Effect of Psychosocial Interventions on Quality of Life in Patients With Chronic Heart Failure: A Meta-analysis of Randomized Controlled Trials

BackgroundPatients with chronic heart failure (CHF) usually experience poor quality of life (QoL). Psychosocial interventions tend to affect QoL in CHF. The aim of this study was to explore: 1) the effectiveness of psychosocial interventions on patients' QoL; 2) the magnitude of this effect; and 3) factors that appear to moderate the reported effect on QoL.Methods and ResultsMeta-analysis of the data of 1,074 intervention patients and 1,106 control patients from 16 randomized controlled trials (RCTs) that reported QoL measures in treatment and control groups before and after a psychosocial intervention. Subgroup analyses were conducted between: 1) face-to-face versus telephone interventions; 2) interventions that included only patients versus those that included patients and their caregivers; and 3) interventions conducted by a physician and a nurse only, versus those conducted by a multidisciplinary team. Psychosocial interventions improved QoL of CHF patients (standardized mean difference 0.46, confidence interval [CI] 0.19–0.72; P < .001). Face-to-face interventions showed greater QoL improvement compared with telephone interventions (χ² = 5.73; df = 1; P < .02). Interventions that included caregivers did not appear to be significantly more effective (χ² = 1.12; df = 1; P > .29). A trend was found for multidisciplinary team approaches being more effective compared with nonmultidisciplinary approaches (χ² = 1.96; df = 1; P = .16).ConclusionsA significant overall QoL improvement emerged after conducting psychosocial interventions with CHF patients. Interventions based on a face-to-face approach showed greater benefit for patients' QoL compared with telephone-based approaches. No significant advantage was found for interventions conducted by a multidisciplinary team compared with a physician and nurse approach, or for psychosocial interventions which included patients' caregivers compared with patient-only approaches.     

Poor level of agreement on the management of postoperative pancreatic fistula: results of an international survey

Objectives

The occurrence of postoperative pancreatic fistula (POPF) is the main cause of severe complications, including death, after pancreatic surgery. This study was conduced to evaluate current practice in the management of POPF after Whipple surgery and distal pancreatectomy (DP).

Methods

An online survey endorsed by the European–African Hepato-Pancreato-Biliary Association (E-AHPBA) was conducted among surgical departments active in pancreatic surgery. A total of 108 centres were contacted by e-mail. The survey focused on the use and timing of drainage, nutrition strategies, provision of somatostatin and antibiotic therapies, imaging strategy and indications for reoperation when POPF is diagnosed after pancreatic surgery.

Results

A total of 55 centres (51%) completed the survey. Overall, responses showed poor agreement among centres (Fleiss'' kappa: <0.40) on 89% of items after Whipple surgery and 78% of items after DP. There was very poor or no agreement (Fleiss'' kappa: <0.1) on postoperative strategies for the management of nutrition and use of somatostatin after both procedures. In the event of POPF, 42% of centres used total oral nutrition and 22% used somatostatin after Whipple surgery, and 71% used total oral nutrition and 31% used somatostatin after DP. There were significant disagreements between units conducting, respectively, more and fewer than 50 Whipple procedures per year on drain removal after DP, and imaging strategy and patient discharge after Whipple surgery and DP.

Conclusions

This survey discloses important disagreements worldwide regarding the management of POPF after both Whipple surgery and DP. The standardized management of POPF would better facilitate the comparison of outcomes in future trials.     

The validity of C-peptide measurement in the diagnosis of factitious hypoglycemia

Summary The case is presented of a 32-year-old obese diabetic nurse, with a history of recent hypoglycemic episodes. Estimation of immunologically measurable insulin during hypoglycemia after an overnight fast revealed high values, while simultaneous determination of serum C-peptide failed to show an increase. This combination is considered pathognomonic for factitious hyperinsulinism. After the hidden vial was discovered and presented to her, the patient finally admitted that she had been surreptitiously injecting insulin. Supported by grants from Social Ministry, Athens, Greece, and the Department of Internal Medicine I (Endocrinology, Metabolism and Immunology), University of Ulm, FRG.     

Dose verification in clinical IMRT prostate incidents

PURPOSE: In view of the need for dose-validation procedures on each individual intensity-modulated radiation therapy (IMRT) plan, dose-verification measurements by film, by ionization chamber, and by polymer gel-MRI dosimetry were performed for a prostate-treatment plan configuration. Treatment planning system (TPS) calculations were evaluated against dose measurements. METHODS AND MATERIALS: Intensity-modulated radiation therapy (IMRT) treatments were planned on a commercial TPS. Kodak EDR-2 films were used for the verification of two-dimensional (2D) dose distributions at 1 coronal and 5 axial planes in a water-equivalent phantom. Full three-dimensional (3D) dose distributions were measured by use of a novel polymer gel formulation and a 3D magnetic resonance imaging (MRI) readout technique. Calculations were compared against measurements by means of isocontour maps, gamma-index maps (3% dose difference, 3-mm distance to agreement) and dose-volume histograms. RESULTS: A good agreement was found between film measurements and TPS predictions for points within the 60% isocontour, for all the examined plans (gamma-index <1 for 96% of pixels). Three-dimensional dose distributions obtained with the polymer gel-MRI method were adequately matched with corresponding TPS calculations, for measurements in a gel phantom covering the planning-target volume (PTV). CONCLUSIONS: Measured 2D and 3D dose distributions suggest that, for the investigated prostate IMRT plan configuration, TPS calculations provide clinically acceptable accuracy.     

Controlled extension of oral antidiabetic therapy on former insulin dependent diabetics by means of the combined i.v. glibenclamide-glucose-response-test

Summary A new sulphonylurea response test is described for predicting the results of long-term treatment with a recently developed sulphonylurea compound, glibenclamide, particularly in insulin-dependent tolbutamide-non-responsive elderly diabetics. The test is based on the observation that the insulin-stimulating capacity of glucose and the determination of the insulin increases are strikingly potentiated following glibenclamide plus glucose i.v. (25 plus 0.33 g/kg body weight) in serum samples where insulin binding antibodies have been removed. 11 out of 40 diabetics demonstrating between 60 and 90 min following injection, a mean increase of insulin of more than 500 per cent above the initial values, correlated satisfactorily with successful long-term oral treatment with glibenclamide. A positive glibenclamide-glucose-response test contrasted with primary failure of glibenclamide therapy in only one patient suffering from haemochromatosis. Oral treatment with glibenclamide may have certain advantages over insulin therapy, especially in elderly diabetics suffering from visual impairment, who are unable to inject themselves with insulin.Support of this Study by Deutsche Forschungsge-meinschaft (Pf 38/28) is gratefully acknowledged.     

Stents: Biomechanics,Biomaterials, and Insights from Computational Modeling

Coronary stents have revolutionized the treatment of coronary artery disease. Improvement in clinical outcomes requires detailed evaluation of the performance of stent biomechanics and the effectiveness as well as safety of biomaterials aiming at optimization of endovascular devices. Stents need to harmonize the hemodynamic environment and promote beneficial vessel healing processes with decreased thrombogenicity. Stent design variables and expansion properties are critical for vessel scaffolding. Drug-elution from stents, can help inhibit in-stent restenosis, but adds further complexity as drug release kinetics and coating formulations can dominate tissue responses. Biodegradable and bioabsorbable stents go one step further providing complete absorption over time governed by corrosion and erosion mechanisms. The advances in computing power and computational methods have enabled the application of numerical simulations and the in silico evaluation of the performance of stent devices made up of complex alloys and bioerodible materials in a range of dimensions and designs and with the capacity to retain and elute bioactive agents. This review presents the current knowledge on stent biomechanics, stent fatigue as well as drug release and mechanisms governing biodegradability focusing on the insights from computational modeling approaches.     

Predictors of endothelial dysfunction in young women with polycystic ovary syndrome

CONTEXT: Women with polycystic ovary syndrome (PCOS) may be at increased risk for cardiovascular disease. Endothelial dysfunction is an early marker of atherosclerosis. OBJECTIVES: The objectives of this study were to 1) compare endothelial function in young women with PCOS and regularly menstruating control women, and 2) to identify the determinants of endothelial function and investigate its relationship with body mass index in women with PCOS. DESIGN: This was a cross-sectional study. SETTING: This study was conducted at a tertiary cardiovascular research center. PATIENTS: Sixty-two young women with PCOS (mean age, 22.7 yr) and 17 control women, matched as a group for age and body mass index, were studied. Twenty-three women with PCOS were lean, 21 were overweight, and 18 were obese. MAIN OUTCOME MEASURES: Endothelium-dependent and -independent vascular function was assessed by measuring flow-mediated dilation (FMD) and nitrate-mediated dilation in the brachial artery (diameter change during hand hyperemia and after sublingual glyceryl trinitrate administration, respectively). RESULTS: FMD and nitrate-mediated dilation were significantly lower in PCOS than in control women (reduced by approximately 50 and 25%, respectively; both P < 0.0005). Insulin resistance, total testosterone, and total cholesterol were independent predictors of FMD, accounting for 21, 10, and 9% of the variance, respectively (P < 0.005 for all). A trend of deterioration in FMD from lean to overweight and obese PCOS women was observed, but differences among groups were not statistically significant. CONCLUSIONS: Women with PCOS have significant endothelial dysfunction at an early age (i.e. early 20s), and largely independent of obesity. This suggests that women with PCOS are at increased risk for early onset cardiovascular disease and may gain particular benefit from measures to improve endothelial function.     

Helicobacter pylori may induce bile reflux: link between H pylori and bile induced injury to gastric epithelium.

Helicobacter pylori and duodenogastric reflux are both recognised as playing aetiological roles in chronic gastritis. This study investigated whether H pylori colonisation of the antral mucosa and duodenogastric reflux are independent phenomena or have a causal relationship. Thirty eight patients (15 men, 23 women) aged (mean (SD)) 48 (17) years participated. Each patient underwent gastroscopy. Antral biopsy specimens were taken to investigate H pylori colonisation. In addition BrIDA-99mTc/111In-DTPA scintigraphy was used to quantify duodenogastric reflux. H pylori positive patients who were found to have duodenogastric reflux were treated with amoxycillin (1 g/d) and metronidazole (1.5 g/d) for seven days and four tablets of bismuth subcitrate daily for four weeks. Follow up antral biopsies and scintigraphy were repeated at six months. Duodenogastric reflux could not be found in 18 patients, including eight (44%) who were H pylori positive. Ten of the 11 patients who had duodenogastric reflux (reflux % 11.6 (9.2)), however, were H pylori positive (chi 2 = 6.26, p = 0.01). These 10 patients were given eradication treatment. At six months, in six patients who became H pylori negative, duodenogastric reflux was significantly reduced from a pretreatment value of 14.3% to 3.3% (two tail, paired t = 2.57, p = 0.016). These data suggest that H pylori may induced duodenogastric reflux which may be important in the pathogenesis of H pylori gastritis or carcinogenesis, or both.