Patient–provider perceptions of diabetes and its impact on self‐management: a comparison of African‐American and White patients

Aims To compare patient–provider differences in diabetes‐related perceptions between African‐American and White patients and to examine its association with self‐care behaviours. Methods One hundred and thirty patient–provider pairs were recruited from the greater Detroit area. Patients and providers completed a survey assessing perceptions about diabetes‐related concepts and demographic background. The Diabetes Semantic Differential Scale was used to measure diabetes‐related perceptions. Patients also reported the frequency of performing self‐care behaviours, including following a healthy eating plan, engaging in physical activity, blood glucose monitoring, and taking medication and/or insulin. Results There were a greater number of patient–provider differences in diabetes‐related perceptions for the African‐American patients (nine of 18 concepts) compared with the White patients (four of 18 concepts). Stepwise regression analyses found patients’ semantic differential scores to be significantly associated with five self‐care behaviours for African‐American patients and two self‐care behaviours for White patients. Providers’ semantic differential scores emerged as predictors of self‐care behaviours for African‐American patients, but not for White patients. Conclusions Our findings suggest that compared with White patients, African‐Americans differ in a greater number of diabetes‐related perceptions than their providers. Patients’ and providers’ perceptions of diabetes care concepts have a significant impact on a greater number of self‐care behaviours for African‐American patients than White patients.     

Management of heart failure patients with COVID‐19: a joint position paper of the Chinese Heart Failure Association & National Heart Failure Committee and the Heart Failure Association of the European Society of Cardiology

The coronavirus disease 2019 (COVID‐19) pandemic of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is causing considerable morbidity and mortality worldwide. Multiple reports have suggested that patients with heart failure (HF) are at a higher risk of severe disease and mortality with COVID‐19. Moreover, evaluating and treating HF patients with comorbid COVID‐19 represents a formidable clinical challenge as symptoms of both conditions may overlap and they may potentiate each other. Limited data exist regarding comprehensive management of HF patients with concomitant COVID‐19. Since these issues pose serious new challenges for clinicians worldwide, HF specialists must develop a structured approach to the care of patients with COVID‐19 and be included early in the care of these patients. Therefore, the Heart Failure Association of the European Society of Cardiology and the Chinese Heart Failure Association & National Heart Failure Committee conducted web‐based meetings to discuss these unique clinical challenges and reach a consensus opinion to help providers worldwide deliver better patient care. The main objective of this position paper is to outline the management of HF patients with concomitant COVID‐19 based on the available data and personal experiences of physicians from Asia, Europe and the United States.     

Sleep‐disordered breathing in heart failure

Sleep‐disordered breathing—comprising obstructive sleep apnoea (OSA), central sleep apnoea (CSA), or a combination of the two—is found in over half of heart failure (HF) patients and may have harmful effects on cardiac function, with swings in intrathoracic pressure (and therefore preload and afterload), blood pressure, sympathetic activity, and repetitive hypoxaemia. It is associated with reduced health‐related quality of life, higher healthcare utilization, and a poor prognosis. Whilst continuous positive airway pressure (CPAP) is the treatment of choice for patients with daytime sleepiness due to OSA, the optimal management of CSA remains uncertain. There is much circumstantial evidence that the treatment of OSA in HF patients with CPAP can improve symptoms, cardiac function, biomarkers of cardiovascular disease, and quality of life, but the quality of evidence for an improvement in mortality is weak. For systolic HF patients with CSA, the CANPAP trial did not demonstrate an overall survival or hospitalization advantage for CPAP. A minute ventilation‐targeted positive airway therapy, adaptive servoventilation (ASV), can control CSA and improves several surrogate markers of cardiovascular outcome, but in the recently published SERVE‐HF randomized trial, ASV was associated with significantly increased mortality and no improvement in HF hospitalization or quality of life. Further research is needed to clarify the therapeutic rationale for the treatment of CSA in HF. Cardiologists should have a high index of suspicion for sleep‐disordered breathing in those with HF, and work closely with sleep physicians to optimize patient management.     

The impact of cognitive impairment in dementia on self‐care domains in diabetes: A systematic search and narrative review

Self‐management is integral to effective chronic disease management. Cognitive impairments (CogImp) associated with dementia have not previously been reviewed in diabetes mellitus (DM) self‐care. The aims of this study are to know (1) whether CogImp associated with dementia impact self‐care and (2) whether specific CogImp affects key DM self‐care processes. A systematic literature search with a narrative review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. This review examined studies published from January, 2000 to February, 2016 describing the relationship between cognition and DM self‐care domains in community dwelling older adults with dementia/CogImp. Eight studies met inclusion criteria. Decrements in all self‐care domains were associated with CogImp. Problem solving was related to reduced disease knowledge (OR 0.87, 95% CI = 0.49‐1.55), resulting in poorer glycemic control. Decision‐making impairments manifested as difficulties in adjusting insulin doses, leading to more hospital admissions. People without CogImp were better able to find/utilize resources by adhering to recommended management (OR 1.03, 95% CI = 1.02‐1.05). A lack of interaction with health care providers was demonstrated through reduced receipt of important routine investigation including eye examinations (ARR = 0.85, 95% CI = 0.85‐0.86), HbA1c testing (ARR = 0.96, 95% CI = 0.96‐0.97), and LDL‐C testing (ARR = 0.91, 95% CI = 0.901‐0.914). People without CogImp had better clinic attendance (OR 2.17, 95% CI = 1.30‐3.70). Action taking deficits were apparent through less self‐testing of blood sugar levels (20.2% vs 24.4%, P = 0.1) resulting in poorer glycemic control, self‐care, and more frequent micro/macrovascular complications. Persons with diabetes and CogImp, particularly in domains of learning, memory and executive function, were significantly impaired in all self‐care tasks.     

Use of sodium–glucose co‐transporter‐2 inhibitors in patients with and without type 2 diabetes: implications for incident and prevalent heart failure

Type 2 diabetes (T2D) is associated with an increased risk of heart failure (HF), with recent reports indicating that HF with preserved ejection fraction (HFpEF) may be more common than HF with reduced ejection fraction (HFrEF) in patients with T2D. T2D and HF result in worse outcomes than either disease alone. Sodium–glucose co‐transporter‐2 inhibitors (SGLT‐2is) have significantly improved HF outcomes in patients with T2D and may represent a new therapeutic alternative for patients with T2D at risk for or with HF. Current guidelines recommend prevention of HF through risk factor management. Once developed, treatment of HFrEF should include neurohormonal and haemodynamic modulations; however, there are no specific treatments available for HFpEF. SGLT‐2is are the first class of glucose‐lowering therapy to prevent HF in clinical trials and real‐world studies in patients with T2D (with or without established cardiovascular disease and with or without baseline HF). Mechanistic studies suggest that SGLT‐2is have beneficial effects on both systolic and diastolic function and additional systemic effects that could benefit HF outcomes. In patients with HFrEF, SGLT‐2i treatment as add‐on to standard HF therapy has had beneficial effects on HF outcomes, irrespective of T2D status. These results and those of ongoing outcomes trials with SGLT‐2is may help establish this drug class as a treatment for HF in patients with HFrEF and HFpEF, as well as HF in patients without T2D.     

Self‐care versus self‐harm: piercing,tattooing, and self‐injuring in eating disorders

Eating disordered patients seem to have a love–hate relationship with their bodies. Why do some decorate their bodies by means of tattooing and piercing, while others deliberately injure themselves and make parts of their body unattractive? We have explored this question in 101 eating‐disordered patients by means of self‐reporting questionnaires about the presence and characteristics of tattooing, piercing and self‐injuring as well as the underlying motives. Furthermore, we studied the co‐occurrence of impulsive behaviours as well as personality traits. In our patient sample, 11.9 per cent had one or more tattoos, 25.7 per cent a piercing and 64.9 per cent showed some form of self‐injurious behaviour (SIB). Tattooing and piercing are clearly driven by esthetical reasons, whereas SIB can have various explanations. All three behaviours were significantly more often linked to substance (ab)use. With respect to personality traits, piercing was positively linked to extraversion (positive affectivity) and openness, and negatively to conscientiousness. SIB, on the contrary, was positively linked to neuroticism (negative affectivity) and conscientiousness, and negatively to extraversion and openness. Tattooing did not show significant correlations with particular personality traits (probably due to the small number of tattooed patients). In summary, piercing and tattooing seem to reflect more self‐care, and might protect some patients against more self‐harm. Copyright © 2005 John Wiley & Sons, Ltd and Eating Disorders Association.     

Cardioembolic strokes resulting from a self‐inflicted needle puncture involving both sides of the heart

Foreign bodies in the heart are rare occurrences with a limited evidence base to guide recommendations on management. We report a case of multiple cardioembolic strokes as a result of a self‐inflicted sewing needle puncture from the anterior chest through the right ventricle and interventricular septum with its tip in the left ventricle close to the subvalvular apparatus in a 39‐year‐old psychiatric patient. We discuss issues surrounding decision making and ongoing care and highlight the importance of further follow‐up and reporting of cases to form a robust evidence base to guide future recommendations.     

Clinical trials update from the European Society of Cardiology Heart Failure Meeting 2010: TRIDENT 1, BENEFICIAL,CUPID, RFA‐HF,MUSIC, DUEL,handheld BNP,phrenic nerve stimulation,CHAMPION and CABG with CRT study

This article provides information and a commentary on key trials relevant to the pathophysiology, prevention and treatment of heart failure (HF) presented at the annual meeting of the Heart Failure Association of the European Society of Cardiology held in Berlin. Unpublished reports should be considered as preliminary, since analyses may change in the final publication. Tonapofylline failed to show efficacy and was associated with an approximately 1% increased risk of seizures in patients with acute decompensated heart failure (ADHF) and renal dysfunction in TRIDENT. Results from BENEFICIAL do not support the use of alagebrium, an advanced glycation end‐product breaker, in clinically stable patients with relatively mild HF symptoms. CUPID showed encouraging preliminary results for augmentation of SERCA2a enzyme activity by gene transfection in patients with severe HF. The RFA‐HF study did not provide convincing evidence for the use of radiofrequency ablation for atrial fibrillation but was underpowered. A wearable, multi‐sensor patch showed potential for detecting impending HF decompensation in MUSIC. A comparison of low‐intensity oral diuretic therapy in patients hospitalized with ADHF suggested that torasemide was superior to furosemide in DUEL. The use of point‐of‐care B‐type natriuretic peptide and echocardiography failed to improve the rate of correct HF diagnosis in primary care. Phrenic nerve stimulation improved symptoms of sleep apnoea in a small study of patients with HF and central sleep apnoea. The use of a novel implantable pulmonary artery pressure monitoring system to guide patient management improved outcomes in the CHAMPION study. A study to evaluate a combined coronary artery bypass grafting (CABG) and epicardial cardiac resynchronization therapy implantation procedure reduced mortality compared with CABG alone.     

Heart failure outcomes in clinical trials of glucose‐lowering agents in patients with diabetes

Diabetes is a major risk factor for heart failure (HF). Patients with diabetes have a high incidence of both clinical HF and subclinical LV dysfunction. Although intensive glucose lowering does not appear to impact on HF outcomes, the choice of glucose‐lowering agents plays an important role in the development of HF and related cardiovascular outcomes. Whilst metformin and insulin appear to have little impact on HF progression, the role of sulphonylurea agents in this patient population remains uncertain. Thiazolidinediones (TZDs) are associated with a significant risk of HF progression and are best avoided in patients at risk. The incretin‐based therapies (GLP agonists and DPP‐4 inhibitors) are generally not associated with any HF interaction. However, a small increase in HF admissions was observed with the DPP‐4 inhibitor saxagliptin. The GLP‐1 agonist liraglutide was recently shown to reduce cardiovascular and all‐cause mortality, yet hospitalization for HF was not significantly reduced. The SGLT2 inhibitor empagliflozin was shown to reduce HF admissions and cardiovascular mortality in patients with prior cardiovascular disease including HF. These recent data showing improved outcomes with a glucose‐lowering category provide a novel strategy to improve survival and reduce morbidity in diabetic patients at high cardiovascular disease risk.     

Galectin‐3: a novel mediator of heart failure development and progression

Galectins are a family of soluble β‐galactoside‐binding lectins that play many important regulatory roles in inflammation, immunity, and cancer. Recently, a role for galectin‐3 in the pathophysiology of heart failure (HF) has been suggested. Numerous studies have demonstrated the up‐regulation of galectin‐3 in hypertrophied hearts, its stimulatory effect on macrophage migration, fibroblast proliferation, and the development of fibrosis. The latter observation is particularly relevant as cardiac remodelling is an important determinant of the clinical outcome of HF and is linked to disease progression and poor prognosis. Because galectin‐3 expression is maximal at peak fibrosis and virtually absent after recovery, routine measurement in patients with HF may prove valuable to identify those patients at highest risk for readmission or death, thus enabling physicians to tailor the level of care to individual patient needs. This review summarizes the most recent advances in galectin‐3 research, with an emphasis on the role galectin‐3 plays in the development and progression of HF.     

Cancer diagnosis in patients with heart failure: epidemiology,clinical implications and gaps in knowledge

Cancer and heart failure (HF) are common medical conditions with a steadily rising prevalence in industrialized countries, particularly in the elderly, and they both potentially carry a poor prognosis. A new diagnosis of malignancy in subjects with pre‐existing HF is not infrequent, and challenges HF specialists as well as oncologists with complex questions relating to both HF and cancer management. An increased incidence of cancer in patients with established HF has also been suggested. This review paper summarizes the epidemiology and the prognostic implications of cancer occurrence in HF, the impact of pre‐existing HF on cancer treatment decisions and the impact of cancer on HF therapeutic options, while providing some practical suggestions regarding patient care and highlighting gaps in knowledge.     

Non‐pharmacological treatments for COPD

Chronic obstructive pulmonary disease (COPD) affects roughly 10% of the global population and is growing in prevalence annually. COPD is characterized by progressive non‐reversible narrowing of airways mainly due to cigarette smoking. Therapeutic interventions aimed at altering this progressive disease course can largely be grouped into pharmacological or non‐pharmacological therapies. The focus of this paper is on the non‐pharmacological aspects of COPD management, reviewing the current literature to provide an evidence‐based management approach. Non‐pharmacological therapies reviewed in this article include the implementation of comprehensive care models utilizing a coordinated multidisciplinary team, tele‐monitoring and patient‐centred approach to optimize COPD care and improve compliance. Preventing progression of COPD via smoking cessation remains of paramount importance, and newer therapeutic options including electronic cigarettes show promise in small studies as cessation aids. COPD has systemic manifestations that can be ameliorated with the enrollment in pulmonary rehabilitation programmes, which focus on exercise endurance to improve dyspnoea and quality of life. Advanced therapeutics for COPD includes lung volume reduction surgery for a pre‐specified cohort and minimally invasive bronchoscopic valves that in recent reviews show promise. Lastly, patients on maximal COPD therapy with progressive disease can be referred for lung transplantation; however, this often requires a highly selected and motivated patient and care team. Survival rates for lung transplantation are improving; thus, this procedure remains a viable option as more expertise and experience are gained.     

HFSA 2010 Comprehensive Heart Failure Practice Guideline

Heart failure (HF) is a syndrome characterized by high mortality, frequent hospitalization, reduced quality of life, and a complex therapeutic regimen. Knowledge about HF is accumulating so rapidly that individual clinicians may be unable to readily and adequately synthesize new information into effective strategies of care for patients with this syndrome. Trial data, though valuable, often do not give direction for individual patient management. These characteristics make HF an ideal candidate for practice guidelines. The 2010 Heart Failure Society of America comprehensive practice guideline addresses the full range of evaluation, care, and management of patients with HF.     

The effect of peer support groups on self‐care for haemophilic patients with HIV in Japan

Experienced peer support groups (EPSG) are expected to improve self‐care and complement professional health care for haemophilic patients, even those living in inconvenient clinical setting. However, these benefits have not been verified quantitatively. The structural equation modelling (SEM) was used to evaluate the effects of contact with EPSG on self‐care for haemophilic patients in the Japanese clinical settings. Factors affecting self‐care were compared between groups with and without EPSG contact. Self‐reported questionnaires were mailed to 652 haemophilic patients with HIV in Japan (September 2005–January 2006). SEM demonstrated significant associations between EPSG contact, self‐care scores and other social and individual factors. The total effect of EPSG contact on self‐care was calculated. The structural differences between models were analysed in a multi‐group analysis. Of the 257 respondents (response rate, 39.4%), 109 reported having contact with an EPSG (EPSG+ group) and 139 reported no contact (EPSG? group). EPSG contact was significantly associated with better self‐care. In the multi‐group analysis, the total effect of inconvenient access to medical services on self‐care in the EPSG+ group was 10% of that in the EPSG? group and was significantly associated with poor illness‐related knowledge and high anxiety level only in the EPSG? group. In the EPSG+ group, patient age was strongly associated with self‐care than in the EPSG? group. These findings suggest that EPSG contact may alleviate inconvenience in medical services. Factors associated with self‐care differed between groups. Health care professionals must carefully assess self‐care behaviours and service accessibility based on these results.     

Evaluation of Synergistic Effects of Resynchronization Therapy and a β‐Blocker Up‐titration Strategy Based on a Predefined Patient‐Management Program: The RESTORE Study

Prior studies have suggested that a substantial number of eligible heart failure (HF) patients fail to receive β‐blocker therapy, or receive it at a suboptimal dose. The aim of this study is to assess the benefit of a predefined management program designed for β‐blocker up‐titration, evaluating the synergistic effect of cardiac resynchronization therapy (CRT) and β‐blockers in a HF population. The Resynchronization Therapy and β‐Blocker Titration (RESTORE) study is a prospective, case‐control, multicenter cohort study designed to test the hypothesis that a β‐blocker up‐titration strategy based on a predefined management program maximizes the beneficial effect of CRT, increasing the number of patients reaching the target dose of β‐blockers and improving their clinical outcome. All study patients receive an implantable defibrillator for CRT delivery in accordance with current guidelines. Enrollments started in December 2011 and are scheduled to end in December 2014. Approximately 250 consecutive patients will be prospectively enrolled in 6 Italian centers and followed up for 24 months after implantation. The primary endpoint is to demonstrate that CRT may allow titration of β‐blockers until the optimal dose, or at least to the effective dose, in patients with HF. This study might provide important information about the benefit of a predefined management program for β‐blocker up‐titration in patients receiving CRT. Moreover, assessment of health‐care utilization and the consumption of resources will allow estimating the potential utility of remote monitoring by means of an automated telemedicine system in facilitating the titration of β‐blockers in comparison with a standard in‐hospital approach.     

Can the application of control theory assist patient management in rheumatoid arthritis?

Supporting patient self‐management is an important part of the care of patients with rheumatoid arthritis (RA) but patients vary in their capacity and willingness to manage their illness and may feel overwhelmed by the challenge of controlling the impact on their life. This paper discusses the value and importance of control theory and how it might be applied to enhance patients' self‐management. Not only does it offer a means of identifying those who might have greatest difficulty in managing their illness, but it also points the way to effective interventions. Copyright © 2010 John Wiley & Sons, Ltd.     

Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline

Heart failure (HF) is a syndrome characterized by high mortality, frequent hospitalization, reduced quality of life, and a complex therapeutic regimen. Knowledge about HF is accumulating so rapidly that individual clinicians may be unable to readily and adequately synthesize new information into effective strategies of care for patients with this syndrome. Trial data, though valuable, often do not give direction for individual patient management. These characteristics make HF an ideal candidate for practice guidelines. The 2010 Heart Failure Society of America comprehensive practice guideline addresses the full range of evaluation, care, and management of patients with HF.     

Management of veno‐occlusive disease: the multidisciplinary approach to care

Although it is considered a relatively rare disorder, veno‐occlusive disease (VOD) is one of the main causes of overall, non‐relapse mortality associated with haematopoietic stem cell transplantation (HSCT). This article, based on the consensus opinion of haemato‐oncology nurses, haemato‐oncologists and pharmacists from both adult and paediatric services at the VOD International Multi‐Disciplinary Advisory Board at the European Society for Blood and Marrow Transplantation (EBMT) meeting, Istanbul, 2015, aims to explore the multidisciplinary approach to care for the management of VOD, with an emphasis on current challenges in this area. The careful monitoring of HSCT patients allows early detection of the symptoms associated with VOD and timely treatment, ultimately improving patient outcomes. As part of a multidisciplinary team, nurses have an essential role to play, from pretransplant assessment to medical management and overall care of the patient. Physicians and pharmacists have a responsibility to facilitate education and training so that nurses can work effectively within that team.