Heart Failure Patients with type II diabetes still require more focus

Funding Acknowledgements

Type of funding sources: None.

Background

A bidirectional relationship exists between heart failure and diabetes; heart failure is a risk factor for type II diabetes and type II diabetes is a risk factor for heart failure. The prevalence of both chronic conditions is on a continuous upward rise. Heart failure has a poorer prognosis than diabetes and therefore heart failure patients with diabetes should be also managed at a heart failure centre. It has been shown that heart failure medication is of benefit to patients with or without diabetes.

Purpose

With new advances in heart failure medication this retrospective and prospective analysis examines if patients with or without type II diabetes receiving similar care at a heart failure centre will have similar outcomes.

Methods

 A retrospective and prospective cohort analyses was performed on 50 patients attending a single centre heart failure clinic over a 12-month period. LVEF, NT Pro BNP and NYHA was examined pre- and post-receiving similar heart failure care.

Results

50 patients were recruited for this study. There were 25 patients in the type II diabetes cohort (10 female: 15 male. Average age 77 years old) and 25 patients in the non-diabetes cohort (7 female:18 male. Average age 79 years old). In the type II diabetes cohort average LVEF pre care 27%: post care 33% (difference 6%), average NT Pro BNP pre care 3558 pg/ml: post care 2564 pg/ml (difference 994 pg/ml), average NYHA pre care II: post care I-II (difference of 0.5).

In the non-diabetic cohort average LVEF pre care 26%: post care 37% (difference 11%), average NT Pro BNP pre care 1679 pg/ml: post care 1135 pg/ml (difference 544 pg/ml), average NYHA pre care II: post care I-II (difference 0.5).

Conclusion

Both cohorts of patients had similar NYHA functional class outcomes. The patients in the type II diabetes cohort had higher NT Pro BNP levels pre care and higher reduction in NT Pro BNP post care than the non-diabetic cohort. Both cohorts had similar LVEF pre care, but the non-diabetic cohort had better improvement post care, with possible avoidance of need for implantable cardiac devices compared to the type II diabetes cohort. This study shows that heart failure nurses should be aware that heart failure patients with type II diabetes carry a higher risk profile and should be actively identified as part of an individualised, person-centred care approach. Heart failure patients with type II diabetes need to have vigilant scrutiny of their care to optimise their outcomes.

P2-10-02: Assessment of Tumor Response to Neoadjuvant Chemotherapy Using Ultrasound-Guided Near Infrared Light

Background

Neoadjuvant chemotherapy has been increasingly used in treating breast cancers. Because breast cancer is a heterogeneous disease, it is important to effectively monitor the tumor response to assist in tailoring treatments to response. In our early study, we have introduced a novel ultrasound (US)-guided diffused light imaging in the near infrared (NIR) spectrum to monitor tumor vascular changes which correlated to tumor response. The objectives of this study are: (a) to validate the initial findings with a larger patient pool, and (b) to assess vascular changes at every treatment cycle and to correlate early vascular changes with the tumor pathological response.

Methods: 33 patients who underwent neoadjuvant treatment were recruited from Dec. 2007 to May 2011 and their tumor vascular content was assessed with a combined imager consisting of a commercial US system coupled to a NIR imager. Patients were imaged before their treatment, at the end of each treatment cycle and before their surgery. The co-registered US was used to localize the tumor and the NIR imager was used to map the tumor vascular distribution which was assessed based on a percentage total hemoglobin (%tHb) concentration normalized to the pre-treatment level. 18 patients were treated with AC followed by Taxol. This group of patients was monitored every two weeks at the end of each treatment. The remaining patients were on 3-week cycles of chemotherapy and monitored every 3 weeks. 6 patients were treated with TC without Adriamycin (TC), or with Adriamycin (TAC), 6 HER2 positive patients were treated with TC and Herceptin (TCH); and 3 patients were treated with AC/Bevacizumab. Pathologic response was graded based on Miller and Payne system as grade 1: non-responders (A); grades 2 and 3: partial responders (B); 4: near-complete and 5: complete responders (C).

Results: In the AC/Taxol group (n=18), there were 5 responders (C), 9 partial (B) and 4 non-responders (A). The statistical significance based on %tHb between groups A and C was achieved at the end of cycle 5 and the rest of the treatment cycles (p<0.05), however, the statistical significance between A and B was only obtained at end of cycle 5 (p<0.05) and not maintained for cycles 6–8. The statistical significance between B and C was only achieved at the end the treatment (p<0.05). For the TC,TAC and TCH group (n=12), there were 6 responders(C) and 6 partial responders (B). The statistical significance between these two groups was achieved at the end of cycle 3 and the rest of the treatment cycles (p<0.05). For the 3 patients who were treated with AC/Bevacizumab, 2 patients achieved complete response and one partial with grade 2. The complete responders had more than 50% reduction in %tHb at the end of cycles 3–4; while the partial one showed only 10–15% reduction during the entire treatment course. Discussion: Our findings indicate that tumor vascular changes assessed by %tHb can be used to predict the tumor pathological response. This is a powerful tool to help predict responsiveness to therapy. Interestingly, dramatic and early responses were noted in the patients who received the biologic agents (bevacizumab and herceptin) and this may be very valuable in following responses using these agents.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-10-02.

"When are you seeing my patient?"--an analysis of the cardiology consultation service in a teaching hospital

The provision of an efficient consultation service is essential to the efficient functioning of any hospital. Surprisingly little is known about this activity. We present the first reported evaluation of a cardiology consultation service in an attempt to determine the characteristics, efficiency and workload implications of such a service. We performed an audit of the in-patient cardiology consultation service over a four week period. During this period, 125 consultations were seen, of which 85 (68%) were requested by medical specialties. Consultations were seen in a timely fashion, with 76 (61%) being seen on the same day that the request was received. The most common problem was chest pain, (49 patients; 38%) which was felt to be of cardiac origin in only a minority (20; 40%) of cases. Consultations had significant resource implications for our department, with 35 (28%) procedures being performed, 25 (20%) patients' care being taken over, and a further 27 (21.6%) new out-patient referrals generated. Our results indicate that the consultation service considered was efficiently delivered but contributed significantly to the department's workload. The most frequent consultation request was for chest pain that was often non-cardiac in nature.

Near Infrared Imaging Using US Localization To Assess Response to Neoadjuvant Chemotherapy

Background: Pilot data obtained from a novel ultrasound (US)-guided diffusive-wave optical tomography in the near infrared (NIR) spectrum showed that it is feasible to use this technique to monitor vascular changes within breast tumors during neoadjuvant chemotherapy. These changes correlated well to tumor pathologic response. The earlier study was performed at a single hospital with a smaller patient pool and the tumor vascular assessment was made at a period of two treatment cycles. The objectives of this study are: (i) to validate the initial findings with a larger patient pool, and (ii) to assess vascular changes at every treatment cycle and to correlate early vascular changes with the tumor pathological response.Materials and Methods: 13 patients who underwent neoadjuvant treatment were recruited from two hospitals from December 2007 to May 2009 and their tumor vascular content was assessed with a combined imager consisting of a commercially available US system coupled to a NIR imager (NIR/US). Patients were imaged before their treatment, at the end of every treatment cycle and before their definitive surgery. The co-registered US was used to localize the tumor and to guide the NIR imaging reconstruction, and the NIR imager was used to map the tumor vascular distribution which was assessed based on a percentage total hemoglobin (%tHb) concentration normalized to the pre-treatment level. Of the 13 patients, 12 patients had contrast enhanced MRI before treatment and prior to surgery. The NIR results were compared with MRI findings. At treatment completion, pathological assessment revealed three response groups: complete or near-complete responders (A), partial responders (B), and non-responders (C).Results: There were four complete or near-complete responders, five partial responders, and four non-responders. The mean %tHbs of groups of A, B and C at the treatment completion were 38%±7.0%, 57.3%±5.7%, and 91.0%±10.1%, respectively (differences statistically significant, p<0.05). At the end of cycle one, the %tHb of group A showed no noticeable difference than that of partial and non-responder groups, however, the %tHb at the end of cycle two or three of group A was significantly lower than that of partial and non-responder groups. Figure 1 shows an example of a complete responder imaged before the treatment and at the end of cycle two.All complete or near-complete responders showed rapid reduction in %tHb at the end of cycle two or three; while all non-responders showed no change or small change in %tHb throughout the treatment. On average, partial responders showed changes in between. Both NIR/US and MRI were equally effective in distinguishing different response groups in this study.Discussion: Our findings indicate that NIR can be used during neoadjuvant chemotherapy to repeatedly monitor tumor vascular changes. NIR/US may also assess early pathological response during treatment.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5016.

Tumor angiogenesis imaged by optical tomography can accurately diagnose early-stage invasive breast cancers

Abstract #52

Background: Our initial clinical results obtained from a novel ultrasound(US)-guided diffusive-wave optical tomography have shown that early-stage invasive breast cancers may be distinguished from benign lesions with an average of two-fold angiogenesis contrast. However, breast cancer is a heterogeneous disease with different growth and metabolic rates that result in a wide range of functional differences. In this report, we present a spectrum of breast lesion angiogenesis distributions from benign lesions, early-stage invasive cancers to advanced cancers. The objective is to investigate the feasibility of optical tomography with US localization in differentiating malignant from benign breast masses.
 Materials and Methods: 123 patients underwent US-guided biopsy and were imaged with a combined imager consisting of a commercially available US system and a near infrared (NIR) imager. A hand-held probe with a centrally located US transducer and NIR sensors surrounding it was used to simultaneously acquire co-registered US images and optical data. The lesion location provided by US was used to guide optical imaging reconstruction. Light absorption was measured at multiple wavelengths. From this, tumor angiogenesis was assessed based on calculated total hemoglobin concentration.
 Results: There were 23 stage I carcinomas, 21 stage II to IIII carcinomas, and 112 benign lesions. The mean maximum and average values of total hemoglobin concentration (tHb) of the stage I malignant group were 102.0 μ mol/liter (±30.7) and 72.3 μ mol/liter ( ±18.1), and the values of the state II to IIII malignant group were 114.4 μ mol/liter (±38.4) and 75.4 μ mol/liter (±25.2), respectively. The mean maximum and average values of the benign group were 54.0 μ mol/liter (±22.3) and 38.2 μ mol/liter (±14.8), respectively. Both maximum and average of tHb level were statistically significantly higher in the malignant groups than the benign group (P<0.01). An example of a six mm stage I cancer imaged by US (Fig.1(a)) and the NIR imager (Fig.1(b) is given in Figure 1.
 
 The detection sensitivity and specificity of the stage I cancer group were 91% and 94%, and 76% and 94% for the stage II to IIII cancer group.
 Discussion: The tumor angiogenesis distributions are complex and the angiogenesis contrast holds great promise for distinguishing early-stage invasive breast cancers from benign lesions. For advanced cancers, the angiogenesis distribution is heterogeneous and often presents periphery enhancement and/or shadow effect which can be used to assist US diagnosis.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 52.

Sensitization in atopic and non-atopic hairdressers with hand eczema

To investigate the capability of atopics to be sensitized to contact allergens, 143 hairdressers with hand eczema, who had been patch tested with the hairdresser's series, were studied. The 125 women and 18 men were grouped according to their personal atopic status. There were 45 eczematous atopics, 32 mucous membrane atopics and 66 non-atopics. Sensitization to at least one of the hairdressing chemicals was found in 60% of the eczematous atopics, 53% of the mucous membrane atopics and 58% of the non-atopics. The commonest sensitizer in each group was glyceryl monothioglycolate followed by para-phenylenediamine and related dyes. None of the 18 men were allergic to nickel but 40% of the women were thus sensitized. Jewelry rather than equipment was thought to be the cause. No significant difference was found between the eczematous atopics, mucous membrane atopics and non-atopics in their capacity to be sensitized to hairdressing allergens or to nickel.

Contact sensitivity to lignocaine

Lignocaine is a rare contact allergen, in contrast to other local anaesthetics such as benzocaine, which commonly sensitize. The case of a patient sensitized to lignocaine through the use of a topical medication for the treatment of haemorrhoids is reported. Previous reports show that application of a lignocaine-containing preparation for pruritus ani is the most frequent cause of sensitization to lignocaine. The significance of sensitization to lignocaine is discussed in the light of its widespread use both in local anaesthesia and as an anti-arrhythmic.

Patients with atopic eczema do become sensitized to contact allergens

Sensitization to contact allergens in atopics was assessed by grouping 989 patients, who were routinely patch tested, by their personal atopic status. Sensitization to > or = 1 allergens occurred in 38% of the 191 patients with existing atopic eczema, in 53% of the 120 with a past history of atopic eczema, in 54% of the 156 with only mucous membrane atopy and in 50% of the 510 who were not atopic. Sensitization to perfume, a common environmental allergen, was similar in all 4 groups, as was nickel among women. Patients with atopic eczema should be patch tested.

Diagnosis of lichen planus pemphigoides in the absence of bullae on normal-appearing skin

A case of lichen planus pemphigoides is described in which bullae and erosions affected the areas of lichen planus only. The diagnosis was confirmed by the finding of linear C3 and IgG deposition in the basement membrane zone (BMZ) of perilesional skin. Indirect immunofluorescence revealed circulating IgG anti-BMZ antibodies and a lamina lucida split was demonstrated by electron microscopy. This case challenges the clinical dogma that the occurrence of bullae on normal-appearing skin is essential for the diagnosis of lichen planus pemphigoides.

Final diagnoses in patients referred for patch testing

The final diagnoses made in 989 patients consecutively patch tested in 1990 have been reviewed. Among the men, their dermatitis was entirely occupational in 17.9% and partially so in 12.5%. Among the women, it was entirely occupational in 6.4% and partially so in 9.5%. In both groups, irritants exceeded allergens as the cause, whereas allergens superseded irritants in the patients with a non-occupational eczema caused or aggravated by external factors. It seems likely that domestic irritants were overlooked in patients with a non-occupational dermatitis.

Recalcitrant pyoderma gangrenosum--two cases successfully treated with cyclosporin A

The successful use of cyclosporin A (CSA) in organ transplantation is now well established. In recent years its usefulness has extended to the treatment of cutaneous autoimmune disorders, including pyoderma gangrenosum (P.G.). We report two further cases of recalcitrant P.G., both associated with rheumatoid arthritis (R.A.) which responded to low dose CSA.

Formaldehyde is a significant allergen in women with hand eczema

Among patients consecutively patch tested at St John's from 1984-1989, the prevalence rate of formaldehyde sensitivity was 2.2% for men and 3.7% for women. During these 6 years, 117 women were primarily sensitized by formaldehyde, of whom 61 (52%) had hand eczema. Exposure was occupational in 12% and domestic in 88%. Cleaning products were the main source of exposure in the domestic group. 20 women with hand eczema avoided formaldehyde and their hands healed in 2, greatly improved in 11 and were better in 7.

Immediate and delayed photocontact dermatitis from isopropyl dibenzoylmethane

Immediate and delayed photocontact dermatitis from the UVA absorber isopropyl dibenzoylmethane is described in 1 patient. In a dose response study in a 2nd patient with delayed photocontact dermatitis, the minimal dose of UVA needed to elicit a positive photopatch to isopropyl dibenzoylmethane 2% was determined to be 2 J/cm2.

Lichen planus pemphigoides

Lichen planus pemphigoides is a rare disease in which blistering occurs in association with lesions of classical lichen planus. We describe a patient with lichen planus pemphigoides and discuss the evidence for there being one disease rather than the coincidence of bullous pemphigoid and lichen planus.

Frequency of sensitisation to the preservative Kathon CG

The incidences of sensitisation to Kathon CG are reported for patients routinely tested from 1984 to 1986 in Bari, London, Louvain, Nijmegen, Oulu and San Francisco. For these 3 years, the overall frequency of sensitisation varied for women from 3.3% in Oulu to 0.6% in London and San Francisco and for men from 1.4% in Oulu to 0% in San Francisco. Women were predominantly sensitised, probably by cosmetics, toiletries and domestic cleaners. Occupational sensitisation was much less frequent.

Dermatitis of the hands in caterers

Hand eczema among 50 caterers was occupational in 47 and endogenous in 3 cases. Irritants were considered more important than sensitisers. There was a correlation between atopy and sensitisation to type-I but not type-IV allergens. The commonest type-I sensitiser was fish and for type-IV was garlic. Dilutions of garlic and of onion 50% in arachis oil were not irritant and seemed effective patch test materials. The prognosis was not good and the hand eczema continued even in some of those who changed their jobs.

Sensitivity to sunscreens

The patients sensitised to sunscreen agents who attended our Contact Dermatitis Clinic between February 1985 to March 1987 have been reviewed. 15 (5%) of 280 patients tested with sunscreens had positive reactions; 3 of them were allergic to more than one agent. The most frequent contact allergens were hydroxy methoxy methyl benzophenone (Mexenone) [6], followed by isopropyl dibenzoylmethane (Eusolex 8020/8021) [5], octyl dimethyl para-aminobenzoate (Escalol 507) [2], and one reaction each to butyl methoxy dibenzoylmethane (Parsol 1789), amyl dimethyl para-aminobenzoate (Escalol 506), and ethoxy ethyl-p-methoxy cinnamate (Givtan F). Positive photopatch tests were seen with isopropyl dibenzoylmethane, butyl methoxy dibenzoylmethane, para-aminobenzoate (PABA) and ethoxy ethyl-p-methoxy cinnamate, one reaction each.

Computing in clinical departments: implications for the design of hospital information systems

Information technology is of increasing importance to the health service. Two main types of system have grown up, those in clinical departments and central administrative systems. It is important to consider their inter-relationships. A clinical system in the Renal Unit at Manchester Royal Infirmary is described, which is typical of many departmental systems. Further work is reported demonstrating an impressive commonality in the requirements of different clinical disciplines and supporting the view that departmental systems are a valuable source of accurate management data. The experience gained from designing departmental systems is reviewed. It is concluded that the participation of users is essential to the successful design and implementation of systems in the National Health Service and that departmental systems have a crucial role to play in the development of district information systems.

Photocontact urticaria from chlorpromazine

Chlorpromazine is well recognized as a cause of delayed photosensitive eczema. A patient illustrated typical features of the phenomenon. Urticarial lesions were also elicited on photopatch testing.

Clinical patterns of hand eczema in women

The hand eczema of 263 women was studied as 4 clinical patterns: palms and fingers, dorsa and fingers, fingers only and the entire hands. The palmar pattern was the commonest. Sensitisers affected the patterns equally but irritants were of less significance in the palmar group than among the rest. Atopics did not appear to have a distinctive pattern. Among the occupational group, irritants were of much greater importance than allergens.

Antioxidants in cosmetics

Antioxidants are commonly added to cosmetics. Allergy to these substances will be missed unless specifically looked for. During a 2-year period, patients with facial dermatitis have been routinely tested with butylhydroxyanisole and tertiary butylhydroquinone. 7 patients are reported who have been shown to have an allergic contact dermatitis to an antioxidant in their cosmetics or toiletries.

Photosensitivity to musk ambrette

Photosensitivity to musk ambrette was confirmed in 15 men previously photopatch tested and in a further 4 men currently attending the clinic. 6 of the recalled patients continued to react adversely to sunlight due either to unrecognised exposure to musk ambrette or to their having become persistent light reactors. Positive photopatch tests, possibly cross reactions, were seen in 3 of the 19 patients with the structurally-related nitromusks, moskene and musk xylene but not with musks ketone and tibetine. Musk ambrette elicited a positive patch test without light in 3 of the 19 patients.

Patch and photopatch testing in chronic actinic dermatitis

Photopatch tests in 47 patients with chronic actinic dermatitis (CAD) showed musk ambrette to be the only significant allergen in our standard photopatch test series. The incidence of positive patch tests to a standard series of contact allergens in this group was compared with 213 men over the age of 50 years with eczema investigated in the contact clinic. Among the photosensitive patients, there was an increased incidence of reaction to thiuram-mix (CAD 10%; controls 3%), carba mix (CAD 6%; controls 1%), nickel sulphate (CAD 6%; controls 2%) and vioform (CAD 10%; controls 0.5%). A decreased incidence of reaction to potassium dichromate (CAD 0%; controls 8%) and balsam of Peru (CAD 4%; controls 10%) was recorded.

Allergy to phenyl salicylate

Six cases of contact dermatitis from a lip salve are described. Five were allergic to phenyl salicylate and one to geraniol in the fragrance. The dermatitis spread in a ring around the mouth. Phenyl salicylate has been removed from the formulation.

Lanolin of reduced sensitizing potential

Confirmation has been obtained that reducing the content of natural free alcohols in lanolin to below 3%, particularly in the absence of detergent residues, reduces the incidence of positive patch test reactions amongst selected lanolin-sensitive skin patients by 99.3%. Only one reaction out of 149 subjects was recorded.

Oil of turpentine--a disappearing allergen

Oil of turpentine has become an infrequent allergen because of its replacement by the petroleum product white spirit, its deliberate exclusion from industrial products, and because the balsam oils used nowadays do not contain the sensitiser delta 3-carene. On the basis of the generally low incidence of sensitisation being currently recorded, the International Contact Dermatitis Group recommend that oil of turpentine be removed from standard patch test series.