A Health eLearning Ontology and Procedural Reasoning Approach for Developing Personalized Courses to Teach Patients about Their Medical Condition and Treatment

We propose a methodological framework to support the development of personalized courses that improve patients’ understanding of their condition and prescribed treatment. Inspired by Intelligent Tutoring Systems (ITSs), the framework uses an eLearning ontology to express domain and learner models and to create a course. We combine the ontology with a procedural reasoning approach and precompiled plans to operationalize a design across disease conditions. The resulting courses generated by the framework are personalized across four patient axes—condition and treatment, comprehension level, learning style based on the VARK (Visual, Aural, Read/write, Kinesthetic) presentation model, and the level of understanding of specific course content according to Bloom’s taxonomy. Customizing educational materials along these learning axes stimulates and sustains patients’ attention when learning about their conditions or treatment options. Our proposed framework creates a personalized course that prepares patients for their meetings with specialists and educates them about their prescribed treatment. We posit that the improvement in patients’ understanding of prescribed care will result in better outcomes and we validate that the constructs of our framework are appropriate for representing content and deriving personalized courses for two use cases: anticoagulation treatment of an atrial fibrillation patient and lower back pain management to treat a lumbar degenerative disc condition. We conduct a mostly qualitative study supported by a quantitative questionnaire to investigate the acceptability of the framework among the target patient population and medical practitioners.

Apixaban use in an atrial fibrillation patient with double mechanical heart valves: a case report

Background Warfarin is the only approved oral anticoagulant for long-term prophylaxis against valve thrombosis and thromboembolism in patients with mechanical heart valves. To date, apixaban for patients with double (aortic and mitral) mechanical heart valves has not been reported in the literature. Case summary We report the case of a 50-year-old female who underwent double (aortic and mitral) mechanical valve replacement in February 2017. Warfarin was prescribed after mechanical valve replacement. However, she complained of side effects of warfarin, including tingling sensation and numbness of legs, urticaria, skin rash, and nausea and voluntarily stopped taking medication. In December 2018, she was admitted to the emergency room due to ongoing chest pain. Coronary angiogram revealed embolic myocardial infarction at the left circumflex coronary artery. Nevertheless, she continued to refuse to take warfarin after anticoagulant therapy for coronary artery embolism. Given the patient’s objection, we prescribed apixaban 5 mg b.i.d. since February 2019. When she was diagnosed with atrial fibrillation in April 2020, no intracardiac thrombosis was confirmed on computed tomography and electrical cardioversion was performed safely. While on apixaban, no evidence of prosthetic valve thrombosis or thrombo-embolic events was observed during a 24-month period. Conclusion We report the efficacy and safety of apixaban in a patient with atrial fibrillation and double mechanical heart valves for preventing prosthetic valve thrombus and systemic embolism.

CVAR-Seg: An Automated Signal Segmentation Pipeline for Conduction Velocity and Amplitude Restitution

BackgroundRate-varying S1S2 stimulation protocols can be used for restitution studies to characterize atrial substrate, ionic remodeling, and atrial fibrillation risk. Clinical restitution studies with numerous patients create large amounts of these data. Thus, an automated pipeline to evaluate clinically acquired S1S2 stimulation protocol data necessitates consistent, robust, reproducible, and precise evaluation of local activation times, electrogram amplitude, and conduction velocity. Here, we present the CVAR-Seg pipeline, developed focusing on three challenges: (i) No previous knowledge of the stimulation parameters is available, thus, arbitrary protocols are supported. (ii) The pipeline remains robust under different noise conditions. (iii) The pipeline supports segmentation of atrial activities in close temporal proximity to the stimulation artifact, which is challenging due to larger amplitude and slope of the stimulus compared to the atrial activity.Methods and ResultsThe S1 basic cycle length was estimated by time interval detection. Stimulation time windows were segmented by detecting synchronous peaks in different channels surpassing an amplitude threshold and identifying time intervals between detected stimuli. Elimination of the stimulation artifact by a matched filter allowed detection of local activation times in temporal proximity. A non-linear signal energy operator was used to segment periods of atrial activity. Geodesic and Euclidean inter electrode distances allowed approximation of conduction velocity. The automatic segmentation performance of the CVAR-Seg pipeline was evaluated on 37 synthetic datasets with decreasing signal-to-noise ratios. Noise was modeled by reconstructing the frequency spectrum of clinical noise. The pipeline retained a median local activation time error below a single sample (1 ms) for signal-to-noise ratios as low as 0 dB representing a high clinical noise level. As a proof of concept, the pipeline was tested on a CARTO case of a paroxysmal atrial fibrillation patient and yielded plausible restitution curves for conduction speed and amplitude.ConclusionThe proposed openly available CVAR-Seg pipeline promises fast, fully automated, robust, and accurate evaluations of atrial signals even with low signal-to-noise ratios. This is achieved by solving the proximity problem of stimulation and atrial activity to enable standardized evaluation without introducing human bias for large data sets.

Pulmonary vein isolation using cryoballoon technique in atrial fibrillation patient after Greenfield vena cava filter implantation

Background: Cryoballoon ablation is an established procedure for atrial fibrillation (AF). Patient with vena cava filter undergoing pulmonary vein isolation (PVI) were seldom reported.Case presentation: We describe an AF ablation technique using the second generation cryoballoon in a patient after vena cava filter implantation. All pulmonary veins were successfully isolated without complication.Conclusions: For AF patient with previously implanted vena cava filter, cryoballoon based PVI appears feasible and safe.

Abstract 16015: A Rare Cutaneous Adverse Drug Reaction With Apixaban

We report a case of apixaban-induced macular rash noticed 3 days after its initiation for atrial fibrillation. Patient denied any fever, arthralgias, myalgias or photosensitivity otherwise. On presentation, she complained of generalized pruritus with a bilateral non-blanchable macular rash on distal lower extremities and dorsum of feet. The labs showed normal cell counts, an elevated serum creatinine of 2.29mg/dl with a bland urine on microscopy. Apixaban was switched to LMWH. Serum creatinine returned to baseline with fluid therapy within 24 hours. Patient was re-challenged with apixaban that caused recurrence of generalized pruritus. It was treated successfully with diphenhydramine and prednisone. She was restarted on LMWH and rash disappeared after 3 days of stopping apixaban. She was later commenced on rivaroxaban without any complications. Several cutaneous adverse drug reactions (cADR) have been reported with direct acting oral anticoagulants (DOAC) like rivaroxaban and edoxaban but are extremely rare with apixaban. The overall reported incidence of dermatologic immune reactions with FXa inhibitors is <0.1%. Previously reported skin eruptions from apixaban include palmoplantar psoriasiform rash, leucocytoclastic vasculitis and acute generalized erythematous pustulosis. Our patient’s Naranjo scale was 7 and her rash improved after cessation of apixaban. The case illustrates a hypersensitivity reaction from apixaban that did not have cross-reactivity with other FXa inhibitors. Early recognition of cADR from this widely used DOAC can avoid potential complications. Minor reactions may be managed by switching to different DOAC therapy. Whether a cross-reactivity truly exists must be explored by validated skin testing.