Professional caregivers' perceived barriers hindering the prevention and reduction of involuntary treatment among older persons receiving long-term care: A mixed methods study.

AIMS: To gain insights into the barriers towards the prevention and/or reduction of involuntary treatment in long-term geriatric care. DESIGN: Mixed methods. BACKGROUND: Measures to which a person resists and/or does not provide consent for are defined as involuntary treatment. The use of involuntary treatment violates the autonomy of (older) persons and causes more harm than benefit. Moreover, it contradicts the values of person-centred care. Nevertheless, its use among people living with dementia (PLWD) is still common practice. METHODS: We conducted a cross-sectional, mixed methods study, including an online survey for professional caregivers and a semistructured focus group interview with professional caregivers. RESULTS: A total of 218 participants completed the questionnaire. The percentage of participants who perceived barriers in one of the 22 survey items ranged from 15% to 42%. Lack of time, the experienced need to use involuntary treatment, uncertainty about responsibilities of stakeholders and a lack of knowledge on methods to prevent and/or reduce the use of involuntary treatment were most seen as barriers. Nursing staff perceived a lack of time hindering them in the prevention or reduction of involuntary treatment more often than other professional caregivers. Working in home care and having no former experience with involuntary treatment usage increased perceived barriers. Participants of the focus group interview confirmed these findings and added that professional caregivers in general lack awareness on the concept of involuntary treatment. CONCLUSIONS: One out of four professional caregivers experiences barriers hindering prevention and/or reduction of involuntary treatment. More research is needed to gain a better understanding of how professional caregivers can be supported to remove barriers and, consequently, prevent and/or reduce the use of involuntary treatment. RELEVANCE TO CLINICAL PRACTICE: Professional caregivers experience many barriers towards the prevention and reduction of involuntary treatment. Future initiatives should aim to remove the perceived barriers.

District nurses' attitudes towards involuntary treatment in dementia care at home: A cross-sectional study.

One in two persons living with dementia (PLWD) at home receive care which they resist to and/or have not given consent to, defined as involuntary treatment. District nurses play a key role in the use of involuntary treatment. However, little is known how their attitudes and opinions influence the use of involuntary treatment. This cross-sectional study aims to investigate the attitudes of district nurses towards the use of involuntary treatment in dementia care at home, determinants and their opinion about its restrictiveness and discomfort. Results show that district nurses perceive involuntary treatment as regular part of nursing care, having neither positive nor negative attitude towards its appropriateness. They consider involuntary treatment usage as moderately restrictive to PLWD and feel moderately uncomfortable when using it. These findings underscore the need to increase the awareness of district nurses regarding the negative consequences of involuntary treatment use to PLWD at home.

Effectiveness of a reablement training program on self-efficacy and outcome expectations regarding client activation in homecare staff: A cluster randomized controlled trial.

Training and supporting homecare staff in reablement aims to change staff behavior from "doing for" to "doing with" older adults, i.e., supporting client activation. We evaluated the effectiveness of the reablement training program "Stay Active at Home" (SAaH) on staff self-efficacy and outcome expectations regarding client activation in a cluster randomized controlled trial. Ten Dutch homecare nursing teams, comprising 135 nursing team members and 178 domestic workers, were randomized into the intervention group (SAaH) or control group (usual care). Data on self-efficacy and outcome expectations were collected at baseline, 6 and 12 months using scales developed for this study. Mixed-effects regression showed no differences between the study groups on either outcome. Therefore, widespread implementation of SAaH in its current form cannot be recommended. More research is needed on the development and psychometric properties of scales to assess staff behavior and behavioral determinants (e.g., self-efficacy and outcomes expectations) regarding client activation.

Variability of cost trajectories over the last year of life in patients with advanced breast cancer in the Netherlands.

OBJECTIVE: In breast cancer patients, treatment at the end of life accounts for a major share of medical spending. However, little is known about the variability of cost trajectories between patients. This study aims to identify underlying latent groups of advanced breast cancer patients with similar cost trajectories over the last year before death. METHODS: Data from deceased advanced breast cancer patients, diagnosed between 2010 and 2017, were retrieved from the Southeast Netherlands Advanced Breast Cancer (SONABRE) Registry. Costs of hospital care over the last twelve months before death were analyzed, and the variability of longitudinal patterns between patients were explored using group-based trajectory modeling. Descriptive statistics and multinomial logistic regression were applied to investigate differences between the identified latent groups. RESULTS: We included 558 patients. Over the last twelve months before death, mean hospital costs were €2,255 (SD = €492) per month. Costs increased over the last five months and reached a maximum of €3,614 in the last month of life, driven by hospital admissions, while spending for medication declined over the last three months of life. Based on patients' individual cost trajectories, we identified six latent groups with distinct longitudinal patterns, of which only two showed a marked increase in costs over the last twelve months before death. Latent groups were constituted of heterogeneous patients, and clinical characteristics explained membership only to a limited extent. CONCLUSIONS: The average costs of advanced breast cancer patients increased towards the end of life. However, we uncovered several latent groups of patients with divergent cost trajectories, which did not reflect the overall increasing trend. The mechanisms underlying the variability in cost trajectories warrants further research.

Swallow-related quality of life and oropharyngeal dysphagia in myotonic dystrophy.

PURPOSE: This study describes swallow-related quality of life (SWAL-QOL) in patients with myotonic dystrophy type 1 (DM1) and investigates its association with swallowing function and disease severity. METHODS: A SWAL-QOL questionnaire was completed by 75 DM1 patients and 25 healthy control subjects. The severity of the disease was evaluated using the muscular impairment rating scale (MIRS). Twenty-eight DM1 patients underwent a videofluroscopic swallowing examination (VFS). Spearman's correlation coefficient was used to measure the direction and strength of associations. RESULTS: The SWAL-QOL median scores were significantly lower for the DM1 group than for the healthy control group. The scores for the majority of the SWAL-QOL domains were lower in patients with proximal muscular weakness (MIRS 4 and 5). Postswallow vallecular pooling and piecemeal deglutition were the most impaired VFS outcome variables. CONCLUSION: Our results suggest that a multidimensional swallowing assessment is recommended for DM1 patients as SWAL-QOL and VFS measure different aspects of the swallowing function, thus providing complementary information.

Group-based multi-trajectory modeling.

Identifying and monitoring multiple disease biomarkers and other clinically important factors affecting the course of a disease, behavior or health status is of great clinical relevance. Yet conventional statistical practice generally falls far short of taking full advantage of the information available in multivariate longitudinal data for tracking the course of the outcome of interest. We demonstrate a method called multi-trajectory modeling that is designed to overcome this limitation. The method is a generalization of group-based trajectory modeling. Group-based trajectory modeling is designed to identify clusters of individuals who are following similar trajectories of a single indicator of interest such as post-operative fever or body mass index. Multi-trajectory modeling identifies latent clusters of individuals following similar trajectories across multiple indicators of an outcome of interest (e.g., the health status of chronic kidney disease patients as measured by their eGFR, hemoglobin, blood CO2 levels). Multi-trajectory modeling is an application of finite mixture modeling. We lay out the underlying likelihood function of the multi-trajectory model and demonstrate its use with two examples.

Identifying Patterns of FEES-Derived Swallowing Trajectories Using Group-Based Trajectory Model.

The present study delineates and visualizes swallowing trajectories along seven swallow trials in dysphagic patients using group-based trajectory modeling (GBTM). This model facilitates the recognition of swallowing functional categories, estimates their frequency of occurrence, and enhances the understanding of swallowing dynamics. Two hundred and five dysphagic patients underwent a standardized FEES examination protocol. Five ordinal variables were blindly assessed for each swallow by two observers independently. GBTM analysis was conducted to find and characterize trajectories of FEES responses. For most FEES outcome variables, trajectories were qualitatively distinct in degree and kind (level of impairment and how this changed over the seven swallow trials). Two FEES outcome variables-delayed initiation of the pharyngeal reflex and postswallow pyriform sinus pooling-showed the highest prevalence of severe swallowing impairment. Highly impaired categories were more stable throughout the different swallow trials. Intermediate trajectories, by contrast, were erratic, responding more sensitively to shifts in bolus consistency. GBTM can identify distinct developmental trajectories of measured FEES variables in patients with oropharyngeal dysphagia. In clinical practice, classification into distinct groups would help to identify the subgroup of dysphagic patients who may need specific medical attention.

Swallowing assessment in myotonic dystrophy type 1 using fiberoptic endoscopic evaluation of swallowing (FEES).

This study describes the swallowing function of patients with myotonic dystrophy type 1 (DM1) and the effect of bolus consistency on swallowing in this group. The aim of the study is twofold: (a) to identify which (and to what extent) swallowing variables change for DM1 patients relative to healthy control subjects and (b) to examine whether the degree of oropharyngeal dysphagia is associated with disease severity. Forty-five consecutive DM1 patients and ten healthy subjects underwent a swallowing assessment, at Maastricht University medical Center in the Netherlands. The assessment included a standardized fiberoptic endoscopic evaluation of swallowing (FEES) protocol using different bolus consistencies. Clinical severity of the disease was assessed using the muscular impairment rating scale (MIRS). Significant differences were found between patients and controls for all FEES variables. The magnitude of these differences depended on the bolus consistency. The odds of a more pathological swallowing outcome increased significantly with higher MIRS levels. In conclusion, swallowing function is found to be significantly altered in DM1 patients. The results emphasize the importance of conducting a detailed swallowing assessment in all patients, even those with mild muscle weakness.

Transgenerational occurrence of allergic disease and autoimmunity: general practice-based epidemiological research.

BACKGROUND: Corresponding with the T helper cell type 1/T helper cell type 2 hypothesis, autoimmune and allergic diseases are considered pathologically distinct and mutually exclusive conditions. Co-occurrence of autoimmune disorders and allergy within patients, however, has been reported. Transgenerational co-occurrence of autoimmune and allergic disease has been less often described and may differ from the intra-patient results. AIMS: To test the hypothesis that autoimmune disorders in parents are a risk factor for the development of an allergic disease in their offspring. METHODS: Prospectively registered (by academic general practitioners) International Classifications of Primary Care (ICPC) for diagnoses of autoimmune disorders and allergy within families were evaluated (n=5,604 families) by performing multiple logistic regression analyses. RESULTS: The presence of any ICPC-encoded autoimmune disorder in fathers appeared to be associated with an increased risk in their eldest children of developing an allergy (odds ratio (OR) 1.4, 95% CI 1.042 to 1.794). Psoriasis in fathers was particularly shown to be of influence (OR 1.5, 95% CI 1.061 to 2.117) and, although any ICPC-encoded autoimmune disease in mothers was found not to be of significance, the combined international code for registering rheumatoid arthritis/ankylosing spondylitis in mothers was OR 1.7 (95% CI 1.031 to 2.852). CONCLUSIONS: The occurrence of ICPC-encoded autoimmune disorders in parents, especially psoriasis and rheumatoid arthritis/ankylosing spondylitis, significantly increases the occurrence of allergic disease in their children. After validation in follow-up research in a larger sample, these results may lead to the inclusion of 'parental autoimmune condition' as a risk factor in the general practitioner's diagnostics of allergic disease.

Surface electrical stimulation in dysphagic Parkinson patients: a randomized clinical trial.

OBJECTIVES/HYPOTHESIS: A new treatment for oropharyngeal dysphagia in Parkinson's disease was evaluated in the present study. STUDY DESIGN: Prospective randomized controlled trial. METHODS: The study describes the effects of surface electrical stimulation (SES) of the neck (submental region) in dysphagic Parkinson patients using different intensities of electrical current. Quasi-random allocation was performed when assigning patients to treatment groups. Three groups consisting of dysphagic patients with idiopathic Parkinson's disease (N = 90) received daily treatment for 15 days with periods of no treatment during the weekend. All three received traditional logopedic dysphagia treatment. In addition, two groups received SES, either motor-level or sensory-level stimulation. A standardized measurement protocol, including fiber optic endoscopic evaluation of swallowing (FEES) and videofluoroscopy of swallowing (VFS), was performed before and after therapy. A team of experienced raters was blinded to the treatment group and to the moment of measurement. Intrarater and interrater reliability were calculated. RESULTS: Using proportional odds models (POMs), some of the visuoperceptual ordinal outcome variables showed significant improvement in all groups following treatment. Following 15 days of SES of the submental region, few significant effects were found, suggesting a therapy effect of traditional logopedic dysphagia treatment without any additional influence of SES. CONCLUSIONS: On the grounds of this study, it is concluded that further research is needed on the exact mechanism of SES and its effects on the neural pathways involved in swallowing.

The effect of surface electrical stimulation on swallowing in dysphagic Parkinson patients.

Surface electrical stimulation has been applied on a large scale to treat oropharyngeal dysphagia. Patients suffering from oropharyngeal dysphagia in the presence of Parkinson's disease have been treated with surface electrical stimulation. Because of controversial reports on this treatment, a pilot study was set up. This study describes the effects of a single session of surface electrical stimulation using different electrode positions in ten patients with idiopathic Parkinson's disease (median Hoehn and Yahr score: II) and oropharyngeal dysphagia compared to ten age- and gender-matched healthy control subjects during videofluoroscopy of swallowing. Three different electrode positions were applied in random order per subject. For each electrode position, the electrical current was respectively turned "on" and "off" in random order. Temporal, spatial, and visuoperceptual variables were scored by experienced raters who were blinded to the group, electrode position, and status (on/off) of the electrical current. Interrater and interrater reliabilities were calculated. Only a few significant effects of a single session of surface electrical stimulation using different electrode positions in dysphagic Parkinson patients could be observed in this study. Furthermore, significant results for temporal and spatial variables were found regardless of the status of the electrical current in both groups suggesting placebo effects. Following adjustment for electrical current status as well as electrode positions (both not significant, P > 0.05) in the statistical model, significant group differences between Parkinson patients and healthy control subjects emerged. Further studies are necessary to evaluate the potential therapeutic effect and mechanism of electrical stimulation in dysphagic patients with Parkinson's disease.

Problematic activities of daily life are weakly associated with clinical characteristics in COPD.

BACKGROUND: Problematic activities of daily life (ADLs) can be the main reason to refer patients with chronic obstructive pulmonary disease (COPD) for pulmonary rehabilitation. To date, information on problematic ADLs and their clinical correlates in COPD remain scarce. This retrospective chart review aimed to identify the most prevalent self-reported problematic ADLs in COPD patients, determine performance and satisfaction scores of these problematic ADLs, and explore the association between 13 clinical determinants and 4 problematic ADL domains. METHODS: A total of 820 COPD patients entering pulmonary rehabilitation assessment were included in this retrospective study. Self-reported problematic ADLs were assessed using the Canadian Occupational Performance Measure, administered by occupational therapists in the form of a semistructured interview. RESULTS: COPD patients (59% male, age 63.6 ± 9.3 years, FEV(1) (%pred): 46.4 ± 18.4) reported 2999 problematic ADLs. The most prevalent problematic ADLs were walking (68%), stair climbing (35%), and cycling (30%). Moreover, 30% of the patients reported "not able to do any of the scored problematic ADL" and 44% were "not satisfied at all with the performance of any of the scored problematic ADL." Significant but weak associations were found between clinical determinants (eg, physical and psychosocial) and problematic ADLs. CONCLUSIONS: The lack of a strong association between problematic ADLs and clinical determinants emphasizes the need for individualized assessment of these ADLs to allow tailored intervention.

Swallowing in Parkinson Patients versus Healthy Controls: Reliability of Measurements in Videofluoroscopy.

Objective. To determine and describe the pathophysiological aspects of oropharyngeal swallowing in patients with Parkinson's disease more accurately, a pilot study of qualitative as well as quantitative parameters of swallowing was performed using videofluoroscopy (VFS). Methods. Ten patients with a diagnosis of idiopathic Parkinson's disease having dysphagic complaints and ten healthy age- and gender-matched control subjects underwent a standardized videofluoroscopic swallowing protocol. Information on the swallowing function was derived from temporal, spatial, and descriptive visuoperceptual parameters. Intra- and interrater reliability was calculated. Results. No significant differences were found between Parkinson patients and healthy control subjects for the majority of the reliable variables. Conclusions. It was concluded that swallowing function seemed to be preserved in the early stages of Parkinson's disease. Furthermore, the reliability of many quantitative as well as qualitative swallowing parameters proved insufficient, raising questions about the interpretation of study outcomes in videofluoroscopy.

The relationships between cardiovascular magnetic resonance imaging variables of acute myocardial infarction and both left ventricular dysfunction and immediate postreperfusion ST segment recovery.

OBJECTIVE: The aim of this study is to explore the relationships between cardiovascular magnetic resonance imaging (CMR)-determined variables of acute myocardial infarction and both left ventricular (LV) dysfunction and immediate postreperfusion ST segment recovery. METHODS: In 79 patients with first acute myocardial infarction, 8 different ST segment recovery (STR) variables were measured 30 and 60 minutes after percutaneous coronary intervention. Cardiovascular magnetic resonance imaging was performed 5 ± 2 and 104 ± 11 days after admission. Using k-means cluster analysis, 3 CMR risk groups for LV dysfunction (low LV ejection fraction at baseline and follow-up) were identified based on combinations of infarct size (IS), infarct transmurality, and microvascular obstruction. Stepwise discriminant analysis was used to determine which STR variable best discriminated between CMR risk groups. RESULTS: Baseline LV ejection fraction improved in all groups but remained lowest in the high-risk group (41% ± 7% and 44% ± 6%), as compared with the intermediate (51% ± 5% and 56% ± 5%) and low-risk groups (56% ± 7% and 58% ± 5%). Infarct size was significantly different among the groups (34% ± 5%, 19% ± 4%, and 6% ± 4%; P < .001) and mainly determined the effect on LV dysfunction. Of all STR variables, worst lead residual ST deviation 30 minutes after reperfusion accurately discriminated between the high- and combined low-/intermediate risk groups. CONCLUSION: Worst lead residual ST deviation 30 minutes after reperfusion allows accurate identification of patients at high risk for LV dysfunction, which was mainly related to IS rather than transmurality or microvascular obstruction.

On the A-optimality criterion for finding two-color microarray optimal designs.

Several studies on two-color microarray experimental designs consider the A-optimality criterion for the assessment and/or search of appropriate/optimal designs. What seems to be widely ignored, however, is the well-known fact that A-optimal designs depend on the choice of scale or code combination of the X-variables. In this article, it is shown that intrinsically different optimal microarray designs will be obtained depending on the chosen code combination of the qualitative factors. Moreover, a substantial loss in efficiency will result when a design, which is optimal for a specific code combination, is used for another one. This coding problematic is also applicable to the admissibility concept.

Endothelial glycocalyx structure in the intact carotid artery: a two-photon laser scanning microscopy study.

BACKGROUND: The endothelial glycocalyx (EG) is the carbohydrate-rich luminal lining of endothelial cells that mediates permeability and blood cell-vessel wall interactions. To establish an atheroprotective role of the EG, adequate imaging and quantification of its properties in intact, viable, atherogenesis-prone arteries is needed. METHODS: Carotid arteries of C57Bl6/J mice (n=22) were isolated including the bifurcation, mounted in a perfusion chamber, and perfused with fluorescent lectin wheat germ agglutinin-fluorescein isothiocyanate. The EG was visualized through the vessel wall using two-photon laser scanning microscopy. An image quantification protocol was developed to assess EG thickness, which was sensitive to hyaluronidase-induced changes. RESULTS: In the lesion-protected common carotid artery, EG thickness was found to be 2.3 ± 0.1 µm (mean ± SEM), while the surface area devoid of (wheat germ agglutinin-sensitive) EG was 8.9 ± 4.2%. Data from the external carotid artery were similar (2.5 ± 0.1 µm; 9.1 ± 5.0%). In the atherogenesis-prone internal carotid artery the EG-devoid surface area was significantly higher (27.4 ± 5.5%, p<0.05); thickness at the remaining areas was 2.5 ± 0.1 µm. CONCLUSION: The EG can be adequately imaged and quantified using two-photon laser scanning microscopy in intact, viable mounted carotid arteries. Spatial EG differences could underlie atherogenesis.

Reproducibility of anterior chamber angle measurements with anterior segment optical coherence tomography.

PURPOSE: To study the reproducibility and variability of iridocorneal angle (ICA) measurements by using anterior segment optical coherence tomography (AS-OCT) by expert and nonexpert observers. METHODS: Twenty-three healthy volunteers (nonexperts with a basic knowledge of ophthalmology) acquired five consecutive AS-OCT images in the enhanced anterior segment single mode in the 180° to 0° meridian of the right eyes of their peers. Two experts and the 23 nonexperts analyzed the images. The ICA software tool was used to determine the angle opening distance (AOD) and the trabecular iris surface area (TISA) at 500 and 750 µm. A random intercept model was fitted to evaluate the variability of acquiring an image. For both the experts and the nonexperts, inter- and intraobserver variability of analyzing an AS-OCT image was determined with the coefficient of variation (CV). Reproducibility was qualified by using the intraclass correlation coefficient (ICC). RESULTS: There was no statistically significant difference in the variability of acquiring an image. The range of intraobserver variability in image analysis was from 9.4% to 12.5% in the experts and from 4.2% to 17.4% in the nonexperts. Interobserver variability was 10.7% in the experts and 10.2% in the nonexperts. The reproducibility was high, 0.875 and 0.942 in the experts and 0.906 in the nonexperts. CONCLUSIONS: The overall reproducibility of the ICA measurements with the AS-OCT is good in open angles. Inter- and intraobserver variability showed similar mean values of reproducibility between the experts and nonexperts. The wide range of intraobserver variation in the nonexperts suggests that this group should undergo extensive instruction before routinely analyzing AS-OCT images.

Energy expenditure in brass and woodwind instrumentalists: the effect of body posture.

OBJECTIVE: Body posture appears to influence fatigue and musculoskeletal complaints in musicians. Our aim was to determine energy expenditure and to investigate whether energy expenditure is affected by body posture in brass and woodwind instrumentalists. METHODS: Eighteen musicians (10 women, 8 men; 6 brass, 12 woodwinds), with a mean age of 39 ± 14 years and mean body mass index of 23.8 ± 4.9 kg/m², played their instruments for 30 minutes twice: once in nonoptimized body posture (posture A), and once in a posture according to the postural exercise therapy method Mensendieck (posture B). Patients were randomized to the order of postures in a crossover design AB/BA. Playing sessions were preceded and followed by 60 minutes of rest. Energy expenditure was measured in a respiration chamber with indirect calorimetry. Basal metabolic rate was measured with a ventilated hood. RESULTS: Mean metabolic equivalents (MET) for playing a wind instrument in the sitting position in a nonoptimized posture and posture according postural exercise therapy were 1.69 (SD 0.18) and 1.80 (SD 0.22), respectively. Percent change between resting metabolic rate and total energy expenditure while playing was 32% (95% CI 25-39%) in posture B and 23% (95% CI 17-30%) in posture A (p = 0.021). CONCLUSION: Average physical activity while playing a wind instrument approximates 1.8 MET. Our data show an association between energy expenditure and body posture while playing a brass or woodwind instrument: playing a musical instrument in a posture according to postural exercise therapy leads to higher energy expenditure as compared to a nonoptimized body posture. These results suggest that fatigue and the general feeling of lack of energy after playing a musical instrument are not related to actual higher energy expenditure.

Clinical implications of microvascular obstruction and intramyocardial haemorrhage in acute myocardial infarction using cardiovascular magnetic resonance imaging.

OBJECTIVES: To investigate the clinical implications of microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH) in acute myocardial infarction (AMI). METHODS: Ninety patients with a first AMI undergoing primary percutaneous coronary intervention (PCI) were studied. T2-weighted, cine and late gadolinium-enhanced cardiovascular magnetic resonance imaging was performed at 5 ± 2 and 103 ± 11 days. Patients were categorised into three groups based on the presence or absence of MVO and IMH. RESULTS: MVO was observed in 54% and IMH in 43% of patients, and correlated significantly (r = 0.8, p < 0.001). Pre-PCI thrombolysis in myocardial infarction 3 flow was only observed in MVO(-)/IMH(-) patients. Infarct size and impairment of systolic function were largest in MVO(+)/IMH(+) patients (n = 39, 23 ± 9% and 47 ± 7%), smallest in MVO(-)/IMH(-) patients (n = 41, 8 ± 8% and 55 ± 8%) and intermediate in MVO(+)/IMH(-) patients (n = 10, 16 ± 7% and 51 ± 6%, p < 0.001). LVEF increased in all three subgroups at follow-up, but remained intermediate in MVO(+)/IMH(-) and was lowest in MVO(+)/IMH(+) patients. Using random intercept model analysis, only infarct size was an independent predictor for adverse LV remodelling. CONCLUSIONS: Intramyocardial haemorrhage and microvascular obstruction are strongly related. Pre-PCI TIMI 3 flow is less frequently observed in patients with MVO and IMH. Only infarct size was an independent predictor of LV remodelling.