Prediction of cardiovascular events in older patients with hypertension in primary care: a cohort study.

BACKGROUND: Accurate risk stratification identifying patients with hypertension at risk of future cardiovascular disease in primary care would be desirable. AIM: To investigate the association between elevated brain natriuretic peptide (BNP), left ventricular hypertrophy (LVH) on an electrocardiogram (ECG), and LVH on an echocardiogram and the development of cardiovascular events (CVEs), especially heart failure and all-cause mortality (ACM), in a primary care population with hypertension without symptoms of heart failure. DESIGN AND SETTING: A prospective cohort study in five Dutch general practices between 2010-2012 and 2020. METHOD: In total, 530 patients (aged 60-85 years) underwent laboratory testing, ECGs, and echocardiograms at baseline. The incidence of new CVEs and ACM at up to 9 years' follow-up was recorded by data extraction from the digital information systems. RESULTS: Among the 530 participants, 31 (5.8%) developed a coronary event, 44 (8.3%) a cerebrovascular accident, 53 (10.0%) atrial fibrillation, 23 (4.3%) heart failure, and 66 (12.5%) died. Cox regression analyses, adjusting for relevant Framingham covariates, showed that elevated BNP increased the risk of ACM, CVEs, and specifically heart failure independently by 44% (hazard ratio [HR] 1.44, 95% confidence interval [CI] = 1.07 to 1.94, P = -0.017), 45% (HR 1.45, 95% CI = 1.15 to 1.82, P = 0.002), and 288% (HR 3.88, 95% CI = 2.13 to 7.10, P<0.001), respectively. LVH on ECG increased the risk of ACM independently by 108% (HR 2.08, 95% CI = 1.14 to 3.81, P = 0.017). LVH either on an ECG and/or echocardiogram increased the risk of heart failure independently by 309% (HR 4.09, 95% CI = 1.34 to 12.49, P = 0.014). CONCLUSION: In primary care patients with hypertension, BNP seems to be an important marker predicting future CVEs, especially heart failure, as well as all-cause mortality.

Breastfeeding continuation is associated with trait mindfulness but not with trajectories of postpartum depressive symptoms.

OBJECTIVE: The WHO recommends breastfeeding for at least six months as breastfeeding has many benefits for both infant and mother. The association of breastfeeding continuation with trait mindfulness during pregnancy and trajectories of postpartum depressive symptoms has not been examined yet. The current study aimed to assess this association using cox regression analysis. DESIGN, SETTING AND PARTICIPANTS: The current research is part of a large longitudinal prospective cohort study following women from 12 weeks of pregnancy onwards in the South-East part of the Netherlands. MEASUREMENTS: A total of 698 participants filled out the Three Facet Mindfulness Questionnaire-Short Form (TFMQ-SF) at 22 weeks of pregnancy and completed both the Edinburgh Postnatal Depression Scale (EPDS) and questions on breastfeeding continuation one week, six weeks, four months, and eight months postpartum. Breastfeeding continuation was defined as exclusive breastfeeding or both breastfeeding and formula. The assessment eight months postpartum was used as a proxy for the WHO recommendation to continue breastfeeding for at least six months. FINDINGS: Two trajectories (classes) of EPDS scores were determined using growth mixture modeling: 1) low stable (N = 631, 90.4%), and 2) increasing (N = 67, 9.6%). Cox regression analysis showed that the trait mindfulness facet non-reacting was significantly and inversely associated with the risk of breastfeeding discontinuation (HR = 0.96, 95% CI [0.94, 0.99], p = .002), while no significant association was found for belonging to the increasing EPDS class versus belonging to the low stable class (p = .735), adjusted for confounders. KEY CONCLUSIONS: This study is the first to show that higher trait mindfulness non-reacting scores, but not persistently low levels of postpartum depressive symptoms, increase the likelihood of breastfeeding continuation. IMPLICATIONS FOR PRACTICE: Improving non-reacting in perinatal women by meditation practice as part of a mindfulness-based intervention may lead to better breastfeeding continuation outcomes. Several mindfulness-based programs may be suitable.

Trait mindfulness scores are related to trajectories of depressive symptoms during pregnancy.

BACKGROUND: Exploring possible protective factors against antenatal depression is important since antenatal depression is common and affects both mother and child. The person characteristic trait mindfulness may be such a protective factor. Because of the high variability in depressive symptoms over time, we aimed to assess the association between trait mindfulness and trajectories of depressive symptoms during pregnancy. METHODS: A subsample of 762 women participating in the HAPPY study completed the Three Facet Mindfulness Questionnaire-Short Form at 22 weeks of pregnancy. Possible different trajectories of Edinburgh Postnatal Depression Scale (EPDS) scores, assessed at each pregnancy trimester, were explored with growth mixture modeling. RESULTS: Three EPDS trajectories (classes) were identified: low stable symptom scores (N = 607, 79.7%), decreasing symptom scores (N = 74, 9.7%) and increasing symptom scores (N = 81, 10.6%). Compared to belonging to the low stable class (reference), women with higher scores on the trait mindfulness facets 'acting with awareness' and 'non-judging' were less likely to belong to the decreasing class (OR = 0.81, 95% CI [0.73, 0.90] and OR = 0.77, 95% CI [0.70, 0.84]) and increasing class (OR = 0.88, 95% CI [0.80, 0.97] and OR = 0.72, 95% CI [0.65, 0.79]). Women with higher scores on 'non-reacting' were less likely to belong to the increasing class (OR = 0.89, 95% CI [0.82, 0.97]), but not the decreasing class (OR = 0.96, 95% CI [0.87, 1.04]). All analyses were adjusted for confounders. CONCLUSIONS: Characteristics of trait mindfulness predicted low stable levels of depressive symptoms throughout pregnancy. Mindfulness-based programs may be beneficial for pregnant women as a strategy to alleviate depression risks.

Breastfeeding intention and trait mindfulness during pregnancy.

OBJECTIVE: Breastfeeding has been associated with many health benefits for both infant and mother. Trait mindfulness during pregnancy may have a beneficial impact on breastfeeding intention. The current study aimed to examine whether trait mindfulness during pregnancy was associated with antenatal breastfeeding intention. DESIGN, SETTING AND PARTICIPANTS: The current study is part of a large prospective population-based cohort study among pregnant women in the south of the Netherlands. MEASUREMENTS: A subsample of participants completed the Three Facet Mindfulness Questionnaire-Short Form at 22 weeks of pregnancy and a question on their breastfeeding intention at 32 weeks of pregnancy (N=790). Moreover, the Edinburgh Depression Scale and Tilburg Pregnancy Distress scale were completed at 32 weeks of pregnancy to assess levels of distress. FINDINGS: Univariate analyses showed that women with breastfeeding intention during pregnancy had significantly higher scores on the mindfulness facet non-reacting (p<.001, medium effect size) and significantly lower scores on acting with awareness (p=.035, small effect size). A subsequent multiple logistic regression analysis showed that only non-reacting remained significantly associated with antenatal breastfeeding intention (OR=1.09, 95% CI [1.03, 1.15], p=.001), after controlling for confounders. Women who eventually initiated breastfeeding had significantly higher non-reacting scores (p<.001, small to medium effect size). KEY CONCLUSIONS: The mindfulness facet non-reacting was found to be associated with antenatal breastfeeding intention. More research is needed to confirm our results, since the current study is one of the first assessing the possible relation of trait mindfulness during pregnancy and breastfeeding intention. IMPLICATIONS FOR PRACTICE: Mindfulness-based programs during pregnancy could be helpful in improving non-reacting in pregnant women, which may enhance breastfeeding intention and ultimately the initiation of breastfeeding.

Development of the Labor Pain Relief Attitude Questionnaire for pregnant women (LPRAQ-p).

BACKGROUND: Receiving epidural analgesia during labor can possibly have negative consequences for mother and child. Yet, the use of epidural analgesia rapidly increased in the Netherlands over the last decade. Since antenatal plans for labor pain relief have been related to epidural analgesia use during labor, the aim of the current study was to develop a Labor Pain Relief Attitude Questionnaire for pregnant women (LPRAQ-p). METHODS: Three focus group interviews were conducted with pregnant women, new mothers and caregivers and 13 candidate items were derived. Psychometric properties were tested with explorative factor analysis in sample I (N = 429) and a subsequent confirmatory factor analysis in a different sample II (N = 432). RESULTS: The explorative factor analysis suggested a two-factor seven-item solution: a 'women's perception' and 'social environment' subscale. The confirmatory factor analysis confirmed an excellent six-item model fit with appropriate internal consistency. Higher scores on the six-item LPRAQ-p indicate greater willingness for request of pain relief medication during labor. Two-tailed t-tests showed that women with elevated levels of depression and pregnancy-specific distress symptoms, nulliparous women and multiparous women with complications during a previous delivery had greater willingness for request of pain relief medication during labor. Linear regression showed that the most important association with higher scores on the LPRAQ-p were high pregnancy-specific distress symptoms. CONCLUSIONS: This study showed the LPRAQ-p to be a valid instrument to evaluate attitude towards labor pain relief in pregnant women. High scores on this questionnaire are associated with high levels of pregnancy-specific distress symptoms.

Psychological risk factors of micro- and macrovascular outcomes in primary care patients with type 2 diabetes: rationale and design of the DiaDDZoB Study.

BACKGROUND: Depression is a common psychiatric complication of diabetes, but little is known about the natural course and the consequences of depressive symptoms in primary care patients with type 2 diabetes. While depression has been related to poor glycemic control and increased risk for macrovascular disease, its association with microvascular complications remains understudied. The predictive role of other psychological risk factors such as Type D (distressed) personality and the mechanisms that possibly link depression and Type D personality with poor vascular outcomes are also still unclear. METHODS/DESIGN: This prospective cohort study will examine: (1) the course of depressive symptoms in primary care patients with type 2 diabetes; (2) whether depressive symptoms and Type D personality are associated with the development of microvascular and/or macrovascular complications and with the risk of all-cause or vascular mortality; and (3) the behavioral and physiological mechanisms that may mediate these associations. The DiaDDZoB Study is embedded within the larger DIAZOB Primary Care Diabetes study, which covers a comprehensive cohort of type 2 diabetes patients treated by over 200 primary care physicians in South-East Brabant, The Netherlands. These patients will be followed during their lifetime and are assessed annually for demographic, clinical, lifestyle and psychosocial factors. Measurements include an interviewer-administered and self-report questionnaire, regular care laboratory tests and physical examinations, and pharmacy medication records. The DiaDDZoB Study uses data that have been collected during the original baseline assessment in 2005 (M0; N = 2,460) and the 2007 (M1; N = 2,225) and 2008 (M2; N = 2,032) follow-up assessments. DISCUSSION: The DiaDDZoB Study is expected to contribute to the current understanding of the course of depression in primary care patients with type 2 diabetes and will also test whether depressed patients or those with Type D personality are at increased risk for (further) development of micro- and cardiovascular disease. More knowledge about the mechanisms behind this association is needed to guide new intervention studies.