[Management of cardiovascular diseases in patients with diabetes : ESC guidelines 2023]. / Management kardiovaskulärer Erkrankungen bei Patienten mit Diabetes : ESC-Leitlinie 2023.

Patients with diabetes mellitus have an increased risk for the development of cardiovascular diseases. The presence of both comorbidities has a major impact not only on the prognosis of the patients but is also decisive for the implementation of evidence-based treatment strategies for reduction of the cardiovascular risk. The new guidelines of the European Society of Cardiology (ESC) were published in 2023 and provide clear recommendations for the management of cardiovascular diseases in patients with diabetes. The most relevant aspects of these guidelines are summarized in the following overview article.

Challenges in heart failure care in four European countries: a comparative study.

BACKGROUND: In Europe, more than 15 million people live with heart failure (HF). It imposes an enormous social, organizational and economic burden. As a reaction to impending impact on healthcare provision, different country-specific structures for HF-care have been established. The aim of this report is to provide an overview and compare the HF-care approaches of Germany, Ireland, the Netherlands and the UK, and to open the possibility of learning from each other's experience. METHODS: A mixed methods approach was implemented that included a literature analysis, interviews and questionnaires with HF-patients and caregivers, and expert interviews with representatives from healthcare, health service research and medical informatics. RESULTS: The models of HF-care in all countries analyzed are based on the European Society of Cardiology guidelines for diagnosis and treatment of HF. Even though the HF-models differed in design and implementation in practice, key challenges were similar: (i) unequal distribution of care between urban and rural areas, (ii) long waiting times, (iii) unequal access to and provision of healthcare services, (iv) information and communication gaps and (v) inadequate implementation and financing of digital applications. CONCLUSION: Although promising approaches exist to structure and improve HF-care, across the four countries, implementation was reluctant to embrace novel methods. A lack of financial resources and insufficient digitalization making it difficult to adopt new concepts. Integration of HF-nurses seems to be an effective way of improving current models of HF-care. Digital solutions offer further opportunities to overcome communication and coordination gaps and to strengthen self-management skills.

Influenza vaccination in patients affected by diabetes.

Type 2 diabetes, obesity-related metabolic syndrome, and insulin resistance are the most common metabolic disorders associated with increased cardiovascular risk. In addition, patients with Type 2 diabetes have an increased risk for a more severe course of influenza virus infection, a common pandemic. There is increasing evidence that influenza vaccination in patients with diabetes can safely and effectively reduce all-cause mortality and cardiovascular death. The effects of vaccination appear to be more effective when using higher-dose and quadrivalent vaccines, although subgroup-specific separate analyses in patients with diabetes are lacking. Clinical recommendations address influenza vaccination in all adults with diabetes. From our point of view, it should be an integral part of treatment strategies in patients with diabetes.

[Lipid lowering: new agents and new concepts]. / Lipidsenkung: neue Substanzen und neue Konzepte.

Low-density lipoprotein (LDL) cholesterol (LDL-C) is a causal risk factor for cardiovascular complications. A target value is set according to risk, guideline-based and individual basis. We now have the means to lower LDL­C levels to ranges that are even associated with plaque volume regression. Moreover, lipid treatment is an example of how pharmacotherapy has evolved from classical selective inhibition of enzymes by drugs (e.g. statins) to targeted neutralization of proteins by antibodies. The reduction of atherogenic lipoproteins by specific inhibition or reduction of mRNA of target proteins, e.g. PCSK­9, ANGPLT3, ApoC-III or Apo (a), and possibly one day by vaccination or even CRISP-based gene therapy will in the long term lead to new concepts in the treatment and prevention of dyslipidemia and cardiovascular complications. The cumulative exposure of atherogenic lipoproteins to the vessel wall is determined by the time-averaged LDL­C level. This essentially depends on patient adherence and prescribed treatment intensity by physicians. Therefore, it is likely that treatment adherence influences the cumulative benefit of treatment. Accordingly, the new therapeutic strategies mentioned above with presumably higher adherence rates could help to optimize cardiovascular prevention. Early and effective LDL­C lowering could drastically reduce the incidence of cardiovascular complications in the long term and help to maintain the health of our patients.

Application of wearables for remote monitoring of oncology patients: A scoping review.

Objective: This review aims to systematically map and categorize the current state of wearable applications among oncology patients and to identify determinants impeding clinical implementation. Methods: A Medline, Embase and clinicaltrials.gov search identified journal articles, conference abstracts, letters, reports, dissertations and registered studies on the use of wearables in patients with malignancies published up to 10 November 2021. Results: Of 2509 records identified, 112 met the eligibility criteria. Of these, 9.8% (11/112) were RCTs and 47.3% (53/112) of publications were observational. Wearables were investigated pre-treatment (2.7%; 3/112), during treatment (34.8%; 39/112), post-treatment (17.9%; 20/112), in survivors (27.7%; 31/112) and in non-specified or multiple treatment phases (17.0%; 19/112). Medical-grade wearables were applied in 22.3% (25/112) of publications. Primary objectives ranged from technical feasibility (8.0%; 9/112), user feasibility (42.9%; 48/112) and correlational analysis (40.2%; 45/112) to outcome change analysis (8.9%; 10/112). Outcome change was mostly investigated regarding physical activity improvement (80.0%; 8/10). Most publications (42.9%; 48/112) and registered studies (39.3%; 24/61) featured multiple cancer types, with breast cancer as the most prevalent specific type (22.3% in publications, 16.4% in registered studies). Conclusions: Most studies among oncology patients using wearables are focused on assessing the user feasibility of consumer-grade wearables, whereas rates of RCTs assessing clinical efficacy are low. Substantial improvements in clinically relevant endpoints by the use of wearables, such as morbidity and mortality are yet to be demonstrated.

Clinical implications and risk factors for QRS prolongation over time in heart failure patients.

BACKGROUND: QRS prolongation is an established prognostic marker in heart failure (HF). In contrast, the role of QRS width progression over time has been incompletely explored. The current study investigates the role of QRS width progression over time on clinical status and identifies underlying predictors. METHODS: Datasets of ≥ 2 consecutive visits from 100 attendees to our HF clinic between April and August 2021 were analysed for changes in QRS complex duration. RESULTS: In total 240 datasets were stratified into tertiles based on change in QRS duration (mm/month) (1st tertile: - 1.65 [1.50] 'regression'; 2nd tertile 0.03 [0.19] 'stable', 3rd tertile 3.57 [10.11] 'progression'). The incidence of the combined endpoint HF hospitalisation and worsening of symptomatic heart failure was significantly higher in the group with QRS width progression (3rd tertile) compared with the stable group (2nd tertile; log-rank test: p = 0.013). These patients were characterised by higher plasma NT-pro-BNP levels (p = 0.008) and higher heart rate (p = 0.007). A spline-based prediction model identified patients at risk of QRS width progression when NT-pro-BNP and heartrate were > 837 pg/ml and > 83/bpm, respectively. These markers were independent of guideline-directed medical HF therapy. Patients beyond both thresholds had a 14-fold increased risk of QRS width progression compared to those with neither or either alone (HR: 14.2 [95% 6.9 - 53.6]; p < 0.0001, p for interaction = 0.016). CONCLUSIONS: This pilot study demonstrates that QRS width progression is associated with clinical deterioration of HF. NTproBNP plasma levels and heart rate indicate patients at risk QRS width progression, independently of HF therapy.

Wearable based monitoring and self-supervised contrastive learning detect clinical complications during treatment of Hematologic malignancies.

Serious clinical complications (SCC; CTCAE grade ≥ 3) occur frequently in patients treated for hematological malignancies. Early diagnosis and treatment of SCC are essential to improve outcomes. Here we report a deep learning model-derived SCC-Score to detect and predict SCC from time-series data recorded continuously by a medical wearable. In this single-arm, single-center, observational cohort study, vital signs and physical activity were recorded with a wearable for 31,234 h in 79 patients (54 Inpatient Cohort (IC)/25 Outpatient Cohort (OC)). Hours with normal physical functioning without evidence of SCC (regular hours) were presented to a deep neural network that was trained by a self-supervised contrastive learning objective to extract features from the time series that are typical in regular periods. The model was used to calculate a SCC-Score that measures the dissimilarity to regular features. Detection and prediction performance of the SCC-Score was compared to clinical documentation of SCC (AUROC ± SD). In total 124 clinically documented SCC occurred in the IC, 16 in the OC. Detection of SCC was achieved in the IC with a sensitivity of 79.7% and specificity of 87.9%, with AUROC of 0.91 ± 0.01 (OC sensitivity 77.4%, specificity 81.8%, AUROC 0.87 ± 0.02). Prediction of infectious SCC was possible up to 2 days before clinical diagnosis (AUROC 0.90 at -24 h and 0.88 at -48 h). We provide proof of principle for the detection and prediction of SCC in patients treated for hematological malignancies using wearable data and a deep learning model. As a consequence, remote patient monitoring may enable pre-emptive complication management.

Diabetes-related research priorities of people with type 1 and type 2 diabetes: a cross-sectional study in Germany.

To investigate (i) the importance and priorities of research objectives for people with type 1 (T1DM) and type 2 diabetes (T2DM); (ii) subgroups with specific research priorities; (iii) associated factors (e.g., sociodemographic characteristics) of the subgroups. The cross-sectional survey was conducted in 2018 using data from 869 respondents (29.0% response, 31.2% female, mean age 61.3 years, 62.7% T2DM) from a German statutory health insurance population. Diabetes-related research priorities were assessed with a questionnaire. Subgroups and associated factors were identified using latent class analysis. Three subgroups were found in T1DM: (1) high priority for the research topic 'healing diabetes' and moderate priority for the research topic 'prevention of long-term complications', (2) priorities for simplifying handling (high) and stress reduction (moderate), (3) priorities for healing diabetes (high) and simplifying handling (high). Three subgroups were found in T2DM: (1) priorities for simplifying handling (moderate), diabetes prevention (moderate) and prevention of long-term complications (moderate), (2) priorities for stress reduction (high) and diabetes prevention (moderate), (3) priorities for simplifying handling (high) and stress reduction (high). Classes differed in age and HbA1c. Knowledge about research priorities enables researchers to align their work with the needs of people with diabetes.

Glycaemic variability is associated with all-cause mortality in COVID-19 patients with ARDS, a retrospective subcohort study.

There is high mortality among intensive care unit (ICU) patients with acute respiratory distress syndrome (ARDS) caused by coronavirus disease (COVID-19). Important factors for COVID-19 mortality are diabetes status and elevated fasting plasma glucose (FPG). However, the effect of glycaemic variability on survival has not been explored in patients with COVID-19 and ARDS. This single-centre cohort study compared several metrics of glycaemic variability for goodness-of-fit in patients requiring mechanical ventilation due to COVID-19 ARDS in the ICU at University Hospital Aachen, Germany. 106 patients had moderate to severe ARDS (P/F ratio median [IQR]: 112 [87-148] mmHg). Continuous HRs showed a proportional increase in mortality risk with daily glycaemic variability (DGV). Multivariable unadjusted and adjusted Cox-models showed a statistically significant difference in mortality for DGV (HR: 1.02, (P) < 0.001, LR(P) < 0.001; HR: 1.016, (P) = 0.001, LR(P) < 0.001, respectively). Kaplan-Meier estimators yielded a shorter median survival (25 vs. 87 days) and a higher likelihood of death (75% vs. 31%) in patients with DGV ≥ 25.5 mg/dl (P < 0.0001). High glycaemic variability during ICU admission is associated with significant increase in all-cause mortality for patients admitted with COVID-19 ARDS to the ICU. This effect persisted even after adjustment for clinically predetermined confounders, including diabetes, median procalcitonin and FPG.

Feasibility of Wearable-Based Remote Monitoring in Patients During Intensive Treatment for Aggressive Hematologic Malignancies.

PURPOSE: Intensive treatment protocols for aggressive hematologic malignancies harbor a high risk of serious clinical complications, such as infections. Current techniques of monitoring vital signs to detect such complications are cumbersome and often fail to diagnose them early. Continuous monitoring of vital signs and physical activity by means of an upper arm medical wearable allowing 24/7 streaming of such parameters may be a promising alternative. METHODS: This single-arm, single-center observational trial evaluated symptom-related patient-reported outcomes and feasibility of a wearable-based remote patient monitoring. All wearable data were reviewed retrospectively and were not available to the patient or clinical staff. A total of 79 patients (54 inpatients and 25 outpatients) participated and received standard-of-care treatment for a hematologic malignancy. In addition, the wearable was continuously worn and self-managed by the patient to record multiple parameters such as heart rate, oxygen saturation, and physical activity. RESULTS: Fifty-one patients (94.4%) in the inpatient cohort and 16 (64.0%) in the outpatient cohort reported gastrointestinal symptoms (diarrhea, nausea, and emesis), pain, dyspnea, or shivering in at least one visit. With the wearable, vital signs and physical activity were recorded for a total of 1,304.8 days. Recordings accounted for 78.0% (63.0-88.5; median [interquartile range]) of the potential recording time for the inpatient cohort and 84.6% (76.3-90.2) for the outpatient cohort. Adherence to the wearable was comparable in both cohorts, but decreased moderately over time during the trial. CONCLUSION: A high adherence to the wearable was observed in patients on intensive treatment protocols for a hematologic malignancy who experience high symptom burden. Remote patient monitoring of vital signs and physical activity was demonstrated to be feasible and of primarily sufficient quality.

[Pathophysiological principles of dyslipoproteinaemia]. / Pathophysiologische Prinzipien von Dyslipoproteinämien.

The effective reduction of atherogenic lipoproteins has contributed to the rate of atherosclerosis-related cardiovascular complications being approximately halved over the last 50 years. Nevertheless, cardiovascular disease will be the leading cause of death worldwide in the coming years. The focus of this review is on the clinical significance of the pathophysiology of changes in lipid and lipoprotein metabolism. Elevated levels of atherogenic lipoproteins are a causal risk factor for atherosclerotic cardiovascular disease. Primary forms of hypercholesterolaemia have a significantly higher ASCVD risk because of the already lifelong LDL elevation (higher cumulative LDL exposure for the vessel wall). Secondary changes in lipid and lipoprotein metabolism (e. g. in diabetes or hypothyroidism) must be excluded or treated. Regulatory key steps in the pathophysiology of lipid metabolism and atherosclerotic plaque are "drug targets" for existing and new lipid and lipoprotein modifying therapies.

Associations Between Migration Background and Media and Information Behavior in Primary School Children.

BACKGROUND: Children with migration background and from low socio-economic status are at higher risk for overweight. To determine appropriate media channels to possibly reach children with targeted health information, it has to be considered that the media and information behavior of children has changed during the last decades. OBJECTIVE: We examined the media and information behavior of children in low socio-economic districts, focusing on those with migration background. METHODS: Fourteen 3rd grade classes (n=250 children, 68.0% with migration background) completed a questionnaire regarding their media consumption, which was based on existing validated surveys. RESULTS: ≥ 50% of the children watched TV and around 40% used both mobile phones and computers/tablets/internet for ≥1 h/day. Books were the most popular analogue media (61.6% of children), whereas magazines/newspapers and radio (18.4 and 16.0% of children, respectively) were used less frequently. Furthermore, they regularly used internet, TV and their teachers (63.0, 48.8 and 44.8% of children, respectively) as information source. Especially children with compared to those without migration background less likely used the radio (P=0.0002) and their family as information source (P=0.0017). CONCLUSIONS: Children attending 3rd grade class, especially with migration background, can be addressed through digital media rather than the radio. This may help to sustainably support children outside school with targeted health information.

Simultaneous acquisition of functional magnetic resonance images and impedance cardiography.

While simultaneous acquisition of electrocardiography (ECG) data during MRI is a widely used clinical technique, the effects of the MRI environment on impedance cardiography (ICG) data have not been characterized. We collected echo planar MRI scans while simultaneously recording ECG and thoracic impedance using carbon fiber electrodes and customized amplifiers. Here, we show that the key changes in impedance (dZ/dt) and features of the ECG waveforms are not obstructed during MRI. We present a method for ensemble averaging ICG/ECG signals collected during MRI and show that it performs comparably with signals collected outside the MRI environment. These results indicate that ICG can be used during MRI to measure stroke volume, cardiac output, preejection period, and left ventricular ejection time.