Medicine (Western Health) - Research Publications

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    Impella versus Venoarterial Extracorporeal Membrane Oxygenation for Acute Myocardial Infarction Cardiogenic Shock: A Systematic Review and Meta-Analysis
    Batchelor, RJ ; Wheelahan, A ; Zheng, WC ; Stub, D ; Yang, Y ; Chan, W (MDPI, 2022-07-01)
    OBJECTIVES: Despite an increase in the use of mechanical circulatory support (MCS) devices for acute myocardial infarction cardiogenic shock (AMI-CS), there is currently no randomised data directly comparing the use of Impella and veno-arterial extra-corporeal membrane oxygenation (VA-ECMO). METHODS: Electronic databases of MEDLINE, EMBASE and CENTRAL were systematically searched in November 2021. Studies directly comparing the use of Impella (CP, 2.5 or 5.0) with VA-ECMO for AMI-CS were included. Studies examining other modalities of MCS, or other causes of cardiogenic shock, were excluded. The primary outcome was in-hospital mortality. RESULTS: No randomised trials comparing VA-ECMO to Impella in patients with AMI-CS were identified. Six cohort studies (five retrospective and one prospective) were included for systematic review. All studies, including 7093 patients, were included in meta-analysis. Five studies reported in-hospital mortality, which, when pooled, was 42.4% in the Impella group versus 50.1% in the VA-ECMO group. Impella support for AMI-CS was associated with an 11% relative risk reduction in in-hospital mortality compared to VA-ECMO (risk ratio 0.89; 95% CI 0.83-0.96, I2 0%). Of the six studies, three studies also adjusted outcome measures via propensity-score matching with reported reductions in in-hospital mortality with Impella compared to VA-ECMO (risk ratio 0.72; 95% CI 0.59-0.86, I2 35%). Pooled analysis of five studies with 6- or 12-month mortality data reported a 14% risk reduction with Impella over the medium-to-long-term (risk ratio 0.86; 95% CI 0.76-0.97, I2 0%). CONCLUSIONS: There is no high-level evidence comparing VA-ECMO and Impella in AMI-CS. In available observation studies, MCS with Impella was associated with a reduced risk of in-hospital and medium-term mortality as compared to VA-ECMO.
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    Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia
    Jessup, RL ; Awad, N ; Beauchamp, A ; Bramston, C ; Campbell, D ; Semciw, A ; Tully, N ; Fabri, AM ; Hayes, J ; Hull, S ; Clarke, AC (BMC, 2022-07-13)
    BACKGROUND: Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic. METHODS: A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews. RESULTS: All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data. CONCLUSION: Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.
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    B-Type Natriuretic Peptide and Long-Term Cardiovascular Mortality in Patients With Coronary Heart Disease.
    Stewart, RAH ; Kirby, A ; White, HD ; Marschner, SL ; West, M ; Thompson, PL ; Sullivan, D ; Janus, E ; Hunt, D ; Kritharides, L ; Keech, A ; Simes, J ; Tonkin, AM (Ovid Technologies (Wolters Kluwer Health), 2022-07-05)
    Background The plasma concentration of B-type natriuretic peptide (BNP) is a strong predictor of adverse cardiovascular events. The aim of this study was to determine whether the association between plasma BNP concentration and cardiovascular mortality is sustained or diminishes with increasing time after BNP is measured. Methods and Results Six thousand seven hundred forty patients with a history of myocardial infarction or unstable angina who participated in the LIPID (Long-Term Intervention with Pravastatin in Ischemic Disease) trial had plasma BNP concentration measured at baseline and after 1 year. Associations with cardiovascular mortality were evaluated in landmark analyses 1 to <5, 5 to <10, and 10 to 16 years after randomization. There were 1640 cardiovascular deaths. The cardiovascular mortality rate increased progressively from 10.2 to 19.1 to 26.3/1000 patient-years from 1 to <5, 5 to <10, and 10 to 16 years after baseline, respectively. The average of baseline and 1-year BNP concentration was more strongly associated with cardiovascular mortality compared with baseline or 1-year BNP only. The hazard ratio (HR) for cardiovascular death associated with each doubling of average BNP concentration was similar during years 1 to <5 (HR, 1.53 [95% CI, 1.44-1.63]), years 5 to <10 (HR, 1.52 [95% CI, 1.44-1.60]), and years 10-16 (HR, 1.43 [95% CI, 1.36-1.50]), P<0.0001 for all. Conclusions BNP concentration remains an independent predictor of cardiovascular mortality more than a decade after it is measured. Because of random variation in plasma concentrations, the average of >1 BNP measurement improves long-term risk prediction.
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    Myocarditis and pericarditis following mRNA vaccination in autoimmune inflammatory rheumatic disease patients: A single-center experience.
    Patel, S ; Wu, E ; Mundae, M ; Lim, K (Wiley, 2022-06)
    Introduction: The mRNA vaccines Comirnaty (Pfizer/BioNTech) and Spikevax (Moderna) are considered safe and highly effective against SARS-COV2. However, they are also associated with a small increased risk of pericarditis and myocarditis. There is concern about an increased risk of these complications in patients with autoimmune inflammatory rheumatic diseases (AIRD). Case Report: We describe three patients with pre-existing AIRD who developed myocarditis or pericarditis shortly after receiving their first dose of the Pfizer-BioNTech vaccine. The first case is a 31-year-old female with systemic lupus erythematosus (SLE) and anti-phospholipid syndrome (APLS) who presented 7 days after receiving the Pfizer-BioNTech vaccine and was diagnosed with myopericarditis following a positive troponin and abnormal transthoracic echocardiogram (TTE). The second case is a 29-year-old man with seronegative inflammatory arthritis and APLS who presented 7 days after receiving the first dose of the Pfizer-BioNTech vaccine. His troponin and TTE were unremarkable however his ECG showed widespread ST elevation. Lastly, the third case is a 34-year-old man with Behcet's disease with a history of recurrent pericarditis. He developed a recurrence of symptoms approximately 7 days after his Pfizer-BioNTech vaccine and self-commenced prednisolone at home. He had normal laboratory and radiological findings. All patients received prednisolone resulting in a quick recovery and resolution of symptoms. Discussion: In this review we discuss the association between myocarditis, pericarditis and mRNA COVID-19 vaccines, those who are at greatest risk and current clinical considerations. We also discuss the possible increased risk in AIRD patients and the current research supporting this.
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    Massive hypertriglyceridemia associated with paclitaxel; a case report.
    Koneshamoorthy, A ; Hulse, D ; Yuen Chong, C ; Krishnamurthy, B ; Ananda, S ; Hamblin, PS (Elsevier BV, 2022-08)
    This report describes a patient who developed massive hypertriglyceridemia (12,488 mg/dL or 141 mmol/L) during paclitaxel and carboplatin adjuvant chemotherapy for high grade serous fallopian tube carcinoma. Paclitaxel was thought to be the causative agent and she had normal triglyceride levels following a change to carboplatin and gemcitabine. To our knowledge, this is the highest reported triglyceride level associated with paclitaxel. Measurement of serum lipids should be considered in individuals receiving taxane chemotherapy, especially in those with type 2 diabetes mellitus or a history of dyslipidemia.
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    Implementing evidence into practice to improve chronic lung disease management in Indigenous Australians: the breathe easy, walk easy, lungs for life (BE WELL) project (protocol).
    Meharg, DP ; Jenkins, CR ; Maguire, GP ; Jan, S ; Shaw, T ; Dennis, SM ; McKeough, Z ; Lee, V ; Gwynne, KG ; McCowen, D ; Rambaldini, B ; Alison, JA (Springer Science and Business Media LLC, 2022-06-21)
    BACKGROUND: Strong evidence exists for the benefits of pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD), however the availability of culturally safe PR for Aboriginal and Torres Strait Islander (Indigenous) Peoples is limited. The study aims to determine whether PR can be implemented within Aboriginal Community Controlled Health Services (ACCHS) to improve outcomes for Indigenous people with COPD. METHODS: Multi-centre cohort study using participatory action research guided by the Knowledge-to-Action Framework. ACCHS supportive of enhancing services for chronic lung disease will be recruited. Aboriginal Health Workers (AHW) and the exercise physiologist (EP) or physiotherapist (PT) within these ACCHS will attend a workshop aimed at increasing knowledge and skills related to management of COPD and the provision of PR. Indigenous people with COPD will be invited to attend an 8-week, twice weekly, supervised PR program. OUTCOMES: AHW, EP/PT knowledge, skills and confidence in the assessment and management of COPD will be measured before and immediately after the BE WELL workshop and at 3, 6 and 12 months using a survey. PR participant measures will be exercise capacity (6-minute walk test (6MWT), health-related quality of life and health status at commencement and completion of an 8-week PR program. Secondary outcomes will include: number, length and cost of hospitalisations for a COPD exacerbation in 12-months prior and 12-months post PR; local contextual factors influencing implementation of PR; specific respiratory services provided by ACCHS to manage COPD prior to project commencement and at project completion. Repeated measures ANOVA will be used to evaluate changes in knowledge and confidence over time of AHWs and EP/PTs. Paired t-tests will be used to evaluate change in patient outcomes from pre- to post-PR. Number of hospital admissions in the 12 months before and after the PR will be compared using unpaired t-tests. DISCUSSION: Pulmonary rehabilitation is an essential component of best-practice management of COPD and is recommended in COPD guidelines. Indigenous peoples have limited access to culturally safe PR programs. This study will evaluate whether PR can be implemented within ACCHS and improve outcomes for Indigenous people with COPD. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001337369, Registered 2nd September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373585&isClinicalTrial=False.
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    Systematic Review of Existing Stroke Guidelines: Case for a Change
    Wijeratne, T ; Sales, C ; Wijeratne, C ; Karimi, L ; Jakovljevic, M ; Rahman Al-Tawaha, A (HINDAWI LTD, 2022-06-15)
    Methods: We systematically searched for guideline recommendation on the day-to-day use of peripheral inflammatory markers such as NLR published in the English language between January 1, 2005, and October 2020. Any other evidence of system biology-based approach or recommendation was explored within the selected guidelines for this scoping review. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 4 authors to determine clinical scenarios explained/given, scientific evidence used, and recommendations presented in the context of system biology. Results: The scoping review found 2,911 titles at the beginning of the search. Final review included with 15 guidelines. Stroke-related organizations wrote sixty-five percent of the guidelines while national ministries wrote a fewer number of guidelines. We were primarily interested in recommendations for acute management in AIS published in the English language. Fifteen eligible guidelines were identified from 15 different countries/regions. None of the guidelines recommended the routine use of peripheral markers of inflammation, such as NLR, among their acute assessment and management recommendations. None of the existing guidelines explored the system biology approach to one of the most complex diseases affecting the human brain, stroke. Conclusions: This systematic review has identified a significant evidence-practice gap in all existing national stroke guidelines published in English medium as of October 2020. These guidelines included the only current "living stroke guidelines," stroke guidelines from Australia with a real opportunity to modernize the living stroke guidelines with systems biology approach, and provide 2020 vision towards better stroke care globally. Investigation of complex disease such as stroke is best served through a systems biology approach. One of the easiest places to start is simple blood tests such as total white cell count and NLR. Systems biology approach point us towards simple tools such immune-inflammatory index (SII) and serial systemic immune inflammatory indices (SSIIi) which should pave the way for the stroke physician community address the challenges in systems biology approach in stroke care. These challenges include translating bench research to the bedside, managing big data (continuous pulse, blood pressure, sleep, oxygen saturation, progressive changes in NLR, SII, SSIIi, etc.). Working with an interdisciplinary team also provides a distinct advantage. Recent adoption of historic WHO-IGAP calls for immediate action. The 2022 World Brain Day campaign on Brain Health for All is the perfect opportunity to raise awareness and start the process.
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    What shapes research and research capacity building in rural health services? Context matters
    Shee, AW ; Quilliam, C ; Corboy, D ; Glenister, K ; McKinstry, C ; Beauchamp, A ; Alston, L ; Maybery, D ; Aras, D ; Mc Namara, K (WILEY, 2022-02-21)
    OBJECTIVE: To determine the contextual factors influencing research and research capacity building in rural health settings. DESIGN: Qualitative study using semi-structured telephone interviews to collect data regarding health professionals' research education and capacity building. Analysis involved inductive coding using Braun and Clark's thematic analysis; and deductive mapping to the Consolidated Framework for Implementation Research (CFIR). SETTING: Victorian rural health services and university campuses. PARTICIPANTS: Twenty senior rural health managers, academics and/or research coordinators. Participants had at least three years' experience in rural public health, health-related research or health education settings. MAIN OUTCOME MEASURES: Contextual factors influencing the operationalisation and prioritisation of research capacity building in rural health services. RESULTS: Findings reflected the CFIR domains and constructs: intervention characteristics (relative advantage); outer setting (cosmopolitanism, external policies and incentives); inner setting (implementation climate, readiness for implementation); characteristics of individuals (self-efficacy); and process (planning, engaging). Findings illustrated the implementation context and the complex contextual tensions, which either prevent or enhance research capacity building in rural health services. CONCLUSIONS: Realising the Australian Government's vision for improved health service provision and health outcomes in rural areas requires a strong culture of research and research capacity building in rural health services. Low levels of rural research funding, chronic workforce shortages and the tension between undertaking research and delivering health care, all significantly impact the operationalisation and prioritisation of research capacity building in rural health services. Effective policy and investment addressing these contextual factors is crucial for the success of research capacity building in rural health services.
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    Carotid artery stenosis and inflammatory biomarkers: the role of inflammation-induced immunological responses affecting the vascular systems
    Wijeratne, T ; Menon, R ; Sales, C ; Karimi, L ; Crewther, S (AME PUBL CO, 2020-10-01)
    The death, disability and economic cost of stroke are enormous. Indeed, among the 16 million people worldwide who suffer a stroke' annually, nearly six million die, and another five million are left permanently disabled making prevention of stroke one of the most important priorities in healthcare. Currently carotid artery stenosis (CS) or narrowing of the common carotid artery (CCA) or internal carotid artery (ICA) due to atherosclerotic plaque, accounts for 20-30% of all ischemic strokes. Atherosclerosis is now regarded as a chronic inflammatory disease in response to vascular compromise especially from hypertension. This has long been known to lead to inflammation and atherosclerotic plaque formation in the blood vessels. This mini-review aims to highlight the role of inflammation and neuro-immunological processes in carotid artery disease. Various cellular elements of inflammation and advanced imaging techniques have been identified as potential markers of plaque progression. Therapies related to decreasing and modulating immune-responsive inflammation in the carotid vessels have been shown to translate into decreased occurrence of acute neurologic events and improvement of clinical outcomes.
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    COLD SNARE POLYPECTOMY OF COLORECTAL POLYPS <= 10MM ON CLOPIDOGREL: AN AUSTRALIAN AND NEW ZEALAND RANDOMISED CONTROLLED TRIAL
    Ket, SN ; Hewett, DG ; Kheir, AO ; Metz, AJ ; Moss, A ; Ogra, R ; Tjandra, DP ; Tam, W ; Secomb, R ; Raftopoulos, S ; Cavalieri, L ; Urquhart, P ; Brown, GJ (MOSBY-ELSEVIER, 2020-06-01)
    Abstract Background and study aims Optimal peri-colonoscopic management of clopidogrel remains unclear. Cold snare polypectomy is safe and effective for removing polyps ≤ 10 mm and clips can control intraprocedural bleeding. We conducted a randomized controlled trial to compare continuation of clopidogrel versus temporary replacement of clopidogrel with aspirin for routine colonoscopy using cold snare polypectomy for polyps ≤ 10 mm. Patients and methods Between August 2016 and August 2019, consenting participants at 12 centers were randomized to continuation of clopidogrel as a single or dual antiplatelet agent, or to temporarily take aspirin alone from 7 days prior to 2 days after routine colonoscopy. Endoscopists were blinded to group allocation. Cold snare polypectomy was used to remove polyps ≤ 10 mm, with endoscopic clips applied if intraprocedural bleeding continued for > 2 minutes. Follow-up was performed on Day 30. The trial was stopped early due to delayed patient enrollment. Results Two hundred seventy-six consecutive polyps ≤ 10 mm were removed from 107 patients. Of the patients, 61.7 % were male with a median age of 69 years (interquartile range [IQR] 63 to 76.75). Fifty-nine patients continued on clopidogrel and 48 temporarily took aspirin instead. One hundred thirty-four polyps were removed from 49 patients who continued on clopidogrel vs 142 from 43 patients temporarily took aspirin instead (P = 0.33). Intraprocedural bleeding requiring clips occurred in 11 of 49 patients who continued on clopidogrel and in two of 43 patients who temporarily took replacing with aspirin instead (P = 0.02). More post-procedural minor bleeding was seen in the aspirin arm (six of 43 vs one of 49; P = 0.03). One patient in each arm had acute coronary syndrome, which was medically managed. None of the patients had clinically significant post-procedural bleeding. Conclusions Continuation of clopidogrel in patients undergoing cold snare polypectomy for colorectal polyps ≤ 10 mm does not appear to increase the rate of clinically significant postpolypectomy bleeding. It is associated with an increase in intraprocedural bleeding, which can be successfully treated with clips.