Transesophageal echocardiography during percutaneous balloon mitral valvuloplasty

To ascertain the value of transesophageal echocardiography during percutaneous balloon mitral valvuloplasty, the present study was undertaken in 26 anesthesized patients (21 women and 5 men; mean age, 47 years) with symptomatic rheumatic mitral valve stenosis. In all but one patient the balloon dilation of the mitral valve was successful and Doppler-derived valve area increased (0.9 +/- 0.3 to 1.9 +/- 0.4 cm2). Transesophageal echocardiography provides continuous monitoring, as well as guidance of the procedure. Crossing the arterial septum, as well as delivery of the sheath through the mitral valve orifice and correct positioning of the balloon, was highly facilitated and reduced x-ray exposure time. The degree of mitral regurgitation and the presence of interatrial shunting at the end of the procedure could be readily assessed, making cineangiography not necessary. Complications of the procedure, such as pericardial effusion, could be detected before hemodynamic deterioration had occurred (one patient). The advantages of transesophageal echocardiography for routine monitoring of percutaneous mitral valvuloplasty, however, should be weighted against the added risk and expense of this support.     

Long-term follow-up of cardiac rhythm after percutaneous mitral balloon valvotomy. Does atrial fibrillation persist?

AIMS: Little information is available about short-term and none about long-term follow-up of cardiac rhythm after percutaneous mitral balloon valvotomy (PTMV). METHODS AND RESULTS: We studied the long-term course of the supraventricular rhythm in 137 consecutive patients with severe mitral stenosis, who underwent PTMV. The rhythm before PTMV was sinus rhythm (SR) in 55% and chronic AF in 45% of patients. The mean follow-up time was 3.7+/-2.5 years (n=126).In patients with SR before PTMV, SR persisted in 91% of patients at the end of follow-up. In patients with chronic AF before PTMV, 84% of these patients were still in chronic AF at the end of follow-up, spontaneous conversion to SR did not occur. In 12 of 14 patients (85%), selected for cardioversion, SR was achieved, by DC cardioversion (n=11) or by drugs alone (n=1). After 2 years this outcome persisted, but after 4 years only 38% remained in SR. CONCLUSION: Pre-procedural SR will persist following PTMV. However in patients with chronic AF PTMV is not associated with reversion to SR, suggesting that measures should be undertaken to restore sinus rhythm.     

Living with heart failure: partner perspectives

To preserve the supportive capabilities of partners of heart failure (HF) patients, it is necessary to gain insight in the experiences and potential needs of these partners. Thirteen partners of HF patients participated in semistructured interviews specifically focused on their experiences as a partner. Patients had had HF for at least 18 months, and their partners were interviewed at home without the patient being present. Content analysis was used to organize the data and to identify categories and themes. Partners of HF patients experience several changes in life as reflected in the main themes: changes in life, changes in relationship, coping, and support. Partners support patients in their daily activities; they often change their own daily schedule and have to adjust joint activities. Regaining a new balance together is one of the challenges that couples face when confronted with HF. Anxiety is an important theme especially in the acute phase that can interfere with adequate coping strategies. Changes in relationship are related to difficulties in communication and sexuality. Although most partners seem to cope relatively well, the impact of HF on their lives is profound. Partners are vulnerable especially at the onset of the illness, and therefore, it is important to involve partners actively in the early process of rehabilitation and recognize their importance to the patient and their potential problems.     

Searching for dose-response in HF clinics.

The study of Strömberg and colleagues¹is one of the firststudies to describe the effectiveness of a nurse-led heart failureclinic in decreasing mortality. Although several studies onheart failure management programmes have shown promising resultsin decreasing readmission and     

Autism as a Natural Human Variation: Reflections on the Claims of the Neurodiversity Movement

Neurodiversity has remained a controversial concept over the last decade. In its broadest sense the concept of neurodiversity regards atypical neurological development as a normal human difference. The neurodiversity claim contains at least two different aspects. The first aspect is that autism, among other neurological conditions, is first and foremost a natural variation. The other aspect is about conferring rights and in particular value to the neurodiversity condition, demanding recognition and acceptance. Autism can be seen as a natural variation on par with for example homosexuality. The broad version of the neurodiversity claim, covering low-functioning as well as high-functioning autism, is problematic. Only a narrow conception of neurodiversity, referring exclusively to high-functioning autists, is reasonable. We will discuss the effects of DSM categorization and the medical model for high functioning autists. After a discussion of autism as a culture we will analyze various possible strategies for the neurodiversity movement to claim extra resources for autists as members of an underprivileged culture without being labelled disabled or as having a disorder. We will discuss their vulnerable status as a group and what obligation that confers on the majority of neurotypicals.     

Compliance in heart failure patients: the importance of knowledge and beliefs.

AIMS: Non-compliance in patients with heart failure (HF) contributes to worsening HF symptoms and may lead to hospitalization. Several smaller studies have examined compliance in HF, but all were limited as they only studied either the individual components of compliance and its related factors or several aspects of compliance without studying the related factors. The aims of this study were to examine all dimensions of compliance and its related factors in one HF population. METHODS AND RESULTS: Data were collected in a cohort of 501 HF patients. Clinical and demographic data were assessed and patients completed questionnaires on compliance, beliefs, knowledge, and self-care behaviour. Overall compliance was 72% in this older HF population. Compliance with medication and appointment keeping was high (>90%). In contrast, compliance with diet (83%), fluid restriction (73%), exercise (39%), and weighing (35%) was markedly lower. Compliance was related to knowledge (OR=5.67; CI 2.87-11.19), beliefs (OR=1.78; CI 1.18-2.69), and depressive symptoms (OR=0.53; CI 0.35-0.78). CONCLUSION: Although some aspects of compliance had an acceptable level, compliance with weighing and exercise were low. In order to improve compliance, an increase of knowledge and a change of patient's beliefs by education and counselling are recommended. Extra attention should be paid to patients with depressive symptoms.     

Identification of symptom clusters among patients with heart failure: An international observational study

Background

Virtually all patients with heart failure experience multiple symptoms simultaneously, yet clinicians and researchers usually consider symptoms in isolation. Recognizing and responding early to escalating symptoms is essential to preventing hospitalizations in heart failure, yet patients have considerable difficulty recognizing symptoms. Identification of symptom clusters could improve symptom recognition, but cultural differences may be present that must be considered.

Objectives

To identify and compare symptom clusters in heart failure patients from the United States, Europe and Asia.

Design

Cross-sectional, observational study.

Settings

In- and out-patient settings in three regions of the world: Asia (i.e., China and Taiwan); Europe (i.e., the Netherlands and Sweden); and the United States.

Participants

A total of 720 patients with confirmed heart failure. Propensity scoring using New York Heart Association Classification was used to match participants from each of the three regions.

Methods

Symptoms were identified using the Minnesota Living with Heart Failure Questionnaire. To identify symptom clusters we used cluster analysis with the hierarchical cluster agglomerative approach. We used the Euclidean distance to measure the similarity of variables. Proximity between groups of variables was measured using Ward's method. The resulting clusters were displayed with dendrograms, which show the proximity of variables to each other on the basis of semi-partial R-squared scores.

Results

There was a core group of symptoms that formed two comparable clusters across the countries. Dyspnea, difficulty in walking or climbing, fatigue/increased need to rest, and fatigue/low energy were grouped into a cluster, which was labeled as a physical capacity symptom cluster. Worrying, feeling depressed, and cognitive problems were grouped into a cluster, which was labeled as an emotional/cognitive symptom cluster. The symptoms of edema and trouble sleeping were variable among the countries and fell into different clusters.

Conclusion

Despite the diversity in cultures studied, we found that symptoms clustered similarly among the cultural groups. Identification of similar symptoms clusters among patients with heart failure may improve symptom recognition in both patients and healthcare providers.