scholarly journals Frailty in Wild-Type Transthyretin Cardiac Amyloidosis: The Tip of the Iceberg

2021 ◽  
Vol 10 (15) ◽  
pp. 3415
Author(s):  
Amaury Broussier ◽  
Jean Philippe David ◽  
Mounira Kharoubi ◽  
Silvia Oghina ◽  
Lauriane Segaux ◽  
...  
Keyword(s):  
Cardiac Amyloidosis ◽  
Amyloid Fibrils ◽  
Nyha Class ◽  
Severe Heart Failure ◽  
Class Iii ◽  
Frailty Phenotype ◽  
Amyloid Disease ◽  
Median Serum ◽  
National Reference Center

ATTRwt-CA occurs in elderly patients and leads to severe heart failure. The disease mechanism involves cardiac and extracardiac infiltration by amyloid fibrils. The objectives of this study are to describe the frailty phenotype in patients with ATTRwt-CA and to assess the associations between frailty parameters, the severity of cardiac involvement, and the course of amyloid disease. We used multidimensional geriatric tools to prospectively assess frailty in patients with ATTRwt-CA consulting (in 2018–2019) in the French National Reference Center for Cardiac Amyloidosis. We included 36 patients (35 males; median age: 82 years (76–86). A third of the patients were categorized as NYHA class III or IV, and 39% had an LVEF below 45%. The median serum NTproBNP was 3188 (1341–8883) pg/mL. The median duration of amyloidosis was 146 months (73–216). The frequency of frailty was 50% and 33% according to the physical frailty phenotype and the Short Emergency Geriatric Assessment questionnaire, respectively. Frailty affected a large number of domains, namely autonomy (69%), balance (58%), muscle weakness (74%), malnutrition (39%), dysexecutive syndrome (72%), and depression (49%). The severity of CA was significantly associated with many frailty parameters independently of age. Balance disorders and poor mobility were also significantly associated with a longer course of amyloid disease. Frailty is frequent in patients with ATTRwt-CA. Some frailty parameters were significantly associated with a longer course of amyloid disease and CA severity. Taking into account frailty in the assessment and management of ATTRwt should improve patients’ quality of life.

Abstract 15675: Bone Marrow Derived Ixmyelocel-T From Patients With Severe Ischemic Dilated Cardiomyopathy Display Robust Anti-Inflammatory and Pro-Angiogenic Properties

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Kelly J Ledford ◽  
Ann E Remmers ◽  
Ross Tubo
Keyword(s):  
Nyha Class ◽  
Systemic Disease ◽  
Severe Heart Failure ◽  
Trophic Factors ◽  
Cardiac Diseases ◽  
Class Iii ◽  
Cell Therapies ◽  
Lps Challenge ◽  
Anti Inflammatory

Ixmyelocel-T, an expanded autologous multicellular therapy cultured from BMMNCs consisting of regenerative MSCs and M2-like macrophages, has shown clinical promise in the treatment of ischemic DCM. However the quality of BM-derived cell therapies from patients with severe heart failure is unclear as reports suggest they are dysfunctional due to advanced age and the systemic disease state. We hypothesized that ixmyelocel-T generated from ischemic DCM patients BMMNCs would consist of expanded MSCs and M2 macrophages, and produce anti-inflammatory and angiogenic factors useful for cardiac repair. BMMNCs were obtained from 55-80 year old ischemic DCM patients, with LVEF < 35% and NYHA Class III or IV, enrolled in the phase 2b clinical IXCELL-DCM trial. The BMMNCs were either used in experiments or expanded in a closed bioreactor system for 12 days to generate ixmyelocel-T (n = 13). FACS revealed a 50 ± 5% fold expansion in CD90+ MSC and a 96 ± 39% fold expansion in CD14+ M2-like macrophages in ixmyelocel-T. Cytokine arrays revealed ixmyelocel-T secreted more regulatory and trophic factors compared to BMMNCs. Specifically, ixmyelocel-T secreted significantly more Flt-3L, GM-CSF, IL-10, IL-13, IL-1ra, IL-2, IL-3, IL-5, MCP-1, CCL18, TGF-β, angiopoietin-2, IL-8, TIMP-1, TIMP-2, and VEGF compared to BMMNCs. ELISA analysis confirmed that ixmyelocel-T secreted significantly higher levels of IL-10 (2092 ± 183 vs 130 ± 17 pg/mL, p < 0.001) and IL-1ra (12241 ± 2806 vs 1857 ± 564, p < 0.001) after LPS challenge. Ixmyelocel-T had higher gene expression of the anti-inflammatory and pro-angiogenic markers HMOX1, CCL18, FGF2, IGF1, PGF, SDF-1α, Ang-1, Ang-2 and lower levels of the pro-inflammatory markers TNFα, IL-1β, IFN[[Unable to Display Character: &#611;]], IL-12 compared to BMMNCs after LPS challenge. Additionally, co-culture of ixmyelocel-T with HUVECs resulted in significant wound healing in an in vitro scratch assay compared to BMMNCs (56 ± 4 vs 39 ± 8%, p < 0.001). This data suggests that the process used to generate ixmyelocel-T is ideal for the therapeutic expansion of BMMNCs from patients with severe cardiac diseases. Ixmyelocel-T retains a regenerative, anti-inflammatory, and pro-angiogenic profile which holds promise for treatment in advanced cardiac diseases where treatment options are limited.

Arterial embolisation and coiling for high-output heart failure and pulmonary hypertension ınduced by hepatic arteriovenous fistula in a patient with hereditary hemorrhagic telengiectasia

Open Medicine ◽  
2009 ◽  
Vol 4 (3) ◽  
pp. 369-373
Author(s):  
Sadık Açikgöz ◽  
Gülten Taçoy ◽  
Baran Önal ◽  
Beytullah Yıldırım ◽  
Atiye Çengel
Keyword(s):  
Heart Failure ◽  
New York ◽  
Pulmonary Hypertension ◽  
Arteriovenous Fistula ◽  
Arteriovenous Malformations ◽  
Nyha Class ◽  
Severe Heart Failure ◽  
Heart Association ◽  
Functional Class ◽  
Class Iii

AbstractHereditary hemorrhagic telangiectasia (HHT) is a genetic vascular disorder characterised by epistaxis, telangiectases, and visceral arteriovenous malformations. Hyperdynamic blood flow associated with arteriovenous malformations may lead to pulmonary hypertension, global heart failure, and valvular insufficiencies. We report a patient who had HHT with severe heart failure (New York Heart Association [NYHA] class III-IV) and pulmonary hypertension caused by an hepatic arteriovenous fistula. After successful transarterial embolisation of the right branch of the hepatic artery with polyvinyl alcohol (PVA) particles and coils, 4 to 7 mm in size, the patient was discharged with functional class II (NYHA) heart failure.

scholarly journals An m-Health intervention to improve education, self-management, and outcomes in patients admitted for acute decompensated heart failure: barriers to effective implementation

2021 ◽  
Author(s):  
Georgios Zisis ◽  
Melinda J Carrington ◽  
Brian Oldenburg ◽  
Kristyn Whitmore ◽  
Maria Lay ◽  
...  
Keyword(s):  
Heart Failure ◽  
High Risk ◽  
Chronic Conditions ◽  
Acute Decompensated Heart Failure ◽  
Controlled Trial ◽  
Nyha Class ◽  
Decompensated Heart Failure ◽  
Class Iii ◽  
Effective Delivery

Abstract Aims Effective and efficient education and patient engagement are fundamental to improve health outcomes in heart failure (HF). The use of artificial intelligence (AI) to enable more effective delivery of education is becoming more widespread for a range of chronic conditions. We sought to determine whether an avatar-based HF-app could improve outcomes by enhancing HF knowledge and improving patient quality of life and self-care behaviour. Methods and results In a randomized controlled trial of patients admitted for acute decompensated HF (ADHF), patients at high risk (≥33%) for 30-day hospital readmission and/or death were randomized to usual care or training with the HF-app. From August 2019 up until December 2020, 200 patients admitted to the hospital for ADHF were enrolled in the Risk-HF study. Of the 72 at high-risk, 36 (25 men; median age 81.5 years; 9.5 years of education; 15 in NYHA Class III at discharge) were randomized into the intervention arm and were offered education involving an HF-app. Whilst 26 (72%) could not use the HF-app, younger patients [odds ratio (OR) 0.89, 95% confidence interval (CI) 0.82–0.97; P &lt; 0.01] and those with a higher education level (OR 1.58, 95% CI 1.09–2.28; P = 0.03) were more likely to enrol. Of those enrolled, only 2 of 10 patients engaged and completed ≥70% of the program, and 6 of the remaining 8 who did not engage were readmitted. Conclusions Although AI-based education is promising in chronic conditions, our study provides a note of caution about the barriers to enrolment in critically ill, post-acute, and elderly patients.

1169Interim analysis of data from a long-term, extension trial of tafamidis meglumine in patients with transthyretin amyloid cardiomyopathy

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
P Elliott ◽  
B M Drachman ◽  
S S Gottlieb ◽  
J E Hoffman ◽  
S L Hummel ◽  
...  
Keyword(s):  
Amyloid Fibrils ◽  
Nyha Class ◽  
Randomized Study ◽  
Pooled Analysis ◽  
Extension Study ◽  
Class Iii ◽  
Double Blind ◽  
All Cause Mortality ◽  
Amyloid Cardiomyopathy

Abstract Background Transthyretin amyloid cardiomyopathy (ATTR-CM), is an underdiagnosed, fatal disease caused by the deposition of transthyretin amyloid fibrils in the heart leading to heart failure. The Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT), an international, multi-center, double-blind, placebo-controlled, randomized study, demonstrated the efficacy and safety of tafamidis treatment for patients with ATTR-CM due to variant (ATTRm) or wild-type (ATTRwt) TTR. Purpose This is a pooled analysis of data from ATTR-ACT and interim data from the ongoing, long-term, extension study to evaluate longer term data on the efficacy of tafamidis in patients with ATTR-CM. Methods Patients who completed ATTR-ACT (which had a duration of 30 months) were eligible to be enrolled in a long-term, extension study in which patients either continued to receive tafamidis meglumine at the same dose (the tafamidis/tafamidis [T/T] group) or, for patients previously treated with placebo, were randomised (in a 1:2 ratio) to tafamidis meglumine 20 mg or 80 mg (the placebo/tafamidis [P/T] group) for up to 60 months. The primary efficacy outcome was all-cause mortality. This analysis combined data from the completed ATTR-ACT with interim data from the extension study (cut-off date: 15 Feb, 2018), and included patients treated with tafamidis meglumine across the two studies with a median follow up of 36 months. Results All-cause mortality was significantly lower in the T/T group (n=264; 88 events, 33.3%) compared with the P/T group (n=177; 88 events, 50.3%); hazard ratio (95% CI), 0.64 (0.47, 0.85); P=0.001. In the subgroup of ATTRwt patients, all-cause mortality was significantly reduced in the T/T group (55/201; 27.4%) compared with the P/T group (60/134; 44.8%); 0.64 (0.44, 0.92); P=0.002. In the 106 (24.0%) ATTRm patients, there was a trend towards a reduction in all-cause mortality in the T/T group (33/63; 52.4%) compared with the P/T group (29/43; 67.4%); 0.66 (0.39, 1.09); P=0.17. In patients who were NYHA Class I or II at baseline, all-cause mortality was significantly reduced in the T/T group (38/186; 20.4%) compared with the P/T group (45/114; 39.5%); 0.49 (0.32, 0.75); P=0.001. In those patients with more severe symptoms at baseline (NYHA Class III), there were fewer deaths in the T/T group (50/78; 64.1%) compared with the P/T group (44/63; 69.8%); 0.80 (0.53, 1.21), but this difference was not statistically significant (P=0.50). Conclusions In ATTR-ACT, tafamidis was shown to significantly improve survival, functional capacity, and quality of life in patients with ATTR-CM. This pooled analysis with data from the ongoing extension study further supports the efficacy of tafamidis in patients over a longer period of time and the importance of early diagnosis and treatment. Acknowledgement/Funding This study was sponsored by Pfizer.

Abstract 139: Angina Frequency, Quality of Life and Functional Status in Patients with Stable Ischemic Heart Disease: Data from the Heart and Soul Study

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Alexis L Beatty ◽  
Mary A Whooley
Keyword(s):  
Quality Of Life ◽  
Heart Disease ◽  
Ischemic Heart Disease ◽  
Nyha Class ◽  
Functional Limitation ◽  
Class Iii ◽  
Physical Limitation ◽  
Angina Frequency

Background: Angina is a common symptom among patients with ischemic heart disease (IHD), but its long-term effects on quality of life and functional limitation have not been quantified. We sought to evaluate the longitudinal association of angina frequency with quality of life and functional limitation in patients with IHD. Methods: We enrolled 1023 outpatients with stable IHD in a prospective cohort study between 2000 and 2002. Participants completed the Seattle Angina Questionnaire (SAQ) at baseline and annually for five years. The longitudinal associations of SAQ angina frequency with overall quality of life (fair or poor vs. excellent, very good, or good), SAQ quality of life score, SAQ physical limitation score, and New York Heart Association (NYHA) functional class (III or IV vs. I or II) were estimated using mixed effects regression models with adjustment for clinical risk factors. Results: At baseline, 633 participants (62%) reported no angina, 279 (27%) reported monthly angina, and 111 (11%) reported daily or weekly angina. At baseline, participants with daily or weekly angina were more likely than those without angina to report fair or poor overall quality of life (46% vs. 18%, P<.001) and NYHA class III or IV symptoms (58% vs. 13%, P<0.001). During five years of follow-up, participants with daily or weekly angina had worse mean SAQ Quality of Life scores (51.7 vs. 89.2, P<.001) and SAQ Physical Limitation scores (62.4 vs. 84.9, P<.001) than participants without angina. After adjusting for age, sex, race, smoking, hypertension, history of heart failure, physical inactivity, depressive symptoms, and medication use, daily or weekly angina remained associated with worse mean SAQ Quality of Life scores (54.7 vs. 88.7, P<.001) and Physical Limitation scores (66.8 vs. 85.0, P<.001). In adjusted analyses, participants with daily or weekly angina had higher odds of reporting fair or poor quality of life (OR 1.78, 95%CI 1.18, 2.69, P<.001) and higher odds of reporting NYHA class III or IV symptoms (OR 6.17, 95%CI 4.34, 8.77, P<.001) during the follow-up period. Conclusions: Angina frequency was associated with longitudinal measures of quality of life and functional limitations in outpatients with IHD.

Abstract 17077: Functional Class, Biomarker Stability, and Clinical Outcomes of Patients With Transthyretin Cardiac Amyloidosis Treated With Tafamidis

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Pranav Chandrashekar ◽  
Zack Dale ◽  
Lana Rashdan ◽  
Miriam Elman ◽  
Babak Nazer ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Real World ◽  
Cardiac Amyloidosis ◽  
Troponin I ◽  
Nyha Class ◽  
Functional Class ◽  
Wilcoxon Test ◽  
World Population ◽  
Class Iii ◽  
Nyha Functional Class

Introduction: Tafamidis has been shown to improve survival and decrease heart failure (CHF) hospitalizations in transthyretin cardiac amyloidosis (ATTR-CM). In the ATTR-ACT trial, survival benefit emerged after approximately 18 months of treatment, with less clear benefit in those with NYHA class III symptoms. We sought to evaluate the short-term changes in NYHA class, biomarkers, and clinical outcomes in a real-world cohort of patients treated with tafamidis. Methods: A single center retrospective observational study of patients with ATTR-CM who were prescribed tafamidis since its FDA approval in May 2019. We collected data on prospectively assessed NYHA class, NTproBNP, Troponin I, and outcomes of CHF hospitalizations and death. Results: Fifty-one patients with ATTR-CM (mean age 73.3±7 years, 100.0% male) were prescribed tafamidis. Forty-five patients had wild-type and 6 had hereditary ATTR-CM. At the visit when tafamidis was initiated 6 (11.8%) patients were NYHA Class I, 24 (47.1%) Class II, 20 (39.2%) Class III, and 1 (2%) Class IV. Over a median follow up of 8 (IQR 6.0-11) months after starting tafamidis, there were no significant differences before and after tafamidis treatment in time-averaged median NYHA functional class (paired Wilcoxon test, p=0.1610; Figure 1A), time-averaged median NTproBNP (paired exact Wilcoxon test, p > 0.9999; Figure 1B), and time-averaged median troponin I (paired exact Wilcoxon test, p=0.9400; Figure 1C). Following initiation of tafamidis, 13 patients (25.5%) were admitted for CHF hospitalization. A total of 8 patients (15.7%) died a median of 9.5 (IQR 2.5-12.5) months after initiation of tafamidis. Conclusions: ATTR-CM patients taking tafamidis were observed to have stable functional status and biomarkers, including those with NYHA class III symptoms. Despite a higher proportion of worse NYHA functional class, the rate of death at 10 months appears comparable to the ATTR-ACT trial in this real-world population.

scholarly journals Health Related Quality of Life in Systolic Heart Failure Patients at Tertiary Care Unit Cardiology OPD Hayatabad Medical Complex Peshawar Pakistan

2021 ◽  
Vol 10 (3) ◽  
pp. 140-146
Author(s):  
Ahsan Ullah ◽  
Ayaz Ayub ◽  
Bakhtawar Shah ◽  
Rahmat Ghaffarr ◽  
Awal Khan ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Heart Failure ◽  
Nyha Class ◽  
Tertiary Care ◽  
Systolic Heart Failure ◽  
Demographic Variables ◽  
Class Iii ◽  
Heart Failure Patients ◽  
Related Quality

Background: Heart failure is a leading cardiac morbidity prevalent across the globe. Its incidence is rising in direct proportion to increasing longevity all over the world. Demographic variables are important predictors of quality of life, morbidity, rehospitalization, and mortality due to systolic heart failure. The objective of our study was to assess the association of demographic variables with quality of life of systolic heart failure in patients presenting at Cardiology Out Patient Department, Hayatabad Medical Complex, Peshawar. Our study aims to inform policy making as it highlights some important demographics factors associated with quality of life. Methods: A cross sectional method was employed in the study to examine systolic heart failure and its prevalence across various demographic variables such as age, gender, marital status, activity, number of children, education, employment status, and BMI at cardiology OPD of a medical teaching institution in Peshawar. Consecutive sampling was used and data were collected through a structured questionnaire from 368 Systolic Heart Failure patients. Data were analyzed using SPSS version 22. Results: We had 368 participants, a majority of whom (n=290; 78.8%), were in NYHA class III. The rest (n=78; 21.2%) were in class IV. Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used to categorize quality of life into ‘Good’, ‘Moderate’ and ‘Poor’. Most participants were in the ‘poor’ category with MLHFQ scores >45 (n=193; 52.4%). Those who had scores between 25 -45 were categorized as ‘moderate’ (n=116; 31.5%), and participants who scored < 24 were categorized as having a ‘good’ quality of life (n=59; 16%). Reliability of tools was checked by Cronbach alpha which was 0.86 Conclusion: It was concluded that demographic variables have a significant effect on the overall morbidity of heart failure patients and heart failure related quality of life.

scholarly journals Prevalence and effect of cardiac cachexia in advanced heart failure patients living in northern ireland

2021 ◽  
Vol 20 (Supplement_1) ◽  
Author(s):  
M Carson ◽  
J Reid ◽  
L Hill ◽  
L Dixon ◽  
P Donnelly ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Heart Failure ◽  
Northern Ireland ◽  
Muscle Mass ◽  
Nyha Class ◽  
Advanced Heart Failure ◽  
Class Iii ◽  
Upper Arm ◽  
Cardiac Cachexia

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Northern Ireland Chest Heart and Stroke Background/Introduction: Cardiac cachexia (CC) is a multifactorial wasting syndrome, resulting in significant weight loss and reduction in muscle mass. This is reflected in a detrimental effect on the patients’ physical condition, quality of life and increases the patient’s risk of premature death. Nonetheless, cardiac cachexia remains frequently unrecognised in clinical practice and therefore understudied. Purpose To determine the prevalence and effect of cardiac cachexia in 200 patients with advanced heart failure (NYHA class III-IV) living in Northern Ireland. Methods A mixed methods cross sectional study of patients recruited from a regional heart failure centre. A total of 200 patients with NYHA class III-IV heart failure were consented, enrolled and detailed data collected from their records. Anthropometric measures were taken (i.e. measures of lean muscle mass and fat tissue) and each individual completed three validated questionnaires - EQ-5D-5L (quality of life), FACIT-Fatigue and FAACT (various wellbeing subscales). Results This population was predominately male (65.5%), with an average age of 74.4 years. Of the 200 NYHA class III-IV patients recruited, 30 were identified as cachectic (15%) Physically, cachectic patients were approximately 25 kg lighter than non-cachectic patients (p &lt; 0.01) with an average BMI of 21.8 ± 4.4. The cachectic group showed significant reductions in mid-upper arm circumference (p &lt; 0.01), skinfold thickness (p &lt; 0.01) and upper arm fat area (p &lt; 0.01), in comparison to the non-cachectic group. Measures of muscle mass were reduced, for example upper arm muscle circumference and area (p &lt; 0.01), as well as grip strength (p &lt; 0.01 for both right and left hands). Quality of life results from the EQ-5D-5L [see figure part b)] indicated an overall reduction for the cachectic group (p = 0.047). Of the EQ-5D-5L subscales, mobility and ‘usual activities’ were significantly reduced (p = 0.02 and p &lt; 0.01 respectively), highlighting a significant change in the daily routine and ability of these patients. The FACIT-Fatigue questionnaire showed cachectic patients to be significantly more fatigued (p &lt; 0.01) [see figure part a)], whilst the FAACT demonstrated reduced physical wellbeing (p = 0.02) and greater issues with diet and appetite (p &lt; 0.01). Conclusions This is the first prevalence study of cardiac cachexia within Northern Ireland. The 15% prevalence rate shows that the syndrome is relatively common in the advanced heart failure population. Cardiac Cachexia has severe physical consequences, attributed to an individual’s weight loss in both fat and muscle tissue. Such changes may explain the subsequent decrease in mobility and the ability of these patients to conduct their ‘usual activities’. Increased fatigue, reduced physical wellbeing and issues with diet and appetite only intensify these dire physical effects. It is hoped that these results will highlight the impact of this syndrome and promote targeted interventions.

scholarly journals The cardiac amyloidosis clinical pathway implementation: a real world experience

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M Brons ◽  
F.H Rutten ◽  
M.C Minnema ◽  
A.F Baas ◽  
F.W Asselbergs ◽  
...  
Keyword(s):  
Clinical Pathway ◽  
Cardiac Amyloidosis ◽  
Nyha Class ◽  
Disease Stage ◽  
Class Iii ◽  
Funding Sources ◽  
Disease Characteristics ◽  
The Impact ◽  
Timely Referral ◽  
Over Time

Abstract Background/Introduction Prognosis for patients with cardiac amyloidosis (CA) is determined by disease stage at diagnosis, underlining the importance of timely referral. In 2018, a CA clinical pathway was implemented in an Amyloidosis Expert Center in The Netherlands to increase regional awareness. Purpose To evaluate the impact of CA clinical pathway implementation. Methods Patients diagnosed before implementation (2007–2018; T1) were retrospectively compared to the period after clinical pathway implementation (2019–2020; T2). Demographics and disease characteristics were collected from electronic health records. Results In total, 113 patients were diagnosed, mean age 67.8±8.5 years, 26% female. AL-CA was diagnosed in 62%, ATTR-CA in 38%. The number of CA diagnoses/year increased over time (Figure 1). NYHA class III (45% vs. 24%,p=0.04), CA stage (MAYO/Gillmore stage III or IV; 59% vs. 33%, p=0.03) and delay between symptoms and diagnosis (14.5 vs. 8.4 months, p&lt;0.01) improved considerably between T1 and T2. Reasons for referral changed over time, with increasing awareness for right ventricular hypertrophy (9% vs. 36%) and unexplained HFpEF (22% vs 38%). Conclusion CA patients were diagnosed earlier with less severe symptoms. Clinical pathway implementation facilitated regional increased awareness and improved timely referral. FUNDunding Acknowledgement Type of funding sources: None.

Sign in / Sign up

Export Citation Format

Share Document