Keeping Track of My Drinking - Patient Perceptions of Using Smartphone Applications as a Treatment Complement for Alcohol Dependence

BACKGROUND

Alcohol dependence is common, yet highly undertreated. Smartphone applications (apps) have potential to enhance treatment accessibility and effectiveness, however evidence is limited, especially studies focussing on user experiences. The aim was to describe patient perceptions on the usability and acceptability of self-monitoring apps provided as treatment complement for alcohol dependence.

METHODS

Individual semi-structured interviews were conducted through video or phone calls with 21 participants, recruited from a randomized controlled trial at a dependency clinic in Stockholm. The participants had used two specific apps for self-monitoring consumption ("Glasklart" and "iBAC") during 12 wk prior to the interviews. Data was analyzed using Qualitative Content Analysis.

RESULTS

Two domains were identified: 1) Smartphone applications as facilitators to treatment, and 2) Barriers to smartphone application use. Using apps within the treatment context was believed to increase the accuracy of the reported consumption. Participants became more aware of their alcohol problem and described the apps as reinforcers that could increase both the motivation to change and the focus on the problem and commitment to treatment. The apps were further described as helpful to control alcohol consumption. However, app usage was constrained by technical problems, unfit app-specific features and procedures, and alcohol-related shame and stigma.

DISCUSSION AND CONCLUSIONS

Self-monitoring alcohol apps have several beneficial features that can help assess, track, and control alcohol consumption, and improve communication with clinicians. The results indicate they can be useful complements to treatment for patients with alcohol dependence, but their use can be limited by different, foremost technical, issues.

Health effects of reduced occupational sedentary behaviour in type 2 diabetes using a mobile health intervention: a study protocol for a 12-month randomized controlled trial-the ROSEBUD study

BACKGROUND

Short-term trials conducted in adults with type 2 diabetes mellitus (T2DM) showed that reducing sedentary behaviour by performing regular short bouts of light-intensity physical activity enhances health. Moreover, support for reducing sedentary behaviour may be provided at a low cost via mobile health technology (mHealth). There are a wide range of mHealth solutions available including SMS text message reminders and activity trackers that monitor the physical activity level and notify the user of prolonged sitting periods. The aim of this study is to evaluate the effects of a mHealth intervention on sedentary behaviour and physical activity and the associated changes in health in adults with T2DM.

METHODS

A dual-arm, 12-month, randomized controlled trial (RCT) will be conducted within a nationwide Swedish collaboration for diabetes research in primary health care. Individuals with T2DM (n = 142) and mainly sedentary work will be recruited across primary health care centres in five regions in Sweden. Participants will be randomized (1:1) into two groups. A mHealth intervention group who will receive an activity tracker wristband (Garmin Vivofit4), regular SMS text message reminders, and counselling with a diabetes specialist nurse, or a comparator group who will receive counselling with a diabetes specialist nurse only. The primary outcomes are device-measured total sitting time and total number of steps (activPAL3). The secondary outcomes are fatigue, health-related quality of life and musculoskeletal problems (self-reported questionnaires), number of sick leave days (diaries), diabetes medications (clinical record review) and cardiometabolic biomarkers including waist circumference, mean blood pressure, HbA1c, HDL-cholesterol and triglycerides.

DISCUSSION

Successful interventions to increase physical activity among those with T2DM have been costly and long-term effectiveness remains uncertain. The use of mHealth technologies such as activity trackers and SMS text reminders may increase awareness of prolonged sedentary behaviour and encourage increase in regular physical activity. mHealth may, therefore, provide a valuable and novel tool to improve health outcomes and clinical management in those with T2DM. This 12-month RCT will evaluate longer-term effects of a mHealth intervention suitable for real-world primary health care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04219800 . Registered on 7 January 2020.

AB0712 Digital Ischemic Complications in Systemic sclerosis associated Raynaud’s: Prevalence, Risk factors and Treatment patterns from a Single Center Cohort

Background

A significant number of Systemic sclerosis (SSc) patients with Raynaud’s phenomenon (RP) experience digital ischemic complications (DICs-digital ulcers, digital pitting/scars, gangrene and/or amputation).

Objectives

We reviewed the prevalence & risk factors for DICs in SSc-RP and compared treatment patterns among patients with & without DICs.

Methods

SSc patients meeting ACR/EULAR 2013 classification criteria that underwent an upper extremity arterial study between 2001-2018 were included. Clinical characteristics, treatment for RP, use of antiplatelet (aspirin 81 mg), statin therapy & occurrence of DICs, digital occlusive arterial disease (DOAD) on laser doppler flowmetry (LDF) and macrovascular disease (MVD) on duplex US were abstracted. Risk factors for DICs and their associations with therapy were evaluated.

Results

We identified 273 SSc patients (mean age 57±13 y, 81% F, 93% Caucasian, mean disease duration 4.8 ± 7.1 y). Cohort characteristics are described in Table 1. 79% (217/273) patients experienced DICs (digital ulcers 203, digital pitting/scar 138, digital gangrene 76). Patients with DICs had a higher prevalence of DOAD (89% vs 54%, p <0.001), MVD (32% vs 9%, p <0.001), ILD (41% vs. 27%, p=0.04), calcinosis (95/192 (49%) vs. 7/44 (16%), p<0.001), and pericardial effusion (25% vs. 12%, p=0.047), compared to those without DICs. No difference was noted between the 2 groups in regard to skin severity, smoking, BMI, hypertension, hyperlipidemia, diabetes, coronary artery disease, telangiectasias, pulmonary hypertension, renal crisis, GI dysmotility or myositis.

Treatment patterns are described in Figure 1. Calcium channel blocker (CCB) and phosphodiesterase 5 inhibitor (PDE5I) use was higher among SSc patients with DICs than in those without DICs (CCBs: 53% vs. 34%, p=0.01; PDE5: 29% vs. 2%, p=0.01) likely due to confounding by indication. The use of aspirin or statins was not associated with DICs, even after adjusting for CV risk factors (ASA: OR 0.83, 95% CI 0.45-1.54; statin OR 0.67, 95% CI 0.28-1.62).

Conclusion

Our study confirms a high prevalence of DICs in SSc, with digital ulcers occurring in nearly 75% patients. A higher risk of DICs is associated with DOAD, MVD, ILD, calcinosis and pericardial effusion. While there is a significantly higher utilization of vasodilators among patients with DICs, the utilization of antiplatelet therapy and statins was not different among these groups. Whether this suggests a lack of evidence supporting their use in clinical practice, or inefficacy in preventing DICs remains unclear and warrants further study.

Table 1.Overall (N=273)DICs (N=217)No DICs (N=56)p-valueDemographicsAge at procedure(y); mean (SD)57.5 (13.3)56.9 (13.6)59.4 (11.8)0.25Sex (Female)220 (81%)173 (80%)47 (84%)0.48Race (White)253 (93%)199 (92%)54 (96%)0.73BMI (kg/m2) at study; mean (SD)26.6 (6.1)26.3 (6.1)27.4 (6.1)0.14Smoking statusNever154 (56%)120 (55%)34 (61%)0.76Former102 (37%)83 (38%)19 (34%)Current17 (6%)14 (6%)3 (5%)Disease characteristicsSSc subtype:Limited211 (77%)166 (76%)45 (80%)0.18Diffuse59 (22%)49 (23%)10 (18%)Time from SSc diagnosis to duplex US (months) mean (SD)57.9 (85.7)63.5 (91.5)36.1 (52.9)0.04Digital occlusive arterial disease223 (82%)193 (89%)30 (54%)<0.001Macrovascular disease74 (27%)69 (32%)5 (9%)<0.001Ulnar Occlusive disease68 (25%)63 (29%)5 (9%)0.002Telangiectasias239 (88%)192 (89%)47 (84%)0.27Calcinosis102 (43%)95 (49%)7 (16%)<0.001Interstitial lung disease105 (38%)90 (41%)15 (27%)0.04Pulmonary hypertension50 (18%)43 (20%)7 (12%)0.21Pericardial effusion61 (22%)54 (25%)7 (12%)0.047Gastrointestinal dysmotility194 (71%)159 (73%)35 (62%)0.11Renal crisis17 (6%)12 (6%)5 (9%)0.35SSc specific antibodies:175 (68%)138 (67%)38 (69%)0.77Centromere116 (63%)95 (63%)21 (64%)0.97Scl-7048 (19%)36 (18%)12 (22%)0.57RNA-Polymerase19 (20%)14 (19%)5 (22%)0.79Figure 1.

Disclosure of Interests

None declared

Reduced progression of carotid intima media thickness by pictorial presentation of subclinical atherosclerosis 3-year follow-up from VIPVIZA a randomized controlled trial

Background

Reduced progression of carotid intima media thickness (cIMT) and atherosclerotic plaque assessed by carotid ultrasound has been reported in pharmacological intervention studies. We have previously provide evidence for improved primary prevention of cardiovascular diseases by pictorial presentation of subclinical atherosclerosis severity based on reduction in traditional risk scores in 1-year follow-up.

Purpose

We aimed to investigate if pictorial presentation of subclinical atherosclerosis severity affected cIMT and plaque progression over a 3-year follow-up period in comparison with a routine primary prevention program.

Methods

Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA) study is a population-based, randomized controlled trial with blinded evaluators (PROBE design). Participants aged 40, 50 and 60 years were enrolled from a prevention program within the routine primary care. Carotid ultrasound examinations were made at baseline and at 3-year follow-up (n: 3154). The ultrasound examinations included standardized measurements of cIMT in the far wall of common carotid artery at predefined angles due to Meijer's arc. Used angles was 240 degrees for left-mean-cIMT and 120 degrees for right-mean-cIMT. Detection of plaque was based on Mannheim consensus and plaque prevalence was evaluated as absent, unilateral or bilateral plaques. Total plaque area (TPA) was a sum of plaque areas and measured off-line form the longitudinal 2D B-mode images. At baseline, the intervention group (n: 1575) and their primary care physicians received a pictorial presentation describing the severity of subclinical atherosclerosis with graphs and colored figures based on measured cIMT and plaque prevalence (Figure 1). The control group with respective physician (n: 1579) did not receive any information about ultrasound results. The bilateral, left and right mean cIMT, plaque prevalence and TPA at 3-year follow-up were compared between groups. Analysis was performed by analysis of covariance and ordinal proportional odds models. Bonferroni correction was applied to account for multiple comparisons, each individual test was performed using α = 0.01.

Results

Reduced cIMT progression in the intervention group was found in left-mean-cIMT with an estimated group difference of −0.011 mm (p=0.001). Estimated group difference of right- and bilateral-mean-cIMT were both −0.005 mm (p=0.223 and 0.036, respectively) (Figure 2). No significant difference between groups was found for plaque prevalence or TPA.

Conclusion

Intervention by pictorial presentation of subclinical atherosclerotic severity reduced the progression of cIMT in comparison with a traditional cardiovascular preventive program only. This was largely driven by changes in the left carotid artery. Long-term follow-up will be required to elucidate if the intervention will have a protective effect on future risk of cardiovascular events.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Heart Foundation of Northern Sweden, Västerbotten County Council. Figure 1Figure 2

OP0177 PRESENCE AND SEVERITY OF DIGITAL OCCLUSIVE ARTERIAL DISEASE PREDICTS DIGITAL ISCHEMIC COMPLICATIONS IN SYSTEMIC SCLEROSIS

Background:

Vasculopathy is a key feature of systemic sclerosis (SSc), manifesting clinically as Raynaud’s phenomenon (RP) with or without digital ischemia. Laser doppler flowmetry (LDF) with thermal challenge is a safe, noninvasive and reproducible technique to detect digital occlusive arterial disease (DOAD) with a high sensitivity and specificity of >90% (1).

Objectives:

To study the prevalence and clinical correlates of DOAD assessed by LDF in patients with SSc referred for evaluation of RP at a tertiary referral center.

Methods:

Medical records of all patients with SSc meeting ACR/EULAR 2013 classification criteria that underwent LDF between Jan 2001-Dec 2018 at our institution were retrospectively reviewed to abstract the presence or absence of DOAD. The presence of DOAD on LDF was confirmed if pre- and post-warming skin blood flow was ≤206 arbitrary units. Severity of DOAD was assessed based on number of digits involved. Risk factors associated with presence of DOAD in SSc, and correlation between presence and severity of DOAD with digital ischemic complications were studied.

Results:

304 patients with SSc (mean age 57.1 ± 3.3 y, 81% females, 93% Caucasians) underwent LDF during the study period. Median time between SSc diagnosis and performing LDF was 12.9 months. Majority of patients with SSc had limited cutaneous SSc (lcSSc) (79.6%) and 64.1% had a positive SSc specific antibody.

On LDF with thermal challenge, presence of DOAD was noted in 243 (79.9%) patients, of whom 78.6% had lcSSc, 42.4% had a centromere antibody (Ab), 17.3% had a Scl-70 Ab, 53.5% had interstitial lung disease, 36.6% had pulmonary arterial hypertension, and 73.3% had gastrointestinal dysmotility (GID). Of 159 patients with DOAD who also had a nailfold capillaroscopy, 70.4% had abnormalities. Large vessel occlusive disease was significantly higher in patients with DOAD in comparison to those without DOAD (29.2% vs 16.4%; p: 0.04). After adjusting for age and sex, GID (OR: 2.73 [95%CI 1.52-4.92]) and telangiectasia (OR: 2.83 [95%CI 1.23-6.40]) were significantly associated with DOAD.

Digital ischemic complications among patients with SSc with DOAD were significantly higher than among those without DOAD (79.8% vs 41.0% had digital ulcers, 53.9% vs 26.2% had pitting/scars, 31.3% vs 8.2% had gangrene/amputation; p <0.001). (Figure 1) Increasing severity of DOAD was associated with a statistically significantly higher incidence of digital ischemic complications as presented in Table 1.

Figure 1.

Correlation between the presence of digital occlusive arterial disease (DOAD) and digital ischemic complications in systemic sclerosis

Table 1.

Logistic regression models for association of digital ischemic complications and severity of digital occlusive arterial disease

Digital InvolvementComplicationOdds Ratio (OR)Reflects “digits vs. 0”ORCI 95%Digital UlcerUnit Increase1.281.19-1.391-22.110.927-4.923-75.572.84-11.28-1010.94.98-25.4Digital Tip Pitting/ScarsUnit Increase1.171.10-1.261-21.920.803-4.613-72.621.35-5.288-105.452.72-11.4Digital Gangrene/AmputationUnit Increase1.261.16-1.371-21.360.317-5.483-74.101.62-12.68-109.053.60-27.7Any Digital InvolvementUnit Increase1.351.24-1.491-22.981.27-7.303-76.163.08-12.78-1018.57.46-53.2

Conclusion:

This is the largest single center study to describe the prevalence and predictors of DOAD on LDF in a well-defined cohort of patients with SSc.

The high prevalence of DOAD on LDF noted in SSc-RP make it a valuable tool not only for evaluation of vasculopathy in SSc but also to distinguish it from Primary RP. The presence and severity of DOAD strongly correlates with digital ischemic complications and can be used as a guide to counsel patients and determine the aggressiveness of therapeutic interventions. Our study underscores the significance of LDF as a reliable non-invasive modality to detect DOAD and a prognostic tool to identify patients at highest risk of digital ischemic complications.

References:

[1]Mahe G et al. J Vasc Surg. 2014 Apr;59(4):1051-1057.e1

Disclosure of Interests:

None declared

Pictorial information about subclinical atherosclerosis reduces the CVD risk: Results from the VIPVIZA RCT

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Region Västerbotten and the Swedish Research Council

Background

The VIPVIZA trial has previously shown beneficial effects on cardiovascular disease (CVD) risk scores 1 year after sending pictorial information of carotid ultrasound imaging (Picture 1) to individuals and their physicians

Purpose

To investigate whether the beneficial effects on CVD-risk observed at 1-year were sustained over three years 

Methods

VIPVIZA is a pragmatic prospective open-label randomized controlled trial with blinded evaluators performed within a CVD prevention programme integrated in the regular primary health care in Västerbotten County, Sweden. Individuals aged 40, 50 or 60 years old with one CVD risk factor were enrolled and randomised 1:1 to intervention (n = 1749, pictorial information about subclinical atherosclerosis provided to participants and physicians, Picture 1) or control group(n = 1783, no information to participants or physicians). Intervention participants also recieved a follow-up phone call and the corresponding physicians written guideline-based information about the clinical significance of carotid ultrasound results. Participants were examined at baseline (2013-2016), after one and at three years

Results

A significant beneficial effect on cardiovascular risk was observed at the 3-year follow-up; Framingham Risk Score (FRS) was 13.38 for the intervention group and 14.08 for the control group(p = 0.047) and SCORE was 1.69 vs. 1.82(p = 0.022) respectively. The 3-year results adjusted for sex and educational level showed significant differences between the intervention and control group in FRS, SCORE, P-Total-Cholesterol, P-LDL-Cholesterol and waist circumference in favour of the intervention group. Analysis by sex showed difference in differences(DID) in FRS for men -1.19(95% CI -2.01 to -0.37) and -0.50(95% CI -0.93 to -0.07) for women and in SCORE for men -0.20(95% CI -0.33 to -0.06) and -0.08 (95% CI -0.13 to -0.04) for women, between the two groups over 3 years. Similarly, there were significant differences in DID in all educational groups. Further stratification by baseline FRS and SCORE risk category, showed a beneficial pattern of the intervention in all risk groups, however the DID at the 3-year follow-up was statistically significant only in the intermediate risk group for both FRS -1.34(95% CI -2.13 to -0.56) and SCORE -0.19(95% CI -0.32 to -0.05)

Conclusions

This study provides evidence of sustained effects over three years of pictorial information of subclinical carotid atherosclerosis on the reduction of cardiovascular risk regardless of sex and educational level. Importantly, a statistically significant intervention effect was seen in the intermediate risk group, where the majority of CVD events occur. Visualization of subclinical atherosclerosis may be one way to approach individuals at intermediate risk of CVD, a group where sufficient prevention is often overlooked. However, further studies are needed to investigate the intervention effect on hard end points as CVD-events and death.

Abstract Figure. Picture 1

Statin use associated with lower mortality in very elderly patients with peripheral arterial disease

Introduction

Given the potential side effects and the lack of data on its efficacy, the role of statins in the very elderly (age 75+) with peripheral arterial disease (PAD) is uncertain. Previous studies have shown significant mortality benefit in very elderly patients with coronary artery disease, but the effect in PAD has not been evaluated.

Methods

Very elderly patients aged 75 to 80 with at least five years of follow-up who underwent ankle-brachial index (ABI) measurement were included. PAD was defined as either low ABI &lt;0.90 or high ABI &gt;1.40. Demographic, medication use, comorbidity and mortality data was obtained using the electronic medical record. Univariate and multivariate Cox proportional hazard analyses were performed.

Results

In total, 4,560 very elderly subjects with PAD were included in the analysis. The median age was 77 (interquartile range 76–79) and 39% were female. 3,462 (76%) had low ABI while 1098 (24%) had high ABI. Univariate analysis showed that patients on statins were more likely to be male, have diabetes, have coronary artery disease, and have hyperlipidemia. Overall, 1,355 (30%) patients died in the five-year period. Unadjusted all-cause mortality hazard ratios for patients with low or high ABI with statin use was 0.66 (95% confidence interval [CI]: 0.57–0.75) and 0.80 (95% CI: 0.66–0.97), respectively. After adjusting for age, sex, coronary artery disease and diabetes, statin use in low and high ABI was still associated with significant reductions in risk of all-cause mortality of 0.59 (95% CI: 0.51–0.67) and 0.66 (95% CI: 0.54–0.80), respectively. The survival curve for very elderly patients with PAD by statin use is shown in Figure 1.

Conclusion

Statin use in the very elderly was associated with lower risk of all-cause mortality in the five-year period after diagnosis of PAD. There appears to be a mortality benefit with statin use in the very elderly with PAD, though careful consideration of benefits and side effects should be individualized in this age group.

Figure 1

Funding Acknowledgement

Type of funding source: None

Complex antithrombotic therapy and bleeding risk in patients with peripheral arterial disease

Introduction

Antiplatelet therapy is the cornerstone of treatment for many atherosclerotic vascular pathologies including peripheral arterial disease (PAD). Patients with PAD often have comorbid conditions that require complex antithrombotic therapy, i.e. combined antiplatelet and anticoagulation.

Methods

All adult patients undergoing ankle brachial index (ABI) measurements were included in the study. ABI values between 1.00 and 1.40 were considered normal, and values below 1.00 or above 1.40 were considered PAD. Demographic, comorbidity and outcome data were obtained using diagnostic codes from the electronic health record. Three medication classes were analyzed: aspirin, non-aspirin oral antiplatelets (e.g. P2Y12 inhibitors) and oral anticoagulants (warfarin and the direct oral anticoagulants). Medication use was determined for patients who had been on a medication for at least one year. Cox proportional hazard analysis for the time to first bleeding event was analyzed. Bleeding was defined as any bleeding requiring medical evaluation (including clinically-relevant non-major bleeding and major bleeding).

Results

In all, 40,144 patients were included in the analysis (mean age 66±15, 43% female). Patients with PAD were more likely to be on double therapy (one antiplatelet with anticoagulation) (28% vs 19%) and triple therapy (dual antiplatelet with anticoagulation) (10% vs 4%). Unadjusted hazard ratios for bleeding risk showed increased risk of bleeding for patients with PAD (1.18, 95% confidence interval [CI]: 1.08–1.29), though the association is no longer present after adjustment for antithrombotic therapy. Adjusting for age, sex and PAD class, compared to no antithrombotic therapy, there was increased risk of bleeding for monotherapy (1.91, 95% CI: 1.61–2.26), double therapy (3.40, 95% CI: 2.89–4.00) and triple therapy (5.00, 95% CI: 4.21–5.96). Among medications, aspirin and anticoagulant use was independently associated with the greatest increase in risk of bleeding.

Conclusion

Patients in PAD are at increased risk of bleeding secondary to antithrombotic therapy. Complex antithrombotic therapy with double or triple therapy confer additional bleeding risk, particularly regimens containing aspirin and oral anticoagulants.

Funding Acknowledgement

Type of funding source: None

P946Abnormal ankle brachial indices are associated with ischemic stroke: evidence from a large cohort study

Background

Peripheral arterial disease is a marker of aggressive atherosclerosis. The ankle brachial index (ABI) is a simple and non-invasive tool to diagnose peripheral arterial disease (PAD). Patients with PAD are at increased risk for ischemic strokes and other cardiovascular diseases.

Purpose

To evaluate the association of abnormal ABI and poorly compressible vessels with ischemic stroke in a large patient cohort.

Methods

We analyzed lower extremity vascular studies of all patients with ABI measurements at a tertiary care hospital between January 1996 and August 2018. PAD is defined as ABI<1.0, and poorly or non-compressible (PC/NC) arteries as ABI>1.4 while ABI between 1.0–1.4 is normal. Association of these ABIs with new ischemic stroke events post ABI measurement were analyzed after adjusting for high risk confounders such as atrial fibrillation. Hazard ratios (HR) were calculated using multivariable Cox proportional regression with 95% confidence intervals.

Results

In total, 38,016 unique patients (mean age 66.1±14.8 years, female 42.3%) were included. Abnormal ABI was found to be more prevalent among elderly male patients compared to patients with normal ABI. In contrast to non-PAD patients, both PAD and PC/NC patients as defined by ABI had a statistically significant risk of ischemic stroke, with PAD conferring the greatest risk compared to PC/NC vessels. The data is summarized in Table 1.

Table 1 Unadjusted HR p-value Adjusted HR p-value PAD vs. No PAD 2.77 (2.62, 2.92) <0.001 2.10 (1.98, 2.22) <0.001 PC/NC vs. No PAD 2.11 (1.95, 2.28) <0.001 1.38 (1.26, 1.51) <0.001 PAD vs. PC/NC 1.37 (1.28, 1.46) <0.001 1.37 (1.28, 1.48) <0.001 Adjusted and unadjusted hazard ratios with p-values. HR adjusted for age, sex, atrial fibrillation, ischemic stroke, transient ischemic attack, chronic heart failure, diabetes mellitus, hyperlipidemia, hypertension, and coronary artery disease. PAD = Peripheral artery disease and PC/NC = poorly compressible/non-compressible.

Conclusion

This study adds to the growing body of evidence that PAD and poorly-compressible vessels are independently associated with an increased risk of ischemic stroke. Given the associated risk of cerebrovascular disease, clinicians should aggressively treat to minimize risk factors in those with abnormal ABIs.

P945Abnormalities in ankle-brachial indices are independently associated with new-onset atrial fibrillation

Introduction

Lower extremity physiologic studies are an important non-invasive diagnostic tool in peripheral arterial disease (PAD). PAD and atrial fibrillation (AF) are associated with increased cardiovascular and all-cause mortality.

Purpose

To evaluate the association between PAD and new-onset AF and the risk of stroke.

Methods

We performed a study of all patients without AF undergoing ankle-brachial index (ABI) for any indication between January 1996 to June 2018. The ABI cut-off were as follows: abnormal ABI (0–0.99), normal ABI (1.00–1.39) and poor vessel compressibility (PC) (1.40+). Demographic, comorbidity, and outcome variables were extracted using the electronic medical record.

Results

Overall, 34,441 patients (mean age 66.8±14.3, 57.3% male, 88.2% white) were included in the study with a median follow-up of 7.2 years (interquartile range, 3.0–12.9 years). Multivariate Cox proportional hazard analysis showed increased risk of new-onset AF for male sex, older age, hypertension, coronary artery disease, cerebrovascular disease, chronic kidney disease stage III or greater, congestive heart failure, chronic obstructive pulmonary disease, and cancer (all p<0.0001). After adjustment, ABI results were significantly associated with new-onset AF, particularly poorly-compressible vessels (adjusted HR: 1.42 (1.30–1.55), p<0.0001) compared to abnormal ABI (adjusted HR: 1.12 (1.05–1.20), p=0.0012). Patients with atrial fibrillation were more likely to experience ischemic stroke (39.2% versus 16.1%, p<0.0001).

Conclusion

Abnormalities in ABI results, particularly poorly-compressible vessels, are independently associated with new-onset atrial fibrillation in a large ambulatory cohort. While the mechanism cannot be assessed, common inflammatory mechanisms and increased vascular stiffness may play an important role. Identification of AF in these at-risk patients may improve cardiovascular outcomes.

The Orbiting Carbon Observatory-2 early science investigations of regional carbon dioxide fluxes

NASA's Orbiting Carbon Observatory-2 (OCO-2) mission was motivated by the need to diagnose how the increasing concentration of atmospheric carbon dioxide (CO2) is altering the productivity of the biosphere and the uptake of CO2 by the oceans. Launched on 2 July 2014, OCO-2 provides retrievals of the column-averaged CO2 dry-air mole fraction ([Formula: see text]) as well as the fluorescence from chlorophyll in terrestrial plants. The seasonal pattern of uptake by the terrestrial biosphere is recorded in fluorescence and the drawdown of [Formula: see text] during summer. Launched just before one of the most intense El Niños of the past century, OCO-2 measurements of [Formula: see text] and fluorescence record the impact of the large change in ocean temperature and rainfall on uptake and release of CO2 by the oceans and biosphere.

Organic nitrate chemistry and its implications for nitrogen budgets in an isoprene- and monoterpene-rich atmosphere: constraints from aircraft (SEAC4RS) and ground-based (SOAS) observations in the Southeast US

Formation of organic nitrates (RONO₂) during oxidation of biogenic volatile organic compounds (BVOCs: isoprene, monoterpenes) is a significant loss pathway for atmospheric nitrogen oxide radicals (NO_x), but the chemistry of RONO₂ formation and degradation remains uncertain. Here we implement a new BVOC oxidation mechanism (including updated isoprene chemistry, new monoterpene chemistry, and particle uptake of RONO₂) in the GEOS-Chem global chemical transport model with ∼25 × 25 km² resolution over North America. We evaluate the model using aircraft (SEAC⁴RS) and ground-based (SOAS) observations of NO_x, BVOCs, and RONO₂ from the Southeast US in summer 2013. The updated simulation successfully reproduces the concentrations of individual gas- and particle-phase RONO₂ species measured during the campaigns. Gas-phase isoprene nitrates account for 25-50% of observed RONO₂ in surface air, and we find that another 10% is contributed by gas-phase monoterpene nitrates. Observations in the free troposphere show an important contribution from long-lived nitrates derived from anthropogenic VOCs. During both campaigns, at least 10% of observed boundary layer RONO₂ were in the particle phase. We find that aerosol uptake followed by hydrolysis to HNO₃ accounts for 60% of simulated gas-phase RONO₂ loss in the boundary layer. Other losses are 20% by photolysis to recycle NO_x and 15% by dry deposition. RONO₂ production accounts for 20% of the net regional NO_x sink in the Southeast US in summer, limited by the spatial segregation between BVOC and NO_x emissions. This segregation implies that RONO₂ production will remain a minor sink for NO_x in the Southeast US in the future even as NO_x emissions continue to decline.

Changes in alcohol consumption between 2009 and 2014 assessed with the AUDIT

BACKGROUND

Alcohol habits in Sweden, assessed as sales and estimates of unrecorded consumption, have changed since joining the EU. Earlier studies using the Alcohol Use Disorders Identification Test (AUDIT) showed that reported consumption is consistent with sales data, which makes it possible to assess consumption according to sex and age.

AIMS

This study reports the changes in alcohol habits between 2009 and 2014, a period starting a couple of years after Sweden joined the EU.

METHOD

The AUDIT was sent to a random sample of the Swedish population aged between 17 and 80 years old.

RESULTS

No statistically significant changes were shown in six age and sex groups.

CONCLUSIONS

Alcohol habits have stabilised in Sweden but on a higher consumption level than before.

Healthy behaviours and 10-year incidence of diabetes: a population cohort study

OBJECTIVE

To examine the association between meeting behavioural goals and diabetes incidence over 10 years in a large, representative Swedish population.

METHODS

Population-based prospective cohort study of 32,120 individuals aged 35 to 55 years participating in a health promotion intervention in Västerbotten County, Sweden (1990 to 2013). Participants underwent an oral glucose tolerance test, clinical measures, and completed diet and activity questionnaires. Poisson regression quantified the association between achieving six behavioural goals at baseline - body mass index (BMI) <25 kg/m(2), moderate physical activity, non-smoker, fat intake <30% of energy, fibre intake ≥15 g/4184 kJ and alcohol intake ≤20 g/day - and diabetes incidence over 10 years.

RESULTS

Median interquartile range (IQR) follow-up time was 9.9 (0.3) years; 2211 individuals (7%) developed diabetes. Only 4.4% of participants met all 6 goals (n=1245) and compared to these individuals, participants meeting 0/1 goals had a 3.74 times higher diabetes incidence (95% confidence interval (CI)=2.50 to 5.59), adjusting for sex, age, calendar period, education, family history of diabetes, history of myocardial infarction and long-term illness. If everyone achieved at least four behavioural goals, 14.1% (95% CI: 11.7 to 16.5%) of incident diabetes cases might be avoided.

CONCLUSION

Interventions promoting the achievement of behavioural goals in the general population could significantly reduce diabetes incidence.

The risk of myocardial infarction and sudden cardiac death amongst snuff users with or without a previous history of smoking

OBJECTIVES

To investigate the risk of a first myocardial infarction (MI) and sudden cardiac death (SCD) amongst male snuff users.

DESIGN

We used a prospective incident case-referent study design nested in the population-based Västerbotten Intervention Program and the Northern Sweden MONICA study.

SUBJECTS

Tobacco habits and cardiovascular risk factors were assessed at baseline screening and compared in 525 male MI cases (including 93 SCD cases) and 1798 matched referents.

RESULTS

Myocardial infarction occurred on average 4 years and 2 months after the baseline screening. No increased risk for MI was found amongst snuff users without a previous history of smoking compared with nontobacco users after adjustments for body mass index, leisure time physical activity, educational level and cholesterol level (OR 0.82; 95% CI, 0.46-1.43). For snuff users with a previous history of smoking, the adjusted OR was 1.25 (95% CI, 0.80-1.96). Significantly increased risk for MI was found in current smokers with or without current snuff use. For SCD cases with survival time<24 h, the adjusted OR for snuff users without previous history of smoking was 1.18 (95% CI, 0.38-3.70) and for cases with survival time<1 h the OR was 0.38 (95% CI, 0.08-1.89).

CONCLUSIONS

We found no increased risk for MI amongst snuff users without a previous history of smoking. Amongst snuff users with a previous history of smoking, the tendency towards an increased risk for MI may reflect the residual risk from former smoking. This study does not support the hypothesis that the risk for SCD is increased amongst snuff users.

TNF-alpha gene polymorphism and plasma TNF-alpha levels are related to lumbar spine bone area in healthy female Caucasian adolescents

OBJECTIVE

The cytokine tumor necrosis factor alpha (TNF-alpha) is an important regulator of bone metabolism. Polymorphisms in the promoter region of the TNF-alpha gene at positions -308 and -863 have been identified. We investigated whether these polymorphisms and circulating TNF-alpha levels were related to bone mineral density and bone area in adolescent girls.

DESIGN

Bone mineral density (BMD), bone area (BA), anthropometric characteristics and biochemical analyses were measured in adolescent girls and compared with regard to TNF-alpha genotype.

METHODS

Allelic variants of the TNF-alpha gene in 97 girls, aged 16.9+/-1.2 years (mean+/-S.D.), were identified using polymerase chain reaction and the restriction endonucleases NcoI and TaiI. Bone mineral density and bone area of the femoral neck, lumbar spine and total body were measured using dual energy X-ray absorptiometry.

RESULTS

Carriers of the rare -863 A allele (n=25) had higher body weight (P=0.03), lumbar spine BMD (P=0.02), and larger total BA (P=0.03), femoral neck area (P<0.05), and lumbar spine area (P=0.01). The independent predictors of BMD and BA were investigated using multiple regression. The TNF-alpha-863 genotypes (beta=0.18, P=0.03) and the TNF-alpha plasma levels (beta=0.19, P=0.04) independently predicted BA of the lumbar spine but not BA or BMD of any other measured sites. No statistically significant differences in body constitution parameters, biochemical parameters, bone density, or bone area at the measured skeletal sites were found when comparing the groups defined by the allelic variants at position -308 (P=0.17-0.84).

CONCLUSIONS

We found the TNF-alpha-863 polymorphism and the TNF-alpha plasma levels to be independent predictors of lumbar spine area in healthy Caucasian adolescent females.

The detection of large HNO3-containing particles in the winter Arctic stratosphere

Large particles containing nitric acid (HNO3) were observed in the 1999/2000 Arctic winter stratosphere. These in situ observations were made over a large altitude range (16 to 21 kilometers) and horizontal extent (1800 kilometers) on several airborne sampling flights during a period of several weeks. With diameters of 10 to 20 micrometers, these sedimenting particles have significant potential to denitrify the lower stratosphere. A microphysical model of nitric acid trihydrate particles is able to simulate the growth and sedimentation of these large sizes in the lower stratosphere, but the nucleation process is not yet known. Accurate modeling of the formation of these large particles is essential for understanding Arctic denitrification and predicting future Arctic ozone abundances.

Variations and stability in drinking patterns in a cohort of Swedish males

OBJECTIVE

Information on drinking patterns may make an important contribution to our understanding of the risks and consequences of alcohol consumption. The objective of the present study is to describe variations and stability of patterns of alcohol use at both the aggregate and the individual levels.

METHODS

The reported alcohol consumption was recorded of a normal, representative birth cohort of Swedish male (n = 122) subjects followed from the age of 18 years to early middle age and more extensively scrutinized at the age of 36, using a 28 day time-line follow-back technique.

RESULTS

In young middle age a high proportion of total consumption occurred on Fridays and Saturdays (about 60%). In addition, it was possible to classify "standard drinkers", "sporadic binge drinkers", and "frequent drinkers" as separate clusters.

CONCLUSION

While binge drinking was more stable than frequency of drinking from the age of 18 to the age of 36, frequent drinking showed the highest short-term stability at the age of 36 years.

Alcohol habits in a suburban male cohort

OBJECTIVE

Using data from a prospective birth-to-maturity project, the study presents normally occurring variations in alcohol involvement of alcohol-related problems among a representative cohort of Swedish males in young middle age, born in a Swedish metropolitan area (n = 106).

METHODS

Description and classification were based on an analysis of self-reported information (collected at about 36 years of age) about frequency and quantity of alcohol consumption (four-week timeline), self-reported alcohol-related symptoms, and registry data.

RESULTS

According to a broad, operationally defined classification of "harmful drinking" (at least three alcohol-related symptoms, including alcohol-related crimes), 43 subjects (41%) had experienced a substantial drinking problem during their lifetime, to an extent that might warrant labels such as "alcoholism" or "hazardous drinking". About one-third of these misusers were currently using other drugs. Of the 106 subjects, 80 (75%) reported having had at least one alcohol-related symptom or problem at some time during their life. Taking various life events into account, including sociomedical circumstances and heavy consumption at 18 and 25 years, 23 subjects (22%) were classified as having a lifetime prevalence of alcohol abuse/dependence according to DSM-III criteria.

CONCLUSION

Problem drinking was largely unknown to the healthcare system and only a few subjects had received treatment. The results are discussed in the light of data from other national and international epidemiological surveys.

Associations between different aspects of alcohol habits in adolescence, early adulthood, and early middle age: a prospective longitudinal study of a representative cohort of men and women

Previous research has indicated that the relation between adolescent and adult alcohol habits is not very strong. The objective of the present study was to illustrate associations between different aspects of alcohol habits from adolescence to early middle age in a normal, representative Swedish birth cohort of male (n = 122) and female (n = 90) participants. The sample was prospectively followed by means of self-reports on drinking habits at ages 18, 25, and 36. The results show that heavy drinking at age 18 and frequent intoxication at age 25 substantially increase the risk of heavy consumption at age 36 but that hazardous alcohol habits at either age 18 or 25 alone cannot be considered a substantial risk factor.

Associations between different aspects of alcohol habits in adolescence, early adulthood, and early middle age: a prospective longitudinal study of a representative cohort of men and women

Previous research has indicated that the relation between adolescent and adult alcohol habits is not very strong. The objective of the present study was to illustrate associations between different aspects of alcohol habits from adolescence to early middle age in a normal, representative Swedish birth cohort of male (n = 122) and female (n = 90) participants. The sample was prospectively followed by means of self-reports on drinking habits at ages 18, 25, and 36. The results show that heavy drinking at age 18 and frequent intoxication at age 25 substantially increase the risk of heavy consumption at age 36 but that hazardous alcohol habits at either age 18 or 25 alone cannot be considered a substantial risk factor.

Severe digital arterial occlusive disease and acute parvovirus B19 infection

We report a case of arterial occlusive disease and digital ischaemia associated with acute parvovirus B19 infection. Treatment with intravenous epoprostanol improved her symptoms.

Hydrogen radicals, nitrogen radicals, and the production of O3 in the upper troposphere

The concentrations of the hydrogen radicals OH and HO2 in the middle and upper troposphere were measured simultaneously with those of NO, O3, CO, H2O, CH4, non-methane hydrocarbons, and with the ultraviolet and visible radiation field. The data allow a direct examination of the processes that produce O3 in this region of the atmosphere. Comparison of the measured concentrations of OH and HO2 with calculations based on their production from water vapor, ozone, and methane demonstrate that these sources are insufficient to explain the observed radical concentrations in the upper troposphere. The photolysis of carbonyl and peroxide compounds transported to this region from the lower troposphere may provide the source of HOx required to sustain the measured abundances of these radical species. The mechanism by which NO affects the production of O3 is also illustrated by the measurements. In the upper tropospheric air masses sampled, the production rate for ozone (determined from the measured concentrations of HO2 and NO) is calculated to be about 1 part per billion by volume each day. This production rate is faster than previously thought and implies that anthropogenic activities that add NO to the upper troposphere, such as biomass burning and aviation, will lead to production of more O3 than expected.

Removal of Stratospheric O3 by Radicals: In Situ Measurements of OH, HO2, NO, NO2, ClO, and BrO

Simultaneous in situ measurements of the concentrations of OH, HO(2), ClO, BrO, NO, and NO(2) demonstrate the predominance of odd-hydrogen and halogen free-radical catalysis in determining the rate of removal of ozone in the lower stratosphere during May 1993. A single catalytic cycle, in which the rate-limiting step is the reaction of HO(2) with ozone, accounted for nearly one-half of the total O(3) removal in this region of the atmosphere. Halogen-radical chemistry was responsible for approximately one-third of the photochemical removal of O(3); reactions involving BrO account for one-half of this loss. Catalytic destruction by NO(2), which for two decades was considered to be the predominant loss process, accounted for less than 20 percent of the O(3) removal. The measurements demonstrate quantitatively the coupling that exists between the radical families. The concentrations of HO(2) and ClO are inversely correlated with those of NO and NO(2). The direct determination of the relative importance of the catalytic loss processes, combined with a demonstration of the reactions linking the hydrogen, halogen, and nitrogen radical concentrations, shows that in the air sampled the rate of O(3) removal was inversely correlated with total NOx, loading.

Rapid, accurate and simultaneous noninvasive assessment of right and left ventricular mass with nuclear magnetic resonance imaging using the snapshot gradient method

Left ventricular, and possibly also right ventricular, mass is an important determinant of prognosis in cardiovascular disease. Consequently, noninvasive estimation of ventricular mass may be an important clinical investigation. The ideal technique for this purpose would be widely available and accurate, employ short study times and avoid exposure to contrast agents and radiation. Conventional nuclear magnetic resonance (NMR) imaging fulfills most of these criteria, but it is time-consuming and expensive. Moreover, its accuracy in estimating right ventricular mass has yet to be assessed. Accordingly, high speed NMR imaging using the snapshot gradient echo technique was used to assess right and left ventricular mass in 10 dogs and the results were compared with values obtained at autopsy, which ranged from 26.1 to 52.9 and 61 to 119.8 g, respectively. The mean absolute difference between the NMR imaging estimates and autopsy findings was 2 +/- 1.2 g (range 0.4 to 4.2) for right ventricular mass and 4.4 +/- 1.7 g (range 1.8 to 6.6) for left ventricular mass. Total NMR imaging time was less than or equal to 5 min. These data demonstrate that high speed NMR imaging can be used to accurately estimate right as well as left ventricular mass.