Variation in Patient-Described Barriers to and Facilitators of Diabetes Management by Individual-Level Characteristics: A Cross-Sectional, Open-Ended Survey

This study analyzed patient-described barriers and facilitators related to diabetes management, focusing on how these differ by glycemia and across individual characteristics. A cross-sectional telephone survey was conducted with adult patients with diabetes in Alberta, Canada, asking two open-ended questions to describe the most helpful and difficult components of their diabetes management. Responses were analyzed using directed content analysis using the Theoretical Domains Framework as a template. The most frequently cited facilitator was care context and information, and the most frequently cited barriers were cognitive challenges and structural barriers, with patient-perceived barriers and facilitators varying by individual-level factors.

The Coronary ARteriogenesis with combined Heparin and EXercise therapy in chronic refractory Angina (CARHEXA) trial: A double-blind, randomized, placebo-controlled stress echocardiographic study

BACKGROUND

Coronary collateral circulation exerts protective effects on myocardial ischaemia due to coronary artery disease and can be promoted by exercise with heparin co-administration. Whether this arteriogenetic effect is accompanied by functional improvement of left ventricle during stress and lessening of angina symptoms remains unknown.

AIMS

To evaluate the anti-ischaemic efficacy of heparin plus exercise in coronary artery disease.

METHODS

In a prospective, single-centre, randomized, double-blind study we recruited 32 'no-option' patients (27 males; mean age 61 ± 8 years) with stable angina, exercise-induced ischaemia and coronary artery disease not suitable for revascularization. All underwent a two-week cycle of exercise (two exercise sessions per day, five days per week) and were randomized (n = 16 per group) to intravenous placebo (0.9% saline) versus unfractionated heparin (5.000 IU intravenously), 10 min prior to exercise. We assessed Canadian Cardiovascular Society angina class, stress electrocardiogram and echo parameters (wall motion score index) and computed tomography angiography for collaterals.

RESULTS

After two-week cycle, Canadian Cardiovascular Society class statistically decreased in both groups (heparin plus exercise group: 2.6 ± 0.7 to 1.9 ± 0.7, p < 0.001, exercise group: 2.4 ± 0.7 to 2.1 ± 0.9, p = 0.046). Only the heparin plus exercise group improved time-to-ST segment depression (before 270, 228-327 s vs. after 339, 280-360 s, p = 0.012) and wall motion score index (before 1.38 ± 0.25 vs. after 1.28 ± 0.18, p = 0.005). By multi-slice computed tomography angiography, collaterals improved in 12/15 (80%) in the heparin plus exercise group versus 2/16 (12.5%) in the exercise group (p < 0.001).

CONCLUSION

A two-week, 10-test cycle of heparin plus exercise is better than exercise in improving angina class, myocardial ischaemia and collaterals by computed tomography angiography.

P1508The Coronary Arteriogenesis with combined Heparin and Exercise therapy in chronic refractory Angina (CARHEXA) trial: a double-blind randomized placebo-controlled stress echocardiographic study

Background

Coronary collateral circulation exerts protective effects on myocardial ischemia due to coronary artery disease (CAD) and can be promoted by exercise (E) with heparin (H) co-administration. Whether this arteriogenetic effects is accompanied by functional improvement of left ventricle (LV) during stress remains unknown.

Purpose

To establish the stress-induced functional effects on LV regional and global function of 2-week cycle of H+E in patients with “no-option” CAD.

Methods

In a prospective, single-center, double-blind, randomized, parallel-group study we recruited 32 “no-option” patients (27 males; mean age of 61±8 years), with stable angina and CTO, refractory to OMT, not suitable for revascularization and with E-induced ischemia. All underwent 2-week cycle of E (2 E test per day, 5 days a week) and were pre-treated with i.v. 0.9% saline or unfractionated H (100 IU/kg up to maximum of 5.000IU, 10 min prior to E). Canadian Class Score (CCS) and 12-lead E-ECG for time-to-1 mm ST-segment depression were assessed at entry and after treatment. LV function was evaluated during treadmill exercise with conventional and advanced imaging indices: Wall Motion Score Index (WMSI); Ejection Fraction (EF); Force (systolic blood pressure/end-systolic volume); Global Longitudinal Strain (GLS).

Results

Post-treatment exercise-time and CCS improved in both groups. In H+E patients exercise-time improved from 369.8±107.8 sec to 475.3±114.6 sec (p=0.001) while in E patients improved from 384±152.7 sec to 464.8±134.1 sec (p=0.019). CCS score changed in H+E from 2.6±0.7 to 1.9±0.7 (p=0.000), and in E group from 2.4±0.7 to 2.1±0.9 (p=0.046). At peak exercise, H+E was different from E group for EF and GLS (see Table).

Effects of H+E on SE parameters H+E p P+E p *H+E vs P+E STRESS Time 0 vs Time 1 Time 0 vs Time 1 Time 0 Time 1 WMSI 1.377 vs 1.279 0.005 1.404 vs 1.376 0.290 0.626 0.255 EF (%) 60.9 vs 64.8 0.016 61.2 vs 57.8 0.284 0.943 0.016 Force (mmHg/mL) 6.36 vs 6.5 0.158 5.82 vs 4.68 0.209 0.760 0.098 GLS (%) −16.96 vs −18.50 0.001 −15.79 vs −15.60 0.380 0.325 0.027 SE = stress echocardiography; H+E = heparin+exercise; P+E = placebo+exercise; Time 0 = before randomization; Time 1 = after 2-week therapy cycle. *p values.

Conclusion

A 2-week, H+E cycle is associated with improvement in regional and global LV function during exercise, concordantly shown by conventional (WMSI, EF) and advanced (GLS) echocardiographic indices of LV function. This integrates and supplements the classical objective index based on ST-segment depression, unable to localize and quantify the functional consequences of therapy on myocardial ischemia.

P2710Anti-ischemic effect of 2-week cycle of heparin plus exercise-to-ischemia twice daily in patients with “no-option” angina: the CARHEXA trial

Background

Coronary collateral circulation (CCC) exerts protective effects on myocardial ischemia due to coronary artery disease (CAD), but the anti-ischemic, pro-CCC effects of exercise (E) with or without heparin (H) co-administration remain unclear.

Purpose

To establish the anti-ischemic functional efficacy of 2-week cycle of E-to-ischemia twice daily, with or without unfractionated i.v. H immediately before E, in patients with “no-option” CAD

Methods

In a prospective, single-center, parallel group study design we recruited 32 “no-option” patients (27 males; mean age of 61±8 years) with at least one chronically occluded coronary artery and stable angina, refractory to optimal medical management, not suitable for revascularization therapy and with E-induced ischemia. All underwent a 2-week cycle of E (2 E test per day, 5 days a week, for 2 weeks) and were randomized, with a double-blind design, to i.v. placebo (0.9% saline) versus unfractionated H (100 IU/kg up to a maximum of 5.000 IU iv, 10 min prior to E). Seattle stable angina questionnaire (SAQ), 12-lead E-ECG for time-to-ischemia (treadmill exercise testing), and MDCT angiography for CCC imaging (Rentrop score, from 0= absent to 3= full opacification of occluded vessel) were assessed at entry and re-assessed after treatment for symptomatic, ECG, and anatomic end-points respectively.

Results

In H+E group (n=16), time to 1 mm ST segment depression (ST-D) increased, and CCC improved, p<0.05. On the contrary, no difference was observed in E group (n=16) in the pre-specified end-points (p>0.05) (see table). Clinically important change of more 10 points in SAQ was observed regarding physical limitation, angina stability and disease perception in H+E patients, and in only angina frequency in E group.

The ECG and angiographic results Heparin + Exercise Placebo + Exercise Rentrop baseline 0.73±0.88 1.06±1.06 Rentrop 2-week 1.6±0.99* 1.19±1.05 Time to ST-D base (s) 269±64 273±176 Time to ST-D 2-week (s) 328±65* 306±151 *p<0.05.

Conclusion

A 2-week, 10 E test cycles are well tolerated and effective particularly with H in ameliorating symptoms, E-induced ischemia and CCC in “no-option” CAD patients with refractory angina.

Walking and type 2 diabetes risk using CANRISK scores among older adults

The objective of this study was to determine the association between pedometer-assessed steps and type 2 diabetes risk using the Public Health Agency of Canada-developed 16-item Canadian Diabetes Risk Questionnaire (CANRISK) among a large population-based sample of older adults across Alberta, Canada. To achieve our study objective, adults without type 2 diabetes (N = 689) aged 55 years and older provided demographic data and CANRISK scores through computer-assisted telephone interviews between September and November 2012. Respondents also wore a step pedometer over 3 consecutive days to estimate average daily steps. Logistic regression was used to assess the association between achieving 7500 steps/day and risk of diabetes (low vs. moderate and high). Overall, 41% were male, average age was 63.4 (SD 5.5) years, body mass index was 26.7 (SD 5.0) kg/m2, and participants averaged 5671 (SD 3529) steps/day. All respondents indicated they were capable of walking for at least 10 min unassisted. CANRISK scores ranged from 13–60, with 18% in the low-risk category (<21). After adjustment, those not achieving 7500 steps/day (n = 507) were more than twice as likely to belong to the higher risk categories for type 2 diabetes compared with those walking ≥7500 steps/day (n = 182) (73.6% vs. 26.4%; odds ratio: 2.37; 95% confidence interval: 1.58 – 3.57). Among older adults without diabetes, daily steps were strongly and inversely associated with diabetes risk using the CANRISK score. Walking remains an important modifiable risk factor target for type 2 diabetes and achieving at least 7500 steps/day may be a reasonable target for older adults.

Prognostic value of calcium score and coronary flow velocity reserve in asymptomatic diabetic patients

BACKGROUND

The risk stratification of patients with diabetes mellitus (DM) is a major objective for the clinicians, and it can be achieved by coronary flow velocity reserve (CFVR) or with coronary artery calcium score (CS). CS evaluates underlying coronary atherosclerotic plaque burden and CFVR estimates both presence of coronary artery stenosis and microvascular function. Consequently, CFVR may provide unique risk information beyond the extent of coronary atherosclerosis.

AIM

Our aim is to assess joint prognostic value of CFVR and CS in asymptomatic DM patients.

MATERIALS AND METHODS

We prospectively included 200 asymptomatic patients (45,5 % male, mean age 57,35 ± 11,25), out of which, there were 101 asymptomatic patients with DM and 99 asymptomatic patients without DM, but with one or more conventionally risk factors for coronary artery disease. We analyzed clinical, biochemical, metabolic, inflammatory parameters, CS by Agatston method, transthoracic Doppler echocardiography CFVR of left anterior descending artery and echocardiographic parameters.

RESULTS

Total CS and CS LAD were significantly higher, while mean CFVR was lower in diabetics compared to the nondiabetics. During 1 year follow-up, 24 patients experienced cardio-vascular events (one cardiovascular death, two strokes, three myocardial infarctions, nine new onsets of unstable angina and nine myocardial revascularizations): 19 patients with DM and five non DM patients, (p = 0,003). Overall event free survival was significantly higher in non DM group, compared to the DM group (94,9 % vs. 81,2 %, p = 0,002 respectively), while the patients with CS ≥200 and CFVR <2 had the worst outcome during 1 year follow up in the whole study population as well as in the DM group. At multivariable analysis CFVR on LAD (HR 12.918, 95 % CI 3.865-43.177, p < 0.001) and total CS (HR 13.393, 95 % CI 1.675-107.119, p = 0.014) were independent prognostic predictors of adverse events in DM group of patients.

CONCLUSION

Both CS and CFVR provide independent and complementary prognostic information in asymptomatic DM patients. When two parameters are analyzed together, the risk stratification ability improves, even when DM patients are analyzed together with non DM patients. As a result, DM patients with CS ≥200 and CFVR <2 had the worst outcome. Consequently, the use of two tests identified subset of patients who can derive the most benefit from the intensive prevention measures.

Diagnostic value of NT-proBNP in identifying impaired coronary flow reserve in asymptomatic moderate or severe aortic stenosis

AIM

NT-proBNP has been shown to be a reliable biochemical marker for left ventricular wall stress. The relationship between NT-proBNP and coronary flow reserve (CFR) was evaluated in patients with significant asymptomatic aortic stenosis (AS).

METHODS

A total of 74 patients with moderate or severe AS, mean age 66.68 ± 10.02 years (56.75% males), were enrolled in this prospective study. All patients underwent coronary angiography and had no obstructive coronary disease (defined as having no stenosis >50% in diameter). They had all undergone standard transthoracic Doppler-echo study and adenosine stress transthoracic-echo for CFR measurement and laboratory analysis for NT-proBNP measurement.

RESULTS

The median NT-proBNP value was significantly increased (417.0 pg/ml; interquartile range [IQR]: 176.8-962.2 pg/ml). NT-proBNP was significantly higher in the group with CFR ≤2.5 (median: 549.0 pg/ml; IQR: 311.5-1131.0 pg/ml; as opposed to median: 291.5 pg/ml; IQR: 123.0-636.2 pg/ml; W = 452; p = 0.012). NT-proBNP showed significant negative correlation with CFR (ρ = -0.377, p = 0.001). There was also significant correlation between NT-proBNP and E/E´, S´ and aortic valve resistance. The NT-proBNP value of 334.00 pg/ml was determined as the best cut-off value for the diagnosis of CFR ≤2.5 (area under the curve: 0.67; 95%CI: 0.54-0.79; p < 0.01) and the sensitivity and specificity were 74 and 64%, respectively.

CONCLUSION

Elevated NT-proBNP can indicate patients with impaired CFR in asymptomatic moderate or severe AS patients with preserved ejection fraction and nonobstructive coronary arteries.

Correlation of different imaging modalities in pre-surgical evaluation of pericardial metastasis of liposarcoma

A patient presented with a large pericardial tumor of uncertain etiology. Five years earlier, she had been treated for myxoid liposarcoma of the thigh. For pre-surgical evaluation, conventional radiography, positron emission tomography/computed tomography (PET/CT), magnetic resonance imaging (MRI), CT of the heart, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were performed. The final histopathologic diagnosis was metastatic liposarcoma. Each of the imaging modalities used had advantages and disadvantages, and their coordination was necessary for optimal evaluation.

The use of EAF dust in cement composites: assessment of environmental impact

Electric arc filter dust (EAF dust) is a waste by-product which occurs in the production of steel. Instead of being disposed of, it can be used in cement composites for civil engineering, and for balances in washing machines. To estimate the environmental impact of the use of EAF dust in cement composites leachability tests based on diffusion were performed using water and salt water as leaching agents. Compact and ground cement composites, and cement composites with addition of 1.5% of EAF dust by mass were studied. The concentrations of total Cr and Cr(VI) were determined in leachates over a time period of 175 days. At the end of the experiment the concentrations of some other metals were also determined in leachates. The results indicated that Cr in leachates was present almost solely in its hexavalent form. No leaching of Cr(VI) was observed in aqueous leachates from compact cement composites and compact cement composites to which different quantities of EAF dust have been added. In ground cement composites and in ground cement composites with addition of EAF dust, Cr(VI) was leached with water in very low concentrations up to 5 microg L(-1). Cr(VI) concentrations were higher in salt water leachates. In compact and ground cement composites with addition of EAF dust Cr(VI) concentrations were 40 and 100 microg L(-1), respectively. It was experimentally found that addition of EAF dust had almost no influence on leaching of Cr(VI) from cement composites. Leaching of Cr(VI) originated primarily from cement. Leaching of other metals from composites investigated did not represent an environmental burden. From the physico-mechanical and environmental aspects EAF dust can be used as a component in cement mixtures.

Leachability of Cr(VI) and other metals from asphalt composites with addition of filter dust

The potential use of filter dust in asphalt composites for road construction was investigated. Filter dust contains high concentrations of metals, of which Cr(VI) and Pb are leached with water. Compact and ground asphalt composites with addition of 2% of filter dust by mass were studied. In order to evaluate their environmental impact, leachability tests were performed using water and salt water as leaching agents. The concentrations of Cr(VI) and Pb were determined in leachates over a time period of 182 days. The results indicated that Pb was not leached with leaching agents from asphalt composites. Cr(VI) was also not leached with leaching agents from compact asphalt composites. However, in ground asphalt composites, Cr(VI) was leached with water in concentrations up to 220 microg L(-1) and in salt water up to 150 microg L(-1). From the physico-mechanical and environmental aspects, filter dust can be used as a component in asphalt mixtures.