An evaluation of involving family caregivers in the self-care of heart failure patients on hospital readmission: Randomised controlled trial (the FAMILY study)

BackgroundThe prevalence of heart failure is increasing in Lebanon but to date there is no systematic evaluation of a disease management intervention.ObjectiveThe aim of this study was to evaluate the effect of involving family caregivers in the self-care of patients with heart failure on the risk of hospital readmission.DesignA multi-site, block randomised controlled trial.SettingsThe study was conducted over a 13-month period in three tertiary medical centres in Beirut and Mount Lebanon, Lebanon.ParticipantsAdult patients presenting for an exacerbation of heart failure to one of the study centres were included. Patients with limited life expectancy or physical functionality, planned cardiac bypass or valve replacement surgery, living alone or in nursing homes, or aged less than 18 years were excluded.MethodsPatients allocated to the intervention group and their family caregivers were provided with a comprehensive, culturally appropriate, educational session on self-care maintenance and symptom management along with self-care resources. The usual care group received the self-care resources only. Follow-up phone calls were conducted 30 days following discharge by a research assistant blinded to treatment assignment. The primary outcome was hospital readmission and the secondary outcomes were self-care, quality of life, major vascular events and healthcare utilization.ResultsThe final sample included 256 patients hospitalized for heart failure randomised into control (130 patients) and intervention (126 patients) groups. The mean age was 67 (SD = 8) years, and the majority (55%) were male. Readmission at 30 days was significantly lower in the intervention group compared to the control group (n = 10, 9% vs. n = 20, 19% respectively, OR = 0.40, 95% CI = 0.02, 0.10, p = 0.02). Self-care scores improved in both groups at 30 days, with a significantly larger improvement in the intervention group than the control group in the maintenance and confidence sub-scales, but not in the self-care management sub-scale. No differences were seen in quality of life scores or emergency department presentations between the groups. More patients in the control group than in the intervention group visited health care facilities (n = 24, 23% vs. n = 12, 11% respectively, OR = 0.39, 95% CI = 0.18, 0.83, p = 0.01).ConclusionThe trial results confirmed the potential of the family-centred self-care educational intervention under evaluation to reduce the risk of readmission in Lebanese patients suffering from exacerbated heart failure. Further research is needed to validate these findings with longer periods of follow-up and to identify the intervention components and intensity required to induce sustained benefits on patients' self-care management and quality of life.     

The effect on patient outcomes of a nursing care and follow-up program for patients with heart failure: A randomized controlled trial

BackgroundHeart failure is associated with exacerbated symptoms such as dyspnea and edema and results in frequent hospitalization and a poor quality of life. With the adoption of a comprehensive nursing care and follow-up program, patients with heart failure may exhibit improvements in their self-care capabilities and their hospitalizations may be reduced.ObjectiveThe purpose of this study was to examine the effect of a nursing care and follow-up program for patients with heart failure on self-care, quality of life, and rehospitalization.Design and settingThis research was conducted as a single-center, single-blind, randomized controlled study at the heart failure outpatient clinic of a university hospital in Turkey.ParticipantsA total of 90 patients with heart failure were randomly assigned into either the specialized nursing care group (n = 45) or the control group (n = 45).MethodsThe nursing care and follow-up program applied in the intervention group was based on the Theory of Heart Failure Self-care. Data were collected at the beginning of the trial, and at three and six months after the study commenced. Self-care of the patients was assessed by the Self-Care of Heart Failure Index. Quality of life was assessed with the “Left Ventricular Dysfunction Scale”. Rehospitalization was evaluated based on information provided by the patients or by hospital records.ResultsA statistically significant difference was found between the intervention and control group with respect to the self-care and quality of life scores at both three and six months. While the intervention group experienced fewer rehospitalizations at three months, no significant differences were found at six months.ConclusionThe results obtained in this study show that the nursing care and follow-up program implemented for patients with heart failure improved self-care and quality of life. Although there were no significant differences between the groups at six months, fewer rehospitalizations in the intervention group was considered to be an important result.     

Tailored educational supportive care programme on sleep quality and psychological distress in patients with heart failure: A randomised controlled trial

BackgroundUp to 74% of patients with heart failure report poor sleep in Taiwan. Poor symptom management or sleep hygiene may affect patients’ sleep quality. An effective educational programme was important to improve patients’ sleep quality and psychological distress. However, research related to sleep disturbance in patients with heart failure is limited in Taiwan.ObjectivesTo examine the effects of a tailored educational supportive care programme on sleep disturbance and psychological distress in patients with heart failure.Designrandomised controlled trial.Participants and settingEighty-four patients with heart failure were recruited from an outpatient department of a medical centre in Taipei, Taiwan. Patients were randomly assigned to the intervention group (n = 43) or the control group (n = 41).MethodsPatients in the intervention group received a 12-week tailored educational supportive care programme including individualised education on sleep hygiene, self-care, emotional support through a monthly nursing visit at home, and telephone follow-up counselling every 2 weeks. The control group received routine nursing care. Data were collected at baseline, the 4th, 8th, and 12th weeks after patients’ enrollment. Outcome measures included sleep quality, daytime sleepiness, anxiety, and depression.ResultsThe intervention group exhibited significant improvement in the level of sleep quality and daytime sleepiness after 12 weeks of the supportive nursing care programme, whereas the control group exhibited no significant differences. Anxiety and depression scores were increased significantly in the control group at the 12th week (p < .001). However, anxiety and depression scores in the intervention group remained unchanged after 12 weeks of the supportive nursing care programme (p > .05). Compared with the control group, the intervention group had significantly greater improvement in sleep quality (β = −2.22, p < .001), daytime sleepiness (β = −4.23, p < .001), anxiety (β = −1.94, p < .001), and depression (β = −3.05, p < .001) after 12 weeks of the intervention.ConclusionThis study confirmed that a supportive nursing care programme could effectively improve sleep quality and psychological distress in patients with heart failure. We suggested that this supportive nursing care programme should be applied to clinical practice in cardiovascular nursing.     

Complementary and alternative medicine self-care strategies for nausea in patients undergoing abdominal or pelvic irradiation for cancer: A longitudinal observational study of implementation in routine care

ObjectiveTo longitudinally describe practice of Complementary and Alternative Medicine (CAM) self-care strategies for nausea during radiotherapy.MethodsTwo hundred patients daily registered nausea and practice of CAM self-care strategies, beside conventional antiemetic medications, for nausea during abdominal/pelvic irradiation (median five weeks) for gynecological (69%) colorectal (27%) or other tumors (4%).ResultsDuring radiotherapy, 131 (66%) experienced nausea, and 50 (25%) practiced self-care for nausea at least once, for a mean (m) of 15.9 days. The six of 50 patients who stayed free from nausea practiced self-care more frequent (m = 25.8 days) than the 44 patients experiencing nausea (m = 14.5) (p = 0.013). The CAM self-care strategies were: modifying eating (80% of all self-care practicing patients, 80% of the nauseous patients versus 83% of the patients free from nausea; ns) or drinking habits (38%, 41% vs 17%; ns), taking rests (18%, 20% vs 0%; ns), physical exercising (6%, 2% vs 33%; p = 0.035), acupressure (4%, 5% vs 0%; ns) and self-induced vomiting (2%, 2% vs 0%; ns).ConclusionA fourth of patients undergoing emetogenic radiotherapy practiced CAM self-care for nausea, mostly by modifying eating or drinking habits. The CAM self-care practicing patients who did not become nauseous practiced self-care more frequent than the nauseous patients did. To make such self-care evidence based, we need studies evaluating its efficacy.     

Modifiable correlates of physical symptoms and health-related quality of life in patients with heart failure: A cross-sectional study

BackgroundHeart failure is associated with high rates of hospitalization and mortality. The majority of patients with heart failure suffer from physical symptoms, and these symptoms are strongly associated with poor health-related quality of life. To improve physical symptoms and health-related quality of life, the modifiable factors associated with physical symptoms need to be examined.PurposeTo examine modifiable psychosocial and behavioral factors associated with physical symptoms and health-related quality of life, and the mediator effects of physical symptoms on the relationships between the modifiable factors and health-related quality of life in patients with heart failure.MethodsData on potential correlates of physical symptoms (i.e., depressive symptoms, perceived control, social support, medication adherence, sodium intake, and self-care management) were collected from 109 patients with heart failure (mean age 58 ± 14 years, 46% male, 89% New York Heart Association class II/III). Data on physical symptoms (Symptom Status Questionnaire-Heart Failure) and health-related quality of life (Minnesota Living with Heart Failure) also were collected. Simple and multiple regression analyses were used to analyze the data.ResultsAmong the potential correlates, depressive symptoms and sodium intake were associated with physical symptoms (F = 11.63, p < .001), and depressive symptoms and perceived control were associated with health-related quality of life (F = 9.917, p < .001). Physical symptoms mediated the relationship between depressive symptoms and health-related quality of life.ConclusionImproving depressive symptoms and eating the appropriate amount of sodium may be primary intervention targets to improve physical symptoms. To improve health-related quality of life, depressive symptoms as well as physical symptoms need to be managed appropriately.     

Low literacy self-care management patient education for a multi-lingual heart failure population: Results of a pilot study

PurposeThe purpose of this pilot study was to test the impact of language-free, low literacy self-care management patient education materials in an ethnically diverse multilingual heart failure (HF) population.MethodsA one group pre-test–post-test design measured changes in self-care, knowledge and health-related quality of life (HRQL) after a 1 month intervention using language-free, low literacy self-care management patient education materials and delivered by a health educator.ResultsThe ethnically diverse sample (n = 21) was predominately male (72%), 48% Black, 42% Hispanic, and 28% marginal/inadequate literacy. There were significant improvements in self-care and knowledge but not HRQL.ConclusionsLanguage-free, low literacy self-care patient education may facilitate improved self-care and knowledge in diverse populations who are at risk for poor HF outcomes.     

Diabetes nurse case management and motivational interviewing for change (DYNAMIC): Study design and baseline characteristics in the Chronic Care Model for type 2 diabetes

BackgroundDespite evidence that diabetes is costly and devastating, the health care system is poorly equipped to meet the challenges of chronic disease care. The Penn State Institute of Diabetes & Obesity is evaluating a model of managing type 2 DM which includes nurse case management (NCM) and motivational interviewing (MI) to foster behavior change. The primary care intervention is designed to improve patients' self care and to reduce clinical inertia through provider use of standardized clinical guidelines to achieve better diabetes outcomes.MethodsThis RCT tests the efficacy of an enhanced NCM intervention on type 2 DM (n = 549) patient outcomes mediated by changes in self-care behavior and diabetes management. Outcome measures include: (a) effect on clinical parameters such as HbA1c (< 7), BP (< 130/80), and LDL (< 100), depression scores and weight; (b) process measures such as complication screening; (c) patient psychological and behavioral outcomes as measured by emotional distress (PAID), diabetes-specific quality of life (ADDQoL), patient satisfaction (DTSQ), self-care activities (SDSCA); and (d) physician satisfaction and cost-effectiveness of the intervention.ConclusionsBaseline includes (mean) age = 58; BMI = 34.4; 57% females; 47% Caucasian, and 39% Hispanic. Patients had elevated HbA1c (8.4), BP (137/77) and LDL (114). Overall, patients were depressed (CES-D = 21.6) and had an extremely negative quality of life (ADDQoL = ? 1.58). We believe that enhanced NCM will both improve self-care and reduce emotional distress for patients with diabetes. If proven effective, enhanced NCM may be translated to other chronic illnesses.     

The role of foot self-care behavior on developing foot ulcers in diabetic patients with peripheral neuropathy: A prospective study

BackgroundAlthough foot self-care behavior is viewed as beneficial for the prevention of diabetic foot ulceration, the effect of foot self-care behavior on the development of diabetic foot ulcer has received little empirical investigation.ObjectiveTo explore the relationship between foot self-care practice and the development of diabetic foot ulcers among diabetic neuropathy patients in northern Taiwan.MethodsA longitudinal study was conducted at one medical center and one teaching hospital in northern Taiwan.ParticipantsA total of 295 diabetic patients who lacked sensitivity to a monofilament were recruited. Five subjects did not provide follow-up data; thus, only the data of 290 subjects were analyzed. The mean age was 67.0 years, and 72.1% had six or fewer years of education.MethodsData were collected by a modified version of the physical assessment portion of the Michigan Neuropathy Screening Instrument and the Diabetes Foot Self-Care Behavior Scale. Cox regression was used to analyze the predictive power of foot self-care behaviors.ResultsA total of 29.3% (n = 85) of diabetic neuropathy patients developed a diabetic foot ulcer by the one-year follow-up. The total score on the Diabetes Foot Self-Care Behavior Scale was significantly associated with the risk of developing foot ulcers (HR = 1.04, 95% CI = 1.01–1.07, p = 0.004). After controlling for the demographic variables and the number of diabetic foot ulcer hospitalizations, however, the effect was non-significant (HR = 1.03, 95% CI = 1.00–1.06, p = 0.061). Among the foot self-care behaviors, lotion-applying behavior was the only variable that significantly predicted the occurrence of diabetic foot ulcer, even after controlling for demographic variables and diabetic foot ulcer predictors (neuropathy severity, number of diabetic foot ulcer hospitalizations, insulin treatment, and peripheral vascular disease; HR = 1.19, 95% CI = 1.04–1.36, p = 0.012).ConclusionsAmong patients with diabetic neuropathy, foot self-care practice may be insufficient to prevent the occurrence of diabetic foot ulcer. Instead, lotion-applying behavior predicted the occurrence of diabetic foot ulcers in diabetic patients with neuropathy. Further studies are needed to explore the mechanism of lotion-applying behavior as it relates to the occurrence of diabetic foot ulcer.     

Effectiveness of a patient-centred,empowerment-based intervention programme among patients with poorly controlled type 2 diabetes: A randomised controlled trial

BackgroundDespite extensive efforts and advances in evidence-based diabetes management, poor glycaemic control still remains a challenge in many countries. There is a paucity of research addressing the needs of patients with poorly controlled type 2 diabetes, or exploring the effectiveness of empowerment-based interventions in this vulnerable population.ObjectivesTo evaluate the effectiveness of a patient-centred, empowerment-based programme on glycaemic control and self-management behaviours among patients with poorly controlled type 2 diabetes.DesignA prospective multi-centre, single-blind, randomised controlled trial.Settings and participantsAdult patients with poorly controlled type 2 diabetes [Haemoglobin A1c (HbA1c) ≥7.5% in the recent six months] were recruited from two tertiary hospitals in Xi’an city, China.MethodsA total of 242 eligible patients were recruited and randomly assigned to the intervention or attentional control groups after baseline measurement. Participants in the intervention group received a 6-week patient-centred, empowerment-based self-management programme, which is theoretically grounded on the principles of the Empowerment Process Model-setting personally meaningful goals, taking action towards goals and reflecting on the impact of action plans. Those in the attentional control group received health education classes and post-discharge follow-up. Outcome measures included glycaemic control (measured by HbA1c) and self-management behaviours. Data were collected at baseline, and at 8th and 20th week after enrolment. Intervention effect were analysed using the generalised estimating equation model on the basis of the intention-to-treat principle.ResultsCompared with the attention control group, the intervention group showed a non-significant HbA1c reduction of 0. 476% (Cohen’s d effect size = 0.31, p = 0.162). The intervention group exhibited significant improvements in general diet management at the 8th-week (β = 0.740; p = 0.013), specific diet management at 8th-week (β = 0.646; p = 0.022) and 20th-week (β = 0.517; p = 0.043), and blood glucose self-monitoring at both the 8th- (β = 0.793; p = 0.009) and 20th-week (β = 0.739; p = 0.017) follow-ups. No intervention-related adverse events were observed.ConclusionsFindings indicate that the patient-centred, empowerment-based self-management intervention program did not induce a significant HbA1c reduction. Whereas this intervention yields improvements in diet management and blood glucose self-monitoring among patients with poorly controlled type 2 diabetes.     

Nasal high flow oxygen therapy in the ward setting: A prospective observational study

BackgroundWhilst research demonstrates the benefits of nasal high flow oxygen in the intensive care setting, limited literature exists on its benefits in ward patients.ObjectivesThis study evaluated the use of nasal high flow oxygen in adult ward patients with respiratory failure or at risk of respiratory deterioration. Primary outcome was an improvement in pulmonary function as indicated by decreases in respiratory and heart rates and an increase in arterial oxygen saturation via pulse oximetry_.Research methodologyUsing a prospective observational research design, purposeful sampling recruited 67 adult ward patients receiving nasal high flow oxygen between May and July 2015 (inclusive). All recruited patients were included in the data analysis.ResultsThe median age was 71.0 years (q25, q75 = 58.0, 78.0) and most patients were medical specialty patients (n = 46, 68.7%). After commencing nasal high flow oxygen, respiratory rate (t = 2.79, p = <0.01) and heart rate (t = 2.23, p = 0.03) decreased and arterial oxygen saturation via pulse oximetry increased (t = 4.08, p = <0.001).ConclusionNasal high flow oxygen appears effective in a selective group of ward patients with respiratory failure, or at risk of respiratory deterioration, and may reduce demand on critical care beds; this warrants further research.     

Soluble TNFα receptor type I and hepcidin as determinants of development of anemia in the long-term follow-up of heart failure patients

BackgroundAnemia is common in patients with chronic heart failure (CHF) and is associated with a worse prognosis. This study aims to identify the biological mechanisms which reflect evolutionary changes in the hemoglobin concentrations in heart failure patients who are still not anaemic.MethodsFifty-nine patients (54 ± 14 years, 83% males) with CHF (LVEF 28 ± 10%), who did not have anemia, and had not received any previous transfusions, were included. The parameters studied were: iron metabolism (ferritin, iron, transferrin, soluble transferrin receptor (sTfR), hepcidin); inflammation (C-reactive protein, soluble TNFα receptor I (sTNFRI), interleukin 6); and myocardial stress (NT-proBNP, high sensitivity TnT, growth differentiation factor 15). All parameters were measured on inclusion and 1 year after inclusion.ResultsBaseline hemoglobin (g/dL) was 14.7 ± 1.5 and at 1 year of follow-up it showed a significant decrease of ? 0.4 (RIC: ? 0.7 to ? 0.06) (p = 0.02). At baseline, only the sTNFRI was a predictor of a decrease in hemoglobin 1 year later (p = 0.007). During follow-up, the increase in sTNFRI (p = 0.002, r = ? 0.39) and hepcidin (p = 0.006, r = ? 0.35) were both associated with a decrease in hemoglobin. Similarly, the patients who became anemic (13%) had higher levels of hepcidin (p = 0.001) and sTNFRI (p = 0.008). The remaining parameters did not show any relationship with the evolution in the hemoglobin.ConclusionsIn CHF patients without anemia, the increase in the inflammatory state (sTNFRI) and the following deterioration in the iron metabolism (hepcidin) were the main determinants of a decrease in hemoglobin and the appearance of anemia in the long term follow-up period.     

Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial

BackgroundThe hypertension prevalence rate is increasing but the control rate is unsatisfactory. Nurse-led healthcare may be an effective way to improve outcomes for hypertensive patients but more evidence is required especially at the community level.ObjectiveThis study aims to establish a nurse-led hypertension management model and to test its effectiveness at the community level.DesignA single-blind, randomized controlled trial was performed in an urban community healthcare center in China. Hypertensive patients with uncontrolled blood pressure (systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg) were randomly allocated into two groups: the study group (n = 67) and the control group (n = 67). The nurse-led hypertension management model included four components (delivery system design, decision support, clinical information system and self-management support). Patients in the control group received usual care. Patients in the study group received a 12-week period of hypertension management. The patient outcomes, which involved blood pressure, self-care behaviors, self-efficacy, quality of life and satisfaction, were assessed at three time points: the baseline, immediately after the intervention and 4 weeks after the intervention.ResultsAfter the intervention, the blood pressure of patients in the study group decreased significantly compared to those in the control group, and the mean reduction of systolic/diastolic blood pressure in the study and control groups was 14.37/7.43 mmHg and 5.10/2.69 mmHg, respectively (p < 0.01). In addition, patients in the study group had significantly greater improvement in self-care behaviors than those in the control group (p < 0.01). The study group had a higher level of satisfaction with hypertensive care than the control group (p < 0.01). No statistically significant difference in self-efficacy and quality of life was detected between the two groups after the intervention.ConclusionsThe nurse-led hypertension management model is feasible and effective in improving the outcomes of patients with uncontrolled blood pressure at the community level.     

Diagnostic performance of BNP and NT-ProBNP measurements in children with heart failure based on congenital heart defects and cardiomyopathies

ObjectivesTo test the diagnostic performance of BNP and NT-ProBNP in children with different hemodynamic dysfunctions.Design and methodsSeventy children who underwent echocardiography and were classified into left and right ventricle volume and pressure overload (LVvO, LVpO, RVvO, and RVpO, respectively) and biventricular volume overload (BVvO) were enrolled.ResultsBNP and NT-ProBNP levels in all groups were higher than those in the control group (p < 0.001, p < 0.001). The increase in peptide levels was strongly correlated with the severity of heart failure (p < 0.001, p < 0.001). There was no significant difference in peptide levels in-between LVvO, LVpO, RVvO, RVpO and BVvO groups. Both measurements were significantly correlated (r = 0.76, p < 0.001) with each other. NT-ProBNP showed a high sensitivity, whereas BNP showed a high specificity and accuracy. AUCs in ROC-curve were 0.97 for BNP and 0.96 for NT-ProBNP.ConclusionsNT-ProBNP may be used in screening of risk groups for cardiac failure because of its' higher sensitivity, but BNP may be specifically used in monitoring patients with heart failure.     

The plasma levels of relaxin-2 and relaxin-3 in patients with diabetes

ObjectivesRelaxin-2 has been found to alleviate fibrosis in experimental diabetic cardiomyopathy. In addition, the levels of serum relaxin-3 were increased and correlated with all the component traits of metabolic syndrome. We investigated the levels of plasma relaxin-2 or relaxin-3 and their relationship to component traits in patients with diabetes.Design and methodsWe studied 33 newly diagnosed type 2 diabetes patients and 38 age-matched healthy subjects. Blood samples were taken at study entry, and relaxin-3, relaxin-2, fasting blood glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides, serum insulin and hemoglobin A_1c (HbA_1c) levels were measured.ResultsRelaxin-2 levels were significantly lower in patients with diabetes than in controls: the median plasma relaxin-2 concentration was 34.68 pg/mL (range, < 29.00–50.81 pg/mL) in patients with diabetes and 45.80 pg/mL (range, < 37.42–54.46 pg/mL) in controls (p = 0.0150). However, no differences in relaxin-3 levels were observed between the diabetes group and controls (p = 0.6550). The plasma levels of relaxin-2 or relaxin-3 were not correlated with systolic blood pressure (BP), diastolic BP, total cholesterol, LDL-C, HDL-C, triglyceride, fasting blood glucose, fasting insulin and HbA_1c in patients with diabetes. Additionally, there was no correlation between the plasma concentrations of relaxin-2 and relaxin-3 in patients with diabetes (r_s = 0.225; p = 0.208).ConclusionsWe conclude that the plasma levels of relaxin-2 in diabetes patients were lower than in controls, however, there are no difference in plasma relaxin-3 concentrations between controls and patients with diabetes. Relaxin-2 or relaxin-3 levels are not related to component traits in patients with diabetes.     

History of diabetes mellitus as a neurologic predictor in comatose survivors of cardiac arrest of cardiac origin treated with mild hypothermia

AimTo investigate the impact of a history of diabetes mellitus on the neurologic outcome in comatose survivors of cardiac arrest of cardiac origin treated with mild hypothermia.MethodsA prospective observational study was performed between September 2003 and July 2008. Eighty comatose survivors of cardiac arrest of cardiac origin were treated with mild hypothermia. Neurologic outcome at the time of hospital discharge, 30-day survival, and complications were assessed.ResultsTwenty-four of the 80 patients (30%) had a history of diabetes. The rate of favorable neurologic outcome was significantly lower in diabetic (17%) than in nondiabetic patients (46%) (p = 0.01). The rate of 30-day survival was lower in diabetic (33%) than in nondiabetic patients (54%), but the difference was not significant (p = 0.10). Multivariate analysis suggested that a history of diabetes was an independent predictor of unfavorable neurologic outcome (odds ratio 7.00, 95% confidence interval 1.42–46.19, p = 0.03), but not for 30-day survival. There was no significant difference in the prevalence of complications.ConclusionA history of diabetes is associated with poor neurologic outcome in comatose survivors of cardiac arrest treated with mild hypothermia.     

HPLC determination of plasma dimethylarginines: Method validation and preliminary clinical application

BackgroundAsymmetric dimethylarginine (ADMA) has been suggested as a possible marker of endothelial dysfunction, and interest in its use in clinical practice is increasing. However, the potential role of symmetric dimethylarginine (SDMA) as an endogenous marker of renal function, has been less widely investigated. The aims of the present study were therefore to determine reference values for dimethylarginines in plasma after method validation, and to ascertain ADMA plasma concentrations in patients with disorders characterized by endothelial dysfunction; a further end-point was to investigate the relationship between SDMA plasma concentrations and estimated GFR (eGFR) as well as plasmatic creatinine in patients with chronic kidney disease (CKD).Materials and methodsHPLC with fluorescence detection was used for the determination of plasma dimethylarginines. To verify the clinical usefulness of ADMA and SDMA, values from 4 groups of patients at a high risk of cardiovascular complications as well renal dysfunction (chronic heart failure n = 126; type II diabetes n = 43; pulmonary arterial hypertension n = 17; chronic kidney disease n = 42) were evaluated, and compared with the reference values, obtained from 225 blood donors.ResultsThe intra- and inter-assay CVs (< 5.2%), the absolute and relative recoveries (96–106%) were highly satisfactory. ADMA levels were significantly elevated in all groups of patients compared with controls (p < 0.001) with the exception of samples from patients with type II diabetes. SDMA levels were significantly elevated both in the patients with chronic kidney disease and in the patients with type II diabetes complicated by renal insufficiency, the values being closely correlated with both eGFR (R = 0.740) and plasmatic creatinine (R = 0.700).ConclusionsThe findings made in the present study shows that ADMA levels are significantly increased in patients with diseases associated with endothelial dysfunction This molecule might, therefore, be used as a biochemical marker for the evaluation of endothelial function. Furthermore, the preliminary results reported suggest that SDMA might be a reliable marker of renal function, especially in peadiatric populations, for which the use of eGFR is not recommended.     

Promotora assisted depression and self-care management among predominantly Latinos with concurrent chronic illness: Safety net care system clinical trial results

The study evaluated depression and self-care management among patients with diabetes and/or heart disease in a 12-month randomized trial conducted in Los Angeles County Department of Health Services (LAC-DHS) community clinics. We compared LAC-DHS clinic usual care (UC) versus A-Helping-Hand (AHH) intervention in which bilingual promotoras, hired and supervised by the research project, provided 6 weekly psychoeducational sessions followed by boosters. Of 1957 screened, 348 depressed patients (PHQ-9 score ≥ 10) were enrolled, randomized to AHH (n = 178) or UC (n = 170) after baseline interview assessing mental health, treatment receipt, co-morbid illness, self-care management, and environmental stressors. Comprehensive assessments were repeated at 6 and 12 months by an independent interviewer blind to the study group.Patients (85% diabetes, 4% heart disease, 11% both) were predominantly female (85%), Latino (99%), born outside of the US (91%). Study attrition at 12 months was 30% (AHH 31%, UC 28%, P = 0.51). No baseline characteristics were associated with attrition. Half of AHH patients received 4 or more sessions. Intend-to-treat analysis found study groups did not vary significantly at 6 and 12 months. Before-after paired t-tests showed significant improvements in most measures in each group.During the trial, LAC-DHS activated healthcare improvements including depression screening, referral to clinic staff including community health workers (with the same role as the promotoras) to improve patient care management. Both patient groups performed equally well which may be a function of the enhanced healthcare model. Future research should replicate the promotora-integrated care model with other groups and care settings with similar comorbid conditions.     

Obesity and the Emergency Short Stay Unit

ObjectivesTo evaluate the health service requirements of obese patients admitted to an Emergency Short Stay Unit (ESSU) and specifically compare length of stay (LOS), failure of ESSU management, and rates of investigations and allied health interventions among obese and non-obese patients.MethodsA prospective cohort study, using convenience sampling was conducted. The body mass index (BMI) of participants was calculated and those with a BMI of ⩾30 were allocated to the obese group, and those that had a BMI of <30 to the non-obese group. Data collected included demographics, admission diagnosis, time and date of ESSU admission and discharge, discharge disposition, radiological investigations, and referrals made to allied health personnel during ESSU admission.ResultsThere were 262 patients that were recruited sub-grouped into 127 (48.5%) obese participants and 135 (51.5%) non-obese participants with similar sex and diagnostic category distributions. The mean LOS in ESSU was similar – 11.5 h (95% CI: 9.9–13.1) for obese patients and, 10.2 h (95% CI: 8.8–11.6) for non-obese patients (p = 0.21). Failure rates of ESSU management, defined as inpatient admission to hospital, were also similar with 29 (22.8%) obese patients admitted to hospital compared to 25 (18.5%) non-obese patients (p = 0.39). Plain X-ray requests were significantly higher among obese patients (71.6 vs 53.3%; p = 0.002), as was the rate of allied health interventions (p = 0.001).ConclusionThere was no significant difference in inpatient admission rates or LOS between obese and non-obese patients managed in the ESSU. Provisions for increased rate of investigations and allied health interventions for obese patients may facilitate timely assessment and disposition from ESSU.     

Relationship between genetic polymorphisms of angiotensin-converting enzyme and methylenetetrahydrofolate reductase as risk factors for type 2 diabetes in Tunisian patients

Background/aimsThe role of methylenetetrahydrofolate reductase (MTHFR) and angiotensin-converting enzyme (ACE) gene polymorphisms as being risk factors for diabetes is still controversial. The aim was to investigate the distribution of ACE and MTHFR genotypes as well as to evaluate the role of plasmatic total homocysteine levels (tHcy) and ACE activity in Tunisian patients with type 2 diabetes mellitus (T2DM).Design and methods115 T2DM patients compared to 116 healthy volunteers.ResultsThe ACE I/D polymorphism was significantly associated with diabetes (p < 0.0001). The DD genotype and D allele were more frequent in patients compared to control group [DD: OR = 4.93; p < 0.0001; 95 % CI: 2.71–8.97; D: OR = 3.08, 95% CI: 2.09–4.51 p < 0.0001]. MTHFR allele and genotype frequencies did not differ between patients and controls. The susceptibility to diabetes in individuals with genotypes DD +vTT was 13.39 and in the individuals with DD + CT was 6.57 times that of the controls. However, individuals with genotypes ID + CC or II + CT have a protective effect against diabetes. The DD and TT genotypes were associated with significantly higher ACE activity and tHcy levels in diabetics.ConclusionOur data suggest that ACE ID polymorphism may act synergistically with MTHFR C677T polymorphism to assess diabetes risk.