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Background: Although guidelines recommend guideline‐directed medical therapy (GDMT) for patients with acute coronary syndrome (ACS), implementation is limited in clinical practice. Aim: To assess the level of GDMT in ACS patients after discharge who attended cardiac rehabilitation (CR) programs and association with clinical outcomes. Method: A cross‐sectional study was conducted in 13 rural and 10 metropolitan CR programs via all modes of delivery (face‐to‐face, telephone, or general practice‐hybrid) operating in South Australia, Australia. ACS patients were included if they were ≥18 years of age and were referred and attended CR programs with medication details recorded in their hospital discharge summary. GDMT was assessed according to the Australian clinical guidelines for the management of acute coronary syndromes 2016. Prescription of all the four recommended medication classes was considered optimal. Logistic regression and χ2 test were used for association. Ethical approval was granted by the South Australian Department for Health and Wellbeing Human Research Ethics Committee (Reference No. HREC/15/SAH/63) and the Northern Territory Department of Health Human Research Ethics Committee (Reference No. HREC 2015‐2484) which included a waiver of consent per the National Statement on Ethical Conduct in Human Research and the study conforms with the Good Clinical Practice Guidelines. Results: Of the 1229 patients included, 74.6% were male and 41.1% had acute myocardial infarction. Only 39.7% of patients received optimal prescription. Prescription of any three or two medication class combinations occurred for 78.3% and 94.1% of patients, respectively. Optimal GDMT was associated with fewer hospital admissions (odds ratio = 0.647, 95% confidence interval 0.424–0.987, p = 0.043) with no significant gender association. Women were less likely to be prescribed angiotensin converting enzyme inhibitors (p = 0.003), angiotensin receptor blockers (p = 0.007), statins (p = 0.005), and any two (p < 0.001) and three combinations (p = 0.023) of medication classes. Conclusion: GDMT prescription was suboptimal in patients with ACS before attendance at CR. Primary care and CR clinicians have missed an opportunity to implement best practice guideline recommendations, particularly for women. [ABSTRACT FROM AUTHOR]

Preclinical and clinical studies demonstrate that T cell‐dependent bispecific antibodies (TDBs) induce systemic changes in addition to tumor killing, leading to adverse events. Here, we report an in‐depth characterization of acute responses to TDBs in tumor‐bearing mice. Contrary to modest changes in tumors, rapid and substantial lymphocyte accumulation and endothelial cell (EC) activation occur around large blood vessels in normal organs including the liver. We hypothesize that organ‐specific ECs may account for the differential responses in normal tissues and tumors, and we identify a list of genes selectively upregulated by TDB in large liver vessels. Using one of the genes as an example, we demonstrate that CD9 facilitates ICAM‐1 to support T cell–EC interaction in response to soluble factors released from a TDB‐mediated cytotoxic reaction. Our results suggest that multiple factors may cooperatively promote T cell infiltration into normal organs as a secondary response to TDB‐mediated tumor killing. These data shed light on how different vascular beds respond to cancer immunotherapy and may help improve their safety and efficacy. Synopsis: T cell‐dependent bispecific antibodies induce adverse systemic changes in addition to tumor killing. This study shows how different vascular beds respond to cancer immunotherapy, suggesting that reducing leukocyte‐endothelial interactions may limit the accumulation of T cells, thereby alleviating off‐tumor adverse responses. An in‐depth characterization of acute systemic responses to T cell‐dependent bispecific antibodies is presented.Immunological and vascular responses in the liver are observed that are more striking than the tumor responses.Liver response shows a vascular‐subtype‐dependent pattern.Transcriptional programs and candidate factors are uncovered that could account for the undesirable response. [ABSTRACT FROM AUTHOR]

Objectives: To investigate causes of death of people with cancer alive five years after diagnosis, and to compare mortality rates for this group with those of the general population. Design, setting, participants: Retrospective cohort study; analysis of South Australian Cancer Registry data for all people diagnosed with cancer during 1990–1999 and alive five years after diagnosis, with follow‐up to 31 December 2016. Main outcome measures: All‐cause and cancer cause‐specific mortality, by cancer diagnosis; standardised mortality ratios (study group v SA general population) by sex, age at diagnosis, follow‐up period, and index cancer. Results: Of 32 646 people with cancer alive five years after diagnosis, 30 309 were of European background (93%) and 16 400 were males (50%); the mean age at diagnosis was 60.3 years (SD, 15.7 years). The median follow‐up time was 17 years (IQR, 11–21 years); 17 268 deaths were recorded (53% of patients; mean age, 80.6 years; SD, 11.4 years): 7845 attributed to cancer (45% of deaths) and 9423 attributed to non‐cancer causes (55%). Ischaemic heart disease was the leading cause of death (2393 deaths), followed by prostate cancer (1424), cerebrovascular disease (1175), and breast cancer (1118). The overall standardised mortality ratio (adjusted for age, sex, and year of diagnosis) was 1.24 (95% CI, 1.22–1.25). The cumulative number of cardiovascular deaths exceeded that of cancer cause‐specific deaths from 13 years after cancer diagnosis. Conclusions: Mortality among people with cancer who are alive at least five years after diagnosis was higher than for the general population, particularly cardiovascular disease‐related mortality. Survivorship care should include early recognition and management of risk factors for cardiovascular disease. [ABSTRACT FROM AUTHOR]

In this study, we examined the effectiveness of a self‐management intervention delivered to people with heart failure in Vietnam. It used teach‐back, a cyclical method of teaching content, checking comprehension, and re‐teaching to improve understanding. A single‐site cluster randomized controlled trial was conducted, and six hospital wards were randomized into two study groups. On the basis of ward allocation, 140 participants received either usual care or the teach‐back heart failure self‐management intervention plus usual care. The intervention involved, prior to discharge, an individual educational session on heart failure self‐care, with understanding reinforced using teach‐back, a heart failure booklet, weighing scales, diary, and a follow‐up phone call 2 weeks post‐discharge. The control group received usual care and the booklet. Outcomes were heart failure knowledge, self‐care (maintenance, management and confidence), and all‐cause hospitalizations assessed at 1 and 3 months (end‐point). Upon completion of the study, the intervention group had significantly greater knowledge and self‐care maintenance than the control group. Other outcomes did not differ between the two groups. The teach‐back self‐management intervention demonstrated promising benefits in promoting self‐care for heart failure patients. [ABSTRACT FROM AUTHOR]

Background: Adverse events occur in health care. Detection and reporting of deterioration therefore have a critical role to play. Patient and family member (consumer) involvement in patient safety has gained powerful support amongst global policymakers. Few studies, with none taking a rigorous qualitative approach, have drawn upon consumers' experiences to establish their preferences in consumer reporting of patient deterioration programmes. Objective: To explore consumers' experiences of previous reporting of patient deterioration; their preferred educational strategies on this role and recommended pathways in a consumer reporting of patient deterioration model. Design, setting and participants: An interpretive, qualitative research design was utilized. Nine focus group interviews were undertaken across Adelaide, capital city of South Australia. Interviews were audio‐taped, transcribed and analysed thematically. Twenty‐six adults described, then reflected, on previous experiences of reporting patient deterioration. Results: Overarching themes incorporated consumers' experiences and patient/family education. Three themes emerged in relation to consumers' experiences: feelings, thoughts and actions. Five themes arose on educating consumers: content, timing, format, information providers and information recipients. The consumers' deep reflections on their past reporting experiences led to the development of a new model for consumer reporting of patient deterioration. Conclusions: Consumers' views on ways to improve consumer reporting of patient deterioration processes emerged. These improvements include structured educational programmes for staff advocating open health‐care professional/consumer communication, educational materials developed and tested with English‐speaking and culturally and linguistically diverse consumers and a model with three consumer reporting pathways. [ABSTRACT FROM AUTHOR]

Aims: Heart failure (HF) patients are taught to identify a rapid 5 lb body‐weight gain for early detection of cardiac decompensation. Few data support this common advice. The study aim was to determine whether a 5 lb weight gain in 1 week and signs and symptoms of HF increased risk for unplanned physician or emergency department (ED) visits or hospital admission in rural HF patients. Methods and results: This was a secondary analysis of a randomized trial. Patients tracked body weight and HF symptoms using diaries. We included patients adherent to daily diaries >50% over 24 months (N = 119). Mean age was 69 ± 11 years; 77% (65) were male, and 67% completed diaries. A weight gain of 5 lb over 7 days was associated with a greater risk for ED visits but not hospital admission [hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.04, 1.08; P < 0.0001 vs. HR 1.01, 95% CI 0.88, 1.16; P = 0.79]. Increased dyspnoea over 7 days was associated with a greater risk of ED visits and hospital admissions (HR 9.64, 95% CI 3.68, 25.22; P < 0.0001 vs. HR 5.89, 95% CI 1.73, 20.04; P = 0.01). Higher diary adherence was associated with older age, non‐sedentary behaviour, lower depression, and HF knowledge. Conclusions: Heart failure patients are counselled to observe for body‐weight gain. Our data do not support that a 5 lb weight gain was associated with hospital admission. Dyspnoea was a better predictor of ED visits and hospital admissions. Daily tracking of dyspnoea symptoms may be an important adjunct to daily weight to prevent hospitalization. [ABSTRACT FROM AUTHOR]

Globally, the increasing prevalence of heart failure is a burden on health‐care systems, especially in under‐resourced countries, such as Vietnam. We describe a prospective single‐site, cluster randomized controlled trial of an intervention designed to teach adult patients about heart failure and how to undertake self‐care activities. The intervention, delivered by a nurse, comprises of an individual teaching session using teach‐back, a heart failure booklet, weighing scales, a diary to document daily weight, and a follow‐up phone call 2 weeks after hospital discharge. Teach‐back is a process of asking patients to repeat information and for the nurse to fill any gaps or misunderstanding until adequate understanding is demonstrated. The control group will receive usual education plus the heart failure (HF) booklet. A total of 140 participants will be allocated into two study groups. The level of randomization is at the ward level. The primary outcome (HF knowledge) and secondary outcomes (self‐care behaviors and all‐cause hospitalizations) will be measured at 1 and 3 months. This study will make an important contribution regarding a protocol of teach‐back and chronic disease self‐management. [ABSTRACT FROM AUTHOR]

Aim: The link between chemotherapy treatment and cardiotoxicity is well established, particularly for adults with blood cancers. However, it is less clear for children. This analysis aimed to compare the trajectory and mortality of children and adults who received chemotherapy for blood cancers and were subsequently hospitalized for heart failure. Methods: Linked data from the Queensland Cancer Registry, Death Registry and Hospital Administration records for initial chemotherapy and later heart failure were reviewed (1996-2009). Of all identified blood cancer patients (N = 23 434), 8339 received chemotherapy, including 817 children (aged ≤18 years at time of cancer diagnosis) and 7522 adults. Time-varying Cox proportional hazards regression models were used to compare the characteristics and survival between the two groups. Results: Of those who were subsequently hospitalized for heart failure, 70% of children and 46% of adults had the index admission within 12 months of their cancer diagnosis. Of these, 53% of the pediatric heart failure population and 71% of the adult heart failure population died within the study period. Following adjustment for age, sex and chemotherapy admissions, children with heart failure had an increased mortality risk compared to their non-heart failure counterparts, a difference which was much greater than that between the adult groups. Conclusion: The impact of heart failure on children previously treated for blood cancer is more severe than for adults, with earlier morbidity and greater mortality. Improved strategies are needed for the prevention and management of cardiotoxicity in this population. [ABSTRACT FROM AUTHOR]

The author talks about the mobile technology in healthcare, also known as mobile health (mHealth) and its implications for global internal medicine. Topics discussed include the number of mHealth apps available to people on mobile phones, the barriers in healthcare access for people across the world, and the different types of mHealth services including video conferencing, text messaging and remote device monitoring.

Post-traumatic stress disorder (PTSD) has been associated with high rates of work-disability. In other domains of research, it has been shown that catastrophic thinking also contributes to work-disability. The present study examined the relation between catastrophic thinking and work-disability in individuals with PTSD. The study sample consisted of 73 work-disabled individuals with PTSD who were referred to an occupational rehabilitation service. Participants completed measures of post-traumatic stress symptoms, depression, pain, catastrophic thinking, and occupational disability at admission and termination of the rehabilitation intervention. Return-to-work was assessed 1 month following the termination of the rehabilitation intervention. Cross-sectional analyses revealed that catastrophic thinking contributed significant unique variance to the prediction of occupational disability, even when controlling for the severity of symptoms of PTSD. Prospective analyses revealed that treatment-related reductions in catastrophic thinking predicted successful return to work, beyond the variance accounted for by reductions in the severity of symptoms of PTSD. The findings suggest that catastrophic thinking is a determinant of occupational disability in individuals with PTSD. The findings further suggest that interventions designed to reduce catastrophic thinking might promote more successful occupational re-integration in individuals recovering from post-traumatic stress symptoms. [ABSTRACT FROM AUTHOR]

Aims Telemonitoring (TM) and structured telephone support (STS) have the potential to deliver specialized management to more patients with chronic heart failure (CHF), but their efficacy is still to be proven. The aim of this meta-analysis was to review randomized controlled trials (RCTs) of TM or STS for all-cause mortality and all-cause and CHF-related hospitalizations in patients with CHF, as a non-invasive remote model of a specialized disease-management intervention. Methods and results We searched all relevant electronic databases and search engines, hand-searched bibliographies of relevant studies, systematic reviews, and meeting abstracts. Two reviewers independently extracted all data. Randomized controlled trials comparing TM or STS to usual care in patients with CHF were included. Studies that included intensified management with additional home or clinic-visits were excluded. Primary outcomes (mortality and hospitalizations) were analysed; secondary outcomes (cost, length of stay, and quality of life) were tabulated. Thirty RCTs of STS and TM were identified (25 peer-reviewed publications (n= 8323) and five abstracts (n= 1482)). Of the 25 peer-reviewed studies, 11 evaluated TM (2710 participants), 16 evaluated STS (5613 participants) with two testing both STS and TM in separate intervention arms compared with usual care. Telemonitoring reduced all-cause mortality {risk ratio (RR) 0.66 [95% confidence interval (CI) 0.54–0.81], P< 0.0001 }and STS showed a similar, but non-significant trend [RR 0.88 (95% CI 0.76–1.01), P= 0.08]. Both TM [RR 0.79 (95% CI 0.67–0.94), P= 0.008], and STS [RR 0.77 (95% CI 0.68–0.87), P< 0.0001] reduced CHF-related hospitalizations. Both interventions improved quality of life, reduced costs, and were acceptable to patients. Improvements in prescribing, patient-knowledge and self-care, and functional class were observed. Conclusion Telemonitoring and STS both appear effective interventions to improve outcomes in patients with CHF. Systematic Review Number: Cochrane Database of Systematic Reviews. 2008:Issue 3. Art. No.: CD007228. DOI: 10.1002/14651858.CD007228. [ABSTRACT FROM AUTHOR]

The article discusses a study on the treatment for chronic heart failure (CHF) for patients diagnosed with heart failure with preserved systolic function (HFPSF). The method made use of a retrospective analysis of longitudinal clinical data from 2961 patients diagnosed with CHF admitted to a tertiary referral hospital. It suggests that older female patients with HFPSF have a higher rate of readmission and less social support and that their reduced survival rate is related more to comorbid conditions rather than suboptimal cardiac management.

Background: Medication-related problems often occur in the immediate post-discharge period. To reduce medication misadventure the Commonwealth Government funds home medicines reviews (HMRs). HMRs are initiated when general practitioners refer consenting patients to their community pharmacists, who then engage accredited pharmacists to review patients' medicines in their homes. Aim: To determine if hospital-initiated medication reviews (HIMRs) can be implemented in a more timely manner than HMRs; and to assess the impact of a bespoke referral form with comorbidity-specific questions on the quality of reports. Method: Eligible medical inpatients at risk of medication misadventure were referred by the hospital liaison pharmacist to participating accredited pharmacists post-discharge from hospital. Social, demographic and laboratory data were collected from medical records and during interviews with consenting patients. Issues raised in the HIMR reports were categorised: intervention/action, information given or recommendation, and assigned a rank of clinical significance. Results: HIMRs were conducted within 11.6 ± 6.6 days post-discharge. 36 HIMR reports were evaluated and 1442 issues identified - information given (n = 1204), recommendations made (n = 88) and actions taken (n = 150). The majority of issues raised (89%) had a minor clinical impact. The bespoke referral form prompted approximately half of the issues raised. Conclusion: HIMRs can be facilitated in a more timely manner than post-discharge HMRs. There was an associated positive clinical impact of issues raised in the HIMR reports. [ABSTRACT FROM AUTHOR]

Aim: To review the management of heart failure in patients not enrolled in specialist multidisciplinary programs. Method: A prospective clinical audit of patients admitted to hospital with either a current or past diagnosis of heart failure and not enrolled in a specialist heart failure program or under the direct care of the cardiology unit. Results: 81 eligible patients were enrolled (1 August to 1 October 2008). The median age was 81 ± 9.4 years and 48% were male. Most patients (63%) were in New York Heart Association Class II or Class III heart failure. On discharge, 59% of patients were prescribed angiotensin converting enzyme inhibitors and 43% were prescribed beta-blockers. During hospitalisation, 8.6% of patients with a past diagnosis of heart failure were started on an angiotensin converting enzyme inhibitor and 4.9% on a beta-blocker. There was evidence of suboptimal dosage on admission and discharge for angiotensin converting enzyme inhibitors (19% and 7.4%) and beta-blockers (29% and 17%). The results compared well with international reports regarding the under-treatment of heart failure. Conclusion: The demonstrated practice gap provides excellent opportunities for the involvement of pharmacists to improve the continuation of care for heart failure patients discharged from hospital in the areas of medication management review, dose titration and monitoring. [ABSTRACT FROM AUTHOR]

Abstract: Background: There are minimal reports of seasonal variations in chronic heart failure (CHF)-related morbidity and mortality beyond the northern hemisphere. Aims and methods: We examined potential seasonal variations with respect to morbidity and all-cause mortality over more than a decade in a cohort of 2961 patients with CHF from a tertiary referral hospital in South Australia subject to mild winters and hot summers. Results: Seasonal variation across all event-types was observed. CHF-related morbidity peaked in winter (July) and was lowest in summer (February): 70 (95% CI: 65 to 76) vs. 33 (95% CI: 30 to 37) admissions/1000 at risk (p <0.005). All-cause admissions (113 (95% CI: 107 to 120) vs. 73 (95% CI 68 to 79) admissions/1000 at risk, p <0.001) and concurrent respiratory disease (21% vs. 12%, p <0.001) were consistently higher in winter. 2010 patients died, mortality was highest in August relative to February: 23 (95% CI: 20 to 27) vs. 12 (95% CI: 10 to 15) deaths per 1000 at risk, p <0.001. Those aged 75 years or older were most at risk of seasonal variations in morbidity and mortality. Conclusion: Seasonal variations in CHF-related morbidity and mortality occur in the hot climate of South Australia, suggesting that relative (rather than absolute) changes in temperature drive this global phenomenon. [Copyright &y& Elsevier]

Abstract: Background: Although the potential to reduce hospitalisation and mortality in chronic heart failure (CHF) is well reported, the feasibility of receiving healthcare by structured telephone support or telemonitoring is not. Aims: To determine; adherence, adaptation and acceptability to a national nurse-coordinated telephone-monitoring CHF management strategy. The Chronic Heart Failure Assistance by Telephone Study (CHAT). Methods: Triangulation of descriptive statistics, feedback surveys and qualitative analysis of clinical notes. Cohort comprised of standard care plus intervention (SC+I) participants who completed the first year of the study. Results: 30 GPs (70% rural) randomised to SC+I recruited 79 eligible participants, of whom 60 (76%) completed the full 12 month follow-up period. During this time 3619 calls were made into the CHAT system (mean 45.81 SD±79.26, range 0–369), Overall there was an adherence to the study protocol of 65.8% (95% CI 0.54–0.75; p =0.001) however, of the 60 participants who completed the 12 month follow-up period the adherence was significantly higher at 92.3% (95% CI 0.82–0.97, p ≤0.001). Only 3% of this elderly group (mean age 74.7±9.3 years) were unable to learn or competently use the technology. Participants rated CHAT with a total acceptability rate of 76.45%. Conclusion: This study shows that elderly CHF patients can adapt quickly, find telephone-monitoring an acceptable part of their healthcare routine, and are able to maintain good adherence for a least 12 months. [Copyright &y& Elsevier]

Distributed hydrologic models which link seasonal streamflow and soil moisture patterns with spatial patterns of vegetation are important tools for understanding the sensitivity of Mediterranean type ecosystems to future climate and land use change. RHESSys (Regional Hydro-Ecologic Simulation System) is a coupled spatially distributed hydroecological model that is designed to be able to represent these feedbacks between hydrologic and vegetation carbon and nutrient cycling processes. However, RHESSys has not previously been applied to semiarid shrubland watersheds. In this study, the hydrologic submodel of RHESSys is evaluated by comparing model predictions of monthly and annual streamflow to stream gage data and by comparing RHESSys behavior to that of another hydrologic model of similar complexity, MIKESHE, for a 34 km² watershed near Santa Barbara, California. In model intercomparison, the differences in predictions of temporal patterns in streamflow, sensitivity of model predictions to calibration parameters and landscape representation, and differences in model estimates of soil moisture patterns are explored. Results from this study show that both models adequately predict seasonal patterns of streamflow response relative to observed data, but differ significantly in terms of estimates of soil moisture patterns and sensitivity of those patterns to the scale of landscape tessellation used to derive spatially distributed elements. This sensitivity has implications for implementing RHESSys as a tool to investigate interactions between hydrology and ecosystem processes. [ABSTRACT FROM AUTHOR]

The article discusses the challenges, strengths, and opportunities of heart failure (HF) nursing in Australia. An overview of the healthcare system in the country is presented. The models of HF care in the country are described including home-based HF programs, cardiac rehabilitation (CR), and integrated palliative care models. Several recommendations for fostering HF nursing in the country are given.

A letter to the editor is presented in response to article "A systematic approach to chronic heart failure care: a consensus statement," by Karen Page and colleagues, focusing on the omission of the discussion about telemonitoring.