A randomised control trial of TeleClinical Care – a smartphone-app based model of care for heart failure and acute coronary syndromes

Background

Acute coronary syndrome (ACS) and heart failure (HF) are frequent causes of hospitalisation and readmissions. A novel smartphone app-based model of care (TeleClinical Care – TCC) was developed to support patients after ACS or HF admission.

Purpose

This randomised control trial aimed to characterise both the intervention and clinical outcomes. The primary endpoint was the incidence of 30-day readmissions. Secondary endpoints included six-month cardiac and all-cause readmissions, mortality, major adverse cardiovascular events (MACE), cardiac rehabilitation (CR) completion, medication adherence, serum low-density lipoprotein (LDL-C), quality of life, blood pressure, body mass index, waist circumference and six-minute walk distance. Additionally, cost-effectiveness and user satisfaction were evaluated.

Methods

Patients were randomised 1:1 to either TCC plus usual care or usual care alone and were followed-up at six months. Intervention arm participants received the TCC app and were asked to use Bluetooth-enabled devices for measuring weight, heart rate, blood pressure and physical activity daily. Readings were automatically transmitted to the patient's smartphone and a secure web-server (KIOLA). Customisable thresholds for each parameter were defined at discharge. Abnormal readings were flagged by email to a monitoring team, who discussed management with the patient's usual healthcare providers. The app also provided educational push notifications.

Results

164 patients from two hospitals in Sydney, Australia were enrolled between February 2019 and March 2020 (TCC n=81, control n=83). Recruitment ceased during the COVID-19 pandemic. The mean age was 61.5 years. 79% of patients were male. The per-patient mean percentage of days with data transmission was 64.2±27.5%. 565 alerts were received, 16% of which resulted in additional investigations, healthcare consultation or a change in management. There was no difference in 30-day readmission rate (11 readmissions in each arm). There was a significant difference in six-month readmissions, favouring the intervention (21 vs. 41 readmissions, HR=0.40, 95% CI 0.16–0.95, P=0.03), driven by a reduction in cardiac readmissions (11 vs. 25, HR=0.51, 95% CI 0.27–0.94, P=0.03). Use of TCC was associated with improved CR completion (39% vs. 18%, P=0.025) and medication adherence (75% vs. 50%, P=0.002). There was no significant difference in mortality, MACE, LDL-C, quality of life or any of the physical parameters. The average user rating was 4.56 out of 5. The study cost EUR 4015 per readmission saved. Upon modelling, it was calculated that if the number of enrolled patients exceeds 243, total expenditure will be overcome by cost savings from reducing readmissions.

Conclusion

The TCC model of care was feasible and safe. In this study, clinical benefits were demonstrated including a reduction in six-month readmissions, improved CR completion and improved medication adherence.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology, Prince of Wales HospitalPrince of Wales Hospital Foundation Figure 1. TCC interfaceFigure 2. Cumulative readmissions over the course of the trial

National quality indicators to promote cardiac rehabilitation service effectiveness in Australia

Background/Introduction

Comprehensive exercise-based cardiac rehabilitation (CR) has well-established efficacy and effectiveness for improving patients' outcomes. There is substantial variability in terms of clinical effectiveness and quality measurement of CR programs internationally which limits service improvement initiatives. In Australia in 2018 a the Australian Cardiovascular Health and Rehabilitation Association (ACRA) and the National Heart Foundation of Australia (NHFA) combined forces to develop nationally-agreed, internationally-consistent, locally-relevant quality indicators (QI).

Purpose

To provide a minimum set of standardised national-level QI that should be collected and reported on by CR programs to determine the quality of delivery and associated outcomes, benchmark performance and support improvement processes.

Methods

We formed the National Cardiac Rehabilitation Measurement (NCRM) Taskforce led by ACRA and NHF and used the National Institute for Health and Care Excellence (NICE) UK guidelines to develop high quality QIs. The process included topic overview, prioritising areas for quality improvement, drafting and consultation, validation and consistency checking.

Results

Eleven preliminary QIs were circulated for ranking and comment to all ACRA members (predominately multidisciplinary CR providers) (68 responses), and to leading national multidisciplinary CR experts from cardiology, research, physiotherapy, nursing, epidemiology and register backgrounds (7 responses). Ratings, comments and suggestions were collated and discussed by the NCRM Taskforce, and the indicators rated most important, useful and feasible were retained, resulting in 10 QIs. These 10 QIs were presented at the ACRA national conference and then discussed at a workshop (55 participants) for this purpose. Ten QIs and accompanying data dictionary with definitions, evidence and allowable values is the final product.

Conclusions

A minimum set of locally relevant, internationally recognised, national QIs for CR is now available for CR providers, health service managers and researchers in Australia, which may be relevant internationally. The QIs will best serve national interests incorporated within a national cardiac registry but will also be useful for site audits and have strong potential to be aggregated across sites, health districts and states. The definitive test of the QIs will be how useful they are for CR program coordinators and funders of such programs; a key consideration for building sustainable business models and ensuring long-term implementation.

Funding Acknowledgement

Type of funding source: None

Disseminated cutaneous infection due to Mycobacterium chelonae following hematopoietic stem cell transplantation

This report describes two cases of disseminated cutaneous Mycobacterium chelonae after hematopoietic stem cell transplantation (HSCT).

Outcomes, infections, and immune reconstitution after double cord blood transplantation in patients with high-risk hematological diseases

Double unrelated cord blood transplant (dUCBT) has been used to circumvent cell dose limitation of single UCBT; however, few data are available describing outcomes, infectious disease, and immune recovery. We analyzed 35 consecutive dUCBT recipients with high-risk malignant disorders (n=21) and bone marrow failure syndromes (n=14). Median follow-up was 32 months. Conditioning regimen was myeloablative in 14 and reduced intensity in 21 patients. Median infused nucleated cell dose was 4 × 10(7) /kg. Median time to absolute neutrophil count >0.5 × 10(9) /L was 25 days. Cumulative incidence (CI) of acute grade II-IV graft-versus-host disease was 47%. Estimated overall survival at 2 years was 48%. CI of first viral infections at 1 year was 92%. We observed 49 viral infections in 30 patients, 34 bacterial infections in 19 patients, and 16 fungal or parasitic infections in 12 patients. Lymphocyte subset analyses were performed at 3, 6, 9, and >12 months after dUCBT. Decreased T-cell and B-cell counts with expansion of natural killer cells were observed until 9 months post transplantation. Recovery of thymopoiesis measured by T-cell receptor excision circles was impaired until 9 months after dUCBT, when the appearance of new thymic precursors was observed. Delayed immune recovery and high incidence of infectious complications were observed after dUCBT in patients with high-risk hematological diseases.

New role for granulocyte colony-stimulating factor-induced extracellular signal-regulated kinase 1/2 in histone modification and retinoic acid receptor α recruitment to gene promoters: relevance to acute promyelocytic leukemia cell differentiation

The induction of the granulocytic differentiation of leukemic cells by all-trans retinoic acid (RA) has been a major breakthrough in terms of survival for acute promyelocytic leukemia (APL) patients. Here we highlight the synergism and the underlying novel mechanism between RA and the granulocyte colony-stimulating factor (G-CSF) to restore differentiation of RA-refractory APL blasts. First, we show that in RA-refractory APL cells (UF-1 cell line), PML-RA receptor alpha (RARα) is not released from target promoters in response to RA, resulting in the maintenance of chromatin repression. Consequently, RARα cannot be recruited, and the RA target genes are not activated. We then deciphered how the combination of G-CSF and RA successfully restored the activation of RA target genes to levels achieved in RA-sensitive APL cells. We demonstrate that G-CSF restores RARα recruitment to target gene promoters through the activation of the extracellular signal-regulated kinase (ERK)/mitogen-activated protein kinase (MAPK) pathway and the subsequent derepression of chromatin. Thus, combinatorial activation of cytokines and RARs potentiates transcriptional activity through epigenetic modifications induced by specific signaling pathways.

Double cord blood transplantation in patients with high risk bone marrow failure syndromes

Patients with bone marrow failure syndromes (BMFS) who reject a first allogeneic transplant or fail immunosuppressive therapy (IST) have an especially grim prognosis. We report 14 patients (eight adults, six children) transplanted with double cord blood transplantation (dUCBT) for BMFS. Neutrophil recovery was observed in eight patients, with full donor chimerism of one unit, and acute GVHD in 10. With a median follow-up of 23 months, the estimated 2 years overall survival was 80 +/- 17% and 33 +/- 16% for patients with acquired and inherited BMFS, respectively. Transplantation of two partially HLA-matched UCB thus enables salvage treatment of high-risk patients with BMFS.

Long-term outcomes after allogeneic stem cell transplantation for children with hematological malignancies

We analyzed long-term outcomes and psycho-social aspects in 112 children with malignancies surviving 1 year after hematopoietic stem cell transplantation. At 10 years, overall survival was 75+/-5%, TRM 18+/-4% and relapse 14+/-3%; 10-year cumulative incidence of infections was 31+/-4%, cataract 44+/-4%, pulmonary dysfunction 20+/-4%, bone and joint complications 29+/-5%, hypothyroidism 36+/-4%, cardiac complications 11+/-3% and secondary malignancies 7+/-3%. Total body irradiation (TBI) was the most significant risk factor associated with cataract, pulmonary impairment, osteoarticular complications and hypothyroidism. Chronic graft-versus-host disease was associated with higher incidence of pulmonary dysfunction. The number of complications per patient increased with time. Half of the patients had psychological disturbance, 13 signs of depression and 16 a history of eating behavior disorders; 54% of patients with one or more long-term complications had psychological problems. Sixty-nine patients had learning difficulties and 36 achieved normal scholarship. With increased follow-up, development of late effects and of psycho-social disturbance are of major concern. While the use of single-dose TBI has now been abandoned, other risk factors are still of concern in the early 2000s.

Hematopoietic stem cell transplantation in severe congenital neutropenia: experience of the French SCN register

Our objective was to study the outcome of allogeneic hematopoietic stem cell transplantation (HSCT) in patients with severe congenital neutropenia (SCN). Among 101 cases of SCN included in the French Severe Chronic Neutropenia Registry, nine patients received HSCT between 1993 and 2003, in seven institutions. The indications were nonresponse to G-CSF therapy in four cases, bone marrow failure in one case, and myelodysplastic syndrome or leukemia in four cases. The conditioning regimen consisted of total body irradiation in two cases and chemotherapy alone in the other seven cases. Seven patients received stem cells from unrelated donors and two from identical siblings. Engraftment occurred in all but one of the patients. Three patients died. The respective causes of death were graft-versus-host disease, infection, and EBV post-transplant lymphoproliferative disease. Six patients are alive and in complete remission, with a median follow-up of 3.1 years. These results indicate that HSCT is feasible for patients with SCN who do not respond to G-CSF, who have malignant transformation, or who are at a high risk of malignant transformation, even if an HLA-identical sibling donor is not available.

Study of a predictive methodology for quantification and mapping of the radon-222 exhalation rate

We propose a new methodology for predicting areas with a strong potential for radon (222Rn) exhalation at the soil surface. This methodology is based on the Rn exhalation rate quantification, starting from a precise characterisation of the main local geological and pedological parameters that control the radon source and its transport to the soil/atmosphere interface. It combines a cross mapping analysis of these parameters into a geographic information system with a model of the Rn vertical transport by diffusion in the soil. The rock and soil chemical and physical properties define the entry parameters of this code (named TRACHGEO) which calculates the radon flux density at the surface. This methodology is validated from in situ measurements of radon levels at the soil/atmosphere interface and in dwellings. We apply this approach to an area located in western France and characterised by a basement displaying a heterogeneous radon source potential, as previously demonstrated by lelsch et al. (J. Environ. Radioactivity 53(1) (2001) 75). The new results obtained show that spatial heterogeneity of pedological characteristics in addition to basement geochemistry--must be taken into account to improve the mapping resolution. The TRACHGEO forecasts explain the Rn exhalation variability on a larger scale and in general correlate well with in situ observations. Moreover, the radon-prone sectors identified by this approach generally correspond to the location of the dwellings showing the highest radon concentrations.

Radon (222Rn) level variations on a regional scale: influence of the basement trace element (U, Th) geochemistry on radon exhalation rates

The approach proposed in this study provides insight into the influence of the basement geochemistry on the spatial distribution of radon (222Rn) levels both at the soil/atmosphere interface and in the atmosphere. We combine different types of in situ radon measurements and a geochemical classification of the lithologies, based on 1/50,000 geological maps, and on their trace element (U, Th) contents. The advantages of this approach are validated by a survey of a stable basement area of Hercynian age, located in South Brittany (western France) and characterized by metamorphic rocks and granitoids displaying a wide range of uranium contents. The radon source-term of the lithologies, their uranium content, is most likely to be the primary parameter which controls the radon concentrations in the outdoor environment. Indeed, the highest radon levels (> or = 100 Bq m-3 in the atmosphere, > or = 100 mBq m-2 s-1 at the surface of the soil) are mostly observed on lithologies whose mean uranium content can exceed 8 ppm and which correspond to peraluminous leucogranites or metagranitoids derived from uraniferous granitoids.

An automatic device for measuring the effect of meteorological factors on radon-222 flux from soils in the long-term

An automatic method for measuring the radon flux at soil surfaces is described. The proposed experimental design minimises the disturbance induced by the accumulator technique widely used to measure radon exhalation from the ground. By exposing the ground surface to the normal weather conditions between two consecutive measurements, this method can be used to study, in the long term, the effects of meteorological factors on the radon flux density at the soil-atmosphere interface.

Radon exhalation from uranium mill tailings: experimental validation of a 1-D model

TRACI, a model based on the physical mechanisms governing the migration of radon in unsaturated soils, has been developed to evaluate the radon flux density at the surface of uranium mill tailings. To check the validity of the TRACI model and the effectiveness of cover layers, an in situ study was launched in 1997 with the French uranium mining company, COGEMA. The study consisted of continuous measurements of moisture content, suction, radon concentration at various depths inside a UMT cover, and flux density at its surface. An initial analysis has shown that radon concentration and flux density, as calculated with a steady-state diffusion model using monthly averaged moisture contents, are in good agreement with measured monthly averaged concentrations and flux densities.

Sequential activation of activator protein-1-related transcription factors and JNK protein kinases may contribute to apoptotic death induced by transient hypoxia in developing brain neurons

Previous studies have demonstrated that transient hypoxia (6 h) induces apoptotic death in cultured neurons isolated from the fetal rat forebrain. Since activation of c-Jun N-terminal kinases (JNKs) and subsequent phosphorylation of c-Jun are suspected to be involved in the apoptotic pathway in several cell types, the time course of activator protein-1 (AP-1) DNA-binding, in line with induction of the AP-1 components and JNK activation, was examined during hypoxia/reoxygenation in the same model. Gel shift analysis depicted the presence of functional AP-1 transcription factors in both control and hypoxic neurons. One hour after the onset of hypoxia, all AP-1 components were markedly overexpressed. They include c-Jun, Jun B, Jun D, c-Fos and Fos-related antigens. Whereas, only c-Jun remained elevated for up to 96 h post-reoxygenation, time at which neurons were injured, other gene products showed patterned induction/repression as hypoxia progressed and then during the post-reoxygenation period, with Fos-related antigens being finally induced at 96 h. Only JNK1 was constitutively detected in cultured neurons, and its expression was inhibited during hypoxia. Nonetheless, both JNK1 and JNK3 were markedly, but transiently, induced at 48 h post-reoxygenation, when apoptosis-related morphological features became apparent. These data support the hypothesis that transient hypoxia, independently of ischemia, may trigger apoptosis through JNK signaling pathway in developing brain neurons.

Infectious pneumoperitoneum as an uncommon presentation of endometrial carcinoma: report of two cases

Two patients with pneumoperitoneum are reported; in both cases, the cause was severe infection of the upper genital tract. Investigation led to the finding of an underlying endometrial carcinoma. Literature review of the etiology of pneumoperitoneum, nature of the usual infecting organisms, and therapeutic principles are presented. Endometrial carcinoma should be considered in the differential diagnosis of infectious pneumoperitoneum, especially where patient risk factors are present.

[Perianal colloid adenocarcinoma. Apropos of a case]

A 50 year old man with a 5-year history of recurrent anal fistula was treated by abdominoperineal amputation of rectum for perianal colloid adenocarcinoma. Characters of this rare affection of debatable pathogenicity are described, based on a literature review of 82 similar cases. The findings illustrate the evocative nature of an induration or better still a mucoid discharge from a recurrent anal fistula, and the need for deep and repeated biopsies to establish diagnosis. Since the course remains for a long period at the local and regional levels the treatment of choice is abdomino-perineal amputation.

[Unusual cause of pneumoperitoneum: upper genital infection complicating endometrial cancer. Apropos of 2 cases]

Two cases are reported that illustrate a very unusual etiology of pneumoperitoneum: production of gas by germs from an infected genital tract lesion. Possible germs that can be involved are described, as well as the therapy applied which led to a favorable outcome in both patients.

[Angiectasis of the colon (Moore's type I angiodysplasia). One case (author's transl)]

A 60-year-old man had severe, recurrent rectal haemorrhages. Arteriography showed lesions suggestive of angiodysplasia located in the initial part of the ascending colon. Right-sided hemicolectomy was performed. Angiectasis of the colon is acquired and degenerative. It affects elderly people and is due to dilatation of the veins in the mucosa of the ascending colon. The lesions are usually too small to be detected by barium enema or colonoscopy, but arteriography of the superior mesenteric artery shows pathognomonic images. The only treatment is right-sided hemicolectomy.

[Prognostic evolution of Graves' disease. Surgical treatment (author's transl)]

We report 80 cases of Graves' disease with goiter and homogeneous scintiscan. All the patients underwent surgery after treatment of hyperthyroidism by ATD then by iodine : bilateral subtotal lobectomy was performed in 89 % of cases. The patients have been followed up for 1 to 10 years after surgery, the actuarial rate of euthyroidism is stable at 77 % from the 3rd to the 10th year on. In the same way, 16 % of hypothyroidism and 9 % of recurrent hyperthyroidism do not change from respectively the first and the third year to the tenth after surgery. No correlation has been found between their appearance and the various clinical and biological parameters which has been studied.