Socioeconomic position and first-time major cardiovascular event in patients with type 2 diabetes: a Danish nationwide cohort study.

AIMS: The association between socioeconomic position and cardiovascular disease has not been well studied in patients with type 2 diabetes. We aimed to examine the association between socioeconomic position and first-time major adverse cardiovascular events (MACE) in patients with type 2 diabetes. METHODS AND RESULTS: Through the Danish nationwide registers, we identified all residents with newly diagnosed type 2 diabetes between 2012 and 2017. Based on sex-stratified multivariable cause-specific Cox regression models, we calculated the standardized absolute 5-year risk of the composite outcome of first-time myocardial infarction, stroke, or cardiovascular mortality (MACE) according to income quartiles. A total of 57 106 patients with type 2 diabetes were included. During 155 989 person years, first-time MACE occurred in 2139 patients. Among both men and women, income was inversely associated with the standardized absolute 5-year risk of MACE. In men, the 5-year risk of MACE increased from 5.7% [95% confidence interval (CI) 4.9-6.5] in the highest income quartile to 9.3% (CI 8.3-10.2) in the lowest income group, with a risk difference of 3.5% (CI 2.4-4.7). In women, the risk of MACE increased from 4.2% (CI 3.4-5.0) to 6.1% (CI 5.2-7.0) according to income level, with a risk difference of 1.9% (CI 0.8-2.9). CONCLUSION: Despite free access to medical care in Denmark, low-socioeconomic position was associated with a higher 5-year risk of first-time MACE in patients with incident type 2 diabetes. Our results suggest prevention strategies could be developed specifically for patients with low-socioeconomic position.

Perceptions of injectable therapies with cardiovascular benefit: an ACNAP survey of healthcare professionals to explore facilitators and barriers.

AIMS: Injectable medicines are increasingly used to manage risk factors for cardiovascular (CV) events, such as dyslipidaemia and diabetes. These include proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. Little is known about perceptions of injectable therapies among CV healthcare professionals (HCPs). This study explores their views to identify relevant facilitators and barriers to the use of injectables with CV benefit. METHODS AND RESULTS: A 22-question survey was distributed internationally via online channels. In total, 192 anonymous responses were received (43.7% physicians, 32.6% nurses, 16.8% pharmacists, 6.8% others). Among respondents with experience of these medicines, 69.1% had used an injectable PCSK9 inhibitor and 67.0% had used an injectable GLP-1 receptor agonist. Commonly raised issues were resource problems (36.5%), lack of knowledge among colleagues (32.3%), paperwork (32.3%), and lack of patient knowledge (28.1%). Key barriers respondents felt made patients decline these treatments were fear of injection (56.6%), lack of awareness or education (26.4%), and administration issues (15.1%); potential reasons for discontinuation included side effects (46.4%), perceived lack of benefit (28.6%), and local reactions (21.4%). The main topics around injectables requiring further support included managing non-adherent patients (16.2%), troubleshooting with patients (16.2%), and educating colleagues about injectables (12.2%). Preferred educational methods to support HCPs were face-to-face training (43.5%) and online learning (26.1%); favoured formats were based on role playing and case studies. CONCLUSION: Healthcare professionals highlighted various potential barriers to initiation, continuation, and adherence with injectable therapies in CV medicine. Although some require healthcare system changes, many could be addressed through simple measures based primarily on enhanced training and support for patients and HCPs.

Level 1 of Entrustable Professional Activities in adult echocardiography: a position statement from the EACVI regarding the training and competence requirements for selecting and interpreting echocardiographic examinations.

The goal of Level 1 training in echocardiography is to enable the trainee to select echocardiography appropriately for the evaluation of a specific clinical question, and then to interpret the report. It is not the goal of Level 1 training to teach how to perform the examination itself-that is the goal of higher levels of training. However, understanding the principles, indications, and findings of this crucial technique is valuable to many medical professionals including outside cardiology. This should be seen as part of a general understanding of cardiac imaging modalities. The purpose of this position statement is to define the scope and outline the general requirements for Level 1 training and competence in echocardiography. Moreover, the document aims to make a clear distinction between Level 1 competence in echocardiography and focus cardiac ultrasound (FoCUS).

The varied role, scope of practice, and education of cardiovascular nurses in ESC-affiliated countries: an ACNAP survey.

AIMS: Cardiovascular disease burden is increasing globally, pressuring nursing staff to deliver high-quality care across a diverse range of treatment areas. As such, an evaluation of the educational preparation of nurses is needed. To determine the current role, scope of practice, education level, and needs of cardiovascular nurses working across the European Society of Cardiology (ESC)-affiliated countries. METHODS AND RESULTS: A short survey was distributed in paper (EuroHeartCare 2018) or electronic format to nurses delivering cardiovascular care. A total of 876 cardiovascular nurses from 26 ESC-affiliated countries completed the survey. Most respondents (79%), were educated to at least bachelor level, with 46% having a masters or doctorate, and were highly motivated to continue their educational development. Despite this, a large number (44.3%) of respondents believed they were not fully prepared for their job. The main areas where further education was requested included acute care in cardiovascular disease (CVD) and CVD risk factor management. Face-to-face courses/training were the most requested delivery mode, followed by E-learning-which appears to be underutilized in this population. Awareness of the existing curricula for cardiovascular nurse education was minimal, and therefore these resources require further promotion and implementation. CONCLUSIONS: This international sample of cardiovascular nurses was generally educated to degree level and motivated to improve their cardiovascular knowledge. Many believed they were underprepared for their role, highlighting the need for increased investment in education. This should be focused on specific needs and delivered using a face-to-face, E-learning, or blended-learning format. Furthermore, increased signposting of existing resources is required.

Internet-based treatment of anxiety and depression in patients with ischaemic heart disease attending cardiac rehabilitation: a feasibility study (eMindYourHeart).

Aims: Anxiety and depression are prevalent in 20% of patients with ischaemic heart disease (IHD); however, treatment of psychological conditions is not commonly integrated in cardiac rehabilitation (CR). Internet-based psychological treatment holds the potential to bridge this gap. To examine the feasibility of an eHealth intervention targeting anxiety and depression in patients with IHD attending CR. Methods and results: We used a mixed-methods design, including quantitative methods to examine drop-out and change in anxiety and depression scores, and qualitative methods (thematic analysis) to evaluate patients' and nurses' experiences with the intervention. The therapist-guided intervention consisted of 12 modules provided via a web-based platform. The primary outcome was drop-out, with a drop-out rate <25% considered acceptable. Patients were considered as non-drop-out if they completed ≥5 modules. Out of 60 patients screened positive for anxiety and/or depression, 29 patients were included. The drop-out rate was 24% (7/29). Patients had a mean improvement in anxiety and depression scores of 5.5 and 4.6, respectively. On average, patients had 8.0 phone calls with their therapist and 19.7 written messages. The qualitative analysis of patients' experiences identified four themes: treatment platform, intervention, communication with therapist, and personal experience. Patients were positive towards the intervention, although some found the assignments burdensome. From the nurses, we identified three themes: intervention, inclusion procedure, and collaboration with study team. The nurses were positive, however, due to limited time some struggled with the inclusion procedure. Conclusion: Integrating an eHealth intervention in CR is feasible and the drop-out rate acceptable.

Psychometric Properties of the Norwegian Version of the Electronic Health Literacy Scale (eHEALS) Among Patients After Percutaneous Coronary Intervention: Cross-Sectional Validation Study.

BACKGROUND: Web-based technology has recently become an important source for sharing health information with patients after an acute cardiac event. Therefore, consideration of patients' perceived electronic health (eHealth) literacy skills is crucial for improving the delivery of patient-centered health information. OBJECTIVE: The aim of this study was to translate and adapt the eHealth Literacy Scale (eHEALS) to conditions in Norway, and to determine its psychometric properties. More specifically, we set out to determine the reliability (internal consistency, test-retest) and construct validity (structural validity, hypotheses testing, and cross-cultural validity) of the eHEALS in self-report format administered to patients after percutaneous coronary intervention. METHODS: The original English version of the eHEALS was translated into Norwegian following a widely used cross-cultural adaptation process. Internal consistency was calculated using Cronbach α. The intraclass correlation coefficient (ICC) was used to assess the test-retest reliability. Confirmatory factor analysis (CFA) was performed for a priori-specified 1-, 2-, and 3-factor models. Demographic, health-related internet use, health literacy, and health status information was collected to examine correlations with eHEALS scores. RESULTS: A total of 1695 patients after percutaneous coronary intervention were included in the validation analysis. The mean age was 66 years, and the majority of patients were men (1313, 77.46%). Cronbach α for the eHEALS was >.99. The corresponding Cronbach α for the 2-week retest was .94. The test-retest ICC for eHEALS was 0.605 (95% CI 0.419-0.743, P<.001). The CFA showed a modest model fit for the 1- and 2-factor models (root mean square error of approximation>0.06). After modifications in the 3-factor model, all of the goodness-of-fit indices indicated a good fit. There was a weak correlation with age (r=-0.206). Between-groups analysis of variance showed a difference according to educational groups and the eHEALS score, with a mean difference ranging from 2.24 (P=.002) to 4.61 (P<.001), and a higher eHEALS score was found for patients who were employed compared to those who were retired (mean difference 2.31, P<.001). The eHEALS score was also higher among patients who reported using the internet to find health information (95% CI -21.40 to -17.21, P<.001), and there was a moderate correlation with the patients' perceived usefulness (r=0.587) and importance (r=0.574) of using the internet for health information. There were also moderate correlations identified between the eHEALS score and the health literacy domains appraisal of health information (r=0.380) and ability to find good health information (r=0.561). Weak correlations with the mental health composite score (r=0.116) and physical health composite score (r=0.116) were identified. CONCLUSIONS: This study provides new information on the psychometric properties of the eHEALS for patients after percutaneous coronary intervention, suggesting a multidimensional rather than unidimensional construct. However, the study also indicated a redundancy of items, indicating the need for further validation studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT03810612; https://clinicaltrials.gov/ct2/show/NCT03810612.

Pharmacological Preventive Potential Among Attenders at Vascular Screening: Findings from the VIVA Trial.

OBJECTIVE: Findings from the Viborg Vascular (VIVA) trial show a mortality benefit of multi-faceted vascular screening which was mainly ascribed to the initiation of prophylactic medication. However, the pharmacological preventive potential, which exists when individuals have a positive screening test result and do not already use statins and anti-platelet agents, has not been analysed. The aim of this study was to investigate factors associated with a pharmacological preventive potential of statins and anti-platelet agents among attenders vascular screening for abdominal aortic aneurysm (AAA) and peripheral arterial disease (PAD). METHODS: This cross-sectional study used data from the VIVA trial screening arm including 25 074 men aged 64-75 years recruited between October 2008 and January 2011. Explanatory variables comprised socio-demographic- and socio-economic characteristics, comorbidities, medication use, and travel distance derived from nationwide registries. Outcomes included a positive screening test result, a pharmacological preventive potential, and attendance. Associations between the explanatory variables and the outcomes were investigated using the chi-square test and multivariate logistic regression. RESULTS: The factors most likely to be associated with a pharmacological preventive potential for positive AAA screening comprised age >70 years (odds ratio (OR) 1.23, 95% confidence interval 1.00-1.51), existing chronic obstructive pulmonary disease (COPD) (OR 2.22, 95% CI 1.38-3.57), and use of anti-hypertensives (OR 1.37, 95% CI 1.09-1.71). For positive PAD screening age >70 years (OR 1.41, 95% CI 1.25-1.60), living alone (OR 1.34, 95% CI 1.14-1.56), low income, COPD (OR 2.13, 95% CI 159-283), use of anti-hypertensives (OR 1.14, 95% CI 1.00-1.29) or anti-diabetics (OR 1.12, 95% CI 1.01-1.28), and short travel distance were associated with a pharmacological preventive potential. For combined vascular screening, age >70 years, living alone, low income, COPD, and use of anti-hypertensives were associated with a pharmacological preventive potential. Among these subgroups, lower attendance was associated with age >70 years, living alone, low income, COPD, and use of anti-diabetics. CONCLUSION: Future vascular screening programmes might benefit from tailoring information to subgroups who are more likely to benefit from screening but less likely to accept an offer.

Diabetes as a cardiovascular risk factor: An overview of global trends of macro and micro vascular complications.

The global prevalence of diabetes is predicted to increase dramatically in the coming decades as the population grows and ages, in parallel with the rising burden of overweight and obesity, in both developed and developing countries. Cardiovascular disease represents the principal cause of death and morbidity among people with diabetes, especially in those with type 2 diabetes mellitus. Adults with diabetes have 2-4 times increased cardiovascular risk compared with adults without diabetes, and the risk rises with worsening glycaemic control. Diabetes has been associated with 75% increase in mortality rate in adults, and cardiovascular disease accounts for a large part of the excess mortality. Diabetes-related macrovascular and microvascular complications, including coronary heart disease, cerebrovascular disease, heart failure, peripheral vascular disease, chronic renal disease, diabetic retinopathy and cardiovascular autonomic neuropathy are responsible for the impaired quality of life, disability and premature death associated with diabetes. Given the substantial clinical impact of diabetes as a cardiovascular risk factor, there has been a growing focus on diabetes-related complications. While some population-based studies suggest that the epidemiology of such complications is changing and that rates of all-cause and cardiovascular mortality among individuals with diabetes are decreasing in high-income countries, the economic and social burden of diabetes is expected to rise due to changing demographics and lifestyle especially in middle- and low-income countries. In this review we outline data from population-based studies on recent and long-term trends in diabetes-related complications.

Lifestyle factors, self-management and patient empowerment in diabetes care.

Although management of diabetes mellitus is improving, inadequately managed cases still exist. Prevention of diabetes mellitus requires an integrated and holistic approach based on the origin of the disease. In Europe only half of diagnosed patients with diabetes mellitus have good glycaemic control. Inadequate glycaemic control is significantly increasing the use of healthcare resources, the medical costs and mortality rates. A review was conducted in order to summarise and discuss central themes for prevention. A search of the databases PubMed, CINAHL, Cochrane and Google Scholar between January 2010-May 2019 was undertaken. The following keywords: 'diabetes mellitus', 'cardiovascular diseases', 'empowerment', 'self-management education' and 'lifestyle factors' were used in different combinations to identify eligible articles. Important variables for the prevention of diabetes mellitus and its complications are self-management of diabetes mellitus and the management of risk factors. Education and support for self-management are fundamental when caring for people with a chronic disease like diabetes mellitus. In order to achieve effective self-management including lifestyle modification it is also crucial to motivate people. In this review, the role of the three main pillars in diabetes care are identified and discussed; patient empowerment, self-management education and lifestyle modification in the management of people with diabetes mellitus.

Modes of e-Health delivery in secondary prevention programmes for patients with coronary artery disease: a systematic review.

BACKGROUND: Electronic health (e-Health) interventions are emerging as an effective alternative model for improving secondary prevention of coronary artery disease (CAD). The aim of this study was to describe the effectiveness of different modes of delivery and components in e-Health secondary prevention programmes on adherence to treatment, modifiable CAD risk factors and psychosocial outcomes for patients with CAD. METHOD: A systematic review was carried out based on articles found in MEDLINE, CINAHL, and Embase. Studies evaluating secondary prevention e-Health programmes provided through mobile-Health (m-Health), web-based technology or a combination of m-Health and web-based technology were eligible. The main outcomes measured were adherence to treatment, modifiable CAD risk factors and psychosocial outcomes. The quality appraisal of the studies included was conducted using the Joanna Briggs Institute critical appraisal tool for RCT. The results were synthesised narratively. RESULT: A total of 4834 titles were identified and 1350 were screened for eligibility. After reviewing 123 articles in full, 24 RCTs including 3654 participants with CAD were included. Eight studies delivered secondary prevention programmes through m-Health, nine through web-based technology, and seven studies used a combination of m-Health and web-based technology. The majority of studies employed two or three secondary prevention components, of which health education was employed in 21 studies. The m-Health programmes reported positive effects on adherence to medication. Most studies evaluating web-based technology programmes alone or in combination with m-Health also utilised traditional CR, and reported improved modifiable CAD risk factors. The quality appraisal showed a moderate methodological quality of the studies. CONCLUSION: Evidence exists that supports the use of e-Health interventions for improving secondary prevention of CAD. However, a comparison across studies highlighted a wide variability of components and outcomes within the different modes of delivery. High quality trials are needed to define the most efficient mode of delivery and components capable of addressing a favourable outcome for patients. TRIAL REGISTRATION: Not applicable.

Role of Experience With Preventive Medication and Personal Risk Attitude in Non-Attendance at Triple Vascular Screening.

BACKGROUND: Non-attendance for vascular screening potentially restricts the overall benefit of screening at population level, but may be the result of rational judgment on the part of invitees who might not consider their risk to be relevant. The aim of this study was to investigate the role of current use of preventive medication and personal risk attitude as potential factors explaining non-attendance at triple vascular screening. METHODS: This was a case control study across 25,078 men offered screening and intervention for abdominal aortic aneurysm, peripheral artery disease, and hypertension in the Viborg Vascular (VIVA) screening trial. Data on socio-demographic and socio-economic characteristics, diagnoses, and use of preventive medication were extracted from national registries. A proxy for personal risk attitude was constructed. Logistic regression was used to estimate odds ratios with 95% confidence intervals. RESULTS: Use of statins (0.78; 95% CI 0.71-0.85), antihypertensives (1.26, 95% CI 1.13-1.41), or antithrombotics (1.13, 95% CI 1.04-1.23) were all associated with non-attendance. With regards to personal risk attitude, a statistically significant association was found between users of preventive medication with no recent diagnosis of cardiovascular disease and non-attendance (0.82, 95% CI 0.72-0.94). The role of traditional factors explaining non-attendance at vascular screening, such as low socio-economic status and comorbidity, was confirmed. CONCLUSION: Non-attendance at triple vascular screening is influenced by use of preventive medications and traditional explanatory factors of non-attendance at vascular screening, including existing CVD comorbidity. Attendance rates might benefit from rethinking risk communication alongside screening invitations according to varying invitee profiles and clinical risk scenarios, and from providing interventions targeted at individuals with lower levels of health literacy.

Patient perceptions of experience with cardiac rehabilitation after isolated heart valve surgery.

BACKGROUND: Little evidence exists on whether cardiac rehabilitation is effective for patients after heart valve surgery. Yet, accepted recommendations for patients with ischaemic heart disease continue to support it. To date, no studies have determined what heart valve surgery patients prefer in a cardiac rehabilitation programme, and none have analysed their experiences with it. AIMS: The purpose of this qualitative analysis was to gain insight into patients' experiences in cardiac rehabilitation, the CopenHeartVR trial. This trial specifically assesses patients undergoing isolated heart valve surgery. METHODS: Semi-structured interviews were conducted with nine patients recruited from the intervention arm of the trial. The intervention consisted of a physical training programme and a psycho-educational intervention. Participants were interviewed three times: 2-3 weeks, 3-4 months and 8-9 months after surgery between April 2013 and October 2014. Data were analysed using qualitative thematic analysis. RESULTS: Participants had diverse needs and preferences. Two overall themes emerged: cardiac rehabilitation played an important role in (i) reducing insecurity and (ii) helping participants to take active personal responsibility for their health. Despite these benefits, participants experienced existential and psychological challenges and musculoskeletal problems. Participants also sought additional advice from healthcare professionals both inside and outside the healthcare system. CONCLUSIONS: Even though the cardiac rehabilitation programme reduced insecurity and helped participants take active personal responsibility for their health, they experienced existential, psychological and physical challenges during recovery. The cardiac rehabilitation programme had several limitations, having implications for designing future programmes.

Cardiac rehabilitation increases physical capacity but not mental health after heart valve surgery: a randomised clinical trial.

OBJECTIVE: The evidence for cardiac rehabilitation after valve surgery remains sparse. Current recommendations are therefore based on patients with ischaemic heart disease. The aim of this randomised clinical trial was to assess the effects of cardiac rehabilitation versus usual care after heart valve surgery. METHODS: The trial was an investigator-initiated, randomised superiority trial (The CopenHeartVR trial, VR; valve replacement or repair). We randomised 147 patients after heart valve surgery 1:1 to 12 weeks of cardiac rehabilitation consisting of physical exercise and monthly psycho-educational consultations (intervention) versus usual care without structured physical exercise or psycho-educational consultations (control). Primary outcome was physical capacity measured by VO2 peak and secondary outcome was self-reported mental health measured by Short Form-36. RESULTS: 76% were men, mean age 62 years, with aortic (62%), mitral (36%) or tricuspid/pulmonary valve surgery (2%). Cardiac rehabilitation compared with control had a beneficial effect on VO2 peak at 4 months (24.8 mL/kg/min vs 22.5 mL/kg/min, p=0.045) but did not affect Short Form-36 Mental Component Scale at 6 months (53.7 vs 55.2 points, p=0.40) or the exploratory physical and mental outcomes. Cardiac rehabilitation increased the occurrence of self-reported non-serious adverse events (11/72 vs 3/75, p=0.02). CONCLUSIONS: Cardiac rehabilitation after heart valve surgery significantly improves VO2 peak at 4 months but has no effect on mental health and other measures of exercise capacity and self-reported outcomes. Further research is needed to justify cardiac rehabilitation in this patient group. TRIAL REGISTRATION NUMBER: NCT01558765, Results.

Risk assessment of Salmonella in Danish meatballs produced in the catering sector.

A modular process risk model approach was used to assess health risks associated with Salmonella spp. after consumption of the Danish meatball product (frikadeller) produced with fresh pork in a catering unit. Meatball production and consumption were described as a series of processes (modules), starting from 1.3kg meat pieces through conversion to 70g meatballs, followed by a dose response model to assess the risk of illness from consumption of these meatballs. Changes in bacterial prevalence, concentration, and unit size were modelled within each module. The risk assessment was built using observational data and models that were specific for Salmonella spp. in meatballs produced in the catering sector. Danish meatballs are often pan-fried followed by baking in an oven before consumption, in order to reach the core temperature of 75°C recommended by the Danish Food Safety Authority. However, in practice this terminal heat treatment in the oven may be accidentally omitted. Eleven production scenarios were evaluated with the model, to test the impact of heat treatments and cooling rates at different room temperatures. The risk estimates revealed that a process comprising heat treatment of meatballs to core temperatures higher than 70°C, and subsequent holding at room temperatures lower than 20°C, for no longer than 3.5h, were very effective in Salmonella control. The current Danish Food Safety Authority recommendation of cooking to an internal temperature of 75°C is conservative, at least with respect to Salmonella risk. Survival and growth of Salmonella during cooling of meatballs not heat treated in oven had a significant impact on the risk estimates, and therefore, cooling should be considered a critical step during meatball processing.

Availability of, referral to and participation in exercise-based cardiac rehabilitation after heart valve surgery: Results from the national CopenHeart survey.

BACKGROUND: As with ischaemic heart disease, cardiac rehabilitation (CR) is recommended for patients undergoing heart valve surgery; recommendations are based on limited evidence. The organization of CR programmes and factors associated with uptake among patients undergoing heart valve surgery have not been studied. This study investigated CR programmes for these patients and factors associated with referral and participation. DESIGN AND METHODS: We distributed two nationwide surveys: one to 37 hospitals and 98 municipalities and one to 742 consecutive patients undergoing heart valve surgery. Data were linked to nationwide registries. We analysed the provision and content of programmes using descriptive statistics, and factors associated with referral and participation using logistic regression analysis. RESULTS: Coverage of CR programmes for these patients was high, with national programme variation. The overall uptake rate was 52%. Simultaneous CABG was associated with a higher probability of referral to CR (OR 2.02 (95%CI 1.12-3.65)); being unmarried (0.44 (0.27-0.72)) and having TAVI with a lower probability (0.26; 0.13-0.52). The referral pattern varied across administrative regions, with patients in the capital region less likely to be referred (0.22 (0.08-0.57)). Patients with TAVI were less likely to participate (0.29 (0.12-0.70)). CONCLUSIONS: Despite high national programme coverage, only half the patients post heart valve surgery received CR. Both factors identified at provider- and patient-level influenced uptake and included significant regional variation in referral pattern. Further research into the effect and organization of CR post heart valve surgery is needed.

Depression, not anxiety, is independently associated with 5-year hospitalizations and mortality in patients with ischemic heart disease.

OBJECTIVE: The objective of the current study was to examine whether depression and anxiety are independently associated with 5-year cardiac-related hospitalizations and all-cause mortality in patients with ischemic heart disease (IHD). METHODS: Patients treated for MI, angina, or ischemic heart failure (N=610) were recruited from Holbæk Hospital, Denmark. All patients completed the Hospital Anxiety and Depression Scale (HADS) in December 2005. Data regarding patient characteristics at baseline, and hospitalizations and deaths during follow-up were collected from Danish population-based registers. Cox and negative binomial regression analyses were performed to examine the relationship between depression, anxiety and the endpoints. RESULTS: At baseline, 71 (11.6%) patients reported depression and 120 (19.7%) reported anxiety. Models including both depression and anxiety showed that depression was independently associated with time to first cardiac-related hospitalization, cumulative number and length of cardiac-related hospitalizations, and all-cause mortality, while anxiety was only associated with the total length of hospitalizations (all p-values <.05). After adding sociodemographic and clinical factors, depression remained associated with the number (incidence rate ratio (IRR)=2.00, 95% confidence interval (CI): 1.44-2.77) and length of cardiac-related hospitalizations (IRR=3.69, 95% CI: 2.75-4.96), and all-cause mortality (hazard ratio (HR)=2.12, 95% CI: 1.13-3.96). The associations between depression and time to first hospitalization and between anxiety and length of stay were eliminated. CONCLUSIONS: The current study showed that depression, and not anxiety, is associated with the number and length of cardiac-related hospitalizations and all-cause mortality in IHD patients, independent of traditional risk factors. In order to improve health outcomes, better awareness and treatment of depression in IHD patients are crucial.

Exercise mediates the association between positive affect and 5-year mortality in patients with ischemic heart disease.

BACKGROUND: Positive affect has been associated with better prognosis in patients with ischemic heart disease, but the underlying mechanisms remain unclear. We examined whether positive affect predicted time to first cardiac-related hospitalization and all-cause mortality, and whether exercise mediated this relationship in patients with established ischemic heart disease. METHODS AND RESULTS: The sample comprised 607 patients with ischemic heart disease from Holbæk Hospital, Denmark. In 2005, patients completed the Global Mood Scale (GMS) to assess positive affect and a purpose-designed question on exercise. Data on mortality and hospitalization were collected from Danish national registers for the period 2006-2010. Adjusted Cox and logistic regression were used to analyze the mediation model. Because no significant association between positive affect and cardiac-related hospitalization was found, we constructed no mediation model for hospitalization. Importantly, patients with high positive affect had a significantly reduced risk of all-cause mortality (hazard ratio, 0.58; 95% confidence interval, 0.37-0.92; unadjusted analysis) and were more likely to exercise (odds ratio, 1.99; 95% confidence interval, 1.44-2.76; unadjusted analysis; odds ratio, 1.48; 95% confidence interval, 1.03-2.13; adjusted analysis). When controlling for positive affect and other relevant variables, patients engaged in exercise were less likely to die during follow-up (hazard ratio, 0.50; 95% confidence interval, 0.31-0.80; P=0.004). Importantly, exercise acted as a mediator in the relationship between positive affect and mortality. CONCLUSIONS: Patients with higher levels of positive affect were more likely to exercise and had a lower risk of dying during 5-year follow-up, with exercise mediating the relationship between positive affect and mortality. Interventions aimed at increasing both positive affect and exercise may have better results with respect to patients' prognosis and psychological well-being than interventions focusing on 1 of these factors alone.

Physical sample structure as predictive factor in growth modeling of Listeria innocua in a white cheese model system.

Growth of Listeria innocua at 9 °C was investigated in white cheeses manufactured from ultra-filtrate milk concentrate added varying amounts of skimmed milk powder, NaCl and glucono-delta-lactone. Characterization of the white cheese structures was performed using nuclear magnetic resonance (NMR) T2 relaxation parameters (relaxation times constants, relative areas and width of peaks) and their applicability as predictive factors for maximum specific growth rate, √µ(max) and log-increase in 6 weeks of L. innocua was evaluated by polynomial modeling. Inclusion of NMR parameters was able to increase the goodness-of-fit of two basic models; one having pH, undissociated gluconic acid (GA(u), mM) and NaCl (% w/v) as predictive factors and another having pH, GA(u) and a(w) as predictive factors. However, the best model fit was observed using √µ(max) as response for the model including pH, GA(u), aw and Width T21 revealing the lowest relative root mean squared errors of 14.0%. As the T2 relaxation population T21 is assigned to represent immobilized bulk water protons and the width T21 the heterogeneity of this water population, growth of L. innocua in white cheese seemed to be dependent on the heterogeneity of the immobilized bulk water present in cheese.

Water properties in cream cheeses with variations in pH, fat, and salt content and correlation to microbial survival.

Water mobility and distribution in cream cheeses with variations in fat (4, 15, and 26%), added salt (0, 0.625, and 1.25%), and pH (4.2, 4.7, and 5.2) were studied using (1)H NMR relaxometry. The cheese samples were inoculated with a mixture of Listeria innocua, Escherichia coli O157 and Staphylococcus aureus, and partial least-squares regression revealed that (1)H T(2) relaxation decay data were able to explain a large part of the variation in the survival of E. coli O157 (64-83%). However, the predictions of L. innocua and S. aureus survival were strongly dependent on the fat/water content of the samples. Consequently, the present results indicate that NMR relaxometry is a promising technique for predicting the survival of these bacteria; however, the characteristics of the sample matrix are substantial.