Changes in personal control as a predictor of quality of life after pulmonary rehabilitation.

OBJECTIVE: Perceptions of mastery and self-efficacy may be related to better outcomes in pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). This study examined (1) whether patients with COPD improved during a rehabilitation programme with respect to quality of life (QoL) and perceptions of self-efficacy and mastery, and (2) whether increased perceptions of mastery and self-efficacy contributed to a higher QoL after rehabilitation. METHODS: Thirty-nine consecutive COPD patients (aged 60.5 +/- 9.0) were included from a rehabilitation centre and completed self-report questionnaires assessing symptoms, QoL, and perceptions of personal control. RESULTS: COPD patients improved during rehabilitation in overall QoL and self-efficacy, although no significant changes were found in QoL domains and mastery. Changes in self-efficacy during rehabilitation contributed to the explanation of the social and psychological functioning QoL domains. CONCLUSION: Even in seriously impaired COPD patients in advanced stages of illness, positive changes in self-efficacy and overall well-being can be established during rehabilitation. Changes in self-efficacy were related to a better QoL, suggesting the importance of personal control in the adjustment to COPD. PRACTICE IMPLICATIONS: Focussing more explicitly on the enhancement of perceptions of personal control in COPD patients may be an important aim of pulmonary rehabilitation.

Evidence-based treatment and quality of life in heart failure.

OBJECTIVES: To explore whether prescription of evidence-based drug therapy is associated with better quality of life (QoL) in patients with heart failure (HF). METHODS: Patients (n = 62) were recruited in the outpatient clinic of Groningen University Hospital. Inclusion criteria were previous diagnosis of HF, age 40-80 years; ejection fraction of less than 45%, free from other serious disease (such as cancer) and psychiatric problems in the last year. QoL was assessed with the RAND 36-item health survey questionnaire, on five scales: physical functioning, mental health, social functioning, vitality and general health perception. Medication prescribed for 1 to 6 months before the QoL assessment was classified as either evidence-based treatment or under-treatment, according to the 2001 European guidelines on optimal HF treatment. The study had a cross-sectional design. RESULTS: QoL did not differ significantly between evidence-based and under-treated patients, unadjusted or after adjustment for significant patient imbalances. CONCLUSIONS: Conventional step-up medication approach in HF may have a positive impact on survival or morbidity, but it seems not beneficial in relation to QoL. Other interventions should be designed to improve QoL of patients with HF.

Consequences of chronic obstructive pulmonary disease and chronic heart failure: the relationship between objective and subjective health.

This study investigates whether the relationship between objective health parameters and general health perceptions was mediated by symptoms of dyspnoea and physical functioning in patients with chronic obstructive pulmonary disease (COPD) and patients with chronic heart failure (CHF). The different health parameters were organised according to Wilson and Cleary's conceptual model of patient outcomes (Wilson & Cleary (1995). Journal of the American Medical Association, 273, 59-65). Second, we investigated whether perceptions of personal control were related to the health parameters in the model. Consecutive patients with COPD and CHF were included from the outpatient clinics of a university hospital and a general hospital, and from a rehabilitation centre, all in the Netherlands. Ninety-five COPD patients (aged 65.0+/-9.3; forced expiratory volume in 1s (FEV1)<70%) were included and compared with 90 CHF patients (aged 59.6+/-10.0; left ventricular ejection fraction (LVEF)<45%). The relationship between objective health parameters (FEV1 or LVEF) and subjective health (self-reported physical functioning) was not mediated by symptoms of dyspnoea. FEV1 or LVEF and symptoms of dyspnoea were independently related to self-reported physical functioning, which was directly related to general health perceptions. Perceived health competence was related to symptoms of dyspnoea and general health perceptions in patients with either COPD or CHF. Although patients with COPD reported lower levels in all self-reported health parameters in the model than the patients with CHF, this study showed that the relations between the health parameters in the model were comparable for COPD and CHF patients.

PET for evaluation of differential myocardial perfusion dynamics after VEGF gene therapy and laser therapy in end-stage coronary artery disease.

UNLABELLED: The purpose of this study was to appraise the value of PET in the assessment of the effect of supposedly proangiogenic new therapies such as gene therapy with vascular endothelial growth factor (VEGF) gene and endomyocardial laser therapy. METHODS: Thirty-five patients with end-stage coronary artery disease and class III (Canadian Cardiovascular Society) angina were included. Myocardial ischemia was evaluated with dipyridamole PET scanning and exercise tolerance with bicycle ergometry. Ten patients were treated with naked plasmid DNA encoding for human VEGF165 (VEGF) and 12 patients were treated with laser therapy (direct myocardial revascularization [DMR]) using an electromechanical mapping system. Thirteen patients were treated with standard medical therapy (control). RESULTS: In both active treatment groups, angina was reduced in most subjects, except in 2 VEGF and 5 DMR patients. In the control group, no improvement in anginal classification was found, except in 3 subjects. On the PET scan, solely in the VEGF group, the stress perfusion was significantly improved (from 57 +/- 33 to 81 +/- 55 mL/min/100 g; P = 0.031). Furthermore, in the VEGF group, the number of ischemic segments was reduced from 274 +/- 41 to 234 +/- 48 segments (P = 0.004) but not in the DMR group (from 209 +/- 43 to 215 +/- 52 segments) or in the control group (from 218 +/- 18 to 213 +/- 28 segments). Bicycle exercise duration showed slight nonsignificant changes in the VEGF group (from 3.6 +/- 2.0 to 4.6 +/- 2.1 min), in the DMR group (from 5.1 +/- 1.5 to 4.7 +/- 1.3 min), and in the control group (from 3.3 +/- 1.8 to 3.5 +/- 2.3 min). CONCLUSION: PET showed that intramyocardial gene therapy with the human VEGF165 gene in contrast to laser DMR treatment effectively reduces myocardial ischemia.

The enigma of quality of life in patients with heart failure.

Current treatment goals in heart failure (HF) aim to improve both survival and quality of life (QoL) of patients. In this brief communication, we reviewed randomized controlled trials that assessed the impact of pharmacological treatment on QoL, and we discussed some methodological limitations of QoL assessment in HF. Studies that assessed QoL with a disease-specific questionnaire were included. We found that at present there is a paradox in HF treatment. Life prolonging therapies, such as angiotensin-converting-enzyme-inhibitors, and angiotensin receptor blockers improve modestly or only delay the progressive worsening of QoL in HF. Treatment with beta blockers does not affect QoL in any way. However, this neutral effect of beta blockers may also be due to some methodological limitations, such as the small number of patients included in beta blocker trials or the short duration of follow-up. Disease-specific questionnaires may also have some limitations, e.g. are not sensitive enough to detect small changes in QoL. On the other hand, therapies that significantly improve QoL in HF (e.g. inotropic agents) do not seem beneficial in relation to survival. We conclude that QoL in HF remains an open field, in which new therapies but also clarification of methodology is required. In the mean time, the use of life prolonging therapies appears as a safe measure to modestly improve or maintain QoL.

BNP and NT-proBNP, predictors of 1-year mortality in nursing home residents.

OBJECTIVES: To investigate 1-year mortality prediction of B type natriuretic peptide (BNP) and N terminal-proBNP (NT-proBNP) in institutionalized elderly with multiple morbidities. DESIGN: Prospective cross-sectional study. SETTING: One nursing home. PARTICIPANTS: Ninety-three residents (mean age 81 +/- 3 years, 66% female). Residents with serious cognitive impairments, aphasia, or metastatic cancer were excluded. MEASUREMENTS: Clinical assessment, immobilization, medical history, electrocardiogram (ECG), echocardiogram, blood samples. One general geriatrician assessed noncardiovascular diseases; a cardiologist panel established the diagnosis of chronic heart failure (CHF). Subjects were tracked for 1 year as far as status of death. MAIN RESULTS: Eighteen of 93 enrolled individuals died. BNP was significantly higher in nonsurvivors compared with survivors (138 [49-753] versus 87 [27-162], P = .029), NT-proBNP was higher but did not reach significance 1382 (193-5683) versus 335 (175-900) pg/mL (interquartile range [IQR], P = .059). The adjusted value on 1-year mortality of 6 predefined chronic diseases, immobilization, age, sex, NT-proBNP, and BNP was estimated by means of Cox proportional hazard regression analyses. Finally, both for NT-proBP and BNP, a mutually adjusted multivariate Cox proportional hazard analysis with the covariates presented that BNP and NT-proBNP predicted 1-year mortality significantly (hazard ratio [HR] 1.67 and P = .000, HR 0.60 and P = .000, respectively). The mortality risk increased at rising BNP and NT-proBNP levels. CONCLUSION: BNP and NT-proBNP are predictors of 1-year mortality independently of age, gender, and morbidity. The mortality risk increases at elevating natriuretic peptide concentrations. We postulate that plasma levels of BNP and NT-proBNP are also of use to predict prognosis in institutionalized elderly with multiple morbidity.

Circulating CD34+ progenitor cells modulate host angiogenesis and inflammation in vivo.

Within the phenotypically and functionally heterogeneous group of circulating progenitor cells (CPC), a subclass of cells with vascular repair potential have been identified. These CPC are detected and isolated based on single or combined expression of CD34, CD133 and VEGFR-2, and referred to as endothelial progenitor cells. Here we asked whether CPC subsets defined by single expression of these markers exhibit functional heterogeneity. As functional parameters, we chose the capacity of CPC to differentiate into endothelial cells. Moreover, we studied their role in remodeling by recruitment of inflammatory cells, an aspect that has been little explored. We established an in vivo model in which the intrinsic functional capacity of these human CPC subsets was studied. Human CD34+ CPC, but not CD133+ or VEGFR-2+ CPC, seeded in Matrigel pellets and transplanted subcutaneously in a nude mouse host, contributed little to donor-derived neovascularization. However, host angiogenesis in the Matrigel implant, as demonstrated by the presence of capillaries containing erythrocytes and expressing mouse CD31, was strong in response to implantation of human CD34+ CPC and significantly lower in response to the other two CPC subsets. Moreover, the CD34+ CPC subset was significantly superior to CD133+ CPC and VEGFR-2+ CPC in the recruitment of host monocytes/macrophages. These three CPC populations were further dissected into seven discrete subsets, based on three-parameter flow cytometry analysis of combined expression patterns of CD34, CD133 and VEGFR-2. In conclusion, in our system, CD34+ CPC contribute marginally to neovascularization by differentiation but are potent regulators of the host angiogenic and pro-inflammatory response, suggesting a possible role for these cells in the remodeling of vascular lesions.