The effectiveness of the Austrian disease management programme for type 2 diabetes: a cluster-randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>Disease management programmes (DMPs) are costly and impose additional work load on general practitioners (GPs). Data on their effectiveness are inconclusive. We therefore conducted a cluster-randomised controlled trial to evaluate the effectiveness of the Austrian DMP for diabetes mellitus type 2 on HbA1c and quality of care for adult patients in primary care.</p> <p>Methods</p> <p>All GPs of Salzburg-province were invited to participate. After cluster-randomisation by district, all patients with diabetes type 2 were recruited consecutively from 7-11/2007. The DMP, consisting mainly of physician and patient education, standardised documentation and agreement on therapeutic goals, was implemented in the intervention group while the control group received usual care. We aimed to show superiority of the intervention regarding metabolic control and process quality. The primary outcome measure was a change in HbA1c after one year. Secondary outcomes were days in the hospital, blood pressure, lipids, body mass index (BMI), enrolment in patient education and regular guideline-adherent examination. Blinding was not possible.</p> <p>Results</p> <p>92 physicians recruited 1489 patients (649 intervention, 840 control). After 401 ± 47 days, 590 intervention-patients and 754 controls had complete data. In the intention to treat analysis (ITT) of all 1489 patients, HbA1c decreased 0.41% in the intervention group and 0.28% in controls. The difference of -0.13% (95% CI -0.24; -0.02) was significant at p = 0.026. Significance was lost in mixed models adjusted for baseline value and cluster-effects (adjusted mean difference -0.03 (95% CI -0.15; 0.09, p = 0.607). Of the secondary outcome measures, BMI and cholesterol were significantly reduced in the intervention group compared to controls in ITT after adjustments (-0.53 kg/m²; 95% CI -1.03;-0.02; p = 0.014 and -0.10 mmol/l; 95% CI -0.21; -0.003; p = 0.043). Additionally, more patients received patient education (49.5% vs. 20.1%, p < 0.0001), eye- (71.0% vs. 51.2%, p < 0.0001), foot examinations (73.8% vs. 45.1%, p < 0.0001), and regular HbA1c checks (44.1% vs. 36.0%, p < 0.01) in the intervention group.</p> <p>Conclusion</p> <p>The Austrian DMP implemented by statutory health insurance improves process quality and enhances weight reduction, but does not significantly improve metabolic control for patients with type 2 diabetes mellitus. Whether the small benefit seen in secondary outcome measures leads to better patient outcomes, remains unclear.</p> <p>Trial Registration</p> <p>Current Controlled trials Ltd., ISRCTN27414162.</p

Head to head comparisons of two modalities of perfusion adenosine stress echocardiography with simultaneous SPECT

<p>Abstract</p> <p>Background</p> <p>Real-time perfusion (RTP) contrast echocardiography can be used during adenosine stress echocardiography (ASE) to evaluate myocardial ischemia. We compared two different types of RTP power modulation techniques, angiomode (AM) and high-resolution grayscale (HR), with ^99mTc-tetrofosmin single-photon emission computed tomography (SPECT) for the detection of myocardial ischemia.</p> <p>Methods</p> <p>Patients with known or suspected coronary artery disease (CAD), admitted to SPECT, were prospectively invited to participate. Patients underwent RTP imaging (SONOS 5500) using AM and HR during Sonovue^®infusion, before and throughout the adenosine stress, also used for SPECT. Analysis of myocardial perfusion and wall motion by RTP-ASE were done for AM and HR at different time points, blinded to one another and to SPECT. Each segment was attributed to one of the three main coronary vessel areas of interest.</p> <p>Results</p> <p>In 50 patients, 150 coronary areas were analyzed by SPECT and RTP-ASE AM and HR. SPECT showed evidence of ischemia in 13 out of 50 patients. There was no significant difference between AM and HR in detecting ischemia (p = 0.08). The agreement for AM and HR, compared to SPECT, was 93% and 96%, with Kappa values of 0.67 and 0.75, respectively (p < 0.001).</p> <p>Conclusion</p> <p>There was no significant difference between AM and HR in correctly detecting myocardial ischemia as judged by SPECT. This suggests that different types of RTP modalities give comparable data during RTP-ASE in patients with known or suspected CAD.</p

Six months into the war: a first-wave study of stress, anxiety, and depression among in Ukraine

Objective: This study examines the prevalence and predictors of mental health issues, specifically anxiety, depression, and stress, among Ukrainians during the military conflict with Russia. Method: A cross-sectional correlational study was conducted six months after the beginning of the conflict. Sociodemographic factors, traumatic experiences, anxiety, depression, and stress were assessed. The study included 706 participants, both men and women, from different age groups and living in various regions of Ukraine. The data were collected from August till October 2022. Results: The study found that a large portion of the Ukrainian population shows increased levels of anxiety, depression, and stress due to the war. Women were found to be more vulnerable to mental health issues than men, and younger people were found to be more resilient. Worsened financial and employment statuses predicted increased anxiety. Ukrainians who fled the conflict to other countries exhibited higher levels of anxiety, depression, and stress. Direct exposure to trauma predicted increased anxiety and depression, while war-related exposure to “other stressful events” predicted increased acute stress levels. Conclusion: The findings of this study highlight the importance of addressing the mental health needs of Ukrainians affected by the ongoing conflict. Interventions and support should be tailored to address the specific needs of different groups, particularly women, younger individuals, and those with worsened financial and employment statuses.ISSN:1664-064

Safety and cardiac chronotropic responsiveness to the early injection of atropine during dobutamine stress echocardiography in the elderly

Objective: To determine the safety and cardiac chronotropic responsiveness to early atropine dobutamine stress echocardiography (DSE) in the elderly. Design: Retrospective study of 258 patients ⩾ 70 years who underwent early atropine DSE and 290 patients ⩾ 70 years who underwent conventional DSE. In the early atropine protocol, atropine was started at 20 μg/kg/min of dobutamine if heart rate was < 100 beats/min, up to 2 mg. The cardiac chronotropic responsiveness in the elderly was compared with a control group of patients < 70 years matched for sex, myocardial infarction, diabetes, and treatment with β blockers and calcium channel blockers. Results: The dose of dobutamine given to elderly patients was lower during early atropine than during conventional DSE (mean (SD) 29 (7) v 38 (4) μg/kg/min, p  =  0.001). Early atropine DSE resulted in diminished incidence of ventricular extrasystoles, non-sustained ventricular tachycardia, bradycardia, and hypotension compared with conventional DSE. In comparison with patients < 70 years, elderly patients required lower doses of dobutamine and atropine and achieved a higher percentage of predicted maximum heart rate (92 (9)% v 88 (10)%, p  =  0.0001). Except for more common hypotension (16% v 10%, p  =  0.004), no other difference in adverse effects was observed between patients ⩾ 70 and < 70 years. Conclusions: Early atropine DSE is a safe strategy in the elderly resulting in lower incidence of minor adverse effects than with the conventional protocol. Elderly patients presented adequate cardiac chronotropic responsiveness to early injections of atropine, requiring lower doses of drugs to reach test end points

Effects of a novel mobile health intervention compared to a multi-component behaviour changing program on body mass index, physical capacities and stress parameters in adolescents with obesity: a randomized controlled trial

Background: Less than 2% of overweight children and adolescents in Switzerland can participate in multi-component behaviour changing interventions (BCI), due to costs and lack of time. Stress often hinders positive health outcomes in youth with obesity. Digital health interventions, with fewer on-site visits, promise health care access in remote regions; however, evidence for their effectiveness is scarce.Methods: This randomized controlled not blinded trial (1:1) was conducted in a childhood obesity center in Switzerland. Forty-one youth aged 10-18 years with body mass index (BMI) > P.90 with risk factors or co-morbidities or BMI > P.97 were recruited. During 5.5 months, the PathMate2 group (PM) received daily conversational agent counselling via mobile app, combined with standardized counselling (4 on-site visits). Controls (CON) participated in a BCI (7 on-site visits). We compared the outcomes of both groups after 5.5 (T1) and 12 (T2) months. Primary outcome was reduction in BMI-SDS (BMI standard deviation score: BMI adjusted for age and sex). Secondary outcomes were changes in body fat and muscle mass (bioelectrical impedance analysis), waist-to-height ratio, physical capacities (modified Dordel-Koch-Test), blood pressure and pulse. Additionally, we hypothesized that less stressed children would lose more weight. Thus, children performed biofeedback relaxation exercises while stress parameters (plasma cortisol, stress questionnaires) were evaluated.Results: At intervention start median BMI-SDS of all patients (18 PM, 13 CON) was 2.61 (obesity > + 2SD). BMI-SDS decreased significantly in CON at T1, but not at T2, and did not decrease in PM during the study. Muscle mass, strength and agility improved significantly in both groups at T2; only PM reduced significantly their body fat at T1 and T2. Average daily PM app usage rate was 71.5%. Cortisol serum levels decreased significantly after biofeedback but with no association between stress parameters and BMI-SDS. No side effects were observed.Conclusions: Equally to BCI, PathMate2 intervention resulted in significant and lasting improvements of physical capacities and body composition, but not in sustained BMI-SDS decrease. This youth-appealing mobile health intervention provides an interesting approach for youth with obesity who have limited access to health care. Biofeedback reduces acute stress and could be an innovative adjunct to usual care.</p