Catherine Smith

Smartphone-based home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial

Objective Cardiac rehabilitation (CR) is pivotal in preventing recurring events of myocardial infarction (MI). This study aims to investigate the effect of a smartphone-based home service delivery (Care Assessment Platform) of CR (CAP-CR) on CR use and health outcomes compared with a traditional, centre-based programme (TCR) in post-MI patients. Methods In this unblinded randomised controlled trial, post-MI patients were randomised to TCR (n=60; 55.7±10.4 years) and CAP-CR (n=60; 55.5±9.6 years) for a 6-week CR and 6-month self-maintenance period. CAP-CR, delivered in participants’ homes, included health and exercise monitoring, motivational and educational material delivery, and weekly mentoring consultations. CAP-CR uptake, adherence and completion rates were compared with TCR using intention-to-treat analyses. Changes in clinical outcomes (modifiable lifestyle factors, biomedical risk factors and health-related quality of life) across baseline, 6 weeks and 6 months were compared within, and between, groups using linear mixed model regression. Results CAP-CR had significantly higher uptake (80% vs 62%), adherence (94% vs 68%) and completion (80% vs 47%) rates than TCR (p<0.05). Both groups showed significant improvements in 6-minute walk test from baseline to 6 weeks (TCR: 537±86–584±99 m; CAP-CR: 510±77–570±80 m), which was maintained at 6 months. CAP-CR showed slight weight reduction (89±20–88±21 kg) and also demonstrated significant improvements in emotional state (K10: median (IQR) 14.6 (13.4–16.0) to 12.6 (11.5–13.8)), and quality of life (EQ5D-Index: median (IQR) 0.84 (0.8–0.9) to 0.92 (0.9–1.0)) at 6 weeks. Conclusions This smartphone-based home care CR programme improved post-MI CR uptake, adherence and completion. The home-based CR programme was as effective in improving physiological and psychological health outcomes as traditional CR. CAP-CR is a viable option towards optimising use of CR services. Trial registration number ANZCTR12609000251224.

Effect of Physical Therapy on Pain and Function in Patients With Hip Osteoarthritis: A Randomized Clinical Trial

IMPORTANCE There is limited evidence supporting use of physical therapy for hip osteoarthritis. OBJECTIVE To determine efficacy of physical therapy on pain and physical function in patients with hip osteoarthritis. DESIGN, SETTING, AND PARTICIPANTS Randomized, placebo-controlled, participant- and assessor-blinded trial involving 102 community volunteers with hip pain levels of 40 or higher on a visual analog scale of 100 mm (range, 0-100 mm; 100 indicates worst pain possible) and hip osteoarthritis confirmed by radiograph. Forty-nine patients in the active group and 53 in the sham group underwent 12 weeks of intervention and 24 weeks of follow-up (May 2010-February 2013) INTERVENTIONS: Participants attended 10 treatment sessions over 12 weeks. Active treatment included education and advice, manual therapy, home exercise, and gait aid if appropriate. Sham treatment included inactive ultrasound and inert gel. For 24 weeks after treatment, the active group continued unsupervised home exercise while the sham group self-applied gel 3 times weekly. MAIN OUTCOMES AND MEASURES Primary outcomes were average pain (0 mm, no pain; 100 mm, worst pain possible) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0 no difficulty to 68 extreme difficulty) at week 13. Secondary outcomes were these measures at week 36 and impairments, physical performance, global change, psychological status, and quality of life at weeks 13 and 36. RESULTS Ninety-six patients (94%) completed week 13 measurements and 83 (81%) completed week 36 measurements. The between-group differences for improvements in pain were not significant. For the active group, the baseline mean (SD) visual analog scale score was 58.8 mm (13.3) and the week-13 score was 40.1 mm (24.6); for the sham group, the baseline score was 58.0 mm (11.6) and the week-13 score was 35.2 mm (21.4). The mean difference was 6.9 mm favoring sham treatment (95% CI, -3.9 to 17.7). The function scores were not significantly different between groups. The baseline mean (SD) physical function score for the active group was 32.3 (9.2) and the week-13 score was 27.5 (12.9) units, whereas the baseline score for the sham treatment group was 32.4 (8.4) units and the week-13 score was 26.4 (11.3) units, for a mean difference of 1.4 units favoring sham (95% CI, -3.8 to 6.5) at week 13. There were no between-group differences in secondary outcomes (except greater week-13 improvement in the balance step test in the active group). Nineteen of 46 patients (41%) in the active group reported 26 mild adverse effects and 7 of 49 (14%) in the sham group reported 9 mild adverse events (P = .003). CONCLUSIONS AND RELEVANCE Among adults with painful hip osteoarthritis, physical therapy did not result in greater improvement in pain or function compared with sham treatment, raising questions about its value for these patients. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12610000439044.

The Role of Adenosine Following Pulmonary Vein Isolation in Patients Undergoing Catheter Ablation for Atrial Fibrillation: A Systematic Review

Pulmonary vein reconnection is a major limitation of pulmonary vein isolation (PVI) for symptomatic atrial fibrillation (AF). Adenosine may unmask dormant PV conduction and facilitate consolidation of PV isolation.

Comorbidities in difficult asthma are independent risk factors for frequent exacerbations, poor control and diminished quality of life

Little is known about how comorbidities affect difficult asthma patients across different domains of asthma outcomes. We hypothesized that comorbidities in difficult asthma significantly influence asthma outcomes.

Postpartum care for Aboriginal and non-Aboriginal women with Gestational Diabetes Mellitus across urban, rural and remote locations: A protocol for a cohort linkage study

BackgroundGestational diabetes mellitus (GDM) is increasing, along with obesity and type 2 diabetes (T2DM), with Aboriginal and Torres Strait Islander (Aboriginala) women in Australia particularly affected. GDM causes serious complications in pregnancy, birth, and the longer term, for women and their infants. Women with GDM have an eightfold risk of developing T2DM after pregnancy, compared to women without GDM. Indigenous women have an even higher risk, at a younger age, and progress more quickly from GDM to T2DM, compared to non-Indigenous women. If left undetected and untreated, T2DM increases risks in subsequent pregnancies, and can lead to heart disease, stroke, kidney failure, limb amputations and blindness for the woman in the longer term. A GDM diagnosis offers a ‘window of opportunity’ to provide acceptable and effective prevention, treatment, and postpartum care. Low rates of postpartum T2DM screening are reported among non-Aboriginal women in Australia and Indigenous women in other countries, however, data for Aboriginal women in Australia are scarce. A healthy diet, exercise and breastfeeding can delay the onset of T2DM, and together with T2DM screening are recommended elements of postpartum care for women with GDM. This paper describes methods for a study evaluating postpartum care among Aboriginal and non-Aboriginal women with GDM.Methods/DesignThis retrospective cohort includes all women who gave birth at Cairns Hospital in far north Queensland, Australia, from 2004 to 2010, coded as having GDM in the Cairns Hospital Clinical Coding system. Data is being linked with the Midwives Perinatal Data Collection, and the three local laboratories. Hospital medical records are being reviewed to validate accuracy of GDM case ascertainment, and gather information on breastfeeding and provision of dietary advice. Survival analysis is being used to estimate time to screening, and rates of progression from GDM to T2DM. Logistic regression is being used to compare postpartum care between Aboriginal and non-Aboriginal women, and assess factors that may be associated with provision of postpartum care.DiscussionThere are challenges to collecting postpartum data for women with GDM, however, this research is urgently needed to ensure adequate postpartum care is provided for women with GDM.

Need for intensive care in patients admitted for asthma: Red flags from the social history

Asthma deaths in Australia are associated with illicit substance abuse, mental health problems and social issues. However, a large proportion of these deaths occurs out of hospital and is difficult to avert by the time the individuals seek medical attention. We hypothesized that these characteristics may also increase the risk for a patient to require intensive care admission when they present to emergency departments.

The role of adenosine challenge in catheter ablation for atrial fibrillation: a systematic review and meta-analysis

AIMS Adenosine may unmask dormant PV conduction and facilitate consolidation of PV isolation. We performed a meta-analysis to determine the impact of adenosine administration on clinical outcomes in patients undergoing PVI. METHODS References and electronic databases reporting AF ablation and adenosine following PVI were searched through to 22nd November 2015. The impact of adenosine on freedom from AF was assessed in twenty publications after radiofrequency ablation (RFA), and in four publications after cryoablation to achieve PVI. Relative risks were calculated and combined in a meta-analysis using random effects modeling. RESULTS In patients undergoing RFA with adenosine challenge, there was a significant reduction in freedom from AF in patients with versus without adenosine induced reconnection (RR 0.86; 95%CI 0.77-0.98; p=0.02) particularly if no further ablation was performed (RR 0.66; 95%CI 0.50-0.87; p<0.01). There was no difference when comparing outcomes in studies of routine adenosine challenge vs no adenosine (RR 1.07; 95%CI 0.93-1.22; p=0.36). There was a non-significant trend to an increase in freedom from AF in patients receiving routine adenosine challenge (RR 1.18 95%CI 0.99-1.42; p=0.07) in non-randomized studies using cryoablation. CONCLUSION Adenosine induced PV reconnection following PVI is associated with a significant increase in AF recurrence, particularly if the reconnection sites are not targeted for ablation. The routine use of adenosine may be beneficial in AF ablation if given early post-PVI, at sufficient dose and reconnection is ablated.

The Incidence and Significance of Raised Troponin Levels in Acute Burns

The place and significance of troponin testing in acute burn injuries has not yet been established. The aims of this study were to determine the incidence and pattern of troponin testing within a large population of acute burn injuries and subsequently to determine the resultant clinical significance of the troponin test results. A retrospective analysis of all patients with acute burn admissions (n = 1,621 patients) to a busy tertiary adult burns center between July 2009 and July 2015. More than a third of our patients had at least one troponin test performed. Men, the elderly, and those with larger burns were more likely to be tested. The majority tested had the laboratory test done within 24 hours of admission. A positive troponin test strongly correlated with increased risk of acute cardiac complication and death, as did burns greater than 15% total body surface area (%TBSA) and age. Acute burns of ≥15% TBSA are associated with elevated troponin levels. Troponins should be tested in those ≥50 years old, with significant burns, and/or premorbid cardiac disease; positive results investigated as they affect cardiac and survival outcomes.

A Primer for Germinant Practice

This paper proposes a conception of architecture as an evolving, rhizomatic practice, as seen in spaces created through a blurring of designing, making and occupying: a design approach called germinant practice. ‘Germinant’ is an adjective meaning ‘growing and sprouting,’ and the term ‘germinal’ has been associated with Gilles Deleuze and Félix Guattari, who see life in proliferating, indeterminable and yet interconnected terms. Germinant design practices help us to see architecture, its inhabitation and its production as the same thing, and therefore provisional, experimental, creative, and unpredictable. This paper focuses on the key issues, methods, sites and materials used in examples of art and building projects reflecting a germinant sensibility.