Early SGLT2 inhibitor use is associated with improved left atrial strain following acute coronary syndrome.

AIM: Left atrial (LA) strain, a novel marker of LA function, reliably predicts diastolic dysfunction. SGLT2 inhibitors improve heart failure outcomes, but limited data exists regarding their use in the immediate aftermath of acute coronary syndrome (ACS). We studied the effect of empagliflozin on LA strain in patients with type 2 diabetes (T2D) and ACS. METHODS: Patients with ACS and T2D were identified and empagliflozin was initiated in eligible patients prior to discharge. Patients not initiated on empagliflozin were analysed as a comparator group. A blinded investigator assessed LA strain using baseline and 3-6 month follow-up echocardiograms. RESULTS: Forty-four participants (n = 22 each group) were included. Baseline characteristics and LA strain were similar in the two groups. LA reservoir, conduit and contractile strain increased in empagliflozin group (28.0 ± 8.4% to 34.6 ± 12.2% p < 0.001, 14.5 ± 5.4% to 16.7 ± 7.0% p = 0.034, 13.5 ± 5.2% to 17.9 ± 7.2% p = 0.005, respectively) but remained unchanged in comparison group (29.2 ± 6.7% to 28.8 ± 7.0%, 12.8 ± 4.2% to 13.3 ± 4.7%, 16.7 ± 5.3% to 15.5 ± 4.5%, respectively, p = NS). The difference in change between groups was significant for LA reservoir (p = 0.003) and contractile strain (p = 0.005). CONCLUSION: In patients with ACS and T2D, addition of empagliflozin to standard ACS therapy prior to discharge is associated with improved LA function.

Empagliflozin and left ventricular diastolic function following an acute coronary syndrome in patients with type 2 diabetes.

Sodium-glucose cotransporter 2 inhibitors can improve heart failure outcomes, however, the effects on left ventricular (LV) function remain unclear. This prospective observational study aimed to investigate whether initiating empagliflozin therapy was associated with improved LV diastolic function following an acute coronary syndrome (ACS) in patients with type 2 diabetes (T2D). Patients with ACS and T2D were identified during hospitalisation in a cardiology unit. Empagliflozin was initiated at discharge in eligible patients (i.e. HbA1c > 7%) without contraindications or precautions. Transthoracic echocardiography was performed during admission and after 3-6 months. Changes in echocardiographic parameters were compared between patients initiated on empagliflozin versus not initiated on empagliflozin (control). There were 22 patients in each group (n = 44). Baseline characteristics, medications and echocardiographic parameters were similar except HbA1c (empagliflozin: 9.8 ± 1.6% versus control: 6.6 ± 0.7%, p < 0.001). Baseline LV global longitudinal strain (GLS) (empagliflozin: - 12.4 ± 2.8 versus control: - 13.0 ± 3.6%) and ejection fraction (51.1 ± 11.3 versus 54.9 ± 10.8%) were similar. The difference in change from baseline to follow-up was significant for LV mass index (empagliflozin: - 14.1 ± 21.6 versus control: 3.6 ± 18.7 g/m2, p = 0.006), left atrial volume index (- 2.1 ± 8.1 versus 3.4 ± 9.5 ml/m2, p = 0.045), mitral valve E-wave velocity (- 0.14 ± 0.23 versus 0.03 ± 0.16 m/s, p = 0.007) and average E/e' (- 2.1 ± 2.6 versus 0.9 ± 3.4, p = 0.002). There were no significant between-group differences in change for LV GLS, ejection fraction and volume. In patients with ACS and T2D, addition of empagliflozin to ACS therapy at discharge was associated with a reduction in LV mass and favourable changes in diastolic function parameters. Further studies are warranted to investigate these findings.

Impacts of long-standing illness and chronic illness on working hours and household income in a longitudinal UK study.

Individuals within households encounter a variety of events including development of a disability or chronic illness. We used data from the Understanding Society, 2009-2016, to determine whether there are changes to working hours or household income as a result of an individual developing an illness. After adjusting for a variety of sociodemographic characteristics, there were few associations observed between one's own individual illness status and household income. There was a clear trend of reduction of weekly working hours with increasing severity and chronicity of the individuals' illness or disease. Individuals who were not ill, but lived in an household with an ill person worked about 30-min less per week, b = -0.69, 95% confidence interval (CI)=(-1.09, -0.30), while those with a limiting long-standing illness and a chronic disease worked 3.5 h less per week, b = -3.64, 95% CI=(-4.21, -3.08), compared to individuals with no illness in their household. Individuals with a limiting illness only had lower incomes, b = -0.04, 95% CI=(-0.07, -0.004) compared to individuals with no household illness. These associations were not greatly changed with the inclusion of reception of benefits or being cared for. Interactions were observed by gender, age being cared for and reception of benefits. Additionally, there were differences were observed by working age groups and between those who lived alone and those who did not. The findings suggest that while there is a reduction of working hours among individuals with an illness or who have an ill person in their home, household income is resilient to the experience of an illness, in the United Kingdom. However, this appeared to differ by household composition, i.e. whether individuals were of working age or whether they lived alone. Identification of households at highest risk of income reduction may serve to inform policy and appropriate distribution of services and support.

An evaluation of the implementation of cascade training for suicide prevention during the 'Choose Life' initiative in Scotland - utilizing Normalization Process Theory.

BACKGROUND: 'Cascade training' or 'train-the-trainers' has been widely utilised in the dissemination of information and expertise in health and social care, but with little examination of the work required for optimal delivery. National suicide prevention strategies commonly include such training initiatives. METHODS: A qualitative study to characterise the work, according to the concepts of Normalization Process Theory, required to disseminate STORM, a model of suicide prevention training across Scotland, and then implement it within organisations. This utilised a cascade style 'train-the trainers' intervention delivered as part of the Choose Life suicide prevention strategy in Scotland during 2008-11. Semi-structured interviews were carried out with 19 training facilitators, 30 of their group participants within organisations and 11 local managers within health boards in Scotland. RESULTS: Crucial to the process of a cascade training approach to implementing suicide prevention within an organisation was the multi-layered activity of constructing coherence of the intervention at every level in order to prevent dilution of the training. This necessitated collaborative work within and between groups of actors- managers, facilitators and participants. Where facilitators were effectively engaged in their role, confident in their ability to train, supported by supervision and possessed the leadership skills to engage both with participants and their local context to deliver training, there was evidence of both successful delivery and embedding within the organisation. However, there was little systematic evidence of institutional level appraisal- crucial to truly implementing a novel intervention within the system - despite efforts at local managerial engagement. CONCLUSIONS: Successful cascade or train-the-trainer implementation of an intervention requires extensive collaborative work to take place between and within groups of actors at all levels of an organization from those working at policy level to the 'coalface'. A priori application of Normalization Process Theory, to specify aims and goals for the necessary work to be carried out between different groups of actors, would assist in embedding a novel working practice at all levels. Future national training strategies for suicide prevention should address what is required to establish a flourishing culture of high-quality skills acquisition and development within healthcare organisations.

Clinical Outcomes of Patients Treated With Pulmonary Vasodilators Early and in High Dose After Left Ventricular Assist Device Implantation.

Right ventricular failure (RVF) is common after left ventricular assist device (LVAD) implantation and a major determinant of adverse outcomes. Optimal perioperative right ventricular (RV) management is not well defined. We evaluated the use of pulmonary vasodilator therapy during LVAD implantation. We performed a retrospective analysis of continuous-flow LVAD implants and pulmonary vasodilator use at our institution between September 2004 and June 2013. Preoperative RVF risk was assessed using recognized variables. Sixty-five patients (80% men, 50 ± 14 years) were included: 52% HeartWare ventricular assist device (HVAD), 11% HeartMate II (HMII), 17% VentrAssist, 20% Jarvik. Predicted RVF risk was comparable with contemporary LVAD populations: 8% ventilated, 14% mechanical support, 86% inotropes, 25% BUN >39 mg/dL, 23% bilirubin ≥2 mg/dL, 31% RV : LV (left ventricular) diameter ≥0.75, 27% RA : PCWP (right atrium : pulmonary capillary wedge pressure) >0.63, 36% RV stroke work index <6 gm-m/m(2)/beat. The majority (91%) received pulmonary vasodilators early and in high dose: 72% nitric oxide, 77% sildenafil (max 200 ± 79 mg/day), 66% iloprost (max 126 ± 37 µg/day). Median hospital stay was 26 (21) days. No patient required RV mechanical support. Of six (9%) patients meeting RVF criteria based on prolonged need for inotropes, four were transplanted, one is alive with an LVAD at 3 years, and one died on day 35 of intracranial hemorrhage. Two-year survival was 77% (92% for HMII/HVAD): transplanted 54%, alive with LVAD 21%, recovery/explanted 2%. A low incidence of RVF and excellent outcomes were observed for patients treated early during LVAD implantation with combination, high-dose pulmonary vasodilators. The results warrant further investigation in a randomized controlled study.

What can multiwave studies teach us about disaster research: an analysis of low-income Hurricane Katrina survivors.

Previous research on natural disasters has been limited by a lack of predisaster data and statistical analyses that do not adequately predict change in psychological symptoms. In the current study, we addressed these limitations through analysis of 3 waves of data from a longitudinal investigation of 313 low-income, African American mothers who were exposed to Hurricane Katrina. Although postdisaster cross-sectional estimates of the impact of traumatic stress exposure and postdisaster social support on postdisaster psychological distress were somewhat inflated, the general trends persisted when controlling for predisaster data (B = 0.88 and -0.33, vs. B = 0.81 and -0.27, respectively). Hierarchical linear modeling of the 3 waves of data revealed that lower predisaster social support was associated with higher psychological distress at the time of the disaster (ß = -.16), and that higher traumatic stress exposure was associated with greater increases in psychological distress after the storm (ß = .86). Based on the results, we suggest that the impact of traumatic stress on psychological trajectories cannot be accounted for solely by preexisting risk, and recommend more complex research designs to further illuminate the complex, dynamic relationships between psychological distress, traumatic stress exposure, and social support.

Influence of sticky trap color and height above ground on capture of alate Elatobium abietinum (Hemiptera: Aphididae) in Sitka spruce plantations.

A series of field trials were used to assess the practicality of using sticky traps to monitor populations of green spruce aphid, Elatobium abietinum (Walker), in plantations of Sitka spruce. The highest numbers of alate E. abietinum were caught on sticky traps placed in the upper third of the live canopy at 9-17 m above the ground, whereas low numbers of aphids were caught just below the live canopy or at 2 m above the ground. Trials in 2005 with sticky traps of different colors showed that significantly more alate E. abietinum were caught on yellow, red, and green sticky traps than on white, blue, and black traps. A repeat trial in 2007 resulted in significantly more alate aphids being caught on red sticky traps than on traps of any other color except for green. Attraction to red is unusual among aphids, as aphids are thought not to possess a red-sensitive photoreceptor. The attraction of E. abietinum to red-colored sticky traps suggests that conifer-feeding aphids might have a fundamentally different color response compared with aphids that live on cereals, grasses, or herbaceous plants. Alternatively, the attraction to red might be a physiological artifact related to the presence of red-screening pigments in the aphid's compound eye.

Dissemination and implementation of suicide prevention training in one Scottish region.

BACKGROUND: As part of a national co-ordinated and multifaceted response to the excess suicide rate, the Choose Life initiative, the Highland Choose Life Group launched an ambitious programme of training for National Health Service (NHS), Council and voluntary organisation staff. In this study of the dissemination and implementation of STORM (Skills-based Training On Risk Management), we set out to explore not only the outcomes of training, but key factors involved in the processes of diffusion, dissemination and implementation of the educational intervention. METHODS: Participants attending STORM training in Highland Region provided by 12 trained facilitators during the period March 2004 to February 2005 were recruited. Quantitative data collection from participants took place at three time points; immediately before training, immediately post-training and six months after training. Semi-structured telephone interviews were carried out with the training facilitators and with a sample of course participants 6 months after they had been trained. We have utilized the conceptual model described by Greenhalgh and colleagues in a Framework analysis of the data, for considering the determinants of diffusion, dissemination and implementation of interventions in health service delivery and organization. RESULTS: Some 203 individuals completed a series of questionnaire measures immediately pre (time 1) and immediately post (time 2) training and there were significant improvements in attitudes and confidence of participants. Key factors in the diffusion, dissemination and implementation process were the presence of a champion or local opinion leader who supported and directed the intervention, local adaptation of the materials, commissioning of a group of facilitators who were provided with financial and administrative support, dedicated time to provide the training and regular peer-support. CONCLUSION: Features that contributed to the success of STORM were related to both the context (the multi-dimensional support provided from the host organisation and the favourable policy environment) and the intervention (openness to local adaptation, clinical relevance and utility), and the dynamic interaction between context and the intervention.

Supportive adult relationships and the academic engagement of Latin American immigrant youth.

The central aim of this study was to explore the academic engagement trajectories of a sample of recently arrived immigrant students from Latin America. Using an analytic framework that can dynamically model time-sensitive fluctuations (HLM; [Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchicical Linear Models: Applications and Data Analysis Methods (2nd Edition ed.). Thousand Oaks, CA: Sage Publications]), we explored how initial engagement, gender, and support from caring adults at school shaped youths' engagement over time. Students reported a range of engagement trajectories, with gender and support emerging as important predictors of youths' engagement trajectories. Additionally, perceptions of support fluctuated from year to year, and these fluctuations were linked to youths' academic engagement. The findings point to associations between support perceptions and engagement, including links between students' current academic motivation and effort and their current connections with adults. Taken together, the findings present a nuanced portrait of academic engagement and suggest how relationships at school might facilitate positive academic adjustment among Latin American immigrant students over time. Implications for future research, public policy, and practice are discussed.

First successful bridge to myocardial recovery with a HeartWare HVAD.

In this report we describe the first successful bridge to myocardial recovery with the HeartWare HVAD. Assessment for explantation included serial echocardiography, hemodynamic monitoring, metabolic analysis and manipulation of pump speed, both at rest and during exercise. A protocol for assessing the degree of myocardial recovery without stopping the device is described.

Improvements to suicide prevention training for prison staff in England and Wales.

Suicide prevention training for the prison service in England and Wales has been criticized. STORM is a package emphasizing the practice and review of interactions with suicidal persons and was evaluated in a pilot study for use in prisons. Trainees completed questionnaires immediately before and after training and at 6 to 8 months follow-up. Training significantly improved attitudes, knowledge, and confidence, and improvements were maintained at follow-up. Satisfaction with training was very high. STORM was successfully adapted for prison settings, and showed good effects among staff trained. It should be provided to the wider prison estate, with regular refresher training.

Evaluating STORM skills training for managing people at risk of suicide.

AIM: This paper reports a study evaluating the Skills Training On Risk Management (STORM) training initiative in three mental health services in the North-West of England, UK. BACKGROUND: Training for health workers has been widely advocated as a key route to suicide prevention. However, reports of evaluations are scarce in the literature. In previous research, we have demonstrated that the STORM intervention results in acquisition of new skills and can be disseminated in a community setting. METHOD: The training was delivered during a 6-month period in 2002 by three mental health nurses who were seconded part-time to the project. The quantitative evaluation, which assessed change in attitudes, confidence, acquisition of skills and satisfaction, used a pretest/post-test design, with participants acting as their own controls. Qualitative interviews were conducted with a purposive sample of 16 participants to explore the impact on clinical practice, and with the three trainers at the end of the study. FINDINGS: Data from 458 staff members were collected during a 6-month period. Positive changes in attitudes and confidence were shown, but previous evidence of skill acquisition was not replicated. Qualitative interviews revealed important insights into changes in clinical practice, particularly for less experienced or unqualified nursing staff, but also concerns about the lack of an educational culture to foster and support such interventions in practice within the organizations. CONCLUSION: STORM training for the assessment and management of suicide risk is both feasible and acceptable in mental health trusts. However, we remain uncertain of its longer-term impact, given the lack of engagement of senior staff in the enterprise and the absence of linked supervision and support from the organizational management to reinforce skill acquisition and development. We consider that regular supervision that links STORM training to actual clinical experience would be the ideal.

Post-traumatic stress and disability.

BACKGROUND: Post-traumatic stress is thought to account for significant disability. It is also known to be highly comorbid with other psychiatric conditions such as depression and alcohol dependence. AIMS: To determine the relationship between post-traumatic stress, depression, alcohol dependence and disability. METHOD: Seventy armed services personnel were assessed for DSM-IV diagnoses of post-traumatic stress disorder, major depressive disorder and alcohol dependence, and with continuous measures of symptoms of post-traumatic stress, depression and alcohol dependence following a traumatic event. These variables, as predictors of disability (using the Sheehan Disability Scale), were analysed using multivariate analysis of variance, analysis of covariance and multiple regression backward elimination models. RESULTS: No significant interaction was found for the diagnostic variables even after controlling for the continuous symptom measures. In the regression models, symptoms of depression were a significant predictor of total disability (R(2)=0.39). Symptoms of alcohol dependence and post-traumatic stress did not significantly predict disability. CONCLUSIONS: Since post-traumatic stress was not found to be associated with disability, its clinical importance may be questionable.