely reminders, sustaining interest through ongoing care and generic messages inadequate to prompt dietary change. There was no difference in adherence to dietary recommendations across treatment groups (odds ratio: 1.21, 95% CI 0.55, 2.72, p=0.6). Secondary exploratory analyses suggested reductions in dietary intake of single nutrients (potassium, phosphorus, sodium, protein), interdialytic weight gains, and phosphate binder usage among intervention participants compared to participants assigned to standard of care. LIMITATIONS: Our feasibility study was of short duration. Adherence was based on self-reported data. Generalizability to populations receiving maintenance hemodialysis outside of an urban, Australian setting is unknown. CONCLUSIONS: A simple mobile phone text messaging intervention was feasible and acceptable to patients. Further investigation of the impact on patient-reported and clinical outcomes is warranted.

2.
Curr Diabetes Rev ; 2021 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-33438542

RESUMO

BACKGROUND: South Asians are at a significantly increased risk of atherosclerotic cardiovascular disease (ASCVD). For a major portion of the South Asian population, the cardiovascular disease events occur at a relatively younger age, are associated with worse outcomes and have potentially more severe socioeconomic implications compared to their western counterparts. METHOD: The term "South Asian" typically constitutes individuals from India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives and expatriates as well as their families from these countries. Based on this, South Asian form approximately 25% of the world's population with a high ASCVD burden this group. In this review, we discuss the pathophysiological factors underlying ASCVD in South Asians, the dyslipidemia types and management as well as discuss approaches to improve the overall ASCVD prevention efforts in this large subset population of the world. Although the pathophysiological mechanisms underlying the excess risk of cardiovascular disease in South Asians are multifactorial, dyslipidemia is a primary risk factor for the incidence and prevalence of this disease. The traditional "South Asian" dyslipidemia pattern include levels of low-density lipoprotein cholesterol (LDL-C) in the normal range with high concentration of LDL particles, elevated triglycerides, low levels of high-density lipoprotein cholesterol (HDL-C) with dysfunctional HDL particles, and high levels of lipoprotein(a). CONCLUSIONS: While combined efforts to study the expatriate South Asians in western countries have been able to identify South Asian specific dyslipidemias, causal associations and optimal management remains relatively less explored. Larger scale studies are needed to better quantify the relationship of each lipid parameter with ASCVD risk among South Asians as well as optimal lipid targets and management strategies to reduce morbidity and mortality in this high-risk group.

3.
Heart Lung Circ ; 30(3): 324-349, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33309206

RESUMO

Familial hypercholesterolaemia (FH) is a dominant and highly penetrant monogenic disorder present from birth that markedly elevates plasma low-density lipoprotein (LDL)-cholesterol concentration and, if untreated, leads to premature atherosclerosis and coronary artery disease (CAD). There are approximately 100,000 people with FH in Australia. However, an overwhelming majority of those affected remain undetected and inadequately treated, consistent with FH being a leading challenge for public health genomics. To further address the unmet need, we provide an updated guidance, presented as a series of systematically collated recommendations, on the care of patients and families with FH. These recommendations have been informed by an exponential growth in published works and new evidence over the last 5 years and are compatible with a contemporary global call to action on FH. Recommendations are given on the detection, diagnosis, assessment and management of FH in adults and children. Recommendations are also made on genetic testing and risk notification of biological relatives who should undergo cascade testing for FH. Guidance on management is based on the concepts of risk re-stratification, adherence to heart healthy lifestyles, treatment of non-cholesterol risk factors, and safe and appropriate use of LDL-cholesterol lowering therapies, including statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors and lipoprotein apheresis. Broad recommendations are also provided for the organisation and development of health care services. Recommendations on best practice need to be underpinned by good clinical judgment and shared decision making with patients and families. Models of care for FH need to be adapted to local and regional health care needs and available resources. A comprehensive and realistic implementation strategy, informed by further research, including assessments of cost-benefit, will be required to ensure that this new guidance benefits all Australian families with or at risk of FH.

4.
J Hypertens ; 39(1): 107-116, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32833918

RESUMO

OBJECTIVE: To determine whether there is an interaction between knowledge about hypertension and awareness of hypertension on the treatment and control of hypertension in three regions of South India at different stages of epidemiological transition (see Video, Supplemental Digital Content 1, http://links.lww.com/HJH/B426). METHODS: Using a cross-sectional design, we randomly selected villages within each of rural Trivandrum, West Godavari, and Chittoor. Sampling was stratified by age group and sex. We measured blood pressure and administered a questionnaire to determine knowledge and awareness of hypertension. Logistic regression was used to assess associations of awareness and knowledge about hypertension with its treatment and control in participants with hypertension, while examining for statistical interaction. RESULTS: Among a total of 11 657 participants (50% male; median age 45 years), 3455 had hypertension. In analyses adjusted for age and sex, both knowledge score [adjusted odds ratio (aOR) 1.14 [95% confidence interval (CI) 1.12--1.17)] and awareness [aOR 104 (95% CI 82--134)] were associated with treatment for hypertension. Similarly, both knowledge score [aOR 1.10; 95% CI (1.08--1.12)] and awareness [aOR 13.4; 95% CI (10.7--16.7)], were positively associated with control of blood pressure in those with hypertension, independent of age and sex. There was an interaction between knowledge and awareness on both treatment and control of hypertension (P of attributable proportion <0.001 for each). CONCLUSION: Health education to improve knowledge about hypertension and screening programs to improve awareness of hypertension may act in an additive fashion to improve management of hypertension in rural Indian populations.

5.
J Clin Transl Endocrinol ; 22: 100240, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33294382

RESUMO

Aims: To use linked routinely-collected health data to estimate diabetes prevalence and incidence in an Australian cohort of adults aged ≥45 years, and examine risk factors associated with incident disease. Research design and methods: The EXamining ouTcomEs in chroNic Disease in the 45 and Up Study (EXTEND45) Study is a linked data study that combines baseline questionnaire responses from the population-based 45 and Up Study (2006-2009, n = 267,153) with multiple routinely-collected health databases up to December 2014. Among participants with ≥1 linked result for any laboratory test, diabetes status was determined from multiple data sources according to standard biochemical criteria, use of glucose-lowering medication or self-report, and the prevalence and incidence rate calculated. Independent risk factors of incident diabetes were examined using multivariable Cox regression. Results: Among 152,169 45 and Up Study participants with ≥1 linked laboratory result in the EXTEND45 database (mean age 63.0 years; 54.9% female), diabetes prevalence was 10.8% (95% confidence interval [CI] 10.6%-10.9%). Incident disease in those without diabetes at baseline (n = 135,810; mean age 62.5 years; 56.1% female) was 10.0 per 1,000 person-years (95% CI 9.8-10.2). In all age groups, diabetes incidence was lower in women compared to men, an association that persisted in the fully adjusted analyses. Other independent risk factors of diabetes were older age, being born outside of Australia (with the highest rate of 19.2 per 1,000 person-years observed in people born in South and Central Asia), lower education status, lower annual household income, residence in a major city, family history of diabetes, personal history of cardiovascular disease or hypertension, higher body mass index, smoking and long sleeping hours. Conclusions: Our study represents an efficient approach to assessing diabetes frequency and its risk factors in the community. The infrastructure provided by the EXTEND45 Study will be useful for diabetes surveillance and examining other important clinical and epidemiological questions.

6.
JAMA Cardiol ; 2020 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-33295965

RESUMO

Importance: Although international guidelines recommend use of the Global Registries of Acute Coronary Events (GRACE) risk score (GRS) to guide acute coronary syndrome (ACS) treatment decisions, the prospective utility of the GRS in improving care and outcomes is unproven. Objective: To assess the effect of routine GRS implementation on guideline-indicated treatments and clinical outcomes of hospitalized patients with ACS. Design, Setting, and Participants: Prospective cluster (hospital-level) randomized open-label blinded end point (PROBE) clinical trial using a multicenter ACS registry of acute care cardiology services. Fixed sampling of the first 10 patients within calendar month, with either ST-segment elevation or non-ST-segment elevation ACS. The study enrolled patients from June 2014 to March 2018, and data were analyzed between February 2020 and April 2020. Interventions: Implementation of routine risk stratification using the GRS and guideline recommendations. Main Outcomes and Measures: The primary outcome was a performance score based on receipt of early invasive treatment, discharge prescription of 4 of 5 guideline-recommended pharmacotherapies, and cardiac rehabilitation referral. Clinical outcomes included a composite of all-cause death and/or myocardial infarction (MI) within 1 year. Results: This study enrolled 2318 patients from 24 hospitals and was stopped prematurely owing to futility. Of the patients enrolled, median age was 65 years (interquartile range, 56-74 years), 29.5% were women (n = 684), and 62.9% were considered high risk (n = 1433). Provision of all 3 measures among high-risk patients did not differ between the randomized arms (GRS: 424 of 717 [59.9%] vs control: 376 of 681 [55.2%]; odds ratio [OR], 1.04; 95% CI, 0.63-1.71; P = .88). The provision of early invasive treatment was increased compared with the control arm (GRS: 1042 of 1135 [91.8%] vs control: 989 of 1183 [83.6%]; OR, 2.26; 95% CI, 1.30-3.96; P = .004). Prescription of 4 of 5 guideline-recommended pharmacotherapies (GRS: 864 of 1135 [76.7%] vs control: 893 of 1183 [77.5%]; OR, 0.97; 95% CI, 0.68-1.38) and cardiac rehabilitation (GRS: 855 of 1135 [75.1%] vs control: 861 of 1183 [72.8%]; OR, 0.68; 95% CI, 0.32-1.44) were not different. By 12 months, GRS intervention was not associated with a significant reduction in death or MI compared with the control group (GRS: 96 of 1044 [9.2%] vs control: 146 of 1087 [13.4%]; OR, 0.66; 95% CI, 0.38-1.14). Conclusions and Relevance: Routine GRS implementation in cardiology services with high levels of clinical care was associated with an increase in early invasive treatment but not other aspects of care. Low event rates and premature study discontinuation indicates the need for further, larger scale randomized studies. Trial Registration: anzctr.org.au Identifier: ACTRN12614000550606.

7.
Heart Lung Circ ; 2020 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-33223494

RESUMO

BACKGROUND: Rapid access cardiology services have been proposed for assessment of acute cardiac conditions via an outpatient model-of-care that potentially could reduce hospitalisations. We describe a new Rapid Access Arrhythmia Clinic (RAAC) and compare major safety endpoints to usual care. METHODS: We matched 312 adult patients with suspected arrhythmia in RAAC to historical age and sex-matched controls discharged from hospital within Western Sydney Local Health District with suspected arrhythmia. The primary endpoint was a composite of time to first unplanned cardiovascular hospitalisation or cardiac death over 12 months. RESULTS: The average age of RAAC patients was 52.2±18.8 years and 51.6±18.8 years for controls, and 48.4% were female in both groups. Mean time from referral to first attended RAAC appointment was 10.5 days. Most were referred from emergency (177, 56.7%) and cardiologists at time of discharge (65, 20.8%). The most common reason for referral was palpitations (180, 57.7%). In total, 155 (49.7%) had a documented arrhythmia, with the most common being atrial fibrillation/flutter (88, 28.2%). The primary endpoint occurred in 35 (11.2%) patients in the RAAC pathway (97.1[95% CI 70-131.3] per 1,000 person-years), compared to 72 (23.1%) patients for usual care controls (229.5[95% CI 180.2-288.1] per 1,000 person-years). Using a propensity score analysis, RAAC pathway significantly reduced the primary endpoint by 59% compared to usual care (HR 0.41, 95% CI 0.27-0.62; p<0.001). CONCLUSIONS: RAACs for the early investigation and management of suspected arrhythmia is superior to usual care in terms of reduction in unplanned cardiovascular hospitalisation and death.

8.
Am Heart J ; 231: 56-67, 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33017580

RESUMO

High blood pressure is the leading cause of preventable morbidity and mortality globally. Many patients remain on single-drug treatment with poor control, although guidelines recognize that most require combination therapy for blood pressure control. Our hypothesis is that a single-pill combination of 4 blood pressure-lowering agents each at a quarter dose may provide a simple, safe, and effective blood pressure-lowering solution which may also improve long-term adherence. The Quadruple UltrA-low-dose tReaTment for hypErTension (QUARTET) double-blind, active-controlled, randomized clinical trial will examine whether ultra-low-dose quadruple combination therapy is more effective than guideline-recommended standard care in lowering blood pressure. QUARTET will enroll 650 participants with high blood pressure either on no treatment or on monotherapy. Participants will be randomized 1:1 and allocated to intervention therapy of a single pill (quadpill) containing irbesartan 37.5 mg, amlodipine 1.25 mg, indapamide 0.625 mg, and bisoprolol 2.5 mg or to control therapy of a single identical-appearing pill containing irbesartan 150 mg. In both arms, step-up therapy of open-label amlodipine 5 mg will be provided if blood pressure is >140/90 at 6 weeks. The primary outcome is the difference between groups in the change from baseline in mean unattended automated office systolic blood pressure at 12-week follow-up. The primary outcome and some secondary outcomes will be assessed at 12 weeks; there is an optional 12-month extension phase to assess longer-term efficacy and tolerability. Our secondary aims are to assess if this approach is safe, has fewer adverse effects, and has better tolerability compared to standard care control. QUARTET will therefore provide evidence for the effectiveness and safety of a new paradigm in the management of high blood pressure.

9.
NPJ Digit Med ; 3: 117, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32964140

RESUMO

Digital health applications (apps) have the potential to improve health behaviors and outcomes. We aimed to examine the effectiveness of a consumer web-based app linked to primary care electronic health records (EHRs). CONNECT was a multicenter randomized controlled trial involving patients with or at risk of cardiovascular disease (CVD) recruited from primary care (Clinical Trial registration ACTRN12613000715774). Intervention participants received an interactive app which was pre-populated and refreshed with EHR risk factor data, diagnoses and, medications. Interactive risk calculators, motivational messages and lifestyle goal tracking were also included. Control group received usual health care. Primary outcome was adherence to guideline-recommended medications (≥80% of days covered for blood pressure (BP) and statin medications). Secondary outcomes included attainment of risk factor targets and eHealth literacy. In total, 934 patients were recruited; mean age 67.6 (±8.1) years. At 12 months, the proportion with >80% days covered with recommended medicines was low overall and there was no difference between the groups (32.8% vs. 29.9%; relative risk [RR] 1.07 [95% CI, 0.88-1.20] p = 0.49). There was borderline improvement in the proportion meeting BP and LDL targets in intervention vs. control (17.1% vs. 12.1% RR 1.40 [95% CI, 0.97-2.03] p = 0.07). The intervention was associated with increased attainment of physical activity targets (87.0% intervention vs. 79.7% control, p = 0.02) and e-health literacy scores (72.6% intervention vs. 64.0% control, p = 0.02). In conclusion, a consumer app integrated with primary health care EHRs was not effective in increasing medication adherence. Borderline improvements in risk factors and modest behavior changes were observed.

10.
J Neurol Sci ; 418: 117115, 2020 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-32916515

RESUMO

BACKGROUND: Strokes in the young and middle-aged are associated with a disproportionately large economic and social impact in addition to their clinical effects. Standard Modifiable Cardiovascular Risk Factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes mellitus and smoking) are key drivers of cardiovascular disease including strokes, however recent temporal trends in the younger stroke population have not been well characterised. We aimed to evaluate recent trends of SMuRFs in a cohort of younger patients with ischaemic stroke. METHODS: Consecutive patients aged <65 years with clinical and/or radiological diagnosis of ischaemic stroke or transient ischaemic attack in a tertiary referral centre (2013-2017) were retrospectively appraised. The demographic and clinical comorbidities of these patients were assessed including their SMuRF profile. The prevalence over time and clinical associations of patients with no SMuRFs were studied and compared to patients with SMuRFs. RESULTS: Of 487 patients (53.49 ± 9.13 yrs., 60% men) analysed, 23% did not have SMuRFs. The proportion of "non-SMuRF" patients increased over time (p < 0.01) and this trend was not influenced by age (p = 0.48) or gender (p = 0.68). The presence of SMuRFs was not associated with in-hospital outcomes, however patients without SMuRFs were significantly less likely to be discharged on blood pressure (p < 0.01) and lipid-lowering therapies (p = 0.03). CONCLUSIONS: The proportion of younger stroke patients without SMuRFs is substantial and has increased over time. Our findings highlight the need for further research to better understand the mechanisms underlying stroke development in this population and whether less risk factor treatment in this population could impact longer term outcomes.

11.
Med J Aust ; 213(4): 182-187, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32734645

RESUMO

INTRODUCTION: The coronavirus 2019 disease (COVID-19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Pre-existing cardiovascular disease (CVD) increases the morbidity and mortality of COVID-19, and COVID-19 itself causes serious cardiac sequelae. Strategies to minimise the risk of viral transmission to health care workers and uninfected cardiac patients while prioritising high quality cardiac care are urgently needed. We conducted a rapid literature appraisal and review of key documents identified by the Cardiac Society of Australia and New Zealand Board and Council members, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and key cardiology, surgical and public health opinion leaders. MAIN RECOMMENDATIONS: Common acute cardiac manifestations of COVID-19 include left ventricular dysfunction, heart failure, arrhythmias and acute coronary syndromes. The presence of underlying CVD confers a five- to tenfold higher case fatality rate with COVID-19 disease. Special precautions are needed to avoid viral transmission to this population at risk. Adaptive health care delivery models and resource allocation are required throughout the health care system to address this need. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: Cardiovascular health services and cardiovascular health care providers need to recognise the increased risk of COVID-19 among CVD patients, upskill in the management of COVID-19 cardiac manifestations, and reorganise and innovate in service delivery models to meet demands. This consensus statement, endorsed by the Cardiac Society of Australia and New Zealand, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the National Heart Foundation of Australia and the High Blood Pressure Research Council of Australia summarises important issues and proposes practical approaches to cardiovascular health care delivery to patients with and without SARS-CoV-2 infection.

12.
Curr Hypertens Rep ; 22(9): 65, 2020 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-32852644

RESUMO

PURPOSE OF REVIEW: To summarise the advances that have been made from 2017 in dual, triple, and quadruple low-dose combination therapy for treating high blood pressure. RECENT FINDINGS: Many people require multiple blood pressure lowering medicines to achieve target blood pressures, and initiating treatment with combination blood pressure lowering therapy is being increasingly investigated and recommended. Low-dose combinations of blood pressure lowering provide more effective blood pressure lowering, with fewer adverse events. Recent advances include listing of four dual combinations on the WHO Essential Medicines List, completion of a triple half-dose combination trial, and a pilot of quadruple quarter-dose combination, and recent cardiovascular polypill trials have included two blood pressure lowering medicines at low dose. These trials all demonstrated improvements in achieving blood pressure targets with low-dose combination therapy. Low-dose combination therapy is a promising option for initial treatment of hypertension that appears to be safe and effective. Larger trials of triple and quadruple low-dose combination therapy in multiple locations are underway and should provide stronger evidence of efficacy as well as information on the side effect profile.

14.
JAMA Netw Open ; 3(7): e209256, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32609351

RESUMO

Importance: Outcomes from out-of-hospital cardiac arrests (OHCAs) remain poor. Outcomes associated with community interventions that address bystander cardiopulmonary resuscitation (CPR) remain unclear and need further study. Objective: To examine community interventions and their association with bystander CPR and survival after OHCA. Data Sources: Literature search of the MEDLINE, Embase, and the Cochrane Library databases from database inception to December 31, 2018, was conducted. Key search terms included cardiopulmonary resuscitation, layperson, basic life support, education, cardiac arrest, and survival. Study Selection: Community intervention studies that reported on comparisons with control and differences in survival following OHCA were included. Studies that focused only on in-hospital interventions, patients with in-hospital cardiac arrest, only dispatcher-assisted CPR, or provision of automated external defibrillators were excluded. Data Extraction and Synthesis: Pooled odds ratios (ORs) and 95% CIs were estimated using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures: Thirty-day survival or survival to hospital discharge and bystander CPR rate. Results: A total of 4480 articles were identified; of these, 15 studies were included for analysis. There were broadly 2 types of interventions: community intervention alone (5 studies) and community intervention combined with changes in health services (10 studies). Four studies involved notification systems that alerted trained lay bystanders to the location of the OHCA in addition to CPR skills training. Meta-analysis of 9 studies including 21 266 patients with OHCA found that community interventions were associated with increased survival to discharge or 30-day survival (OR, 1.34; 95% CI, 1.14-1.57; I2 = 33%) and greater bystander CPR rate (OR, 1.28; 95% CI, 1.06-1.54; I2 = 82%). Compared with community intervention alone, community plus health service intervention was associated with a greater bystander CPR rate compared with community alone (community plus intervention: OR, 1.74; 95% CI, 1.26-2.40 vs community alone: OR, 1.06; 95% CI, 0.85-1.31) (P = .01). Survival rate, however, was not significantly different between intervention types: community plus health service intervention OR, 1.71; 95% CI, 1.09-2.68 vs community only OR, 1.26; 95% CI, 1.05-1.50 (P = .21). Conclusions and Relevance: In this study, while the evidence base is limited, community-based interventions with a focus on improving bystander CPR appeared to be associated with improved survival following OHCA. Further evaluations in diverse settings are needed to enable widespread implementation of such interventions.

15.
JMIR Mhealth Uhealth ; 8(6): e19200, 2020 06 16.
Artigo em Inglês | MEDLINE | ID: mdl-32543439

RESUMO

BACKGROUND: SMS text messaging programs are increasingly being used for secondary prevention, and have been shown to be effective in a number of health conditions including cardiovascular disease. SMS text messaging programs have the potential to increase the reach of an intervention, at a reduced cost, to larger numbers of people who may not access traditional programs. However, patients regularly reply to the SMS text messages, leading to additional staffing requirements to monitor and moderate the patients' SMS text messaging replies. This additional staff requirement directly impacts the cost-effectiveness and scalability of SMS text messaging interventions. OBJECTIVE: This study aimed to test the feasibility and accuracy of developing a machine learning (ML) program to triage SMS text messaging replies (ie, identify which SMS text messaging replies require a health professional review). METHODS: SMS text messaging replies received from 2 clinical trials were manually coded (1) into "Is staff review required?" (binary response of yes/no); and then (2) into 12 general categories. Five ML models (Naïve Bayes, OneVsRest, Random Forest Decision Trees, Gradient Boosted Trees, and Multilayer Perceptron) and an ensemble model were tested. For each model run, data were randomly allocated into training set (2183/3118, 70.01%) and test set (935/3118, 29.98%). Accuracy for the yes/no classification was calculated using area under the receiver operating characteristics curve (AUC), false positives, and false negatives. Accuracy for classification into 12 categories was compared using multiclass classification evaluators. RESULTS: A manual review of 3118 SMS text messaging replies showed that 22.00% (686/3118) required staff review. For determining need for staff review, the Multilayer Perceptron model had highest accuracy (AUC 0.86; 4.85% false negatives; and 4.63% false positives); with addition of heuristics (specified keywords) fewer false negatives were identified (3.19%), with small increase in false positives (7.66%) and AUC 0.79. Application of this model would result in 26.7% of SMS text messaging replies requiring review (true + false positives). The ensemble model produced the lowest false negatives (1.43%) at the expense of higher false positives (16.19%). OneVsRest was the most accurate (72.3%) for the 12-category classification. CONCLUSIONS: The ML program has high sensitivity for identifying the SMS text messaging replies requiring staff input; however, future research is required to validate the models against larger data sets. Incorporation of an ML program to review SMS text messaging replies could significantly reduce staff workload, as staff would not have to review all incoming SMS text messages. This could lead to substantial improvements in cost-effectiveness, scalability, and capacity of SMS text messaging-based interventions.

16.
BMC Fam Pract ; 21(1): 79, 2020 05 06.
Artigo em Inglês | MEDLINE | ID: mdl-32375662

RESUMO

BACKGROUND: Atrial fibrillation (AF) and other arrhythmias are prevalent and often encountered by general practitioners (GPs). In response to the growing prevalence and to assist practitioners in the diagnosis and management of AF, the Cardiac Society of Australia & New Zealand and Heart Foundation of Australia published the first Australian AF Guidelines in 2018. We aimed to examine (a) the proportion of GPs who performed any form of AF screening and identify the methods they applied, (b) GPs' awareness of the AF Guidelines and approaches to arrhythmia screening, (c) the roles of conventional 12-lead ECG and mobile health devices, and (d) GPs' confidence in ECG interpretation and need for training. METHODS: A cross-sectional online survey titled "GPs Screen their patients for Atrial Fibrillation and othEr aRrhythmia (GPSAFER)" was conducted from October 2018 to March 2019. The participants were recruited via various GP networks across Australia. Ethics approval was granted by The University of Sydney. RESULTS: A total of 463 surveys were completed. Many GPs (394/463, 85.1%, 95% CI 81.5-88.2%) performed some forms of AF screening and applied at least one AF screening method, most frequently pulse palpation (389/463, 84.0%). Some (299/463, 64.6%) GPs considered assessing their patients for other arrhythmias (237/299, 79.3% for complete heart block and 236/299, 78.9% for long-QT). Most GPs (424/463, 91.6%) were not using mobile ECG devices in their practice but some (147/463, 31.7%) were contemplating it. One third (175/463, 37.8%) of GPs were aware of the Australian AF Guidelines; those aware were more likely to perform AF screening (98.9% vs 76.7%, p <  0.001). Factors significantly and positively associated with AF screening were "awareness of the AF Guidelines" (p <  0.001), "number of years working in general practice" (p <  0.001), and "confidence in ECG interpretation of AF" (p = 0.003). Most GPs reported that they were very or extremely confident in interpreting AF (381/463, 82.3%) and complete heart block (266/463, 57.5%). Many GPs (349/463, 75.4%) would like to receive online ECG interpretation training. CONCLUSIONS: Assessment of arrhythmias is common in general practice and GPs are open to further training in ECG interpretation and using mobile ECG devices to aid their clinical practice. Increasing awareness of AF Guidelines and improving confidence in ECG interpretation may increase AF screening.

17.
Inquiry ; 57: 46958020910305, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32349581

RESUMO

As pressure increases on public health systems globally, a potential consequence is that this is transferred to patients in the form of longer waiting times to receive care. In this review, we overview what waiting for health care encompasses, its measurement, and the data available in terms of trends and comparability. We also discuss whether waiting time is equally distributed according to socioeconomic status. Finally, we discuss the policy implications and potential approaches to addressing the burden of waiting time. Waiting time for elective surgery and emergency department care is the best described type of waiting time, and it either increases or remains unchanged across multiple developed countries. There are many challenges in drawing direct comparisons internationally, as definitions for these types of waiting times vary. There are less data on waiting time from other settings, but existing data suggest waiting time presents a significant barrier to health care access for a range of health services. There is also evidence that waiting time is unequally distributed to those of lower socioeconomic status, although this may be improving in some countries. Further work to better clarify definitions, identify driving factors, and understand hidden waiting times and identify opportunities for reducing waiting time or better using waiting time could improve health outcomes of our health services.


Assuntos
Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde , Listas de Espera , Austrália , Inglaterra , Europa (Continente) , Saúde Global , Acesso aos Serviços de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/tendências , Humanos , Fatores Socioeconômicos
18.
Heart ; 106(16): 1211-1217, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32393588

RESUMO

With increasing use of handheld ECG devices for atrial fibrillation (AF) screening, it is important to understand their accuracy in community and hospital settings and how it differs among settings and other factors. A systematic review of eligible studies from community or hospital settings reporting the diagnostic accuracy of handheld ECG devices (ie, devices producing a rhythm strip) in detecting AF in adults, compared with a gold standard 12-lead ECG or Holter monitor, was performed. Bivariate hierarchical random-effects meta-analysis and meta-regression were performed using R V.3.6.0. The search identified 858 articles, of which 14 were included. Six studies recruited from community (n=6064 ECGs) and eight studies from hospital (n=2116 ECGs) settings. The pooled sensitivity was 89% (95% CI 81% to 94%) in the community and 92% (95% CI 83% to 97%) in the hospital. The pooled specificity was 99% (95% CI 98% to 99%) in the community and 95% (95% CI 90% to 98%) in the hospital. Accuracy of ECG devices varied: sensitivity ranged from 54.5% to 100% and specificity ranged from 61.9% to 100%. Meta-regression showed that setting (p=0.032) and ECG device type (p=0.022) significantly contributed to variations in sensitivity and specificity. The pooled sensitivity and specificity of single-lead handheld ECG devices were high. Setting and handheld ECG device type were significant factors of variation in sensitivity and specificity. These findings suggest that the setting including user training and handheld ECG device type should be carefully reviewed.

19.
Heart Lung Circ ; 29(7): e94-e98, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32418875

RESUMO

Up to one-third of COVID-19 patients admitted to intensive care develop an acute cardiomyopathy, which may represent myocarditis or stress cardiomyopathy. Further, while mortality in older patients with COVID-19 appears related to multi-organ failure complicating acute respiratory distress syndrome (ARDS), the cause of death in younger patients may be related to acute heart failure. Cardiac involvement needs to be considered early on in critically ill COVID-19 patients, and even after the acute respiratory phase is passing. This Statement presents a screening algorithm to better identify COVID-19 patients at risk for severe heart failure and circulatory collapse, while balancing the need to protect health care workers and preserve personal protective equipment (PPE). The significance of serum troponin levels and the role of telemetry and targeted transthoracic echocardiography (TTE) in patient investigation and management are addressed, as are fundamental considerations in the management of acute heart failure in COVID-19 patients.


Assuntos
Cardiologia , Infecções por Coronavirus , Insuficiência Cardíaca , Controle de Infecções , Miocardite , Pandemias , Administração dos Cuidados ao Paciente/métodos , Pneumonia Viral , Austrália/epidemiologia , Betacoronavirus , Cardiologia/métodos , Cardiologia/organização & administração , Cardiologia/tendências , Consenso , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Estado Terminal/terapia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Miocardite/complicações , Miocardite/virologia , Nova Zelândia/epidemiologia , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Risco Ajustado/métodos , Sociedades Médicas
20.
Lancet ; 396(10244): 97-109, 2020 07 11.
Artigo em Inglês | MEDLINE | ID: mdl-32445693

RESUMO

BACKGROUND: Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies. METHODS: In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death. FINDINGS: From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease. INTERPRETATION: Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men. FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).


Assuntos
Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/prevenção & controle , Países em Desenvolvimento/economia , Adulto , Idoso , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/epidemiologia , Estudos de Casos e Controles , Causas de Morte/tendências , Doença das Coronárias/epidemiologia , Países em Desenvolvimento/estatística & dados numéricos , Estudos Epidemiológicos , Feminino , Estilo de Vida Saudável/fisiologia , Humanos , Incidência , Renda , Masculino , Pessoa de Meia-Idade , Pobreza , Estudos Prospectivos , Fatores de Risco , População Rural , Prevenção Secundária , Fatores Socioeconômicos
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