What kind of patient education and self-care support do patients with heart failure receive, and by whom? Implementation of the ESC guidelines for heart failure in three European regions.

BACKGROUND: In order to manage Heart Failure (HF) properly, both pharmacological and non-pharmacological interventions including patient education and self-care (SC) support are important. Appropriate health care (HC) professional support is necessary to improve patient SC-skills. However, little is known which HC-professionals deliver specific education and support in daily HF-care. OBJECTIVES: To describe patient-education and SC-support as perceived by different HC-professionals in three neighboring North-West European regions: Maastricht(the Netherlands), Noorder-Kempen(Belgium), Aachen (Germany). METHODS: Semi-structured interviews with cardiologists, HF-nurses and general practitioners (GPs) were performed, followed by qualitative content analysis with a five-step approach: 1) familiarization with data, 2) initial coding with an a-priori code manual, 3) structuring of data in main themes, 4) revision and recoding of initial codes and 5) synthesizing codes in main themes. RESULTS: The sample consisted of 15 cardiologists, 35 GPs and 8 HF-nurses. All interviewed HC-professionals provide HF patient-education, yet, the extent differs between them. Whereas HF-nurses identify patient-education and SC-support as one of their main tasks, physicians report that they provide little education. Moreover, little patient education takes place in primary care; with almost none of the GPs reporting to educate patients about SC. GPs in region 2 refer HF-patients to their practice nurse for education and SC-support. None of the HC-professionals reported to provide patients with all key-topics for patient education and SC-support as defined by the ESC. CONCLUSION: HF nurses consider patient-education and SC-support as one of their main tasks, whereas physicians pay limited attention to education. In none of the three regions, all recommended topics are addressed.

Use of artificial intelligence to assess the risk of coronary artery disease without additional (non-invasive) testing: validation in a low-risk to intermediate-risk outpatient clinic cohort.

OBJECTIVES: Predicting the presence or absence of coronary artery disease (CAD) is clinically important. Pretest probability (PTP) and CAD consortium clinical (CAD2) model and risk scores used in the guidelines are not sufficiently accurate as the only guidance for applying invasive testing or discharging a patient. Artificial intelligence without the need of additional non-invasive testing is not yet used in this context, as previous results of the model are promising, but available in high-risk population only. Still, validation in low-risk patients, which is clinically most relevant, is lacking. DESIGN: Retrospective cohort study. SETTING: Secondary outpatient clinic care in one Dutch academic hospital. PARTICIPANTS: We included 696 patients referred from primary care for further testing regarding the presence or absence of CAD. The results were compared with PTP and CAD2 using receiver operating characteristic (ROC) curves (area under the curve (AUC)). CAD was defined by a coronary stenosis >50% in at least one coronary vessel in invasive coronary or CT angiography, or having a coronary event within 6 months. OUTCOME MEASURES: The first cohort validating the memetic pattern-based algorithm (MPA) model developed in two high-risk populations in a low-risk to intermediate-risk cohort to improve risk stratification for non-invasive diagnosis of the presence or absence of CAD. RESULTS: The population contained 49% male, average age was 65.6±12.6 years. 16.2% had CAD. The AUCs of the MPA model, the PTP and the CAD2 were 0.87, 0.80, and 0.82, respectively. Applying the MPA model resulted in possible discharge of 67.7% of the patients with an acceptable CAD rate of 4.2%. CONCLUSIONS: In this low-risk to intermediate-risk population, the MPA model provides a good risk stratification of presence or absence of CAD with a better ROC compared with traditional risk scores. The results are promising but need prospective confirmation.

Pulmonary and right ventricular dysfunction are frequently present in heart failure irrespective of left ventricular ejection fraction.

BACKGROUND: Heart failure (HF) may influence the lungs and vice versa. However, this interaction and the influence on right ventricular function (RVF) are insufficiently described in patients with HF divided into the recent groups based on left ventricular ejection fraction (LVEF): HF with reduced, midrange and preserved ejection fraction (HFrEF, HFmrEF and HFpEF, respectively). METHODS: Overall, 186 consecutive stable patients with HF seen in our outpatient clinic were retrospectively divided into HFrEF (n=70), HFmrEF (n=55) and HFpEF (n=61). Airflow limitation and gas exchange disturbance were measured by spirometry (forced expiratory volume in the first second/forced vital capacity (FEV1/FVC) (%)) and diffusion capacity of the lungs for carbon monoxide (DLCO). Standard echocardiography was performed to measure RV structure (RV diameter) and function (tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP)). Correlations were used to assess possible relations between pulmonary dysfunction and measurements of the RV. RESULTS: None of the investigated parameters differed significantly between the three groups (all p>0.1); FEV1/FVC was 70%±12%, 70%±13% and 74%±10% in patients with HFrEF, HFmrEF and HFpEF (p=0.12) and DLCO was 5.7±1.6, 5.7±1.8 and 5.6±1.6 mmol/min/kPa, respectively (p=0.95). RV structure and function did not differ either (TAPSE/PASP 0.58, 0.60 and 0.57, respectively (p=0.84)). There was a correlation of DLCO with RV function (r=0.34, p<0.001). CONCLUSION: The investigated cardiopulmonary parameters were comparable in the three HF groups. Diffusion capacity was impaired in more than half of the stable HF population independently of the LVEF and showed a correlation with RV function.

Improving kNowledge Transfer to Efficaciously RAise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF): Study protocol of a mixed methods study.

Heart failure is a complex disease with poor outcome. This complexity may prevent care providers from covering all aspects of care. This could not only be relevant for individual patient care, but also for care organisation. Disease management programmes applying a multidisciplinary approach are recommended to improve heart failure care. However, there is a scarcity of research considering how disease management programme perform, in what form they should be offered, and what care and support patients and care providers would benefit most. Therefore, the Improving kNowledge Transfer to Efficaciously Raise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF) study aims to explore the current processes of heart failure care and to identify factors that may facilitate and factors that may hamper heart failure care and guideline adherence. Within a cross-sectional mixed method design in three regions of the North-West part of Europe, patients (n = 88) and their care providers (n = 59) were interviewed. Prior to the in-depth interviews, patients were asked to complete three questionnaires: The Dutch Heart Failure Knowledge scale, The European Heart Failure Self-care Behaviour Scale and The global health status and social economic status. In parallel, retrospective data based on records from these (n = 88) and additional patients (n = 82) are reviewed. All interviews were audiotaped and transcribed verbatim for analysis.

Biomarker Guided Therapy in Chronic Heart Failure.

This review article addresses the question of whether biomarker-guided therapy is ready for clinical implementation in chronic heart failure. The most well-known biomarkers in heart failure are natriuretic peptides, namely B-type natriuretic peptide (BNP) and N-terminal pro-BNP. They are well-established in the diagnostic process of acute heart failure and prediction of disease prognosis. They may also be helpful in screening patients at risk of developing heart failure. Although studied by 11 small- to medium-scale trials resulting in several positive meta-analyses, it is less well-established whether natriuretic peptides are also helpful for guiding chronic heart failure therapy. This uncertainty is expressed by differences in European and American guideline recommendations. In addition to reviewing the evidence surrounding the use of natriuretic peptides to guide chronic heart failure therapy, this article gives an overview of the shortcomings of the trials, how the results may be interpreted and the future directions necessary to fill the current gaps in knowledge. Therapy guidance in chronic heart failure using other biomarkers has not been prospectively tested to date. Emerging biomarkers, such as galectin-3 and soluble ST2, might be useful in this regard, as suggested by several post-hoc analyses.

Arsenic removal in a sulfidogenic fixed-bed column bioreactor.

In the present study, the bioremoval of arsenic from synthetic acidic wastewater containing arsenate (As(5+)) (0.5-20mg/L), ferrous iron (Fe(2+)) (100-200mg/L) and sulfate (2,000 mg/L) was investigated in an ethanol fed (780-1,560 mg/L chemical oxygen demand (COD)) anaerobic up-flow fixed bed column bioreactor at constant hydraulic retention time (HRT) of 9.6h. Arsenic removal efficiency was low and averaged 8% in case iron was not supplemented to the synthetic wastewater. Neutral to slightly alkaline pH and high sulfide concentration in the bioreactor retarded the precipitation of arsenic. Addition of 100mg/L Fe(2+) increased arsenic removal efficiency to 63%. Further increase of influent Fe(2+) concentration to 200mg/L improved arsenic removal to 85%. Decrease of influent COD concentration to its half, 780 mg/L, resulted in further increase of As removal to 96% when Fe(2+) and As(5+) concentrations remained at 200mg/L and 20mg/L, respectively. As a result of the sulfidogenic activity in the bioreactor the effluent pH and alkalinity concentration averaged 7.4 ± 0.2 and 1,736 ± 239 mg CaCO3/L respectively. Electron flow from ethanol to sulfate averaged 72 ± 10%. X-ray diffraction (XRD), X-ray fluorescence (XRF), scanning electron microscopy (SEM) and energy dispersive X-ray spectroscopy (EDS) analyses were carried out to identify the nature of the precipitate generated by sulfate reducing bacteria (SRB) activity. Precipitation of arsenic in the form of As2S3 (orpiment) and co-precipitation with ferrous sulfide (FeS), pyrite (FeS2) or arsenopyrite (FeAsS) were the main arsenic removal mechanisms.

Preconcentration and determination of iron and copper in spice samples by cloud point extraction and flow injection flame atomic absorption spectrometry.

A flow injection (FI) cloud point extraction (CPE) method for the determination of iron and copper by flame atomic absorption spectrometer (FAAS) has been improved. The analytes were complexed with 3-amino-7-dimethylamino-2-methylphenazine (Neutral Red, NR) and octylphenoxypolyethoxyethanol (Triton X-114)wasadded as a surfactant. The micellar solutionwasheated above 50 degrees C and loaded through a column packed with cotton for phase separation. Then the surfactant-rich phase was eluted using 0.05 mol L(-1) H2SO4 and the analytes were determined by FAAS. Chemical and flow variables influencing the instrumental and extraction conditions were optimized. Under optimized conditions for 25 mL of preconcentrated solution, the enrichment factors were 98 and 69, the limits of detection (3s) were 0.7 and 0.3 ng mL(-1), the limits of quantification (10s) were 2.2 and 1.0 ng mL(-1) for iron and copper, respectively. The relative standard deviation (RSD) for ten replicate measurements of 10 ng mL(-1) iron and copper were 2.1% and 1.8%, respectively. The proposed method was successfully applied to determination of iron and copper in spice samples.

Preconcentration and determination of lead, cadmium and nickel from water samples using a polyethylene glycol dye immobilized on poly(hydroxyethylmethacrylate) microspheres.

A simple and sensitive preconcentration analysis-atomic absorption spectrometric procedure is described for the determination of lead, cadmium and nickel. The method is based upon on-line preconcentration of metal ions on a minicolumn of Cibacron Blue F3-GA immobilized on poly(hydroxyethylmethacrylate), poly(HEMA). The enrichment factors obtained were 42 for lead, 52 for cadmium and 63 for nickel (sample volume 10 mL and sample flow rate 5 mL/min). The relative standard deviations (n = 10), in 10 mL sample solutions containing 100 microg/L Pb(2+), 10 microg/L Cd(2+) and 100 microg/L Ni(2+) were 8.9, 3.7 and 3.5%, respectively. The limits of detection (blank + 3s) (n = 10), were found to be 12.01 microg/L for Pb(2+), 1.34 microg/L for Cd(2+) and 28.73 microg/L for Ni(2+). The accuracy of the system was checked with certified and tap water samples spiked with known amounts of metal ions. No significant difference was found between the achieved results and the certified values.

Biosorption of Hg2+, Cd2+, and Zn2+ by Ca-alginate and immobilized wood-rotting fungus Funalia trogii.

Funalia trogii biomass was immobilized in Ca-alginate gel beads. The live and heat inactivated immobilized forms were used for the biosorption of Hg2+, Cd2+ and Zn2+ ions by using plain Ca-alginate gel beads as a control system. The effect of pH was investigated and the maximum adsorption of metal ions on the Ca-alginate and both live and inactivated immobilized fungal preparations were observed at pH 6.0. The temperature change between 15 and 45 degrees C did not affect the biosorption capacity. The biosorption of Hg2+, Cd2+ and Zn2+ ions on the Ca-alginate beads and on both immobilized forms was studied in aqueous solutions in the concentration range of 30-600 mg/L. The metal biosorption capacities of the heat inactivated immobilized F. trogii for Hg2+, Cd2+ and Zn2+ were 403.2, 191.6, and 54.0 mg/g, respectively, while Hg2+, Cd2+ and Zn2+ biosorption capacities of the immobilized live form were 333.0, 164.8 and 42.1 mg/g, respectively. The same affinity order on a molar basis was observed for single or multi-metal ions (Hg2+ > Cd2+ > Zn2+). The Langmuir and the Freundlich type models were found to exhibit good fit to the experimental data. The experimental data were analyzed using the first-order (Langergren equations) and the second order (Ritchie equations). The experimental biosorption capacity with time is found to be best fit the second-order equations. The alginate-fungus system could be regenerated by washing with a solution of hydrochloride acid (10 mM). The percent desorption achieved was as high as 97. The biosorbents were reused in five biosorption-desorption cycles without significant loss of their initial biosorption capacity.

Biosorption of heavy metal ions on immobilized white-rot fungus Trametes versicolor.

Trametes versicolor mycelia were immobilized in carboxymethylcellulose, CMC, beads via entrapment, and the bead containing immobilized fungus spores were incubated at 30 degrees C for 3 days to attain uniform growth on the bead surface. After incubation, the live and heat inactivated immobilized fungus on the CMC beads were used for the biosorption of Cu(2+), Pb(2+) and Zn(2+) ions. Plain CMC beads were used as a control system. The biosorption of Cu(2+), Pb(2+) and Zn(2+) ions by the CMC and both live and inactivated immobilized preparations increased as the initial concentration of Cu(2+), Pb(2+) and Zn(2+) ions in the medium increased. The maximum biosorption capacities for both immobilized live and heat inactivated Trametes versicolor were 1.51 and 1.84mmol Cu(2+), 0.85 and 1.11mmol Pb(2+) and 1.33 and 1.67mmol Zn(2+) per g of dry biosorbents, respectively. Biosorption equilibrium was established in about 1.0h and the equilibrium was well described by Langmuir and Freundlich isotherms. A temperature change in the range of 15-45 degrees C did not affect the biosorption capacity. The affect of pH was also investigated and the maximum adsorption of Cu(2+), Pb(2+) and Zn(2+) ions on the CMC and both live and inactivated immobilized fungal biomass was observed between pH 4.0 and 6.0. The CMC beads with the immobilized fungus can be regenerated using 10mM HCl, with up to 97% recovery of the metal ions; the biosorbents reused up to five biosorption-desorption cycles without any major loss in the biosorption capacity.