The gap between policy and practice: a systematic review of patient-centred care interventions in chronic heart failure.

Patient-centred care (PCC) is recommended in policy documents for chronic heart failure (CHF) service provision, yet it lacks an agreed definition. A systematic review was conducted to identify PCC interventions in CHF and to describe the PCC domains and outcomes. Medline, Embase, CINAHL, PsycINFO, ASSIA, the Cochrane database, clinicaltrials.gov, key journals and citations were searched for original studies on patients with CHF staged II-IV using the New York Heart Association (NYHA) classification. Included interventions actively supported patients to play informed, active roles in decision-making about their goals of care. Search terms included 'patient-centred care', 'quality of life' and 'shared decision making'. Of 13,944 screened citations, 15 articles regarding 10 studies were included involving 2540 CHF patients. Three studies were randomised controlled trials, and seven were non-randomised studies. PCC interventions focused on collaborative goal setting between patients and healthcare professionals regarding immediate clinical choices and future care. Core domains included healthcare professional-patient collaboration, identification of patient preferences, patient-identified goals and patient motivation. While the strength of evidence is poor, PCC has been shown to reduce symptom burden, improve health-related quality of life, reduce readmission rates and enhance patient engagement for patients with CHF. There is a small but growing body of evidence, which demonstrates the benefits of a PCC approach to care for CHF patients. Research is needed to identify the key components of effective PCC interventions before being able to deliver on policy recommendations.

To glue or not to glue? Reassembling broken otoliths for population discrimination.

Twenty-five Atlantic cod Gadus morhua otoliths were examined using eight shape measurements along with Fourier analysis of their outlines to test whether discrimination using otolith shape is affected by gluing broken otoliths. Small differences in seven of the eight shape measurements were found between unbroken otoliths and the same otoliths after breaking and subsequently gluing together; however, none of the Fourier descriptors differed. Cluster analyses indicated that resultant morphological differences will have no impact when applying discriminant analysis.

Identification of stock components using morphological markers.

This study investigated the development of a quantitative method for distinguishing stock components of Icelandic cod Gadus morhua based on visual examination of morphology. The stock is known to be structured into genetically distinct geographic components (north and south of Iceland) and behavioural types that spawn sympatrically. Differences in morphology were tested between locations, genotypes (a proxy for behaviour) and sexes. Results show morphological markers on the head, fins and body of G. morhua that are correlated with the sex, genotype of the fish at the pantophysin (pan-I) locus and the location at which the fish were caught. Females were found to have relatively deep bodies, and the pan-I(BB) genotype (associated with deep-water feeding behaviour) have greater gaps between their fins. Overall, morphology is more useful for distinguishing sympatric genotypes but less powerful at identifying genetically distinct geographic sub-populations, perhaps because counter-gradient evolution reduces phenotypic differences even with an underlying genetic cause.

Effect of regulated expression of human cyclooxygenase isoforms on eicosanoid and isoeicosanoid production in inflammation.

To examine the role of cyclooxygenase (COX) isozymes in prostaglandin formation and oxidant stress in inflammation, we administered to volunteer subjects placebo or bolus injections of lipopolysaccharide (LPS), which caused a dose-dependent increase in temperature, heart rate, and plasma cortisol. LPS caused also dose-dependent elevations in urinary excretion of 2,3-dinor 6-keto PGF(1alpha) (PGI-M) and 11-dehydro thromboxane B(2) (Tx-M). Platelet COX-1 inhibition by chronic administration of low-dose aspirin before LPS did not alter the symptomatic and febrile responses to LPS, but the increment in urinary PGI-M and Tx-M were both partially depressed. Pretreatment with ibuprofen, a nonspecific COX inhibitor, attenuated the febrile and systemic response to LPS and inhibited prostanoid biosynthesis. Both celecoxib, a selective COX-2 inhibitor, and ibuprofen attenuated the pyrexial, but not the chronotropic, response to LPS. Experimental endotoxemia caused differential expression of the COX isozymes in monocytes and polymorphonuclear leucocytes ex vivo. LPS also increased urinary iPF(2alpha)-III, iPF(2alpha)-VI, and 8,12-iso-iPF(2alpha)-VI, isoprostane (iP) indices of lipid peroxidation, and none of the drugs blunted this response. These studies indicate that (a) although COX-2 predominates, both COX isozymes are induced and contribute to the prostaglandin response to LPS in humans; (b) COX activation contributes undetectably to lipid peroxidation induced by LPS; and (c) COX-2, but not COX-1, contributes to the constitutional response to LPS in humans.

Evaluating cardioversion outcomes for atrial fibrillation on novel oral anticoagulants versus warfarin: experience at a tertiary referral centre.

BACKGROUND: Current guidelines recommend anticoagulation prior to cardioversion in patients with atrial fibrillation of >48 h or unknown duration to reduce thromboembolic risk. Therapeutic anticoagulation with warfarin, with INR between 2 and 3, is consistently achieved in approximately 60% of patients. AIMS: We evaluated outcomes and assessed differences in direct current cardioversion (DCCV) in patients treated with warfarin and novel oral anticoagulants (NOAC) at our institution. METHODS: A retrospective analysis of consecutive DCCV at a tertiary referral over 18 months was conducted. Analysis of cardioversion records allowed completion of a standardised dataset. Clinical variables recorded included (1) CHADSVASC score, (2) anticoagulant use, and (3) bleeding complications. RESULTS: During this period 187 DCCVs were scheduled; 119 on warfarin and 68 on NOAC. DCCV was deferred in 26% (n = 31) of the warfarin group and 4.4% (n = 3) of the NOAC group (p = 0.0002). The average time interval between referral and DCCV was 144.43 and 109.32 days for the warfarin and NOAC groups, respectively (p value = 0.023). 7.56% (n = 9) of the warfarin population had a bleeding event compared to a 2.94% total bleeding rate in NOAC group (p = 0.213). Deferral of elective DCCV and additional anticoagulant monitoring was estimated at €1160 per procedure. CONCLUSION: In elective cardioversions, the group anticoagulated with NOAC was less likely to have subtherapeutic anticoagulation and hence deferred procedures and had reduced health care consumption when compared to the group anticoagulated with warfarin.

Readmission rates among cardiology inpatients with echocardiography abnormalities associated with heart failure.

BACKGROUND: Heart failure is a condition associated with significant morbidity. It is caused by structural or functional abnormalities of the heart. Many of these abnormalities if detected and managed early would prevent the onset of heart failure. AIMS: The aim of this study was to to determine the usefulness of echocardiography as a means of predicting readmission rates. A secondary aim was to profile patients with echocardiography abnormalities. METHODS: This was a prospective cohort study that followed patients over 36 months. Data were abstracted from the medical records of 76 cardiology patients in a large urban teaching hospital between 1.6.11 and 31.8.14. The outcome of interest was the number of readmissions occurring up to 48 months after discharge. We also aimed to profile these patients in terms of their co-morbidities and their medication history. RESULTS: Of those patients who had echocardiography (n = 447), 76 were considered to have a cardiac disorder (HHD, VHD, or LVSD) (n = 29). The mean readmission rate for HHD was 0.82, LVSD 0.62, and HHD 0.98. Patients with HHD were associated with a higher readmission rate of 1.8980 and for LVSD-1.24 times more likely. Those with a cardiac disorder were 13 % more likely to have a readmission within the next 36 months than those without a cardiac disorder. CONCLUSIONS: A significant proportion of patients were found to have a cardiac disorder related to HF. Echocardiographic abnormalities were shown to be an independent risk factor for readmission.

Percutaneous endoscopic gastrostomy--results of an Irish single unit series.

The technique of percutaneous endoscopic gastrostomy (PEG) was first described in 1980, as an alternative to traditional surgical methods. The main indication for PEG is the need for longterm nutritional support. It is reported to have many advantages over surgical gastrostomy, being safer and cheaper. We reviewed our experience with the first 44 patients referred to our unit for PEG. The most common indications for referral were stroke, head injury and post brain surgery. There was a success rate of 97.6% and a complication rate of 13.8%. One patient (2.3%) suffered major complications as a result of early tube displacement. There were no procedure related deaths in our series and no deaths as a result of an underlying disease process within 30 days, reflecting appropriate patient selection. All patients benefited nutritionally from PEG placement. Two patients recovered sufficiently to no longer require a gastrostomy and the tube was easily removed in both cases.

Lateral and anterior reciprocal electrocardiographic changes: relationship to ST segment elevation and underlying coronary artery disease in inferior myocardial infarction.

The electrocardiogram in patients with acute inferior myocardial infarction frequently displays ST depression in non-infarct leads. The significance of this finding is uncertain. The relationship between ST depression, ST elevation and arteriographic severity of coronary artery disease was explored. 22 patients with acute inferior myocardial infarction, receiving thrombolysis and undergoing acute (within seven hours of the onset of chest pain) coronary angiography were studied prospectively. The electrocardiographic ST segment elevation in the inferior leads and ST segment depression in the lateral and in the anterior precordial leads were measured. In each group of leads, the maximum value of ST deviation in any lead as well as the sum of the values for ST deviation in the individual leads was determined. Gensini scores of total coronary artery disease and component scores for the major coronary arteries were determined from the coronary arteriogram. There was a strong correlation of maximum inferior ST elevation with both maximum lateral ST depression (r = 0.96, p < 0.001) and with maximum anterior precordial ST depression (r = 0.78, p < 0.001). The corresponding correlations for sum of ST deviations were r = 0.91, p < 0.001 and r = 0.79, p < 0.001 respectively. There was no relationship between Gensini scores of coronary artery disease and measures of electrocardiographic ST segment depression or elevation. Electrocardiographic ST depression in non-infarct leads in patients with inferior myocardial infarction, does not provide information regarding the degree of coronary artery disease. The ST depression in both lateral and anterior precordial leads correlates with and is a reflection of inferior ST elevation.

Immediate and follow-up results of coronary angioplasty--lessons for the future.

In a series of 129 patients having coronary angioplasties in St. James's Hospital in 1989, the average age was 54.8 (30-77 years). There were 102 (79%) men and 27 (21%) females. Clinical indications were unstable angina 62, stable angina 26, post myocardial infarction 39 and asymptomatic ischaemia 2. The distribution of coronary disease was single vessel 62%, double vessel 28%, triple vessel 7% and previous coronary bypass surgery 3%. Only 10 patients had more than one vessel dilated. Primary success was achieved in 119 (92%), there were no deaths, 3 patients had abrupt closure of the vessel during angioplasty and sustained a nonfatal myocardial infarction, 1 patient required urgent bypass surgery and 2 patients had peripheral vascular complications requiring surgery. There were 6 failed angioplasties, 4 of which had chronic total occlusion. At a mean follow-up of 5.3 months, 85 patients had no symptoms, 34 had angina, 2 developed myocardial infarction and 1 died suddenly at 5 months. Repeat angiography was performed in 96 (79%) patients. At follow-up, no symptoms were present in 69% of those with single vessel disease and 70% of multivessel disease. Of those who had more than one vessel dilated in multivessel disease, 80% were asymptomatic (P = NS). There were 11 patients with initial total occlusion at presentation, 4 had failed angioplasties, 5 recurrent angina of which 4 reoccluded and 1 restenosed and only 2 were asymptomatic and without restenosis. Angioplasty was performed with primary success (92%) and follow up results (70% asymptomatic). Those with single or multivessel disease had similar clinical outcome, favouring the use of target vessel angioplasty. Long term results following angioplasty of chronic total occlusions were poor and suggests the need for additional treatment.