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In pursuit of mental wellness, many find that behavioral change is necessary. This process can often be difficult but is facilitated by strong social support. This paper explores the role of social support across behavioral change journeys among young adults, a group at high risk for mental health challenges, but with the lowest rates of mental health treatment utilization. Given that digital mental health tools are effective for treating mental health conditions, they hold particular promise for bridging the treatment gap among young adults, many of whom, are not interested in - or cannot access - traditional mental healthcare. We recruited a sample of young adults with depression who were seeking information about their symptoms online to participate in an Asynchronous Remote Community (ARC) elicitation workshop. Participants detailed the changing nature of social interactions across their behavior change journeys. They noted that both directed and undirected support are necessary early in behavioral change and certain needs such as informational support are particularly pronounced, while healthy coping partnerships and accountability are more important later in the change process. We discuss the conceptual and design implications of our findings for the next generation of digital mental health tools.

Collaborative Care Programs (CCPs) integrate mental health services into primary care settings to help patients access much needed treatment. Technologies could increase the effectiveness of CCPs, but we know little about what collaboration challenges technologies must address in this complex clinical setting. To investigate these challenges and technology opportunities, we conducted interviews and contextual inquiries with 30 patients and providers in an obstetric CCP. Using the Parallel Journeys Framework as a lens, we uncover new collaboration challenges (e.g., weighing risks and benefits of treatment, conflicting opinions and ambiguous responsibilities) at the intersection of patients' obstetric and psychosocial care journeys. We discuss new CSCW implications and technology opportunities, such as the importance of addressing support gaps in cyclical experiences, and the need to resolve provider conflicts to refocus on patient needs. These contributions inform how technologies can support patient engagement and collaboration with providers to access and receive treatment, as well as improve health outcomes.

Digital tools can support individuals managing mental health concerns, but delivering sufficiently engaging content is challenging. This paper seeks to clarify how individuals with mental health concerns can contribute content to improve push-based mental health messaging tools. We recruited crowdworkers with mental health symptoms to evaluate and revise expert-composed content for an automated messaging tool, and to generate new topics and messages. A second wave of crowdworkers evaluated expert and crowdsourced content. Crowdworkers generated topics for messages that had not been prioritized by experts, including self-care, positive thinking, inspiration, relaxation, and reassurance. Peer evaluators rated messages written by experts and peers similarly. Our findings also suggest the importance of personalization, particularly when content adaptation occurs over time as users interact with example messages. These findings demonstrate the potential of crowdsourcing for generating diverse and engaging content for push-based tools, and suggest the need to support users in meaningful content customization.

Background: Thromboembolism-associated stroke is the most feared complication of Atrial fibrillation (AF). Percutaneous left atrial appendage closure (pLAAC) is indicated for stroke prevention in patients with AF who can’t tolerate long-term anticoagulation. We aim to study gender differences in peri-procedural and readmissions outcomes in pLAAC patients. Methods: Using the national readmission database from January 2016 to December 2018, AF patients undergoing the pLAAC procedure were identified. We used multivariate logistic regression analyses and time-to-event Cox regression analyses to conduct the study. Propensity matching with the Greedy method was done for the accuracy of results. Result: 28,819 patients were included in our study. Among them 11,946 (41.5%) were women and 16,873 (58.6%) were men. The mean age of overall population was 76.1 ± 8.5 years, with women ~ 1 year older than men. The overall rate of complications was higher in women (8.6% vs 6.6%, P

Patients with left ventricular assist devices (LVAD) often tolerate ventricular arrhythmias (VA). We aim to assess the frequency and outcomes of ICD therapies averted by ultraconservative ICD programming (UCP) in LVAD patients.This single center, retrospective cohort study included patients with LVADs and ICDs implanted from 2015 to 2019 that had UCP. The aim for UCP was to maximally delay VA treatments and maximize anti-tachycardia pacing (ATP) prior to ICD shocks. VA events were reviewed after UCP and evaluated under prior conservative programming to assess for potentially averted events (that would have resulted in either ATP or defibrillation with prior programming).Fifty patients were included in the study with follow-up of median 16 ± 10.2 months after UCP. The median time from LVAD implantation to reprogramming was 7 days (IQR 5-9 days). Fourteen patients (28%) had potentially averted VA events that would have been treated with their prior ICD programming (82 total events, median two events per patient, IQR 1-10 events). Treated VA events occurred in 15 patients (30%). Eleven of the 14 patients with potentially averted VAs had treated events as well. Only one patient reported definitive symptoms of self-limited "dizziness" during a potentially averted event that did not result in hospitalization. No patients died of complications from or needed emergent care/hospitalization due a potentially averted VA.UCP in LVAD patients likely prevented unnecessary VA treatments in many patients with minimal reported symptoms during these potentially averted events. Prospective studies are necessary to confirm these findings.

Introduction Electromagnetic interference (EMI) from left ventricular assist devices (LVADs) can cause implantable cardioverter-defibrillator (ICD) oversensing. We sought to assess the frequency of inappropriate shocks/oversensing due to LVAD-related EMI and prospectively compare integrated (IB) versus dedicated bipolar (DB) sensing in patients with LVADs. Methods Single-center study in LVAD patients with Medtronic or Abbott ICDs between September 2017 and March 2020. We excluded patients that were pacemaker dependent. Measurements were obtained of IB and DB sensing and noise to calculate a signal-to-noise ratio (SNR). Device checks were reviewed to assess appropriate and inappropriate sensing events. Results Forty patients (age 52 ± 14 years, 75% men, 38% ischemic cardiomyopathy) were included with the median time between LVAD implantation and enrollment of 6.7 months [2.3, 11.4 months]. LVAD subtypes included: HeartWare (n=22, 55%), Heartmate II (n=10, 25%), and Heartmate III (n=8, 20%). Over a follow-up duration of 21.6 ± 12.9 months after LVAD implantation, 5% of patients (n=2) had oversensing of EMI from the LVAD (both with HeartWare LVADs and Abbott ICDs) at 4 days and 10.8 months after LVAD implantation. Both patients underwent adjustment of ventricular sensing with resolution of oversensing and no further events over 5 and 15 months of further follow-up. The SNR was similar between IB and DB sensing (50 [29-67] and 57 [41-69], p=0.89). Conclusion ICD oversensing of EMI from LVADs is infrequent and can be managed with reprogramming the sensitivity. There was no significant difference in the R-wave SNR with IB versus DB ICD leads. This article is protected by copyright. All rights reserved.

The subcutaneous ICD (S-ICD) is a viable alternative to transvenous ICD and avoids intravascular complications in patients without a pacing indication. The outcomes of S-ICD implantation are uncertain in patients with prior sternotomy.We aim to compare the implant techniques and outcomes with S-ICD implantation in patients with and without prior sternotomy.Multicenter retrospective cohort study including adult patients with an S-ICD implanted between January 2014 and June 2020. Outcomes were compared between patients with and without prior sternotomy.Among the 212 patients (49 ± 15 years old, 43% women, BMI 30 ± 8 kg/mImplantation of an S-ICD in patients with prior sternotomy is safe with a similar risk of 30-day complications and inappropriate ICD shocks as patients without prior sternotomy.

Many techniques exist for venous access (VA) during cardiac implantable electronic device (CIED) implantation.We sought to evaluate the learning curve with ultrasound (US) guided axillary vein access (USAA).Single-center prospective randomized controlled trial of patients undergoing CIED implantation. Patients were randomized in a 2:1 fashion to USAA versus conventional VA techniques. The primary outcomes were the success rates, VA times and 30-day complication rates.The study included 100 patients (age 68 ± 14 years, BMI 27 ± 4 kg/mAlthough the success rate with USAA was high, there was a significant learning curve. Once experienced with the USAA technique, there is the potential for reduced complications without adding to the procedure duration.

Aim: To identify implementation strategies for collaborative care (CC) that are successful in the context of perinatal care. Background: Perinatal depression is one of the most common complications of pregnancy and is associated with adverse maternal, obstetric, and neonatal outcomes. Although treating depressive symptoms reduces risks to mom and baby, barriers to accessing psychiatric treatment remain. CC has demonstrated benefit in primary care, expanding access, yet few studies have examined the implementation of CC in perinatal care which presents unique characteristics and challenges. Methods: We conducted qualitative interviews with 20 patients and 10 stakeholders from Collaborative Care Model for Perinatal Depression Support Services (COMPASS), a perinatal collaborative care (pCC) program implemented since 2017. We analyzed interview data by employing the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to organize empirically selected implementation strategies from Expert Recommendations for Implementing Change (ERIC) to create a guide for the development of pCC programs. Findings: We identified 14 implementation strategies used in the implementation of COMPASS. Strategies were varied, cutting across ERIC domains (eg, plan, educate, finance) and across EPIS contexts (eg, inner context – characteristics of the pCC program). The majority of strategies were identified by patients and staff as facilitators of pCC implementation. In addition, findings show opportunities for improving the implementation strategies used, such as optimal dissemination of educational materials for obstetric clinicians. The implementation of COMPASS can serve as a model for the process of building a pCC program. The identified strategies can support the implementation of this evidence-based practice for addressing postpartum depression.

Purpose of review To review recent evidence evaluating the long-term safety and efficacy outcomes of left atrial appendage occlusion (LAAO), current guideline recommendations for LAAO use, performance of LAAO in comparison with direct oral anticoagulants (DOAC) and recently approved LAAO device. Recent findings The last 18 months have been marked with increasing evidence of the utility of LAAO in patients who are not candidates for long-term oral anticoagulation (OAC). Long-term data from two continued access registries to PROTECT-AF and PREVAIL support LAAO as a safe and effective long-term anticoagulation therapy. This new evidence led to class IIb recommendation for LAAO in nonvalvular atrial fibrillation (NVAF) patients not eligible for long-term OAC. PRAGUE-17 randomized controlled trial showed LAAO is noninferior to DOAC lending support to use of this modality in current era. PINNACLE FLX trial showed improved implant success and adequate closure rate which led to the device's Food and Drug Administration approval. Summary In conclusion, percutaneous LAAO appears to be a promising option for NVAF patients who are not candidates for long-term OAC in the current era. Further evidence guiding optimal patient selection and periprocedural antithrombotic regimen will help identify the patients who would benefit the most from this procedure.

Young adults have high rates of mental health conditions, yet they are the age group least likely to seek traditional treatment. They do, however, seek information about their mental health online, including by filling out online mental health screeners. To better understand online self-screening, and its role in help-seeking, we conducted focus groups with 50 young adults who voluntarily completed a mental health screener hosted on an advocacy website. We explored (1) catalysts for taking the screener, (2) anticipated outcomes, (3) reactions to the results, and (4) desired next steps. For many participants, the screener results validated their lived experiences of symptoms, but they were nevertheless unsure how to use the information to improve their mental health moving forward. Our findings suggest that online screeners can serve as a transition point in young people’s mental health journeys. We discuss design implications for online screeners, post-screener feedback, and digital interventions broadly.

Introduction Prospective studies on rivaroxaban and apixaban have shown the safety and efficacy of direct anticoagulation agents (DOAC)s used peri-procedurally during radiofrequency ablation (RFA) of atrial fibrillation (AF). Studies comparing the two agents have not been performed. Methods Consecutive patients from a prospective registry who underwent RFA of AF between April 2012 and March 2015 and were on apixaban or rivaroxaban were studied. Clinical variables and outcomes were noted. Results There were a total of 358 patients (n = 56 on apixaban and n = 302 on rivaroxaban). There were no differences in baseline characteristics between both groups. The last dose of rivaroxaban was administered the night before the procedure in 96% of patients. In patients on apixaban, 48% of patients whose procedure was in the afternoon took the medication on the morning of the procedure. TIA/CVA occurred in 2 patients (0.6%) in rivaroxaban group with none in apixaban group (p = 0.4). There was no difference in the rate of pericardial effusion between apixaban and rivaroxaban groups [1.7% vs 0.6% (p = 0.4)]. Five percent of patients in both groups had groin complications (p = 0.9). In apixaban group, all groin complications were small hematomas except one patient who had a pseudoaneurysm (1.6%). One pseudo-aneurysm, 1 fistula and 3 large hematomas were noted in patients on rivaroxaban (1.7%) with the rest being small hematomas. DOACs were restarted post procedure typically 4 h post hemostasis. Conclusions Peri-procedural uninterrupted use of apixaban and rivaroxaban during AF RFA is safe and there are no major differences between both groups.

Nonsuicidal self-injury (NSSI) affects approximately 13% of young adults. Though evidence-based treatments for NSSI exist, most young adults do not receive treatment. Digital interventions can provide access to evidence-based treatments for NSSI at scale. Further, preliminary research suggests the acceptability, feasibility, and potential efficacy of digital interventions for NSSI. To date, however, there are few publicly available digital interventions developed specifically for young adults who engage in NSSI. The aim of this study was to solicit young adults’ impressions of early app prototypes to identify ways of improving interactive features and content needs. Building on a prior interview study which explored young adults’ self-management of NSSI and their use of technology in self-management, this study involved three waves of iterative app prototype feedback sessions with 10 young adults with past month NSSI. In general, participants responded favorably and provided feedback to augment the app to better meet their needs, including adding new features and functionality as well as increasing opportunities for personalization. We discuss two key design challenges related to the roles of tracking and temporality in digital interventions for NSSI, and then frame design considerations related to these challenges within the lived informatics model.

Introduction: The instantaneous absolute 3D ECG voltage integrated over the duration of QRS (VTI QRS-3D ), also measured as 3D QRS area, is a marker for left ventricular electrical dyssynchrony in patients with left bundle branch block. Hypothesis: We sought to investigate if VTI QRS-3D predicts pacing induced cardiomyopathy in patients with chronic (>3 months) right ventricular pacing (RVp). Methods: We retrospectively evaluated RVp ECGs from consecutive patients with pacing induced cardiomyopathy (left ventricular ejection fraction ≤50%) and compared to patients with normal ejection fraction (>50%). Patients were excluded if they did not have ECG and/or echocardiogram. 12-lead ECGs were converted to orthogonal X, Y, Z leads using Kors matrix. VTI QRS-3D was obtained by voltage-time-integral from root-mean-squared 3D ECG. Results: We analyzed 320 RVp patients (age 73 ± 14 years, 40% female), 206 with preserved ejection fraction (LVEF 60.4 ± 4.1%) and 114 with pacing induced cardiomyopathy (LVEF 29.2 ± 8.1%). Pacing induced cardiomyopathy was associated with a longer QRS duration, larger QRS voltage and larger VTI QRS-3D (Table). VTI QRS-3D ≥90 μVs had 81% sensitivity to identify pacing induced cardiomyopathy (specificity 47%). Conclusions: In the setting of chronic right ventricle pacing, QRS 3D voltage time integral ≥90 μVs on ECG can be used as a screening tool to identify patients needing further evaluation for cardiomyopathy.

Background Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting approximately 1–2% overall population (1). Its causal relationship with colorectal cancer (CRC) is much for debate. According to one hypothesis, the presence of autoantibodies directed against ionic channels or acetylcholine receptors can predispose to the development of atrial fibrillation (2–3). Thus, AF may be regarded as an inflammatory complication in patients with colon cancer. Our study objective was to determine if AF impacts the outcome of patients with CRC. Method We analyzed the National Inpatient Sample (NIS) database from Oct-2015 to Dec 2018 using Stata 16.0. The NIS databases are released under the Healthcare Cost and Utilization Project, which includes inpatient admissions from the United States' participating hospitals. Total population with CRC were identified using their respective ICD-10 diagnostic codes then divided based on AF. To determine atrial fibrillation association with mortality and complications, we used multivariate logistic regression analysis using weights to generate nationally representative results. Later, a propensity-matched population analysis was done for the accuracy of the results. Result We found 245,305 patients admitted with CRC between Oct 2015 to Dec-2018 in the USA, out of which 28,170 (11.5%) were having AF. The mean age for the patients with AF was 77±10 compare to 65±14 years in those without AF. Patients with AF were associated with higher comorbidities and had a high population percentage with Carlson category three or above. There were 1,456 (5.2%) mortalities in the AF group compared to 5,689 (2.6%) in the other. The higher odds of mortality in patients with AF was present in multivariate logistic regression analysis in both non-propensity matched [1.71 (1.45–2.02), P-value: Conclusion In our retrospective, propensity-matched national inpatient sample analyses of patients admitted with colorectal cancer, atrial fibrillation is associated with higher morbidity and mortality. AF was associated with a high burden of complications with prolonged hospital stay leading to increased health care expenditures. Funding Acknowledgement Type of funding sources: None.

IntroductionLeft atrial appendage occlusion (LAAO) is recommended in patients with non-valvular atrial fibrillation (AF) who have contraindications to or are intolerant of long-term oral anticoagulants (OAC), but its impact on hospitalization rates has not been well described. The objective of our study is to describe the incidence of all-cause, bleeding-related, and thrombosis-related hospitalizations before and after LAAO.Material and methodsWe used the Nationwide Readmission Database to include patients aged ≥ 18 years with a diagnosis of AF who underwent transcatheter LAAO during the months of February-November in each year between 2016 and 2018. Patients who died during the index procedure or had missing length of hospital stay or mortality information were excluded.ResultsA total of 27,633 patients were included (median age: 77 years, 41% female) with an average pre- and post-LAAO monitoring period of 6.5 and 5.5 months respectively. Of these, 10,808 (39.1%) patients had one or more admissions prior to the procedure compared to 7,196 (26.0%) after the procedure. There was a 26% reduction in incidence of all-cause admissions (rate ratio (RR) = 0.74, 95% confidence interval (CI): 0.71–0.76; p < 0.001), 49% reduction in bleeding-related admissions (RR = 0.51, 95% CI: 0.48–0.55; p < 0.001), and 71% reduction in thrombosis-related readmissions (RR = 0.29, 95% CI: 0.26–0.33; p < 0.001) after LAAO.ConclusionsIn a contemporary, nationally representative dataset, we found that LAAO is associated with a significant decrease in all-cause, bleeding-related, and thrombosis-related admissions. These findings lend support to the current use of transcatheter LAAO in clinical practice for patients with contraindications to OAC and/or at high risk of bleeding.

BACKGROUND The prevalence of self-injurious thoughts and behaviors (SITB) signals a growing public health crisis. Despite a recognized need for improved and scalable interventions, the field of SITB intervention faces several challenges: existing interventions are often time and resource intensive, most individuals with SITB do not seek formal mental health care, and efficacious treatments are characterized by small effects. Combined, these challenges indicate a need for improved SITB interventions for individuals in formal treatment and those who are not treatment engaged but are at high risk of worsening mental health and future suicide attempts. OBJECTIVE We present a methodological approach and set of techniques that may address these challenges by centering the lived experience of individuals with SITB in the process of developing needed services: user-centered design (UCD). METHODS We highlight the value of UCD in the context of digital interventions for SITB by describing the UCD approach and explicating how it can be leveraged to include lived experience throughout the development and evaluation process. We provide a detailed case example highlighting 3 phases of the early development process that can be used to design an intervention that is engaging and meets end-user needs. In addition, we point to novel applications of UCD to complement new directions in SITB research. RESULTS In this paper, we offer a 2-pronged approach to meet these challenges. First, in terms of addressing access to effective interventions, digital interventions hold promise to extend the reach of evidence-based treatments outside of brick-and-mortar health care settings. Second, to address challenges related to treatment targets and engagement, we propose involving individuals with lived experience in the design and research process. CONCLUSIONS UCD offers a well-developed and systematic process to center the unique needs, preferences, and perceived barriers of individuals with lived SITB experience in the development and evaluation of digital interventions.

Introduction: Watchman device is an alternative for anticoagulation in atrial fibrillation (AF) patients for stroke prevention but there is paucity of data on 30-day readmission trends and factors influencing it. Methods: We queried the 2016-2017 National Readmission Database for all adult AF patients, who had procedure done in January to November and discharged alive, using ICD10 code of 02L73DK. We divided the study population into deciles and used the annual procedure volume cut-off of 20 to compare the lowest volume decile with rest of the study population. Hierarchical multivariable logistic regression model was created to identify predictors of 30-day readmission and hospitals were included as random effect. Results: A total of 4565 and 9219 procedures were included for 2016 and 2017; respectively. Overall readmission rate was 1287 (9.3%) and of these 43 (3.3%) died on readmission. The 30-day readmission rate in 2017 was 906 (9.8%) compared to 381 (8.4%) in 2016 (p = 0.053) but the mortality associated with readmission was significantly higher in 2017 at 38 (0.42%) compared to 5 (0.11%) in 2016 (p=0.01). The proportion of patients with Charlson co-morbidity index ≥5 was significantly higher in 2017 at 1177 (12.8%) compared to 384 (8.4%) in 2016 (p Conclusions: Thirty-day readmission rate and mortality has been increasing along with the procedural volume which could be related to patients with higher number of co-morbidities receiving the device. Lower procedural volume of the hospital is an independent predictor of readmission.

Introduction: There are no randomized controlled trials that compared the outcomes of leadless pacemaker (L-PPM) implantation with transvenous pacemaker (TV-PPM) and there is scarcity of data on real world outcomes. Methods: We queried National Inpatient Sample to identify all adult patients who had primary discharge diagnosis of conduction disorders or tachy-arrhythmias and excluded patients who had a concomitant procedure for valve replacement, coronary artery bypass grafting, ablation and/or cardiac implantable electronic device removal so that complications can be attributed to the pacemaker implantation. We included only procedures from November 2016 to December 2017 as Micra was the only available L-PPM during that period. For the comparison cohort we selected patients, during the same time period, who had a procedure code for single chamber pacemaker implantation in conjunction with right ventricular lead placement. We performed 1:1 propensity score matching and the variables used for matching are marked with asterisk in Table 1. All the codes used to identify complications has been previously validated from the Micra Post-approval registry and Coverage with Evidence Study. Results: Total of 1,305 patients for L-PPM and 13,905 patients in the TV-PPM group were included. Baseline characteristics with standardized mean difference before and after matching are shown in Table 1. Briefly, patients in L-PPM group were younger but had higher co-morbidities compared to TV-PPM group. The complications before and after matching are shown in Table 2. Conclusions: In conclusion, we found no significant difference between in-hospital complications after propensity score matching, with the exception of deep venous thrombosis. There was no difference between length of stay but cost for L-PPM was significantly higher. In this real-world analysis, we found that the leadless PPM implantation is safe in comparison to transvenous PPM.