Impact of a geriatric intervention based on the Comprehensive Geriatrics Assessment on avoidable admissions in older patients at risk evaluated in the Emergency Department.

OBJECTIVE: To know the impact of a geriatric intervention based on the Comprehensive Geriatric Assessment (CGA) on avoidable admissions in older patients at risk evaluated in the Emergency Department. METHOD: Prospective observational unicenter study. We included patients, from October 1, 2018 to January 31, 2020, over 75 years who were attended at the Emergency Department with a Triage Risk Screening Tool (TRST) score≥2. All patients were evaluated by a geriatrician through the CGA. The reasons for going to the Emergency room were collected and also the main intervention carried out by Geriatrics, whether admission or discharge was indicated and whether the admission was avoidable. We did a cost analysis calculating this by (bed/day×average stay×number of admissions avoided). RESULTS: We included 260 patients, 66% were women and the mean age was 86 years. 73.5% patients had polypharmacy, the mean Charlson index was 2.5 (5.6). 63.3% were independent for walking and 20.8% independent for basic activities of daily living. 59% had cognitive impairment. 91.5% lived at home. The most frequent reason for visiting the Emergency room was decline of general state in 22% and the most frequent intervention carried out by Geriatrics was assistance in the decision making process in 35.4% followed by referral to a preferential outpatient geriatric care circuit in 32.7%. Other interventions carried out by Geriatrics was assistance in clarifying diagnosis (4.2%), assistance in pharmacological adjustment (8.5%), referral to a standard geriatric care pathway (13.1%), telephone follow-up (4.2%) and/or coordination with Social Services for care planning (11.2%). Including all patients, 29.2% required hospital admission and 70.8% were discharged. 40% admissions were avoided, which meant more than 540 thousand euros saved. CONCLUSIONS: A standardized CGA coordinated by Geriatrics in older patients at risk of suffering adverse events in the Emergency room reduces admissions and costs, so it should therefore be established as a recommendation of good clinical practice.

Regulation of TSC2 lysosome translocation and mitochondrial turnover by TSC2 acetylation status.

Sirtuin1 (SIRT1) activity decreases the tuberous sclerosis complex 2 (TSC2) lysine acetylation status, inhibiting the mechanistic target of rapamycin complex 1 (mTORC1) signalling and concomitantly, activating autophagy. This study analyzes the role of TSC2 acetylation levels in its translocation to the lysosome and the mitochondrial turnover in both mouse embryonic fibroblast (MEF) and in mouse insulinoma cells (MIN6) as a model of pancreatic ß cells. Resveratrol (RESV), an activator of SIRT1 activity, promotes TSC2 deacetylation and its translocation to the lysosome, inhibiting mTORC1 activity. An improvement in mitochondrial turnover was also observed in cells treated with RESV, associated with an increase in the fissioned mitochondria, positive autophagic and mitophagic fluxes and an enhancement of mitochondrial biogenesis. This study proves that TSC2 in its deacetylated form is essential for regulating mTORC1 signalling and the maintenance of the mitochondrial quality control, which is involved in the homeostasis of pancreatic beta cells and prevents from several metabolic disorders such as Type 2 Diabetes Mellitus.

The Role of Extracellular Vesicles in Metabolic Diseases.

Extracellular vesicles represent a group of structures with the capacity to communicate with different cells and organs. This complex network of interactions can regulate multiple physiological processes in the organism. Very importantly, these processes can be altered during the appearance of different diseases including cancer, metabolic diseases, etc. In addition, these extracellular vesicles can transport different cargoes, altering the initiation of the disease, driving the progression, or even accelerating the pathogenesis. Then, we have explored the implication of these structures in different alterations such as pancreatic cancer, and in different metabolic alterations such as diabetes and its complications and non-alcoholic fatty liver disease. Finally, we have explored in more detail the communication between the liver and the pancreas. In summary, extracellular vesicles represent a very efficient system for the communication among different tissues and permit an efficient system as biomarkers of the disease, as well as being involved in the extracellular-vesicle-mediated transport of molecules, serving as a potential therapy for different diseases.

Mohs micrographic surgery in immunosuppressed vs immunocompetent patients: Results of a prospective nationwide cohort study (REGESMOHS, Spanish registry of Mohs surgery).

BACKGROUND: Immunosuppressed (IS) patients, particularly solid organ transplant recipients and those on immunosuppressive therapy, face a higher incidence and recurrence of nonmelanoma skin cancers (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Mohs micrographic surgery (MMS) is the preferred treatment for high-risk NMSC due to its high cure rate and margin examination capabilities. However, IS patients may experience more complications, such as surgical site infections, and a greater risk of recurrence, making their outcomes a subject of interest. OBJECTIVES: This study aimed to compare IS and immunocompetent (IC) patients undergoing MMS for NMSC in terms of baseline characteristics, intra- and post-surgical complications, and postoperative recurrence rates. METHODS: The study utilized data from the REGESMOHS registry, a 7-year prospective cohort study in Spain. It included 5226 patients, categorizing them into IC (5069) and IS (157) groups. IS patients included solid organ transplant recipients, those on immunosuppressive treatments, individuals with haematological tumours and HIV-positive patients. Patient data, tumour characteristics, surgical details and outcomes were collected and analysed. RESULTS: IS patients demonstrated a higher proportion of SCC, multiple synchronous tumours and tumours invading deeper structures. Complex closures, unfinished MMS and more surgical sections were observed in the IS group. Although intra-operative morbidity was higher among IS patients, this difference became non-significant when adjusted for other variables such as year of surgery, antiplatelet/anticoagulant treatment or type of closure. Importantly, IS patients had a substantially higher recurrence rate (IRR 2.79) compared to IC patients. CONCLUSIONS: This study suggests that IS patients may be at a higher risk of development of AE such as bleeding or tumour necrosis and are at a higher risk of tumour recurrence. Close follow-up and consideration of the specific characteristics of NMSC in IS patients are crucial. Further research with extended follow-up is needed to better understand the long-term outcomes for this patient group.

Long-Term Improvement of Different Types of Acne Vulgaris Using a Mild Photodynamic Therapy Protocol with BF-200 ALA Gel: A Series of Cases.

Background: Photodynamic therapy (PDT) can be a promising alternative for patients with acne vulgaris. Our study aimed to evaluate the efficacy and safety of red light photodynamic therapy with BF-200 ALA gel in the treatment of different types of acne vulgaris. Methods: We performed a retrospective, observational study of a series of 22 cases. All patients were treated according to a mild PDT protocol. After a careful wash of the affected skin areas, BF-200 ALA gel was applied to the skin in a thin layer and incubated for 30 min, followed by illumination using narrow-spectrum red light (635 nm) at a dose of 4 J/cm2. Most patients received one (36.4%), two (27.3%), or three (22.7%) PDT sessions. About a third of the patients received concomitant acne treatment with topical retinoids. Results: Patients of 25.1 ± 8.9 years suffering from papulopustular (45.5%), nodular (27.3%), and comedonal acne (27.3%) in the face were included. Irrespective of acne type or severity, 95.5% of patients had good or excellent responses to the treatment with PDT (≥60% lesion clearance). We found no association between concomitant acne medication and the favorable results achieved by PDT. Most patients reported no adverse events (72.7%), except for six patients who experienced erythema. The good efficacy results were maintained over a follow-up period of 12.5 ± 10.8 months. Conclusions: In this study, we show that PDT with BF-200 ALA gel and low light dose is an effective and long-lasting option for the treatment of different acne types.

Performance of 3 frailty scales for predicting adverse outcomes at 30 days in older patients discharged from emergency departments. / Rendimiento de tres escalas de fragilidad para predecir resultados adversos a 30 días en los pacientes mayores dados de alta en los servicios de urgencias.

OBJECTIVES: To compare the ability of 3 frailty scales (the Clinical Frailty Scale [CFS], the Functional Index - eMergency [FIM], and the Identification of Seniors at Risk [ISAR] scale) to predict adverse outcomes at 30 days in older patients discharged from hospital emergency departments (EDs). MATERIAL AND METHODS: Secondary analysis of data from the FRAIL-Madrid registry of patients aged 75 years or older who were discharged from Madrid EDs over a period of 3 months in 2018 and 2019. Frailty was defined by a CFS score over 4, a FIM score over 2, or an ISAR score over 3. The outcome variables were revisits to an ED, hospitalization, functional decline, death, and a composite variable of finding any of the previously named variables within 30 days of discharge. RESULTS: A total of 619 patients were studied. The mean (SD) age was 84 (7) years, and 59.1% were women. The CFS identified as frail a total of 339 patients (54.8%), the FIM 386 (62.4%), and the ISAR 301 (48.6%). An adverse outcome occurred within 30 days in 226 patients (36.5%): 21.5% revisited, 12.6% were hospitalized, 18.4% experienced functional decline, and 3.6% died. The areas under the receiver operating characteristic curves were as follows: CFS, 0.66 (95% CI, 0.62-0.70; P = .022); FIM, 0.67 (95% CI, 0.62-0.71; P = .021), and ISAR, 0.64 (95% CI, 0.60-0.69; P = .023). Adjusted odds ratios (aOR) showed that frailty was an independent risk factor for presenting any of the named adverse outcomes: aOR for CFS >4, 3.18 (95% CI, 2.02-5.01), P .001; aOR for FIM > 2, 3.49 (95% CI, 2.15-5.66), P .001; and aOR for ISAR >3, 2.46 (95% CI, 1.60-3.79), P .001. CONCLUSION: All 3 scales studied - the CFS, the FIM and the ISAR - are useful for identifying frail older patients at high risk of developing an adverse outcome (death, functional decline, hospitalization, or revisiting the ED) within 30 days after discharge.

OBJETIVO: Comparar la capacidad de tres escalas de fragilidad, Clinical Frailty Scale (CFS), Functional Index ­ eMergency (FIM) e Identification Senior at Risk (ISAR), para predecir resultados adversos (RA) a 30 días en los pacientes mayores dados de alta desde el servicio de urgencias hospitalario (SUH). METODO: Análisis secundario del registro FRAIL-Madrid que incluyó pacientes 75 años dados de alta de 10 SUH de Madrid durante un periodo de 3 meses entre 2018 y 2019. Se definió fragilidad como CFS 4, FIM 2 e ISAR 3. Las variables de resultado fueron revisita en urgencias, hospitalización, deterioro funcional, muerte y la variable compuesta por algún RA de los anteriores en los 30 días posteriores al alta del SUH. RESULTADOS: Se incluyeron 619 pacientes, la edad media fue de 84 años (DE 7), 59,1% eran mujeres. Hubo 339 pacientes (54,8%) identificados como frágiles en el SUH según CFS 4, 386 (62,4%) según FIM 2 y 301 (48,6%) según ISAR 3. Hubo 226 pacientes (36,5%) que presentaron algún RA a los 30 días tras el alta (21,5% revisita, 12,6% hospitalización,18,4% deterioro funcional y 3,6% muerte). El área bajo la curva (ABC) de la escala CFS fue de 0,66 (0,62-0,70; p = 0,022), de FIM 0,67 (0,62-0,71; p = 0,021) y de ISAR 0,64 (0,60-0,69; p = 0,023). La presencia de fragilidad fue un factor independiente de presentar algún RA a los 30 días tras el alta (CFS 4 ORa 3,18 [IC 95% 2,02-5,01, p 0,001], FIM 2 ORa 3,49 [IC 95% 2,15-5,66, p 0,001] e ISAR 3 ORa 2,46 [IC 95% 1,60-3,79, p 0,001]). CONCLUSIONES: Las tres escalas estudiadas ­CFS, FIM, ISAR­ son útiles y tienen una capacidad similar para identificar al paciente mayor frágil dado de alta del SUH con alto riesgo de presentar RA (muerte, deterioro funcional, hospitalización o revisita al SUH) a los 30 días.

Rendimiento de tres escalas de fragilidad para predecir resultados adversos a 30 días en los pacientes mayores dados de alta en los servicios de urgencias / Performance of 3 frailty scales for predicting adverse outcomes at 30 days in older patients discharged from emergency departments

Objetivo: Comparar la capacidad de tres escalas de fragilidad, Clinical Frailty Scale (CFS), Functional Index eMergency (FIM) e Identification Senior at Risk (ISAR), para predecir resultados adversos (RA) a 30 días en los pacientes mayores dados de alta desde el servicio de urgencias hospitalario (SUH). Método: Análisis secundario del registro FRAIL-Madrid que incluyó pacientes $ 75 años dados de alta de 10 SUH de Madrid durante un periodo de 3 meses entre 2018 y 2019. Se definió fragilidad como CFS $ 4, FIM $ 2 e ISAR $ 3. Las variables de resultado fueron revisita en urgencias, hospitalización, deterioro funcional, muerte y la variable compuesta por algún RA de los anteriores en los 30 días posteriores al alta del SUH. Resultados: Se incluyeron 619 pacientes, la edad media fue de 84 años (DE 7), 59,1% eran mujeres. Hubo 339 pacientes (54,8%) identificados como frágiles en el SUH según CFS $ 4, 386 (62,4%) según FIM $ 2 y 301 (48,6%) según ISAR $ 3. Hubo 226 pacientes (36,5%) que presentaron algún RA a los 30 días tras el alta (21,5% revisita, 12,6% hospitalización, 18,4% deterioro funcional y 3,6% muerte). El área bajo la curva (ABC) de la escala CFS fue de 0,66 (0,62-0,70; p = 0,022), de FIM 0,67 (0,62-0,71; p = 0,021) y de ISAR 0,64 (0,60-0,69; p = 0,023). La presencia de fragilidad fue un factor independiente de presentar algún RA a los 30 días tras el alta (CFS $ 4 ORa 3,18 [IC 95% 2,02-5,01, p < 0,001], FIM $ 2 ORa 3,49 [IC 95% 2,15-5,66, p < 0,001] e ISAR $ 3 ORa 2,46 [IC 95% 1,60-3,79, p < 0,001]). Conclusiones: Las tres escalas estudiadas –CFS, FIM, ISAR– son útiles y tienen una capacidad similar para identificar al paciente mayor frágil dado de alta del SUH con alto riesgo de presentar RA (muerte, deterioro funcional, hospitalización o revisita al SUH) a los 30 días. (AU)

Objective: To compare the ability of 3 frailty scales (the Clinical Frailty Scale [CFS], the Functional Index – eMergency [FIM], and the Identification of Seniors at Risk [ISAR] scale) to predict adverse outcomes at 30 days in older patients discharged from hospital emergency departments (EDs). Methods: Secondary analysis of data from the FRAIL-Madrid registry of patients aged 75 years or older who were discharged from Madrid EDs over a period of 3 months in 2018 and 2019. Frailty was defined by a CFS score over 4, a FIM score over 2, or an ISAR score over 3. The outcome variables were revisits to an ED, hospitalization, functionaldecline, death, and a composite variable of finding any of the previously named variables within 30 days of discharge. Results: A total of 619 patients were studied. The mean (SD) age was 84 (7) years, and 59.1% were women. The CFS identified as frail a total of 339 patients (54.8%), the FIM 386 (62.4%), and the ISAR 301 (48.6%). An adverse outcome occurred within 30 days in 226 patients (36.5%): 21.5% revisited, 12.6% were hospitalized, 18.4% experienced functional decline, and 3.6% died. The areas under the receiver operating characteristic curves were as follows: CFS, 0.66 (95% CI, 0.62-0.70; P = .022); FIM, 0.67 (95% CI, 0.62-0.71; P = .021), and ISAR, 0.64 (95% CI, 0.60-0.69; P = .023). Adjusted odds ratios (aOR) showed that frailty was an independent risk factor for presenting anyof the named adverse outcomes: aOR for CFS >4, 3.18 (95% CI, 2.02-5.01), P < .001; aOR for FIM > 2, 3.49 (95% CI, 2.15-5.66), P < .001; and aOR for ISAR >3, 2.46 (95% CI, 1.60-3.79), P < .001. Conclusions: All 3 scales studied — the CFS, the FIM and the ISAR — are useful for identifying frail older patients at high risk of developing an adverse outcome (death, functional decline, hospitalization, or revisiting the ED) within 30 days after discharge. (AU)

Targeting pancreatic beta cell death in type 2 diabetes by polyphenols.

Diabetes is a very complex disease which is characterized by the appearance of insulin resistance that is primarily compensated by an increase in pancreatic beta cell mass, generating hyperinsulinemia. After time, pancreatic beta cells die by apoptosis appearing in the second phase of the disease, and characterized by hypoinsulinemia. There are multiple conditions that can alter pancreatic beta cell homeostasis and viability, being the most relevant ones; ER stress, cytotoxicity by amylin, mTORC1 hyperactivity, oxidative stress, mitochondrial dysfunction, inflammation and alterations in autophagy/mitophagy flux. In addition, the possible effects that different polyphenols could exert in the modulation of these mechanisms and regulating pancreatic beta cell viability are analyzed. It is necessary a profound analysis and understanding of all the possible mechanisms involved in the control and maintenance of pancreatic beta cell viability to develop more accurate and target treatments for controlling beta cell homeostasis and preventing or even reversing type 2 diabetes mellitus.

Effect of EARLY administration of DEXamethasone in patients with COVID-19 pneumonia without acute hypoxemic respiratory failure and risk of development of acute respiratory distress syndrome (EARLY-DEX COVID-19): study protocol for a randomized controlled trial.

BACKGROUND: Corticosteroids are one of the few drugs that have shown a reduction in mortality in coronavirus disease 2019 (COVID-19). In the RECOVERY trial, the use of dexamethasone reduced 28-day mortality compared to standard care in hospitalized patients with suspected or confirmed COVID-19 requiring supplemental oxygen or invasive mechanical ventilation. Evidence has shown that 30% of COVID-19 patients with mild symptoms at presentation will progress to acute respiratory distress syndrome (ARDS), particularly patients in whom laboratory inflammatory biomarkers associated with COVID-19 disease progression are detected. We postulated that dexamethasone treatment in hospitalized patients with COVID-19 pneumonia without additional oxygen requirements and at risk of progressing to severe disease might lead to a decrease in the development of ARDS and thereby reduce death. METHODS/DESIGN: This is a multicenter, randomized, controlled, parallel, open-label trial testing dexamethasone in 252 adult patients with COVID-19 pneumonia who do not require supplementary oxygen on admission but are at risk factors for the development of ARDS. Risk for the development of ARDS is defined as levels of lactate dehydrogenase > 245 U/L, C-reactive protein > 100 mg/L, and lymphocyte count of < 0.80 × 109/L. Eligible patients will be randomly assigned to receive either dexamethasone or standard of care. Patients in the dexamethasone group will receive a dose of 6 mg once daily during 7 days. The primary outcome is a composite of the development of moderate or more severe ARDS and all-cause mortality during the 30-day period following enrolment. DISCUSSION: If our hypothesis is correct, the results of this study will provide additional insights into the management and progression of this specific subpopulation of patients with COVID-19 pneumonia without additional oxygen requirements and at risk of progressing to severe disease. TRIAL REGISTRATION: ClinicalTrials.gov NCT04836780. Registered on 8 April 2021 as EARLY-DEX COVID-19.

Experience with sonidegib in patients with advanced basal cell carcinoma: case reports.

Sonidegib is a Hedgehog signalling pathway inhibitor approved for use in patients with advanced basal cell carcinoma (BCC) not eligible for surgery or radiotherapy. This report describes clinical experience with sonidegib in two patients with locally advanced BCC (one with a tumour adjacent to the right eye and the other with a tumour associated with the left ear) and in one patient with Gorlin syndrome. Two of the patients had recurrent and intractable tumours. Treatment with sonidegib 200 mg/day led to remission in both patients with locally advanced BCC within 7 months and to a reduction in the size and number of lesions after 4 months in the patient with Gorlin syndrome. Adverse effects reported in these patients were cramps, alopecia, ageusia and weight loss, all of which were mild and consistent with the known toxicity profile for sonidegib. Sonidegib has an important role to play in the effective treatment of challenging cases of advanced BCC. In parallel, a need remains to improve management protocols for patients with advanced BCC, particularly through earlier intervention and a multidisciplinary team approach.

Cell immortalization facilitates prelamin A clearance by increasing both cell proliferation and autophagic flux.

Hutchinson-Gilford Progeria Syndrome is an ultrarare disease which is characterized by an accelerated senescence phenotype with deleterious consequences to people suffering this pathology. The production of an abnormal protein derived from lamin A, called progerin, presents a farnesylated domain, which is not eliminated by the causal mutation of the disease, and accumulates in the interior of the nucleus, provoking a disruption of nuclear membrane, chromatin organization and an altered gene expression. The mutation in these patients occurs in a single nucleotide change, which creates a de novo splicing site, producing a shorter version of the protein. Apart from this mutation, an alteration in the metalloproteinase Zmpste24, involved in the maturation of lamin A, causing a similar alteration than in progeria. However, in this case, patients accumulate a protein, called prelamin A, which generates similar alterations in the nucleus than progerin. The reduction of prelamin A protein levels facilitates the recovery of the phenotype in different mice models of the disease, reducing the aging process. Different strategies have been studied for eliminating this toxic protein. Here, we report that immortalization of primary cells derived from the Zmpste24 KO mice, facilitates prelamin A degradation by different mechanisms, being essential, the enhancing proliferative capacity that the immortalized cells present. Then, these data suggest that using different treatments for increasing proliferative capacity of these cells, potentially could have a beneficial effect, facilitating prelamin A toxicity.

Multi-Organ Crosstalk with Endocrine Pancreas: A Focus on How Gut Microbiota Shapes Pancreatic Beta-Cells.

Type 2 diabetes (T2D) results from impaired beta-cell function and insufficient beta-cell mass compensation in the setting of insulin resistance. Current therapeutic strategies focus their efforts on promoting the maintenance of functional beta-cell mass to ensure appropriate glycemic control. Thus, understanding how beta-cells communicate with metabolic and non-metabolic tissues provides a novel area for investigation and implicates the importance of inter-organ communication in the pathology of metabolic diseases such as T2D. In this review, we provide an overview of secreted factors from diverse organs and tissues that have been shown to impact beta-cell biology. Specifically, we discuss experimental and clinical evidence in support for a role of gut to beta-cell crosstalk, paying particular attention to bacteria-derived factors including short-chain fatty acids, lipopolysaccharide, and factors contained within extracellular vesicles that influence the function and/or the survival of beta cells under normal or diabetogenic conditions.

Determination of Margins for Tumor Clearance in Dermatofibrosarcoma Protuberans: A Single-Center Study of 222 Cases Treated With Modified Mohs Surgery.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an invasive skin tumor traditionally associated with very high recurrence rates when treated with conventional surgery (CS). OBJECTIVE: To calculate the minimum margin that would have been required to achieve complete tumor clearance with hypothetical CS. To analyze DFSP characteristics and Mohs micrographic surgery (MMS) effectiveness in treatment of this tumor. MATERIALS AND METHODS: Minimum margin was calculated by measuring the largest distance from the visible edge of the tumor to the edge of the surgical defect. Tumor variables (age, sex, size, time since onset, and location) were correlated with surgical variables (number of stages and minimum margin). RESULTS: We studied 222 cases of DFSP treated with MMS. A mean of 1.47 MMS stages and a mean minimum margin of 1.23 cm were required to achieve tumor clearance. Tumors on the head and neck required significantly more stages and a significantly wider margin. Tumor size was positively correlated with time to diagnosis, age, and number of MMS stages. CONCLUSION: Tumors located on the head and neck have greater subclinical extension. Tumor size was also a predictor of surgical difficulty, but time to diagnosis was not.

Developing modular training components to support home hospital digital solutions: Results of a Delphi panel.

BACKGROUND: Home hospitalization (HH) has demonstrated to be a cost-effective alternative with respect ti traditional hospitalization. Digital technologies, such as remote monitoring, have the potential to contribute to its expansion. Tailored educational content is a need to ensure patient safety during the whole admission. PURPOSE: The objective of this study was to systematically obtain consensus on patients with HH using training in the digital monitoring system. The goal of this work was to develop an adaptable modular and personalized training program for patients to support quality and safety care for HH. METHODS: The methodological approach for developing the proposed training content followed a modified Delphi technique with a multidisciplinary group of experts with significant knowledge of health informatics and HH protocols in Spain. The study comprised two rounds of training material description and gathering were completed. In Round 1, the experts received 58 predefined items obtained from the literature review and protocol selection. 20 items were rejected for different reasons and 25 new items were proposed. In Round 2, the experts selected the final items to build on the training content for every type of user and illness. RESULTS: A total of 21 experts completed rounds 1 and 2. The consensus was reached at the end of Round 2 with the inclusion of 53 items to build the training material. This included 17 treatment procedures, 4 diagnosis procedures, 22 additional support content, and 10 content features that describe how to build and deliver customized training content. CONCLUSIONS: Participants agreed on the type of content, its structure, and delivery methods to build modular training materials that support patients when they are hospitalized at home with the help of digital monitoring tools. This information can be used to create HH training programs that support new HH protocols and provide a standard for evaluating the quality of existing educational materials and programs.