ORCID Profile
0000-0002-7222-7314
Current Organisations
Royal Perth Hospital
,
University of Western Australia
,
Fiona Stanley Hospital
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Publisher: Elsevier BV
Date: 07-2023
Publisher: Wiley
Date: 04-09-2022
DOI: 10.1111/IMJ.15700
Abstract: Guidelines advocate for intensive lipid-lowering in patients with atherosclerotic cardiovascular disease (ASCVD). In May 2020, evolocumab, a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor, became government subsidised in Australia for patients with ASCVD requiring further low-density lipoprotein cholesterol (LDL-C) lowering. To identify barriers to prescribing PCSK9 inhibitors in hospitalised patients with ASCVD. A retrospective 3-month, single-site, observational analysis was conducted in consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Lipid-lowering therapy prescriptions, including PSCK9 inhibitors, were assessed using electronic medical records, compared against the Australian Pharmaceutical Benefits eligibility criteria, and barriers to PCSK9 inhibitor use identified. Of 331 patients, 244 (73.7%) underwent PCI and 87 (26.3%) underwent CABG surgery. A lipid profile during or within 8 weeks of admission was measured for 202 (82.8%) patients undergoing PCI and 59 (67.8%) undergoing CABG surgery. In patients taking high-intensity statins on admission (n = 109), LDL-C ≥1.4, ≥1.8 and >2.6mmol/L was seen in 64 (58.7%), 44 (40.4%) and 19 (17.4%) patients respectively. High-intensity statin prescribing at discharge was high (>80%) however, ezetimibe was initiated in zero patients with LDL-C ≥1.4 mmol/L. There was variable advice given by clinicians for LDL-C targets. No patients met the criteria for subsidised PSCK9 inhibitor therapy, largely due to lack of qualifying lipid levels following combined statin and ezetimibe therapy. Prescribing of non-statin LDL-C-lowering therapies remains low in patients with ASCVD. Underprescribing of ezetimibe and suboptimal lipid testing rates are barriers to accessing subsidised PCSK9i therapy using current Australian eligibility criteria.
Publisher: Wiley
Date: 09-08-2019
DOI: 10.1111/DME.14095
Abstract: Diabetes mellitus is associated with increased risk of adverse outcomes following acute coronary syndrome. Translating evidence-based recommendations into practice is necessary to improve outcomes. We evaluated whether implementing algorithms to guide inpatient care improved glycaemic control, and increased use of sodium-glucose co-transporter 2 (SGLT2) inhibitors and lipid-lowering medication in a tertiary cardiac unit. A 3-month audit (phase 1) was conducted to evaluate hyperglycaemia and dyslipidaemia management, and medication prescriptions. Consecutive people with diabetes admitted for acute coronary syndrome were prospectively identified. Target blood glucose level was defined as 5-10 mmol/l. A multidisciplinary committee designed and implemented decision-support algorithms plus education. A 3-month post-implementation audit (phase 2) was conducted. There were 104 people in phase 1 and 101 in phase 2, with similar characteristics [HbA Implementing decision-support algorithms was associated with improved inpatient glycaemic control and increased use of cardioprotective therapies at discharge in people with diabetes and acute coronary syndrome.
Publisher: Wiley
Date: 08-11-2018
DOI: 10.1002/DMRR.3090
Abstract: Dyslipidaemia is an important modifiable risk factor contributing to the increased risk of atherosclerotic cardiovascular disease in diabetes. However, determining when to initiate statin therapy in young adults with type 1 diabetes mellitus (T1DM) can often be challenging. This is due to a relative paucity of data in this area to guide management and for developing T1DM-specific risk engines. Current recommendations from international guidelines offer differing approaches to cardiovascular risk stratification and management of dyslipidaemia in T1DM. We present a clinical vignette and comment on the use of nontraditional methods of cardiovascular risk stratification. The strategy for managing dyslipidaemia in young T1DM should be in idualized, and recommendations from guidelines should serve to inform clinical judgement.
Publisher: Springer Science and Business Media LLC
Date: 16-09-2019
Publisher: Elsevier BV
Date: 02-2023
Publisher: Elsevier BV
Date: 09-2020
Publisher: Elsevier BV
Date: 09-2023
Publisher: Elsevier BV
Date: 07-2018
DOI: 10.1016/J.CARPATH.2018.04.006
Abstract: Ehlers-Danlos Syndrome comprises a heterogeneous group of heritable connective tissue disorders resulting from various gene mutations. We present an unusual case of vascular Ehlers-Danlos Syndrome with distinctive physical characteristics and a cardiomyopathy with features suggesting isolated left ventricular non-compaction. The cardiac features represent the first report of a cardiomyopathy associated with a mutation in the COL3A1 gene. This case also illustrates the multi-system nature of Ehlers-Danlos Syndrome and the complexity of managing patients with the vascular subtype.
Publisher: Wiley
Date: 10-08-2019
DOI: 10.1002/EHF2.12505
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-10-2022
Publisher: Elsevier BV
Date: 05-2021
Publisher: Springer Science and Business Media LLC
Date: 20-08-2022
DOI: 10.1007/S00330-022-09028-3
Abstract: Coronary artery calcium (CAC) scores derived from computed tomography (CT) scans are used for cardiovascular risk stratification. Artificial intelligence (AI) can assist in CAC quantification and potentially reduce the time required for human analysis. This study aimed to develop and evaluate a fully automated model that identifies and quantifies CAC. Fully convolutional neural networks for automated CAC scoring were developed and trained on 2439 cardiac CT scans and validated using 771 scans. The model was tested on an independent set of 1849 cardiac CT scans. Agatston CAC scores were further categorised into five risk categories (0, 1–10, 11–100, 101–400, and 400). Automated scores were compared to the manual reference standard (level 3 expert readers). Of 1849 scans used for model testing (mean age 55.7 ± 10.5 years, 49% males), the automated model detected the presence of CAC in 867 (47%) scans compared with 815 (44%) by human readers ( p = 0.09). CAC scores from the model correlated very strongly with the manual score (Spearman’s r = 0.90, 95% confidence interval [CI] 0.89–0.91, p 0.001 and intraclass correlation coefficient = 0.98, 95% CI 0.98–0.99, p 0.001). The model classified 1646 (89%) into the same risk category as human observers. The Bland–Altman analysis demonstrated little difference (1.69, 95% limits of agreement: −41.22, 44.60) and there was almost excellent agreement (Cohen’s κ = 0.90, 95% CI 0.88–0.91, p 0.001). Model analysis time was 13.1 ± 3.2 s/scan. This artificial intelligence–based fully automated CAC scoring model shows high accuracy and low analysis times. Its potential to optimise clinical workflow efficiency and patient outcomes requires evaluation. • Coronary artery calcium (CAC) scores are traditionally assessed using cardiac computed tomography and require manual input by human operators to identify calcified lesions. • A novel artificial intelligence (AI)–based model for fully automated CAC scoring was developed and tested on an independent dataset of computed tomography scans, showing very high levels of correlation and agreement with manual measurements as a reference standard. • AI has the potential to assist in the identification and quantification of CAC, thereby reducing the time required for human analysis.
Publisher: Informa UK Limited
Date: 28-04-2021
Publisher: Wiley
Date: 04-2019
DOI: 10.1111/IMJ.14247
Publisher: Korean Society of Lipidology and Atherosclerosis
Date: 2022
Publisher: Elsevier BV
Date: 09-2023
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 29-08-2023
DOI: 10.1097/MCO.0000000000000976
Abstract: Calcific aortic valve disease (CAVD), the most common cause of aortic stenosis (AS), is characterized by slowly progressive fibrocalcific remodelling of the valve cusps. Once symptomatic, severe AS is associated with poor survival unless surgical or transcatheter valve replacement is performed. Unfortunately, no pharmacological interventions have been demonstrated to alter the natural history of CAVD. Lipoprotein(a) [Lp(a)], a low-density lipoprotein-like particle, has been implicated in the pathophysiology of CAVD. The mechanisms by which Lp(a) results in CAVD are not well understood. However, the oxidized phospholipids carried by Lp(a) are considered a crucial mediator of the disease process. An increasing number of studies demonstrate a causal association between plasma Lp(a) levels and frequency of AS and need for aortic valve replacement, which is independent of inflammation, as measured by plasma C-reactive protein levels. However, not all studies show an association between Lp(a) and increased progression of calcification in in iduals with established CAVD. Epidemiologic, genetic, and Mendelian randomization studies have collectively suggested that Lp(a) is a causal risk factor for CAVD. Whether Lp(a)-lowering can prevent initiation or slow progression of CAVD remains to be demonstrated.
Publisher: Wiley
Date: 11-2020
DOI: 10.1111/IMJ.15055
Publisher: Elsevier BV
Date: 05-2021
Publisher: Springer International Publishing
Date: 2023
Publisher: Elsevier BV
Date: 2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 24-03-2023
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-07-2022
Publisher: Springer Science and Business Media LLC
Date: 21-09-2020
Publisher: Elsevier BV
Date: 08-2019
DOI: 10.1016/J.HLC.2018.07.007
Abstract: Patent foramen ovale (PFO) is a potential mechanism for paradoxical embolism in cryptogenic ischaemic stroke or transient ischaemic attack (TIA). PFO is typically demonstrated with agitated saline ("bubble study", BS) during echocardiography. We hypothesised that the BS is frequently requested in patients that have a readily identifiable cause of stroke, that any PFO detected is likely incidental, and its detection often does not alter management. This was a retrospective observational study of patients with recent ischaemic stroke/TIA referred for a BS. Patient demographics, stroke risk factors, vascular/cerebral imaging results and transoesophageal echocardiogram (TOE) reports were recorded. A "modified" Risk of Paradoxical Embolism (RoPE) score was calculated. Change in management was defined as antiplatelet/anticoagulant therapy alteration or referral for PFO closure. Bubble Study complications were recorded. Among 715 patients with ischaemic stroke/TIA referred for a BS, 8.7% had atrial fibrillation and 9.2% had carotid stenosis ≥70%. At least three stroke risk factors were present in 39.3% and only 47.1% of patients screened had a "modified" RoPE score of >5. A PFO was detected in 248 patients of whom only 31% (77/248) had a subsequent change in management. Of BS performed, 1/924 patients (0.1%) suffered a TIA as a complication. The echocardiographic BS is frequently performed in patients that have a readily identifiable cause of stroke and whose PFO unlikely relates to the stroke/TIA. Bubble Study findings resulted in a change in management in the minority. The procedure is safe but the complication rate warrants informed consent.
Publisher: Elsevier BV
Date: 10-2022
DOI: 10.1016/J.DIABRES.2022.110093
Abstract: This study explored characteristics and outcomes of patients with type 1 diabetes mellitus (T1DM) and acute coronary syndromes (ACS). A retrospective analysis of patients with T1DM admitted with ACS to an Australian hospital was conducted. Risk factor targets were defined by 2021 European Society of Cardiology Guidelines. Outcomes were defined as an adverse cardiovascular event (ACS, unplanned revascularisation, heart failure, stroke, or cardiovascular death) or all-cause mortality within six-months after discharge. 61 patients were included [age 58.5 ± 12.8 years, 39 % female]. Dyslipidaemia (85 %), hypertension (75 %), smoking (28 %), prior coronary artery disease (CAD) (44 %), and microvascular complications (62 %) were common. HbA1c, low-density lipoprotein cholesterol, and blood pressure targets were attained in 12 %, 36 % and 47 %, respectively. ST-elevation myocardial infarction (65 % versus 7 %, p < 0.001) and revascularisation (77 % versus 41 %, p = 0.008) were more common in those without prior CAD. Peak inpatient blood glucose correlated directly with peak troponin (p = 0.011) and inversely with left ventricular ejection fraction (p = 0.027). Nineteen patients experienced an adverse six-month outcome, with peripheral neuropathy (p = 0.039) and in-hospital hypoglycaemia (p = 0.012) being independent predictors. Patients with T1DM and ACS often do not meet guideline targets for cardiovascular risk factors, and frequently present with transmural infarctions. Dysglycemia and microvascular complications predict poorer outcomes.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 17-01-2022
Publisher: Massachusetts Medical Society
Date: 23-05-2019
DOI: 10.1056/NEJMC1902955
Publisher: Australasian Association for Clinical Biochemistry and Laboratory Medicine
Date: 2019
Abstract: The diagnosis of acute myocardial injury requires a rise and/or fall of cardiac troponin (cTn) on serial testing, with at least one concentration above the 99th percentile value of a normal reference population according to the recently published Fourth Universal Definition of Myocardial Infarction.1 However, the magnitude of change in cTn that constitutes a significant rise and/or fall was again not specified in detail. High-sensitivity cardiac troponin (hs-cTn) assays can measure ten-fold lower concentrations of cTn with more precision than older assays, and can accurately quantitate cTn in more than 50% of healthy in iduals with a coefficient of variation of less than 10% at the 99th percentile. These hs-cTn assays are also able to detect the normal variations in cTn results that are due to biological variability. Understanding and quantifying the normal variations in cTn is important as this would allow significant changes to be better defined. Numerous studies have sought to investigate the biological variability of cTn over the last ten years. Such studies are usually conducted in healthy in iduals, however in iduals with chronic cardiac disease or chronic renal failure have also been examined. These studies have yielded varying results in regards to significant change values for cTn. In light of the recent redefinition for myocardial infarction, the purpose of this mini-review is to revisit the biological variability of cTn. In particular, we outline concepts for determining a significant change value, review the results of previous studies on the biological variation of cTn and discuss potential considerations for clinical practice.
Publisher: Wiley
Date: 17-02-2022
Publisher: Wiley
Date: 04-07-2023
DOI: 10.5694/MJA2.52018
Abstract: To examine the severity of coronary artery disease (CAD) in people from rural or remote Western Australia referred for invasive coronary angiography (ICA) in Perth and their subsequent management to estimate the cost savings were computed tomography coronary angiography (CTCA) offered in rural centres as a first line investigation for people with suspected CAD. Retrospective cohort study. Adults with stable symptoms in rural and remote WA referred to Perth public tertiary hospitals for ICA evaluation during the 2019 calendar year. Severity and management of CAD (medical management or revascularisation) health care costs by care model (standard care or a proposed alternative model with local CTCA assessment). The mean age of the 1017 people from rural and remote WA who underwent ICA in Perth was 62 years (standard deviation, 13 years) 680 were men (66.9%), 245 were Indigenous people (24.1%). Indications for referral were non‐ST elevation myocardial infarction (438, 43.1%), chest pain with normal troponin level (394, 38.7%), and other (185, 18.2%). After ICA assessment, 619 people were medically managed (60.9%) and 398 underwent revascularisation (39.1%). None of the 365 patients (35.9%) without obstructed coronaries ( 50% stenosis) underwent revascularisation nine patients with moderate CAD (50–69% stenosis 7%) and 389 with severe CAD (≥ 70% stenosis or occluded vessel 75.5%) underwent revascularisation. Were CTCA used locally to determine the need for referral, 527 referrals could have been averted (53%), the ICA:revascularisation ratio would have improved from 2.6 to 1.6, and 1757 metropolitan hospital bed‐days (43% reduction) and $7.3 million in health care costs (36% reduction) would have been saved. Many rural and remote Western Australians transferred for ICA in Perth have non‐obstructive CAD and are medically managed. Providing CTCA as a first line investigation in rural centres could avert half of these transfers and be a cost‐effective strategy for risk stratification of people with suspected CAD.
Publisher: Elsevier BV
Date: 02-2019
DOI: 10.1016/J.PATHOL.2018.10.015
Abstract: Familial hypercholesterolaemia (FH) is a dominantly inherited disorder of low-density lipoprotein (LDL) catabolism, which if untreated causes lifelong elevated LDL-cholesterol (LDL-c), accelerated atherosclerosis and premature cardiovascular disease. Recent evidence suggests the prevalence of heterozygous FH is ∼1:220, making FH the most common autosomal dominant condition. Lowering LDL-c with statin and lifestyle therapy reduces the risk of cardiovascular events. Furthermore, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors significantly lower LDL-c in addition to statin therapy, and early outcome data suggest improved vascular outcomes with these agents in FH patients in addition to statins. However, the vast majority of people with FH still remain undiagnosed. The onus is on clinicians to identify kindreds with FH, as PCSK9 inhibitors, although expensive, are funded for patients with FH in Australia. Multiple strategies for detecting FH have been proposed. The detection of index cases can be achieved through applying electronic screening tools to general practice databases, universal screening of children during immunisation, and targeted screening of patients with premature cardiovascular disease. Advances in genomic technology have decreased costs of genetic testing, improved the understanding of the pathogenesis of FH and facilitated cascade screening. However, awareness of FH amongst clinicians and the general public still requires optimisation. This review outlines recent advances in FH detection, including emerging strategies and challenges for the next decade.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2017
Publisher: S. Karger AG
Date: 2023
DOI: 10.1159/000529600
Abstract: b i Background: /i /b Lipoprotein(a) (Lp[a]) is a risk factor for cardiovascular disease. The burden of thrombus in ST-segment elevation myocardial infarction (STEMI) has implications on treatment and outcomes. However, the association between Lp(a) and atherothrombosis in STEMI remains unclear. b i Objectives: /i /b The aim of the study was to determine the association between Lp(a) and culprit artery thrombus burden in younger patients with STEMI. b i Methods: /i /b This was a single-center study of 83 patients aged & #x3c years with STEMI between 2016–2018 who underwent percutaneous coronary intervention and measurement of Lp(a) those receiving thrombolytic therapy were excluded. Thrombus burden in the culprit artery was determined angiographically using the Thrombolysis In Myocardial Infarction score and classified as absent-to-small, moderate, or large. Elevated Lp(a) was defined as plasma mass concentration & #x3e mg/dL. Multivariate analysis was performed adjusting for cardiovascular risk factors. b i Results: /i /b The mean age was 48.0 ± 8.4 years, and 78.3% were male. Thirteen (16%), 9 (11%), and 61 (73%) patients had small, moderate, or large thrombus burden, respectively, and 34 (41%) had elevated Lp(a). Elevated Lp(a) was associated with greater thrombus burden compared to normal Lp(a) (large burden 85% vs. 65% i /i = 0.024). Elevated Lp(a) was associated with moderate or large thrombus in univariate (OR 10.70 [95% CI 1.32–86.82] i /i = 0.026) and multivariate analysis (OR 10.33 [95% CI 1.19–89.52] i /i = 0.034). Lp(a) was not associated with culprit artery or stenosis location according to culprit artery. b i Conclusions: /i /b Elevated Lp(a) is associated with greater thrombus burden in younger patients with STEMI. The finding of this observational study accords with the thrombotic and anti-fibrinolytic properties of Lp(a). A causal relationship requires verification.
Publisher: Elsevier BV
Date: 08-2023
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2017
Publisher: Wiley
Date: 03-2021
DOI: 10.1111/IMJ.15245
Publisher: Hindawi Limited
Date: 07-06-2018
DOI: 10.1155/2018/9763452
Abstract: Thyrotoxic periodic paralysis is an infrequent manifestation of hyperthyroidism and an uncommon cause of muscle weakness in western countries. The diagnosis should be considered in the differential when a patient presents with transient and recurrent weakness associated with hypokalaemia. We present a case of a 26-year-old Asian male presenting with sudden onset muscle weakness affecting predominantly his lower limbs on a background of weight loss. Physical examination demonstrated symmetrical proximal muscle weakness with normal sensation and reflexes. Initial biochemical investigations revealed hypokalaemia, hypomagnesaemia, and hyperthyroidism. Intravenous electrolyte replacement was administered in the emergency department. The patient’s symptoms resolved during inpatient admission. Subsequent TSH receptor antibody testing and radionuclide thyroid scan confirmed a diagnosis of Graves’ disease. The patient was discharged on antithyroid medication with no further episodes of weakness on follow-up. Therefore, thyrotoxic periodic paralysis can be the presenting feature of previously undiagnosed Graves’ disease and should be considered in the differential diagnosis in patients presenting with weakness.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-12-2021
Publisher: Elsevier BV
Date: 08-2023
Publisher: Wiley
Date: 09-08-2018
DOI: 10.1111/COA.12936
Abstract: To investigate the relationship between hearing loss and cardiovascular disease risk factors. Cross-sectional study. Participants were recruited between May 2010 and December 2015 and answered a health and risk factor questionnaire. Physical and biochemical assessments were performed. A community-based population. A total of 5107 participants born within the years 1946-1964 enrolled in the Busselton Healthy Ageing Study. Hearing was assessed behaviourally through the best ear pure-tone average (500, 1000, 2000, 4000 Hz), low-frequency average (250, 500, 1000 Hz) and high-frequency average (4000, 8000 Hz). Self-reported hearing loss, tinnitus and hyperacusis were assessed via questionnaire. Cardiovascular risk factors were assessed via a patient-completed questionnaire and objective measurements including blood pressure, body mass index, waist circumference, lipid profile and glycated haemoglobin. Of the participants, 54% were female, with the mean age of 58 years (range 45-69 years). Age, sex and family history of hearing loss were consistently strong determinants of hearing loss outcomes. After adjusting for these, obesity, current smoking, peripheral arterial disease and history of cardiovascular disease were significantly associated with pure-tone, low-frequency and high-frequency hearing loss. In addition, high blood pressure, triglyceride and glycated haemoglobin were significantly associated with low-frequency hearing loss. There was a graded association between hearing loss and Framingham Risk Score for cardiovascular risk (P<0.001). Established cardiovascular disease and in idual and combined cardiovascular disease risk factors were found to be associated with hearing loss. Future research should prospectively investigate whether targeting cardiovascular disease can prevent hearing loss.
Publisher: Wiley
Date: 18-08-2023
Abstract: International guidelines provide increasing support for computed tomography coronary angiography (CTCA) in investigating chest pain. A pathway utilising CTCA first‐line for outpatient stable chest pain evaluation was implemented in an Australian ED. In pre‐post design, the impact of the pathway was prospectively assessed over 6 months (August 2021 to January 2022) and compared with a 6‐month pre‐implementation group (February 2021 to July 2021). CTCA was recommended first‐line in suspected stable cardiac chest pain, followed by chest pain clinic review. Predefined criteria were provided recommending functional testing in select patients. The impact of CTCA versus functional testing was evaluated. Data were obtained from digital medical records. Three hundred and fifteen patients were included, 143 pre‐implementation and 172 post‐implementation. Characteristics were similar except age (pre‐implementation: 58.9 ± 12.0 vs post‐implementation: 62.8 ± 12.3 years, P = 0.004). Pathway‐guided management resulted in higher first‐line CTCA (73.3% vs 46.2%, P 0.001), lower functional testing (30.2% vs 56.6%, P 0.001) and lower proportion undergoing two non‐invasive tests (4.7% vs 10.5%, P = 0.047), without increasing investigation costs or invasive coronary angiography (ICA) (pre‐implementation: 13.3% vs post‐implementation: 9.3%, P = 0.263). In patients undergoing CTCA, 40.7% had normal coronaries and 36.2% minimal/mild disease, with no difference in disease burden post‐implementation. More medication changes occurred following CTCA compared with functional testing (aspirin: P = 0.005, statin: P 0.001). In patients undergoing ICA, revascularisation to ICA ratio was higher following CTCA compared with functional testing (91.7% vs 18.2%, P 0.001). No 30‐day myocardial infarction or death occurred. The pathway increased CTCA utilisation and reduced downstream investigations. CTCA was associated with medication changes and improved ICA efficiency.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-12-2022
Publisher: SAGE Publications
Date: 11-2017
Abstract: Worldwide, approximately 11% of patients on dialysis receive peritoneal dialysis (PD). Whilst PD may offer more autonomy to patients compared with hemodialysis, patient and caregiver burnout, technique failure, and peritonitis remain major challenges to the success of PD. Improvements in care and outcomes are likely to be mediated by randomized trials of innovative therapies, but will be limited if the outcomes measured and reported are not important for patients and clinicians. The aim of the Standardised Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) study is to establish a set of core outcomes for trials in patients on PD based on the shared priorities of all stakeholders, so that outcomes of most relevance for decision-making can be evaluated, and that interventions can be compared reliably. The 5 phases in the SONG-PD project are: a systematic review to identify outcomes and outcome measures that have been reported in randomized trials involving patients on PD focus groups using nominal group technique with patients and caregivers to identify, rank, and describe reasons for their choice of outcomes semi-structured key informant interviews with health professionals a 3-round international Delphi survey involving a multi-stakeholder panel and a consensus workshop to review and endorse the proposed set of core outcome domains for PD trials. The establishment of 3 to 5 high-priority core outcomes, to be measured and reported consistently in all trials in PD, will enable patients and clinicians to make informed decisions about the relative effectiveness of interventions, based upon outcomes of common importance.
Publisher: Elsevier BV
Date: 09-2020
Publisher: Wiley
Date: 28-03-2019
DOI: 10.1111/DOM.13689
Abstract: The risk of atherosclerotic cardiovascular disease (ASCVD) can be significantly reduced in patients with diabetes who are undergoing low-density lipoprotein cholesterol-reducing therapies. However, the elevated triglyceride levels seen in diabetic dyslipidaemia can contribute to residual ASCVD risk. Icosapent ethyl (IPE) has recently been shown to substantially reduce major cardiovascular events in high-risk patients with hypertriglyceridaemia who are undergoing statin therapy. In a real-world study of patients with diabetes and acute coronary syndrome (ACS), 17.1% were found to be eligible for treatment with IPE based on Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) criteria. A significant proportion of patients with diabetes and ACS merit receiving IPE therapy, with important implications for evolving clinical practice guidelines and best standard of care.
Publisher: Elsevier BV
Date: 02-2020
DOI: 10.1016/J.ECHO.2019.09.012
Abstract: Exercise training is an important component of multidisciplinary heart failure management. However, the effects of aerobic training (AT) versus resistance training (RT) on cardiac function in patients with heart failure with reduced ejection fraction are not well defined. The aim of this study was to evaluate the impact of these exercise modalities on echocardiographic parameters. Participants with stable heart failure with reduced ejection fraction (ejection fraction < 50%) were randomized to 12 weeks of AT, RT, or untrained control. Exercise was performed at matched relative intensities of each training modality (50%-70% of maximum). Echocardiography and cardiopulmonary exercise testing were performed at baseline and after 12 weeks of training. Thirty-eight participants were randomized, and 12 in each group completed the intervention (mean age, 61.5 ± 1.7 years 89% men). Peak oxygen consumption increased from 14.5 ± 1.3 to 17.2 ± 1.6 ml · min There is a differential effect of AT versus RT on some echocardiographic parameters in patients with heart failure with reduced ejection fraction. AT was associated with evidence of worsening myocardial diastolic function, whereas this was not apparent after RT. Further studies are indicated to investigate the long-term clinical significance of these adaptations.
Publisher: Elsevier BV
Date: 08-2022
DOI: 10.1016/J.CARREV.2021.12.025
Abstract: Icosapent ethyl reduces cardiovascular events in high-risk patients with hypertriglyceridaemia on statin therapy. However, it is not widely available and the potential application following coronary artery bypass graft (CABG) surgery is not well-established. We aimed to determine the real-world percentage of CABG surgery patients who may be eligible for the therapy. A retrospective analysis was performed between February 2015 and August 2020 in an Australian hospital. Patients were included if a lipid profile was performed at least three weeks following CABG surgery. Data was extracted from electronic medical records. Eligibility for icosapent ethyl was defined according to inclusion criteria from the REDUCE-IT trial. Of 484 patients with follow-up lipid profiles, 21 (4.3%) were not eligible for icosapent ethyl based on age and 39 (8.1%) were not prescribed statin therapy or were prescribed a fibrate. After applying triglyceride and low-density lipoprotein cholesterol level criteria, 124 (25.6%) patients were potentially eligible for icosapent ethyl therapy. Of those eligible, high-intensity statin therapy were prescribed in 108 (87.1%). A substantial percentage of CABG surgery patients may be eligible for icosapent ethyl and could potentially benefit from its cardiovascular protection. Further research should evaluate the additional cardiovascular benefits of icosapent ethyl in this very high-risk group of patients who are already treated with high-intensity statins.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-03-2019
Abstract: The Framingham Risk Score estimates the 10‐year risk of cardiovascular events. However, it performs poorly in older adults. We evaluated the incremental benefit of adding high‐sensitivity cardiac troponin I (hs‐cTnI) to the Framingham Risk Score. The HIMS (Health in Men Study) is a cohort study of community‐dwelling men aged 70 to 89 years in Western Australia. Participants were identified from the electoral roll, with a subset undergoing plasma analysis. Hs‐ cTnI (Abbott Architect i2000 SR ) was measured in 1151 men without prior cardiovascular disease. The Western Australia Data Linkage System was used to identify incident cardiovascular events. After 10 years of follow‐up, 252 men (22%) had a cardiovascular event ( CVE +) and 899 did not (CVE–). The Framingham Risk Score placed 148 (59%) CVE + and 415 (46%) CVE– in the high‐risk category. In CVE – men, adding hs‐ cTnI affected the risk categories of 244 (27.2%) men, with 64.8% appropriately reclassified to a lower and 35.2% to a higher category, which decreased the number of high‐risk men in the CVE– to 39%. In CVE + men, adding hs‐ cTnI affected the risk categories of 61 (24.2%), with 50.8% appropriately reclassified to a higher and 49.2% to a lower category and 82.5% remaining above the 15% risk treatment threshold. The net reclassification index was 0.305 ( P .001). Adding hs‐ cTnI increased the C‐statistic modestly from 0.588 (95% CI , 0.552–0.624) to 0.624 (95% CI , 0.589–0.659) and improved model fit (likelihood ratio test, P .001). Adding hs‐ cTnI to the Framingham Risk Score provided incremental prognostic benefit in older men, especially aiding reclassification of in iduals into a lower risk category.
Publisher: Frontiers Media SA
Date: 31-08-2023
DOI: 10.3389/FCVM.2023.1220017
Abstract: Icosapent ethyl (IPE) is a purified eicosapentaenoic acid–only omega-3 fatty acid that significantly reduced cardiovascular (CV) events in patients receiving statins with established cardiovascular disease (CVD) and those with diabetes and additional risk factors in the pivotal REDUCE-IT trial. Since the publication of REDUCE-IT, there has been global interest in determining IPE eligibility in different patient populations, the proportion of patients who may benefit from IPE, and cost effectiveness of IPE in primary and secondary prevention settings. The aim of this review is to summarize information from eligibility and cost effectiveness studies of IPE to date. A total of sixteen studies were reviewed, involving 2,068,111 patients in the primary or secondary prevention settings worldwide. Up to forty-five percent of patients were eligible for IPE, depending on the selection criteria used (ie, REDUCE-IT criteria, US Food and Drug Administration label, Health Canada label, practice guidelines) and the population studied. Overall, eight cost-effectiveness studies across the United States, Canada, Germany, Israel, and Australia were included in this review and findings indicated that IPE is particularly cost effective in patients with established CVD.
Publisher: Walter de Gruyter GmbH
Date: 29-06-2020
Abstract: High-sensitivity (hs) cardiac troponin (cTn) assays can quantitate small fluctuations in cTn concentration. Determining biological variation allows calculation of reference change values (RCV), to define significant changes. We assessed the short- and long-term biological variation of cardiac troponin I (cTnI) in healthy in iduals and patients with renal failure requiring haemodialysis or cardiomyopathy. Plasma s les were collected hourly for 4 h and weekly for seven further weeks from 20 healthy in iduals, 9 renal failure patients and 20 cardiomyopathy patients. Pre- and post-haemodialysis s les were collected weekly for 7 weeks. S les were analysed using a hs-cTnI assay (Abbott Alinity ci-series). Within-subject biological variation (CV I ), analytical variation (CV A ) and between-subject biological variation (CV G ) was used to calculate RCVs and index of in iduality (II). For healthy in iduals, CV I , CV A , CV G , RCV and II values were 8.8, 14.0, 43.1, 45.8% and 0.38 respectively for short-term, and 41.4, 14.0, 25.8, 121.0% and 1.69 for long-term. For renal failure patients, these were 2.6, 5.8, 50.5, 17.6% and 0.30 respectively for short-term, and 19.1, 5.8, 11.2, 55.2% and 1.78 for long-term. For cardiomyopathy patients, these were 4.2, 10.0, 65.9, 30.0% and 0.16 respectively for short-term, and 17.5, 10.0, 63.1, 55.8% and 0.32 for long-term. Mean cTnI concentration was lower post-haemodialysis (15.2 vs. 17.8 ng/L, p 0.0001), with a 16.9% mean relative change. The biological variation of cTnI is similar between end-stage renal failure and cardiomyopathy patients, but proportionately greater in well-selected healthy in iduals with very low baseline cTnI concentrations.
Publisher: Springer Science and Business Media LLC
Date: 02-01-2023
Publisher: Wiley
Date: 23-05-2022
DOI: 10.1111/IMJ.15393
Abstract: Guidelines advocate multifactorial cardiovascular risk management in patients with diabetes and atherosclerotic cardiovascular disease. In hospitalised patients with diabetes following coronary artery bypass graft (CABG), we aimed to evaluate the impacts of decision-support algorithms for optimising glycaemia and lipid-lowering. We also assessed the safety of initiating sodium-glucose cotransporter 2 (SGLT2) inhibitors near time of hospital discharge. This was a single-site, pre- and post-intervention analysis of glucose and lipid management in consecutive hospitalised patients with diabetes undergoing CABG surgery. The intervention involved education and decision-support algorithms designed by a multidisciplinary committee to guide cardiac surgery unit clinicians. A total of 200 patients were included in the study. The pre- and post-intervention groups had similar baseline characteristics (HbA1c 7.9 ± 1.9% vs 8.1 ± 1.8%). Of 4092 blood glucose measurements, the incidence of levels between 5 and 10 mmol/L was not different post-intervention (55.5% vs 57.0% P = 0.441). Fewer endocrinology consultations occurred (59.0% vs 45.0% P = 0.048) and rates of hypoglycaemia remained low. High-intensity statin was prescribed in >90% pre- and post-intervention, although non-statin lipid-lowering agents remained <10% despite patients not achieving LDL-C targets. No 30-day readmissions for diabetic ketoacidosis occurred in patients prescribed SGLT2 inhibitors. The intervention did not improve inpatient glycaemia or increase non-statin lipid-lowering prescriptions in patients with diabetes following CABG surgery but did reduce reliance on specialty input. Initiation of SGLT2 inhibitor therapy near time of hospital discharge was not associated with safety concerns. Alternative interventions or strategies are required to optimise glycaemia and non-statin lipid-lowering therapy prescribing in this setting.
Publisher: Wiley
Date: 05-2023
DOI: 10.1111/IMJ.16089
Publisher: Elsevier BV
Date: 08-2023
Publisher: Elsevier BV
Date: 09-2021
Publisher: Elsevier BV
Date: 07-2020
Publisher: Kare Publishing
Date: 2023
Publisher: Elsevier BV
Date: 12-2021
DOI: 10.1016/J.JDIACOMP.2021.108057
Abstract: In this real-world study, the main barriers for not initiating SGLT2 inhibitor therapy early after an acute cardiac event are prescribing criteria around glycated haemoglobin and renal function. Initiation of SGLT2 inhibitors near to, or at, hospital discharge following the cardiac event was not associated with 30-day diabetic ketoacidosis readmissions.
Publisher: Elsevier BV
Date: 03-2023
Publisher: Medknow
Date: 2022
Abstract: Medical student placements in teaching hospitals are a cornerstone for gaining clinical experience. However, the ever-evolving nature of health care has also changed the delivery of student education. Few studies have examined clinicians' perspectives toward teaching students in this setting. We sought to explore the attitudes of clinicians involved in teaching medical students at an Australian tertiary hospital. Clinicians were invited by email to complete an anonymous online survey developed using a combination of questions from previously validated surveys. The questions utilized 5-point Likert scale statements and were based around the themes of "personal purpose and enjoyment of teaching" and "barriers and challenges to teaching." Results for each question are presented as frequency and percentage. Of 490 invited, 67 (13.7%) consultant clinicians from various specialties responded. The majority ( %) enjoy teaching and see it as part of their work. However, approximately half thought that medical student teaching was under-recognized and half did not have adequate time to teach due to workload. Approximately 60% responded that there was insufficient time to get to know students to provide feedback and approximately 40% indicated that the scope of student knowledge and desired outcomes are not clearly defined by medical schools. Our contemporary survey identifies modifiable factors which should be targeted. If these factors are addressed successfully, it may allow the hospital and university medical school to harness the valuable resource of clinical teachers. This could enhance the medical student experience and promote a culture of teaching and learning in hospitals.
No related grants have been discovered for Nick S. R. Lan.