Reduced HbA1c levels in type 2 diabetes patients: An interaction between a pedagogical format for students and psycho-educational intervention for patients.

In this prospective study we compared Hemoglobin A1c (HbA1c) levels in T2DM (Type 2 diabetes) patients who received psycho-educational intervention vs. usual care. Intervention was provided by pharmaceutics students, and accompanied by an academic course. We further examined the effect of the pedagogical format by which students were taught on HbA1c levels of the patients. The format of the academic course varied: the simultaneous format included theoretical, clinical, and practical themes taught within each lesson; whereas in the non-simultaneous format, theoretical themes were taught during the first several lessons, followed by practical skills taught in the following ones. T2DM patients (n = 171) were recruited through 10 primary care clinics. The inclusion criterion was patients with uncontrolled type 2 diabetes (HbA1c > 7%). Patients were randomly allocated to a training or control group. Pharmaceutics students (n = 85) in their fourth year participated in an academic course and were randomly allocated to a simultaneous vs. non-simultaneous pedagogical format. The interaction effect between intervention type and pedagogical format was significant. Only patients who participated in the training group consisting of students who participated in the simultaneous course format showed improvement on their HbA1c levels. Implications on patients' outcome and suggestions for future studies are discussed.

Molecular and cellular interface between behavior and acute coronary syndromes.

This review article integrates empirical findings from various scientific disciplines into a proposed psychoneuroimmunological (PNI) model of the acute coronary syndrome (ACS). Our starting point is an existing, mild, atherosclerotic plaque and a dysfunctional endothelium. The ACS is triggered by three stages. (1) Plaque instability: Pro-inflammatory cytokines (IL-1, IL-6, TNF-alpha) and chemoattractants (MCP-1, IL-8) induce leukocyte chemoattraction to the endothelium, and together with other triggers such as the CD40L-CD40 co-stimulation system activate plaque monocytes (macrophages). The macrophages then produce matrix metalloproteinases that disintegrate extra-cellular plaque matrix, causing coronary plaque instability. Acute stress, hostility, depression and vital exhaustion (VE) have been associated with elevated pro-inflammatory cytokines and leukocyte levels and their recruitment. (2) Extra-plaque factors promoting rupture: Neuro-endocrinological factors (norepinephrine) and cytokines induce vasoconstriction and elevated blood pressure (BP), both provoking a vulnerable plaque to rupture. Hostility/anger and acute stress can lead to vasoconstriction and elevated BP via catecholamines. (3) Superimposed thrombosis at a ruptured site: Increases in coagulation factors and reductions in anticoagulation factors (e.g. protein C) induced by inflammatory factors enhance platelet aggregation, a key stage in thrombosis. Hostility, depression and VE have been positively correlated with platelet aggregation. Thrombosis can lead to severe coronary occlusion, clinically manifested as an ACS. Thus, PNI processes might, at least in part, contribute to the pathogenesis of the ACS. This chain of events may endure due to lack of neuroendocrine-to-immune negative feedback stemming from cortisol resistance. This model has implications for the use of psychological interventions in ACS patients.

Interactions of psychological factors and family history in relation to coronary artery disease.

BACKGROUND: Psychological factors including hostility, depression and stress have been associated with severity of coronary artery disease (CAD). However, few studies have examined interactions between such factors and typical CAD risk factors. Investigating interactive effects simulates their co-occurrence and complex effects in illness, as well as helping to identify groups of patients at greatest risk of morbidity. This study examined the interactive effects of hostility, hopelessness and daily hassles with family history of CAD in relation to CAD severity. DESIGN: Correlation design. METHODS: Seventy-three patients were assessed for hostility, hopelessness and daily hassles before undergoing coronary artery angiography. Severity of CAD was assessed by a cardiologist who was blind to patients' psychological data, with a scale considering type and proximity of occluded artery: the Ilia-score. RESULTS: Hostility significantly interacted with family history in relation to CAD severity. Hostility was positively correlated with CAD severity when family history was positive (r = 0.43, P< 0.05), but not when family history was absent (r = -0.10, NS). No other interaction effects were found. Interestingly, patients with family history of CAD had significantly lower hostility scores (14.4) compared to patients without such history (19.2; P= 0.002). No background or typical-risk factor correlated with CAD severity. CONCLUSION: Hostility synergistically interacted with family history of CAD in relation to CAD severity. The mechanisms of this interaction need to be explored in future studies. Hostility-reduction interventions provided to high-hostile patients with a genetic predisposition to CAD may be relevant for primary and secondary CAD prevention.

[Stress and hypertension].

Stress has many mental and biological effects. In this review we discuss the cardiovascular effects of mental stress and particularly, the relationship between stress and hypertension. The issues include: physiology, effect on blood pressure, job stress, white coat hypertension and the effect on the treatment of hypertension. This interaction could help us to understand the hypertension associated symptoms and to decide on the appropriate treatment.