Depression,medication adherence,and service utilization in systemic lupus erythematosus

Objective

Forgetting to take medications is an important cause of nonadherence. This study evaluated factors associated with forgetting to take medications in a large cohort of persons with systemic lupus erythematosus (SLE) participating in the University of California, San Francisco Lupus Outcomes Study (LOS). Relationships among adherence problems and service utilization (outpatient visits, emergency department visits, and hospitalizations) were also evaluated.

Methods

The cohort consisted of 834 LOS participants who provided self‐reported frequency of forgetting to take medications as directed. Predictors of adherence and service utilization patterns included self‐reported sociodemographics, disease‐related characteristics (e.g., disease activity, recent SLE flare), and mental health characteristics (Center for Epidemiologic Studies Depression Scale and cognitive function screen). Health care utilization patterns included the presence and quantity of visits to rheumatologists, primary care physicians, other care providers, emergency departments, and hospitalizations.

Results

Forty‐six percent of the LOS cohort reported forgetting to take medications at least some of the time. Depressive symptom severity was a strong predictor of adherence difficulties (odds ratio [OR] 1.04, 95% confidence interval [95% CI] 1.02–1.05; P < 0.0001) after accounting for all other predictors. Persons reporting adherence difficulties had significantly greater numbers of outpatient rheumatology and primary care visits, and were more likely to visit the emergency department (OR 1.45, 95% CI 1.04–2.04; P = 0.03).

Conclusion

Depression may be an important cause of medication adherence problems, and difficulties with adherence are significantly associated with high‐cost service utilization, specifically emergency department visits. In an era of rapidly evolving treatments for lupus, identifying patients at risk for adherence problems may decrease medical expenditures and improve patient outcomes in SLE.     

Hospital admissions and length of stay for coronary disease in an Aboriginal cohort

Background and aimsCoronary disease (CHD)-related hospital admission is more common among indigenous than non-indigenous Australians. We aimed to identify predictors of hospital admission potentially useful in planning prevention programs.Methods and resultsLength of stay (LOS), interval between, and number of recurrent admissions were modelled with proportional hazards or negative binomial models using lifestyle data recorded in 1988–1989 among Aborigines (256 women, 258 men, aged 15–88 years) linked to hospital records to 2002. Among 106 Aborigines with CHD, hypertension (hazard ratio (HR) 1.69, 95% CI 1.05–2.73); smoking (HR 1.90, 95% CI 1.02–3.53); consuming processed meat >4 times/month (HR 1.81, 95% CI 1.01–3.24); >6 eggs/week (HR 1.73, 95% CI 1.03–2.94); and lower intake of alcohol (HR 0.54, 95% CI 0.35–0.83) predicted LOS. Eating eggs (HR 1.05, 95% CI 1.01–1.09) and bush meats ≥7 times/month (HR 0.46, 95% CI 0.23–0.92) predicted interval between recurrent admissions. Hypertension (IRR 4.07; 95% CI 1.32–12.52), being an ex-drinker (IRR 6.60, 95% CI 2.30–19.00), eating red meat >6 times/week (IRR 0.98, 95% CI 0.97–0.99), bush meats >7 times/month (IRR 0.26, 95% CI 0.10–0.67), and adding salt to meals (IRR 3.16, 95% CI 1.12–8.92) predicted number of admissions.ConclusionHypertension, alcohol drinking, smoking, and diet influence hospital admissions for CHD in Aboriginal Australians.     

Kinetics of interferon‐gamma producing cytomegalovirus (CMV)‐specific CD4+ and CD8+ T lymphocytes and the risk of subsequent CMV viremia after allogeneic hematopoietic stem cell transplantation

Background. Deficiencies in cytomegalovirus (CMV)‐specific T lymphocytes impair the immunologic response against CMV reactivation after allogeneic hematopoietic stem cell transplantation (HSCT). Methods. A time‐dependent analysis was conducted to determine the association between the percentages and kinetics of interferon‐gamma‐producing CMV‐specific CD4+ and CD8+ T lymphocytes and CMV viremia among 30 allogeneic HSCT recipients. Results. Higher percentages of CD4+ T lymphocytes activated with CMVpp65 (hazard ratio [HR]: 2.06; 95% confidence interval [95% CI]: 1.18–3.6; P=0.011) and CMV lysate (HR: 1.18; 95% CI: 0.99–1.42; P=0.072), and higher percentages of CD8+ T lymphocytes activated by CMV immediate early‐1 (HR: 1.2; 95% CI: 1.01–1.43; P=0.038) and CMVpp65 (HR: 1.12; 95% CI: 1.0–1.27; P=0.060) were associated with time‐to‐CMV viremia. Furthermore, a higher degree in the decline of CMV lysate‐activated CD4+ T lymphocytes (HR: 1.14; 95% CI: 0.96–1.36; P=0.125) and CMVpp65‐activated CD8+ T lymphocytes (HR: 1.36; 95% CI: 1.03–1.78; P=0.031) was suggestive of or significantly associated with time‐to‐CMV viremia. Conclusions. Higher levels of CMV‐specific CD4+ and CD8+ T lymphocytes were associated with subsequent CMV viremia after HSCT. The association between CMV viremia and the degree of decline in CMV‐specific T lymphocytes suggests that severe disruption in homeostatic CMV‐specific immune environment contributes to the immunopathogenesis of CMV after allogeneic HSCT.     

Prediction of functional disability by depressive state among community‐dwelling elderly in Japan: A prospective cohort study

Aim: We carried out a prospective cohort study to evaluate the risk factors of functional disability by depressive state. Methods: A total of 783 men and women, aged 70 years and over, participated in this study. We followed the participants in terms of the onset of functional disability by using a public long‐term care insurance database. The Geriatric Depression Scale (GDS) was used to measure depressive state. Age, sex, history of chronic disease, living alone, fall experience, cognitive impairment, instrumental activities of daily living (IADL), the Motor Fitness Scale (MFS), frequency of going out and social support at baseline were used as the main covariates. The Cox regression analysis was used to examine the difference in functional disability stratified according to depressive state. Results: The incidence of functional disability was 38 persons in the non‐depression group and 42 persons in the depression group (RR 2.34; 95% CI 1.46–3.79). The results of the depression group showed a significant difference in cognitive impairment (HR 3.51; 95% CI 1.39–8.85), MFS (HR 5.60; 95% CI 1.32–23.81) and IADL (HR 3.37; 95% CI 1.65–6.85). The results of the non‐depression group showed a significant difference in MFS (HR 2.97; 95% CI 1.47–6.96), and frequency of going out (HR 3.21; 95% CI 1.47–6.96). Conclusions: In conclusion, risk factors for functional disability were found to differ on the basis of whether or not community‐dwelling elderly individuals experience depressive state. The type of support offered must be based on whether or not depressive state is present. Geriatr Gerontol Int 2012; ??: ??–?? .     

Adherence to a multifactorial fall prevention program following paramedic care: Predictors and impact on falls and health service use. Results from an RCT a priori subgroup analysis

Objective

To identify predictors and impact of adherence to a multifactorial fall‐prevention program on falls and health service utilisation.

Methods

Randomised controlled trial with a priori subgroup analysis within intervention group according to adherence. Participants were community dwelling, (≥65 years), not transported to hospital following fall‐related paramedic care. The Attitudes to Falls‐Related Interventions Scale (AFRIS) was completed at baseline, adherence levels were measured (three‐point scale) at six months, and falls and health service utilisation were recorded for 12 months. Multivariate logistic regression and area under the curve were calculated with 95% confidence interval (CI).

Results

Attitudes to Falls‐Related Interventions Scale scores (n = 85) were independent of baseline characteristics. At six months, 39 (46%) participants reported full adherence. Independent predictors of adherence were positive AFRIS (OR 4.10, 95% CI 1.48–11.39) and receiving 3+ recommendations (OR 3.36, 95% CI 1.26–9.00). Adherers experienced fewer falls (IRR 0.53, 95% CI 0.45–0.80) and fall‐related health service use (emergency department presentations IRR 0.37, 95% CI 0.17–0.82) compared to non‐adherers.

Conclusion

Older adults who adhere to recommendations benefit, regardless of fall‐risk profile.     

Age,pre-arrest neurological condition,and functional status as outcome predictors in out-of-hospital cardiac arrest: Secondary analysis of the Jerusalem Cohort Study data

PurposeInvestigate the relation between age, baseline neurological and functional status, and survival after out-of-hospital cardiac arrest (OHCA).MethodsData analysis from the Jerusalem District Resuscitation Study. Patients >80 years and those 18–80 years with OHCA from 4/2005–12/2010 were compared. Primary outcome: survival at four time points; secondary outcomes: neurological and functional status at hospital discharge, and relationship between survival, age and pre-arrest activities of daily living (ADL) and Cerebral Performance Category (CPC) scores (higher scores indicate worse function in both).Results3,211 patients (1,259 >80 years, 1952 aged 18–80) with median follow-up 5.9 years (range 0.1–11.1 years) were included. Survival was better for younger patients at all four time points, including 7.8% versus 2.5% at hospital discharge, 4.6% versus 0.2% at late follow-up. Functional status at discharge was also better, 4.8 ± 5.4 versus 9.0 ± 4.7, p<0.001, and more young patients had CPC1/2, 60.7% versus 32.2%, p = 0.004. Older patients who survived to emergency department admission had increased mortality per year of age (2.6%, hazard ratio [HR] 1.026, 95% confidence interval [CI] 1.006–1.048 versus 1.7%, HR 1.017, 95% CI 1.010–1.025), per point in pre-arrest ADL (3.0%, HR 1.030, 95% CI 1.007–1.054 versus 5.8%, HR 1.058, 95% CI 1.036–1.080), and per point in pre-arrest CPC (24%, HR 1.242, 95% CI 1.097–1.406 versus 37%, HR 1.370 95% CI 1.232–1.524).ConclusionPatient independence before arrest may be a more crucial determinant of resuscitation outcome than older age alone. Discussion of end-of-life preferences is particularly important for older individuals with functional and cognitive decline.     

Health-protective and adverse effects of the apolipoprotein E epsilon2 allele in older men

OBJECTIVES: To reexamine a health‐protective role of the common apolipoprotein E (APOE) polymorphism focusing on connections between the APOE?2—containing genotypes and impairments in instrumental activities of daily living (IADLs) in older (≥65) men and women and to examine how diagnosed coronary heart disease (CHD), Alzheimer's disease, colorectal cancer, macular degeneration, and atherosclerosis may mediate these connections. DESIGN: Retrospective cross‐sectional study. SETTING: The unique disability‐focused data from a genetic subsample of the 1999 National Long Term Care Survey linked with Medicare service use files. PARTICIPANTS: One thousand seven hundred thirty‐three genotyped individuals interviewed regarding IADL disabilities. MEASUREMENTS: Indicators of IADL impairments, five geriatric disorders, and ?2‐containing genotypes. RESULTS: The ?2/3 genotype is a major contributor to adverse associations between the ?2 allele and IADL disability in men (odds ratio (OR)=3.09, 95% confidence interval (CI)=1.53–6.26), although it provides significant protective effects for CHD (OR=0.55, 95% CI=0.33–0.92), whereas CHD is adversely associated with IADL disability (OR=2.18, 95% CI=1.28–3.72). Adjustment for five diseases does not significantly alter the adverse association between ?2‐containing genotypes and disability. Protective effects of the ?2/3 genotype for CHD (OR=0.52, 95% CI=0.27–0.99) and deleterious effects for IADLs (OR=3.50, 95% CI=1.71–7.14) for men hold in multivariate models with both these factors included. No significant associations between the ?2‐containing genotypes and IADL are found in women. CONCLUSION: The ?2 allele can play a dual role in men, protecting them against some health disorders, while promoting others. Strong adverse relationships with disability suggest that ?2‐containing genotypes can be unfavorable factors for the health and well‐being of aging men.     

Indications for hospitalization and in-hospital mortality in Thai systemic sclerosis

This study aimed to identify the indications for hospitalization, hospital mortality rate, predictors of hospital mortality, and clinical parameters affecting length of stay (LOS) among Thai systemic sclerosis (SSc). A retrospective study was performed in SSc patients admitted in Khon Kaen University, Thailand, between January 2008 and December 2010. The respective clinical factors affecting LOS and predictors of mortality were analyzed using the Spearman's rank correlation and the Cox regression model. There were 202 hospital admissions among 131 SSc patients. The female-to-male ratio was 1.6:1. The median age at admission was 54.7 years (interquartile range (IQR) 49.2–62.9), the duration of disease at admission was 2.9 years (IQR 1.1–7.8), and the LOS was 5 days (IQR 2–10). The indications for hospitalization were divided equally between SSc-related and non-SSc-related events (53.5 vs. 46.5 %, respectively). The most common indication for hospitalization was infection (23.3 %) and pneumonia is the most common cause of infection (58.0 %). Prolonged LOS was related to fatigability status (p?<?0.01), intestinal involvement (p?<?0.01), electrolyte disorders (p?<?0.01), multiple comorbidities (p?<?0.01), modified Rodnan skin score ≥20 points (p?=?0.01), disease duration under 5 years (p?=?0.02), cardiac arrhythmia (p?=?0.04), and deficiency anemia (p?=?0.04). Hospital mortality was 16.8 per 100 person-years (95 % confidence interval (95 % CI) 10.8–24.3). Infection (59.1 %) was the most common cause of death, particularly from bacterial pneumonia. Clinical predictors of mortality were: disseminated intravascular coagulation related to infection (hazard ratio (HR) 52.73; 95 % CI 1.26–403.74), cardiac arrhythmia (HR 32.89; 95 % CI 3.00–359.95), electrolyte disorders (HR 15.66; 95 % CI 2.04–119.98), renal crisis (HR 13.38; 95 % CI 1.80–99.36), intestinal involvement (HR 10.42; 95 % CI 2.58–42.01), admission due to a non-SSc-related condition (HR 8.93; 95 % CI 2.21–36.13), and disease duration under 5 years (HR 6.67; 95 % CI 1.21–36.52). Infection was the most common cause of hospitalization. Prolonged LOS and hospital mortality should be warning signs in patients with shorter disease duration, presence of intestinal involvement, cardiac arrhythmia, and multiple comorbidities.     

Prognostic factors in short‐term disability due to musculoskeletal disorders

Objective

To identify factors associated with poor outcome in temporary work disability (TWD) due to musculoskeletal disorders (MSDs).

Methods

We conducted a secondary data analysis of a 2‐year randomized controlled trial in which all patients with TWD due to MSDs in 3 health districts of Madrid (Spain) were included. Analyses refer to the patients in the intervention group. Primary outcome variables were duration of TWD and recurrence. Diagnoses, sociodemographic, work‐related administrative, and occupational factors were analyzed by Cox proportional hazards models.

Results

We studied 3,311 patients with 4,424 TWD episodes. The following were independently associated with slower return to work: age (hazard ratio [HR] 0.99, 95% confidence interval [95% CI] 0.98–0.99), female sex (HR 0.84, 95% CI 0.78–0.90), married (HR 0.90, 95% CI 0.83–0.97), peripheral osteoarthritis (HR 0.77, 95% CI 0.6–0.9), sciatica (HR 0.59, 95% CI 0.54–0.65), self‐employment (HR 0.56, 95% CI 0.48–0.65), unemployment (HR 0.41, 95% CI 0.28–0.58), manual worker (HR 0.86, 95% CI 0.79–0.94), and work position covered during sick leave (HR 0.84, 95% CI 0.77–0.92). The factors that better predicted recurrence were peripheral osteoarthritis (HR 1.75, 95% CI 1.14–2.6), inflammatory diseases (HR 1.66, 95% CI 1.009–2.72), sciatica (HR 1.30, 95% CI 1.08–1.56), indefinite work contract (HR 1.43, 95% CI 1.14–1.75), frequent kneeling (HR 1.39, 95% CI 1.15–1.69), manual worker (HR 1.19, 95% CI 1.003–1.42), and duration of previous episodes (HR 1.003, 95% CI 1.001–1.005).

Conclusion

Sociodemographic, work‐related administrative factors, diagnosis, and, to a lesser extent, occupational factors may explain the duration and recurrence of TWD related to MSD.     

Mortality risk in older men associated with changes in weight, lean mass, and fat mass

OBJECTIVES: To evaluate risk of all‐cause mortality associated with changes in body weight, total lean mass, and total fat mass in older men. DESIGN: Longitudinal cohort study. SETTING: Six U.S. clinical centers. PARTICIPANTS: Four thousand three hundred thirty‐one ambulatory men aged 65 to 93 at baseline. MEASUREMENTS: Repeated measurements of body weight and total lean and fat mass were taken using dual‐energy X‐ray absorptiometry 4.6 ± 0.4 years apart. Percentage changes in these measures were categorized as gain (+5%), loss (–5%), or stable (?5% to +5%). Deaths were verified centrally according to death certificate reviews, and proportional hazard models were used to estimate the risk of mortality. RESULTS: After accounting for baseline lifestyle factors and medical conditions, a higher risk of mortality was found for men with weight loss (hazard rat (HR)=1.84, 95% confidence interval (CI)=1.50–2.26), total lean mass loss (HR=1.78, 95% CI=1.45–2.19), and total fat mass loss (HR=1.72, 95% CI=1.34–2.20) than for men who were stable for each body composition measure. Men with total fat mass gain had a slightly greater mortality risk (HR=1.29, 95% CI=0.99–1.67) than those who remained stable. These associations did not differ according to baseline age, obesity, or self‐reported health status (P for interactions >.10), although self‐reported weight loss intent altered mortality risks with total fat mass (P for interaction=.04) and total lean mass (P for interaction=.09) change. CONCLUSION: Older men who lost weight, total lean mass, or total fat mass had a higher risk of mortality than men who remained stable.     

Early and mid-term clinical outcome of emergency PCI in patients with STEMI due to unprotected left main coronary artery disease

Objectives: Evaluation of acute and mid‐term outcomes of patients with ST‐elevation myocardial infarction (STEMI) undergoing emergency PCI due to unprotected left main coronary artery (ULMCA) disease. Background: STEMI patients due to ULMCA disease represent a rare, high risk group. Percutaneous coronary intervention (PCI) may be the preferred strategy of myocardial revascularization but there are few data about this topic. Methods: We analyzed 30‐day and mid‐term mortality of 58 patients with STEMI and ULMCA disease as culprit lesion treated in our centre by emergency PCI between 2000 to 2010. Results: Mean age was 67.3 ± 11.5 years. Thirty (51.7%) patients had cardiogenic shock on admission. PCI success was achieved in 54 patients (93.1%). Mean follow‐up was 15.8 ± 10.9 months (median 14, range 6–45). Thirty‐day and mid‐term mortality rates were 39.7% and 44%. Backward binary logistic regression model identified cardiogenic shock at presentation (OR 12.6, 95% CI 2.97–53.6, P < 0.001), age ≥75 years (OR 5.9, 95% CI 1.3–26.5, P = 0.019) and post‐PCI TIMI flow grade <3 (OR 2.9, 95% CI 1.8–5.7 P = 0.02) as independent predictors of 30‐day mortality. Cox proportional hazard ratio (HR) identified shock at presentation (HR 5.2, 95% CI 1.8–14.3, P < 0.002), age ≥75 years (HR 3.9, 95% CI 1.8–8.7, P < 0.001), post‐PCI TIMI flow grade <3 (HR 4.9, 95% CI 1.6–14.6; P < 0.005) as independent predictors of mid‐term mortality. Conclusions: In patients with STEMI and ULMCA as culprit lesion, emergency PCI is a valuable therapeutic strategy. Early and mid‐term survival depends on cardiogenic shock, advanced age, and PCI failure. Patients surviving the first month have good mid‐term prognosis. (J Interven Cardiol 2012;25:215–222)     

Disability transitions in the oldest old in the general population. The Leiden 85-plus study

Transitions between disability states in older people occur frequently. This study investigated predictors of disability transitions in the oldest old and was performed in the Leiden 85-plus study, a population-based prospective cohort study among 597 participants aged 85 years. At baseline (age 85 years), data on sociodemographic characteristics and chronic diseases were obtained. Disabilities in basic activities of daily living (BADL) and instrumental activities of daily living (IADL) were measured annually for 5 years with the Groningen Activities Restriction Scale (GARS). Mortality data were obtained. A statistical multi-state model was used to assess the risks of transitions between no disabilities, IADL disability, BADL disability, and death. At baseline, 299 participants (50.0 %) were disabled in IADL only, and 155 participants (26.0 %) were disabled in both BADL and IADL. During 5-year follow-up, 374 participants (62.6 %) made >1 transition between disability states, mostly deterioration in disability. Males had a lower risk of deterioration [hazard ratio (HR), 0.75 (95 % CI, 0.58–0.96)] compared to females. No gender differences were observed for improvement [HR, 0.64 (95 % CI, 0.37–1.11)]. Participants with depressive symptoms were less likely to improve [HR, 0.50 (95 % CI, 0.28–0.87)]. Participants with depressive symptoms [HR, 1.46 (95 % CI, 1.12–1.91)], >1 chronic disease [HR, 1.60 (95 % CI, 1.27–2.01)], and with cognitive impairment [HR, 1.60 (95 % CI, 1.20–2.13)] had the highest risk of deteriorating. Disability is a dynamic process in the oldest old. Deterioration is more common than improvement. Older men are less likely to deteriorate than women. The presence of depressive symptoms, chronic disease, and cognitive impairment predicts deterioration.     

NT-proBNP levels, echocardiographic findings, and outcomes in breathless patients: results from the ProBNP Investigation of Dyspnoea in the Emergency Department (PRIDE) echocardiographic substudy.

AIMS: The objective of this study was to determine the integrative utility of measuring plasma NT-proBNP levels with echocardiography in the evaluation of dyspnoeic patients. METHODS AND RESULTS: Of 599 emergency department patients enrolled in a clinical study of NT-proBNP at a tertiary-care hospital, 134 (22%) had echocardiographic results available for analysis. Echocardiographic parameters correlating with NT-proBNP levels were determined using multivariable linear-regression analysis. Independent predictors of 1-year mortality were determined using Cox-proportional hazard analysis. Independent relationships were found between NT-proBNP levels and ejection fraction (P = 0.012), tissue Doppler early and late mitral annular diastolic velocities (P = 0.007 and 0.018), right ventricular (RV) hypokinesis (P = 0.006), and tricuspid regurgitation severity (P < 0.001) and velocity (P = 0.007). An NT-proBNP level <300 pg/mL had a negative predictive value of 91% for significant left ventricular systolic and diastolic dysfunction. Overall 1-year mortality was 20.1% and was independently predicted by NT-proBNP level [HR 8.65, 95% confidence interval (CI) 2.7-27.8, P = 0.0003], ejection fraction (HR 0.95, 95% CI 0.91-0.99, P = 0.009), RV dilation (HR 2.98, 95% CI 1.05-12.8, P = 0.04), and systolic blood pressure (HR 0.97, 95% CI 0.96-0.99, P = 0.01). CONCLUSION: NT-proBNP levels correlate with, and provide important prognostic information beyond, echocardiographic parameters of cardiac structure and function. Routine NT-proBNP testing may thus be useful to triage patients to more timely or deferred echocardiographic evaluation.     

Survival analysis of platinum‐refractory patients with advanced esophageal cancer treated with docetaxel or best supportive care alone: a retrospective study

The survival benefit of second‐line chemotherapy with docetaxel in platinum‐refractory patients with advanced esophageal cancer (AEC) remains unclear. A retrospective analysis of AEC patients with Eastern Cooperative Oncology Group performance status (PS) ≤ 2 was performed, and major organ functions were preserved, who determined to receive docetaxel or best supportive care (BSC) alone after failure of platinum‐based chemotherapy. The post‐progression survival (PPS), defined as survival time after disease progression following platinum‐based chemotherapy, was analyzed by multivariate Cox regression analysis using factors identified as significant in univariate analysis of various 20 characteristics (age, sex, PS, primary tumor location, etc) including Glasgow prognostic score (GPS), which is a well‐known prognostic factor in many malignant tumors. Sixty‐six and 45 patients were determined to receive docetaxel and BSC between January 2007 and December 2011, respectively. The median PPS was 5.4 months (95% confidence interval [CI] 4.8–6.0) in the docetaxel group and 3.3 months (95% CI 2.5–4.0) in the BSC group (hazard ratio [HR] 0.56, 95% CI 0.38–0.84, P = 0.005). Univariate analysis revealed six significant factors: treatment, PS, GPS, number of metastatic organs, liver metastasis, and bone metastasis. Multivariate analysis including these significant factors revealed three independent prognostic factors: docetaxel treatment (HR 0.62, 95% CI 0.39–0.99, P = 0.043), better GPS (HR 0.61, 95% CI 0.46–0.81, P = 0.001), and no bone metastasis (HR 0.31, 95% CI 0.15–0.68, P = 0.003). There was a trend for PPS in favor of the docetaxel group compared with patients who refused docetaxel treatment in the BSC group (adjusted HR 0.61, 95% CI 0.29–1.29, P = 0.20). Docetaxel treatment may have prolonged survival in platinum‐refractory patients with AEC.     

Effect on Mode of Death of Heart Failure Treatment Started with Bisoprolol Followed by Enalapril,Compared to the Opposite Order: Results of the Randomized CIBIS III Trial

Background: Mode of death in chronic heart failure (CHF) may be of relevance to choice of therapy for this condition. Sudden death is particularly common in patients with early and/or mild/moderate CHF. β‐Blockade may provide better protection against sudden death than ACE inhibition (ACEI) in this setting. Methods: We randomized 1010 patients with mild or moderate, stable CHF and left ventricular ejection fraction ≤35%, without ACEI, β‐blocker or angiotensin‐receptor‐blocker therapy, to either bisoprolol (n = 505) or enalapril (n = 505) for 6 months, followed by their combination for 6–24 months. The two strategies were blindly compared regarding adjudicated mode of death, including sudden death and progressive pump failure death. Results: During the monotherapy phase, 8 of 23 deaths in the bisoprolol‐first group were sudden, compared to 16 of 32 in the enalapril‐first group: hazard ratio (HR) for sudden death 0.50; 95% confidence interval (CI) 0.21–1.16; P= 0.107. At 1 year, 16 of 42 versus 29 of 60 deaths were sudden: HR 0.54; 95% CI 0.29–1.00; P= 0.049. At study end, 29 of 65 versus 34 of 73 deaths were sudden: HR 0.84; 95% CI 0.51–1.38; P= 0.487. Comparable figures for pump failure death were: monotherapy, 7 of 23 deaths versus 2 of 32: HR 3.43; 95% CI 0.71–16.53; P= 0.124, at 1 year, 13 of 42 versus 5 of 60: HR 2.57; 95% CI 0.92–7.20; P= 0.073, at study end, 17 of 65 versus 7 of 73: HR 2.39; 95% CI 0.99–5.75; P= 0.053. There were no significant between‐group differences in any other fatal events. Conclusion: Initiating therapy with bisoprolol compared to enalapril decreased the risk of sudden death during the first year in this mild systolic CHF cohort. This was somewhat offset by an increase in pump failure deaths in the bisoprolol‐first cohort.     

Percutaneous Coronary Intervention,Comorbidities, and Mortality among Emergency Department–Admitted ST‐Elevation Myocardial Infarction Patients in Florida

Background: Risk of mortality following an ST‐elevation myocardial infarction (STEMI) can be significantly reduced by prompt percutaneous coronary intervention (PCI). National guidelines specify primary PCI as the preferred recommended treatment for STEMI. In this study, we examined same‐day PCI as an independent predictor of in‐hospital mortality, after adjustment for comorbidities, other patient factors, and hospital PCI‐volume using unselected surveillance data from Florida. Methods: We analyzed hospital discharge data for adults, 18+ years old, with a primary diagnosis of STEMI who were admitted to PCI‐capable hospitals through the emergency department during 2001–2005 (n = 43,849). Hierarchical (multilevel) logistic regression models were used for analysis. Results: Overall, 4,143 STEMI patients (9.4%) did not survive to hospital discharge. In late 2005, the in‐hospital mortality rates were 1.9% for those who received same‐day PCI versus 13.0% for those who did not. After adjustment for multiple patient factors, same‐day PCI was a significant predictor of in‐hospital survival with a strong protective effect (adjusted OR = 0.35, 95% CI 0.31–0.38 P < 0.0001). Restriction of the analysis to those patients who survived the first day of admission did not appreciably change this result (adjust OR = 0.37, 95% CI 0.33–0.42, P < 0.0001). Hospital PCI‐volume did not significantly impact mortality risk. Conclusions: Same‐day PCI markedly reduced the risk of in‐hospital mortality among STEMI patients after multivariate adjustment. Serious comorbidities and complications, older age, and female gender continued to predict elevated risk of mortality after control for treatment status. Our results provide additional evidence in support of national clinical recommendations and aggressive treatment of STEMI. (J Interven Cardiol 2010;23:205–215)     

Musculoskeletal pain and incident disability in community‐dwelling older adults

Objective

To test the hypothesis that the number of areas of musculoskeletal pain reported is related to incident disability.

Methods

Subjects included 898 older persons from the Rush Memory and Aging Project without dementia, stroke, or Parkinson's disease at baseline. All participants underwent detailed baseline evaluation of self‐reported pain in the neck or back, hands, hips, knees, or feet, as well as annual self‐reported assessments of instrumental activities of daily living (IADLs), basic activities of daily living (ADLs), and mobility disability. Mobility disability was also assessed using a performance‐based measure.

Results

The average followup was 5.6 years. Using a series of proportional hazards models that controlled for age, sex, and education, the risk of IADL disability increased by ～10% for each additional painful area reported (hazard ratio [HR] 1.10, 95% confidence interval [95% CI] 1.01–1.20) and the risk of ADL disability increased by ～20% for each additional painful area (HR 1.20, 95% CI 1.11–1.31). The association with self‐report mobility disability did not reach significance (HR 1.09, 95% CI 0.99–1.20). However, the risk of mobility disability based on gait speed performance increased by ～13% for each additional painful area (HR 1.13, 95% CI 1.04–1.22). These associations did not vary by age, sex, or education and were unchanged after controlling for several potential confounding variables including body mass index, physical activity, cognition, depressive symptoms, vascular risk factors, and vascular diseases.

Conclusion

Among nondisabled community‐dwelling older adults, the risk of disability increases with the number of areas reported with musculoskeletal pain.     

Serum sodium and hydration status predict transplant-free survival independent of MELD score in patients with cirrhosis

Background and Aim: Serum sodium may have prognostic value in addition to the model for end‐stage liver disease (MELD) score for prediction of early mortality in patients listed for liver transplant. In patients with cirrhosis, over‐hydration is a common feature but its prognostic value has not been evaluated. This study examines the independent prognostic significance of MELD, serum sodium and hydration status on long‐term survival in patients with cirrhosis. Methods: Serum sodium and hydration (total body water as a percentage of fat‐free mass) were measured in 227 consecutive cirrhotic patients (146 male, 81 female; median age 49 years, range 19–73 years; median MELD score 13, range 6–36). Patients with hepatocellular carcinoma or listed for liver transplantation at the time of initial assessment were excluded. A competing risks Cox proportional hazards analysis was performed to evaluate the influence of MELD, sodium and hydration on risk of death or transplant. Results: Median follow‐up was 52 (range 4–93) months. Serum sodium and hydration were each associated with reduction in time to death or transplant on univariate analysis (sodium: hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.87–0.94, P < 0.0001; hydration: HR 1.20, 95% CI 1.10–1.30, P < 0.0001). On multivariate analysis, MELD, serum sodium and hydration were independently predictive of death or transplant (MELD: HR 1.12, 95% CI 1.06–1.19, P < 0.0001; sodium: HR 0.93, 95% CI 0.87–0.99, P = 0.04; hydration: HR 1.17, 95% CI 1.02–1.33, P = 0.02). Conclusions: In non‐waitlisted patients with cirrhosis, serum sodium is predictive of transplant or death independent of MELD score.     

A randomised controlled trial of an exercise intervention to reduce functional decline and health service utilisation in the hospitalised elderly

Objective: Functional decline is experienced by up to 50% of older hospitalised patients and is associated with increased institutionalisation, mortality and length of stay (LOS). We aimed to determine the effectiveness of an exercise program in reducing functional decline and health service utilisation in older inpatients. Methods: A single‐blinded randomised controlled trial was conducted in a tertiary metropolitan hospital involving 180 acute general medical patients aged ≥ 65 years. In addition to usual physiotherapy care, the intervention group performed an exercise program for 30 minutes, twice daily, with supervision and assistance. Change in physical function was measured by the modified Barthel index (mBI). Analysis was done on an intention‐to‐treat basis. Results: When admission mBI scores were low, there was a greater improvement in mBI scores in the intervention group compared with the control group. The intervention group had a shorter total LOS (Hazard ratio (HR) 1.46 (95%CI 1.04–2.05); P = 0.026).     

Improved efficiency in acute myocardial infarction care through commitment to emergency department-initiated primary PCI

STUDY OBJECTIVE: Demonstrate improved efficiency of initial and subsequent in-hospital care following emergency department (ED) physician-initiated primary angioplasty (1 PCI). METHODS: An observational study was undertaken in ST-elevation myocardial infarction patients presenting to a community hospital emergency department. Outcomes of patients who received ED physician-directed 1 PCI were compared with patients previously treated by a mix of ED physician and cardiologist co-determined thrombolysis or 1 PCI. A process improvement initiative supported the change to ED-directed 1 PCI. RESULTS: The study included 287 eligible acute reperfusion patients. Median door-to-balloon time (MDBT) improved from 88 minutes (95% CI, 80 96) to 61 minutes (95% CI, 57 70; p < 0.0001). Necessary subsequent in-hospital interventions (NSI) occurred in 70 of 107 (65.4%; 95% CI, 55.6 74.4%) thrombolytic patients, versus 3 of 99 (3.0%; 95% CI, 0.6 8.6%) 1 PCI patients at baseline, and 1 of 81 (1.2%; 95% CI, 0.0 6.7%) 1 PCI patients after process change. Median length of stay (LOS) decreased from 4 days for thrombolytic patients and 3 days for 1 PCI patients at baseline, to 2 days for 1 PCI after adopting the improved process (p < 0.0001). Effectiveness outcomes demonstrating improvement included discharge on beta-blocker (p = 0.0039), angiotensin-converting-enzyme inhibitor (p < 0.0001) and anti-lipid therapy (p = 0.0039), with favorable trends in survival to discharge, and 30-day major adverse cardiac events (MACE). CONCLUSIONS: Conversion to ED physician-initiated 1 PCI for ST-elevation myocardial infarction significantly improved efficiency of care as measured by MDBT, NSI and LOS. Effectiveness measures, including survival to discharge, discharge medications and 30-day MACE, demonstrated improvement or favorable trends.