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  • TeleClinical Care: A novel digital technology to enhance delivery of cardiovascular healthcare.
    (2022) Indraratna, Praveen
    Thesis
    Cardiovascular disease (CVD) is the leading cause of global mortality. Two forms of CVD are acute coronary syndromes (ACS) and heart failure (HF). Patients with either are prone to repeat hospitalisations, which are detrimental to both patients and the healthcare system. Traditional care models are suboptimal in preventing readmissions. Mobile health interventions (MHIs) are attractive due to the computing power and convenience of the smartphone. Firstly, the literature regarding MHIs in CVD is systematically reviewed and meta-analysed. MHIs improved medication adherence in ACS patients and hospitalisation rates in HF patients. The review noted limitations of published trials and identified features of successful MHIs, which were incorporated into the design of a novel smartphone app-based model of care (TeleClinical Care, TCC). TCC allows home measurement of blood pressure, heart rate and weight by patients. The readings are automatically transmitted to a central server, where clinicians can identify abnormalities and intervene accordingly. A pilot RCT comparing TCC and usual care (UC) to UC alone was performed (n=164). Patients using TCC had fewer readmissions at 6 months (41 vs. 21, hazard ratio 0.51, P= 0.015), and were more likely to be adherent with medications (75% vs. 50%, P= 0.001) and complete cardiac rehabilitation (39% vs. 18%, odds ratio 2.9, P= 0.02) compared to patients in the control arm. A process evaluation of the RCT was subsequently undertaken, which identified several contributory factors to TCC’s success, such as a helpful orientation protocol for team members, and high background rates of HF outreach service and cardiologist follow-up in both trial arms. Via a series of interviews, methods to improve the future delivery of TCC were identified, particularly relating to its integration into mainstream healthcare. Patterns of smartphone ownership among cardiac inpatients were also examined. Age, sex, diagnosis, and private health insurance subscription influenced smartphone ownership. These data will help identify patients who may be excluded from MHIs. The thesis contains a cost-effectiveness model of TCC if applied widely. When enrolment exceeds 237 patients, TCC will reduce healthcare costs relative to UC, resultant to readmission prevention. Enrolment of 500 patients is projected to save $100,000 annually. In conclusion, TCC is demonstrated as a feasible, beneficial, safe, and cost-effective intervention for patients with CVD.
  • Muscle growth in the lower legs of typically developing children
    (2023) Chow, Brian
    Thesis
    Little is known about human muscle growth in children with and without cerebral palsy (CP). The MUGgLE study aims to investigate growth-related changes in the three-dimensional (3D) architecture of lower leg muscles (muscle volume, physiological cross-sectional area (PCSA), fascicle length, and pennation angle) in 320 infants and children with and without CP aged < 3 months and 5 to 15 years. Infants have one leg scan (anatomical magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI) images), while children have three scans over three years. The MUGgLE study is ongoing. This thesis presents data derived from the first scan conducted on each of 208 typically developing (TD) infants and children. Chapter 2 provides muscle volumes of ten muscle groups in infants, and the architecture and moment arms of the medial (MG) and lateral gastrocnemius (LG) muscles. By comparing these data to data obtained from adults, it was shown that MG muscle fascicles grow primarily in cross-section rather than in length from birth to adulthood. Chapter 3 determines if lower leg muscles grow synchronously from birth to 15 years. The data show that muscle volumes, normalised to total lower leg volume, vary with age, indicating asynchronous growth. The soleus and MG muscles grow disproportionately faster. Chapter 4 determines muscle-, age-, and sex-conditional distributions of MG and tibialis anterior (TA) muscle architecture from birth to 15 years. Up to age 15 years, both muscles grow nonlinearly in volume, PCSA, and fascicle length, while the pennation angles remain nearly constant. The MG and TA muscle fascicles grow primarily transversely rather than longitudinally over this period. Chapter 5 explores the development and evaluation of a portable dynamometer used to estimate the passive length-tension curves of the gastrocnemius muscles in children. The evaluation shows that the dynamometer requires further methodological refinements to be reliable enough for clinical and research use. This thesis contributes to the fields of biomechanics, muscle physiology, and human anatomy, providing the largest high-resolution 3D dataset of muscle architecture in children to date. Biomechanists can use the data to build more effective structure-function models of children’s muscles, clinicians can use the data to investigate disordered muscle growth in children and inform early interventions and treatments, and academics can use the data to teach muscle and bone anatomy.