Improvement of quality of life after percutaneous balloon mitral valvulotomy in patients with mitral stenosis: does rhythm matter?

BACKGROUND AND AIM OF THE STUDY: Limited data are available on the effect of percutaneous balloon mitral valvulotomy (PBMV) on quality of life (QoL) in patients with mitral stenosis (MS), and whether the effect is similar between patients in sinus rhythm (SR) and with atrial fibrillation (AF). The study aim was to determine the effect of PBMV on the QoL of such patient groups. METHODS: A total of 130 patients with symptomatic MS and scheduled for PBMV was studied. Patients with AF were predominantly male, and had more severe symptoms, a larger left atrial size and a lower left ventricular ejection fraction (LVEF). Baseline characteristics were collected together with PBMV outcomes. QoL was assessed using the SF-36 questionnaire at baseline, and at one and six months after PBMV. The QoL assessment included eight aspects: physical functioning; role physical; bodily pain; general health; vitality; social functioning; role emotional; and mental health. The raw scale was transformed into a transformed scale from 0 (worst) to 100 (best). Physical and mental subscales were calculated. RESULTS: The cardiac rhythm was AF in 65 patients (50%). QoL on physical and mental scales was significantly improved after PBMV. There was no difference in the effect of PBMV on QoL improvement in patients with AF and SR. QoL improvement was demonstrated in all aspects, except for bodily pain. PBMV also improved NYHA functional class and mitral valve area, but decreased left atrial diameter and right ventricular systolic pressure in both groups. An increase in LVEF was observed in patients with AF CONCLUSION: PBMV was shown to improve QoL in patients with MS, irrespective of their baseline cardiac rhythm.     

Health and living arrangements among older Americans: does marriage matter?

OBJECTIVE: This research examines how physical and mental health influence living arrangements among older Americans and whether these effects differ for married and unmarried persons. METHODS: Data came from the Asset and Health Dynamics Among the Oldest Old study. These two intervals were pooled, and hierarchical multinomial logistic regressions were used to analyze pooled time lags. RESULTS: Functional status and cognitive functioning are significantly associated with living arrangements among those not married. Health conditions exert no significant effects among those married. Given the same functional status, unmarried elders are significantly more likely than their married counterparts to reside with their children or with others. DISCUSSION: These results underscore the critical role of the spouse in influencing living arrangements, providing new evidence supporting the assertion that a spouse is the greatest guarantee of support in old age and the importance of the marriage institution.     

Why evaluate the quality of life in patients with bronchial obstruction?

Quality of life, more precisely health related quality of life, is gaining basic importance in evaluating of patient's health status and results of medical interventions. On the example of patients with bronchial obstruction is demonstrated that quality of life evaluation, although not usually used in clinical practice yet, is in significant correlation with some of usual clinical measures; moreover, it brings otherwise inaccessible information about patient's subjective assessment of his disease and his health situation.     

Health status: what does it mean for payers and patients?

Disturbances to health can be divided broadly into limitations of basic activities of daily living (washing, dressing, etc.) that are common to all patients and other limitations that depend on individual circumstances. A distinction should be drawn between health status and health-related quality of life. Health status questionnaires are standardized for "typical patients," and this should be borne in mind when interpreting such scores from studies that give an average result using population-based measurements. Such studies give a good indication to payers of the average effects of a treatment, but provide no indication other than probability of benefit to individuals. This applies even more with health improvements that manifest uniquely in each patient. Two widely used disease-specific questionnaires in chronic obstructive pulmonary disease-the Chronic Respiratory Questionnaire and the St. George's Respiratory Questionnaire-are health status, rather than quality of life, instruments. Health status scores from questionnaires provide measures of the effects of disease, not measures of the disease itself. The relationship between high health status score and increased risk of dying is due to the fact that both reflect underlying disease activity. In therapeutic studies, health status improves because the underlying disease activity has been moderated by therapy. Improved health does not improve mortality or morbidity per se. It is also important to appreciate that the impact of any measured change in health may also be determined by the patient's baseline state.     

Recognising older frail patients near the end of life: What next?

Frailty is a state of vulnerability resulting from cumulative decline in many physiological systems during a lifetime. It is progressive and considered largely irreversible, but its progression may be controlled and can be slowed down and its precursor –pre-frailty- can be treated with multidisciplinary intervention. The aim of this narrative review is to provide an overview of the different ways of measuring frailty in community settings, hospital, emergency, general practice and residential aged care; suggest occupational groups who can assess frailty in various services; discuss the feasibility of comprehensive geriatric assessments; and summarise current evidence of its management guidelines. We also suggest practical recommendations to recognise frail patients near the end of life, so discussions on goals of care, advance care directives, and shared decision-making including early referrals to palliative and supportive care can take place before an emergency arises. We acknowledge the barriers to systematically assess frailty and the absence of consensus on best instruments for different settings. Nevertheless, given its potential consequences including prolonged suffering, disability and death, we recommend identification of frailty levels should be universally attempted in older people at any health service, to facilitate care coordination, and honest discussions on preferences for advance care with patients and their caregivers.     

Does quality of life evidence assist in the selection of patients for resynchronization therapy?

Results from clinical trials of cardiac resynchronization therapy with biventricular pacemakers have demonstrated improvements in a variety of clinical parameters measured in patients over short-term follow-up. While not all approved medical therapies for heart failure improve quality of life, biventricular pacemakers offer a substantial opportunity for improving functional status and quality of life in patients with severe symptoms. This paper explores the evidence for routine measures of self-reported functional status and quality life as measures by which physicians might select individuals for resynchronization therapy. Data sources suggest approximately 50% of those individuals eligible for biventricular pacing have reduced quality of life at baseline, and hence, have considerable room for symptomatic improvement after implantation. Since baseline assessment of quality of life further predicts one-year mortality or hospitalization, it is likely that use of self reported quality of life, in addition to other factors as a guide for selection criteria, will result in improved event-free survival with biventricular pacing. In conclusion, assessment of quality of life before device implantation is necessary in order to select those individuals who are most likely to benefit from cardiac resynchronization therapy.     

The life course of severe obesity: does childhood overweight matter?

OBJECTIVES: A life course perspective is used to examine the epidemiology of severe obesity in adulthood, defined as a body mass index > or = 35 kg/m(2). METHODS: Data from adults in the National Health and Nutrition Examination Survey I: Epidemiologic Followup Study, including their reports of childhood overweight, were used to examine the risk of severe obesity and mortality over 20 years (N = 6,767). All multivariate models control for age, sex, race, smoking, and socioeconomic resources. RESULTS: Childhood overweight was significantly associated with severe obesity for both women and men, although the effect was stronger for men. The prevalence of severe obesity was highest between 45 and 64 years of age than for persons under 45 or over 65, and higher for African Americans than White Americans. Childhood overweight was associated with lower mortality risk for women, but not for men. Mortality risk was higher for persons with severe obesity (relative risk = 1.571, 95% confidence interval = 1.335-1.849, p <.001). DISCUSSION: The findings demonstrate the importance of childhood overweight as a risk factor for severe obesity over the life course. Nevertheless, overweight children who did not become severely obese were not at greater risk of mortality.     

Health‐related quality of life in patients with inflammatory bowel disease five years after the initial diagnosis

Background: Health‐related quality of life (HRQOL) has become an important tool in evaluating patient satisfaction in inflammatory bowel disease (IBD). So far, few prospective follow‐up studies have been done to identify variables that influence HRQOL. We aimed to identify demographic and clinical variables that influence HRQOL 5 years after diagnosis in patients with ulcerative colitis (UC) or Crohn disease (CD) included in a prospective follow‐up study from 1990 to 1994 (the IBSEN study). Methods: All patients completed the Inflammatory Bowel Disease Questionnaire (IBDQ), a disease‐specific quality‐of‐life questionnaire translated into Norwegian and validated. We present data from 497 patients (328 UC patients and 169 CD patients, mean age 43.3 years, 48% female). The impact of age, gender, smoking, symptom severity, disease distribution, rheumatic symptoms and surgery on IBD patients' HRQOL was analysed. Results: Women had a reduction in IBDQ total score of 10 points compared to men, CD patients had a reduction of 7.5 compared to UC patients. The patients with moderate/severe symptoms had a 50 points lower score than the patients without symptoms. The patients with rheumatic symptoms had a 10 points lower total score than the patients without these symptoms. All differences were statistically significant. The multiple regression analysis showed that symptom severity, rheumatic symptoms and female gender were the strongest predictors of reduction in HRQOL for both diagnosis groups. Conclusion: IBD symptoms, rheumatic symptoms and female gender have a significant influence on patients' HRQOL as measured by IBDQ. This was confirmed by the regression analysis.