Feasibility and Acceptability of Home-Delivered Medically Tailored Meals for Treatment of Diabetes in Pregnancy

BACKGROUND

Diabetes complicates ≤7% of pregnancies in the United States. Although medical nutrition therapy is the mainstay of diabetes treatment, many barriers exist to the successful implementation of dietary modifications. Home-delivered medically tailored meals (MTMs) are promising to overcome such barriers.

OBJECTIVE

The objective of this study was to evaluate the feasibility and acceptability of home-delivered MTM in pregnant patients with diabetes.

METHODS

We performed a prospective cohort study of home-delivered MTM for pregnant patients with diabetes using a mixed-methods approach. Participants <35 wk of gestation at the time of enrollment received weekly home delivery of diabetes-specific meals. Qualitative semistructured interviews were conducted to gain insight into participants' experience. Diabetes self-efficacy was assessed pre- and postintervention using the Diabetes Self-Efficacy Scale and 2-Item Diabetes Distress Screening Scale. The difference in mean scores was compared using t-tests with P value of <0.05 considered significant. Feasibility and acceptability were evaluated through participants' attitude toward MTM in qualitative interviews and indirectly evaluated through diabetes self-efficacy surveys.

RESULTS

Twenty pregnant people with diabetes who received home-delivered MTM during pregnancy were interviewed postpartum. Participants found this program convenient for various reasons, including reduced time for grocery shopping and preparing meals. Participants were satisfied with meals, citing a positive impact on diabetes management, accessibility of healthy foods, reduced stress with meal planning, and greater perceived control of blood glucose. Most participants shared meals with their families or received specific meals for their dependents, which was positively received. Reduced financial and mental stress was also widely reported. Diabetes self-efficacy was significantly improved postintervention with MTM.

CONCLUSION

Home-delivered MTM is feasible and acceptable in pregnant patients with diabetes and may improve diabetes self-efficacy. Individual experiences offered insight into various barriers overcome by using this service. Home-delivered MTM may help ensure an accessible, healthy diet for pregnant patients with diabetes.

Risk assessment of slow or no-reflow phenomenon in aortocoronary vein graft percutaneous intervention

Slow or no-reflow phenomenon (SNR) complicates 10%-15% of cases of percutaneous intervention (PCI) in aortocoronary saphenous vein grafts (SVG). At present, there are no uniform, effective strategies to predict or prevent this common and potentially serious complication. The purpose of our study was to characterize variables correlated with the risk of SNR in SVG PCI in the era of stenting and glycoprotein IIb/IIIa receptor inhibitors. We identified 2,898 consecutive patients who had PCI, of whom 163 underwent PCI of at least one SVG. The clinical and angiographic characteristics of patients who developed SNR (SNR group) were compared with those who did not (no-SNR group). A total of 23 patients experienced SNR and 140 did not. Using a stepwise multivariate logistic regression analysis, four independent predictors for SNR were detected: probable thrombus (OR 6.9; 95% CI, 2.1-23.9; P = 0.001), acute coronary syndromes (OR 6.4; 95% CI, 2.0-25.3; P = 0.003), degenerated vein graft (OR 5.2; 95% CI, 1.7-16.6; P = 0.003), and ulcer (OR 3.4; 95% CI, 0.99-11.6; P = 0.04). The risk of developing SNR could be estimated according to the number of predictors found: low-grade risk (1%-10%) if < or = one variable was present, moderate risk (20%-40%) if two variables were present, and high risk (60%-90%) if three or more variables were present. We identified and quantified current risk factors for SNR and concluded that the risk of developing SNR during PCI in SVG can be predicted by simple clinical and angiographic variables obtained before PCI. This information may be useful when the risk of PCI has to be balanced against alternative strategies such as medical therapy or redo-bypass surgery or in the selection of those patients that will most benefit from the use of protection devices during PCI.

Hypothermia after cardiac arrest: feasibility and safety of an external cooling protocol

BACKGROUND

No proven neuroprotective treatment exists for ischemic brain injury after cardiac arrest. Mild-to-moderate induced hypothermia (MIH) is effective in animal models.

METHODS AND RESULTS

A safety and feasibility trial was designed to evaluate mild-to-moderate induced hypothermia by use of external cooling blankets after cardiac arrest. Inclusion criteria were return of spontaneous circulation within 60 minutes of advanced cardiac life support, hypothermia initiated within 90 minutes, persistent coma, and lack of acute myocardial infarction or unstable dysrhythmia. Hypothermia to 33 degrees C was maintained for 24 hours followed by passive rewarming. Nine patients were prospectively enrolled. Mean time from advanced cardiac life support to return of spontaneous circulation was 11 minutes (range 3 to 30); advanced cardiac life support to initiation of hypothermia was 78 minutes (range 40 to 109); achieving 33 degrees C took 301 minutes (range 90 to 690). Three patients completely recovered, and 1 had partial neurological recovery. One patient developed unstable cardiac dysrhythmia. No other unexpected complications occurred.

CONCLUSIONS

Mild-to-moderate induced hypothermia after cardiac arrest is feasible and safe. However, external cooling is slow and imprecise. Efforts to speed the start of cooling and to improve the cooling process are needed.

Percutaneous and surgical interventions for in-stent restenosis: long-term outcomes and effect of diabetes mellitus

OBJECTIVE

We examined long-term outcomes of patients with in-stent restenosis (ISR) who underwent different percutaneous interventions at the discretion of individual operators: balloon angioplasty (BA), repeat stent or rotational atherectomy (RA). We also examined long-term outcomes of patients with ISR who underwent coronary artery bypass surgery (CABG).

BACKGROUND

In-stent restenosis remains a challenging problem, and its optimal management is still unknown.

METHODS

Symptomatic patients (n = 510) with ISR were identified using cardiac catheterization laboratory data. Management for ISR included BA (169 patients), repeat stenting (117 patients), RA (107 patients) or CABG (117 patients). Clinical outcome events of interest included death, myocardial infarction, target vessel revascularization (TVR) and a combined end point of these major adverse cardiovascular events (MACE). Mean follow-up was 19+/-12 months (range = 6 to 61 months).

RESULTS

Patients with ISR treated with repeat stent had significantly larger average post-procedure minimal lumen diameter compared with BA or RA (3.3+/-0.4 mm vs. 3.0+/-0.4 vs. 2.9+/-0.5, respectively, p < 0.05). Incidence of TVR and MACE were similar in the BA, stent and RA groups (39%, 40%, 33% for TVR and 43%, 40%, 33% for MACE, p = NS). Patients with diabetes who underwent RA had similar outcomes as patients without diabetes, while patients with diabetes who underwent BA or stent had worse outcomes than patients without diabetes. Patients who underwent CABG for ISR, mainly because of the presence of multivessel disease, had significantly better outcomes than any percutaneous treatment (8% for TVR and 23% for MACE).

CONCLUSIONS

In this large cohort of patients with ISR and in the subset of patients without diabetes, long-term outcomes were similar in the BA, repeat stent and RA groups. Tissue debulking with RA yielded better results only in diabetic patients. Bypass surgery for patients with multivessel disease and ISR provided the best outcomes.

Adenosine use during aortocoronary vein graft interventions reverses but does not prevent the slow-no reflow phenomenon

Slow or no reflow (SNR) complicates 10-15% of cases of percutaneous intervention (PI) in saphenous vein bypass graft (SVG). To date there have been limited options for the prevention and treatment of this common and potentially serious complication. We evaluated the procedural outcome of 143 consecutive SVG interventions. We compared patients who received pre-intervention intra-graft adenosine boluses with those who did not. In addition we examined the efficacy of adenosine boluses to reverse slow-no reflow events. Angiograms were reviewed and flow graded (TIMI grade) by film readers blinded to the use of any intraprocedural drug or clinical history. Seventy patients received intragraft adenosine boluses before percutaneous intervention (APPI), 73 received no preintervention adenosine (NoAPPI). There were no significant angiographic differences between the two groups at baseline. A total of 20 patients experienced SNR. The incidence of SNR was similar in the two groups (APPI = 14.2% vs. NoAPPI = 13.6%, P = 0.9). SNR was treated with repeated, rapid boluses (24 microg each) of intra-graft adenosine. Reversal of SNR was observed in 10 of 11 patients (91%) who received high doses of adenosine (>/=5 boluses, mean 7.7 +/- 2.6) and in 3 of 9 (33%) of those who received low doses (<5 boluses, mean 1.5 +/- 1.2). Final TIMI flow was significantly better in the high dose than in the low dose group (final TIMI 2.7 +/- 0.6 vs. 2 +/- 0.8, P = 0.04). No significant untoward complications were observed during adenosine infusion. These findings suggest that SNR after PI in SVG is not prevented by pre-intervention adenosine, but it can be safely and effectively reversed by delivery of multiple, rapid and repeated boluses of 24 microg of intra-graft adenosine.

Causes of early reintervention after successful coronary artery stenting

Acute reintervention was performed in 26 of 1,620 patients after coronary stenting (1.6%). Half of the patients had stent thrombosis and the other half residual anatomic problems. The mean time for reintervention was shorter in patients with stent thrombosis. All patients with stent thrombosis had a sudden recurrence of chest pain. Electrocardiographic changes were more common with stent thrombosis. Composite end point occurred in 10 patients (77%) with stent thrombosis versus 5 (39%) in the other group (p = 0.04).

Estrogen replacement therapy and outcome of coronary balloon angioplasty in postmenopausal women

Estrogen replacement therapy (ERT) in women after menopause is associated with prevention of clinical coronary artery disease. However, few studies have investigated possible benefits from ERT in postmenopausal women undergoing treatment for established coronary disease. We therefore retrospectively reviewed the clinical outcomes of 428 postmenopausal women undergoing percutaneous transluminal coronary balloon angioplasty (PTCA) to test the hypothesis that ERT has a beneficial effect in this setting. The women were divided into 2 groups based on ERT status at the time of the procedure. Estrogen users were younger (60 +/- 10 vs 68 +/- 9 years, p <0.001), more commonly had family histories of coronary heart disease (54% vs 41%, p = 0.04), had less incidence of hypertension (63% vs 76%, p = 0.02), and had slightly fewer diseased vessels per patient (1.3 +/- 0.5 vs 1.5 +/- 0.7, p = 0.03) compared with nonusers. No in-hospital deaths occurred in estrogen users compared with 5% hospital mortality in nonusers (p = 0.01). The combined outcome of death or myocardial infarction (MI) also was lower in estrogen users (4% vs 12%, p = 0.04). Of 348 women discharged after successful PTCA, 336 (97%) were able to be contacted at an average follow-up interval of 22 +/- 17 months (range 5 to 82). Estrogen users had superior event-free survival both for death as well as for death or nonfatal MI. Repeat revascularizations were similar in both groups (32% vs 24%, p = 0.15). In a Cox proportional-hazards model, nonusers had 4 times the likelihood of death after angioplasty compared with estrogen users (OR = 4.025, 95% CI = 1.3 to 13.4, p = 0.02). We conclude that estrogen replacement may offer protection against clinical coronary events in postmenopausal women who already have established coronary disease and are undergoing balloon angioplasty. The benefit was independent of age, smoking, presence of diabetes mellitus, or the number of diseased coronary vessels. However, it did not include a reduction in repeat revascularization procedures, suggesting no reduction in restenosis.

Activation of diacylglycerol in cultured endothelial cells exposed to cyclic strain

Confluent bovine aortic endothelial cells (EC) were grown on flexible membranes and subjected to 10% average strain at 60 cycles/min for up to 500 s. A biphasic increase in diacylglycerol (DAG) occurred, with an initial transient peak at 10 s followed by sustained elevation to 500 s. The early peak corresponded to the transient formation of inositol 1,4,5-trisphosphate, demonstrating hydrolysis of L-alpha-phosphatidylinositol (PI) by PI-specific phospholipase C. To determine the origin of the sustained DAG phase, we incubated confluent bovine aortic EC with 1 microCi/ml [14C]myristate overnight and subjected them to cyclic strain. There was a decrease in phosphatidylcholine (PC) and a corresponding increase in DAG at 10 s and 250 s, suggesting PC hydrolysis with the generation of DAG at both an early (10 s) and a late (250 s) phase. [14C]phosphatidylethanol, a specific product of phospholipase D (PLD) in the presence of 1% ethanol, was measured in EC preincubated with [14C]myristate. Cyclic strain led to an immediate and sustained activation of PLD. Increased ethanol concentration led to a consistent decrease in DAG. Furthermore, when EC were pretreated with 1% ethanol, the strain-induced proliferative response was attenuated.

Phospholipase C: a putative mechanotransducer for endothelial cell response to acute hemodynamic changes

Endothelial cells (EC) in vivo are exposed to a multitude of physical forces with each pulse of the cardiac cycle. Ongoing studies support the concept that EC respond to these forces through specific signal transduction pathways. Previous investigations in our laboratory have shown that EC respond to the initiation of cyclic strain or to an acute increase in cyclic strain frequency with the production of inositol 1,4,5-trisphosphate (IP3). This study demonstrates that EC also respond to an acute decrease in cyclic stretch frequency with a transient increase in IP3 production. Thus, EC detect both increases and decreases in cyclic stretch frequency with phospholipase C (PLC) activation leading to IP3 generation.

Effect of cyclic stretch on endothelial cells from different vascular beds

Endothelial cells (EC) mediate many of the organ responses to shock. Much of our knowledge of EC are obtained from cell culture studies. However, compared to the dynamic milieu in vivo, the stationary environment for large-vessel EC may be artificial and inappropriate. In this study, the morphology, growth rate, and production of prostacyclin (PGI2) by EC obtained from different vascular beds under stationary and dynamic conditions were examined. EC were harvested from the thoracic aorta (Ao), pulmonary artery (PA), and vena cava (VC) of the same calves and exposed to 0.5 sec 24% deformation alternating with 0.5 sec relaxation (i.e., 60 cycles/min). Our results show that in response to the cyclic regimen, VCEC were elongated perpendicular to the force vector and their actin filaments aligned in the same direction, while AoEC and PAEC did not exhibit any morphological changes. The growth rate of AoEC (but not PAEC or VCEC) was significantly enhanced when stimulated by cyclic stretch. In addition, AoEC demonstrated an increased PGI2 synthetic activity with cyclic stretch, while PAEC and VCEC were unaltered. We conclude that the maintenance of EC phenotype and function is dependent on the hemodynamic milieu in vivo and may be influenced by the vascular origin of the cultured EC.

Stimulation of endothelial secretion of tissue-type plasminogen activator by repetitive stretch

Endothelial cells (EC) synthesize many of the fibrinolytic components and anticoagulants present in plasma. EC have been demonstrated to release tissue type plasminogen activator (t-PA) and its rapid inhibitor type 1 plasminogen activator inhibitor (PAI-1). In vivo, EC lining a blood vessel are exposed to the forces of the circulation, predominantly shear stress and pulsatile stretch. We have previously reported that repetitive stretch of EC in culture will stimulate prostacyclin secretion. In this study, the effects of cyclic stretch on the production of t-PA and PAI-1 by cultured EC were examined. EC harvested from human saphenous vein were seeded in culture plates with flexible membrane bottoms and grown to confluence. Vacuum (-20 kPa) was used to deform the membrane bottoms to 24% maximum strain. EC in the experimental group were subjected to 24% maximum strain at 60 cycles/min (0.5 sec elongation alternating with 0.5 sec relaxation), while control EC were grown on the same membranes but kept stationary in the same incubator. After 1, 3, and 5 days, the cell numbers were counted and the media were collected and analyzed for t-PA and PAI-1 by ELISA. The result shows a significant increase in t-PA production with the cyclic stretch on Days 3 and 5. There was no significant difference in PAI-1 levels in stretched versus stationary EC. We concluded that cyclic stretch of EC in vitro can selectively stimulate t-PA production and may account for the relative nonthrombogenicity of the endothelium in vivo.

Stimulation of adenylate cyclase activity in cultured endothelial cells subjected to cyclic stretch

While vascular endothelial cells are repeatedly stretched by the pulsatile nature of cardiac output, in vitro models traditionally used to study vascular biology involve static culture techniques. We have recently shown that pulsatile stretching of endothelial cells in culture will increase their rates of proliferation and regulate their secretion of macromolecules. The aim of this study was to determine whether membrane adenylate cyclase is involved in intracellular signalling during pulsatile stress. Bovine aortic endothelial cells were seeded on flexible-bottomed culture wells (3 x 10(5) cells/25 mm well) and allowed to attach for 48 hours. The culture wells were placed in a vacuum-operated stress providing instrument and subjected to 0.5 s of 24% strain, 0.5 s relaxation (60 cycles/min) for 0, 1, 3, 5, 7, 10 and 15 minutes (N = 24 wells/time point). Cells were homogenized and a crude membrane preparation (27,000 x g) was assayed for adenylate cyclase under basal and forskolin (100 microM) stimulated conditions. The results indicate that there is a time-dependent increase in both basal and stimulated adenylate cyclase with cyclic deformation and suggest that there may be a "stretch receptor" coupled to adenylate cyclase which can modulate endothelial cell function with hemodynamic changes.