Clinically Significant Depressive Symptoms Are Prevalent in People With Extremely Short Prognoses—A Systematic Review

ContextCurrently, systematic evidence of the prevalence of clinically significant depressive symptoms in people with extremely short prognoses is not available to inform its global burden, assessment, and management.ObjectivesTo determine the prevalence of clinically significant depressive symptoms in people with advanced life-limiting illnesses and extremely short prognoses (range of days to weeks).MethodsA systematic review and meta-analysis (random-effects model) were performed (PROSPERO: CRD42019125119). MEDLINE, Embase, PsycINFO, CINAHL, and CareSearch were searched for studies (1994–2019). Data were screened for the prevalence of clinically significant depressive symptoms (assessed using validated depression-specific screening tools or diagnostic criteria) of adults with advanced life-limiting illnesses and extremely short prognoses (defined by survival or functional status). Quality assessment was performed using the Joanna Briggs Institute Systematic Reviews Checklist for Prevalence Studies for individual studies and Grading of Recommendations Assessment, Development and Evaluation (GRADE) across studies.ResultsThirteen studies were included. The overall pooled prevalence of clinically significant depressive symptoms in adults with extremely short prognoses (n = 10 studies; extremely short prognoses: N = 905) using depression-specific screening tools was 50% (95% CI: 29%–70%; I² = 97.6%). Prevalence of major and minor depression was 10% (95% CI: 4%–16%) and 5% (95% CI: 2%–8%), respectively. Major limitations included high heterogeneity, selection bias, and small sample sizes in individual studies.ConclusionsClinically, significant depressive symptoms were prevalent in people with advanced life-limiting illnesses and extremely short prognoses. Clinicians need to be proactive in the recognition and assessment of these symptoms to allow for timely intervention.     

Co-Trimoxazole in Chronic Renal Failure–A Controlled Experiment in Wistar Rats

Abstract

To evaluate the possible effect of opiates on blood rheology, the plasma fibrinogen, prothrombin time and leukocyte aggregation were measured in 75 heroin addicts categorized by the time of abstention from heroin and the administration of naltrexone (25 active heroin abusers, 25 abstaining for 1 week, 11 abstaining for at least 5 months and 14 abstaining for 1 month and taking naltrexone during this period). No difference was detected in prothrombin time, but the leukocyte aggregation and fibrinogen were significantly different among the four groups (p = 0.028 and p = 0.0001, respectively). In particular, fibrinogen was 318 ± 10.9?mg/dL in heroin abusers, significantly higher than that of the remaining three groups; the percentage of aggregated leukocytes was 5.01 ± 0.77 in heroin users, significantly higher than that of subjects abstaining for at least 5 months. The fibrinogen levels declined sharply with abstention and an additive effect was noted with the administration of naltrexone, but leukocyte aggregation changed more slowly, and the effect of naltrexone (if any) was weaker. These data indicate an adverse effect of opiates on blood rheology and suggest that further studies should be performed to evaluate whether naltrexone may be useful in the prevention of major ischemic syndromes in patients with hyperfibrinogenemia and, perhaps, in those with high levels of leukocyte aggregation.     

Perceived Risk of Heart Attack: A Function of Gender?

TOPIC: The influence of gender on women's risk beliefs for heart attack. PURPOSE: To inform healthcare providers how women's beliefs and attitudes contribute to treatment-seeking delay in the event of a heart attack, and to establish the importance of risk beliefs in women. SOURCES: Published literature in MEDLINE and CINAHL computerized databases, reference lists of obtained articles. CONCLUSIONS: Women's perceived risk beliefs for heart attack are influenced by the effects of media, cultural, and gender roles and the modeling of bias in health care. There is a need for healthcare providers to change their focus from acting on (etic) a patient to interacting within (emic) the belief systems of their patients to optimize positive outcomes.     

Does Health Literacy Affect Self-Care in Patients with Heart Failure?

Low health literacy may be one reason that patients with heart failure fail to take care of their health. We examined the effect of health literacy on self-care in patients with heart failure. The study was conducted between September 1, 2016, and September 1, 2017, with 110 patients in a university hospital. Data were collected using the European Health Literacy Survey and the Self-Care of Heart Failure Index. Pearson correlation and multiple regression analysis were used. Study results revealed that health literacy significantly affected all scales of the Self-Care of Heart Failure Index. Based on these results, we recommend implementation of interventions designed to increase patients’ health literacy.     

High Calorie Intake Is Associated With Worsening Insulin Resistance and β-Cell Function in Hispanic Women After Gestational Diabetes Mellitus

OBJECTIVETo assess associations between dietary intake and rates of change in insulin resistance and β-cell function in Hispanic women with prior gestational diabetes mellitus (GDM).RESULTSThe median length of follow-up from the first postpartum evaluation was 8.0 years (interquartile range 4.5–10.8 years). At baseline, women were 32 ± 5.7 years old and had a median calorie intake of 2,091 kcal/day. Over the course of follow-up, dietary intake did not change significantly. Higher baseline calorie intake was associated with a faster decline in insulin sensitivity, measured by the insulin sensitivity index (S_I) (P = 0.029), and β-cell compensation, measured by the disposition index (DI) (P = 0.027), over time. These associations remained after adjustment for baseline characteristics; changes in BMI, calorie intake, levels of physical activity; and additional pregnancies during the follow-up period. The median rates were −0.06 vs. −0.02 units/year for S_I and −810 vs. −692 units/year for DI for women with baseline calorie intake above versus below the cohort median.CONCLUSIONSHigh calorie intake is associated with a faster decline in insulin sensitivity and β-cell compensation in Hispanic women who are at high risk for type 2 diabetes, independent of adiposity.     

Is There a Role for Ivabradine in the Contemporary Management of Patients with Chronic Heart Failure in Academic and Community Heart Failure Clinics in Canada?

Introduction

In patients with heart failure (HF) and reduced ejection fraction, increased heart rate (HR) is an independent risk factor for adverse outcomes. In systolic HF treatment with the If inhibitor ivabradine trial (SHIFT), Ivabradine improved survival when added to conventional treatment including β-blockers. However, the extent of benefit in the real world is unclear. We examined the characteristics of patients on guideline-directed therapy and determined who had SHIFT-like characteristics.

Methods

A total of 1096 patients with chronic HF were reviewed from June 2014 to April 2015 in two HF clinics in Toronto: an academic institution (AI), and a community hospital (CH) clinic. SHIFT-like characteristics [left ventricular ejection fraction (LVEF) ≤35%; sinus rhythm; and HR ≥ 70 bpm] were described.

Results

For all patients, mean age was 75 ± 13 years, overall LVEF was 44 ± 15%, AI less than CH (41.9 ± 14.0% vs. 45.7 ± 15.0%; p < 0.0001). More than two-thirds of patients in both groups were on β-blockers; with less than one-third at target dose. The proportion of patients with SHIFT-like characteristics was 8.4% AI and 11.7% CH, respectively (p = 0.0658).

Conclusion

In HF clinics from both academic and community hospitals in Toronto, up-titration in the dose of β-blockers and other guideline therapy can be improved on. A small proportion of patients with HF and SHIFT-like characteristics may potentially benefit from the addition of Ivabradine, just approved in Canada; this number will be further reduced if target dosage for β-blockers is achieved.

Funding

Servier Inc.

     

Primary Defects in ��-Cell Function Further Exacerbated by Worsening of Insulin Resistance Mark the Development of Impaired Glucose Tolerance in Obese Adolescents

OBJECTIVE—Impaired glucose tolerance (IGT) is a pre-diabetic state of increasing prevalence among obese adolescents. The purpose of this study was to determine the natural history of progression from normal glucose tolerance (NGT) to IGT in obese adolescents.RESEARCH DESIGN AND METHODS—We determined the evolution of β-cell function, insulin sensitivity (S_I), and glucose tolerance in a multiethnic group of 60 obese adolescents over the course of approximately 30 months. Each subject underwent three serial 3-h oral glucose tolerance tests. Dynamic, static, and total β-cell responsivity (Φ_d, Φ_s, and Φ_tot, respectively) and S_i were assessed by oral C-peptide and glucose minimal models. The disposition index (DI), which adjusts insulin secretion for S_i, was calculated.RESULTS—At baseline, all 60 subjects had NGT. Seventy-seven percent (46 subjects) maintained NGT over the three testing periods (nonprogressors), whereas 23% (14 subjects) developed IGT over time (progressors). At baseline, percent fat and BMI Z score were comparable between the groups. Fasting plasma glucose, 2-h glucose, glucose area under the curve at 180 min, and Φ_d were significantly different between the two groups at baseline, whereas S_i was comparable between the two groups. Over time, although S_i remained unchanged in nonprogressors, it steadily worsened by ∼45% (P > 0.04) in progressors. β-Cell responsivity decreased by 20% in progressors, whereas it remained stable in nonprogressors. The DI showed a progressive decline in progressors compared with a modest improvement in nonprogressors (P = 0.02).CONCLUSIONS—Obese adolescents who progress to IGT may manifest primary defects in β-cell function. In addition, progressive decline in S_i further aggravates β-cell function, contributing to the worsening of glucose intolerance.Understanding the underlying putative metabolic defects leading to the development of type 2 diabetes requires studies that focus on the earliest stages of the disease before the onset of any alterations in glucose tolerance. In adults, type 2 diabetes is the final stage in the progression of the disease (1–3), characterized by a progressive worsening in both insulin resistance and secretion (4–7). Whether a similar profile also occurs in youth developing type 2 diabetes is unknown. Much of the understanding of type 2 diabetes in youth originates from cross-sectional studies performed in obese adolescents with overt disease (8) or with impaired glucose tolerance (IGT) (9,10). One longitudinal study in obese adolescents with IGT at baseline indicated that over a period of 23 months, 45% reverted to normal glucose tolerance (NGT), 30% maintained IGT, and 25% developed type 2 diabetes(11). Thus, youth with IGT are at high risk for developing type 2 diabetes because of the presence of both insulin resistance and β-cell dysfunction.To assess the metabolic sequence of events that might be implicated in the transition from NGT to IGT, we performed serial oral glucose tolerance tests (OGTTs) along with anthropometric measures in a group of obese adolescents over a period of approximately 3 years. Using the oral minimal model (OMM) (12,13), we determined β-cell responsivity (Φ), insulin sensitivity (S_i), and disposition index (DI) and thus have repeated measures of both insulin secretion and insulin action before and during the evolution of IGT in obese adolescents. In a longitudinal study, we tested the hypothesis that preexisting β-cell dysfunction, further exacerbated by a progressive worsening in S_i, characterizes the onset of IGT in childhood obesity.     

Does RV Lead Positioning Provide Additional Benefit to Cardiac Resynchronization Therapy in Patients with Advanced Heart Failure?

BACKGROUND AND OBJECTIVES: The left ventricular (LV) stimulation site is currently recommended to position the lead at the lateral wall. However, little is known as to whether right ventricular (RV) lead positioning is also important for cardiac resynchronization therapy. This study compared the acute hemodynamic response to biventricular pacing (BiV) at two different RV stimulation sites: RV high septum (RVHS) and RV apex (RVA). METHODS AND RESULTS: Using micro-manometer-tipped catheter, LV pressure was measured during BiV pacing at RV (RVA or RVHS) and LV free wall in 33 patients. Changes in LV dP/dt(max) and dP/dt(min) from baseline were compared between RVA and RVHS. BiV pacing increased dP/dt(max) by 30.3 +/- 1.2% in RVHS and by 33.3 +/- 1.7% in RVA (P = n.s.), and decreased dP/dt(min) by 11.4 +/- 0.7% in RVHS and by 13.0 +/- 1.0% in RVA (P = n.s.). To explore the optimal combination of RV and LV stimulation sites, we assessed separately the role of RV positioning with LV pacing at anterolateral (AL), lateral (LAT), or posterolateral (PL) segment. When the LV was paced at AL or LAT, the increase in dP/dt(max) with RVHS pacing was smaller than that with RVA pacing (AL: 12.2 +/- 2.2% vs 19.3 +/- 2.1%, P < 0.05; LAT: 22.0 +/- 2.7% vs 28.5 +/- 2.2%, P < 0.05). There was no difference in dP/dt(min) between RVHS- and RVA pacing in individual LV segments. CONCLUSIONS: RVHS stimulation has no overall advantage as an alternative stimulation site for RVA during BiV pacing. RVHS was equivalent with RVA in combination with the PL LV site, while RVA was superior to RVHS in combination with AL or LAT LV site.     

Pain Management in Patients with Heart Failure: A Survey of Nurses’ Perception

BackgroundOver 50% of patients with heart failure (HF) report suffering from pain and pain-related burdens; however, pain in HF patients has not been recognized or well treated. Few studies have comprehensively examined pain management in patients with HF from nurses’ perception.AimsTo investigate nurses’ perception of pain management in HF patients.MethodsMembers of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional online survey.ResultsA total of 147 nurses responded and completed the survey. The majority agreed that pain in HF patients was related to anxiety, depression, fatigue, and unplanned hospitalization, and that pain should be individually assessed and managed. More than 80% thought pain management practice in HF patients should be improved, and 78.1% were interested in getting more information and believed an online education module was the most preferable approach. Lack of pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding opioid use in pain management in HF. The gaps in pain management in HF patients included lack of knowledge of opioid use, lack of consideration and awareness of pain, no clinical guidelines for pain assessment and treatment, and complicated pain management with multiple chronic conditions.ConclusionsThe impact of pain and need for individual assessment and management of pain in HF patients were perceived by nurses; improvement in pain management practice in HF patients is needed. Concerns regarding opioid use and gaps in pain management of HF patients should be addressed.     

Differential Effect of β-Blockers According to Heart Rate in Acute Myocardial Infarction Without Heart Failure or Left Ventricular Systolic Dysfunction: A Cohort Study

ObjectiveTo evaluate the effect of β-blockers according to heart rate in patients with acute myocardial infarction (AMI) without heart failure (HF) or left ventricular systolic dysfunction (LVSD).Patients and MethodsWe enrolled patients with AMI without HF or LVSD between June 1, 2003, and February 28, 2015, from Seoul National University Hospital Acute Myocardial Infarction Registry. Patients were categorized according to discharge heart rate recorded on electrocardiographs and β-blocker use. Low heart rate was defined as less than 75 beats/min. The primary end point was 5-year all-cause mortality according to discharge heart rate and β-blocker use.ResultsOf 2271 patients, 1696 (74.7%) received β-blockers and 1427 (62.8%) had low heart rates. At 5 years after discharge, 205 patients died. Overall, patients with low heart rates (P<.001) and those with β-blocker treatment had lower mortality (P<.001). After adjustment for covariates, β-blocker use was associated with 48% reduced risk for 5-year mortality in patients with high heart rates (hazard ratio, 0.52; 95% CI, 0.35-0.76), but not in those with low heart rates (P=.97). In an inverse-probability treatment-weighted cohort, β-blocker use was also associated with improved mortality in those with a high heart rate. Findings were similar for 5-year cardiovascular mortality.ConclusionAmong survivors with AMI without HF or LVSD, β-blocker use was associated with reduced 5-year all-cause mortality in patients who have high heart rates, but not in those with low heart rates.