A complementary medicine student-led telehealth clinic: evaluating learning & teaching perceptions

OBJECTIVES

This study evaluates a multi-centered complementary medicine (CM) student-led telehealth clinic during the COVID-19 pandemic. Likert and qualitative responses explore student and educator learning and teaching perceptions of the implementation of a successful telehealth clinic.

RESULTS

51 students and 17 educators completed the survey. Respondents agreed that support from educators (90%) and orientation (70%) assisted effective performance. Over 90% (93%) of all respondents supported telehealth in student-led clinics, whilst 87% encountered barriers such as technical and infrastructure issues. Respondents agreed that telehealth practice skills improved in case history taking (90%), treatment (90%) and building patient rapport (60%). Respondents (61%) disagreed that physical examination was effectively performed, and 100% of respondents agreed telehealth was a valuable learning experience. This study is the first to explore student and educator perceptions of telehealth in an Australian University multi-centered CM student-led clinic. To be successful in an educational environment, students and educators require digital literacy and adequate telehealth practice infrastructure. Whilst some in-person practice skills are transferable to telehealth, educators need to adapt curriculum to ensure counselling and physical examination skills are specifically taught for virtual consultations. Telehealth in clinical practice requires continued investigation and educational development.

The influence of aortic stiffness on carotid stiffness: computational simulations using a human aorta carotid model

Increased aortic and carotid stiffness are independent predictors of adverse cardiovascular events. Arterial stiffness is not uniform across the arterial tree and its accurate assessment is challenging. The complex interactions and influence of aortic stiffness on carotid stiffness have not been investigated. The aim of this study was to evaluate the effect of aortic stiffness on carotid stiffness under physiological pressure conditions. A realistic patient-specific geometry was used based on magnetic resonance images obtained from the OsiriX library. The luminal aortic-carotid model was reconstructed from magnetic resonance images using 3D Slicer. A series of aortic stiffness simulations were performed at different regional aortic areas (levels). By applying variable Young's modulus to the aortic wall under two pulse pressure conditions, one could examine the deformation, compliance and von Mises stress between the aorta and carotid arteries. An increase of Young's modulus in an aortic area resulted in a notable difference in the mechanical properties of the aortic tree. Regional deformation, compliance and von Mises stress changes across the aorta and carotid arteries were noted with an increase of the aortic Young's modulus. Our results indicate that increased carotid stiffness may be associated with increased aortic stiffness. Large-scale clinical validation is warranted to examine the influence of aortic stiffness on carotid stiffness.

A novel transcranial photobiomodulation device to address motor signs of Parkinson's disease: a parallel randomised feasibility study

BACKGROUND

Parkinson's disease is a progressive neurological disease with limited treatment options. Animal models and a proof-of-concept case series have suggested that photobiomodulation may be an effective adjunct treatment for the symptoms of Parkinson's disease. The aim was to determine the safety and feasibility of transcranial photobiomodulation (tPBM) to reduce the motor signs of Parkinson's disease.

METHODS

In this double-blind, randomised, sham-controlled feasibility trial, patients (aged 59-85 years) with idiopathic Parkinson's disease were treated with a tPBM helmet for 12 weeks (72 treatments with either active or sham therapy; stage 1). Treatment was delivered in the participants' homes, monitored by internet video conferencing (Zoom). Stage 1 was followed by 12 weeks of no treatment for those on active therapy (active-to-no-treatment group), and 12 weeks of active treatment for those on sham (sham-to-active group), for participants who chose to continue (stage 2). The active helmet device delivered red and infrared light to the head for 24 min, 6 days per week. The primary endpoints were safety and motor signs, as assessed by a modified Movement Disorders Society revision of the Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS-III)-motor scale. This trial is registered with ANZCTR, ACTRN 12621001722886.

FINDINGS

Between Dec 6, 2021, and Aug 12, 2022, 20 participants were randomly allocated to each of the two groups (10 females plus 10 males per group). All participants in the active group and 18 in the sham group completed 12 weeks of treatment. 14 participants in the sham group chose to continue to active treatment and 12 completed the full 12 weeks of active treatment. Treatment was well tolerated and feasible to deliver, with only minor, temporary adverse events. Of the nine suspected adverse events that were identified, two minor reactions may have been attributable to the device in the sham-to-active group during the active treatment weeks of the trial. One participant experienced temporary leg weakness. A second participant reported decreased fine motor function in the right hand. Both participants continued the trial. The mean modified MDS-UPDRS-III scores for the sham-to-active group at baseline, after 12 weeks of sham treatment, and after 12 weeks of active treatment were 26.8 (sd 14.6), 20.4 (sd 12.8), and 12.2 (sd 8.9), respectively, and for the active-to-no-treatment group these values were 21.3 (sd 9.4), 16.5 (sd 9.4), and 15.3 (sd 10.8), respectively. There was no significant difference between groups at any assessment point. The mean difference between groups at baseline was 5.5 (95% confidence interval (CI) -2.4 to 13.4), after stage 1 was 3.9 (95% CI -3.5 to 11.3 and after stage 2 was -3.1 (95% CI 2.7 to -10.6).

INTERPRETATION

Our findings add to the evidence base to suggest that tPBM is a safe, tolerable, and feasible non-pharmaceutical adjunct therapy for Parkinson's disease. While future work is needed our results lay the foundations for an adequately powered randomised placebo-controlled clinical trial.

FUNDING

SYMBYX Pty Ltd.

Estimating mean population salt intake using spot urine samples in Nepal: a cross-sectional study

INTRODUCTION

Little is known about the usefulness of spot urine testing compared with 24-h urine samples to estimate salt intake in low-income settings. This is given 24-h urinary collection can be costly, burdensome, and impractical in population surveys. The primary objective of the study was to compare urinary sodium levels (as an estimate of salt intake) of Nepalese population between 24-h urine and spot urine using previously established spot urine-based equations. Additionally, this study explored the 24-h prediction of creatinine and potassium excretion from spot urine samples using available prediction equations.

METHODS

The sample population was derived from the community-based survey conducted in Nepal in 2018. Mean salt intake was estimated from spot urine samples comparing previously published equations, and this was then contrasted with mean salt intake estimations from 24-h urine samples, using paired t test, Pearson correlation coefficient, intraclass correlation coefficient, and Bland-Altman plots.

RESULTS

A total of 451 participants provided both complete 24-h and morning spot urine samples. Unweighted mean (±SD) salt intake based on 24-h urine collection was 13.28 ± 4.72 g/day. The corresponding estimates were 15.44 ± 5.92 g/day for the Kawasaki, 11.06 ± 3.17 g/day for the Tanaka, 15.22 ± 16.72 g/day for the Mage, 10.66 ± 3.35 g/day for the Toft, 8.57 ± 1.72 g/day for the INTERSALT with potassium, 8.51 ± 1.73 g/day for the INTERSALT without potassium, 7.88 ± 1.94 g/day for the Whitton, 18.13 ± 19.92 g/day for the Uechi simple-mean and 12.07 ± 1.77 g/day using the Uechi regression. As compared with 24-h urine estimates, all equations showed significant mean differences (biases); the Uechi regression had the least difference with 9% underestimation (-1.21 g/day, P  < 0.001).Proportional biases were evident for all equations depending on the level of salt intake in the Bland-Altman plots.

CONCLUSION

None of the included spot urine-based equations accurately corresponded to 24-h salt intake in the present study. These equations may be useful for longitudinal monitoring of population salt intake in Nepal, our study highlights that there are limitations on using existing equations for estimating mean salt intake in Nepali population. Further studies are warranted for accuracy and validation.

Transcriptomic Comparison of Human Peripartum and Dilated Cardiomyopathy Identifies Differences in Key Disease Pathways

Peripartum cardiomyopathy (PPCM) is a rare form of acute onset heart failure that presents in otherwise healthy pregnant women around the time of delivery. While most of these women respond to early intervention, about 20% progress to end-stage heart failure that symptomatically resembles dilated cardiomyopathy (DCM). In this study, we examined two independent RNAseq datasets from the left ventricle of end-stage PPCM patients and compared gene expression profiles to female DCM and non-failing donors. Differential gene expression, enrichment analysis and cellular deconvolution were performed to identify key processes in disease pathology. PPCM and DCM display similar enrichment in metabolic pathways and extracellular matrix remodeling suggesting these are similar processes across end-stage systolic heart failure. Genes involved in golgi vesicles biogenesis and budding were enriched in PPCM left ventricles compared to healthy donors but were not found in DCM. Furthermore, changes in immune cell populations are evident in PPCM but to a lesser extent compared to DCM, where the latter is associated with pronounced pro-inflammatory and cytotoxic T cell activity. This study reveals several pathways that are common to end-stage heart failure but also identifies potential targets of disease that may be unique to PPCM and DCM.

Comparison of Parameters for Assessment of Carotid Stiffness and Their Association with Carotid Atherosclerosis in Rural Australian Adults: A Pilot Study

Carotid stiffness has been associated with the development and progression of carotid artery disease and is an independent factor for stroke and dementia. There has also been a lack of comparison of different ultrasound-derived carotid stiffness parameters and their association with carotid atherosclerosis. This pilot study aimed to investigate the associations between carotid stiffness parameters (derived via ultrasound echo tracking) and the presence of carotid plaques in Australian rural adults. In cross-sectional analyses, we assessed forty-six subjects (68 ± 9 years; mean ± SD) who underwent carotid ultrasound examinations. Carotid stiffness was assessed by a noninvasive echo-tracking method, measuring and comparing multiple carotid stiffness parameters, including stroke change in diameter (ΔD), stroke change in lumen area (ΔA), β- stiffness index, pulse wave velocity beta (PWV-β), compliance coefficient (CC), distensibility coefficient (DC), Young's elastic modulus (YEM), Peterson elastic modulus (Ep), and strain. Carotid atherosclerosis was assessed bilaterally by the presence of plaques in the common and internal carotid arteries, while carotid stiffness was assessed at the right common carotid artery. β-stiffness index, PWV-β, and Ep were significantly higher (p = 0.006, p = 0.004, p = 0.02, respectively), whilst ΔD, CC, DC, and strain were lower among subjects with carotid plaques (p = 0.036, p = 0.032, p = 0.01, p = 0.02, respectively) comparing to subjects without carotid plaques. YEM and ΔA did not significantly differ among the groups. Carotid plaques were associated with age, history of stroke, coronary artery disease, and previous coronary interventions. These results suggest that unilateral carotid stiffness is associated with the presence of carotid plaques.

A Randomized Placebo-Controlled Study of a Transcranial Photobiomodulation Helmet in Parkinson's Disease: Post-Hoc Analysis of Motor Outcomes

Emerging evidence is increasingly supporting the use of transcranial photobiomodulation (tPBM) to improve symptoms of neurodegenerative diseases, including Parkinson's disease (PD). The objective of this study was to analyse the safety and efficacy of tPBM for PD motor symptoms. The study was a triple blind, randomized placebo-controlled trial with 40 idiopathic PD patients receiving either active tPBM (635 nm plus 810 nm LEDs) or sham tPBM for 24 min per day (56.88J), six days per week, for 12 weeks. The primary outcome measures were treatment safety and a 37-item MDS-UPDRS-III (motor domain) assessed at baseline and 12 weeks. Individual MDS-UPDRS-III items were clustered into sub-score domains (facial, upper-limb, lower-limb, gait, and tremor). The treatment produced no safety concerns or adverse events, apart from occasional temporary and minor dizziness. There was no significant difference in total MDS-UPDRS-III scores between groups, presumably due to the placebo effect. Additional analyses demonstrated that facial and lower-limb sub-scores significantly improved with active treatment, while gait and lower-limb sub-scores significantly improved with sham treatment. Approximately 70% of participants responded to active treatment (≥5 decrease in MDS-UPDRS-III score) and improved in all sub-scores, while sham responders improved in lower-limb sub-scores only. tPBM appears to be a safe treatment and improved several PD motor symptoms in patients that responded to treatment. tPBM is proving to be increasingly attractive as a possible non-pharmaceutical adjunct therapy.

A Narrative Review of Commercial Platforms Offering Tracking of Heart Rate Variability in Corporate Employees to Detect and Manage Stress

The COVID-19 pandemic has resulted in employees being at risk of significant stress. There is increased interest by employers to offer employees stress monitoring via third party commercial sensor-based devices. These devices assess physiological parameters such as heart rate variability and are marketed as an indirect measure of the cardiac autonomic nervous system. Stress is correlated with an increase in sympathetic nervous activity that may be associated with an acute or chronic stress response. Interestingly, recent studies have shown that individuals affected with COVID will have some residual autonomic dysfunction that will likely render it difficult to track both stress and stress reduction using heart rate variability. The aims of the present study are to explore web and blog information using five operational commercial technology solution platforms that offer heart rate variability for stress detection. Across five platforms we found a number that combined HRV with other biometrics to assess stress. The type of stress being measured was not defined. Importantly, no company considered cardiac autonomic dysfunction because of post-COVID infection and only one other company mentioned other factors affecting the cardiac autonomic nervous system and how this may impact HRV accuracy. All companies suggested they could only assess associations with stress and were careful not to claim HRV could diagnosis stress. We recommend that managers think carefully about whether HRV is accurate enough for their employees to manage their stress during COVID.

Understanding Unmet Care Needs of Rural Older Adults with Chronic Health Conditions: A Qualitative Study

BACKGROUND

Rural populations experience poorer access to the necessary health services for chronic health conditions. Although studies of rural healthcare access continue to expand, most are based on quantitative data, yet normative views and lived experiences of rural adults might offer a better understanding of healthcare access and their specific unmet needs. This qualitative study sought the views of both rural-centric older people and healthcare professionals to understand health needs, barriers, and enablers of accessing health services, with a focus on chronic health condition(s).

METHODS

Between April and July 2022, separate in-depth interviews were conducted with 20 older people (≥60 years) in a rural South Australian community. Additionally, focus group interviews were conducted with 15 healthcare professionals involved in providing health services to older adults. Transcripts were coded using the NVivo software and data were thematically analysed.

RESULTS

Participants described a range of unmet care needs including chronic disease management, specialist care, psychological distress, and the need for formal care services. Four barriers to meeting care needs were identified: Workforce shortages, a lack of continuity of care, self-transportation, and long waiting times for appointments. Self-efficacy, social support, and positive provider attitudes emerged as crucial enabling factors of service use among rural ageing populations.

DISCUSSION

Older adults confront four broad ranges of unmet needs: Chronic disease management care, specialist care, psychological care, and formal care. There are potential facilitators, such as self-efficacy, provider positive attitudes, and social support, that could be leveraged to improve healthcare services access for older adults.

Work-related, socio-cultural, and personal factors associated with locus of control among Australian general practitioners

BACKGROUND

Locus of control (LoC) is a social cognition, that relates to the level of self-control that people have over their personal environment that influences their life. In this context, LoC is frequently associated with work-related behavioral outcomes, ranging from job attitudes, career behaviors, stress, and burnout.

OBJECTIVE

To investigate the association between LoC, and work-related behavioral factors, socio-cultural factors, and personal factors among Australian General Practitioners (GPs).

METHODS

This study utilized data from the 2010 Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors. Locus of control (LoC) was measured by a 7-point Likert scale based on Pearlin-Schooler Mastery/Self-efficacy 7-item Scale. Higher score indicated lower internal LoC. Multivariate linear regression model was performed to determine the independent predictors of LoC.

RESULTS

Of 3,664 GP participants, LoC did not differ by gender. Poor/fair self-rated health, working in urban location, running a stressful practice, poor balance of professional and personal commitments, poor support network, financial circumstances after retirement, and perception of unrealistic expectation by patients were significant predictors for a lower Internal LoC in a multivariate linear regression model. Adjusted R² explained 22.4% of variation in predicting the LoC in our models.

CONCLUSIONS

LoC of Australian GPs is negatively affected by poor work-life balance, inadequate support, and unrealistic patient expectation. These work-place specific factors could be targeted by interventions to improve GPs wellbeing.

Protocol for randomized controlled trial to evaluate the safety and feasibility of a novel helmet to deliver transcranial light emitting diodes photobiomodulation therapy to patients with Parkinson’s disease

Introduction

Parkinson’s disease (PD) is the second most common, progressive, and debilitating neurodegenerative disease associated with aging and the most common movement disorder. Photobiomodulation (PBM), the use of non-thermal light for therapeutic purposes using laser or light emitting diodes (LED) is an emerging non-invasive treatment for a diverse range of neurological conditions. The main objectives of this clinical trial are to investigate the feasibility, safety, tolerability, and efficacy of a novel transcranial LED helmet device (the “PDNeuro”) in the alleviation of symptoms of PD.

Methods and analysis

This is a 24-week, two-arm, triple-blinded randomized placebo-controlled clinical trial of a novel transcranial “PDNeuro” LED Helmet, comparing an active helmet to a sham helmet device. In a survey, 40 PD participants with Hoehn and Yahr Stage I–III during ON periods will be enrolled and randomly assigned into two groups. Both groups will be monitored weekly for the safety and tolerability of the “PDNeuro” LED Helmet. Clinical signs and symptoms assessed will include mobility, fine motor skills and cognition, with data collected at baseline, 12 weeks, and 24 weeks. Assessment tools include the TUG, UPDRS, and MoCA all validated for use in PD patients. Patient’s adherence to the device usage and participant drop out will be monitored weekly. At 12 weeks both placebo and treatment groups will crossover and placebo participants offered the treatment. The main indicator for clinical efficacy of the “PDneuro” Helmet is evidence of sustained improvements in motor and non-motor symptoms obtained from participant self-reported changes, carer reporting of changes and objective reassessment by the investigators. The outcomes will assist in a future larger randomized trial design.

Clinical Trial Registration

[https://www.anzctr.org.au], identifier [12621001722886].

Evaluation of home-based naturopathic telehealth clinic: an innovative COVID-19 pandemic response

OBJECTIVES

The COVID-19 pandemic in Australia disrupted usual clinical training placements for naturopathic students. An innovative, remote Telehealth clinic was developed and implemented. This pilot study evaluates student and educator learning and teaching experiences in Telehealth. A survey assessed Likert and qualitative written responses to student and staff interaction with the Telehealth clinic.

RESULTS

Nine student and 12 educator responses were included in the analysis. All students positively rated Telehealth training resources and the educator support provided. Students rated the Telehealth learning experience as 'very good' (78%) or 'good' (22%) with educator ratings of 'very good' (67%) or 'good' (33%). Thematic analysis of student written responses showed increased client diversity, collaboration, peer learning, increased feedback, and improved digital and technology skills. Virtual physical examination and infrastructure limitations were reported as Telehealth clinical practicum challenges. Naturopathic Telehealth clinic practicum is a valuable alternative to in-person clinical practicums for Australian students. It enhances student collaboration and peer learning. Challenges of technology, infrastructure and incorporating Telehealth in curriculum may be barriers to implementation of Telehealth. However, Telehealth is an important clinical training option to prepare student practitioners for contemporary professional practice if in-person consultation is prohibitive, such as during the COVID-19 pandemic.

Aromas Influencing the GABAergic System

Aromas have a powerful influence in our everyday life and are known to exhibit an array of pharmacological properties, including anxiolytic, anti-stress, relaxing, and sedative effects. Numerous animal and human studies support the use of aromas and their constituents to reduce anxiety-related symptoms and/or behaviours. Although the exact mechanism of how these aromas exert their anxiolytic effects is not fully understood, the GABAergic system is thought to be primarily involved. The fragrance emitted from a number of plant essential oils has shown promise in recent studies in modulating GABAergic neurotransmission, with GABA_A receptors being the primary therapeutic target. This review will explore the anxiolytic and sedative properties of aromas found in common beverages, such as coffee, tea, and whisky as well aromas found in food, spices, volatile organic compounds, and popular botanicals and their constituents. In doing so, this review will focus on these aromas and their influence on the GABAergic system and provide greater insight into viable anxiety treatment options.

The relationship between neurocognitive performance and HRV parameters in nurses and non-healthcare participants

Nurses represent the largest sector of the healthcare workforce, and it is established that they are faced with ongoing physical and mental demands that leave many continuously stressed. In turn, this chronic stress may affect cardiac autonomic activity, which can be non-invasively evaluated using heart rate variability (HRV). The association between neurocognitive parameters during acute stress situations and HRV has not been previously explored in nurses compared to non-nurses and such, our study aimed to assess these differences. Neurocognitive data were obtained using the Mini-Mental State Examination and Cognistat psychometric questionnaires. ECG-derived HRV parameters were acquired during the Trier Social Stress Test. Between-group differences were found in domain-specific cognitive performance for the similarities (p = .03), and judgment (p = .002) domains and in the following HRV parameters: SDNN_baseline, (p = .004), LF_preparation (p = .002), SDNN_preparation (p = .002), HF_preparation (p = .02), and TP_preparation (p = .003). Negative correlations were found between HF power and domain-specific cognitive performance in nurses. In contrast, both negative and positive correlations were found between HRV and domain-specific cognitive performance in the non-nurse group. The current findings highlight the prospective use of autonomic HRV markers in relation to cognitive performance while building a relationship between autonomic dysfunction and cognition.

Machine learning based deconvolution of microarray atrial samples from atrial fibrillation patients reveals increased fractions of follicular CD4+ T lymphocytes and gamma-delta T cells

A potential relationship between T cell immunity and development of atrial fibrillation (AF) has been proposed. Historically in AF patients it has been reported that peripheral blood had elevated CD4+ T cells. However few studies have explored whether there is a direct increase of CD4+ T cells in atrial tissues with AF. In this study, public domain micro-array dataset of cardiac surgery patients with atrial tissue biopsies in AF and non-AF patients have been used to explore immune cell subsets. Machine learning based deconvolution of permanent atrial fibrillation microarray atrial samples was applied using Cibersort to enumerate the relative fractions of twenty-two different leukocyte sub-populations. Cibersort enumerated significantly increased fractions of follicular CD4+ T lymphocytes and gamma-delta T cells in the atria of permanent AF subjects. Gene expression analysis of permanent AF microarray tissue samples with elevated follicular CD4+ T cell fractions with gene pathways associated with myocardial substrate remodelling. That is both integrin and non-integrin mediated gene interactions between inflammatory cells and the extra cellular matrix, including infiltrating follicular CD4+ T cells that trafficked to the atria by virtue of the repertoire of cell surfaced expressed adhesion molecules. Additionally, IL-17 and other interleukin inflammatory gene heat maps were associated with enhanced CD4+ follicular T cell expression in our profiled atrial tissues with AF. These observations suggest that atrial structural remodelling was associated with the presence of pathogenic T cell mediated inflammation, present in AF atria but not in non-AF atria.

Immune cell profile and immune-related gene expression of obese peripheral blood and liver tissue

Obesity is associated with changes in immune cell subpopulations. However, tissue and blood obesity-responsive immune phenotypic pathways have not been contrasted. Here, the local niche immune cell population and gene expression in fatty liver is compared to peripheral blood of obese individuals. The Cibersort algorithm enumerated increased fractions of memory CD4⁺ T lymphocytes and reductions in natural killer and memory B cells in obese liver tissue and obese blood, with similar reductions found in nonalcoholic fatty liver disease tissue. Gene expression analysis identified inflammatory immune signatures of regulatory CD4⁺ T cells with inferred Th1, Th17, Th2, or Treg phenotypes that differed between liver and blood. Our study suggests that the local tissue-specific immune phenotype in the liver differs from the obese peripheral circulation, with the latter reflective of multisystemic persistent inflammation that is characteristic of obesity.

RUNX1T1 rs34269950 is associated with obesity and metabolic syndrome

BACKGROUND

Runt-related transcription factor 1 (RUNX1T1) isoforms are involved in adipogenesis. RUNX1T1 is mediated by the fat mass and obesity-associated (FTO). However, the extent to which RUNX1T1 single-nucleotide polymorphisms (SNPs) are associated with obesity risk or metabolic abnormalities in a community population basis is unknown.

METHODS

Samples were obtained from the Australian Crossroads study bio-bank. SNPs located in the coding region and 3'untranslated regions of RUNX1T1 with minor allele frequency ≥0.05 were analysed using Taqman genotyping assays.

RESULTS

Eight candidate SNPs were genotyped successfully in 1440 participants. Of these SNPs only rs34269950 located in the 'RRACH' motif, the most common N6-methyladenosine (m6A) methylation modification site (recognized by FTO), was significantly associated with obesity risk and metabolic abnormalities. Specifically, compared to AA genotype, rs34269950 del/del genotype was associated with a 1.47 [95% confidence interval (CI): 1.01-2.14, P = 0.042] fold higher rate of obesity risk. Additionally, the del/del genotype was associated with a 60% increased risk of metabolic syndrome (MetS) [odds ratio (OR) = 1.60, 95% CI: 1.10-2.32, P = 0.015], in comparison to the AA genotype. Finally, rs34269950 del/del increased the risk of a larger waist circumference (OR = 1.65, 95% CI: 1.15-2.36, P = 0.007), but not other components of MetS.

CONCLUSION

Our study demonstrates that RUNX1T1 rs34269950, located in a potential FTO recognition motif, is significantly associated with waist circumference. This provides novel evidence to suggest SNPs located in RRACH motif may be involved in RNA m6A modification and mechanistic pathways that influence abdominal obesity.

The Prevalence of Chronic Physical and Mental Health Conditions in Older Adults Across South Australia and Their Independent Effects on General Practitioner Visits

Rural older adults (≥60), compared to their urban counterparts, are identified as higher users of general practitioner (GP) services. However, whether this pattern of health seeking is influenced more so by physical or mental conditions is unclear. We explore the independent effect of chronic physical and mental health conditions on GP use in Australia. Datasets on population health was available from the South Australia's Department of health in 2013-2017 (n = 20,522). We examined prevalence of common physical and mental conditions and GP use by the Modified Monash Model of remoteness. Physical and mental health burden was similar across South Australia. General practitioner visits with suicidal ideation for rural and remote locations were 4.7 (95% CI, 1.6-13.6) and 4.8 (95% CI, 1.9-11.7), respectively, compared to urban Adelaide 1.5 (95% CI, 1.0-2.3). While there is equal burden of mental health across South Australia, access to mental health resources for nonurban Australians remains a significant challenge.

Active commuting and leisure-time physical activity among adults in western Nepal: a cross-sectional study

OBJECTIVE

To determine the prevalence and sociodemographic factors associated with active commuting and leisure-time physical activity (LTPA) among adults in western Nepal.

DESIGN

Cross-sectional study.

SETTING

Adults from semiurban areas in western Nepal.

PARTICIPANTS

2815 adults aged 25-65 years who participated in the 'Community-Based Management of Hypertension in Nepal (COBIN)' Study. Multiple logistic regression analysis was used to identify the sociodemographic factors associated with active commuting and LTPA.

OUTCOME

Self-reported participation in active commuting and LTPA.

RESULTS

Most study participants (96%) commuted actively (walked or cycled) from one place to another. Our results showed that only a small proportion (3.7%) of participants engaged in moderate or vigorous LTPA. Compared with those in paid employment, the odds of commuting actively were higher among people working in agriculture or as labourers (OR: 4.57, 95% CI: 2.46 to 8.48), those retired/unemployed (OR: 2.98, 95% CI: 1.42 to 6.25) and those in unpaid employment (OR: 1.85, 95% CI: 1.06 to 3.22). Adults who were overweight or had obesity were less likely to commute actively. Compared with adults aged 25-34 years, older adults were less likely (OR: 0.35, 95% CI: 0.17 to 0.72) to engage in LTPA. Women were 0.46 times less likely to engage in LTPA compared with men.

CONCLUSION

Most adults engaged in active commuting for work or travel. Less than 5% participated in any form of moderate or vigorous LTPA. Longitudinal studies incorporating objective assessment of physical activity and a range of individual, interpersonal, and environmental factors will help understand how to promote active commuting and LTPA among Nepalese adults.Trial registration number: ClinicalTrials.gov NCT02428075.

Matrix Metalloproteinase-3 (MMP-3) Polymorphisms Are Associated with Prolonged ECG-Derived QTc Interval: A Cross-Sectional Study of the Australian Rural Population

Matrix metalloproteinases (MMPs) are enzymes that are integral in extracellular matrix (ECM) remodeling. In age or disease, ECM may become dysregulated and contribute to fibrosis, which impairs cardiac electrical conduction. Two alleles regulate matrix metalloproteinase-3 (MMP-3) activity: one with five adenosine bases (5A; associated with higher MMP-3 activity and decreased fibrosis) and another with six adenosine bases (6A; associated with lower MMP-3 activity and increased fibrosis). Here, we determined whether ECG-derived QTc and related parameters are associated with the MMP-3 5A/6A genotype in a cross-section of the Australian rural population. A retrospective cross-sectional population was obtained from the Charles Sturt University Diabetes Screening Research Initiative. Genotype and resting 12-lead ECG parameters of 295 participants were analyzed. Amongst these participants, 85 individuals carried the 5A/5A genotype, 141 individuals carried the 5A/6A genotype, and 65 individuals carried the 6A/6A genotype. Compared to 5A/5A genotype carriers, 5A/6A genotype carriers had a significantly longer QTc duration by 9.50 ms (95% CI: 3.48-15.52, p = 0.002), whilst 6A/6A genotype carriers had an even longer QTc duration by 12.19 ms (95% CI: 5.04-19.34, p = 0.001). We found an association between MMP-3 5A/6A polymorphisms and QTc, independent of adjustments for age, gender, alcohol consumption, smoking status, body mass index and blood pressure.

May Measurement Month 2019: an analysis of blood pressure screening results from Nepal

May Measurement Month (MMM) is a global initiative to screen high blood pressure (BP) in the community and increase awareness at the population level. High BP is the leading risk factor for mortality worldwide and in Nepal. This study presents the results of the 2019 MMM in Nepal. Opportunistic BP screening was conducted in 30 out of 77 districts across Nepal and aged ≥18 years at the community and public places. BP was measured three times in a seated position. A total of 74 205 individuals participated in the study, mean age 39.9 years, and 58% were male. BP measurements for the second and third readings were available for 69 292 (93.3%) individuals. The proportion of the population that were hypertensive was 27.5% (n = 20 429). Among those hypertensives, 46.3% were aware of their hypertensive status and of these, 37.5% were on antihypertensive medication. Only 54.3% of those on antihypertensive medication had their BP controlled. Of the community screened, those self reporting to have diabetes, current tobacco users, and current alcohol drinkers were 6.7%, 23.6%, and 31.9%, respectively; 20.6% of the participants were overweight, and 6.5% were obese. Since the first BP screening campaign, MMM 2017 in Nepal, the number of participants screened has largely increased over the years. MMM’s success in Nepal is through a coordinated mobilization of trained health science students and volunteers in the communities. The Nepal MMM data demonstrates that large community-based BP screening campaigns are possible in low resource settings.

Smart Devices and Wearable Technologies to Detect and Monitor Mental Health Conditions and Stress: A Systematic Review

Recently, there has been an increase in the production of devices to monitor mental health and stress as means for expediting detection, and subsequent management of these conditions. The objective of this review is to identify and critically appraise the most recent smart devices and wearable technologies used to identify depression, anxiety, and stress, and the physiological process(es) linked to their detection. The MEDLINE, CINAHL, Cochrane Central, and PsycINFO databases were used to identify studies which utilised smart devices and wearable technologies to detect or monitor anxiety, depression, or stress. The included articles that assessed stress and anxiety unanimously used heart rate variability (HRV) parameters for detection of anxiety and stress, with the latter better detected by HRV and electroencephalogram (EGG) together. Electrodermal activity was used in recent studies, with high accuracy for stress detection; however, with questionable reliability. Depression was found to be largely detected using specific EEG signatures; however, devices detecting depression using EEG are not currently available on the market. This systematic review highlights that average heart rate used by many commercially available smart devices is not as accurate in the detection of stress and anxiety compared with heart rate variability, electrodermal activity, and possibly respiratory rate.

Impact of acute stress on cortical electrical activity and cardiac autonomic coupling

Assessment of heart rate variability (reflective of the cardiac autonomic nervous system) has shown some predictive power for stress. Further, the predictive power of the distinct patterns of cortical brain activity and - cardiac autonomic interactions are yet to be explored in the context of acute stress, as assessed by an electrocardiogram and electroencephalogram. The present study identified distinct patterns of neural-cardiac autonomic coupling during both resting and acute stress states. In particular, during the stress task, frontal delta waves activity was positively associated with low-frequency heart rate variability and negatively associated with high-frequency heart rate variability. Low high-frequency power is associated with stress and anxiety and reduced vagal control. A positive association between resting high-frequency heart rate variability and frontocentral gamma activity was found, with a direct inverse relationship of low-frequency heart rate variability and gamma wave coupling at rest. During the stress task, low-frequency heart rate variability was positively associated with frontal delta activity. That is, the parasympathetic nervous system is reduced during a stress task, whereas frontal delta wave activity is increased. Our findings suggest an association between cardiac parasympathetic nervous system activity and frontocentral gamma and delta activity at rest and during acute stress. This suggests that parasympathetic activity is decreased during acute stress, and this is coupled with neuronal cortical prefrontal activity. The distinct patterns of neural-cardiac coupling identified in this study provide a unique insight into the dynamic associations between brain and heart function during both resting and acute stress states.

Factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events

BACKGROUND

The World Health Organization recommends consumption of a minimum of 400 g of fruits and vegetables per day for prevention of cardiovascular disease. Low fruit and vegetable intake is associated with an increased risk of stroke by 11% and ischemic heart disease by 31%. The present study aims to explore factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events (myocardial infarction and stroke).

METHOD

Data for this cross-sectional study were collected as part of the study "Community Based Management of Hypertension in Nepal" initiated in the Lekhnath Municipality in 2013. Demographic and nutrition information were collected using the WHO STEPwise approach to a surveillance tool. Descriptive statistics identified the frequency and percentage of fruit and vegetable intake. A Chi-square test examined the association between fruit and vegetable intake and history of self-reported cardiovascular events, socio-demographic and cardiovascular risk factors. Binary logistic regression analysis identified odds ratio with 95% confidence intervals between fruit and vegetable intake and history of self-reported cardiovascular events.

RESULTS

The mean and median intake of fruits and vegetables were 3.3 ± 0.79 and 3 servings respectively. Of the 2815 respondents, 2% (59) reported having a history of major cardiovascular events. The adjusted odds of having a history of major cardiovascular events was 2.22 (95%CI, 1.06-4.66) for those who consumed < 3 servings compared to those who consumed ≥3 servings of fruits and vegetables a day.

CONCLUSION

The respondents who consumed < 3 servings of fruits and vegetables a day had higher odds of a history of major cardiovascular events in comparison to those who consumed ≥3 servings. This finding may carry a policy recommendation for those settings where the current recommendation of having ≥5 servings of fruits and vegetables a day is not possible. Our findings also suggest that surviving a major cardiovascular event was not enough in itself to modify nutritional intake. As many Nepali consumes low amount of fruits and vegetables, appropriate measures should be taken to increase this consumption to prevent cardiovascular morbidity and mortality.

Atrial fibrillation in COVID-19: A review of possible mechanisms

A relationship between COVID-19 infection and an increasing incidence of atrial fibrillation has been observed. However, the underlying pathophysiology as a precipitant to AF has not been reviewed. This paper will consider the possible pathological and immunological AF mechanisms as a result, of COVID-19 infection. We discuss the role myocardial microvascular pericytes expressing the ACE-2 receptor and their potential for an organ-specific cardiac involvement with COVID-19. Dysfunctional microvascular support by pericytes or endothelial cells may increase the propensity for AF via increased myocardial inflammation, fibrosis, increased tissue edema, and interstitial hydrostatic pressure. All of these factors can lead to electrical perturbances at the tissue and cellular level. We also consider the contribution of Angiotensin, pulmonary hypertension, and regulatory T cells as additional contributors to AF during COVID-19 infection. Finally, reference is given to two common drugs, corticosteroids and metformin, in COVID-19 and how they might influence AF incidence.

Sex-specific educational attainment is associated with telomere length in an Australian rural population

BACKGROUND

There is limited understanding on whether and how socioeconomic status (SES), particularly educational attainment and household income, impacts on telomere length in an Australian rural context. Additionally, it is unknown whether access to health services via the Australian public or private health system influences telomere length.

AIM

This study investigates whether there is a relationship between telomere length and SES indicators (income, education) as well as health insurance status in a rural Australian population.

METHODS

Samples were drawn from the Australian Rural Victoria cross-sectional Crossroads Study. Leucocyte telomere length (LTL) was measured using a multiplex quantitative polymerase chain reaction method.

RESULTS

Among 1424 participants, we did not find a significant main effect association with LTL across education, income level and health insurance. An exploratory finding was sex may influence the relationship between educational attainment and LTL (P = 0.021). In males, but not females, higher education was associated with longer LTL by 0.033 [95% confidence interval (CI) 0.002-0.063, P = 0.035]; in those with low education attainment, male participants had shorter LTL by 0.058 (95% CI -0.086 to -0.029) than female participants (P < 0.0001).

CONCLUSION

Being male and having lower education attainment was associated with shorter telomere length in our rural population. Evidence from our study supports the importance of education on LTL in males in rural Australia. Our studies also support previous findings that LTL in later life may not be closely associated with indicators of SES.

Computational evaluation of an extra-aortic elastic-wrap applied to simulated aging anisotropic human aorta models

Structural changes occurring to the aortic wall can result in vascular stiffening. This is represented by a loss of vascular compliance during pulsatile flow, resulting in increased systolic and pulse blood pressure, particularly in populations aged 50 and over. Aortic stiffness is thought to be permanent and an active de-stiffening strategy is yet to be developed. Extra aortic elastic wrapping has been proposed as a surgical technique to boost aortic distensibility and treat hypertension in the elderly. Previously, in-vivo and in-vitro testing have suggested a pulse-pressure reduction potential of elastic wrapping in the stiffened aortas. Herein, we explore the feasibility of elastic aortic wrapping to improve simulated aortic compliance across the age span. Detailed computational studies of the anisotropic aortic wall mechanics, using data from human subjects, were performed, evaluating key performance properties for the interaction between the aortic wall and elastic aortic wrap procedure. Main determinants of the procedure’s efficiency are identified using a pre-defined aortic stiffness and wrap elasticity. Finite element analysis predicts that segmental aortic distensibility can be increased if elastic wrapping is applied to a simulated stiff aorta. Elastic aortic wrapping is calculated to have little impact on the compliance of an initially distensible aorta.

Chronic dosing with metformin plus bosentan decreases in vitro pulmonary artery contraction from isolated arteries in adults with pulmonary hypertension

Introduction: Pulmonary arterial hypertension (PAH) specific drug therapy using bosentan has significantly improved quality of life and survival, although PAH is still an incurable disease. Recent studies suggest metformin may have additional treatment benefits in PAH. We therefore investigated in vitro pulmonary artery reactivity after combination therapy of bosentan and metformin in PAH patients as compared with bosentan monotherapy in a prospective, randomized study.

Methods: Adult patients with PAH associated with congenital heart defects (PAH-CHD) were randomised to receive bosentan (initially at 62.5 mg twice daily for 4 weeks and then 125 mg twice daily) for 3 months with or without the combination treatment of metformin (500 mg twice daily). Vessel reactivity of isolated pulmonary arteries was examined using a wire myograph.

Results: Phenylephrine (PE)-induced contractions of arteries in patients received combination therapy were significantly attenuated at concentrations of 3 × 10^-7 M, 10^-6 M and 3 × 10^-6 M, compared to those received bosentan monotherapy. After denudation, PE-induced contractions at concentrations of 3 × 10^-6 M and 10^-5 M were significantly decreased in the combination therapy group. AMP-activated protein kinase (AMPK) inhibitor compound C abrogated the inhibitory effects of metformin on PE-induced contractility. AMPK and eNOS phosphorylation in the pulmonary arteries of patients treated with combination therapy was increased compared to monotherapy (P < 0.05).

Conclusion: Adding metformin to bosentan therapy in patients with PAH-CHD decreased in vitro pulmonary artery contraction induced by PE, which is possibly related to increased AMPK phosphorylation.

Screening for burn-out in Australian medical students undertaking a rural clinical placement

OBJECTIVE

To investigate Australian medical student burn-out during rural clinical placement. Second, to examine the association between perceived burn-out and rural career intent at the time of finishing their rural placement.

DESIGN, SETTINGS AND PARTICIPANTS

The 2016 Federation of Rural Australian Medical Educators evaluation survey is a cross-sectional study of medical students from 17 Australian universities. Specifically, those medical students who completed a full academic year or more at a Rural Clinical School (RCS). Responses from 638 medical students from regional Australia were analysed in the study of all eligible 756 medical students (response rate 84.3%).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary objective was to determine self-reported burn-out (emotional exhaustion) in rural placements for medical students. Secondary outcome measures were designed to explore interactions with rural practice self-efficacy and rural intentions. Logistic regression models explored factors associated with burn-out.

RESULTS

26.5% of students reported experiencing burn-out during a rural placement. Factors associated with burn-out were female gender, rural origin, low preference for RCS, stress in the year prior to a rural clinical placement, perceived social isolation during rural placement and lower rural practice self-efficacy. Burn-out was not associated with rural career intentions. Social isolation and low rural self-efficacy were independently associated with burn-out during rural placement and together explained 10% of variance in burn-out (Model Nagelkerke R²=0.23).

CONCLUSION

Burn-out during rural placement may be a consequence of stress prior to a medical school placement. Social isolation and rural self-efficacy are amendable factors to mitigate medical student burn-out during rural placements.

Metformin added to bosentan therapy in patients with pulmonary arterial hypertension associated with congenital heart defects: a pilot study

Pulmonary arterial hypertension (PAH) is a common complication of a congenital heart defect (CHD). Recent studies suggest metformin may be a potential drug to improve cardiac function in PAH. A pilot study was conducted to investigate the efficacy of short-term treatment with a combination regimen consisting of bosentan and metformin in PAH-CHD patients as compared with bosentan monotherapy in a prospective, randomised study.

Patients with PAH-CHD were randomised to receive bosentan (initially at 62.5 mg twice daily for 4 weeks and then 125 mg twice daily) for 3 months with or without the combination treatment of metformin (500 mg twice daily).

93 patients were enrolled to bosentan monotherapy (n=48) or bosentan/metformin combination treatment (n=45). After 3 months, both treatments significantly improved World Health Organization functional class, 6-min walking distance (6MWD), N-terminal pro-brain natriuretic peptide and right heart haemodynamic parameters. The improvements in 6MWD and pulmonary vascular resistance index were significantly greater in patients treated with combination therapy than in those who received monotherapy (mean±sd 95±136 versus 48±119 m (p=0.017) and −1.8±1.2 versus −1.2±1.3 Wood units per m² (p<0.001), respectively). Pulmonary endothelin (EDN)1 was significantly decreased after combination therapy (p=0.006). However, plasma EDN1 levels were not affected.

Combination therapy with bosentan and metformin in PAH-CHD patients provides improvements in important outcomes such as exercise capacity and pulmonary haemodynamics, compared with bosentan alone.

This study investigated, for the first time, the efficacy of a combination regimen consisting of bosentan and metformin in patients with pulmonary arterial hypertension associated with congenital heart defect as compared with bosentan monotherapyhttp://ow.ly/n4nJ30kT98d

Over-Wrapping of the Aortic Wall with an Elastic Extra-Aortic Wrap Results in Luminal Creasing

Elastic extra-aortic wrapping is a potential non-pharmacological way to improve aortic compliance and treat isolated systolic hypertension associated with a stiffened aorta. We aimed to use computer simulations to re-evaluate whether there is aortic shape distortion in aortic wrapping to achieve greater elasticity of the wrapped aortic segment. Non-linear transient numerical analysis based on an idealized hyper-elastic single-layered aorta model was performed to simulate the force/displacement regimes of external aortic wrapping. Pressure-displacement relationships were used to establish model aortic wall distensibilities of 4.3 and 5.5 (10⁻³ mmHg⁻¹). A physiological pulsatile lumen pressure was employed to estimate the potential improvements in aortic distensibility by compression forces representing elastic aortic wrapping. In the less distensible model of the aortic wall there was increased systolic expansion in the wrapped segment. We found a risk of creasing of the aortic luminal wall with wrapping. Sufficient unloading of a thick and elastic aortic wall to induce increased compliance, as observed in elastic wrapping, is associated with the potential risk of over compression and folding (creasing) inside the lumen.

Self-efficacy reduces the impact of social isolation on medical student's rural career intent

BACKGROUND

Social isolation in medical students is a subjective experience that may influence medical career decision making. Rural self-efficacy has been shown to influence rural career intentions following a rural clinical placement, however its impact on social isolation during a rural clinical placement has not been previously modeled. The objective of this study is to explore whether self-perception of social isolation is associated with rural career intent in rural medical students. Secondly, to determine whether self-efficacy influences the association between social isolation and rural career intent.

METHODS

2015 data, from a cross-sectional survey of the National Federation of Rural Australian Medical Educators (FRAME) study. Among 619 medical students attending rural clinical schools (RCS), rural career intent was assessed. This included intended rural location for either postgraduate medical specialist or generalist training or completion of that training. Self-efficacy beliefs in rural medical practice were based on a validated scale consisting of six questions. Social isolation was measured asking students whether they felt socially isolated during their RCS placement.

RESULTS

31.3% of surveyed students self-reported feeling socially isolated during their rural placement. Social isolation was associated with reduced rural career intent after controlling for gender, rural background, RCS preference, RCS support and wellbeing. In step-wise logistic regression the association between social isolation and rural intent disappeared with the inclusion of rural self-efficacy.

CONCLUSIONS

Social isolation during a rural clinical placement is commonly reported and is shown to reduce rural career intent. High levels of rural clinical self-efficacy reduce the effects of social isolation on future rural workforce intentions.

Review of screening studies for atrial fibrillation in rural populations of 11 countries

Atrial fibrillation (AF) is a common cardiac arrhythmia, and pathological burden can be influenced by environmental factors. The rural environment may influence the burden of AF, although no systematic review studies have been conducted to address this issue. We performed a systematic review of AF screening studies conducted in rural global populations to determine the burden, risk factors, and screening methods surrounding AF in these settings. Out of the 1792 articles gathered from a keyword search of medical databases and reference lists, 18 publications from 11 countries were included in our analysis. The pooled prevalence of AF across the studies was 2.05% (95% confidence interval, 1.97%-2.13%) and ranged from 0.3% to 10.87%. Only one study utilized a handheld electrocardiogram to screen AF, while the rest used the 12-lead electrocardiogram. AF risk factors reported across studies varied and included increasing age, male gender, hypertension, diabetes, prior myocardial infarction or stroke, obesity, hyperlipidemia/hypercholesterolemia, alcohol consumption, and heart failure. However, none of the studies assessed all risk factors. We suggest that future research on AF in rural communities examine a complete checklist of AF risk factors to better understand their influence on AF burden and development. This will aid in understanding rural prevention strategies and the management of detected AF cases specific to rural areas. At present, the burden of AF in rural communities is poorly understood and has been underreported.

Awareness, Prevalence, Treatment, and Control of Hypertension in Western Nepal

BACKGROUND

Hypertension is a significant contributor to cardiovascular and renal diseases. In low-income settings like Nepal, there are few epidemiological studies assessing hypertension burden. Thus, the purpose was to determine prevalence, awareness, treatment, and control of hypertension in Nepal.

METHODS

A cross-sectional survey was conducted in semi-urban area of western Nepal among randomly selected participants, aged between 25 and 65 years. Systolic blood pressure (BP) ≥140 mm Hg and/or diastolic BP of ≥90 mm Hg and/or taking current antihypertensive medicine defined as hypertension.

RESULTS

Study included 2,815 participants, 1,844 were women. The age- and sex-adjusted prevalence of hypertension was 28%. Of the study participants, 17% were daily smokers, 12% harmful alcohol drinkers, 90% consuming low levels of fruit and/or vegetable, and 7% reported low physical activity. Among hypertensive participants, 46% were aware of their preexisting hypertension, 31% were on hypertensive medication, and 15% met BP control targets. Increasing age (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 1.06; 1.08), higher body mass index (OR: 1.09, 95% CI: 1.06; 1.12), men (OR: 1.63, 95% CI: 1.25; 2.14), harmful alcohol intake (Or: 2.46; 95% CI: 1.73; 3.51), family history of hypertension (OR: 1.42; 95% CI: 1.14; 1.76), and diabetes (OR: 2.08, 95% CI: 1.30; 3.33) were independently associated with hypertension.

CONCLUSIONS

The prevalence of hypertension was found high in western Nepal. A number of risk factors were identified as possible drivers of this burden. Thus, there is an urgent need to address modifiable risk factors in semi-urban settings of western Nepal.

FTO associations with obesity and telomere length

This review examines the biology of the Fat mass- and obesity-associated gene (FTO), and the implications of genetic association of FTO SNPs with obesity and genetic aging. Notably, we focus on the role of FTO in the regulation of methylation status as possible regulators of weight gain and genetic aging. We present a theoretical review of the FTO gene with a particular emphasis on associations with UCP2, AMPK, RBL2, IRX3, CUX1, mTORC1 and hormones involved in hunger regulation. These associations are important for dietary behavior regulation and cellular nutrient sensing via amino acids. We suggest that these pathways may also influence telomere regulation. Telomere length (TL) attrition may be influenced by obesity-related inflammation and oxidative stress, and FTO gene-involved pathways. There is additional emerging evidence to suggest that telomere length and obesity are bi-directionally associated. However, the role of obesity risk-related genotypes and associations with TL are not well understood. The FTO gene may influence pathways implicated in regulation of TL, which could help to explain some of the non-consistent relationship between weight phenotype and telomere length that is observed in population studies investigating obesity.

rs9939609 FTO genotype associations with FTO methylation level influences body mass and telomere length in an Australian rural population

BACKGROUND

The fat mass- and obesity-associated (FTO) gene influences energy homeostasis in humans. Although the obesity-related variant, rs9939609 has been replicated across a number of cohort studies, there remains significant variance and a low to modest association. Telomere length is another commonly reported obesity risk factor. We hypothesize understanding the associations between FTO rs9939609 with FTO methylation and telomere length will provide a more accurate assessment of obesity risk.

METHODS

Overall, 942 participants free of diabetes or pre-diabetes were included in the retrospective study. Leukocyte genomic DNA was analyzed for rs9939609 genotyping, FTO gene methylation and leukocyte telomere length (LTL) measurement.

RESULTS

In general linear models, rs9939609 AA genotypes were associated with increased fat percentage (3.15%, P=0.001), fat mass (4.16 kg, P=0.001), body mass index (BMI) (1.38, P=0.006) and waist circumference (3.35 cm, P=0.006), but not with FTO methylation or LTL in this overall population. However, when participants were stratified into higher and lower FTO methylation groups, the AA genotype possesses a 2.04-fold increased obesity risk in comparison to TT genotype (95%CI, 1.07-3.89, P=0.031) in participants with a higher FTO methylation level, but this association was absent in the lower FTO methylation sub-group. Moreover, AT and AA genotype carriers were associated with shorter LTL compared to TT carriers (P=0.020 and P=0.111, respectively) in the higher FTO methylation level group. However, this association was absent in the lower methylation group. Furthermore, FTO gene methylation level was significantly associated with LTL in the 942 samples (P=0.017).

CONCLUSIONS

FTO rs9939609 is associated with obesity risk and LTL in this study, where this association is only observed at higher, but not lower, FTO methylation levels of participants. Our data suggest association of multiple factors, including FTO methylation level, may be involved in one of several mechanisms underlying the commonly reported obesity risk of this FTO polymorphism.

Electrocardiogram QRS duration and associations with telomere length: A cross-sectional analysis in Australian rural diabetic and non-diabetic population

Prolonged electrocardiogram QRS durations are often present in aging populations. Shorter telomere length is considered a biomarker of cellular aging. Decreased telomere length has been associated with coronary artery risk, and ventricular remodeling. However, the association between telomeres and cardiac conduction abnormalities, such as increased QRS duration are not well understood. A retrospective cross-sectional population was obtained from the CSU Diabetes Screening Research Initiative database where 273 participants had both ECG-derived QRS duration and DNA to permit leukocyte telomere length (LTL) determination. Telomere length was determined using the monochrome multiplex quantitative PCR method to measure mean relative LTL. Resting 12-lead electrocardiograms were obtained from each subject using a Welch Allyn PC-Based ECG system. Relative LTL was moderately negatively associated with QRS duration in type 2 diabetes mellitus (T2DM) patients (R²=0.055), compared to controls (R²=0.010). In general linear models with no adjustments a significant interaction between QRS duration and LTL is observed for a combined population of T2DM and non-diabetics. When we compared T2DM to non-diabetics, we found that T2DM increased the effect size for relative LTL on QRS duration in comparison to controls. Hence, for each 0.1 unit of relative LTL attrition, QRS duration in T2DM patients increased by 3.24ms (95% CI, -63.00 to -1.84), compared to 1.65ms in controls (95% CI, -40.44 to 7.40). In summary we have observed an association between LTL in a rural aging mixed population of T2DM and non-diabetes. We have observed an unadjusted association between QRS duration and LTL in T2DM. We noted that the control group demonstrated no such association. This highlights the complexity of T2DM when exploring disease phenotype-telomere interactions.

Randomised controlled trial examining the effect of an outpatient exercise training programme on haemodynamics and cardiac MR parameters of right ventricular function in patients with pulmonary arterial hypertension: the ExPAH study protocol

INTRODUCTION

Pulmonary hypertension (PH) is a potentially life-threatening condition characterised by elevated pulmonary artery pressure. Early stage PH patients are often asymptomatic. Disease progression is associated with impairment of right ventricular function and progressive dyspnoea. Current guidelines recommend exercise training (grade IIa, level B). However, many questions remain regarding the mechanisms of improvement, intensity of supervision and optimal frequency, duration and intensity of exercise. This study will assess the effect of an outpatient rehabilitation programme on haemodynamics and cardiac right ventricular function in patients with pulmonary arterial hypertension (PAH), a subgroup of PH.

METHODS AND ANALYSIS

This randomised controlled trial involves both a major urban tertiary and smaller regional hospital in New South Wales, Australia. The intervention will compare an outpatient rehabilitation programme with a control group (home exercise programme). Participants will be stable on oral PAH-specific therapy. The primary outcome measure will be right ventricular ejection fraction measured by cardiac MRI. Secondary outcomes will include haemodynamics measured by right heart catheterisation, endurance, functional capacity, health-related quality of life questionnaires and biomarkers of cardiac function and inflammation.

ETHICS APPROVAL AND DISSEMINATION

Ethical approval has been granted by St Vincent's Hospital, Sydney (HREC/14/SVH/341). Results of this study will be disseminated through presentation at scientific conferences and in scientific journals.

TRIAL REGISTRATION NUMBER

ACTRN12615001041549; pre-results.

The association of uncoupling protein 2 (UCP2) exon 8 insertion/deletion polymorphism and ECG derived QRS duration: A cross-sectional study in an Australian rural population

BACKGROUND

Associations between inherited mitochondrial disease and cardiac conduction have been previously described. However, there are no available studies exploring the mitochondrial uncoupling protein 2 gene (UCP2) insertion/deletion (I/D) polymorphisms interaction on cardiac electrical conduction. Our aim was to determine if ECG-derived QRS duration is associated with UCP2 DD genotype in a cross-sectional Australian aging rural population.

METHODS

A retrospective study design utilizing a rural health diabetic screening clinic data-base containing observational data from September 2011 to September 2014. Inclusion criteria included were having ECG parameters such as QRS duration measures and a DNA sample within the same subject. Genomic DNA was extracted and subjects were genotyped for the 45-bp I/D polymorphism in the 3'-untranslated region of UCP2.

RESULTS

281 individuals were available for analysis. On the basis of QRS duration >140ms we found an increased percentage of our population with DD homozygotes, compared to ID heterozygotes and II homozygotes (p=0.047). For other ECG parameters; mean PQ duration, QTc across UCP2 genotypes was not significant (p=NS). QTc using a cut-off >440ms in contingency table analysis revealed no significant differences across UCP2 I/D genotypes. Mean QT dispersion (QTd) was paradoxically less in the UCP2 DD genotype compared to UCP2 II subgroup (p=0.034).

DISCUSSION

We have demonstrated an association between increasing ECG-derived QRS duration >140ms and the UCP2 DD polymorphism. The lack of association with ECG derived QTd and UCP2 DD may suggest that gene-related QRS duration prolongation is independent of cardiac hypertrophy.

Cognitive impairment and reduced quality of life among old-age groups in Southern Urban India: home-based community residents, free and paid old-age home residents

AIM

The purpose of the study were (i) to screen for cognitive impairment using Mini-Mental Status Examination among three old-age groups based on dwelling types in Chennai, India i.e. residential paid old-age homes, residential free (charitable) homes and home-based community-dwelling residents; (ii) secondly to investigate factors (demographic, psychological, medical and disability) associated with cognitive impairment in the these old-age; (iii) third, to investigate the independent association between cognitive impairment and health-related quality of life (QOL) among elderly across aged care dwelling types.

METHODS

A total of 499 elderly from three old-age groups were interviewed in this cross-sectional study (173 elderly home-based community-dwellers, 176 paid-home and 150 free-home residents). All the participants were interviewed for their socio-economic condition, medical morbidity, self-reported worry and anxiety, disability and QOL.

RESULTS

42.7% free-home elderly residents were found to have cognitive impairment, whereas 32.4% of paid-home and 21.9% of community-dwelling elderly had cognitive impairment. The residents of free-home were less educated, had lower income and reported higher incidence of worry, anxiety, disability and poor QOL than community-dwelling or paid-home residents. Increasing age, low education, female gender, high blood pressure and disability were associated with cognitive impairment. Cognitive impairment had significant negative effect on their health-related QOL (b = -0.10, P = 0.01), independent of age, gender, education, chronic illness and dwelling type.

CONCLUSION

The burden of cognitive impairment was high in all aged-care dwelling types in urban India; with free charitable home residents being worse affected. Cognitive impairment was associated with disability and poor health-related QOL in these age-care settings.

Community-based intervention for blood pressure reduction in Nepal (COBIN trial): study protocol for a cluster-randomized controlled trial

Background

Hypertension contributes to a significant burden of cardiovascular disease in low- and middle-income countries; however, responses are inadequate because of a lack of conclusive evidence on population-based approaches to hypertension control.

Methods/design

The objective of the present study is to determine the effect of family-based home health education and blood pressure monitoring by trained female community health volunteers. The primary outcome is change in mean systolic blood pressure. A community-based, open-masked, two-armed, cluster-randomized trial will be conducted in Lekhnath Municipality of Nepal. The municipality is divided into 15 administrative clusters. Randomization will be conducted for 14 clusters: 7 for the intervention arm and 7 for the control arm. The participants were recruited from a prevalence study conducted earlier. On the basis of population proportion size, 929 individuals for the intervention group and 709 individuals for the control group will participate in the study. Due to the nature of the study, study participants are not compensated or insured. As part of the blood pressure intervention, trained female community health volunteers will conduct home visits for health education and blood pressure measurement. The primary outcomes will be modeled by using multiple linear regression analysis.

Discussion

This project will be an investigation of a community-based intervention to control blood pressure in countries with limited resources. The study will provide detailed information on the burden of blood pressure and also whether treatment targets are being met. Moreover, evidence will be provided on the future role of female community health volunteers for hypertension management in Nepal. The lessons learned from this study may also be replicated in other rural areas of Nepal and elsewhere in the world with similar settings.

Trial registration

ClinicalTrials.gov NCT02428075. Registered on 23 April 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1412-3) contains supplementary material, which is available to authorized users.

Elevated neutrophil to lymphocyte ratio predicts mortality in medical inpatients with multiple chronic conditions

Neutrophil to lymphocyte ratio (NLR) is an easy measurable laboratory marker used to evaluate systemic inflammation. Elevated NLR is associated with poor survival and increased morbidity in cancer and cardiovascular disease. However, the usefulness of NLR to predict morbidity and mortality in a hospital setting for patients with multiple chronic conditions has not been previously examined. In this study, we investigate the association between NLR and mortality in multimorbid medical inpatients. Two hundred thirty medical in-patients with chronic conditions were selected from a single academic medical center in Taiwan. Retrospective NLRs were calculated from routine full blood counts previously obtained during the initial hospital admission and at the time of discharge. Self-rated health (using a single-item question), medical disorders, depressive symptoms, and medical service utilization over a 1-year period were included in the analyses. Mortality outcomes were ascertained by reviewing electronic medical records and follow-up. The mortality rate at 2-year follow-up was 23%. Depression (odds ratio [OR] 1.9 [95% CI 1.0-3.7]), poor self-rated health (OR 2.1 [95% CI 1.1-3.9]), being hospitalized 2 or more times in the previous year (OR 2.3 [95% CI 1.2-4.6]), metastatic cancer (OR 4.7 [95% CI 2.3-9.7]), and chronic liver disease (OR 4.3 [95% CI 1.5-12.1]) were associated with 2-year mortality. The median (interquartile range) NLR at admission and discharge were 4.47 (2.4-8.7) and 3.65 (2.1-6.5), respectively. Two-year mortality rates were higher in patients with an elevated NLR at admission (NLR <3 = 15.5%, NLR >3 = 27.6%) and discharge (NLR < 3 = 14.7%, NLR >3 = 29.1%). Multivariate logistic regression demonstrated that an elevated NLR >3.0 at admission (OR 2.3 [95% CI 1.0-5.2]) and discharge (OR 2.3 [95% CI 1.1-5.0]) were associated with mortality independent of baseline age, sex, education, metastatic cancer, liver disease, depression, and previous hospitalization. Increased NLR is associated with mortality among medical inpatients with multiple chronic conditions. NLR may provide added value to predict both risk of mortality for the inpatients with chronic conditions, in addition to allowing predictions of likely hospital service needs such as re-admissions that are associated with long-term mortality.

Shortened leukocyte telomere length in type 2 diabetes mellitus: genetic polymorphisms in mitochondrial uncoupling proteins and telomeric pathways

Current debate in type 2 diabetes (T2DM) has focused on shortened leukocyte telomere length (LTL) as the result of a number of possible causes, including polymorphisms in mitochondrial uncoupling proteins (UCPs) leading to oxidative stress, telomere regulatory pathway gene polymorphisms, or as a direct result of associated cardiovascular complications inducing tissue organ inflammation and oxidative stress. There is evidence that a heritable shorter telomere trait is a risk factor for development of T2DM. This review discusses the contribution and balance of genetic regulation of UCPs and telomere pathways in the context of T2DM. We discuss genotypes that are well known to influence the shortening of LTL, in particular OBFC1 and telomerase genotypes such as TERC. Interestingly, the interaction between short telomeres and T2DM risk appears to involve mitochondrial dysfunction as an intermediate process. A hypothesis is presented that genetic heterogeneity within UCPs may directly affect oxidative stress that feeds back to influence the fine balance of telomere regulation, cell cycle regulation and diabetes risk and/or metabolic disease progression.

Electrocardiogram derived QRS duration associations with elevated central aortic systolic pressure (CASP) in a rural Australian population

Background

Prolonged electrocardiogram QRS durations are often present in hypertensive patients. Small increases in QRS duration serve as independent risk factors for both increased cardiovascular and all-cause mortality. Aortic stiffness is associated with increases in central aortic systolic blood pressure (CASP). However CASP and ECG QRS duration interactions have not been established in rural community populations. Our aims are to determine if QRS duration > 100 msec is associated with an elevated CASP measure in an Australian rural population.

Methods

A retrospective cross sectional population was obtained from the CSU Diabetes Screening Research Initiative data base where 68 participants had both central aortic pressure recorded and ECG derived QRS duration. Central aortic pressure was determined by directly recording radial arterial tonometry and brachial cuff pressure (HealthStats, Singapore). Resting 12-lead electrocardiograms were obtained from each subject using a Welch Allyn PC-Based ECG system.

Results

The population had a mean CASP of 137.8 mmHg, higher than previously reported in other population studies. In 8/68 subjects with a prolonged cardiac QRS duration >120 msec, CASP ranged from 129 mmHg – 182 mmHg. When subgroup analysis was stratified on the basis QRS duration <100 msec and ≥100 msec significant differences (p = 0.036) were observed for mean CASP, 130.6 mmHg ± 15.6 (SD) versus 140.6 mmHg ± 16.8 (SD), respectively.

Conclusions

Our results suggest that an arbitrary CASP reading greater than a value 140 mmHg raises suspicion of a prolonged QRS duration. QRS durations ≥100 msec in an aging rural population are associated with higher CASP measures. Our results also suggest in aging Australian rural populations CASP is likely to be elevated, possibly due to age related aortic stiffening.

Association between self-efficacy, career interest and rural career intent in Australian medical students with rural clinical school experience

OBJECTIVES

To investigate medical student's self-efficacy at the time of finishing their rural clinical school (RCS) placement and factors associated with self-efficacy. Secondary aims are to explore whether interest levels or self-efficacy are associated with rural or remote career intentions.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional study of medical students who had completed their RCS term in 17 Australian universities. Data were derived from the 2013 Federation of Rural Australian Medical Educators (FRAME) evaluation survey. Questionnaire responses were analysed from 653 medical students from regional Australia. All 732 students who completed their RCS term in 2013 were invited to participate.

PRIMARY AND SECONDARY OUTCOME MEASURES

Rural self-efficacy: Six questions to measure self-efficacy beliefs in rural medical practice, based on the sources of self-efficacy described by Bandura. Rural career intention: Students were asked to identify their preferred location for future practice. The options were, Capital or Major City; Inner regional city or large town; Smaller town and very remote area.

RESULTS

Questionnaire responses were analysed from 653 medical students from regional Australia (response rate 89.2%). 83.8% of all students recalled an increase in their interest levels for rural medicine as a result of their RCS experience. Actual career intention to work in a regional area or rural area was 60.2%. Bivariate analyses showed female gender (p=0.003), rural background (p<0.001), an RCS preference for clinical training (p<0.001) and general practice intentions (p=0.004) were factors associated with higher levels of self-efficacy. Logistic regression analyses showed that self-efficacy was independently associated with increased interest in rural medicine (OR 1.4 (95% CI 1.3 to 1.5)) and rural career intent (OR 1.2 (95% CI 1.1 to 1.3)). (Model included gender, rural background, preference for RCS, generalist intent, rural practice interest and self-efficacy).

CONCLUSIONS

Self-efficacy is associated with increased interest levels for rural medicine and rural medical career intent.

Use of hypofractionated post-mastectomy radiotherapy reduces health costs by over $2000 per patient: An Australian perspective

INTRODUCTION

The most recent clinical practice guidelines released by Cancer Australia draw attention to unanswered questions concerning the health economic considerations associated with hypofractionated radiotherapy. This study aimed to quantify and compare the healthcare costs at a regional Australian radiotherapy institute with respect to conventionally fractionated post-mastectomy radiotherapy (Cf-PMRT) versus hypofractionated post-mastectomy radiotherapy (Hf-PMRT) administration.

METHODS

Medical records of 196 patients treated with post-mastectomy radiotherapy at the NSW North Coast Cancer Institute from February 2008 to June 2014 were retrospectively reviewed. Australian Medicare item numbers billed for patients receiving either Cf-PMRT of 50 Gy in 25 daily fractions or Hf-PMRT of 40.05 Gy in 15 daily fractions were calculated. Decision tree analysis was used to model costs. Independent-samples t-tests and Mann-Whitney U-tests were used to compare crude average costs for Cf-PMRT and Hf-PMRT and determine which treatment components accounted for any differences.

RESULTS

Hf-PMRT, with or without irradiation to the regional lymph nodes, was associated with significantly reduced Medicare costs ($5613 AUD per patient for Hf-PMRT vs $8272 AUD per patient for Cf-PMRT; P < 0.001). Savings associated with Hf-PMRT ranged from $1353 (22.1%) for patients receiving no regional irradiation to $2898 (32.0%) for patients receiving both axillary and supraclavicular therapy.

CONCLUSIONS

Hf-PMRT results in a significant reduction in the financial costs associated with treating breast cancer patients in a regional Australian setting when compared with Cf-PMRT.

Poor Self-Rated Health Influences Hospital Service Use in Hospitalized Inpatients With Chronic Conditions in Taiwan

Our aim was to investigate the association between self-rated health (SRH) and use of hospital services (ie, medical outpatient department, emergency department, and general ward. admissions). Cross-sectional study data were collected from 230 consecutive patients admitted to medical departments of a 2000-bed academic medical center in Taiwan using standardized operating procedures for data collection of SRH (ie, a single-item question inquiring overall perceived health status), medical disorders, depressive symptoms, and combined service utilization over a 1-year period (ie, number of visits to outpatient department, number of visits to emergency department, and number of hospitalizations). Electronic medical records were retrieved, with self-reported external medical visits added to in-hospital frequencies of service use to provide better estimation of health service utilization. Fifty-two percent of study patients rated their health as poor or very poor. Poor SRH was associated with more visits to medical outpatient department, emergency department, and hospital admission. Multivariate logistic regression demonstrated an independent association between poor SRH and services utilization after adjustment for age, gender, hypertension, diabetes, metastatic cancer, number of chronic illness, life-threatening event, life-time suicidal ideation, and depression. SRH may be a useful research tool to model medical service use for inpatients with chronic conditions.