Optimising Transitional Care Following a Heart Failure Hospitalisation in Australia

Hospitalisations for heart failure (HF) are associated with high rates of readmission and death, the most vulnerable period being within the first few weeks post-hospital discharge. Effective transition of care from hospital to community settings for patients with HF can help reduce readmission and mortality over the vulnerable period, and improve long-term outcomes for patients, their family or carers, and the healthcare system. Planning and communication underpin a seamless transition of care, by ensuring that the changes to patients' management initiated in hospital continue to be implemented following discharge and in the long term. This evidence-based guide, developed by a multidisciplinary group of Australian experts in HF, discusses best practice for achieving appropriate and effective transition of patients hospitalised with HF to community care in the Australian setting. It provides guidance on key factors to address before and after hospital discharge, as well as practical tools that can be used to facilitate a smooth transition of care.

Interpreting Wide-Complex Tachycardia using Artificial Intelligence

BACKGROUND

Adopting artificial intelligence in medicine may improve speed and accuracy in patient diagnosis. We sought to develop an artificial intelligence (AI) algorithm to interpret wide complex tachycardia (WCT) electrocardiograms (ECG) and compare its diagnostic accuracy to cardiologists.

METHODS

Using 3330 WCT ECGs (2906 SVT and 424 VT), we created a training/validation (3131) and test set (199 ECGs). A convolutional neural network (CNN) structure using a modification of differentiable architecture search (DARTS), ZeroLess-DARTS, was developed to differentiate between SVT and VT.

RESULTS

The mean accuracy of electrophysiology (EP) cardiologists was 92.5% with a sensitivity of 91.7%, specificity of 93.4%, positive predictive value of 93.7%, negative predictive value of 91.7%. NonEP cardiologists had an accuracy of 73.2 ± 14.4% with a sensitivity, specificity, positive and negative predictive value of 59.8 ± 18.2%, 93.8 ± 3.7%, 93.6 ± 2.3%, and 73.2 ± 14.4%, respectively. AI had superior sensitivity and accuracy (91.9% and 93.0%, respectively) than NonEP cardiologists, and had similar performance of EP cardiologists. Mean time to interpret each ECG varied between 10.1-13.8 seconds for EP cardiologists and 3.1 -16.6 seconds for NonEP cardiologists. Conversely AI required a mean of 0.0092 ± 0.0035 seconds for each ECG interpretation.

CONCLUSIONS

AI appears to diagnose WCT with superior accuracy than Cardiologists and similar to those of Electrophysiologists. Using AI to assist with ECG interpretations may improve patient care.

The effects of telerehabilitation in adults with complex biventricular congenital heart conditions: protocol for a multi-centre, randomised controlled trial-CH-FIT

BACKGROUND

Accumulated evidence suggests that exercise training exerts beneficial effects on people with congenital heart conditions. These findings are predominantly derived from small, single-centre exercise trials conducted in outpatient rehabilitation facilities. In recent years, the delivery of exercise interventions remotely has increased through digital communications technology (telerehabilitation). However, very little research to date has been conducted into the efficacy of telerehabilitation in people with a congenital heart condition.

AIMS

To evaluate the effects of a telehealth-delivered exercise intervention in people with a history of a surgical biventricular repair due to a congenital heart condition.

METHODS

One hundred eligible adolescent (≥ 16 years) and adult participants living with a complex biventricular congenital heart condition will be recruited from four Australian sites and randomised to either (1) a 16-week telehealth-delivered combined (aerobic and resistance) exercise training programme of moderate-to-vigorous intensity or (2) usual care (control group), in a 1:1 allocation, with an 8-month follow-up.

OUTCOMES OF INTEREST

The primary outcome will be the change in aerobic capacity expressed as peak oxygen uptake (VO2peak). Secondary outcomes will include changes in vascular function, muscle oxygenation, metabolic profile, body composition and musculoskeletal fitness, neurohormonal activation, neurocognitive function, physical activity levels, dietary and nutritional status, and quality of life. Outcomes will be assessed at baseline, 16 weeks, and 12 months (to determine longer-term maintenance potential).

DISCUSSION

If found to be efficacious, telerehabilitation may be an alternative option for delivering exercise, improving health outcomes, and increasing accessibility to exercise programmes. Efficacy data is required to quantify the clinical significance of this delivery mode of exercise.

TRIAL REGISTRATION

ACTRN12622000050752 Trial registration date: 17 January 2022 Trial registration URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382635&showOriginal=true&isReview=true Trial registry name: Australian and New Zealand Clinical Trials Registry.

Client and Clinician Experiences and Perspectives of Exercise Physiology Services During the COVID-19 Pandemic: Qualitative Study

BACKGROUND

The COVID-19 pandemic led to changes in the delivery of exercise physiology services. The lived experience of those who continued to provide or receive exercise physiology services during the heightened public health restrictions of the inaugural year of the COVID-19 pandemic has received little attention to date. Acquiring this knowledge will be fundamental in addressing whether telehealth is a viable option for service delivery in exercise care, research, and policy. This is especially pertinent in the wake of the COVID-19 pandemic and subsequent global interest in digital health delivery of health care services.

OBJECTIVE

This study aims to explore the clinician and client experiences and perspectives of exercise physiology services delivered in person or via telehealth during the inaugural year of the COVID-19 pandemic (after January 25, 2020; the date of the first confirmed case in Australia).

METHODS

Eligible participants for this study were adult (aged 18 years or older; capable of understanding and writing in English) clients who received and clinicians who delivered 1 or more exercise physiology sessions in Australia during the first year of the COVID-19 pandemic (June 2020 to June 2021). The data collection period spanned from January 20, 2021, to September 24, 2021. A total of 18 semistructured individual interviews were conducted with accredited exercise physiologists (n=7) and clients (n=11) who engaged with exercise physiology services during this period. All interviews were digitally recorded and transcribed verbatim. Thematic analysis was conducted with themes and subthemes derived using deductive and inductive approaches.

RESULTS

A total of 3 dominant themes, each with 2 subthemes, were identified. The first theme was that telehealth enables access to services but limits the use of some clinical tools. Remote access to services was valued by both clinicians and clients, but the exercise clinical environment could not be replicated over telehealth. This was especially true regarding access to exercise equipment. Second, engagement and the "relational space" are limited by telehealth. Perceived challenges regarding social interactions and a sense of community were a limitation for clients, and difficulties fostering clinician-client report were noted by clinicians. Finally, technological challenges are pervasive in the telehealth delivery of exercise services. Both clinicians and clients noted that systems necessary to facilitate telehealth frequently disrupted delivery, and client-based technical issues were influenced by digital health literacy.

CONCLUSIONS

Shared client and accredited exercise physiologist experiences highlight key considerations for the ongoing implementation of telehealth to facilitate the uptake and effectiveness of exercise physiology services. These findings imply that the co-design of solutions to client-perceived limitations of telehealth delivery is warranted.

Scale-up of the Australian Fans in Training (Aussie-FIT) men's health behaviour change program: a protocol for a randomised controlled hybrid effectiveness-implementation trial

INTRODUCTION

Improving physical activity (PA) and healthy eating is critical for primary and secondary prevention of cardiovascular disease (CVD). Behaviour change programmes delivered in sporting clubs can engage men in health behaviour change, but are rarely sustained or scaled-up post trial. Following the success of pilot studies of the Australian Fans in Training (Aussie-FIT) programme, a hybrid effectiveness-implementation trial protocol was developed. This protocol outlines methods to: (1) establish if Aussie-FIT is effective at supporting men with or at risk of CVD to sustain improvements in moderate-to-vigorous PA (primary outcome), diet and physical and psychological health and (2) examine the feasibility and utility of implementation strategies to support programme adoption, implementation and sustainment.

METHODS AND ANALYSIS

A pragmatic multistate/territory hybrid type 2 effectiveness-implementation parallel group randomised controlled trial with a 6-month wait list control arm in Australia. 320 men aged 35-75 years with or at risk of CVD will be recruited. Aussie-FIT involves 12 weekly face-to-face sessions including coach-led interactive education workshops and PA delivered in Australian Football League (Western Australia, Northern Territory) and rugby (Queensland) sports club settings. Follow-up measures will be at 3 and 6 months (both groups) and at 12 months to assess maintenance (intervention group only). Implementation outcomes will be reported using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework.

ETHICS AND DISSEMINATION

This multisite study has been approved by the lead ethics committees in the lead site's jurisdiction, the South Metropolitan Health Service Human Research Ethics Committee (Reference RGS4254) and the West Australian Aboriginal Health Ethics Committee (HREC1221). Findings will be disseminated at academic conferences, peer-reviewed journals and via presentations and reports to stakeholders, including consumers. Findings will inform a blueprint to support the sustainment and scale-up of Aussie-FIT across diverse Australian settings and populations to benefit men's health.

TRIAL REGISTRATION NUMBER

This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12623000437662).

Preterm birth and exercise capacity: what do we currently know?

Objectives

The long-term cardiopulmonary outcomes following preterm birth during the surfactant era remain unclear. Respiratory symptoms, particularly exertional symptoms, are common in preterm children. Therefore, cardiopulmonary exercise testing may provide insights into the pathophysiology driving exertional respiratory symptoms in those born preterm. This review aims to outline the current knowledge of cardiopulmonary exercise testing in the assessment of children born preterm in the surfactant era.

Design

This study is a narrative literature review.

Methods

Published manuscripts concerning the assessment of pulmonary outcomes using cardiopulmonary exercise testing in preterm children (aged <18 years) were reviewed. Search terms related to preterm birth, bronchopulmonary dysplasia, and exercise were entered into electronic databases, including Medline, PubMed, and Google Scholar. Reference lists from included studies were scanned for additional manuscripts.

Results

Preterm children have disrupted lung development with significant structural and functional lung disease and increased respiratory symptoms. The association between these (resting) assessments of respiratory health and exercise capacity is unclear; however, expiratory flow limitation and an altered ventilatory response (rapid, shallow breathing) are seen during exercise. Due to the heterogeneity of participants, treatments, and exercise protocols, the effect of the aforementioned limitations on exercise capacity in children born preterm is conflicting and poorly understood.

Conclusion

Risk factors for reduced exercise capacity in those born preterm remain poorly understood; however, utilizing cardiopulmonary exercise testing to its full potential, the pathophysiology of exercise limitation in survivors of preterm birth will enhance our understanding of the role exercise may play. The role of exercise interventions in mitigating the risk of chronic disease and premature death following preterm birth has yet to be fully realized and should be a focus of future robust randomized controlled trials.

Cluster Sets to Prescribe Interval Resistance Training: A Potential Method to Optimise Resistance Training Safety, Feasibility and Efficacy in Cardiac Patients

The integration of resistance training for cardiac patients leads to important health outcomes that are not optimally obtained with aerobic exercise; these include an increase in muscle mass, maintenance of bone mineral density, and improvements in muscular fitness parameters. Despite the proliferation of evidence supporting resistance exercise in recent decades, the implementation of resistance training is underutilised, and prescription is often sub-optimal in cardiac patients. This is frequently associated with safety concerns and inadequate methods of practical exercise prescription. This review discusses the potential application of cluster sets to prescribe interval resistance training in cardiac populations. The addition of planned, regular passive intra-set rest periods (cluster sets) in resistance training (i.e., interval resistance training) may be a practical solution for reducing the magnitude of haemodynamic responses observed with traditional resistance training. This interval resistance training approach may be a more suitable option for cardiac patients. Additionally, many cardiac patients present with impaired exercise tolerance; this model of interval resistance training may be a more suitable option to reduce fatigue, increase patient tolerance and enhance performance to these workloads. Practical strategies to implement interval resistance training for cardiac patients are also discussed. Preliminary evidence suggests that interval resistance training may lead to safer acute haemodynamic responses in cardiac patients. Future research is needed to determine the efficacy and feasibility of interval resistance training for health outcomes in this population.

Recommendations for objective cardiovascular assessment to inform clinical exercise prescription: An Exercise Physiologist and Physiotherapist expert consensus

OBJECTIVES

Exercise is beneficial in managing cardiovascular health. Objective assessments of cardiovascular function assist in identifying the presence or absence of exertional symptoms, and functional and physiological thresholds necessary to inform safe and effective exercise programmes. This study aimed to generate expert consensus on assessments of cardiovascular function to support clinical decision-making for professionals providing clinical exercise services.

DESIGN

Three-round e-Delphi.

METHODS

Expert Exercise Physiologists and Physiotherapists were recruited to participate in an e-Delphi. Experts were asked to list all objective cardiovascular assessments deemed necessary to inform safe and effective exercise prescription. In subsequent e-Delphi rounds, experts rated the importance of each item, provided a rationale to support their assertions, and reconsidered others' ratings and rationale to shift or reaffirm their position. These results were then translated into a clinical guidance document by the authors in consultation with a Cardiologist and an experienced Exercise Physiologist with expertise in cardiovascular assessment.

RESULTS

Thirty-one experts participated in the e-Delphi and fourteen participants completed all three rounds. Forty objective assessments were initially suggested. Six items reached consensus by the end of Round 2 (resting and exercise heart rate, resting, exercise, and recovery blood pressure, and peak exercise-induced rating of perceived exertion). One additional item reached consensus in Round 3 (exercise oxygen saturation).

CONCLUSIONS

In the absence of research evidence, the collective experience and insights of an expert panel can inform an evidence gap. Further research is required to determine the feasibility of implementing these seven assessments in practice where CV assessment is indicated.

A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

Models of radon exhalation from building structures: General and case-specific solutions

Assessing the radon activity that exhales from building structures is crucial to identify the best strategies to prevent radon from entering a building or reducing its concentration in the inhabited spaces. The direct measurement is extremely difficult, so the common approach has consisted in developing models describing the radon migration and exhalation phenomena for building porous materials. However, due to the mathematical complexity of comprehensively modelling the radon transport phenomenon in buildings, simplified equations have been mostly adopted until now to assess the radon exhalation. A systematic analysis of the models applicable to radon transport has been carried out and it has resulted in four models differing in the migration mechanisms - only diffusive or diffusive and advective - and the presence of inner radon generation. The general solutions have been obtained for all the models. Moreover, three case-specific sets of boundary conditions have been formulated to account for all the actual scenarios occurring in buildings: both perimetral and partition walls and building structures in direct contact with soil or embankments. The corresponding case-specific solutions obtained serve as a key practical tool to improve the accuracy in assessing the contribution of building materials to indoor radon concentration according to the site-specific installation conditions in addition to the material inner properties.

A cross-sectional study on smartphone uses among pregnant women attending childbirth classes in the Metropolitan Area of Palermo, Italy: The Stop-Phone study

Background

Prevalence of mobile device addiction has increased over the years; both women and men have assimilated the mobile phone as a central component of their personal existence: integrating it into their lifestyle or becoming so dependent on it that life without it has become unimaginable. Smartphones generate radio-frequency electromagnetic fields. While short-term exposure in adults was considered quite safe, effects of long-term exposure or exposure during pregnancy on fetuses or during breastfeeding on newborns are not well studied yet. The objective of the present study was to investigate the prevalence and usage characteristics of smartphones among a sample of pregnant women, and promote the correct and conscious use of the smartphone.

Methods

A cross-sectional study was conducted, with a questionnaire administered during childbirth classes and - after the questionnaire administration - an educational intervention focused on promoting the correct and conscious use of smartphones was carried out by psychologists and psychotherapists.

Results

The findings of our study suggest that a significant number of the participants suffered addiction to mobile phone usage, but were not aware of it. More than two third of the sample (67.2%) have not changed their smartphone use habits since the beginning of their pregnancy and even more significant data shows that almost all future moms (98.3%) never speak with their doctor about smartphone use during pregnancy.

Conclusions

Data collected suggest a lack of attention to the proposed topic, especially in relation to pregnancy. It seems necessary to sensitize future mothers on this topic. The promotion of a more conscious and controlled use of electronic devices can help reduce the radiation to which the unborn child may be exposed, but has a fundamental role even after birth, to ensure an adequate psychomotor and relational development of the child and do not affect, due to uncontrolled use of smartphones, the mother-child relationship.

Primary care Adherence To Heart Failure guidelines IN Diagnosis, Evaluation and Routine management (PATHFINDER): a randomised controlled trial protocol

INTRODUCTION

General practitioners (GPs) routinely provide care for patients with heart failure (HF); however, adherence to management guidelines, including titrating medication to optimal dose, can be challenging in this setting. This study will evaluate the effectiveness of a multifaceted intervention to support adherence to HF management guidelines in primary care.

METHODS AND ANALYSIS

We will undertake a multicentre, parallel-group, randomised controlled trial of 200 participants with HF with reduced ejection fraction. Participants will be recruited during a hospital admission due to HF. Following hospital discharge, the intervention group will have follow-up with their GP scheduled at 1 week, 4 weeks and 3 months with the provision of a medication titration plan approved by a specialist HF cardiologist. The control group will receive usual care. The primary endpoint, assessed at 6 months, will be the difference between groups in the proportion of participants being prescribed five guideline-recommended treatments; (1) ACE inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor at least 50% of target dose, (2) beta-blocker at least 50% of target dose, (3) mineralocorticoid receptor antagonist at any dose, (4) anticoagulation for patients diagnosed with atrial fibrillation, (5) referral to cardiac rehabilitation. Secondary outcomes will include functional capacity (6-minute walk test); quality of life (Kansas City Cardiomyopathy Questionnaire); depressive symptoms (Patient Health Questionnaire-2); self-care behaviour (Self-Care of Heart Failure Index). Resource utilisation will also be assessed.

ETHICS AND DISSEMINATION

Ethical approval was granted by the South Metropolitan Health Service Ethics Committee (RGS3531), with reciprocal approval at Curtin University (HRE2020-0322). Results will be disseminated via peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12620001069943.

The Effectiveness of Exercise Physiology Services During the COVID-19 Pandemic: A Pragmatic Cohort Study

BACKGROUND

The COVID-19 pandemic markedly changed how healthcare services are delivered and telehealth delivery has increased worldwide. Whether changes in healthcare delivery borne from the COVID-19 pandemic impact effectiveness is unknown. Therefore, we examined the effectiveness of exercise physiology services provided during the COVID-19 pandemic.

METHODS

This prospective cohort study included 138 clients who received exercise physiology services during the initial COVID-19 pandemic. Outcome measures of interest were EQ-5D-5L, EQ-VAS, patient-specific functional scale, numeric pain rating scale and goal attainment scaling.

RESULTS

Most (59%, n = 82) clients received in-person delivery only, whereas 8% (n = 11) received telehealth delivery only and 33% (n = 45) received a combination of delivery modes. Mean (SD) treatment duration was 11 (7) weeks and included 12 (6) sessions lasting 48 (9) minutes. The majority (73%, n = 101) of clients completed > 80% of exercise sessions. Exercise physiology improved mobility by 14% (β = 0.23, P = 0.003), capacity to complete usual activities by 18% (β = 0.29, P < 0.001), capacity to complete important activities that the client was unable to do or having difficulty performing by 54% (β = 2.46, P < 0.001), current pain intensity by 16% (β = - 0.55, P = 0.038) and goal attainment scaling t-scores by 50% (β = 18.37, P < 0.001). Effectiveness did not differ between delivery modes (all: P > 0.087).

CONCLUSIONS

Exercise physiology services provided during the COVID-19 pandemic improved a range of client-reported outcomes regardless of delivery mode. Further exploration of cost-effectiveness is warranted.

Impact of the COVID-19 Pandemic on Exercise Physiology Services in Australia: A Retrospective Audit

Introduction

The COVID-19 pandemic has led to a shift in healthcare towards telehealth delivery, which presents challenges for exercise physiology services. We aimed to examine the impact of the COVID-19 pandemic on the reach, efficacy, adoption and implementation of telehealth delivery for exercise physiology services by comparing Australian practises before (prior to 25 January 2020) and during the COVID-19 pandemic (after 25 January 2020).

Methods

This retrospective audit included 80 accredited exercise physiology clinicians. We examined relevant dimensions of the RE-AIM framework (reach, effectiveness, adoption and implementation) from the clinician perspective.

Results

During the COVID-19 pandemic, 91% (n = 73/80) of surveyed clinicians offered telehealth delivery service, compared to 25% (n = 20/80) prior. Mean (SD) telehealth delivery per week doubled from 5 (7) to 10 (8) hours. In-person delivery decreased from 23 (11) to 15 (11) hours per week. Typical reasons for not offering telehealth delivery were client physical/cognitive incapacity (n = 33/80, 41%) and safety (n = 24/80, 30%). Clinician-reported reasons for typical clients not adopting telehealth delivery were personal preference (n = 57/71, 80%), physical capacity (n = 35/71, 49%) and access to reliable delivery platforms (n = 27/71, 38%). Zoom (n = 54/71, 76%) and telephone (n = 53/71, 75%) were the most commonly used platforms. Of the reasons contributing to incomplete treatment, lack of confidence in delivery mode was sevenfold higher for telehealth compared to in-person delivery. No serious treatment-related adverse events were reported.

Conclusions

During the COVID-19 pandemic, telehealth delivery of exercise physiology services increased and in-person delivery decreased, which suggests the profession was adaptable and agile. However, further research determining comparative efficacy and cost-effectiveness is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00483-2.

Type-2 Diabetes and the Clinical Importance of Exaggerated Exercise Blood Pressure

BACKGROUND

Exaggerated exercise blood pressure (EEBP) during clinical exercise testing is associated with poor blood pressure (BP) control and cardiovascular disease (CVD). Type-2 diabetes (T2DM) is thought to be associated with increased prevalence of EEBP, but this has never been definitively determined and was the aim of this study.

METHODS

Clinical exercise test records were analyzed from 13 268 people (aged 53±13 years, 59% male) who completed the Bruce treadmill protocol (stages 1-4, and peak) at 4 Australian public hospitals. Records (including BP) were linked to administrative health datasets (hospital and emergency admissions) to define clinical characteristics and classify T2DM (n=1199) versus no T2DM (n=12 069). EEBP was defined as systolic BP ≥90th percentile at each test stage. Exercise BP was regressed on T2DM history and adjusted for CVD and risk factors.

RESULTS

Prevalence of EEBP (age, sex, preexercise BP, hypertension history, CVD history and aerobic capacity adjusted) was 12% to 51% greater in T2DM versus no T2DM (prevalence ratio [95% CI], stage 1, 1.12 [1.02-1.24]; stage 2, 1.51 [1.41-1.61]; stage 3, 1.25 [1.10-1.42]; peak, 1.18 [1.09-1.29]). At stages 1 to 3, 8.6% to 15.8% (4.8%-9.7% T2DM versus 3.5% to 6.1% no-T2DM) of people with 'normal' preexercise BP (<140/90 mm Hg) were identified with EEBP. Exercise systolic BP relative to aerobic capacity (stages 1-4 and peak) was higher in T2DM with adjustment for all CVD risk factors.

CONCLUSIONS

People with T2DM have higher prevalence of EEBP and exercise systolic BP independent of CVD and many of its known risk factors. Clinicians supervising exercise testing should be alerted to increased likelihood of EEBP and thus poor BP control warranting follow-up care in people with T2DM.

POS0919 MOLECULAR AND BIOLOGICAL PATHWAYS OF BREAST CANCER IN PATIENTS WITH SYSTEMIC SCLEROSIS: IMMUNOHISTOCHEMICAL INVESTIGATIONS FROM THE SCLERO-BREAST STUDY

Background

Systemic Sclerosis (SSc) is a life-threatening connective tissue disease characterized by endothelial dysfunction, autoimmune abnormalities and aberrant fibrosis. Several reports showed an increased risk of cancer in SSc compared to general population, including breast cancer (BC). The relationship between BC and SSc has long been discussed with contradictory results. In our recent Sclero-Breast study we analyzed clinical-pathological features of BC in SSc; we finally observed the development of BC with early stages and good prognosis among these patients.

Objectives

The aim of this project was to explore the immunohistochemical (IHC) expression of potential biomarkers involved in the molecular pathways at the basis of SSc and BC etiophatogenesis as update analysis from the Sclero-Breast study.

Methods

Our observational multicenter retrospective study, performed at Modena University Hospital and Reggio Emilia Hospital in northern Italy, enrolled 33 SSc women with a personal history of BC between January 2017 and December 2019. Clinical and pathological characteristics of BC and SSc were collected. For 22 patients, BC tissues were available and IHC analysis was performed using specific antibodies to evaluate biomarkers and pathways potentially involved. The antibodies used included: PI3K/mTOR/TGFβ/PDGFRα/PDGFRβ/VEGF/EGFR/IL-6/CTLA-4/PDL1. We also reported TILs percentage (stromal tumor-infiltrating lymphocytes) of each sample. The following scores were assigned for general IHC analysis: (-) negative, (1+) positive tumor cells <20%, (2+) positive tumor cells 20-50%, (3+) positive tumor cells >50%. For PDL1 we considered a positivity in case of PD-L1 expression ≥1% in infiltrating inflammatory cells. For TILs quantification we applied the score: 0 (negative), ≤ 50% (low-median expression), >50% (high expression).

Results

The first IHC analysis was performed on the samples of invasive BC patients (20 pts) and showed a prevalence of high PI3K expression (score of 3+ in 55% of cases) with mTOR overexpression in 45%. A PDL1 positivity was detected in 30%, with high TILs expression in 30%. Biopsies from the 2 pts with ductal carcinoma in situ were characterized by a negativity of almost all parameters, except for a medium-high TILs expression reported (40%/90% respectively). See Figure 1. IHC analysis was also performed according to BC subtypes. The group of HR+/HER2 negative showed high PI3K expression (score 3+) in most of cases (59%) with mTOR overexpression in 50%. CTLA-4 and PDL1 were positive in 25%, with high TILs expression in 25%. HER2 positive patients showed a high PI3K positivity in 50% of cases with mTOR positivity (score 3+) in 25% and high TGFβ expression (score 3+) in 25%. PDL1 was positive in 50% with high TILs expression in 25%. In Triple Negative group, PI3K overexpression was found in 75% of pts with half of cases represented by mTOR score 3+. PDL1 was positive in 50% with high TILs representation (80% of total cell count) in 50% of pts.

Figure 1.

IHC analysis and TILs% expression in histological samples of SSc patients with invasive BC.

Conclusion

According to our results, SSc patients with BC showed high positivity for PDL1 and high TILs representations in all subtypes. Furthermore, the high expression of PI3K, did not always correlate with mTOR overexpression. Further investigations on larger numbers are needed; however, these aspects seem to confirm that SSc subjects might develop BC at good prognosis, suggesting again a de-escalation strategy of cancer therapies. Finally, the possibility to personalize oncological targeted treatments in this subset of fragile patients could be promising.

Disclosure of Interests

None declared

Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome: The TEXTMEDS Randomized Clinical Trial

BACKGROUND

TEXTMEDS (Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome) examined the effects of text message-delivered cardiac education and support on medication adherence after an acute coronary syndrome.

METHODS

TEXTMEDS was a single-blind, multicenter, randomized controlled trial of patients after acute coronary syndrome. The control group received usual care (secondary prevention as determined by the treating clinician); the intervention group also received multiple motivational and supportive weekly text messages on medications and healthy lifestyle with the opportunity for 2-way communication (text or telephone). The primary end point of self-reported medication adherence was the percentage of patients who were adherent, defined as >80% adherence to each of up to 5 indicated cardioprotective medications, at both 6 and 12 months.

RESULTS

A total of 1424 patients (mean age, 58 years [SD, 11]; 79% male) were randomized from 18 Australian public teaching hospitals. There was no significant difference in the primary end point of self-reported medication adherence between the intervention and control groups (relative risk, 0.93 [95% CI, 0.84-1.03]; P=0.15). There was no difference between intervention and control groups at 12 months in adherence to individual medications (aspirin, 96% vs 96%; β-blocker, 84% vs 84%; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 77% vs 80%; statin, 95% vs 95%; second antiplatelet, 84% vs 84% [all P>0.05]), systolic blood pressure (130 vs 129 mm Hg; P=0.26), low-density lipoprotein cholesterol (2.0 vs 1.9 mmol/L; P=0.34), smoking (P=0.59), or exercising regularly (71% vs 68%; P=0.52). There were small differences in lifestyle risk factors in favor of intervention on body mass index <25 kg/m² (21% vs 18%; P=0.01), eating ≥5 servings per day of vegetables (9% vs 5%; P=0.03), and eating ≥2 servings per day of fruit (44% vs 39%; P=0.01).

CONCLUSIONS

A text message-based program had no effect on medical adherence but small effects on lifestyle risk factors.

REGISTRATION

URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448; Unique identifier: ANZCTR ACTRN12613000793718.

The Identification and Management of High Blood Pressure Using Exercise Blood Pressure: Current Evidence and Practical Guidance

High blood pressure (BP) is a leading risk factor for cardiovascular disease (CVD). The identification of high BP is conventionally based on in-clinic (resting) BP measures, performed within primary health care settings. However, many cases of high BP go unrecognised or remain inadequately controlled. Thus, there is a need for complementary settings and methods for BP assessment to identify and control high BP more effectively. Exaggerated exercise BP is associated with increased CVD risk and may be a medium to improve identification and control of high BP because it is suggestive of high BP gone undetected on the basis of standard in-clinic BP measures at rest. This paper provides the evidence to support a pathway to aid identification and control of high BP in clinical exercise settings via the measurement of exercise BP. It is recommended that exercise professionals conducting exercise testing should measure BP at a fixed submaximal exercise workload at moderate intensity (e.g., ~70% age-predicted heart rate maximum, stage 1-2 of a standard Bruce treadmill protocol). If exercise systolic BP is raised (≥170 mmHg), uncontrolled high BP should be assumed and should trigger correspondence with a primary care physician to encourage follow-up care to ascertain true BP control (i.e., home, or ambulatory BP) alongside a hypertension-guided exercise and lifestyle intervention to lower CVD risk related to high BP.

Impact of endometriosis on obstetric outcome after natural conception: a multicenter Italian study

Purpose

To evaluate obstetric outcome in women with endometriosis who conceive naturally and receive standard obstetric care in Italy.

Methods

Cases were consecutive women with endometriosis managed in eleven Italian referral centers. Controls were women in whom endometriosis was excluded. All women filled in a questionnaire addressing previous natural pregnancies. Marginal logistic regression models were fitted to evaluate the impact of endometriosis on obstetric outcome. A post hoc analysis was performed within the endometriosis group comparing women with severe adenomyosis versus women with absent or mild adenomyosis.

Results

Three hundred and fifty-five pregnancies in endometriosis group and 741 pregnancies in control group were included. Women with endometriosis had a higher risk of preterm delivery < 34 weeks (6.4% vs 2.8%, OR 2.42, 95% CI 1.22–4.82), preterm delivery < 37 weeks (17.8% vs 9.7%, OR 1.98, 95% CI 1.23–3.19), and neonatal admission to Intensive Care Unit (14.1% vs 7.0%, OR 2.04, 95% CI 1.23–3.36). At post hoc analysis, women with endometriosis and severe adenomyosis had an increased risk of placenta previa (23.1% vs 1.8%, OR 16.68, 95% CI 3.49–79.71), cesarean delivery (84.6% vs 38.9%, OR 8.03, 95% CI 1.69–38.25) and preterm delivery < 34 weeks (23.1% vs 5.7%, OR 5.52, 95% CI 1.38–22.09).

Conclusion

Women with endometriosis who conceive naturally have increased risk of preterm delivery and neonatal admission to intensive care unit. When severe adenomyosis is coexistent with endometriosis, women may be at increased risk of placenta previa and cesarean delivery.

Trial registration

Clinical trial registration number: NCT03354793.

Twelve weeks of water-based circuit training exercise improves fitness, body fat and leg strength in people with stable coronary heart disease: a randomised trial

QUESTION

In people with stable coronary heart disease, what are the effects of water-based circuit training exercise on aerobic capacity, strength and body composition? How do these effects compare with those of gym-based exercise?

DESIGN

Parallel group, randomised controlled trial with concealed allocation and intention-to-treat analysis.

PARTICIPANTS

Fifty-two participants with stable coronary heart disease.

INTERVENTIONS

Twelve weeks of: three 1-hour sessions per week of moderate-intensity water-based circuit training exercise with alternating aerobic and resistance stations (WEX); three 1-hour sessions per week of moderate-intensity gym-based circuit training exercise (GEX); or continuing usual activities (control).

OUTCOME MEASURES

Aerobic capacity (VO_2peak), upper and lower limb one repetition maximum strength (biceps curl, latissimus dorsi pulldown, hamstring curl and leg press), anthropometry (weight, body mass index and girth) and dual energy x-ray absorptiometry.

RESULTS

Forty-five participants completed the study (WEX n = 15, GEX n = 18, control n = 12). Both training groups significantly improved VO_2peak compared with control: WEX by 2.5 ml/kg/min (95% CI 0.6 to 4.4) and GEX by 2.3 ml/kg/min (95% CI 0.6 to 4.0). WEX and GEX improved hamstring strength compared with control: WEX by 6.3 kg (95% CI 1.2 to 11.3) and GEX by 7.6 kg (95% CI 2.9 to 12.2). Compared with control, GEX increased leg press strength by 15.5 kg (95% CI 5.7 to 25.3), whereas the effect of WEX was less clear (MD 7.1 kg, 95% CI -3.5 to 17.7). Only GEX improved latissimus dorsi pulldown strength. Compared with control, total body fat was reduced with WEX (-1.1 kg, 95% CI -2.3 to 0.0) and GEX (-1.2 kg, 95% CI -2.3 to -0.1). There were negligible between-group differences in weight or waist circumference.

CONCLUSION

WEX was well tolerated and improved aerobic capacity, leg strength and body fat to a similar degree as GEX in people with coronary heart disease. These findings suggest that WEX is an effective exercise training alternative to GEX for people with coronary heart disease.

TRIAL REGISTRATION

ANZCTR12616000102471.

Patient Perspectives on Innovative Telemonitoring Enhanced Care Program for Chronic Heart Failure (ITEC-CHF): Usability Study

Background

Telemonitoring enables care providers to remotely support outpatients in self-managing chronic heart failure (CHF), but little is known about the usability and patients’ willingness to engage with this technology.

Objective

This study aims to evaluate feedback from patients with CHF following participation in the Innovative Telemonitoring Enhanced Care program for CHF (ITEC-CHF) study.

Methods

The telemonitoring intervention consisted of three components: remote weight monitoring, structured telephone support, and nurse-led collaborative care. Participants were provided with electronic weighing scales (W550; ForaCare), and a computer tablet (Galaxy Tab A; Samsung). They were asked to weigh themselves on the provided scales daily. Telemonitoring was integrated with a personal assistance call service and a nurse care service according to their workflows in usual care. Feedback on the usability of ITEC-CHF was collected via survey from study participants following 6 months of receiving telemonitoring care for their body weight. Survey responses were provided on a 5-point Likert scale and through open-ended questions to determine participants’ perceived benefits and barriers to using ITEC-CHF.

Results

A total of 67 participants (49/67, 73% male), with a mean age of 69.8 (SD 12.4) years completed the survey. The majority of participants agreed or strongly agreed that the ITEC-CHF program was easy to use (61/67, 91%), easy to navigate (51/65, 78%), useful (59/65, 91%), and made them feel more confident in managing their weight (57/67, 85%). Themes related to participants’ perceptions of telemonitoring included increased support for early intervention of clinical deterioration, improved compliance to daily weighing, a sense of reassurance, and improved self-care and accountability, among others.

Conclusions

ITEC-CHF was rated highly on usability and was well accepted by users as part of their routine self-management activities. Participants were willing to use telemonitoring because they perceived a broad spectrum of benefits for CHF management.

Trial Registration

Australian New Zealand Clinical Trial Registry ID ACTRN 12614000916640; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366691.

Characterising running economy and change of direction economy between soccer players of different playing positions, levels and sex

Traditional movement economy (ME) measures the energetic cost of in-line running. However, it is debatable whether such a measure is representative of movement efficiency for team sport athletes who are required to run and change direction repeatedly. This study evaluated ME during both in-line running and runs with directional changes and provided a preliminary exploration as to whether these abilities discriminate soccer players according to playing position, level, and sex. Forty-three soccer players were assessed for ME as extrapolated from oxygen uptake during in-line running (RE) and running with changes of directions (using 20 and 10 m shuttle runs [SRE₂₀ and SRE₁₀]) at 8.4 km/h mean speed. ME worsened with change of direction frequency (p < 0.001). Coefficient of determination was high between RE and SRE₂₀ (r²=0.601) but dropped below 0.5 for RE and SRE₁₀ (r² = 0.280) as change of direction frequency increased. No significant differences were observed between different player positions, however, centre midfielders reported the best ME across any position and running mode, with the largest differences observed in centre backs over SRE₁₀ (41.9 ± 2.7 ml/kg/min [centre midfielders] vs 45 ± 1.8 ml/kg/min [centre backs]; ES = 1.19). No significant differences were observed for ME over any running condition for male players of different playing levels. Female players exhibited better ME than male players with significant differences observed for SRE₁₀ (41.5 ± 2.6 ml/kg/min [females] vs 44 ± 2.6 ml/kg/min [males]; p = 0.013; ES = 0.94). RE does not adequately account for efficiency during activities that involve changes of direction. SRE₁₀ is a stronger discriminator of ME between soccer players of different position and sex.

Scar endometriosis: not a rare cause for a painful scar

Conclusion

High suspicion of scar endometriosis are painful no-dule in the abdominal scar. Wide surgical excision is the treatment of choice.

Introduction

Endometriosis has been described as the presence of endometrial tissue outside uterine cavity. Scar endometriosis (SE) is a rare disease reported in 0.03-1.08% of women following gynaecologic surgery. In our retrospective observational cohort study we studied anamnesis, symptoms, surgical procedures and outcomes linked to scar endometriosis in our medical experience from 2004 to 2018.

Methods

We reviewed the medical records of 46 patients with a histopathological diagnosis of SE. All patients had a history of at least one previous caesarean section (n=46, 100%). Forty-two patients (91,3%) complained gradually growing nodular abdominal mass near or adjacent to caesarean incision scar, while only 4 patients (8,6%) complained aspecific abdominal pain. Ultrasound scan was performed in all patients (n=46, 100%) and mean size of the nodules at US was 26,8 ± 13,8 mm.

Results

All patients underwent surgery. Seven patients (15,2%) needed mesh implantation, while 39 patients (84,8%) underwent local resection with reconstruction of muscle fascia. Mean follow-up was 31,6 ± 14 months and no patients reported local recurrence of disease.

AB0425 CLINICAL AND PATHOLOGICAL FEATURES OF BREAST CANCER IN PATIENTS WITH SYSTEMIC SCLEROSIS: PRELIMINARY DATA FROM THE SCLERO-BREAST STUDY

Background:

Systemic Sclerosis (SSc) is a rare and life-threatening connective tissue disease characterized by vascular dysfunction, specific autoimmune abnormalities and fibrosis of the skin and internal organs. Previous studies have shown a 1.5-fold increase in cancer risk in SSc patients compared with the general population, including breast cancer (BC). The relationship between BC and SSc has long been discussed but past research has been contradictory and inconclusive on this topic.

Objectives:

The aim of our project was to analyze clinical and pathological characteristics of BC developed by SSc subjects and possible correlations with scleroderma features. Here we present the preliminary data from the Sclero-Breast study.

Methods:

Our observational retrospective multicenter study enrolled 33 SSc women with a personal history of BC identified at two Rheumatology/SSc Units in the north of Italy between January 2017 and December 2019 (lc/dcSSc 23/9, 1 unknown; mean age at SSc onset 57 years, range 32-73). All patients underwent general and instrumental assessment: smoking habits; presence of skin ulcers, calcinosis, teleangectasia; presence of gastro-intestinal and kidney involvement; interstitial lung disease (at HR-CT); pulmonary function tests; ECG abnormalities; echocardiographic assessment of pulmonary arterial hypertension (PAH); videocapillaroscopic pattern; autoantibody profile; exposure to immunosuppressive and vasoactive therapies; status at last follow-up evaluation and cause of death. Clinical and pathological characteristics of BC were also evaluated: age at diagnosis; menopausal status; histotype; hormone receptor status; MIB1, HER2 expression; clinical and pathological stage at diagnosis; metastatic sites; type of loco-regional treatment (surgery and radiotherapy); type of systemic treatment (neoadjuvant/adjuvant chemotherapy and endocrine treatment); other cancers and time from diagnosis of the first disorder to the second one.

Results:

A total of 54.5% of subjects developed BC before SSc (median interval of 5 years), whereas 45.5% of patients developed BC after SSc (median delay of 8 years). 54.5% of patients showed interstitial lung disease and the cause of death of the 6 deceased subjects was PAH. A significant association (p<0.05) was observed between the use of immunosuppressive therapy and diffuse skin extension, negative ACA, positive Anti-Scl-70 and interstitial lung disease, but not with BC status. 93.1% of patients were diagnosed with an early-stage tumor, 70.8% of invasive carcinomas with a low MIB-1, 8.3% with a tubular histotype, while 42.8% presented with a Luminal A-like tumor. 66.6% underwent breast conserving surgery and 55.5% RT after surgery. 40% of patients developed interstitial lung disease after RT and 20% dcSSc.

Conclusion:

According to our preliminary data, SSc patients developed BC at good prognosis, suggesting a de-escalation strategy of cancer therapies. On these grounds, a proper screening is mandatory in order to allow for early cancer detection in SSc patients. Further investigations on larger numbers of patients are needed. First of all, they would further clarify the intriguing relationship between BC and SSc. Secondly, they would help to explore the common biological and molecular pathways at the basis of these two disorders, with the aim to improve BC diagnosis and prognosis and to personalize oncological targeted treatments in this subset of fragile patients.

Disclosure of Interests:

None declared

Reference Intervals for Brachial Artery Flow-Mediated Dilation and the Relation With Cardiovascular Risk Factors

[Figure: see text].

Move your mind: embedding accredited exercise physiology services within a hospital-based mental health service

OBJECTIVE

Despite support for the role of exercise in improving physical and mental health for various psychiatric disorders, few service implementation evaluations within diverse hospital environments exist. This study presents the feasibility and implementation of a clinical exercise physiology service within a hospital mental health service.

METHOD

Feasibility and service data were collected from databases and self-report (consumer and staff) for 6 months from the commencement of new exercise services (gym and group sessions) for community and inpatients (one secure and three open wards).

RESULTS

One hundred and twenty consumers engaged with exercise services with 70 direct referrals over the 6-month audit period (mean age 40 ± 13 years (19-69); 41% male). The overwhelming reason for referral was related to weight loss/management (65.7%), with the majority of patients (51%) presenting with schizophrenia spectrum and other psychotic disorders. Further, 549 exercise service interactions were delivered and 78% gym attendees and 69% group session attendees rated the exercise sessions as 'Good' or 'Great', and intention to return ranged from 78% for inpatient gym sessions to 91% for community gym sessions.

CONCLUSIONS

Embedding exercise physiology into a mental health service is feasible and well accepted and the evaluation of long-term consumer outcomes in 'real-world' will serve as a crucial step.

High-intensity Interval Training Shock Microcycle Improves Running Performance but not Economy in Female Soccer Players

This study aimed to evaluate the effect of high-intensity interval training shock microcycles (HIIT_SM) on endurance, running economy and change of direction economy in female soccer players. Nineteen sub-elite female soccer players were randomised to two groups: HIIT_SM (10 HIIT sessions over 13 days) or HIIT_TRAD (4 HIIT sessions over 13 days) interventions. Endurance performance was evaluated through the 30-15 intermittent fitness test (30-15_IFT); running economy over a 5-min treadmill run; and change of direction economy over two conditions: (1) 5-min 20m shuttle run, and (2) 5-min 10m shuttle run. HIIT_SM significantly improved 30-15_IFT scores compared to baseline (+4.4%, p=0.009; d=0.96) and 30-15_IFT scores relative to HIIT_TRAD (p=0.002; d=2.01). There was no significant interaction (group×time) for running economy and change of direction economy. Pre- to post- intervention there was a significant main time effect for blood lactate over 20m and 10m shuttle runs (p<0.001 and p=0.037, respectively), with large (d=0.93) and moderate (d=0.53) changes observed for the HIIT_SM over the two distances, respectively. HIIT_SM may be more effective than HIIT_TRAD to improve 30-15_IFT over shorter training periods but may not affect running economy and change of direction economy.

Exercise Testing and Training in Adults With Congenital Heart Disease: A Surgical Perspective

In the current era, the majority of children born with congenital heart disease (CHD) will survive well into adulthood because of major advances in surgical techniques, as well as in critical and medical care. However, reoperation and palliative surgical interventions are increasingly common in the adults with CHD. Tools to risk stratify patients effectively and therapies to improve outcomes are required to optimize the management of adult patients with CHD during the preoperative and postoperative periods and beyond. Exercise testing is an invaluable tool to guide risk stratification. In addition, exercise training in patients with CHD may decrease postoperative complications by enhancing physiological reserve and also has an important role in physical rehabilitation. This review aims to provide individualized recommendations on exercise prescription in patients with CHD in the preoperative and postoperative settings. The response to exercise testing and prognostic implications is also discussed.

Effects of Different Telemonitoring Strategies on Chronic Heart Failure Care: Systematic Review and Subgroup Meta-Analysis

BACKGROUND

Telemonitoring studies in chronic heart failure are characterized by mixed mortality and hospitalization outcomes, which have deterred the uptake of telemonitoring in clinical practice. These mixed outcomes may reflect the diverse range of patient management strategies incorporated in telemonitoring. To address this, we compared the effects of different telemonitoring strategies on clinical outcomes.

OBJECTIVE

The aim of this systematic review and subgroup meta-analysis was to identify noninvasive telemonitoring strategies attributing to improvements in all-cause mortality or hospitalization outcomes for patients with chronic heart failure.

METHODS

We reviewed and analyzed telemonitoring strategies from randomized controlled trials (RCTs) comparing telemonitoring intervention with usual care. For each strategy, we examined whether RCTs that applied the strategy in the telemonitoring intervention (subgroup 1) resulted in a significantly lower risk ratio (RR) of all-cause mortality or incidence rate ratio (IRR) of all-cause hospitalization compared with RCTs that did not apply this strategy (subgroup 2).

RESULTS

We included 26 RCTs (N=11,450) incorporating 18 different telemonitoring strategies. RCTs that provided medication support were found to be associated with a significantly lower IRR value than RCTs that did not provide this type of support (P=.01; subgroup 1 IRR=0.83, 95% CI 0.72-0.95 vs subgroup 2 IRR=1.02, 95% CI 0.93-1.12). RCTs that applied mobile health were associated with a significantly lower IRR (P=.03; IRR=0.79, 95% CI 0.64-0.96 vs IRR=1.00, 95% CI 0.94-1.06) and RR (P=.01; RR=0.67, 95% CI 0.53-0.85 vs RR=0.95, 95% CI 0.84-1.07).

CONCLUSIONS

Telemonitoring strategies involving medication support and mobile health were associated with improvements in all-cause mortality or hospitalization outcomes. These strategies should be prioritized in telemonitoring interventions for the management of patients with chronic heart failure.

Lung abnormalities do not influence aerobic capacity in school children born preterm

PURPOSE

Children born preterm have impaired lung function and altered lung structure. However, there are conflicting reports on how preterm birth impacts aerobic exercise capacity in childhood. We aimed to investigate how neonatal history and a diagnosis of bronchopulmonary dysplasia (BPD) impact the relationship between function and structure of the lung, and aerobic capacity in school-aged children born very preterm.

METHODS

Preterm children (≤ 32 w completed gestation) aged 9-12 years with (n = 38) and without (n = 35) BPD, and term-born controls (n = 31), underwent spirometry, lung volume measurements, gas transfer capacity, a high-resolution computer tomography (CT) scan of the chest, and an incremental treadmill exercise test.

RESULTS

Children born preterm with BPD had an elevated breathing frequency to tidal volume ratio compared to term controls (76% vs 63%, p = 0.002). The majority (88%) of preterm children had structural changes on CT scan. There were no differences in peak V̇O₂ (47.1 vs 47.7 mL/kg/min, p = 0.407) or oxygen uptake efficiency slope when corrected for body weight (67.6 vs 67.3, p = 0.5) between preterm children with BPD and term controls. There were no differences in any other exercise outcomes. The severity of structural lung disease was not associated with exercise outcomes in this preterm population.

CONCLUSION

Children born preterm have impaired lung function, and a high prevalence of structural lung abnormalities. However, abnormal lung function and structure do not appear to impact on the aerobic exercise capacity of preterm children at school age.

The Effects of Telemonitoring on Patient Compliance With Self-Management Recommendations and Outcomes of the Innovative Telemonitoring Enhanced Care Program for Chronic Heart Failure: Randomized Controlled Trial

Background

Telemonitoring enables care providers to remotely support outpatients in self-managing chronic heart failure (CHF), but the objective assessment of patient compliance with self-management recommendations has seldom been studied.

Objective

This study aimed to evaluate patient compliance with self-management recommendations of an innovative telemonitoring enhanced care program for CHF (ITEC-CHF).

Methods

We conducted a multicenter randomized controlled trial with a 6-month follow-up. The ITEC-CHF program comprised the provision of Bluetooth-enabled scales linked to a call center and nurse care services to assist participants with weight monitoring compliance. Compliance was defined a priori as weighing at least 4 days per week, analyzed objectively from weight recordings on the scales. The intention-to-treat principle was used to perform the analysis.

Results

A total of 184 participants (141/184, 76.6% male), with a mean age of 70.1 (SD 12.3) years, were randomized to receive either ITEC-CHF (n=91) or usual care (control; n=93), of which 67 ITEC-CHF and 81 control participants completed the intervention. For the compliance criterion of weighing at least 4 days per week, the proportion of compliant participants in the ITEC-CHF group was not significantly higher than that in the control group (ITEC-CHF: 67/91, 74% vs control: 56/91, 60%; P=.06). However, the proportion of ITEC-CHF participants achieving the stricter compliance standard of at least 6 days a week was significantly higher than that in the control group (ITEC-CHF: 41/91, 45% vs control: 23/93, 25%; P=.005).

Conclusions

ITEC-CHF improved participant compliance with weight monitoring, although the withdrawal rate was high. Telemonitoring is a promising method for supporting both patients and clinicians in the management of CHF. However, further refinements are required to optimize this model of care.

Trial Registration

Australian New Zealand Clinical Trial Registry ACTRN12614000916640; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366691

Nivolumab in metastatic melanoma: good efficacy and tolerability in elderly patients

Background

Nivolumab is an anti-PD-1 antibody that restores the antitumour immune function of T cells, blocking the binding of PD-1 with its ligand PD-L1. PD-1 is expressed on T cells and interacts with PD-L1 on tumour cells. The PD-1-PD-L1 link inhibits T cell activation. In metastatic melanoma, PD-1-PD-L1 binding plays a critical role, and the advent of the immune checkpoint inhibitor nivolumab has delivered new and effective treatment options with proven clinical benefit. In the present study, we evaluated the efficacy of nivolumab in elderly patients with metastatic melanoma.

Methods

The study enrolled 55 elderly patients (75 years of age and older) with a diagnosis of metastatic melanoma. Primary endpoints of the study were progression-free survival (pfs) and the objective response rate; secondary endpoints were overall survival, reduction in serum lactate dehydrogenase (ldh) from before to after treatment, and tolerability.

Results

Nivolumab was well tolerated and resulted in good disease control, with a manageable toxicity profile and significant clinical benefit. The duration of pfs was 5.1 months (95% confidence interval: 3.5 months to 6.8 months). A significant correlation was observed between reduction in serum ldh and pfs: 0.60 (95% confidence interval: 0.28 to 0.86; p = 0.002).

Conclusions

Nivolumab is an immunotherapy treatment that has proved to be an effective and well-tolerated therapeutic option in elderly patients with metastatic melanoma.

Lack of Cited Evidence Underpinning Recommendations for Objective Assessment of Cardiovascular Function to Inform Exercise Prescription: A Systematic Review

BACKGROUND

The effectiveness of exercise in managing cardiovascular (CV) health and function is well established. Less clear is the process for optimising the safety and efficacy of an intervention, particularly how objective assessments might inform this process.

OBJECTIVE

The aim of this review was to investigate the cited evidence underpinning recommendations for assessing CV function to inform the safe and effective prescription of exercise in populations with established CV disease, as published in documents to guide practice authored by prominent organisations in cardiology and sports medicine.

METHODS

A systematic review of position statements and guiding documents on exercise prescription for CV health was conducted. Included documents were published between 1997 and 2016.

RESULTS

Following removal of duplicates, 3158 documents were considered, with full-text screening required for 334. Twenty-seven documents were included which provided 106 individual recommendations for specific objective assessments. Of the total number of recommendations, 60% had no accompanying citation and 28% of recommendations provided citations that did not directly support the statement made. Additionally, 52% of included documents did not state the methods of document development. That is, it was not clear if there was a literature review and/or expert consensus that was used to form recommendations included within.

CONCLUSION

Almost no cited evidence underpinning the extracted recommendations from the included guiding documents, nor any acknowledgement of this deficiency was established. There were limited explanations found for the methods involved in developing such guiding documents.

Association of tumor-infiltrating lymphocytes with distant disease-free survival in the ShortHER randomized adjuvant trial for patients with early HER2+ breast cancer

BACKGROUND

There is the need to identify new prognostic markers to refine risk stratification for HER2-positive early breast cancer patients. The aim of this study was to evaluate the association of tumor-infiltrating lymphocytes (TILs) with distant disease-free survival (DDFS) in patients with HER2-positive early breast cancer enrolled in the ShortHER adjuvant trial which compared 9 weeks versus 1-year trastuzumab in addition to chemotherapy, and to test the interaction between TILs and treatment arm.

PATIENTS AND METHODS

Stromal TILs were assessed for 866 cases on centralized hematoxylin and eosin-stained tumor slides. The association of TILs as 10% increments with DDFS was assessed with Cox models. Kaplan-Meier curves were estimated for patients with TILs ≥20% and TILs <20%. Median follow-up was 6.1 years.

RESULTS

Median TILs was 5% (Q1-Q3 1%-15%). Increased TILs were independently associated with better DDFS in multivariable model [hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.59-0.89, P = 0.006, for each 10% TILs increment]. Five years DDFS rates were 91.1% for patients with TILs <20% and 95.7% for patients with TILs ≥20% (P = 0.025). The association between 10% TILs increments and DDFS was significant for patients randomized to 9 weeks of trastuzumab (HR 0.60, 95% CI 0.41-0.88) but not for patients treated with 1 year of trastuzumab (HR 0.89, 95% CI 0.71-1.12; test for interaction P = 0.088). For patients with TILs <20%, the HR for the comparison between the short versus the long arm was 1.75 (95% CI 1.09-2.80, P=0.021); whereas, for patients with TILs ≥20% the HR for the comparison of short versus long arm was 0.23 (95% CI 0.05-1.09, P = 0.064), resulting in a significant interaction (P = 0.015).

CONCLUSIONS

TILs are an independent prognostic factor for HER2-positive early breast cancer patients treated with adjuvant chemotherapy and trastuzumab and may refine the ability to identify patients at low risk of relapse eligible for de-escalated adjuvant therapy.

Physical Activity Is Higher in Patients with Left Ventricular Assist Device Compared with Chronic Heart Failure

PURPOSE

Left ventricular assist devices (LVAD) are associated with an increased aerobic capacity in patients with chronic heart failure (CHF). However, studies evaluating the impact of LVAD implantation on physical activity (PA) are lacking. The aim of this study was to compare daily PA levels in participants with LVAD with well-matched CHF participants.

METHODS

Sixteen participants with an LVAD (age, 59.1 ± 10.8 yr) were case-matched to 16 participants with advanced CHF (age, 58.3 ± 8.7 yr), who were listed or being considered for cardiac transplantation. Participants underwent a cardiopulmonary exercise test to determine peak oxygen consumption (V˙O2 peak). Physical activity was monitored continuously for seven consecutive days with an Actiheart monitor.

RESULTS

V˙O2 peak in the CHF group (12.3 ± 3.5 mL·kg·min) was not significantly different to the LVAD group before LVAD implantation (10.4 ± 2.1 mL·kg·min), but was lower than in the LVAD group after implantation (15.8 ± 4.3 mL·kg·min; P < 0.05). Physical activity was higher in the LVAD (19.7 ± 6.4 kJ·kg·d) compared with the CHF group (11.6 ± 6.9 kJ·kg·d; P = 0.001). The LVAD participants spent more time performing moderate-intensity PA than their CHF counterparts (median, 26 min·d; interquartile range, 24-40 min·d vs median, 12 min·d; interquartile range, 9-16 min·d; P < 0.001). Physical activity was correlated with V˙O2 peak (r = 0.582; P = 0.001) across participants in the CHF and LVAD groups.

CONCLUSIONS

Higher levels of PA were observed in participants with LVAD compared with patients with advanced CHF. This may be due to a higher V˙O2 peak, resulting in an improved capacity to perform activities of daily living with less symptoms.