Pain and quality of life in hospitalized patients with heart failure

Chronic pain in multiple sites is associated with cardiovascular dysfunction: an observational UK Biobank cohort study

BACKGROUND

Chronic pain is associated with development of cardiovascular disease. We investigated the association between how widespread chronic pain is and the development of cardiovascular dysfunction.

METHODS

We analysed data from participants enrolled in the UK Biobank study who underwent examinations at baseline, plus first follow-up and two imaging visits. Pain sites (including hip, knee, back, neck/shoulder, or 'all over the body') and pain duration were recorded at each visit. Chronic pain was defined as pain lasting for ≥3 months. Participants were categorised into six groups: no chronic pain, chronic pain in one, two, three, or four sites, or 'all over the body'. Arterial stiffness index was measured at each time point. Carotid intima-media thickness, cardiac index, and left ventricular ejection fraction (LVEF) were measured using ultrasound and heart MRI at two additional imaging visits in a subset of participants. Mixed-effect linear regression models were used for the analyses.

RESULTS

The number of chronic pain sites was directly related to increased arterial stiffness index (n=159,360; β=0.06 per one site increase, 95% confidence interval 0.04 to 0.08). In 23,899 participants, lower LVEF was associated with widespread chronic pain (β=-0.17 per one site increase, 95% confidence interval -0.27 to -0.07). The number of chronic pain sites was not associated with carotid intima-media thickness (n=30,628) or cardiac index (n=23,899).

CONCLUSION

A greater number of chronic pain sites is associated with increased arterial stiffness and poorer cardiac function, suggesting that widespread chronic pain is an important contributor to cardiovascular dysfunction.

Pain and Heart Failure During Transport by Emergency Medical Services and Its Associated Outcomes: Hospitalization, Mortality, and Length of Stay

BACKGROUND

Over 22% of patients with heart failure (HF) are transported by emergency medical services (EMSs) for a primary complaint of pain. The relationship between a primary complaint of pain on hospitalization status, mortality, or length of stay following transport by EMS is understudied.

OBJECTIVES

The objective of this study was to determine whether a primary complaint of pain during EMS transport predicted hospitalization status, mortality, or inpatient length of stay.

METHODS

In this retrospective longitudinal cohort study, data were analyzed from electronic health records of 3539 patients with HF. Descriptive statistics and multivariate logistic and linear regression analyses were used to achieve study objectives.

RESULTS

Demographics were mean age 64.83 years (standard deviation [SD] = 14.58); gender 57.3% women, 42.7% men; self-reported race 56.2% black, 43.2% white, and 0.7% other. Of 3539 patients, 2346 (66.3%) were hospitalized, 149 (4.2%) died, and the mean length of stay was 6.02 (SD = 7.55) days. A primary complaint of pain did not predict increased odds of in-hospital mortality but did predict 39% lower odds of hospitalization (p < .001), and 26.7% shorter length of stay (p < .001). Chest pain predicted 49% lower odds of hospitalization (p < .001) and 34.1% (p < .001) shorter length of stay, whereas generalized pain predicted 45% lower odds of hospitalization (p = .044) following post-hoc analysis.

CONCLUSIONS

A primary complaint of chest pain predicted lower odds of hospitalization and shorter length of stay, possibly due to established treatment regimens. Additional research is needed to examine chronic pain rather than a primary complaint of pain.

Prevalence of chronic pain and chronic widespread pain among subjects with heart failure in the general population: The HUNT study

BACKGROUND

Pain in chronic heart failure (HF) is a significant but often unrecognized symptom. Characteristics of pain in subjects with HF are largely undescribed. The study aimed to address a knowledge gap in the relationship between HF and pain by investigating the prevalence of chronic pain and chronic widespread pain (CWP) among subjects with HF.

METHODS

Population data from the HUNT3 study in Norway (2006-2008, n = 50,802) was used. HF was measured by self-report. CWP was defined as having pain in both sides of the body, pain in the upper and lower limbs, and axial pain for at least 3 months in the last year. Associations between HF and CWP and HF and moderate to high pain intensity were analysed with logistic regression.

RESULTS

Among subjects with HF in the general population, the prevalence of chronic pain was 67.8%, 20.7% had CWP, and 58.8% had moderate to high intensity pain. Compared to participants with cardiovascular disease but not HF, the odds of both CWP (OR = 1.6; 95% CI: 1.3-2.0) and moderate to high intensity pain (OR = 1.3; 95% CI: 1.3-1.8) were higher among participants with HF-controlled for age, sex, body mass index, and comorbidity.

CONCLUSIONS

Our study confirmed the high prevalence of pain among HF subjects. This pain could not be explained by comorbidity or sociodemographic factors, which are relevant for clinical and research purposes. Pain management should not be restricted to cardiac-related pain but to chronic pain in general.

SIGNIFICANCE

This epidemiological study corroborates previous studies reporting a high prevalence of pain in the HF-population. We found that the relationship between HF, CWP, and pain intensity could not be explained by comorbidity or sociodemographic factors, illustrating the burden of chronic pain related to HF. Our results expand the understanding of pain in HF and highlight the need to identify and manage chronic pain among individuals with HF, as widespread pain adds to the symptom burden in individuals with HF.

Self-Care and Compliance with Medication and Their Relationship to the Quality of Life of Patients with Heart Failure

INTRODUCTION

Heart failure is a major health problem, often accompanied by limited physical activity and severe effects in various areas of patient quality of life. Self-care, as well as compliance with medication, can further contribute to clinical stability and improved patient outcomes.

PURPOSE

The purpose of this chapter is to assess the effect of self-care and compliance with medication, on the quality of life of patients with heart failure.

METHOD

The research sample consisted of 67 patients diagnosed with heart failure who visited the cardiology outpatient clinic of a general hospital in the capital of Greece. The assessment of self-care behavior was performed by the scale EHFScBS and SCHFI v.6, the Morsiky Green Levine Adherence Scale (MAQ) was used for the evaluation of adherence to medical treatment, while for the evaluation of the quality of life the questionnaire MLWHFQ was used.

RESULTS

The multifactorial linear regression analysis showed that age, compliance with medication and scoring in the dimension "Self-care confidence" relates independently to the overall quality-of-life scale rating. In particular, participants over 80 had a significantly higher score, that is, worse quality of life, compared to those under the age of 70 (p < 0.001), while participants with low compliance with treatment had a significantly worse quality of life compared to participants with high compliance (p < 0.001). It has been noticed that the better self-care they had and the higher compliance with their medication, their quality of life was better.

CONCLUSION

Self-care behavior and adherence to medical treatment of patients with heart failure are related to their quality of life. Age, educational level, and "Self-care confidence" are factors that influence self-care behavior, compliance with medication, and quality of life. In-depth patient information on the need for adherence to therapeutic guidelines may help to reduce pharmaceutical costs and maximize the therapeutic effect. For this reason, health professionals treating these patients should take into account all the factors that negatively affect their quality of life and treat them with the appropriate interventions.

Prevalence of pain and its association with quality of life of patients with heart failure in a developing country: findings from a multicenter cross-sectional study

BACKGROUND

Heart failure (HF) is considered one of the main causes of morbidity and death among chronic diseases worldwide. Patients have increasingly reported chronic pain in long-standing heart failure as a disturbing symptom. Its unknown etiology and mechanism, in addition to its insidious progressive nature, made both the doctor and the patient not notice it until it affects the quality of life (QoL) and general health status. The primary objective of this study is to find the prevalence of pain in chronic heart failure patients and its impact on their QoL. The secondary objective is to determine the predictors of QoL in HF patients.

METHODS

A multicenter cross-sectional design was used. The European Quality of Life scale five dimensions scale and the Brief Pain Inventory were adopted to evaluate QoL and pain, respectively. The Statistical Package for the Social Sciences version 25 was applied to present the data. The Mann-Whitney U, Kruskal-Wallis, and Cronbach alpha tests were used.

RESULTS

The final study had a total of 142 individuals. The prevalence of pain among HF patients was 84.5%. Knee pain was the main complaint among patients. Our patients' median pain severity score was 18 [5.00-25.00], while the median pain interference score was 39 [24.75-53.00]. They had a median EQ-5D score of 0.34 [0.0-0.6] and an EQ-VAS score of 50 [30-70]. Pain severity (p = 0.004 and p < 0.001, respectively) and pain interference (p < 0.001 and p = 0.001, respectively) were found to significantly associated with both QoL scores; the visual analogue scale (EQ-VAS) and EQ-5D-5L. In multivariate analysis, monthly income was the only variable significantly correlated with EQ-VAS and EQ-5D-5L, along with pain variables.

CONCLUSIONS

Pain is a common symptom among patients with HF and is significantly associated with their QoL. Low income is also highly associated with poor QoL. Definitive guidelines should be achieved to increase awareness and understanding of the importance of pain management, reaching a higher QoL level, less pain, and good adherence to HF medications.

Identifying Feasible Heart Failure Interventions Suitable for the Jordan Healthcare system: A Delphi Study

Interventions and strategies should align with the context and capacity of the health system. Identifying the most feasible and appropriate heart failure interventions in Jordan will improve heart failure management and clinical outcomes. Therefore, this study aimed to derive consensus from clinicians (using the Delphi method) regarding the most feasible and appropriate heart failure interventions in Jordan. A two-round Delphi study involving seven clinicians and policy makers were conducted. The Delphi results found consensus for the feasibility of the educational materials, follow up phone call, cardiac rehabilitation, group session, and training courses for staff. The components that were not feasible were: multidisciplinary team, individual session, and telemonitoring devices. The present study demonstrates the importance of utilizing interventions tailored to patients' characteristics and aligned with the capacity of healthcare system.

Characterizing Pain Leading to Emergency Medical Services Activation in Heart Failure

BACKGROUND

Pain is a common but understudied symptom among patients with heart failure (HF) transported by emergency medical services (EMS). The aims were to determine explanatory factors of a primary complaint of pain and pain severity, and characterize pain among patients with HF transported by EMS.

METHODS

Data from electronic health records of patients with HF transported by EMS within a midwestern United States county from 2009 to 2017 were analyzed. Descriptive statistics, χ 2 , analysis of variance, and logistic and multiple linear regression analyses were used.

RESULTS

The sample (N = 4663) was predominantly women (58.1%) with self-reported race as Black (57.7%). The mean age was 64.2 ± 14.3 years. Pain was the primary complaint in 22.2% of the sample, with an average pain score of 6.8 ± 3.1 out of 10. The most common pain complaint was chest pain (68.1%). Factors associated with a primary pain complaint were younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.96-0.97), history of myocardial infarction (OR, 1.96; 95% CI, 1.55-2.49), and absence of shortness of breath (OR, 0.67; 95% CI, 0.58-0.77). Factors associated with higher pain severity were younger age ( b = -0.05, SE = 0.013), being a woman ( b = 1.17, SE = 0.357), and White race ( b = -1.11, SE = 0.349).

CONCLUSIONS

Clinical and demographic factors need consideration in understanding pain in HF during EMS transport. Additional research is needed to examine these factors to improve pain management and reduce transports due to pain.

Antinociceptive activities of a novel diarylpentanoid analogue, 2-benzoyl-6-(3-bromo-4-hydroxybenzylidene)cyclohexen-1-ol, and its possible mechanisms of action in mice

A novel synthetic compound from the 2-benzoyl-6-benzylidenecyclohexanone analogue, namely 2-benzoyl-6-(3-bromo-4-hydroxybenzylidene)cyclohexen-1-ol (BBHC), showed pronounced nitric oxide inhibition in IFN-γ/LPS-induced RAW 264.7 cells. Based on this previous finding, our present study aimed to investigate the antinociceptive effects of BBHC via chemical and thermal stimuli in vivo. The investigation of the antinociceptive activity of BBHC (0.1, 0.3, 1.0 and 3.0 mg/kg, i.p.) was initiated with 3 preliminary screening tests, then BBHC was subjected to investigate its possible involvement with excitatory neurotransmitters and opioid receptors. The potential acute toxicity of BBHC administration was also studied. Administration of BBHC significantly inhibited acetic acid-induced abdominal constrictions, formalin-induced paw licking activity and developed notable increment in the latency time. BBHC’s ability to suppress capsaicin- and glutamate-induced paw licking activities, as well as to antagonise the effect of naloxone, had indicated the possible involvement of its antinociception with TRPV1, glutamate and opioid receptors, respectively. The antinociceptive activities of BBHC was not related to any sedative action and no evidence of acute toxic effect was detected. The present study showed that BBHC possessed significant peripheral and central antinociceptive activities via chemical- and thermal-induced nociceptive murine models without any locomotor alteration and acute toxicity.

Virtual reality for pain management in advanced heart failure: A randomized controlled study

BACKGROUND

Hospitalized patients with advanced heart failure often experience acute and/or chronic pain. While virtual reality has been extensively studied across a wide range of clinical settings, no studies have yet evaluated potential impact on pain management on this patient population.

AIM

To investigate the impact of a virtual reality experience on self-reported pain, quality-of-life, general distress, and satisfaction compared to a two-dimensional guided imagery active control.

DESIGN

Single-center prospective randomized controlled study. The primary outcome was the difference in pre- versus post-intervention self-reported pain scores on a numerical rating scale from 0 to 10. Secondary outcomes included changes in quality-of-life scores, general distress, and satisfaction with the intervention.

SETTING/PARTICIPANTS

Between October 2018 and March 2020, 88 participants hospitalized with advanced heart failure were recruited from an urban tertiary academic medical center.

RESULTS

Participants experienced significant improvement in pain score after either 10 minutes of virtual reality (change from pre- to post -2.9 ± 2.6, p < 0.0001) or 10 minutes of guided imagery (change from pre- to post -1.3 ± 1.8, p = 0.0001); the virtual reality arm experienced a 1.5 unit comparatively greater reduction in pain score compared to guided imagery (p = 0.0011). Total quality-of-life and general distress scores did not significantly change for either arm. Seventy-eight participants (89%) responded that they would be willing to use the assigned intervention again.

CONCLUSION

Virtual reality may be an effective nonpharmacologic adjuvant pain management intervention in hospitalized patients with heart failure.

TRIAL REGISTRATION

ClinicalTrials.gov database (NCT04572425).

Influence of mutuality on quality of life in heart failure patient with inadequate self-care and caregiver dyads: an actor-partner interdependence model analysis

AIMS

Mutuality, a positive quality of the relationship between patients and their informal caregivers characterized by love and affection, shared pleasurable activities, shared values, and reciprocity, influences several patient-caregiver outcomes in chronic-condition cases, but it remains unknown whether it influences the heart failure (HF) patient-caregiver dyad quality of life (QOL). The aim of this study was to evaluate the influence of mutuality and its four dimensions (love and affection, shared pleasurable activities, shared values, and reciprocity) on QOL in HF patient-caregiver dyads.

METHODS AND RESULTS

Cross-sectional study: Using the actor-partner interdependence model, we examined how an individual's mutuality influenced his/her own QOL (actor effect) and his/her partner's QOL (partner effect). Mutuality and physical and mental QOL were measured with the Mutuality Scale and Short Form 12, respectively. A total of 494 HF patient-caregiver dyads were enrolled in the study. Mutuality showed strong evidence of caregiver partner effects on the HF patients' physical QOL (total score B = 2.503, P = 0.001; shared pleasurable activities B = 2.265, P < 0.001; shared values B = 1.174, P = 0.420 and reciprocity B = 1.888, P = 0.001). For the mental QOL, mutuality and its four subscales had actor effects only on the patients' mental health (total mutuality B = 2.646, P = 0.003; love and affection B = 1.599, P = 0.360; shared pleasurable activities B = 2.599, P = 0.001; shared values B = 1.564, P = 0.001 and reciprocity B = 1.739, P = 0.020). In caregivers, mutuality had an actor effects on mental QOL (total score B = 1.548, P = 0.041 and reciprocity B = 1.526, P = 0.009).

CONCLUSION

Our results confirm the important role of mutuality in determining the physical and mental QOL in HF patient-caregiver dyads. Interventions aimed at improving the relationships within HF patient-caregiver dyads may have an impact on HF patients' and caregivers' QOL.

Effects of pain on depression, sleep, exercise tolerance, and quality of life in patients with nontuberculous mycobacterial pulmonary disease

The experience and causes of pain in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) have not been clarified.This study aimed to determine the prevalence and severity of bodily pain (BP) in patients with NTM-PD. We also investigated the clinical indicators that contribute to pain.We used a retrospective cross-sectional study design. The participants were 114 NTM-PD patients (109 women) with a mean age of 65 years. The prevalence and severity of pain were measured using 2 items from the 36-Item Short Form Survey version 2 (SF-36), and the BP score was calculated. Functional limitation due to dyspnea was quantified using the Modified Medical Research Council Dyspnea Scale (mMRC), depression was assessed using the Center for Epidemiological Studies Depression Scale (CES-D), sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI); health-related quality of life was assessed using the Leicester Cough Questionnaire (LCQ), and exercise tolerance was measured using the Incremental Shuttle Walk Test (ISWT).Pain was reported by 70.2% of the patients (n = 80), and of these, 35.7% (n = 25) reported moderate to very severe pain. NTM-PD patients with high levels of pain had significantly higher scores on the mMRC, CES-D, and PSQI scores, and significantly lower performance on the ISWT and LCQ. Multiple regression analysis identified ISWT, CES-D, and PSQI as independent factors that affected BP scores.Our findings suggest that pain significantly impacts daily life associated with reduced exercise tolerance, the presence of depressive symptoms, and poor sleep quality in patients with NTM-PD.

Health-Related Quality of Life and Associated Factors Among Adult Patients with Heart Failure in Wolaita Zone Governmental Hospitals, Southern Ethiopia

Background

Knowing how heart failure affects patients’ quality of life and its associated factors are crucial for a better patient-centred approach and management. Therefore, this study aims to assess health-related quality of life and its associated factors among adult heart failure patients in southern Ethiopia hospitals.

Methods

The facility-based cross-sectional study design was conducted in Wolaita zone governmental hospitals from March to April 2018. The population was all adult heart failure patients in the chronic illness follow-up clinic and inpatient department. All adult heart failure patients on follow-up clinic and inpatient departments who have at least a 6-month follow-up were included in the study. In contrast, patients who had chronic comorbidities were excluded from the study. Minnesota Living with Heart Failure Questionnaire (MLHFQ) tool was used to measure the outcome variable health-related quality of life (HRQoL). Interviews and client medical record reviews also collected socio-demographic, clinical and behavioural characteristics of participants. The data were analyzed using STATA version 14, and multiple linear regression analysis with P-value < 0.05 was used to measure the degree of association between HRQoL and independent variables.

Results

A total of 372 patients participated in the study. The HRQoL score for the physical, emotional, and total were 22.2, 7.7, and 46.37, respectively. HRQoL was significantly associated with gender, age, family size, occupation, residency, and recent admission within the past six months, New York Heart Association (NYHA) functional class, department of treatment, salt intake, and health perception.

Conclusion

Generally, the HRQoL for patients with heart failure was found to be low. Besides the variables age and gender of participants, family size, occupation, residency, admission history, salt intake, and NYHA class were significant factors for the HRQoL of patients with heart failure.

Palliative Care in Acute Heart Failure

Purpose of Review

Palliative care is increasingly acknowledged as beneficial in supporting patients and families affected by heart failure, but policy documents have generally focused on the chronic form of this disease. We examined palliative care provision for those with acute heart failure, based on the recently updated National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

Recent Findings

The commonest reason for hospitalization in those > 65 years, acute heart failure admissions delineate crisis points on the unpredictable disease trajectory. Palliative care is underutilized, often perceived as limited to end-of-life care rather than determined by regular systematic needs assessment. No dominant paradigm of palliative care provision has emerged from the nascent evidence base related to this clinical cohort, underscoring the need for further research.

Summary

Embedding palliative support as mainstream to heart failure care from the point of diagnosis may better ensure treatment strategies for those admitted with acute heart failure remain consistent with patients’ preferences and values.

Changes in and predictors of pain and mortality in patients with chronic obstructive pulmonary disease

This longitudinal study of patients with chronic obstructive pulmonary disease (COPD) aimed to investigate changes in pain characteristics (i.e., occurrence, intensity, and interference) and covariates associated with pain from study enrollment to 12 months, and to investigate if the different pain characteristics were associated with 5-year mortality. In total, 267 patients with COPD completed questionnaires five times over 1 year. The mean age of the patients was 63 years (standard deviation: 9.0), 53% were women, and 46% had very severe COPD. Median number of comorbidities was 2.0 (range: 0-11) and 47% of patients reported back/neck pain. Mixed models and Cox regression models were used for analyses. In total, 60% of the patients reported pain at baseline, and 61% at 12 months. The mixed model analyses revealed that those with better forced expiratory volume in 1 s (% predicted), more comorbidities, only primary school education, and more respiratory symptoms reported significantly higher average pain intensity. Moreover, those with more comorbidities, more respiratory symptoms, and more depression reported higher pain interference with function. At the 5-year follow-up, 64 patients (24%) were deceased, and the cumulative 5-year mortality rate was 22% (95% confidence interval [19-25]). Older age, lower forced expiratory volume in 1 s (% predicted), and higher pain interference at enrollment were all independently and significantly associated with higher 5-year mortality. Our findings show that many patients with COPD have persistent pain, and awareness regarding comorbidities and how pain interferes with their lives is needed.

Hospice in heart failure: why, when, and what then?

Hospice is a model of care for patients nearing the end of their lives that emphasizes symptom management, quality of life (QOL), and support of the patient and caregiving family through the death of the patient and the family's bereavement. It is associated with high patient and caregiver satisfaction and appears to not shorten lifespan for appropriately referred patients. Patients with advanced heart failure are being referred to hospice care more often than in the past, but the majority of deaths occur without this benefit. Hospice care in the USA is defined by the Medicare Hospice Benefit and associated regulations. Hospice is appropriate for patients with an expected survival prognosis of 6 months or less, and multiple predictive factors and tools are available to assist in prognostication. Management of symptoms and specific drug therapy options are discussed. For many patients, deactivation of electronic cardiac devices is appropriate when the goals of care are comfort and QOL. Ongoing collaboration of the referring physician with the hospice agency and staff offers opportunities for seamless and quality care.

Utilizing Home Healthcare Electronic Health Records for Telehomecare Patients With Heart Failure: A Decision Tree Approach to Detect Associations With Rehospitalizations

Heart failure is a complex condition with a significant impact on patients' lives. A few studies have identified risk factors associated with rehospitalization among telehomecare patients with heart failure using logistic regression or survival analysis models. To date, there are no published studies that have used data mining techniques to detect associations with rehospitalizations among telehomecare patients with heart failure. This study is a secondary analysis of the home healthcare electronic medical record called the Outcome and Assessment Information Set-C for 552 telemonitored heart failure patients. Bivariate analyses using SAS and a decision tree technique using Waikato Environment for Knowledge Analysis were used. From the decision tree technique, the presence of skin issues was identified as the top predictor of rehospitalization that could be identified during the start of care assessment, followed by patient's living situation, patient's overall health status, severe pain experiences, frequency of activity-limiting pain, and total number of anticipated therapy visits combined. Examining risk factors for rehospitalization from the Outcome and Assessment Information Set-C database using a decision tree approach among a cohort of telehomecare patients provided a broad understanding of the characteristics of patients who are appropriate for the use of telehomecare or who need additional supports.

Rahman S, Hamid SSA, Ching SM, Teh LK, Salleh MZ, Deny S, Taher M. Antinociception of petroleum ether fraction derived from crude methanol extract of Melastoma malabathricum leaves and its possible mechanisms of action in animal models

Background

Melastoma malabathricum L. (family Melastomaceae) has been traditionally used as remedies against various ailments including those related to pain. The methanol extract of M. malabathricum leaves has been proven to show antinociceptive activity. Thus, the present study aimed to determine the most effective fraction among the petroleum ether- (PEMM), ethyl acetate- (EAMM) and aqueous- (AQMM) fractions obtained through successive fractionation of crude, dried methanol extract of M. malabathricum (MEMM) and to elucidate the possible mechanisms of antinociception involved.

Methods

The effectiveness of fractions (100, 250 and 500 mg/kg; orally) were determine using the acetic acid-induced abdominal constriction test and the most effective extract was further subjected to the hot plate- or formalin-induced paw licking-test to establish its antinociceptive profile. Further elucidation of the role of opioid and vanilloid receptors, glutamatergic system, and nitric oxide/cyclic guanosine phosphate (NO/cGMP) pathway was also performed using the appropriate nociceptive models while the phytoconstituents analyses were performed using the phytochemical screening test and, HPLC-ESI and GCMS analyses.

Results

PEMM, EAMM and AQMM significantly (p < 0.05) attenuated acetic acid-induced nociception with the recorded EC₅₀ of 119.5, 125.9 and 352.6 mg/kg. Based on the EC₅₀ value, PEMM was further studied and also exerted significant (p < 0.05) antinociception against the hot plate- and formalin-induced paw licking-test. With regards to the mechanisms of antinociception,: i) PEMM significantly (p < 0.05) attenuated the nociceptive action in capsaicin- and glutamate-induced paw licking test.; ii) naloxone (5 mg/kg), a non-selective opioid antagonist, failed to significantly (p < 0.05) inhibit PEMM’s antinociception iii) L-arginine (a nitric oxide precursor), but not N^G-nitro-L-arginine methyl esters (L-NAME; an inhibitor of NO synthase), methylene blue (MB; an inhibitor of cGMP), or their respective combination, significantly (p < 0.05) reversed the antinociception of PEMM. Phytochemical analyses revealed the presence of several antinociceptive-bearing bioactive compounds, such as triterpenes and volatile compounds like oleoamide and palmitic acid. The presence of low flavonoids, such as gallocatechin and epigallocatechin, saponins and tannins in PEMM might synergistically contribute to enhance the major compounds antinociceptive effect.

Conclusion

PEMM exerted a non-opioid-mediated antinociceptive activity at the central and peripheral levels via the inhibition of vanilloid receptors and glutamatergic system, and the activation of NO-mediated/cGMP-independent pathway. Triterpenes, as well as volatile oleoamide and palmitic acid, might be responsible for the observed antinociceptive activity of PEMM.

Risk Factors for All-Cause Rehospitalization Among Medicare Recipients with Heart Failure Receiving Telehomecare

OBJECTIVE

To identify potential risk factors associated with rehospitalization among Medicare recipients with heart failure (HF) receiving telehomecare.

MATERIALS AND METHODS

This study is a nonexperimental, cross-sectional secondary data analysis of the Centers for Medicare and Medicaid (CMS) mandated assessment called the Outcome and Assessment Information Set (OASIS)-C, provided by a large home care company. A total of 526 patients who received telehomecare from January 1, 2011 to August 31, 2013 were included in the analyses, which used multiple logistic regression.

RESULTS

The overall rate of rehospitalization was 36% while patients were receiving telehomecare. Moderately frail health status (p = 0.01), the presence of severe pain (p = 0.01), the presence of dermatologic problems (p = 0.03), and independence in dressing one's lower body (compared to slightly dependent [p = 0.01] or mostly dependent patient groups [p = 0.02]) were identified as risk factors for rehospitalization.

CONCLUSIONS

The risk factors identified from this study may be used to drive more effective telehomecare placements, and referrals for additional services among telehomecare patients with HF.

Quality of life and palliative care needs of elderly patients with advanced heart failure

OBJECTIVE

To examine the quality of life and palliative care needs of elderly patients with advanced heart failure (HF).

METHODS

This was a correlation descriptive study conducted at a 650-bed sub-acute hospital. Patients who were aged 65 or over, diagnosed with HF of New York Heart Association Class III or IV symptoms, and mentally sound were eligible to the study. The Edmonton Symptom Assessment Scale, the overall quality of life single item scale, and the McQill Quality of Life Questionnaire (MQoL), were used for measurement. Multiple regression analysis was performed to determine factors for predicting quality of life.

RESULTS

A convenience sample of 112 patients was recruited. Their age was 81.5 ± 8.5 years. The three most distressing symptoms reported by the patients were tiredness (5.96 ± 2.78), drowsiness (5.47 ± 2.93), and shortness of breath (5.34 ± 2.96). Their mean overall quality of life single item scale score was 4.72 ± 2.06 out of 10. The mean MQoL physical subscale score was the lowest (4.20 ± 1.767), whereas their mean psychological subscale was the highest (7.14 ± 2.39). However, in a multivariate analysis model, quality of life was significantly associated with existential wellbeing, physical wellbeing, psychological wellbeing and educational level.

CONCLUSIONS

The findings highlight that spiritual concerns are significant palliative care needs among elderly patients with advanced HF, in addition to symptom management. This is in line with the argument that palliative care that places great emphasis on holistic care should be integrated to the care of this group of patients.

Changes in self-reported health and quality of life in octogenarian patients one month after transcatheter aortic valve implantation

BACKGROUND

In addition to favourable results regarding mortality and morbidity it is important to identify the impact transcatheter aortic valve implantation (TAVI) has on patients' quality of life.

AIMS

The aims were: (i) to describe clinical characteristics, self-reported health and quality of life in octogenarians before TAVI intervention; (ii) to determine changes in self-reported health and quality of life one month after TAVI; and (iii) to establish the clinical importance of the findings.

METHODS

A prospective cohort study was conducted on consecutively enrolled octogenarians with severe aortic stenosis undergoing TAVI ( N = 65). Self-reported health and quality of life were recorded at baseline and one month later using two global questions from the World Health Organization Quality of Life Instrument Abbreviated (WHOQOL-BREF), the generic Short Form Health 12 and the disease-specific Minnesota Living with Heart Failure Questionnaire.

RESULTS

One month after TAVI, WHOQOL-BREF showed that self-reported health improved moderately ( p < 0.001), while quality of life improved slightly, but not statistically significantly ( p = 0.06). There were changes in all Short Form Health 12 domains, except social functioning and role emotional. The estimated changes were 3.6 to 5.8 with large confidence intervals. The Physical Component Summary increased statistically significantly from baseline to 30 days (30.6-34.7; p = 0.02), but the Mental Component Summary did not (46.9-50.0; p = 0.13).

CONCLUSION

Despite being an advanced treatment performed in a high risk population, TAVI in octogenarians improves short-term self-reported global health and generic physical health and quality of life. These patient-reported outcomes have importance, particularly in this age group.

Pain among hospitalized older people with heart failure and their preparation to manage this symptom on discharge: a descriptive-observational study

Globally, heart failure (HF) is one of the major health issues faced by many older people. It causes significant symptom burden that requires ongoing management. This paper reports on a descriptive-observational study undertaken to: (1) describe the prevalence of pain and analgesic prescription usage in hospitalized older HF patients; (2) determine the degree to which these patients are provided with a pain self-management strategy prior to discharge; and (3) determine if the patients' pain self-management strategy has been detailed in the discharge summary. A total of 122 older HF patients were included in this study. Results indicated that moderate to severe pain (Numeric Rating Scale score ≥4) is experienced by a substantial number of older people hospitalized with HF. There is little documented evidence that older people are provided with adequate analgesic prescriptions and the instructions required to effectively manage their pain on discharge to the community.

[Characteristics of the population hospitalized for advanced and terminal heart failure and experiences in palliative caring in the Intensive Care Unit of cardiology]

PURPOSE

Advanced heart failure incidence is in progression. Palliative care access remains difficult due to its unpredictable course. The aim of this study was to describe the characteristics of patients admitted in Cardiology Intensive Care Unit for advanced heart failure who received palliative care and compare them to the whole population of acute heart failure hospitalized in the same period.

PATIENTS AND METHODS

The patients hospitalized for acute heart failure were retrospectively included from 2009 to 2013. We identified among them those who received palliative care. Specific caring was decided in pluridisciplinary meeting.

RESULTS

On 940 patients included, 42 patients (4.5%) receive palliative care. Ischemic heart disease was the main etiology (n=19; 45.2%). Right ventricular dysfunction (n=34; 80.9%) was associated with supra-ventricular arrhythmia (n=28; 66.7%). Twenty-eight patients (57.1%) have died in hospital, 9 (21.4%) were referred to a palliative care unit and 8 (19.1%) was discharged or referred to a rehabilitation center. Time between inclusion and death was 6 days on average. Intra-hospital mortality in control group was 6.8%.

CONCLUSION

Palliative care in cardiology is uncommon and has often been too late because of its poor adaptability to advanced heart failure. It is, as consequence, necessary to identify the prognostic factors of these patients in order to propose a personalized care and to adjust the intensity of care ahead of the terminal evolution of heart failure.

Quality of Life for Saudi Patients With Heart Failure: A Cross-Sectional Correlational Study

Introduction:

Heart failure is a major public health issue and a growing concern in developing countries, including Saudi Arabia. Most related research was conducted in Western cultures and may have limited applicability for individuals in Saudi Arabia. Thus, this study assesses the quality of life of Saudi patients with heart failure.

Materials and Methods:

A cross-sectional correlational design was used on a convenient sample of 103 patients with heart failure. Data were collected using the Short Form-36 and the Medical Outcomes Study-Social Support Survey.

Results:

Overall, the patients’ scores were low for all domains of Quality of Life. The Physical Component Summary and Mental Component Summary mean scores and SDs were (36.7±12.4, 48.8±6.5) respectively, indicating poor Quality of Life. Left ventricular ejection fraction was the strongest predictor of both physical and mental summaries.

Conclusion:

Identifying factors that impact quality of life for Saudi heart failure patients is important in identifying and meeting their physical and psychosocial needs.

Rates and risk factors for prolonged opioid use after major surgery: population based cohort study

OBJECTIVE

To describe rates and risk factors for prolonged postoperative use of opioids in patients who had not previously used opioids and undergoing major elective surgery.

DESIGN

Population based retrospective cohort study.

SETTING

Acute care hospitals in Ontario, Canada, between 1 April 2003 and 31 March 2010.

PARTICIPANTS

39,140 opioid naïve patients aged 66 years or older who had major elective surgery, including cardiac, intrathoracic, intra-abdominal, and pelvic procedures.

MAIN OUTCOME MEASURE

Prolonged opioid use after discharge, as defined by ongoing outpatient prescriptions for opioids for more than 90 days after surgery.

RESULTS

Of the 39,140 patients in the entire cohort, 49.2% (n=19,256) were discharged from hospital with an opioid prescription, and 3.1% (n=1229) continued to receive opioids for more than 90 days after surgery. Following risk adjustment with multivariable logistic regression modelling, patient related factors associated with significantly higher risks of prolonged opioid use included younger age, lower household income, specific comorbidities (diabetes, heart failure, pulmonary disease), and use of specific drugs preoperatively (benzodiazepines, selective serotonin reuptake inhibitors, angiotensin converting enzyme inhibitors). The type of surgical procedure was also highly associated with prolonged opioid use. Compared with open radical prostatectomies, both open and minimally invasive thoracic procedures were associated with significantly higher risks (odds ratio 2.58, 95% confidence interval 2.03 to 3.28 and 1.95 1.36 to 2.78, respectively). Conversely, open and minimally invasive major gynaecological procedures were associated with significantly lower risks (0.73, 0.55 to 0.98 and 0.45, 0.33 to 0.62, respectively).

CONCLUSIONS

Approximately 3% of previously opioid naïve patients continued to use opioids for more than 90 days after major elective surgery. Specific patient and surgical characteristics were associated with the development of prolonged postoperative use of opioids. Our findings can help better inform understanding about the long term risks of opioid treatment for acute postoperative pain and define patient subgroups that warrant interventions to prevent progression to prolonged postoperative opioid use.

Understanding palliative care on the heart failure care team: an innovative research methodology

CONTEXT

There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team.

OBJECTIVES

To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team.

METHODS

This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams.

RESULTS

We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps.

CONCLUSION

We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

Evaluation of the prevalence and severity of pain in patients with stable chronic heart failure

AIM

To evaluate the prevalence and severity of pain in patients with chronic stable heart failure (HF) in an outpatient clinic setting.

METHODS

This is a cross-sectional study evaluating symptoms of generalized or specific pain in patients with chronic stable heart failure. A standardized questionnaire (Edmonton Symptom Assessment System) was administered during a routine outpatient clinic visit. The severity of pain and other symptoms were assessed on a 10 point scale with 10 being the worst and 0 representing no symptoms.

RESULTS

Sixty-two patients [age 56 ± 13 years, 51 males, 11 females, mean ejection fraction (EF) 33% ± 17%] completed the assessment. Thirty-two patients (52%) reported any pain of various character and location such as chest, back, abdomen or the extremities, with a mean pain score of 2.5 ± 3.1. Patients with an EF less than 40% (n = 45, 73%) reported higher pain scores than patients with an EF greater than 40% (n = 17, 27%), scores were 3.1 ± 3.3 vs 1.2 ± 1.9, P < 0.001. Most frequent symptoms were tiredness (in 75% of patients), decreased wellbeing (84%), shortness of breath (SOB, 76%), and drowsiness (70%). The most severe symptom was tiredness with a score of 4.0 ± 2.8, followed by decreased wellbeing (3.7 ± 2.7), SOB (3.6 ± 2.8), and drowsiness (2.8 ± 2.8).

CONCLUSION

Pain appears to be prevalent and significantly affects quality of life in HF patients. Adequate pain assessment and management should be an integral part of chronic heart failure management.

Do patients with chronic heart failure have chest pain?

OBJECTIVE

In questionnaire surveys, patients with chronic heart failure frequently report "pain" as a symptom. We investigated the prevalence of chest pain as a possible cause for pain, particularly in patients with prior myocardial infarction.

DESIGN

Questionnaire survey.

SETTING

Community heart failure clinic.

PATIENTS

1 786 patients with heart failure due to left ventricular systolic dysfunction (mean ± SD age 70.1 ± 11.0 years; 73% male; left ventricular ejection fraction (LVEF) 35.3 ± 9.9%; 65.6 with underlying ischaemic heart disease (IHD)).

INTERVENTION

Patients with chronic heart failure completed a questionnaire.

MAIN OUTCOME MEASURES

Answers to the questions: (1) "In the last week, how many days did you get angina chest pain?"; and "In the last month, how much did the following affect you:" (2) "chest pains at rest"; (3) "chest pains during normal activity".

RESULTS

73% of those with IHD, and 84% of those without had had no angina in the previous week; 79% and 82%, respectively, had at most "little" chest pain at rest; 67% and 76%, respectively, had at most "little" chest pain during exertion. Angina increased with NYHA class, but there was no relation between angina and sex of patient, age or LVEF. There was a weak relation between chest pain and an adverse outcome in the patients with ischaemic heart disease.

CONCLUSIONS

Although pain is commonly reported in patients with chronic heart failure, it seems unlikely that the pain is due to angina, even in patients with underlying coronary heart disease.

Antinociceptive activity of a synthetic curcuminoid analogue, 2,6-bis-(4-hydroxy-3-methoxybenzylidene)cyclohexanone, on nociception-induced models in mice

This study investigated the potential antinociceptive efficacy of a novel synthetic curcuminoid analogue, 2,6-bis-(4-hydroxy-3-methoxybenzylidene)cyclohexanone (BHMC), using chemical- and thermal-induced nociception test models in mice. BHMC (0.03, 0.1, 0.3 and 1.0 mg/kg) administered via intraperitoneal route (i.p.) produced significant dose-related inhibition in the acetic acid-induced abdominal constriction test in mice with an ID(50) of 0.15 (0.13-0.18) mg/kg. It was also demonstrated that BHMC produced significant inhibition in both neurogenic (first phase) and inflammatory phases (second phase) of the formalin-induced paw licking test with an ID(50) of 0.35 (0.27-0.46) mg/kg and 0.07 (0.06-0.08) mg/kg, respectively. Similarly, BHMC also exerted significant increase in the response latency period in the hot-plate test. Moreover, the antinociceptive effect of the BHMC in the formalin-induced paw licking test and the hot-plate test was antagonized by pre-treatment with the non-selective opioid receptor antagonist, naloxone. Together, these results indicate that the compound acts both centrally and peripherally. In addition, administration of BHMC exhibited significant inhibition of the neurogenic nociception induced by intraplantar injections of glutamate and capsaicin with ID(50) of 0.66 (0.41-1.07) mg/kg and 0.42 (0.38-0.51) mg/kg, respectively. Finally, it was also shown that BHMC-induced antinociception was devoid of toxic effects and its antinociceptive effect was associated with neither muscle relaxant nor sedative action. In conclusion, BHMC at all doses investigated did not cause any toxic and sedative effects and produced pronounced central and peripheral antinociceptive activities. The central antinociceptive activity of BHMC was possibly mediated through activation of the opioid system as well as inhibition of the glutamatergic system and TRPV1 receptors, while the peripheral antinociceptive activity was perhaps mediated through inhibition of various inflammatory mediators.

Pain and quality of life with chronic obstructive pulmonary disease

BACKGROUND

Pain as a symptom may be underrecognized in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE

The aim of this study is to explore the prevalence and intensity of pain, its location, how demographic and clinical variables may be related to pain, and how pain is associated with quality of life (QOL).

METHODS

In this cross-sectional study, 154 patients with COPD answered the Brief Pain Inventory, Respiratory Quality of Life Questionnaire, and Quality of Life Scale, and performed spirometry.

RESULTS

Seventy-two percent of the patients indicated the location of pain on a body diagram. Lower lung function, higher score of pain intensity, and pain interference were associated with lower disease QOL. A higher score of pain interference was associated with lower global QOL. When controlling for disease QOL in the equation of global QOL, pain interference was no longer significant.

CONCLUSION

The experience of pain is related to disease QOL in patients with COPD.

How to evaluate physical fitness without a stress test?

To assess cardiorespiratory fitness (CF), usually a stress test is necessary. Our aims were to assess CF in a patient population with suspected or known coronary artery disease (CAD) based on a questionnaire (quest); to compare estimated CF with achieved workloads, and to evaluate its prediction of stress modality (physical/pharmacologic). Consecutive 612 patients undergoing myocardial perfusion SPECT (MPS) completed quest. They first chose one category which best described their daily physical activities. The second part contained patient characteristics (gender, age, BMI, and resting heart rate). An activity score was calculated and metabolic equivalents (METs) were estimated. Estimated and achieved results were compared. Patients with pharmacologic test (n = 208) provided a lower estimate of their performance than physically stressed patients (n = 404): 7.0 ± 2.1 and 8.2 ± 2.3 METs, respectively (P < 0.0001). The latter showed a good correlation between estimated and achieved METs (r = 0.63, P < 0.0001). Regarding prediction of the stress modality, area under the curve (ROC) was 0.65 (P < 0.0001). The quest can easily be applied in daily practice to assess CF in a patient population with CAD and for estimating whether an adequate physical stress test can be carried out.

Chronic musculoskeletal pain predicted hospitalisation due to serious medical conditions in a 10 year follow up study

BACKGROUND

The aim was to examine if self reported chronic regional pain (CRP) and chronic widespread pain (CWP) predicted inpatient care due to serious medical conditions such as cerebrovascular diseases, ischemic heart diseases, neoplasms and infectious diseases in a general population cohort over a ten year follow-up period.

METHODS

A ten-year follow up of a cohort from the general adult population in two health care districts with mixed urban and rural population in the south of Sweden, that in 1995 participated in a survey on health and musculoskeletal pain experience. Information on hospitalisation for each subject was taken from the regional health care register. Multiple logistic regression analyses were used to study the associations between chronic musculoskeletal pain and different medical conditions as causes of hospitalisation.

RESULTS

A report of CRP (OR = 1.6; p < 0.001) or CWP ( OR = 2.1; p < 0.001) predicted at least one episode of inpatient care over a ten year period, with an increased risk in almost all diagnostic subgroups, including cerebrovascular diseases, ischemic heart diseases, and infectious diseases. There was however no increased risk of hospitalisation due to neoplasms.

CONCLUSIONS

The presence of especially CWP was associated with hospital inpatient care due to several serious medical disorders. This may imply a general vulnerability to different medical conditions that has to be addressed in the assessment and management of subjects with chronic musculoskeletal pain.

Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology

Heart failure is a serious condition and equivalent to malignant disease in terms of symptom burden and mortality. At this moment only a comparatively small number of heart failure patients receive specialist palliative care. Heart failure patients may have generic palliative care needs, such as refractory multifaceted symptoms, communication and decision making issues and the requirement for family support. The Advanced Heart Failure Study Group of the Heart Failure Association of the European Society of Cardiology organized a workshop to address the issue of palliative care in heart failure to increase awareness of the need for palliative care. Additional objectives included improving the accessibility and quality of palliative care for heart failure patients and promoting the development of heart failure-orientated palliative care services across Europe. This document represents a synthesis of the presentations and discussion during the workshop and describes recommendations in the area of delivery of quality care to patients and families, education, treatment coordination, research and policy.

Antinociceptive and anti-allodynic effects of 3-alkynyl selenophene on different models of nociception in mice

In this study, antinociceptive and anti-hyperalgesic effects of 3-alkynyl selenophene (3-ASP) were evaluated in mice. Acute toxicity of 3-ASP (1-50 mg/kg, per oral) was investigated in mice. 3-ASP neither caused toxicity nor affects locomotor activity in the rota-rod test. 3-ASP did not change plasma aspartate (AST) and alanine aminotransferase (ALT) activities, urea and creatinine levels. 3-ASP caused a significant increase in tail-immersion and hot-plate response latencies time. 3-ASP inhibited early and late phases of nociception caused by intraplantar (i.pl.) injection of formalin. 3-ASP reduced nociception produced by i.pl. injection of glutamate, bradykinin, phorbol myristate acetate (PMA) and capsaicin in mice. Mechanical hyperalgesia induced by Freund's Complete Adjuvant (CFA) was attenuated by 3-ASP administration to mice (maximal inhibition of 42+/-11%). The anti-hyperalgesic effect of 3-ASP was maintained for up to 6 h. The antinociceptive effect of 3-ASP was not abolished by naloxone (5 mg/kg), discarding the involvement of opioidergic mechanism in this effect. These results indicate that 3-ASP at a dose range of 5-50 mg/kg was especially potent and produced systemic anti-hyperalgesic and antinociceptive actions in mice.