Do families have moderating or mediating effects on early health inequalities? A scoping review

Background

During early childhood, families have a crucial impact on children's health behaviour, health, and development (bhd). However, a family's socioeconomic position (SEP) determines both the parental behaviour, living conditions, and child health. To understand how family characteristics may influence the development of health inequalities, this scoping review synthesised research on their mediating and moderating effects.

Methods

The review followed the guidelines of the PRISMA Extension for Scoping Reviews. The search included German and English peer-reviewed articles published between January 1st, 2000 and December 19th, 2019. The search in PubMed, PsycINFO, and Scopus used both free text terms in the title/abstract and index terms within linked keyword blocks: (1) family characteristics, (2) inequalities, (3) income, education, occupation, (4) bhd, (5) newborn, infant, toddler, preschooler. Two researchers independently examined eligibility for inclusion in two rounds (title/abstract; full-text).

Results

Of 7,089 articles identified, ten sources were included that studied family characteristics and health inequalities among 0-6 years olds. Parental rules, stress, and screentime, and TV in bedroom showed mediating effects on inequalities in behaviour problems or children's screentime. Families' negativity, single parenthood, and the number of children in the household moderated differences in impairment, health, behaviour problems, development or breastfeeding initiation.

Conclusions

The effect of family characteristics on early health inequalities has been sparsely investigated. The evidence supported models of family stress and investment. Further research is needed to comprehensively understand this association.

Key messages

Family characteristics contribute to health inequalities. Taking families’ stress and investment into account could improve targeted prevention efforts aimed at reducing health inequalities.

ADP-receptor antagonists in patients with acute myocardial infarction complicated by cardiogenic shock: a pooled IABP-SHOCK II and CULPRIT-SHOCK trial sub-analysis

Purpose

The purpose of this pooled analysis is to compare the clinical outcome of patients with acute myocardial infarction complicated by cardiogenic shock treated with either clopidogrel or the newer, more potent ADP-receptor antagonists prasugrel or ticagrelor. Patients from the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) and Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial were included.

Methods and results

For the current analysis, the primary endpoint was 1-year mortality and the secondary safety endpoint was moderate or severe bleedings until hospital discharge with respect to three different ADP-receptor antagonists. Eight hundred fifty-six patients were eligible for analysis. Of these, five hundred seven patients (59.2%) received clopidogrel, one hundred seventy-eight patients (20.8%) prasugrel and one hundred seventy-one patients (20.0%) ticagrelor as acute antiplatelet therapy. The adjusted rate of mortality after 1-year did not differ between prasugrel and clopidogrel (hazard ratio [HR]: 0.81, 95% confidence interval [CI] 0.60–1.09, padj=0.17) or between ticagrelor and clopidogrel treated patients (HR: 0.86, 95% CI 0.65–1.15, padj=0.31). In-hospital bleeding events were significantly less frequent in patients treated with ticagrelor vs. clopidogrel (HR: 0.37, 95% CI 0.20–0.69, padj=0.002) and not different in patients treated with prasugrel vs. clopidogrel (HR: 0.73, 95% CI 0.43–1.24, padj=0.24), see Table 1.

Conclusion

This pooled sub-analysis is the largest analysis on safety and efficacy of three oral ADP-receptor antagonists and shows that an acute therapy with either clopidogrel, prasugrel or ticagrelor is no predictor of 1-year mortality. Treatment with ticagrelor seems to be associated with less in-hospital moderate and severe bleeding events in comparison to clopidogrel.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): German Heart FoundationEuropean Union 7th Framework Program

Interventional treatment of para-valvular leaks after prosthetic valve replacement with plug devices -first results from a prospective registry

Background

Interventional closure of symptomatic paravalvular leaks (PVL) after surgical or interventional valve replacement by plug implantation has emerged as an alternative to surgical correction, which is associated with high morbitity and mortality rates. To date, data on procedural efficacy and clinical outcome after transcatheter closure with plugs is sparse, especially prospective data are missing.

Methods

We analysed data from a multi-center prospective registry on interventional PVL closure with plug devices.

Results

Between 06/2012 and 04/2020 55 interventions were performed with different numbers of plugs (maximal 4) in 51 patients at 9 hospitals. Interventions were performed in 15 women and 36 men at high surgical risk for repeat surgery. 48% of procedures were performed for mitral PVLs and 52% procedures were performed for aortic PVLs. Mean age of the population treated was 69±13 years and mean log. Euro-Score I was 22.5±14.2%. Patients were treated by implantation of Amplatzer Vascular Plug III (80%) and Occlutec occluders (9%). Aortic PVLs were treated using a retrograde transfemoral access, mitral PVLs were treated using either a transseptal (25/26) or transapical access (1/26) with 3-dimensional transesophageal echocardiographic and fluoroscopic guidance. Indication for PVL closure was previous surgery (n=39), high-risk patients (n=24), heart failure (n=22), age (n=20) and hemolysis (n=12). 40 patients had NYHA class III/IV at admission. Interventional closure of PVL was completely successful in 40 procedures (73%), partially successful in 7 procedures (13%) and failed in 7 procedures (13%). NYHA class I/II after PVL closure was achieved in 75% patients. However, 8 out of 12 patients with hemolysis as indication still hemolyzed at discharge. Complications occurred in 16% of patients. In-hospital mortality rate was 4% of procedures (2/51). After hospital discharge no death occurred during 30-day follow-up.

Conclusions

In this prospective interventional PVL registry inclusion rate was lower than expected. There was an equal distribution of aortal and mitral PVLs. At least partial success could be achieved in 86% of patients, with significant functional improvement in most patients. In this high risk population hospital mortaliy was low (4%), indicating that interventional PVL treatment should be the treatment of choice, when discussed by a heart team.

Funding Acknowledgement

Type of funding sources: None.

Comparison of risk prediction models in infarct-related cardiogenic shock

Background

Several prediction models have been developed to allow accurate risk assessment and provide better treatment guidance in patients with infarct-related cardiogenic shock (CS). However, comparative data between these models are still scarce.

Objectives

To externally validate different risk prediction models in infarct-related CS and compare their predictive value in the early clinical course.

Methods

The Simplified Acute Physiology Score (SAPS)-II Score, the CardShock score, the IABP-SHOCK II score and the Society for Cardiovascular Angiography and Intervention (SCAI) classification were each externally validated in a total of 1055 patients with infarct-related CS enrolled into the randomized CULPRIT-SHOCK trial or the corresponding registry. Discriminative power was assessed by comparing area under the curves (AUC) in case of continuous scores.

Results

In direct comparison of the continuous scores in a total of 161 patients, the IABP-SHOCK II score revealed best discrimination (AUC=0.74), followed by the CardShock score (AUC=0.69) and the SAPS-II score, giving only moderate discrimination (AUC=0.63). All of the three scores revealed acceptable calibration by Hosmer-Lemeshow test. The SCAI classification as a categorical predictive model displayed good prognostic assessment for the highest risk group (stage E), but showed poor discrimination between stages C and D with respect to short-term-mortality.

Conclusion

Based on the present findings, the IABP-SHOCK II score appears to be the most suitable of the examined models for immediate risk prediction in infarct-related CS. Prospective evaluation of the models, further modification or even development of new scores might be necessary to reach higher levels of discrimination.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, German Centre for Cardiovascular Research Survival probabilities continuous scoresSurvival probabilities SCAI

EU-CaRE study: Could exercise-based cardiac telerehabilitation also be cost-effective in elderly?

BACKGROUND

The role of cardiac rehabilitation (CR) is well established in the secondary prevention of ischemic heart disease. Unfortunately, the participation rates across Europe remain low, especially in elderly. The EU-CaRE RCT investigated the effectiveness of a home-based mobile CR programme in elderly patients that were not willing to participate in centre-based CR. The initial study concluded that a 6-month home-based mobile CR programme was safe and beneficial in improving VO₂peak when compared with no CR.

OBJECTIVE

To assess whether a 6-month guided mobile CR programme is a cost-effective therapy for elderly patients who decline participation in CR.

METHODS

Patients were enrolled in a multicentre randomised clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. A total of 179 patients who declined participation in centre-based CR and met the inclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programs in the Elderly trial. The data of patients (n = 17) that were lost in follow-up were excluded from this analysis. The intervention (n = 79) consisted of 6 months of mobile CR programme with telemonitoring, and coaching based on motivational interviewing to stimulate patients to reach exercise goals. Control patients did not receive any form of CR throughout the study period. The costs considered for the cost-effectiveness analysis of the RCT are direct costs 1) of the mobile CR programme, and 2) of the care utilisation recorded during the observation time from randomisation to the end of the study. Costs and outcomes (utilities) were compared by calculation of the incremental cost-effectiveness ratio.

RESULTS

The healthcare utilisation costs (P = 0.802) were not significantly different between the two groups. However, the total costs were significantly higher in the intervention group (P = 0.040). The incremental cost-effectiveness ratio for the primary endpoint VO₂peak at 6 months was €1085 per 1-unit [ml/kg/min] improvement in change VO₂peak and at 12 months it was €1103 per 1 unit [ml/kg/min] improvement in change VO2peak. Big differences in the incremental cost-effectiveness ratios for the primary endpoint VO₂peak at 6 months and 12 months were present between the adherent participants and the non-adherent participants.

CONCLUSION

From a health-economic point of view the home-based mobile CR programme is an effective and cost-effective alternative for elderly cardiac patients who are not willing to participate in a regular rehabilitation programme to improve cardiorespiratory fitness. The change of QoL between the mobile CR was similar for both groups. Adherence to the mobile CR programme plays a significant role in the cost-effectiveness of the intervention. Future research should focus on the determinants of adherence, on increasing the adherence of patients and the implementation of comprehensive home-based mobile CR programmes in standard care.

Monte Carlo simulations of weak polyampholyte microgels: pH-dependence of conformation and ionization

We performed Metropolis Monte Carlo simulations to investigate the impact of varying acid and base dissociation constants on the pH-dependent ionization and conformation of weak polyampholyte microgels under salt-free conditions and under explicit consideration of the chemical ionization equilibria of the acidic and basic groups and their electrostatic interaction. Irrespective of their relative acid and base dissociation constant, all of the microgels undergo a pH-dependent charge reversal from positive to negative with a neutral charge at the isoelectric point. This charge reversal is accompanied by a U-shaped swelling transition of the microgels with a minimum of their size at the point of charge neutrality. The width of the U-shaped swelling transition, however, is found to depend on the chosen relative acid and base dissociation constants through which the extent of the favorable electrostatic intramolecular interaction of the ionized acidic and basic groups is altered. The pH-dependent swelling transition of the microgels is found to become broader, the stronger the intramolecular electrostatic interaction of the oppositely charged ionized species is. In addition, the intramolecular charge compensation of the acidic and basic groups of the microgels allows their counterions to abandon the microgel and the associated gain in translational entropy further amplifies the broadening of the pH-dependent swelling transition. The analysis of the radial ionization profiles of the acidic and basic groups of the differently composed microgels reveals a variety of radial ionization patterns with a dependence on the overall charge of the microgels.

COMPARATIVE ASSESSMENT OF THE STATUS OF PERI-IMPLANT AND PARODONTAL TISSUES

One of the controversial issues of modern dentistry is the assessment of how parodontitis arises or aggravates in the area of own teeth the severity of its course after installing orthopedic structures with support on dental implants affects the state of peri-implant tissues. Using clinical, R-genological, molecular genetic methods of research, to give a comparative assessment of the condition of parodontal tissues of own teeth and peri-implant tissues in patients who have been using fixed orthopedic constructions with support on dental implants for the treatment of partial secondary adentia for more than 5 years. To achieve this goal, we formed two groups of patients. Group 1 consisted of 34 patients (19 female and 15 male) who did not have secondary biological complications of dental implantation. The average age of patients in this group was (m. 61.3±7.8 years, f. 58.4±8.1 years) the average service life of orthopedic structures with support on dental implants was 8.3±2.3 years. The 2nd group consisted of 27 patients (15 f., 12 m.) who, on the basis of a clinical examination, R-gene examination, were diagnosed with: peri-implantitis in the area of one or more implants serving as a support for a fixed orthopedic structure. The average age of patients in this group was (m. 63±8.2 years, F 59.6±7.7 years). The average service life of an orthopedic construction was 8.8±2.5 years. In a comparative analysis of the species composition of microorganisms in the tissues of pathological parodontal pockets and peri-implant sulcus, the quantitative and species composition of microorganisms is identical in 75% of the examined patients and is individual for each patient. Based on a clinical examination, analysis of panoramic R-graphs data, parodontal diagnosis was made to patients of the 1st and 2nd groups. Based on a comparative assessment of the status of parodontal peri-implant tissues, their microbial contamination, in patients who successfully used fixed orthopedic constructions supported by dental implants to replace partial dentition defects for more than 5 years, it was found that the resistance of microbial invasion of peri-implant tissues is higher than the parodontal tissues of own teeth.

Effects of a Brief Web-Based "Social Norms"-Intervention on Alcohol, Tobacco and Cannabis Use Among German University Students: Results of a Cluster-Controlled Trial Conducted at Eight Universities

Background and Aim: "Social norms" (SN)-interventions are aimed at changing existing misperceptions regarding peer substance use by providing feedback on actual norms, thereby affecting personal substance use. It is unknown whether SN-intervention effects previously demonstrated in US students can be replicated in German students. The aim of the INSIST-study was to examine the effects of a web-based SN-intervention on substance use. Design: Cluster-controlled trial. Setting: Eight Universities in Germany. Participants and Measurements: Students were recruited at four intervention vs. four delayed intervention control Universities. 4,463 students completed baseline, 1,255 students (59% female) completed both baseline and 5-months follow-up web-based surveys on personal and perceived peer substance use. Intervention participants received feedback contrasting personal and perceived peer use with previously assessed use and perceptions of same-sex, same-university peers. Intervention effects were assessed via multivariable mixed logistic regression models. Findings: Relative to controls, reception of SN-feedback was associated with higher odds for decreased alcohol use (OR: 1.91, 95% CI 1.42-2.56). This effect was most pronounced in students overestimating peer use at baseline and under or accurately estimating it at follow-up (OR: 6.28, 95% CI 2.00-19.8). The OR was 1.33 (95% CI 0.67-2.65) for decreased cannabis use in students at intervention Universities and was statistically significant at 1.70 (95% CI 1.13-2.55) when contrasting unchanged and decreased with increased use. Regarding tobacco use and episodes of drunkenness, no intervention effects were found. Conclusions: This study was the first cluster-controlled trial suggesting beneficial effects of web-based SN-intervention on alcohol and cannabis use in a large sample of German University students. Clinical Trial Registration: The trial registration number of the INSIST-study is DRKS00007635 at the "German Clinical Trials Register."

Does a lower self-concept contribute to mental health disparities of diverse immigrant youth from middle childhood to late adolescence?

BACKGROUND

Three out of ten children in Germany have immigrant backgrounds and this proportion is expected to further increase in subsequent years. While immigrant youth have been found more vulnerable to developing symptoms of depression and anxiety, the underlying mechanisms of how such disparities unfold during youth development are still understudied. Some previous research has found that immigrant youth are at risk of experiencing a less positive self-concept compared to non-immigrant youth. We investigated whether the self-concept mediates mental health disparities and explored variability in such associations from middle childhood to late adolescence.

METHODS

Overall 1839 children and adolescents aged 6-21 years (M = 14.05 years, SD = 3.03, 49.8% female, n = 782 with immigrant status) participated in a cross-sectional self-report survey in classroom settings using scales from the Beck Youth Inventories II (Beck et al. in Beck Youth Inventories - Second Edition, Psychological Corporation, San Antonio, 2005) to assess self-concept and symptoms of depression and anxiety. Links between immigrant status, age, self-concept and symptom levels of depression as well as anxiety were examined using hierarchical regression and moderated mediation models.

RESULTS

Immigrant youth reported higher symptom levels of depression and anxiety than their non-immigrant peers but did not differ in their self-concepts. Hypothesized moderated mediation models were not fully supported and self-concept neither mediated the link between immigrant status and depression nor immigrant status and anxiety. However, self-concept was a significant predictor for symptom levels of depression as well as anxiety, with stronger associations in adolescents.

CONCLUSIONS

Our study substantiates previous findings that immigrant youth in Germany have overall increased symptom levels of depression and anxiety compared to non-immigrant youth. Our study however does not support that immigrant youth have a more negative self-concept and that the self-concept mediates such internalizing mental health disparities. Findings match previous evidence that developing a positive attitude towards the self is linked to better mental health. Beyond that, our findings suggest that mental health interventions addressing the self-concept could be especially relevant when targeting adolescents. Further research is needed to deepen the understanding of the mediating processes between migration status and mental health variables.

Nutrition education in medical schools (NEMS) project: Joining ESPEN and university point of view

BACKGROUND & AIMS

Nutrition education is not well represented in the medical curriculum. The aim of this original paper was to describe the Nutrition Education in Medical Schools (NEMS) Project of the European Society for Clinical Nutrition and Metabolism (ESPEN).

METHODS

On 19 January 2020, a meeting was held on this topic that was attended by 51 delegates (27 council members) from 34 countries, and 13 European University representatives.

RESULTS

This article includes the contents of the meeting that concluded with the signing of the Manifesto for the Implementation of Nutrition Education in the Undergraduate Medical Curriculum.

CONCLUSION

The meeting represented a significant step forward, moved towards implementation of nutrition education in medical education in general and in clinical practice in particular, in compliance with the aims of the ESPEN Nutrition Education Study Group (NESG).

Vacuum mattress or long spine board: which method of spinal stabilisation in trauma patients is more time consuming? A simulation study

BACKGROUND

Spinal stabilisation is recommended for prehospital trauma treatment. In Germany, vacuum mattresses are traditionally used for spinal stabilisation, whereas in anglo-american countries, long spine boards are preferred. While it is recommended that the on-scene time is as short as possible, even less than 10 minutes for unstable patients, spinal stabilisation is a time-consuming procedure. For this reason, the time needed for spinal stabilisation may prevent the on-scene time from being brief. The aim of this simulation study was to compare the time required for spinal stabilisation between a scoop stretcher in conjunction with a vacuum mattress and a long spine board.

METHODS

Medical personnel of different professions were asked to perform spinal immobilizations with both methods. A total of 172 volunteers were immobilized under ideal conditions as well as under realistic conditions. A vacuum mattress was used for 78 spinal stabilisations, and a long spinal board was used for 94. The duration of the procedures were measured by video analysis.

RESULTS

Under ideal conditions, spinal stabilisation on a vacuum mattress and a spine board required 254.4 s (95 % CI 235.6-273.2 s) and 83.4 s (95 % CI 77.5-89.3 s), respectively (p < 0.01). Under realistic conditions, the vacuum mattress and spine board required 358.3 s (95 % CI 316.0-400.6 s) and 112.6 s (95 % CI 102.6-122.6 s), respectively (p < 0.01).

CONCLUSIONS

Spinal stabilisation for trauma patients is significantly more time consuming on a vacuum mattress than on a long spine board. Considering that the prehospital time of EMS should not exceed 60 minutes and the on-scene time should not exceed 30 minutes or even 10 minutes if the patient is in extremis, based on our results, spinal stabilisation on a vacuum mattress may consume more than 20 % of the recommended on-scene time. In contrast, stabilisation on a spine board requires only one third of the time required for that on a vacuum mattress. We conclude that a long spine board may be feasible for spinal stabilisation for critical trauma patients with timesensitive life threatening ABCDE-problems to ensure the shortest possible on-scene time for prehospital trauma treatment, not least if a patient has to be rescued from an open or inaccessible terrain, especially that with uneven overgrown land.

NMR studies on the influence of silica confinements on local and diffusive dynamics in LiCl aqueous solutions approaching their glass transitions

We use ¹H, ²H, and ⁷Li NMR to investigate the molecular dynamics of glass-forming LiCl-7H₂O and LiCl-7D₂O solutions confined to MCM-41 or SBA-15 silica pores with diameters in the range of d = 2.8 nm-5.4 nm. Specifically, it is exploited that NMR experiments in homogeneous and gradient magnetic fields provide access to local and diffusive motions, respectively, and that the isotope selectivity of the method allows us to characterize the dynamics of the water molecules and the lithium ions separately. We find that the silica confinements cause a slowdown of the dynamics on all length scales, which is stronger at lower temperatures and in narrower pores and is more prominent for the lithium ions than the water molecules. However, we do not observe a temperature-dependent decoupling of short-range and long-range dynamics inside the pores. ⁷Li NMR correlation functions show bimodal decays when the pores are sufficiently wide (d > 3 nm) so that bulk-like ion dynamics in the pore centers can be distinguished from significantly retarded ion dynamics at the pore walls, possibly in a Stern layer. However, we do not find evidence for truly immobile fractions of water molecules or lithium ions and, hence, for the existence of a static Stern layer in any of the studied silica pores.

Prognostic impact of active mechanical circulatory support in cardiogenic shock complicating acute myocardial infarction: results from the CULPRIT-SHOCK trial

Background

Active mechanical circulatory support (MCS) devices are increasingly used in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). However, data derived from randomized controlled trials on the efficacy and safety of these devices are still limited.

Purpose

To analyze the prognostic impact of active MCS devices in a large prospective contemporary cohort of patients with CS complicating AMI.

Methods

This is a predefined subanalysis of the Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups; (1) use of at least one active MCS device, vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or need of renal replacement therapy at 30 days.

Results

Two hundred of 1055 (19%) patients received at least one active MCS device (n=112 Impella®; n=95 extracorporeal membrane oxygenation [ECMO]; n=6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared to those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p&lt;0.001). All-cause mortality at 30 days and 1 year as well as bleeding rates were significantly higher in the active MCS group (all p&lt;0.001). After multivariable adjustment the use of active MCS was significantly associated with the primary endpoint (odds ratio [OR] 4.0, 95% confidence interval [CI] 2.7–5.9; p&lt;0.001).

Conclusion

In the CULPRIT-SHOCK randomized trial and prospective registry approximately one fifth of patients was treated with active MCS devices. Compared to patients without active MCS, patients treated with active MCS devices showed worse outcome at 30 days and 1 year.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): Supported by a grant (FP7/2007-2013) from the European Union 7th Framework Program and by the German Heart Research Foundation and the German Cardiac Society.

Impact of pre-hospital resuscitation on short-and long-term mortality in patients with cardiogenic shock and multivessel disease. Results of the CULPRIT trial

Background

There are only a few prospective data on the outcome of patients with cardio-pulmonary resuscitation (CPR) admitted with acute myocardial infarction (AMI) complicated by cardiogenic shock and an invasive strategy including primary percutaneous coronary intervention (PCI). Therefore, we evaluated the impact of pre-hospital CPR on outcomes in a large group of patients with AMI complicated by cardiogenic shock.

Methods

We used the data of the prospective CULPRIT-Shock trial and registry and including patients with acute myocardial infarction complicated by cardiogenic shock. The primary endpoint was 30-day mortality or renal replacement therapy.

Results

Between 2013 and 2017, a total of 1055 patients were included in the randomized trial (n=686) and in the registry (n=369), 550 (54%) had CPR, 40 had no information regarding CPR. Baseline characteristics, procedural features and outcomes in the two groups with and without CPR are given in the table.

Conclusion

Patients with pre-hospital CPR represent more than half of the population with AMI complicated by cardiogenic shock. They are younger, have less risk factors and more often LAD as infarct vessel. Despite the younger age and a high success rate of PCI patients with CPR have a high 30-day mortality.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsches Zentrum fuer Herz-Kreislauf-Forschung - DZHK