Deborah A Chyun

Abstract

Context Coronary artery disease (CAD) is the major cause of mortality and morbidity in patients with type 2 diabetes. But the utility of screening patients with type 2 diabetes for asymptomatic CAD is controversial. Objective To assess whether routine screening for CAD identifies patients with type 2 diabetes as being at high cardiac risk and whether it affects their cardiac outcomes. Design, Setting, and Patients The Detection of Ischemia in Asymptomatic Diabetics (DIAD) study is a randomized controlled trial in which 1123 participants with type 2 diabetes and no symptoms of CAD were randomly assigned to be screened with adenosine-stress radionuclide myocardial perfusion imaging (MPI) or not to be screened. Participants were recruited from diabetes clinics and practices and prospectively followed up from August 2000 to September 2007. Main Outcome Measure Cardiac death or nonfatal myocardial infarction (MI). Results The cumulative cardiac event rate was 2.9% over a mean (SD) follow-up of 4.8 (0.9) years for an average of 0.6% per year. Seven nonfatal MIs and 8 cardiac deaths (2.7%) occurred among the screened group and 10 nonfatal MIs and 7 cardiac deaths (3.0%) among the not-screened group (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.44-1.88; P=.73). Of those in the screened group, 409 participants with normal results and 50 with small MPI defects had lower event rates than the 33 with moderate or large MPI defects; 0.4% per year vs 2.4% per year (HR, 6.3; 95% CI, 1.9-20.1; P=.001). Nevertheless, the positive predictive value of having moderate or large MPI defects was only 12%. The overall rate of coronary revascularization was low in both groups: 31 (5.5%) in the screened group and 44 (7.8%) in the unscreened group (HR, 0.71; 95% CI, 0.45-1.1; P=.14). During the course of study there was a significant and equivalent increase in primary medical prevention in both groups. Conclusion In this contemporary study population of patients with diabetes, the cardiac event rates were low and were not significantly reduced by MPI screening for myocardial ischemia over 4.8 years. Trial Registration clinicaltrials.gov Identifier: NCT00769275

Abstract

Patients with diffuse pulmonary arteriovenous malformations (PAVMs) are subject to frequent complications and need to be followed closely. As part of this followup, we have employed exercise stress testing (EST) as an aid to assess their status. Twenty patients from a cohort of 35 with diffuse PAVMs have undergone EST using a standard cycle ergometer test. All patients had previously undergone pulmonary angiography, noncontrast chest computed tomography (CT), and repair of large focal PAVMs, prior to EST. Mean room air oxygen saturation at baseline and at maximum exercise (85% of maximum heart rate) were tabulated. Serial studies in six children and young adults were plotted by year and compared using the patient as their own control. Fourteen females and six males ranging in age from 4 to 50 years (mean 22 years) were studied. Baseline mean oxygen saturation was 84% and fell to 73% at maximum exercise. There was no significant difference between those with unilateral and bilateral involvement (P = 0.09). In four of the six patients with serial EST, the baseline and exercise oxygen saturations were quite stable. In the two patients who became symptomatic, with age, growth, and more activity, complete embolization of one or more segments of the lung improved their EST and functionality. Based on our previous work in patients with diffuse PAVMs, EST appears to offer a relatively safe and noninvasive method for assessing these patients. Our limited experience with serial EST suggests a good correlation with decreased functionality in these patients.

Abstract

A descriptive study examining the relationship of denial of illness and compliance with inhaled controller asthma medications is conducted with 51 adults taking inhaled asthma controller medications. Affective and cognitive denial are assessed with the Levine Denial of Illness Scale. Severity is determined by portable spirometry; compliance is measured for 2 weeks with DOSER, a microelectronic monitor. The mean percent compliance rate for inhaled controller medications is 36%, with only 10.4% of the participants demonstrating optimal compliance (>80%). Although cognitive denial is not significantly associated with compliance, those in the suboptimal compliance group do have significantly higher information avoidance subscale scores (M = 1.88; p =.02). Affective denial is inversely correlated with compliance (r = -.31; p =.05) and is significantly higher in the suboptimal compliance group (M = 11.51; p =.05). These study findings suggest that affective denial may be a contributor to suboptimal compliance.

Abstract

Objective: To describe grandparenthood status and determine the relationship between grandparenthood status, metabolic control, and psychosocial factors in African American women with type 2 diabetes. Methods: A secondary, descriptive, exploratory analysis was conducted to examine the relationship between grandparenting status, physiologic indices related to metabolic control (body mass index, hemoglobin A1c, systolic blood pressure, low-density lipoprotein cholesterol) and psychosocial factors (emotional distress and quality of life) in a sample of 109 urban midlife African American women with type 2 diabetes. Results: Grandmothers made up 60% of the sample and were stratified into three groups on the basis of caretaking status. Grandmothers who cared for but did not live with grandchildren had the highest body mass index, hemoglobin A1c, low-density lipoprotein cholesterol, and systolic blood pressure. Caregiving grandmothers also had higher diabetes-related emotional distress scores but had better quality of life scores than did the non-caretaking grandmothers. Non-grandmothers had the lowest quality of life scores. Conclusions: These findings suggest relationships between grandmother caretaking status and metabolic and psychosocial factors. Research is needed to further examine these relationships and implications on practice and policy decisions.

Abstract

Background: Patients with diffuse pulmonary arteriovenous malformations (PAVM), a small but important subset of the PAVM population, have significant morbidity and mortality rates. Methods: Thirty-six patients (21 female and 15 male) with diffuse PAVM from a cohort of 821 consecutive patients with PAVM were evaluated. Diffuse PAVM were categorized angiographically: involvement of one or more segmental pulmonary arteries in one or both lungs. Hereditary hemorrhagic telangiectasia (HHT) status, gender, presence or absence of large (≥ 3-mm diameter artery) focal PAVM, oxygen saturations, complications including hemoptysis, years of follow-up, and survival were tabulated. Results: HHT was present in 29 of 36 patients (81%), and diffuse PAVM were more commonly bilateral (26 of 36 patients, 72%) than unilateral (10 of 36 patients, 28%) [p = 0.02]. Female gender was associated with bilateral diffuse PAVM (19 of 26 patients, 73%) [p = 0.01]. Focal PAVM were present in both groups but more commonly in patients with bilateral involvement (16 of 26 patients, 62%) [p = 0.02]. Initial oxygen saturations (pulse oximetry, standing) of patients with unilateral and bilateral diffuse PAVM were 87 ± 7% and 79 ± 8% (mean ± SD), respectively (p = 0.02). The last or current values for patients with unilateral and bilateral involvement are 95 ± 3% and 85 ± 7%, respectively (p < 0.0001). Nine deaths occurred, and all were in patients with bilateral involvement. Deaths were due to hemoptysis of bronchial artery origin (n = 2), hemorrhage from duodenal ulcer (n = 1), spontaneous liver necrosis (n = 3), brain hemorrhage (n = 1), brain abscess (n = 1), and operative death during attempted lung transplant (n = 1). Conclusions: Patients with diffuse PAVM are a high-risk group, and yearly follow-up is recommended.

Abstract

▶ Background: Although religion and spirituality are prominent in the lives of Black women with type 2 diabetes (T2DM), there is little research on the relationships of religion and spirituality to glycemic control (GC) in this population. ▶ Objective: To examine the relations of religion and spirituality to GC. ▶ Methods: Using a cross-sectional, descriptive, correlational design, a convenience sample of 109 Black women with T2DM was recruited. Measures of demographic (age, income, and education), clinical (body mass index and use of diabetes medications), psychosocial (emotional distress and social support), religion and spirituality (religious and existential well-being), and GC (hemoglobin A1c) factors were collected. A theoretical model, based on the work of Koenig, McCullough, and Larson (2001), informed linear regression analyses to examine the relations of religion and spirituality to GC, with psychosocial factors as putative mediators. ▶ Results: With age (β = -.133, SE = .020, p = .145), income (β =.020, SE = .139, p = .853), education (β = -.221, SE = .204, p = .040), body mass index (β= - .237, SE = .031, p = .011), and diabetes medications (β = .338, SE = .216, p < .001) held constant, religion and spirituality demonstrated significant relations with GC (β = .289, SE = .032, p = .028 and β = -.358, SE = .030, p = .006, respectively). Evidence of emotional distress and social support as mediators in the relationships of religion and spirituality to GC was lacking. ▶ Discussion: Religion and spirituality were related to GC, with evidence of psychosocial mediation lacking, thereby forcing revision of the model for the study population. Research is warranted to validate the findings, with further examination of theoretical mediators linking religion and spirituality to GC. Findings suggest that religion and spirituality be addressed in diabetes care to improve GC in Black women with T2DM.