Symptom clusters predict event-free survival in patients with heart failure

Symptom-Hemodynamic Mismatch and Heart Failure Event Risk

BACKGROUND

Heart failure (HF) is a heterogeneous condition of both symptoms and hemodynamics.

OBJECTIVE

The goals of this study were to identify distinct profiles among integrated data on physical and psychological symptoms and hemodynamics and quantify differences in 180-day event risk among observed profiles.

METHODS

A secondary analysis of data collected during 2 prospective cohort studies by a single group of investigators was performed. Latent class mixture modeling was used to identify distinct symptom-hemodynamic profiles. Cox proportional hazards modeling was used to quantify difference in event risk (HF emergency visit, hospitalization, or death) among profiles.

RESULTS

The mean age (n = 291) was 57 ± 13 years, 38% were female, and 61% had class III/IV HF. Three distinct symptom-hemodynamic profiles were identified: 17.9% of patients had concordant symptoms and hemodynamics (ie, moderate physical and psychological symptoms matched the comparatively good hemodynamic profile), 17.9% had severe symptoms and average hemodynamics, and 64.2% had poor hemodynamics and mild symptoms. Compared with those in the concordant profile, both profiles of symptom-hemodynamic mismatch were associated with a markedly increased event risk (severe symptoms hazards ratio, 3.38; P = .033; poor hemodynamics hazards ratio, 3.48; P = .016).

CONCLUSIONS

A minority of adults with HF have concordant symptoms and hemodynamics. Either profile of symptom-hemodynamic mismatch in HF is associated with a greater risk of healthcare utilization for HF or death.

Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: Testing a mediation model

BACKGROUND

Cognitive impairment can reduce the self-care abilities of heart failure patients. Theory and preliminary evidence suggest that self-care confidence may mediate the relationship between cognition and self-care, but further study is needed to validate this finding.

OBJECTIVES

The aim of this study was to test the mediating role of self-care confidence between specific cognitive domains and heart failure self-care.

DESIGN

Secondary analysis of data from a descriptive study.

SETTINGS

Three out-patient sites in Pennsylvania and Delaware, USA.

PARTICIPANTS

A sample of 280 adults with chronic heart failure, 62 years old on average and mostly male (64.3%).

METHODS

Data on heart failure self-care and self-care confidence were collected with the Self-Care of Heart Failure Index 6.2. Data on cognition were collected by trained research assistants using a neuropsychological test battery measuring simple and complex attention, processing speed, working memory, and short-term memory. Sociodemographic data were collected by self-report. Clinical information was abstracted from the medical record. Mediation analysis was performed with structural equation modeling and indirect effects were evaluated with bootstrapping.

RESULTS

Most participants had at least 1 impaired cognitive domain. In mediation models, self-care confidence consistently influenced self-care and totally mediated the relationship between simple attention and self-care and between working memory and self-care (comparative fit index range: .929-.968; root mean squared error of approximation range: .032-.052). Except for short-term memory, which had a direct effect on self-care maintenance, the other cognitive domains were unrelated to self-care.

CONCLUSIONS

Self-care confidence appears to be an important factor influencing heart failure self-care even in patients with impaired cognition. As few studies have successfully improved cognition, interventions addressing confidence should be considered as a way to improve self-care in this population.

Developing EHR-driven heart failure risk prediction models using CPXR(Log) with the probabilistic loss function

Computerized survival prediction in healthcare identifying the risk of disease mortality, helps healthcare providers to effectively manage their patients by providing appropriate treatment options. In this study, we propose to apply a classification algorithm, Contrast Pattern Aided Logistic Regression (CPXR(Log)) with the probabilistic loss function, to develop and validate prognostic risk models to predict 1, 2, and 5year survival in heart failure (HF) using data from electronic health records (EHRs) at Mayo Clinic. The CPXR(Log) constructs a pattern aided logistic regression model defined by several patterns and corresponding local logistic regression models. One of the models generated by CPXR(Log) achieved an AUC and accuracy of 0.94 and 0.91, respectively, and significantly outperformed prognostic models reported in prior studies. Data extracted from EHRs allowed incorporation of patient co-morbidities into our models which helped improve the performance of the CPXR(Log) models (15.9% AUC improvement), although did not improve the accuracy of the models built by other classifiers. We also propose a probabilistic loss function to determine the large error and small error instances. The new loss function used in the algorithm outperforms other functions used in the previous studies by 1% improvement in the AUC. This study revealed that using EHR data to build prediction models can be very challenging using existing classification methods due to the high dimensionality and complexity of EHR data. The risk models developed by CPXR(Log) also reveal that HF is a highly heterogeneous disease, i.e., different subgroups of HF patients require different types of considerations with their diagnosis and treatment. Our risk models provided two valuable insights for application of predictive modeling techniques in biomedicine: Logistic risk models often make systematic prediction errors, and it is prudent to use subgroup based prediction models such as those given by CPXR(Log) when investigating heterogeneous diseases.

Prevalence and associated factors for decreased appetite among patients with stable heart failure

AIMS AND OBJECTIVES

To explore the prevalence of decreased appetite and factors associated with appetite among patients with stable heart failure.

BACKGROUND

Decreased appetite is an important factor for the development of undernutrition among patients with heart failure, but there are knowledge gaps about prevalence and the factors related to appetite in this patient group.

DESIGN

Observational, cross-sectional study.

METHODS

A total of 186 patients with mild to severe heart failure were consecutively recruited from three heart failure outpatient clinics. Data were obtained from medical records (heart failure diagnosis, comorbidity and medical treatment) and self-rated questionnaires (demographics, appetite, self-perceived health, symptoms of depression and sleep). Blood samples were taken to determine myocardial stress and nutrition status. Heart failure symptoms and cognitive function were assessed by clinical examinations. The Council on Nutrition Appetite Questionnaire was used to assess self-reported appetite. Bivariate correlations and multivariate linear regression analyses were conducted to explore factors associated with appetite.

RESULTS

Seventy-one patients (38%) experienced a loss of appetite with a significant risk of developing weight loss. The final multiple regression model showed that age, symptoms of depression, insomnia, cognitive function and pharmacological treatment were associated with appetite, explaining 27% of the total variance.

CONCLUSION

In this cross-sectional study, a large share of patients with heart failure was affected by decreased appetite, associated with demographic, psychosocial and medical factors.

RELEVANCE TO CLINICAL PRACTICE

Loss of appetite is a prevalent problem among patients with heart failure that may lead to undernutrition. Health care professionals should routinely assess appetite and discuss patients' experiences of appetite, nutrition intake and body weight and give appropriate nutritional advice with respect to individual needs.

Clinical significance of bilateral leg edema and added value of monitoring weight gain during follow-up of patients with established heart failure

PURPOSE

This study evaluated the clinical characteristics of bilateral leg edema during follow-up of heart failure (HF) patients and determined the added value of monitoring fluid weight gain for deciding whether this non-specific sign is a more clinically relevant sign.

METHODS

Retrospective analysis was performed on 1826 visits from 83 ambulatory patients with established mild-to-moderate HF. Evaluated HF-related signs included leg edema, pulmonary crackles, S3, weight gain, and ultrasound pleural effusion.

RESULTS

During follow-up, 75 patients with 161 visits had at least one of the following HF-related events: weight gain (n = 107), leg edema (n = 90), ultrasound pleural effusion (n = 85), pulmonary crackles (n = 29), and S3 (n = 16). Compared with the events of sole leg edema (n = 23), leg edema events with additional HF-related sign(s) (n = 67) accompanied more symptomatic worsening (7% vs. 55%, P < 0.0001), and a higher incidence (61% vs. 96%, P = 0.0002) and magnitude of increased serum B-type natriuretic peptide. Sole leg edema events rarely progressed to worsening HF before the next regular clinic visit. Patients with the event of both leg edema and weight gain more often experienced worsening HF requiring extra clinic visits and/or hospitalization. Amongst a total of 67 leg edema events with additional HF-related signs, 56 (84%) coexisted with weight gain. Therefore, additional monitoring of weight gain efficiently distinguished the clinically significant leg edema events from insignificant sole leg edema events.

CONCLUSIONS

During follow-up of mild-to-moderate HF patients, sole leg edema appeared around 30% of the leg edema events, which is considered clinically insignificant. Additional checking for weight gain could be useful for determining whether this sign is a clinically relevant HF-related sign. The appearance of these both signs during follow-up of established HF patients should be intentionally watched or treated by extra diuretics and/or drug adjustment to prevent worsening of HF.

Psychometric Evaluation of Two Appetite Questionnaires in Patients With Heart Failure

BACKGROUND

Decreased appetite in heart failure (HF) may lead to undernutrition which could negatively influence prognosis. Appetite is a complex clinical issue that is often best measured with the use of self-report instruments. However, there is a lack of self-rated appetite instruments. The Council on Nutrition Appetite Questionnaire (CNAQ) and the Simplified Nutritional Appetite Questionnaire (SNAQ) are validated instruments developed primarily for elderly people. Yet, the psychometric properties have not been evaluated in HF populations. The aim of the present study was to evaluate the psychometric properties of CNAQ and SNAQ in patients with HF.

METHODS AND RESULTS

A total of 186 outpatients with reduced ejection fraction and New York Heart Association (NYHA) functional classifications II-IV were included (median age 72 y; 70% men). Data were collected with the use of a questionnaire that included the CNAQ and SNAQ. The psychometric evaluation included data quality, factor structure, construct validity, known-group validity, and internal consistency. Unidimensionality was supported by means of parallel analysis and confirmatory factor analyses (CFAs). The CFA results indicated sufficient model fit. Both construct validity and known-group validity were supported. Internal consistency reliability was acceptable, with ordinal coefficient alpha estimates of 0.82 for CNAQ and 0.77 for SNAQ.

CONCLUSIONS

CNAQ and SNAQ demonstrated sound psychometric properties and can be used to measure appetite in patients with HF.

Feasibility and Efficacy of a Self-Management Intervention for Insomnia in Stable Heart Failure

BACKGROUND

Chronic insomnia is common among patients with heart failure (HF) and may contribute to fatigue and poor function. However, to date there have been no randomized controlled trials focused on treatment of insomnia or daytime symptoms in this population.

OBJECTIVES

The purpose of this study was to examine the preliminary efficacy, feasibility, and acceptability of a self-management intervention (cognitive behavioral therapy [CBT-I]) for insomnia among patients with stable HF.

METHODS

We conducted a pilot randomized controlled trial (RCT) in which patients with stable Class I-III HF (n = 25/52.1% women; mean age = 59 ± 14.8 years) were randomized in groups to CBT-I (n = 29) or an attention control condition (HF self-management with sleep hygiene; n = 19). Participants completed 2 weeks of wrist actigraphy, the insomnia severity index, and measures of fatigue, depression, sleepiness, and functional performance at baseline and follow-up. We computed the size of the effects on the dependent variables and used MANOVA to evaluate the effects of CBT-I on insomnia and fatigue.

RESULTS

CBT-I was feasible and acceptable and had a statistically significant effect on insomnia and fatigue, while controlling for the effects of comorbidity and age.

CONCLUSIONS

CBT-I has short-term efficacy as a treatment for chronic insomnia among patients with stable HF. Future studies are needed to address its sustained effects.

Cognitive Behavioral Therapy for Insomnia in the Context of Cardiovascular Conditions

Cardiovascular disease (CVD) is the leading cause of death worldwide and is associated with high levels of morbidity, disability and poor quality of life. The prevalence of insomnia symptoms and diagnosis of insomnia are high among those with CVD. Although insomnia appears to be important to CVD, less is known about the effects of insomnia treatment on important biological, sleep, symptom, quality of life, functional and morbidity or mortality outcomes in people with or at-risk for CVD. The purposes of this paper are to review the literature on the effects of CBT-I on insomnia, sleep, daytime symptoms, function, and biological outcomes in the context of CVD and to suggest implications for future research and practice. Limited available evidence suggests that CBT-I improves biomarkers that may contribute to CVD risk. CBT-I shows promise as a way to improve cardiovascular morbidity associated with the negative biological consequences of chronic insomnia, as well as symptom burden, functional performance and quality of life in the large population of people who are living with chronic CVD and insomnia. Additional research is needed to answer basic questions about short and long term outcomes, the role of biomarkers, and optimal delivery methods of CBT-I in cardiac conditions.

Self-care confidence may be the key: A cross-sectional study on the association between cognition and self-care behaviors in adults with heart failure

BACKGROUND

Self-care, a key element of heart failure care, is challenging for patients with impaired cognition. Mechanisms through which cognitive impairment affects self-care are not currently well defined but evidence from other patient populations suggests that self-efficacy, or task-specific confidence, mediates the relationship between cognitive functioning and patient behaviors such as self-care.

OBJECTIVE

The aim of this study was to test the mediating role of self-care confidence in the relationship between cognition and self-care behaviors.

DESIGN

A secondary analysis of data from a cross-sectional study.

SETTING

Outpatient heart failure clinics in 28 Italian provinces.

PARTICIPANTS

628 Italian heart failure patients.

METHODS

We used the Self-Care of Heart Failure Index v.6.2 to measure self-care maintenance, self-care management, and self-care confidence. Cognition was assessed with the Mini Mental State Examination. Structural equation modeling was used to analyze the data.

RESULTS

Participants were 73 years old on average (SD=11), mostly (58%) male and mostly (77%) in New York Heart Association functional classes II and III. The mediation model showed excellent fit (comparative fit index=1.0; root mean square error of approximation=0.02): Self-care confidence totally mediated the relationship between cognition and self-care maintenance and management.

CONCLUSION

Cognition affects self-care behaviors indirectly, through self-care confidence. Interventions aimed at improving self-care confidence may improve self-care, even in heart failure patients with impaired cognition.

Identifying relationships between symptom clusters and quality of life in adults with chronic mixed venous and arterial leg ulcers

The objective of this study was to identify symptom clusters and their effect on quality of life (QOL) of adults with chronic leg ulcers of mixed venous and arterial aetiology. A secondary analysis of data from four existing prospective longitudinal studies conducted by a wound healing research group in Australia was undertaken. A total of 110 patients who met the inclusion criteria were selected for this study. Exploratory factor analysis (EFA) was used to identify symptom clusters and correlational analyses to examine relationships between the identified symptom clusters and QOL. The EFA identified two distinct symptom clusters: a 'systemic symptom cluster' consisting of pain, fatigue and depressive symptoms; and a 'localised-leg symptom cluster' including pain, fatigue, oedema, lower limb inflammation and exudate. Physical QOL correlated significantly with the systemic symptom cluster (r = -0·055, P < 0·0001) and the localised-leg symptom cluster (r = -0·054, P < 0·0001), whereas mental QOL was associated only with the systemic symptom cluster (r = -0·038, P = 0·01). The results suggest that appropriate intervention strategies targeting specific symptom clusters should be developed. Targeting patients with symptom clusters is particularly important because they are at high risk and the most vulnerable for reduced QOL.

Identifying relationships between symptom clusters and quality of life in adults with chronic mixed venous and arterial leg ulcers

The objective of this study was to identify symptom clusters and their effect on quality of life (QOL) of adults with chronic leg ulcers of mixed venous and arterial aetiology. A secondary analysis of data from four existing prospective longitudinal studies conducted by a wound healing research group in Australia was undertaken. A total of 110 patients who met the inclusion criteria were selected for this study. Exploratory factor analysis (EFA) was used to identify symptom clusters and correlational analyses to examine relationships between the identified symptom clusters and QOL. The EFA identified two distinct symptom clusters: a 'systemic symptom cluster' consisting of pain, fatigue and depressive symptoms; and a 'localised-leg symptom cluster' including pain, fatigue, oedema, lower limb inflammation and exudate. Physical QOL correlated significantly with the systemic symptom cluster (r = -0·055, P < 0·0001) and the localised-leg symptom cluster (r = -0·054, P < 0·0001), whereas mental QOL was associated only with the systemic symptom cluster (r = -0·038, P = 0·01). The results suggest that appropriate intervention strategies targeting specific symptom clusters should be developed. Targeting patients with symptom clusters is particularly important because they are at high risk and the most vulnerable for reduced QOL.

Physical and psychological symptom profiling and event-free survival in adults with moderate to advanced heart failure

: Heart failure (HF) is a heterogeneous symptomatic disorder. The goal of this study was to identify and link common profiles of physical and psychological symptoms to 1-year event-free survival in adults with moderate to advanced HF.

METHODS

Multiple valid, reliable, and domain-specific measures were used to assess physical and psychological symptoms. Latent class mixture modeling was used to identify distinct symptom profiles. Associations between observed symptom profiles and 1-year event-free survival were quantified using Cox proportional hazards modeling.

RESULTS

The mean age of the participants (n = 202) was 57 ± 13 years, 50% were men, and 60% had class III/IV HF. Three distinct profiles, mild (41.7%), moderate (30.2%), and severe (28.1%), that captured a gradient of both physical and psychological symptom burden were identified (P < .001 for all comparisons). Controlling for the Seattle HF Score, adults with the moderate symptom profile were 82% more likely (hazard ratio, 1.82; 95% confidence interval, 1.07-3.11; P = .028) and adults with the severe symptom profile were more than twice as likely (hazard ratio, 2.06; 95% confidence interval, 1.21-3.52; P = .001) to have a clinical event within 1 year than patients with the mild symptom profile.

CONCLUSIONS

Profiling patterns among physical and psychological symptoms identifies HF patient subgroups with significantly worse 1-year event-free survival independent of prognostication based on objective clinical HF data.

Symptom burden in stable COPD patients with moderate or severe airflow limitation

OBJECTIVES

To describe a multidimensional symptom profile in patients with stable chronic obstructive pulmonary disease (COPD) and determine whether symptom experience differed between patients with moderate or severe airflow limitations.

BACKGROUND

Patients with severe airflow limitation experience numerous symptoms, but little is known regarding patients with moderate airflow limitation.

METHODS

A multidimensional symptom profile (Memorial Symptom Assessment Scale) was assessed in 42 outpatients with moderate and 49 with severe airflow limitations.

RESULTS

The mean number of symptoms in the total sample was 7.9 (±4.3) with no difference between patients with moderate and severe airflow limitations. The most prevalent symptoms with the highest MSAS symptom burden scores were shortness of breath, dry mouth, cough, sleep problems, and lack of energy in both groups.

CONCLUSIONS

Patients with moderate or severe airflow limitations experience multiple symptoms with high severity and distress. An assessment of their multidimensional symptom profile might contribute to better symptom management.

Identification of symptom clusters in patients with chronic venous leg ulcers

CONTEXT

Patients with venous leg ulcers experience multiple symptoms, including pain, depression, and discomfort from lower leg inflammation and wound exudate. Some of these symptoms impair wound healing and decrease quality of life (QOL). The presence of co-occurring symptoms may have a negative effect on these outcomes. The identification of symptom clusters could potentially lead to improvements in symptom management and QOL.

OBJECTIVES

To identify the prevalence and severity of common symptoms and the occurrence of symptom clusters in patients with venous leg ulcers.

METHODS

For this secondary analysis, data on sociodemographic characteristics, medical history, venous history, ulcer and lower limb clinical characteristics, symptoms, treatments, healing, and QOL were analyzed from a sample of 318 patients with venous leg ulcers who were recruited from hospital outpatient and community nursing clinics for leg ulcers. Exploratory factor analysis was used to identify symptom clusters.

RESULTS

Almost two-thirds (64%) of the patients experienced four or more concurrent symptoms. The most frequent symptoms were sleep disturbance (80%), pain (74%), and lower limb swelling (67%). Sixty percent of patients reported three or more symptoms at a moderate-to-severe level of intensity (e.g., 78% reported disturbed sleep frequently or always; the mean pain severity score was 49 of 100, SD 26.5). Exploratory factor analysis identified two symptom clusters: pain, depression, sleep disturbance, and fatigue; and swelling, inflammation, exudate, and fatigue.

CONCLUSION

Two symptom clusters were identified in this sample of patients with venous leg ulcers. Further research is needed to verify these symptom clusters and to evaluate their effect on patient outcomes.

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.

Simple measures of function and symptoms in hospitalized heart failure patients predict short-term cardiac event-free survival

Background. Heart failure (HF) is a prevalent chronic condition where patients experience numerous uncomfortable symptoms, low functional status, and high mortality rates. Objective. To determine whether function and/or symptoms predict cardiac event-free survival in hospitalized HF patients within 90 days of hospital discharge. Methods. Inpatients (N = 32) had HF symptoms assessed with 4 yes/no questions. Function was determined with NYHA Classification, Katz Index of Activities of Daily Living (ADLs), and directly with the short physical performance battery (SPPB). Survival was analyzed with time to the first postdischarge cardiac event with events defined as cardiac rehospitalization, heart transplantation, or death. Results. Mean age was 58.2 ± 13.6 years. Patient reported ADL function was nearly independent (5.6 ± 1.1) while direct measure (SPPB) showed moderate functional limitation (6.4 ± 3.1). Within 90 days, 40.6% patients had a cardiac event. At discharge, each increase in NYHA Classification was associated with a 3.4-fold higher risk of cardiac events (95% CI 1.4–8.5). Patients reporting symptoms of dyspnea, fatigue, and orthopnea before discharge had a 4.0-fold, 9.7-fold, and 12.8-fold, respectively, greater risk of cardiac events (95% CI 1.2–13.2; 1.2–75.1; 1.7–99.7). Conclusions. Simple assessments of function and symptoms easily performed at discharge may predict short-term cardiac outcomes in hospitalized HF patients.

Clinical trials with new oral anticoagulants. Additive value of indirect comparisons also named network meta-analyses

To compare the efficacy and safety of the new oral anticoagulants (NOAC), ideally head-to-head clinical trials should be performed. Given the expense of such an undertaking, it is highly unlikely that such a comparison would be performed. Therefore, there is a need for an unbiased comparative assessment of the benefits and risks of the NOACs, based on the available trial data. Indirect or mixed treatment comparisons may be an useful tool to overcome these limitations also known as network meta-analysis (NMA). The aim of this paper is to give an overview on published NMAs for dabigatran, rivaroxaban and apixaban, each assessed against warfarin in patients with atrial fibrillation, and against enoxaparin in patients undergoing total knee and total hip replacement surgery, in order to obtain insights into the comparability of the adopted methodological techniques.

Heart failure symptom measures: critical review

OBJECTIVE

To provide a critical review and analysis of heart failure (HF)-specific symptom measures

METHODS

A systematic search using the PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases and reference lists of relevant papers was undertaken to identify symptom measures that were primarily designed for patients with HF.

RESULTS

The systematic search yielded seven instruments that included three or more symptoms. Of the seven instruments, only five had psychometric properties available and these were reviewed. Levels of comprehensiveness of symptom measures varied including the number of symptoms assessed (13-32 symptoms/signs) and symptom dimensions (e.g. frequency and severity). Information about reading levels, time to completion, and completion rates was limited. Psychometric properties of the five measures have not been extensively investigated or reported.

CONCLUSION

The development and use of the HF symptoms instruments is at a relatively early stage. Thus, further investigation of the psychometric characteristics of existing HF-specific symptom instruments is necessary before one can be recommended for research and clinical use.

Cluster analysis of symptoms in pulmonary arterial hypertension: a pilot study

BACKGROUND

Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary artery pressures leading to right heart failure and death.

AIMS

The aim of this study was to use cluster analysis to describe the symptom profile in PAH and differences in the health outcomes of health status, health-related quality of life (HRQoL) and psychological states in the cluster groups.

METHODS

A cross-sectional descriptive design was used. A convenience sample completed a socio-demographic and clinical data form, a PAH Symptom Severity and Interference Scale, the Medical Outcomes Study Short Form (SF-36), the United States Cambridge Pulmonary Hypertension Outcome Review (US CAMPHOR) and the Short Form of the Profile of Mood States (POMS).

RESULTS

Of the 151 participants, the mean age was 53.5 ± 15.1 with the majority female (n = 128, 85%). Fifty-eight (41%) were disabled and 67 (44%) were Functional Class IV. The most prevalent symptoms were shortness of breath with exertion (n = 149, 99%) and fatigue (n = 144, 93%). Three clusters emerged: Cluster 1 diffuse symptoms (n = 93), Cluster 2 severe cardiopulmonary symptoms (n = 32) and Cluster 3 moderate cardiopulmonary symptoms (n = 26). Overall, on the SF-36 the participants had poor general health, reduced physical function, role physical, vitality, and a low composite score for physical health. On the POMS the sample had limited vigor and increased fatigue. Cluster 2 Severe Cardiopulmonary Symptoms had worse SF-36, US CAMPHOR and POMS scores than the other cluster groups.

CONCLUSIONS

Patients with PAH are experiencing a constellation of symptoms that are interfering with their life and emerging clusters were present.

Relationship between appetite and symptoms of depression and anxiety in patients on chronic hemodialysis

OBJECTIVE

We aimed at evaluating the association between appetite and symptoms of depression and anxiety, cognitive dysfunction, fatigue, and comorbidities in patients on hemodialysis (HD).

DESIGN

A cross-sectional study was conducted.

SETTING

The study was conducted in an outpatient HD service of a tertiary level academic hospital.

PATIENTS

A total of 90 patients on HD were evaluated for appetite (during the past week, how would you rate your appetite?), symptoms of depression (Beck Depression Inventory [BDI]) and anxiety (Hamilton Anxiety Rating Scale [HARS]), cognitive dysfunction (Mini Mental State Examination [MMSE]), and comorbidities (Charlson Comorbidity Index).

MAIN OUTCOME MEASURE

Relationship between appetite and symptoms of depression and/or anxiety, cognitive dysfunction, and comorbidities was assessed.

RESULTS

In 43 patients, the appetite was very good/good (group 1), in 22, it was fair (group 2), and in 25, it was poor/very poor (group 3). Mean and median BDI were significantly higher in group 3 as well as the percentage of patients with BDI ≥16. Mean and median HARS and the percentage of patients with HARS >13 were significantly higher in group 3. MMSE was significantly lower in group 3 as well as the percentage of patients with MMSE ≤23. Multiple linear regression analysis showed a dependence of appetite by age and BDI (P = .007 and P = .002, respectively).

CONCLUSIONS

Anorexia is associated with older age and symptoms of depression in patients on HD.