Digital Health to Improve Australians Experience of Care: The case of melanoma post-treatment care

Improving access to care is not enough if it is not effectively delivered. Poor quality healthcare services have proven to slow progress to achieve better health outcomes and substantially increase the societal and economic burden of diseases. It is essential to provide healthcare services that constantly meet client-specific needs, which vary widely per individual, and to consider factors such as sociodemographic, psychological, health conditions. The emergence of digital technologies has played a critical role in the advancement of the healthcare sector. However, there remains critical knowledge-gaps demonstrating best practices to support digital health adoption and integration. The current research aimed to address this gap by making a case for providing a user-informed digital health model to improve Australians’ experience of melanoma post-treatment care. It captured information about the experience of care from a melanoma patient’s perspective and attitude toward digital health interventions. The data were collected through an online questionnaire developed based on clinical recommendations from melanoma guidelines and the literature. 95 patients were investigated, as well as their attitude toward digital health. Overall, 30% expressed difficulties accessing care due to geographical barriers, cost and time pressure. A majority presented signs of distress and desire for more educational and psychosocial support. The data also identified significant associations between access and psychological distress. Overall, participants reported positive attitudes toward the use of digital health, particularly if it can improve their quality of life. The findings showed that adapted uses of digital health could increase self-management and healthy behaviour; reduce psychological distress and social isolation; enable timely access to healthcare providers and communication, and support collaboration between clinicians. However, the study also reported a substantial lack of knowledge and awareness about technologies made available to melanoma patients. Recommendations on where to start and how we could encourage digital health uptake to provide high-quality, effective and adequate care are proposed. The thesis concludes on a call to action for healthcare stakeholders to ‘upgrade’ the existing melanoma healthcare system

188: Prevalence of early repolarization in congenital long QT syndrome A combination of early and delayed repolarization

Introductionearly repolarization (ER) in Brugada or short QT syndrome is common and has been associated to a less favourable outcome. Even if apparently paradoxical, ER can also be seen in long QT (LQT) but prevalence and correlations to other variables are unknown.Methods12 lead ECG of 37 LQT pts (19 men, 39±21 yo) and 80 matched controls were reviewed. LQT pts were selected by a positive genetic testing (n=27) or by showing abnormal T wave and long QT interval (n=10) either spontaneously or during epinephrin infusion. ER was defined by >1mm J point elevation in the inferior or lateral leads with notch or slurring pattern. Presence of ER was correlated to the clinical and ECG characteristics and results genetic analysis.ResultsQT was 409±53 msec in pts and 372±24 in controls (p<0.0001) (QTc 476±52 vs 392±26 msec, p<0.0001). Two LQT pts presented with resuscitated sudden death and 4 with syncope at the time of diagnosis.14/37 LQT pts (38%) had ER compared to 17/80 (21%) controls (p=0.05).ER was more frequent in men (12/19, 63%) compared to women (2/18, 11%) (p=0.001) but was not correlated to age. Pts with ER had slower heart rate (63±10 vs 75±18 bpm, p=0.02).ER was not correlated to symptoms or cardiac events (no ER in the 2 pts with SD and in 2/4 pts with syncope).QT were longer in pts with ER (450±68 vs 397±54 msec in V2, p=0.01) but there was no correlations between ER and corrected QT intervals.ER was more often seen in pts with or without mutations although non significantly (8/27 vs 6/10, p=0.09), but there was a trend toward more frequent ER in case of HeRG mutations (6/12) than KCNQ1 or KCNJ2 mutations (2/11 and 0/4) (p=0.09).ConclusionER is very common in LQT pts and is related to the gender and to the heart rate but not to the corrected QT duration. ER does not seem to be correlated to cardiac events in this series but may be linked to some gene mutations. Further studies are needed for demonstrating additional mutations/ variants or the existence of an early transient voltage gradient due to altered kinetics in muted potassium channels with loss of function

Measures of Right Atrial Organization as a Mean to Select Candidates for Sinus Rhythm Restoration by Catheter Ablation

Stepwise catheter ablation (step-CA) can terminate long-standing persistent atrial fibrillation (LS-pAF) within the left atrium (LA) or may require additional right atrial (RA) ablation. Intracardiac organization indices such as AF cycle length (AFCL) have been used to track the efficiency of step-CA, but predictive parameters of procedural success are lacking. In this study, we hypothesized that the oscillations of time intervals between consecutive AF wavefronts reflect the underlying AF dynamic. We report a new method for quantifying the temporal variability of atrial activation wavefronts (VAW). Our results suggest that the mean and variance of the oscillations around the mean AFCL computed before any ablation can identify patients whose LS-pAF will terminate within the left atrium. These findings are indicative of a higher baseline organization in AF terminated within the left atrium

Changes in insulin resistance indicators, IGFs, and adipokines in a year-long trial of aerobic exercise in postmenopausal women

Physical activity is a known modifiable lifestyle means for reducing postmenopausal breast cancer risk, but the biologic mechanisms are not well understood. Metabolic factors may be involved. In this study, we aimed to determine the effects of exercise on insulin resistance (IR) indicators, IGF1, and adipokines in postmenopausal women. The Alberta Physical Activity and Breast Cancer Prevention Trial was a two-armed randomized controlled trial in postmenopausal, inactive, cancer-free women. A year-long aerobic exercise intervention of 225 min/week (n=160) was compared with a control group asked to maintain usual activity levels (n=160). Baseline, 6- and 12-month serum levels of insulin, glucose, IGF1, IGF-binding protein 3 (IGFBP3), adiponectin, and leptin were assayed, and after data collection, homeostasis model assessment of IR (HOMA-IR) scores were calculated. Intention-to-treat analyses were performed using linear mixed models. The treatment effect ratio (TER) of exercisers to controls was calculated. Data were available on 308 (96.3%) women at 6 months and 310 (96.9%) women at 12 months. Across the study period, statistically significant reductions in insulin (TER=0.87, 95% confidence interval (95% CI)=0.81–0.93), HOMA-IR (TER=0.86, 95% CI=0.80–0.93), and leptin (TER=0.82, 95% CI=0.78–0.87), and an increase in the adiponectin/leptin ratio (TER=1.21, 95% CI=1.13–1.28) were observed in the exercise group compared with the control group. No significant differences were observed for glucose, IGF1, IGFBP3, adiponectin or the IGF1/IGFBP3 ratio. Previously inactive postmenopausal women who engaged in a moderate-to-vigorous intensity exercise program experienced changes in insulin, HOMA-IR, leptin, and adiponectin/leptin that might decrease the risk for postmenopausal breast cancer

Radio-frequency ablation as primary management of well-tolerated sustained monomorphic ventricular tachycardia in patients with structural heart disease and left ventricular ejection fraction over 30%

Aims Patients with well-tolerated sustained monomorphic ventricular tachycardia (SMVT) and left ventricular ejection fraction (LVEF) over 30% may benefit from a primary strategy of VT ablation without immediate need for a ‘back-up' implantable cardioverter-defibrillator (ICD). Methods and results One hundred and sixty-six patients with structural heart disease (SHD), LVEF over 30%, and well-tolerated SMVT (no syncope) underwent primary radiofrequency ablation without ICD implantation at eight European centres. There were 139 men (84%) with mean age 62 ± 15 years and mean LVEF of 50 ± 10%. Fifty-five percent had ischaemic heart disease, 19% non-ischaemic cardiomyopathy, and 12% arrhythmogenic right ventricular cardiomyopathy. Three hundred seventy-eight similar patients were implanted with an ICD during the same period and serve as a control group. All-cause mortality was 12% (20 patients) over a mean follow-up of 32 ± 27 months. Eight patients (40%) died from non-cardiovascular causes, 8 (40%) died from non-arrhythmic cardiovascular causes, and 4 (20%) died suddenly (SD) (2.4% of the population). All-cause mortality in the control group was 12%. Twenty-seven patients (16%) had a non-fatal recurrence at a median time of 5 months, while 20 patients (12%) required an ICD, of whom 4 died (20%). Conclusion Patients with well-tolerated SMVT, SHD, and LVEF > 30% undergoing primary VT ablation without a back-up ICD had a very low rate of arrhythmic death and recurrences were generally non-fatal. These data would support a randomized clinical trial comparing this approach with others incorporating implantation of an ICD as a primary strateg

The Canadian Perinatal Network: A National Network Focused on Threatened Preterm Birth at 22 to 28 Weeks\u27 Gestation

Objective: The Canadian Perinatal Network (CPN) maintains an ongoing national database focused on threatened very preterm birth. The objective of the network is to facilitate between-hospital comparisons and other research that will lead to reductions in the burden of illness associated with very preterm birth. Methods: Women were included in the database if they were admitted to a participating tertiary perinatal unit at 22+0 to 28+6 weeks\u27 gestation with one or more conditions most commonly responsible for very preterm birth, including spontaneous preterm labour with contractions, incompetent cervix, prolapsing membranes, preterm prelabour rupture of membranes, gestational hypertension, intrauterine growth restriction, or antepartum hemorrhage. Data were collected by review of maternal and infant charts, entered directly into standardized electronic data forms and uploaded to the CPN via a secure network. Results: Between 2005 and 2009, the CPN enrolled 2524 women from 14 hospitals including those with preterm labour and contractions (27.4%), short cervix without contractions (16.3%), prolapsing membranes (9.4%), antepartum hemorrhage (26.0%), and preterm prelabour rupture of membranes (23 0%) The mean gestational age at enrolment was 25.9 ± 1.9 weeks and the mean gestation age at delivery was 29.9 ± 5.1 weeks; 57.0% delivered at \u3c 29 weeks and 75.4% at \u3c 34 weeks. Complication rates were high and included serious maternal complications (26 7%), stillbirth (8.2%), neonatal death (16.3%), neonatal intensive care unit admission (60 7%), and serious neonatal morbidity (35 0%). Conclusion: This national dataset contains detailed information about women at risk of very preterm birth. It is available to clinicians and researchers who are working with one or more CPN collaborators and who are interested in studies relating processes of care to maternal or perinatal outcomes

Multi-national survey on the methods, efficacy, and safety on the post-approval clinical use of pulsed field ablation (MANIFEST-PF).

AIMS Pulsed field ablation (PFA) is a novel atrial fibrillation (AF) ablation modality that has demonstrated preferential tissue ablation, including no oesophageal damage, in first-in-human clinical trials. In the MANIFEST-PF survey, we investigated the 'real world' performance of the only approved PFA catheter, including acute effectiveness and safety-in particular, rare oesophageal effects and other unforeseen PFA-related complications. METHODS AND RESULTS This retrospective survey included all 24 clinical centres using the pentaspline PFA catheter after regulatory approval. Institution-level data were obtained on patient characteristics, procedure parameters, acute efficacy, and adverse events. With an average of 73 patients treated per centre (range 7-291), full cohort included 1758 patients: mean age 61.6 years (range 19-92), female 34%, first-time ablation 94%, paroxysmal/persistent AF 58/35%. Most procedures employed deep sedation without intubation (82.1%), and 15.1% were discharged same day. Pulmonary vein isolation (PVI) was successful in 99.9% (range 98.9-100%). Procedure time was 65 min (38-215). There were no oesophageal complications or phrenic nerve injuries persisting past hospital discharge. Major complications (1.6%) were pericardial tamponade (0.97%) and stroke (0.4%); one stroke resulted in death (0.06%). Minor complications (3.9%) were primarily vascular (3.3%), but also included transient phrenic nerve paresis (0.46%), and TIA (0.11%). Rare complications included coronary artery spasm, haemoptysis, and dry cough persistent for 6 weeks (0.06% each). CONCLUSION In a large cohort of unselected patients, PFA was efficacious for PVI, and expressed a safety profile consistent with preferential tissue ablation. However, the frequency of 'generic' catheter complications (tamponade, stroke) underscores the need for improvement

Structural MRI predicts clinical progression in presymptomatic genetic frontotemporal dementia: findings from the GENetic Frontotemporal dementia Initiative (GENFI) cohort

Abstract Biomarkers that can predict disease progression in individuals with genetic frontotemporal dementia are urgently needed. We aimed to identify whether baseline MRI-based grey and white matter abnormalities are associated with different clinical progression profiles in presymptomatic mutation carriers in the GENetic Frontotemporal dementia Initiative. 387 mutation carriers were included (160 GRN, 160 C9orf72, 67 MAPT), together with 240 non-carrier cognitively normal controls. Cortical and subcortical grey matter volumes were generated using automated parcellation methods on volumetric 3 T T1-weighted MRI scans, while white matter characteristics were estimated using diffusion tensor imaging. Mutation carriers were divided into two disease stages based on their global CDR®+NACC-FTLD score: presymptomatic (0 or 0.5) and fully symptomatic (1 or greater). W-scores in each grey matter volumes and white matter diffusion measures were computed to quantify the degree of abnormality compared to controls for each presymptomatic carrier, adjusting for their age, sex, total intracranial volume, and scanner type. Presymptomatic carriers were classified as “normal” or “abnormal” based on whether their grey matter volume and white matter diffusion measure w-scores were above or below the cut point corresponding to the 10th percentile of the controls. We then compared the change in disease severity between baseline and one year later in both the “normal” and “abnormal” groups within each genetic subtype, as measured by the CDR®+NACC-FTLD sum-of-boxes score and revised Cambridge Behavioural Inventory total score. Overall, presymptomatic carriers with normal regional w-scores at baseline did not progress clinically as much as those with abnormal regional w-scores. Having abnormal grey or white matter measures at baseline was associated with a statistically significant increase in the CDR®+NACC-FTLD of up to 4 points in C9orf72 expansion carriers, and 5 points in the GRN group as well as a statistically significant increase in the revised Cambridge Behavioural Inventory of up to 11 points in MAPT, 10 points in GRN, and 8 points in C9orf72 mutation carriers. Baseline regional brain abnormalities on MRI in presymptomatic mutation carriers are associated with different profiles of clinical progression over time. These results may be helpful to inform stratification of participants in future trials