Older patients' use of technology for a post-discharge nutritional intervention - A mixed-methods feasibility study

BACKGROUND

Malnutrition is frequent in older people and a precursor for morbidity and hospitalisation; furthermore low intake and weight loss during and after hospitalisation is well-described. Such patients are often excluded from technology projects on account of lack of skills. This is a barrier for their access to many current and future health care offers.

OBJECTIVES

To test the acceptability, feasibility and preliminary efficacy of technology-supported energy- and protein-enforced homedelivered meals for older patients discharged from hospital.

DESIGN

Mixed method design including a quasi-experimental controlled feasibility trial and embedded qualitative interviews.

PARTICIPANTS

Older medical patients (mean age 79.4 years; women 66.7%) at nutritional risk and discharged to own home were included consecutively to first the control group (n=18) and later the intervention group (n=18). Nine intervention and 16 control group patients completed the project.

METHODS

Intervention: group received: 1) enriched meals delivered to participants' homes 12 weeks after discharge, and 2) a tablet computer combining goal setting for intake with self-monitoring and feedback. Control group were treated as usual. Data collection was done at baseline, and at six and 12 weeks follow-up. Feasibility evaluation focused on 1) inclusion and retention and 2) acceptability and functionality of the intervention. Efficacy primary endpoint: Muscle strength and BMI. Secondary: Health related quality of life (HRQoL), depression; readmissions, mortality.

RESULTS

Technology challenges were related to immaturity of the out-of hospital app version; however, participants were motivated and capable of using the device. Inclusion and retention was challenged by the acceptability of the nutritional intervention and exhaustion among patients. Mortality was high. Although weaker at baseline the intervention group increased their muscle strength more consistently than did the control group: Handgrip strength with 2.5kg vs 0.9kg and chairto-stand-test with 3.3 vs. 1.8 times. They also improved their depression score and HRQoL more, and patients reported increased intake, appetite, and energy in the interviews. Relatives confirmed this and also reported positive impact on their level of worry and on the relationship with the older person.

CONCLUSION

The study provided valuable insight into appropriate methods and procedures as well as older people's preferences and views on barriers to successful intervention and use of technology in health care. This will guide the design of a future sufficiently powered study. Effect evaluation provided guidance for future sample size calculation.

Wake and light therapy for moderate-to-severe depression - a randomized controlled trial

OBJECTIVE

To examine the efficacy of using wake and light therapy as a supplement to standard treatment of hospitalized patients with depression.

METHOD

In this randomized, controlled study, 64 patients with moderate-to-severe depression were allocated to standard treatment or to the intervention, which additionally consisted of three wake therapy sessions in one week, 30-min daily light treatment and sleep time stabilization over the entire nine-week study period.

RESULTS

Patients in the wake therapy group had a significant decrease in depressive symptoms in week one as measured by HAM-D₁₇ , 17.39 (CI 15.6-19.2) vs. 20.19 (CI 18.3-22.09) (P = 0.04), whereas no statistically significant differences were found between the groups in weeks two to nine. At week nine, the wake therapy group had a significantly larger increase in general self-efficacy (P = 0.001), and waking up during nights was a significantly less frequent problem (1.9 times vs. 3.2) (P = 0.0008). In most weeks, significantly fewer patients in the wake therapy group slept during the daytime, and if they slept, their naps were shorter (week three: 66 min vs. 117 min P = 0.02).

CONCLUSION

The antidepressant effect initially achieved could not be maintained during the nine-week study period. However, sleep and general self-efficacy improved.

Continuous monitoring of global left ventricular ejection fraction during percutaneous transluminal coronary angioplasty

Continuous monitoring of left ventricular (LV) function during percutaneous transluminal coronary angioplasty (PTCA) was performed in 40 patients (53 +/- 2 years) with a miniature, nuclear detector system after labeling the patients' red blood cells with technetium-99m. Balloon dilation (113 seconds, range 60 to 240) induced on average a 0.12 ejection fraction (EF) unit (19%) decrease in the LVEF, which was explained by a 34% increase in end-systolic counts. Balloon dilation of the left anterior descending artery (n = 23) produced a decrease in the LVEF of 0.17 +/- 0.13 EF units compared with the decrease of 0.06 +/- 0.07 EF units in patients undergoing dilation of the left circumflex artery (n = 9) and 0.05 +/- 0.04 EF units in patients treated for a stenosis of the right coronary artery (n = 8), (p = 0.02). Balloon deflation was associated with an immediate return to pre-PTCA levels. In 10 patients with 2 identical balloon occlusions, the second occlusion led to a significantly less decrease in the LVEF (0.41 +/- 0.14 vs 0.44 +/- 0.15) and electrocardiographic ST-segment deviation (88 +/- 54 microV vs 65 +/- 42 microV) than the first. We conclude that PTCA is associated with an abrupt transient decrease in the LVEF. The effect of balloon occlusion of the left anterior descending artery is more pronounced than balloon occlusion of the left circumflex and the right coronary arteries. Neither single nor multiple balloon occlusions were associated with post-PTCA global LV dysfunction, whereas the lesser degree of LV dysfunction and electrocardiographic signs of myocardial ischemia during the second of 2 identical balloon occlusions suggests that preconditioning can be induced during PTCA.

Pharmacological modulation of the ATP sensitive potassium channels during repeated coronary occlusions: no effect on myocardial ischaemia or function

BACKGROUND

Repeated episodes of myocardial ischaemia may lead to ischaemic preconditioning. This is believed to be mediated by the ATP sensitive potassium channels.

OBJECTIVE

To examine the effect of pharmacological modulation of the ATP sensitive potassium channels during repeated coronary occlusions.

DESIGN

Double blind, double dummy study.

METHODS

38 patients with a proximal stenosis of the left anterior descending coronary artery and no visible coronary collateral vessels underwent three identical 90 second balloon occlusions, each followed by five minutes of reperfusion. The patients were randomised to pinacidil 25 mg, glibenclamide 10.5 mg, or matching placebo 90 minutes before the start of the procedure. Myocardial ischaemia was measured by continuous monitoring of ECG ST segment changes. Changes in left ventricular function were recorded with a miniature radionuclide detector, and angina was scored on the Borg scale.

RESULTS

In all patients the first balloon occlusion led to significant ST segment elevation, a clear decrease in left ventricular ejection fraction, and angina pectoris. This response was not attenuated at the second or third balloon occlusion, either in the placebo group or in the patients pretreated with pinacidil or glibenclamide.

CONCLUSIONS

Under the given experimental conditions, this randomised and double blind study did not support the view that the human myocardium has an intrinsic protective mechanism that is activated by short lasting episodes of ischaemia.

Monitoring of left ventricular ejection fraction with a miniature, nonimaging nuclear detector: accuracy and reliability over time with special reference to blood labeling

BACKGROUND

The purpose of this study was to determine the accuracy of determinations of left ventricular ejection fraction (LVEF) by a nonimaging miniature nuclear detector system (Cardioscint) and to evaluate the feasibility of long-term LVEF monitoring in patients admitted to the coronary care unit, with special reference to the blood-labeling technique.

METHODS AND RESULTS

Cardioscint LVEF values were compared with measurements of LVEF by conventional gamma camera radionuclide ventriculography in 33 patients with a wide range of LVEF values. In 21 of the 33 patients, long-term monitoring was carried out for 1 to 4 hours (mean 186 minutes), with three different kits: one for in vivo and two for in vitro red blood cell labeling. The stability of the labeling was assessed by determination of the activity of blood samples taken during the first 24 hours after blood labeling. The agreement between Cardioscint LVEF and gamma camera LVEF was good with automatic background correction (r = 0.82; regression equation y = 1.04x + 3.88) but poor with manual background correction (r = 0.50; y = 0.88x - 0.55). The agreement was highest in patients without wall motion abnormalities. The long-term monitoring showed no difference between morning and afternoon Cardioscint LVEF values. Short-lasting fluctuations in LVEFs greater than 10 EF units were observed in the majority of the patients. After 24 hours, the mean reduction in the physical decay-corrected count rate of the blood samples was most pronounced for the two in vitro blood-labeling kits (57% +/- 9% and 41% +/- 3%) and less for the in vivo blood-labeling kit (32% +/- 26%). This "biologic decay" had a marked influence on the Cardioscint monitoring results, demanding frequent background correction.

CONCLUSION

A fairly accurate estimate of LVEF can be obtained with the nonimaging Cardioscint system, and continuous bedside LVEF monitoring can proceed for hours with little inconvenience to the patients. Instability of the red blood cell labeling during long-term monitoring necessitates frequent background correction.

3153Rate versus rhythm control and mortality in atrial fibrillation patients: a Danish nationwide cohort study

Background

Treatment of AF patients with rate or rhythm drug therapy have shown no difference in mortality in clinical trials. However, the generalizability of these trials to real-world populations can be questioned.

Purpose

We aimed to investigate the all-cause and cardiovascular (CV) mortality risk in a nationwide AF cohort by treatment strategy (rate vs. rhythm) and by individual drug classes.

Methods

We queried the Danish nationwide registries from 2000 to 2015 to identify patients with AF. A rate control strategy included the use of one or more of the following medications: beta-blocker, digoxin, and a class-4 calcium channel blocker (CCB). A rhythm control strategy included the use of an anti-arrhythmic drug (amiodarone and class-1C). Primary outcome was all-cause mortality. Secondary outcome was CV mortality. Adjusted incidence rate ratios (IRR) were computed using Poisson regression with time-dependent covariates allowing patients to switch treatment during follow-up.

Results

Of 140,697 AF patients, 131,793 were on rate control therapy and n=8,904 were on rhythm control therapy. At baseline, patients on rhythm control therapy were younger (71 yrs [IQR: 62–78] vs 74 [65–82], p<0.001) more likely male (63.5% vs 51.7% p<0.001), had more prevalent heart failure (31.1% vs 19.4%, p<0.001) and ischemic heart disease (40.1% vs. 23.3%, p<0.001), and had more prior CV-related procedures; PCI (7.4% vs. 4.0% p<0.001) and CABG (15.0% vs. 2.3%, p<0.001).

During a median follow up of 4.0 (IQR: 1.7–7.3) years, there were 64,653 (46.0%) deaths from any-cause, of which 27,025 (19.2%) were CVD deaths. After appropriate adjustments and compared to rate control therapy, we found a lower IRR of mortality and CV mortality in those treated with rhythm control therapy (IRR: 0.93 [95% CI: 0.90–0.97] and IRR 0.84 [95% CI: 0.79–0.90]). Compared with beta-blockers, digoxin was associated with increased risk of all-cause and CV mortality (IRR: 1.26 [95% CI: 1.24–1.29] and IRR: 1.32 [95% CI: 1.28–1.36]), so was amiodarone: IRR for all-cause mortality: 1.16 [95% CI: 1.11–1.21] and IRR for CV mortality: 1.12 [95% CI: 1.05–1.19]. Class-1C was associated with lower all-cause (0.43 [95% CI: 0.37–0.49]) and CV mortality (0.35 [95% CI: 0.28–0.44]).

Figure 1. Models were adjusted for age, sex, ischemic heart disease, stroke, chronic obstructive pulmonary disease, chronic kidney disease, valvular atrial fibrillation, bleeding, diabetes, ablation, pacemaker, implantable cardioverter defibrillator, hypertension, heart failure, use of loop diuretics, calendar year, and time on treatment. Abbreviations; CCB; calcium channel blocker, PY; person years.

Conclusions

In a real-world AF cohort, we found that compared with rate control therapy, rhythm control therapy was associated with a lower risk of all-cause and CV mortality. The reduced mortality risk with rhythm therapy could reflect an appropriate patient selection.

Acknowledgement/Funding

The Danish Heart Foundation

Type 2 diabetes is associated with higher risk of 3rd degree atrioventricular block: a Danish nationwide registry study

Background

Type 2 diabetes (T2DM) is suggested to affect the function of the cardiomyocytes and electrical pathways which could cause conduction abnormalities and cardiac arrhythmias, such as 3rd degree atrioventricular block. The association of T2DM and 3rd degree atrioventricular block has never been confirmed in large nationwide studies.

Purpose

To determine the association between T2DM and 3rd degree atrioventricular block.

Method

This nationwide nested case-control study design included patients older than 18 years, diagnosed with 3rd degree atrioventricular block between 1st of July 1995 and 31st of December 2018. Five controls from the risk set of each case of 3rd degree atrioventricular block were matched on age and sex to fit a Cox regression model with time-dependent exposure (T2DM) and time-dependent covariates and baseline hazard function stratified for age and sex. Subgroup analysis was conducted with Cox models for each subgroup.

Results

We identified 31.177 cases with 3rd degree atrioventricular block that were matched with 155.885 controls. The mean age was 78 years and 60% were males. Cases had higher prevalence of T2DM (20% vs 7.8%), hypertension (70% vs 43%) myocardial infarction (16% vs 6.6%), and heart failure (21% vs 5.9%) compared to the control group. In a Cox analysis T2DM was significantly associated with a higher rate of 3rd degree atrioventricular block [HR 2.61 (95% CI: 2.54–2.71)]. The association remained in several subgroup analyses of diseases suspected to be associated with 3rd degree atrioventricular block. There was a significant interaction with sex and age groups and comorbidities of interest including hypertension, atrial fibrillation, heart failure and myocardial infarction (Figure 1).

Conclusion

T2DM is associated with a higher rate of 3rd degree atrioventricular block. The findings were consistent across subgroups.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was funded by the independent research foundation Skibsreder Per Henrik, R. og Hustrus Fond

[Vasospastic angina pectoris following abortion induced by prostaglandin analogue]

A case of vasospastic angina pectoris with loss of consciousness, bradycardia and seizures induced by medical abortion following administration of mifepristone and gemeprost is reported. The patient had a history of smoking and migraine, and former treatment with ergot alkaloids or serotonin agonists had also resulted in chest pain and lipothymia. The case underlines the importance of obtaining a detailed history of vasospastic disorders in women referred for medical abortion.