Patients experiences of using a publicly avaliable mobile health application for self-care of heart failure in a real-world setting

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): University of Kentucky disseration award

Background

Publicly available patient-focused mobile health applications (mHealth apps) are being increasingly integrated into routine heart failure (HF)-related self-care. However, there is a dearth of research on patients’ experiences using mHealth apps for self-care in real-world settings. The purpose of this study was to explore patients’ experiences using a publicly available mHealth app, OnTrack to Health, for HF self-care in a real-world setting.

Method

Patient satisfaction, measured with a 5-point Likert scale and an open-ended survey were used to gather data from 23 patients with HF who were provided the OnTrack to Health app as a part of routine HF management. A content analysis of patients’ responses was conducted with qualitative software, Atlas. ti version 8.

Results

Patients (median age = 64.0 [57.0, 70.5] years, 73.9% (n = 17) male) used OnTrack to Health for a median duration of 164.0 [ 51.2, 639.9] days before the survey. All patients reported excellent experiences related to app use and would recommend the app to other patients with HF. Four themes emerged from the responses to the open-ended questions: (1) perceived benefits (simplified self-care tasks, improved adherence to medications, enhanced communication and connection with healthcare providers, facilitated HF symptoms monitoring, improved HF knowledge, decreased hospitalization, and provided assurance of safety); (2) barriers (challenges of abandoning previous self-care strategies); (3) facilitators (perceived ease of use, availability of technical support); (4) suggested improvements (streamlining data entry, integration of apps with an electronic medical record, and personalization of app features).

Conclusion

Patients were satisfied with using mHealth apps for self-care. They perceived apps as a valuable tool for improving self-care ability and decreasing hospitalization rates. Personalization of app features and integration of mHealth apps with electronic health records are essential to sustain high-quality patient experiences related to app use for self-care.

Does perceived stress mediate the relationship between financial status, depression, and anxiety in caregivers at risk for cardiovascular disease (CVD)?

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Institutes of Health National Institute of Nursing Research

Background/Introduction

Caregivers are at high risk of anxiety and depression, and caregiver mental health is linked to higher CVD risk in caregivers over their non-caregiving peers. Most research focuses on caregiver burden as a primary cause for caregiver’s emotional distress, such as anxiety and depression. Other stressors like financial burden are less emphasized, despite widespread documentation of financial burden as a key social determinant of health. We hypothesize financial status predicts anxiety and depression through perceived stress.

Purpose

To identify the relationship between financial status and caregiver anxiety and depression and determine if it is mediated by perceived stress.

Methods

We analyzed cross-sectional data from the Rural Intervention for Caregiver’s Heart Health study. Anxiety was assessed using the Brief Symptom Inventory – Anxiety subscale (range 0 -3.5) and depression was assessed by the Patient Health Questionnaire –9 (range 0 - 27). Financial status was measured with one item that asked participants to rank their financial situation by level of comfort (not enough to make ends meet, enough to make ends meet, and comfortable), and perceived stress measured with Cohen’s Perceived Stress Scale – 4. Analysis was performed separately for the two mental health outcomes using OLS regression and, to test mediation, the PROCESS macro for SPSS and the bootstrapping procedure with 5,000 samples. We included age, gender, marital status, number of people in the household, body mass index, smoking status, and caregiver burden as covariates.

Results

Of the 287 participants, average age was 54 ± 13; 76% were female, 95.8% were Caucasian, and 70.4% were married. Controlling for covariates, caregivers with not enough to make ends meet reported substantially greater depressive symptoms (b=2.22, 95% CI = 0.48 – 3.96) and marginally greater anxiety (b=0.23, 95% CI = -0.02 – 0.47) compared to caregivers who were financially comfortable. These associations were not mediated by perceived stress as hypothesized.

Conclusions

Among caregivers who are at risk for CVD, financial status was important in reporting both depression and to a lesser extent, anxiety however perceived stress does not mediate this relationship. This is interesting as perceived stress is often a target for interventions that focus on reducing depression and anxiety in this population however our analysis emphasizes the importance of financial status alone. When designing interventions to reduce the CVD risk factors of anxiety and depression, more attention should be paid to relieving financial burden.

Linking salt preference to enjoyment of low sodium diet in patients with heart failure

Background

Preference for salty foods is linked to dietary sodium intake. Increased salt preference is a barrier to low sodium diet (LSD) adherence due to perceived poor taste. Although patients with heart failure (HF) are advised to follow a LSD, the adherence remains poor. Understanding the relationship among attitudes, subjective norms (individuals' beliefs about how much they follow the advice of respected others), and perceived control for following a LSD, salt preference, and LSD enjoyment will help in designing interventions to increase adherence in patients with HF.

Purpose

The purpose of this study was to examine whether attitudes toward following a LSD, subjective norms about LSD, and perceived behavioral control for following a LSD mediated the association between salt preference and enjoyment of a LSD in patients with HF.

Methods

In this cross-sectional study, outpatients with HF completed the Dietary Sodium Restriction Questionnaire (DSRQ) based on the Theory of Planned Behavior, and rated salt preference and enjoyment of a LSD on a scale from 0 to 10 with 10 indicating the highest salt preference and enjoyment of LSD. Parallel mediation analyses were conducted using the PROCESS macro program in SPSS with 5,000 bootstrap samples controlling for age and gender. Three subscales of the DSRQ (i.e., attitude, subjective norms, and perceived behavioral control) were used as mediators.

Results

A sample of 117 patients with HF (65% male, mean age = 61.2±14.3, range 27 to 94, 82% white) completed the study. The mean salt preference rating was 5.26 (SD=2.7), and the LSD enjoyment rating was 4.56 (SD=2.5). Salt preference was not directly associated with LSD enjoyment (direct effect = −0.0506, 95% CI: [−0.2394, 0.1381]). There was a significant indirect effect of salt preference on the enjoyment of LSD through perceived behavioral control (indirect effect = −0.1178, 95% CI: [−0.0321, 0.0446]) (Figure 1). Patients with a high salt preference were more likely to have low levels of LSD enjoyment through the mediator of having low levels of perceived behavioral control over following a LSD. Subjective norms and attitudes toward LSD were not significant mediators of the association between salt preference and LSD enjoyment.

Conclusion

High preference for salty food decreased perceived behavioral control of LSD, which reduced enjoyment of LSD in patients with HF. Salt preference and perceived behavioral control in LSD are behavioral barriers in hedonic shift in LSD enjoyment. The findings suggest that intervention to promote LSD adherence should include strategies to increase perceived behavioral control in eating LSD and decreasing salt preference.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health in the USA

Association of age and dietary sodium intake in patients with heart failure: testing mediating effects of preference for salt and enjoyment of sodium-restricted diet

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): National Institutes of Health (NIH)

Background

The poor taste foods in a low sodium diet and patients’ preferences for salty foods are known barriers to sodium restricted diet (SRD) adherence. Older adults may experience less enjoyment of SRD due to decreased sense of taste. However, little is known about how age is associated with sodium intake, preference for salt, and enjoyment of SRD in patients with heart failure (HF).

Purpose

The purpose of this study was to examine effect of age on dietary sodium intake through their preference for salt and enjoyment of SRD in patients with HF.

Methods

 In this cross-sectional study, we used baseline data from participants in a randomized controlled trial of a SRD intervention for patients with HF and their caregivers. Patients were asked to collect 24-hour urine to measure dietary sodium intake. Preference for salty food and enjoyment of SRD were assessed using a question on an 11-point numeric scale (range 0 to 10). Parallel mediation analyses were conducted using the PROCESS macro program in SPSS with 5,000 bootstrap samples.

Results

A total of 136 patients with HF (64% male, mean age = 60.3 ± 14.4, range 27 to 90, 80.1% white) had a mean 24-hr urine sodium of 4320mg (SD = 2053, range: 1553 mg – 11495 mg) with most (71%) having a 24-hr urine sodium > 3000mg. The mean preference for salty food was 5.3 (SD = 2.8) on a scale from 0 to 10 with 10 indicating greater preference and enjoyment of SRD was 4.4 (SD = 2.5) on the same scale. Age was significantly associated with sodium intake in that older patients were more likely to eat less sodium (effect= -40.3236, 95% CI= [-63.7151, -16.9321]). The indirect effects of age on sodium intake through preference of salty food (effect= .7033, 95% CI = [-2.3361, 4.5357]) and enjoyment of SRD (effect = -.0271, 95% CI = [ -3.2736, 2.2213]) were not significant, indicating that these factors did not mediate the relationship between age and dietary sodium consumption. When we controlled gender, education, and ethnicity, age was also associated with sodium intake, but the two indirect effects were not significant.

Conclusion

Although most patients consumed foods high in sodium, older patients were more likely to consume foods lower in salt. However, contrary to what we expected, preference for salty foods and enjoyment of SRD did not play mediator roles in the association of age with salt consumption. The findings suggest that older adults may need different types of intervention to promote adherence than younger patients. Further research is needed to explore other factors related to SRD (e.g., efficacy of SRD or perceived control of diet behaviors) that affect sodium intake in patients with HF.

Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for youth with Type 2 diabetes: reliability and validity

AIM

To test the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module originally developed in Type 1 diabetes in youth with Type 2 diabetes.

METHODS

The PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were administered in a field test study to 100 young people aged 9-25 years with Type 2 diabetes. Factor analysis was conducted to determine the factor structure of the items.

RESULTS

The 15-item Diabetes Symptoms Summary Score and 12-item Type 2-specific Diabetes Management Summary Score were empirically derived through factor analysis. The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores showed acceptable to excellent reliability across the age groups tested (α = 0.85-0.94). The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores evidenced construct validity through large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.67 and 0.57, respectively). HbA_1c was correlated with the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores (r = -0.13 and -0.22). Minimal clinically important difference (MCID) scores were 5.91 and 7.39 for the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores.

CONCLUSIONS

The PedsQL 3.2 Diabetes Module Diabetes Symptoms Summary Score and Type 2-specific Diabetes Management Summary Score exhibited satisfactory measurement properties for use as youth self-reported diabetes symptoms and diabetes management outcomes for clinical research and clinical practice for young people with Type 2 diabetes.

Maternal blood-pressure trends throughout pregnancy and development of pre-eclampsia in women receiving first-trimester aspirin prophylaxis

OBJECTIVES

To study women who initiated aspirin in the first trimester for high risk of pre-eclampsia, and compare blood-pressure trends throughout pregnancy between those with normal outcome and those who subsequently developed pre-eclampsia.

METHODS

Women were enrolled into a prospective observational study at 9-14 weeks' gestation. This was a secondary analysis of those who started daily doses of 81 mg of aspirin before 16 weeks for increased risk of pre-eclampsia based on maternal history and bilateral uterine artery notching. Enrollment characteristics and blood-pressure measurements throughout gestation were compared between women who did and those who did not develop pre-eclampsia.

RESULTS

Of the 237 women who initiated first-trimester aspirin prophylaxis, 29 (12.2%) developed pre-eclampsia. A total of 2881 serial blood-pressure measurements obtained between 4 and 41 weeks' gestation (747 in the first trimester, 1008 in the second and 1126 in the third) showed that women with pre-eclampsia started pregnancy with higher blood pressure and maintained this trend despite taking aspirin (mean arterial blood pressure in women with pre-eclampsia = (0.13 × gestational age (weeks)) + 93.63, vs (0.11 × gestational age (weeks)) + 82.61 in those without; P < 0.005). First-trimester diastolic and second-trimester systolic blood pressure were independent risk factors for pre-eclampsia (β = 1.087 and 1.050, respectively; r²  = 0.24, P < 0.0001). When average first-trimester diastolic blood pressure was >74 mmHg, the odds ratio for pre-eclampsia was 6.5 (95% CI, 2.8-15.1; P < 0.001) and that for pre-eclampsia before 34 weeks was 14.6 (95% CI, 1.72-123.5; P = 0.004). If, in addition, average second-trimester systolic blood pressure was >125 mmHg, the odds ratio for pre-eclampsia was 9.4 (95% CI, 4.1-22.4; P < 0.001) and that for early-onset disease was 34.6 (95% CI, 4.1-296.4; P = 0.004).

CONCLUSION

In women treated with prophylactic aspirin from the first trimester, those who develop pre-eclampsia have significantly and sustained higher blood pressure from the onset of pregnancy compared with those who do not develop pre-eclampsia. This raises the possibility that mildly elevated blood pressure predisposes women to abnormal placentation, which then acts synergistically with elevated blood pressure to predispose such women to pre-eclampsia to a degree that is incompletely mitigated by aspirin. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Fetal blood-gas values during fetoscopic myelomeningocele repair performed under carbon dioxide insufflation

Fetoscopic myelomeningocele (MMC) repair is performed using intrauterine carbon dioxide (CO₂ ) insufflation. Sheep experiments have shown that CO₂ insufflation is associated with significant fetal acidemia; however, corresponding data for human pregnancy are not available. We performed umbilical venous cord blood sampling in three patients during fetoscopic MMC repair at 25 + 1, 25 + 3 and 24 + 0 weeks' gestation, respectively. Fetal venous pH at the beginning of CO₂ insufflation was 7.36, 7.46 and 7.37, respectively in the three fetuses, and repeat values were 7.28, 7.35 and 7.36 after 181, 159 and 149 min, respectively. The partial pressure of oxygen and CO₂ was maintained in the normal range during these times, and pH decrease was less in Patient 3 who received humidified CO₂ insufflation. Our observations suggest that, in contrast to sheep experiments, CO₂ insufflation during fetoscopic myelomeningocele repair does not cause acidemia in human fetuses. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Increasing Incidence of Thyroid Nodules and Thyroid Cancer: Does Increased Detection of a Subclinical Reservoir Justify the Associated Anxiety and Treatment?

The incidence of thyroid cancer has been increasing over the last few decades, and it is subject to debate regarding whether the incidence is reflective of better diagnostic techniques and therefore better detection or if it is a reflection of a true increase in incidence. This increase in incidence has been most clearly manifested by an exponential increase in the diagnosis of micropapillary thyroid carcinomas. This article reviews the diagnosis of thyroid cancers, the dilemmas facing clinicians in the management of these micropapillary thyroid carcinomas, and the advances in molecular diagnostics that are being used to assist in the decision-making process. We consider the possibility of overtreatment of a relatively indolent disease and propose a less aggressive management plan in the appropriate clinical scenario.

Angiofibroma in a cockatiel (Nymphicus hollandicus)

Human angiofibromas are rare and arise typically in the nasopharynx. In veterinary medicine they have only been described in the dog. Microscopically, angiofibromas consist of irregular groups of blood vessels within a stroma of connective tissue, with oedema and secondary inflammation often present. A cockatiel (Nymphicus hollandicus) was presented with an oral mass that consisted of aggregates of blood vessels surrounded by a connective tissue stroma, with the presence of oedema and secondary inflammation. Tumours of the oral cavity are uncommon in birds and to the authors' knowledge this is the first case of avian angiofibroma.

N-acetyl-L-aspartyl-L-glutamate peptidase-like 2 is overexpressed in cancer and promotes a pro-migratory and pro-metastatic phenotype

N-acetyl-L-aspartyl-L-glutamate peptidase-like 2 (NAALADL2) is a member of the glutamate carboxypeptidase II family, best characterized by prostate-specific membrane antigen (PSMA/NAALAD1). Using immunohistochemistry (IHC), we have shown overexpression of NAALADL2 in colon and prostate tumours when compared with benign tissue. In prostate cancer, NAALADL2 expression was associated with stage and Grade, as well as circulating mRNA levels of the NAALADL2 gene. Overexpression of NAALADL2 was shown to predict poor survival following radical prostatectomy. In contrast to PSMA/NAALAD1, NAALADL2 was localized at the basal cell surface where it promotes adhesion to extracellular matrix proteins. Using stable knockdown and overexpression cell lines, we have demonstrated NAALADL2-dependent changes in cell migration, invasion and colony-forming potential. Expression arrays of the knockdown and overexpression cell lines have identified nine genes that co-expressed with NAALADL2, which included membrane proteins and genes known to be androgen regulated, including the prostate cancer biomarkers AGR2 and SPON2. Androgen regulation was confirmed in a number of these genes, although NAALADL2 itself was not found to be androgen regulated. NAALADL2 was also found to regulate levels of Ser133 phosphorylated C-AMP-binding protein (CREB), a master regulator of a number of cellular processes involved in cancer development and progression. In combination, these data suggest that changes in expression of NAALADL2 can impact upon a number of pro-oncogenic pathways and processes, making it a useful biomarker for both diagnosis and prognosis.

Strain-specific antiviral activity of iminosugars against human influenza A viruses

Objectives

Drugs that target host cell processes can be employed to complement drugs that specifically target viruses, and iminosugar compounds that inhibit host α-glucosidases have been reported to show antiviral activity against multiple viruses. Here the effect and mechanism of two iminosugar α-glucosidase inhibitors, N-butyl-deoxynojirimycin (NB-DNJ) and N-nonyl-deoxynojirimycin (NN-DNJ), on human influenza A viruses was examined.

Methods

The viruses examined were a recently circulating seasonal influenza A(H3N2) virus strain A/Brisbane/10/2007, an older H3N2 strain A/Udorn/307/72, and A/Lviv/N6/2009, a strain representative of the currently circulating pandemic influenza A(H1N1)pdm09 virus.

Results

The inhibitors had the strongest effect on Brisbane/10 and NN-DNJ was more potent than NB-DNJ. Both compounds showed antiviral activity in cell culture against three human influenza A viruses in a strain-specific manner. Consistent with its action as an α-glucosidase inhibitor, NN-DNJ treatment resulted in an altered glycan processing of influenza haemagglutinin (HA) and neuraminidase (NA), confirmed by MS. NN-DNJ treatment was found to reduce the cell surface expression of the H3 subtype HA. The level of sialidase activity of NA was reduced in infected cells, but the addition of exogenous sialidase to the cells did not complement the NN-DNJ-mediated inhibition of virus replication. Using reassortant viruses, the drug susceptibility profile was determined to correlate with the origin of the HA.

Conclusions

NN-DNJ inhibits influenza A virus replication in a strain-specific manner that is dependent on the HA.

Visceral smooth muscle α-actin deficiency associated with chronic intestinal pseudo-obstruction in a Bengal cat (Felis catus x Prionailurus bengalensis)

An adult Bengal cat (Felis catus × Prionailurus bengalensis) with a prolonged history of partial anorexia, regurgitation, and weight loss and a clinical, radiographic, and ultrasonographic diagnosis of persistent megaesophagus and gastrointestinal ileus was submitted for necropsy. The intestinal tract was diffusely distended by gas and fluid with appreciable loss of muscle tone and an absence of luminal obstruction, consistent with the clinical history of chronic intestinal pseudo-obstruction. Histologically, the autonomic nervous system was intact, but the smooth muscle within the gastrointestinal wall exhibited a marked basophilia that was most pronounced in the jejunum. Immunohistochemistry for neurofilament, synaptophysin, CD117, and desmin demonstrated that the number of myenteric ganglia, number of interstitial cells, and leiomyocyte desmin content were similar when compared with the unaffected age- and species-matched control. Immunohistochemistry for smooth muscle α-actin demonstrated a striking loss of immunoreactivity, predominantly in the circular layer of the jejunum, that corresponded with the tinctorial change in leiomyocytes. Transmission electron microscopy revealed loss of myofibrils, loss of organelle polarity, and significantly larger central mitochondria (megamitochondria) in affected leiomyocytes, as well as nonspecific degenerative changes. Although the presence of a primary leiomyopathy and a causal relationship could not be confirmed in this case, leiomyopathies are considered a cause of chronic intestinal pseudo-obstruction in human medicine, and loss of smooth muscle α-actin immunoreactivity is one recognized marker for intestinal dysmotility.