Informal Family Care Partner Well-Being Is Diminished in End-Stage Liver Disease.

BACKGROUND: Chronic liver disease is a significant global neglected public health problem. End-stage liver disease is associated with substantial symptom complexity, disability, and care needs that require assistance from informal family care partners. Research on these care partners' caregiver burden or strain, symptoms, and quality of life is sparse and has not focused on these variables as co-occurring or in the context of the quality of the relationship care partners have with the patients. OBJECTIVES: The purpose of this study was to provide a collective presentation of patterns and determinants of well-being as measured by caregiver strain, depression, sleep, and quality of life in a cohort of informal family care partners for adult outpatients with end-stage liver disease. METHODS: Care partners (aged >18 years) were recruited from two liver clinics within two tertiary healthcare systems and invited to complete a cross-sectional survey. They completed the Multidimensional Caregiver Strain Index, Patient Health Questionnaire, Pittsburgh Sleep Quality Index, Short Form Health Survey, and Mutuality Scale. Descriptive statistics and latent class mixture modeling were used to analyze these data. RESULTS: The sample was predominantly female and White. The well-being of care partners was diminished. Three distinct classes of well-being were identified: mildly diminished (53.2%), moderately diminished (39.0%), and severely diminished (7.8%). Those at a greater risk of worse well-being were younger and spouses and had poorer relationship quality with the patients. DISCUSSION: To improve the well-being of care partners in moderately and severely diminished classes, assessing and addressing caregiver strain and co-occurring symptoms is essential. Addressing the strain and symptoms has the potential to maintain or optimize care partners' ability to provide care to patients. Future researchers should include longitudinal and dyadic studies to examine how patients' disease progression and symptoms may affect family care partners' well-being and vice versa.

The role of nurse-patient mutuality on self-care behaviours in patients with chronic illness.

AIM: To examine the role of nurse-patient mutuality on three self-care behaviours in chronic illness patients. DESIGN: A cross-sectional multi-centre study was conducted. METHODS: Mutuality was measured with the Nurse-Patient Mutuality in Chronic Illness scale which has the dimensions of developing and going beyond, being a point of reference and deciding and sharing care, and self-care was measured with the Self-care of Chronic Illness Inventory (SC-CII). Multivariable linear regression analyses were used to assess the contribution of three dimensions of mutuality on self-care maintenance, monitoring and management behaviours controlling for patient gender, age, education, number of medications, and presence of a family caregiver. RESULTS: The sample included 465 inpatients and outpatients with at least one chronic illness. The three dimensions of mutuality had different roles in their influence on the three dimensions of self-care. Developing and going beyond was significantly associated with self-care maintenance and self-care monitoring behaviours. Point of reference was significantly associated with self-care maintenance behaviour. Deciding and sharing care was significantly associated with self-care monitoring and self-care management behaviours. CONCLUSION: The mutuality between nurse and patient may be a novel area of research to support and improve patient self-care behaviours with implications for clinical practice and education. IMPLICATION FOR PROFESSION AND PATIENT CARE: Mutuality between nurse and patient increases patient engagement, symptom recognition, decision-making process and patient-centred approach favouring the development of self-care behaviours. IMPACT: Mutuality between nurse and patient is a new concept and its association with the patient outcomes could bring relevance to the nursing profession. Self-care behaviours are important in the management of chronic diseases, but are difficult to perform. Mutuality between nurse and patient influences the three different behaviours of self-care in chronic illness, for this reason it is important to increase the level of mutuality in this dyad. REPORTING METHOD: STROBE checklist for cross-sectional studies was followed in this study. PATIENT OR PUBLIC CONTRIBUTION: Patients were involved in the sample of the study.

State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association.

Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients' daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS: A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS: A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Person with Heart Failure and Care Partner Dyads: Current Knowledge, Challenges, and Future Directions: State-of-the-Art Review.

Over the past decade, there has been substantial growth in heart failure (HF) research that focuses on persons with HF and their care partners (family members or other close friends that provide unpaid support) as an interdependent team, or care dyad. In this state-of-the-art review, we use a dyadic lens to identify and summarize current research on HF care dyads, from qualitative studies, to nonexperimental quantitative studies, to randomized controlled trials. Although much work has been done, this literature is younger and less well-developed than care dyad literatures from other conditions (eg, cancer, Alzheimer's disease). We discuss the substantial challenges and limitations in this body of work, with an eye toward addressing common issues that impact rigor. We also look toward future directions, and discuss the promise dyadic research holds for improving patient, care partner, and relationship health.

Frequency and Predictors of Falls Among Adults With Heart Failure: A Prospective Study.

OBJECTIVE: Adults with heart failure (HF) may be at high risk for falling due to age, comorbidities and frailty; however, few studies have examined falls in HF. The purpose of this study was to quantify the frequency and predictors of falls over 1 year among adults with HF. METHODS: We conducted a prospective study of adults with New York Heart Association (NYHA) functional class I-IV HF. After baseline assessment of physical frailty and clinical characteristics, participants self-reported falls every 3 months during 1 year. Comparative statistics were used to identify baseline differences between those who fell vs those who did not. A stepwise negative binomial regression model was used to identify predictors of fall rate over 1 year. RESULTS: The sample (n = 111) was 63.4 ± 15.7 years old, 48% were women, 28% had HF with preserved ejection fraction, and 41% were frail. Over 1 year, 43 (39%) of participants reported at least 1 fall and 28 (25%) of participants reported 2+ falls. Among those who fell, 29 (67%) reported injurious falls. Those who fell had significantly higher body mass indexes and were more likely to have NYHA class III/IV, type 2 diabetes and HF with preserved ejection fraction and to meet slowness and physical exhaustion criteria than those who did not fall. The fall rate was elevated among those with type 2 diabetes and those meeting the slowness and physical exhaustion criteria for physical frailty. CONCLUSIONS: Nearly 40% of adults with HF experienced a fall within 1 year. Screening for comorbidities, slowness and exhaustion may help to identify those at risk for a fall.

PROMIS: Physical, Mental and Social Health Outcomes Improve From Before to Early After LVAD Implant: Findings From the Mechanical Circulatory Support: Measures of Adjustment and Quality of Life (MCS A-QOL) Study.

Study participants (n = 272) completed 12 Patient-Reported Outcomes Measurement Information System (PROMIS) physical, mental and social health measures (questionnaires) prior to implantation of a left ventricular assist device (LVAD) and again at 3 and 6 months postimplant. All but 1 PROMIS measure demonstrated significant improvement from pre-implant to 3 months; there was little change between 3 and 6 months. Because PROMIS measures were developed in the general population, patients with an LVAD, their caregivers and their clinicians can interpret the meaning of PROMIS scores in relation to the general population, helping them to monitor a return to normalcy in everyday life.

Predictors of Fertility-Awareness-Based Method Use Among Women Trying to Conceive and Women Contemplating Pregnancy.

BACKGROUND: Fertility-awareness-based methods have been linked to shorter time to conception; however, little is known about the predictors of fertility-awareness-based method use among women who are currently or will soon be trying to conceive. OBJECTIVES: The aim of this study was to identify predictors of fertility-awareness-based methods use among women trying to conceive or contemplating pregnancy within the next year. METHODS: Women participating in the Nurses' Health Study 3 were asked if they were trying to become pregnant or contemplating pregnancy and whether they are using fertility-awareness-based methods. Multivariable negative binomial regression was used to identify predictors for a number of fertility-awareness-based methods used. RESULTS: Among the 23,418 women asked about pregnancy intention since 2015, 955 were trying to conceive, and 2,282 were contemplating pregnancy within the next year. The three most used fertility-awareness-based methods among women trying to conceive were menstrual cycle tracking, ovulation prediction kits, and cervical mucus monitoring. Among women contemplating pregnancy, the three most commonly used methods were menstrual cycle tracking, cervical mucus monitoring, and basal body temperature monitoring. The ongoing duration of pregnancy attempts and gravidity were associated with the number of methods used among women actively trying to conceive. When compared with women who were trying for 2 months or less, the number of methods was 29% higher when trying for 3-5 months, 45% higher when trying for 6-12 months, and 38% higher when trying for more than 1 year. Compared with nulligravid women, the number of methods was lower for women with a history of two or more pregnancies. Among women contemplating pregnancy, those who were married or in a domestic partnership used more fertility-awareness-based methods than unpartnered women. No other significant predictors of fertility-awareness-based method use were identified. DISCUSSION: Duration of ongoing pregnancy attempt and gravidity were the only significant predictors for the number of fertility-awareness-based methods used among women actively trying to conceive, whereas partnership was the only significant predictor of the number of fertility-awareness-based methods among women contemplating pregnancy.

Self-Management and Glycemic Targets in Adult Haitian Immigrants With Type 2 Diabetes: Research Protocol.

BACKGROUND: Type 2 diabetes (T2D) is a chronic condition affecting more than 34.2 million U.S. adults, and people of African descent have a disproportionate burden. Haitian immigrants' unique cultural and biological factors put them at elevated risk for T2D-related complications. Despite prior research highlighting the success of multimethod approaches to T2D self-management behaviors on glycemic targets, a dearth of studies have used these methods to improve diabetes self-management in this marginalized population. OBJECTIVES: This article describes a repeated-measures design protocol of a going study about self-management behaviors among adult Haitian immigrants with T2D and characterizing their barriers to T2D self-management. METHODS: We will enroll 100 Haitian immigrants aged 18-64 years who have lived with T2D for at least 1 year. Using multiple recruitment methods and Research Electronic Data Capture, subjective and objective data on T2D self-management practices, glucose variability via continuous glucose monitor, and a comprehensive view of physical activity via actigraphy are collected. RESULTS: Data analysis will follow a two-part approach mirroring the two primary study objectives. DISCUSSION: Findings from the study will guide the development and testing of a culturally tailored diabetes self-management education program that will contribute essential information about best practices for this population and break barriers that may impede research on unique individuals and subsequent effective self-management.

Psychometric Testing of the Control Attitudes Scale-Revised for Patients With a Left Ventricular Assist Device.

BACKGROUND: Perceived control, an indicator of the patient's ability to cope and thrive with a chronic illness, is a common target of nursing interventions. As of 2019, more than 25 000 patients had been implanted with a left ventricular assist device (LVAD) as a treatment of advanced heart failure. Patients with an LVAD experience significant life changes that affect anxiety, depression, health-related quality of life, and, presumably, perceived control. To adequately intervene and improve perceived control, a reliable and valid measure is needed. OBJECTIVES: The objectives of this analysis were to (1) assess item discrimination and anticipated range of scores of the Control Attitudes Scale-Revised (CAS-R), (2) assess the internal consistency and validity of the CAS-R, and (3) examine perceived control in a sample of patients with an LVAD. METHODS: Two cohorts of patients with an LVAD (n = 113) were combined to evaluate the psychometric qualities of the CAS-R. Correlations among patient-reported outcomes and perceived control were used to evaluate validity. Cronbach α was used to test internal consistency. Item response theory was used to measure item discrimination and anticipated scores. Descriptive statistics describe perceived control in the sample. RESULTS: Overall, the CAS-R demonstrated good internal consistency and convergent validity with other patient-reported outcomes. Using the item response theory, we saw that the CAS-R was a good predictor of lower-moderate scorers but was not good at differentiating high performers. There were several items that were poor discriminators and could be altered or discarded to create a more predictive instrument. CONCLUSIONS: The CAS-R is a valid and reliable instrument to measure perceived control in patients who have LVAD implants; however, more work could be done to improve item-level information.

Nurse Performance Metrics: A Scoping Review.

OBJECTIVE: The purposes of this scoping review are: 1) to identify instances in the literature that describe measuring individual nurse performance and 2) characterize those metrics. BACKGROUND: The impact of nurses on patient outcomes has been demonstrated at the unit or hospital level, with nurses measured in aggregate. There is an opportunity to evaluate individual nurse performance by creating metrics that capture it. METHODS: A scoping review based on the framework published by the Joanna Briggs Institute was performed. RESULTS: Researchers identified 12 articles. Three themes were trended: the emerging nature of these metrics in the literature, variability in their applications, and performance implications. CONCLUSIONS: Individual nurse performance metrics is an emerging body of research with variability in the types of metrics developed. There is an opportunity for future researchers to work with nurse leaders and staff nurses to optimize these metrics and to use them to support nursing practice and patient care.

Protective Role of Caregiver Preparedness on the Relationship Between Depression and Quality of Life in Stroke Dyads.

BACKGROUND AND PURPOSE: Depression and quality of life (QOL) have an interdependent and transactional nature in stroke survivor-caregiver dyads. While the strong relationship between depression and physical and emotional QOL in stroke survivor-caregiver dyads is well known, it is less clear if this relationship is moderated by caregiver preparedness, which could easily be targeted with interventions. In this study, we examined the moderating role of caregiver preparedness on the association between depression and QOL in stroke survivor-caregiver dyads. METHODS: We used a longitudinal design with follow-ups every 3 months over a 1-year period. Considering the nonindependent nature of the data (survivors and their caregivers), we used multilevel modeling to analyze data at the dyad level. We implemented 4 longitudinal dyadic moderation models (one for each QOL domain: physical, psychological, social, and environmental) using hierarchical linear modeling. RESULTS: A sample of 222 stroke survivor-caregiver dyads was analyzed. Stroke survivors were older (M=70.8, SD=11.9) than their caregivers (M=52.4, SD=13.1). Stroke survivors predominantly had an ischemic stroke, equally distributed by site. Caregivers were primarily female (66%), with a medium to high educational level (57%). Caregiver preparedness significantly moderated the association between survivor depression and survivor psychological (B=0.56, P<0.01) and environmental (B=0.58, P<0.01) QOL at baseline and social QOL over time (B=0.24, P<0.05). Similarly, caregiver preparedness significantly moderated the association between caregiver depression and caregiver physical (B=0.25, P<0.01) and environmental (B=0.18, P<0.05) QOL over time. CONCLUSIONS: Caregiver preparedness has a positive influence on both members of the dyad. Assessment of stroke-caregiver preparedness could be helpful to motivate clinicians to develop and implement interventions for stroke survivor-caregiver dyads.

Symptom Classes in Decompensated Liver Disease.

BACKGROUND & AIMS: Patients with decompensated liver disease have been categorized by disease severity. This analysis sought to classify patients with end-stage liver disease based on symptoms rather than disease state and to identify distinct severity classes of physical and psychological symptoms. METHODS: Patients with a model for end-stage liver disease-sodium score of 15 or higher were recruited from liver clinics in 2 health care organizations. They completed the Condensed Memorial Symptom Assessment Scale, Revised Ways of Coping Checklist, Patient Health Questionnaire, Life Orientation Test-Revised, and the Short-Form Health Survey. Cross-sectional data were analyzed using latent class mixture modeling. RESULTS: The sample (N = 191; age, 56.6 ± 11.1 y; 33.5% ETOH; 28.3% nonalcoholic fatty liver disease; 13.1% autoimmune/primary biliary cholangitis/primary sclerosing cholangitis) was predominantly male (64.2%), Child-Turcotte-Pugh class C (49.5%), with an average model for end-stage liver disease-sodium score of 18.7 ± 4.9. Three distinct classes of symptoms were identified, as follows: mild (26.7%), moderate (41.4%), or severe (31.9%) symptoms. Symptom classes were independent of disease severity and demographic characteristics, except age. All Condensed Memorial Symptom Assessment Scale symptoms and Patient Health Questionnaire scores were significantly different across the 3 classes (P < .05). The symptom classes also differed significantly in physical and mental quality of life, optimism, and avoidance coping behaviors (all P < .001). CONCLUSIONS: Patient-reported symptom severity occurred independent of disease severity, contrary to common assumptions. Focusing on the moderate and severe symptom classes as well as patient history of end-stage liver disease complications may enhance providers' ability to improve symptom management for this population.

A primer on incorporating sex as a biological variable into the conduct and reporting of basic and clinical research studies.

The recent move to require sex as a biological variable (SABV), which includes gender, into the reporting of research published by the American Journal of Physiology-Heart and Circulatory Physiology follows a growing, and much-needed, trend by journals. Understandably, there is concern over how to do this without adding considerable work, especially if one's primary research focus is not on elucidating sex/gender differences. The purpose of this article is to provide additional guidance and examples on how to incorporate SABV into the conduct and reporting of basic and clinical research. Using examples from our research, which includes both studies focused and not focused on sex/gender differences, we offer suggestions for how to incorporate SABV into basic and clinical research studies.

Fatigue in Persons With Heart Failure: A Systematic Literature Review and Meta-Synthesis Using the Biopsychosocial Model of Health.

BACKGROUND: Fatigue is a common and distressing symptom of heart failure (HF) and has important implications for patient-reported and clinical outcomes. Despite being a common and bothersome symptom, fatigue has been understudied in HF. We sought to synthesize existing literature on fatigue in HF through a systematic literature review guided by the biopsychosocial model of health. METHODS AND RESULTS: A systematic search of the literature was performed on March 18, 2020, using Pubmed, Embase, and CINAHL. Full-text, primary research articles, written in English, in which fatigue was a primary symptom of interest in adults with a diagnosis of HF, were included. The search yielded 1138 articles; 33 articles that met inclusion criteria were selected for extraction and synthesis. Biological and psychological factors associated with fatigue were New York Heart Association functional class, hemoglobin level, history of stroke, and depression. However, there are limited HF-specific factors linked to fatigue. Social factors related to fatigue included social roles, relationship strain, and loneliness and isolation. Few nonpharmacologic interventions have been tested by show some promise for alleviating fatigue in HF. Studies show conflicting evidence related to the prognostic implications of fatigue. CONCLUSIONS: Important biological correlates of fatigue were identified; however, psychological and social variables were limited to qualitative description. There is need for expanded models to better understand the complex physiologic nature of fatigue in HF. Additionally, more research is needed to (1) define the relationships between fatigue and both psychological and social factors, (2) better describe the prognostic implications of fatigue, and (3) develop more therapeutic approaches to alleviate fatigue with the goal of improving overall quality of life.

Background and Design of the Biological and Physiological Mechanisms of Symptom Clusters in Heart Failure (BIOMES-HF) Study.

BACKGROUND: Symptoms, which often cluster together, are a significant problem in heart failure (HF). There is considerable heterogeneity in symptom burden, particularly in the vulnerable transition period after a hospitalization for HF, and the biological underpinnings of symptoms during transitions are unclear. The purpose of this article is to describe the background and design of a study that addresses these knowledge gaps, entitled Biological and Physiological Mechanisms of Symptom Clusters in Heart Failure (BIOMES-HF). METHODS AND RESULTS: BIOMES-HF is a prospective gender- and age-balanced longitudinal study of 240 adults during the 6-month transition period after a HF hospitalization. The aims are to (1) identify clusters of change in physical symptoms, (2) quantify longitudinal associations between biomarkers and physical symptoms, and (3) quantify longitudinal associations between physical frailty and physical symptoms among adults with HF. We will measure multiple symptoms, biomarkers, and physical frailty at discharge and then at 1 week and 1, 3, and 6 months after hospitalization. We will use growth mixture modeling and longitudinal mediation modeling to examine changes in symptoms, biomarkers, and physical frailty after HF hospitalization and associations therein. CONCLUSIONS: This innovative study will advance HF symptom science by using a multibiomarker panel and the physical frailty phenotype to capture the multifaceted nature of HF. Using advanced quantitative modeling, we will characterize heterogeneity and identify potential mechanisms of symptoms in HF. As a result, this research will pinpoint amenable targets for intervention to provide better, individualized treatment to improve symptom burden in HF. LAY SUMMARY: Adults with heart failure may have significant symptom burden. This study is designed to shed light on our understanding of the role of biological and physiological mechanisms in explaining heart failure symptoms, particularly groups of co-occurring symptoms, over time. We explore how symptoms, biomarkers, and physical frailty change after a heart failure hospitalization. The knowledge generated from this study will be used to guide the management and self-care for adults with heart failure.

2022 American College of Cardiology/American Heart Association/Heart Failure Society of America Guideline for the Management of Heart Failure: Executive Summary.

BACKGROUND: The 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America (AHA/ACC/HFSA) Guideline for the Management of Heart Failure replaces the 2013 ACCF/AHA Guideline for the Management of Heart Failure and the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose and manage patients with heart failure. METHODS: A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews and other evidence conducted in human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies published through September 2021 were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. RESULTS AND CONCLUSIONS: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments that have high-quality published economic analyses.

Symptom Frequency and Distress Underestimated in Decompensated Cirrhosis.

BACKGROUND: Studies assessing multiple symptoms and the distress of these symptoms in decompensated cirrhosis are lacking. AIMS: The aims of this study were to assess symptom prevalence and distress among patients with decompensated cirrhosis and to describe medical management of the most prevalent symptoms. METHODS: Patients were recruited from hepatology clinics within two health-care systems. Eligibility criteria included a model for end-stage liver disease (MELD-Na) score ≥15. Patients completed the Condensed Memorial Symptom Assessment Scale and Patient Health Questionnaire. Comparative statistics were used to analyze the cross-sectional survey data. RESULTS: Of the sample (n = 146), most patients were Child-Turcotte-Pugh (CTP) class B (49.7%) and C (46.2%). Mean age was 56.5 years, 65.1% were male, and 88.4% were white. Average MELD-Na score was 19.1 ± 4.5. The most prevalent symptoms were lack of energy and feeling drowsy while the most distressing were lack of energy and difficulty sleeping. Only 24 patients (16.4%) were treated for their difficulty sleeping with sleep medication. Importantly, those prescribed sleep medications had similar distress (3.9 ± 1.2 vs. 3.5 ± 1.2, p = 0.229) compared with patients not prescribed sleep medications. Opioids were prescribed to 57 (39.0%) patients; antidepressants to 34 (23.3%). Forty patients (27.4%) who reported moderate or greater depression were not prescribed an antidepressant. CONCLUSIONS: The study highlights the multiple symptoms and distress experienced by patients with decompensated cirrhosis, and the need for improved medical management by health-care providers through enhanced awareness and attention to these complex symptoms. Future research should focus on improvements in symptom management.

A Multibiomarker Latent Class Analysis in Moderate to Advanced Heart Failure: Differentiating Factors.

BACKGROUND: Biomarker science in heart failure (HF) is advancing quickly in our ability to diagnosis and treat patients with this complex syndrome. Researchers are urged to not use single-marker strategies, but instead evaluate biomarkers in patterns to better understand their relationship to one another, as well as disease progression. Latent class mixture modeling allows researchers to determine novel associations between biomarkers. OBJECTIVE: The objectives of this study were to identify and compare latent classes of cardiovascular biomarkers among patients with moderate to advanced HF. METHODS: This was a cross-sectional study of 96 participants with moderate to advanced HF. Latent class mixture modeling was used to identify unique classes of biomarkers and their associations to sociodemographic and clinical variables. RESULTS: The average age of the sample was 54 years, with most of the sample being men (77%) and having an average ejection fraction of 23%. Two unique classes of biomarkers were identified. Latent class 1 had higher levels of all biomarkers, whereas latent class 2 had lower levels. The higher biomarker class had, on average, more neurohormonal activation and fluid retention; however, the higher levels of biomarker class were not more likely to be diagnosed with advanced HF or have more comorbidities. CONCLUSION: By identifying classes of biomarkers, providers may be better able to identify patients who are at risk of progressing into advanced HF quicker or those who are more likely to have more severe complications, such as fluid overload or renal disease.