Implications for clinical practice from a multicenter survey of heart failure management centers

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Influencia de los factores psicosociales sobre el estado clínico de pacientes con insuficiencia cardiaca crónica manejados en una unidad multidisciplinaria / Influence of psychosocial factors on the clinical status of chronic heart failure patients, managed in a multidisciplinary unit

Introducción: los factores psicosociales han mostrado influenciar el estado clínico de pacientes con insuficiencia cardiaca (IC) crónica, particularmente en aquellos pacientes dependientes con alteración del estado mental o déficit del soporte social, en Colombia pocos estudios han sido conducidos para describir la influencia de factores psicosociales y otros factores clínicos relacionados con la enfermedad; por lo cual se realizó la siguiente pregunta de investigación: ¿Cuál es el diagnóstico psicosocial de una cohorte de pacientes del Programa de falla cardiaca y su correlación entre sí y con los parámetros clínicos medidos por Clase funcional, NT-ProBNP y fracción de eyección del ventrículo izquierdo (FEVI%)?. Conclusiones: en pacientes con insuficiencia cardiaca crónica, los factores psicosociales se relacionan con el estado clínico y factores pronóstico, en esta cohorte de pacientes se demuestra la relación de estado afectivo con los niveles de NT pro-BNP y una relación directa del deterioro de la calidad de vida en relación con el NT pro-BNP y la FEVI. La evaluación de la función psicosocial a través de escalas validadas debe ser fortalecida en el escenario de las unidades de insuficiencia cardiaca, con el fin de identificar oportunamente estos pacientes e implementar intervenciones multidisciplinarias que mejoren su pronóstico.

Background: Psychosocial factors have been shown its influence on the clinical status of patients with chronic heart failure (HF), particularly in patients with altered mental status, dependent, or with social support deficit, in Colombia, few studies have been conducted to describe the influence of Psychosocial factors and clinical characteristics associated with HF, which was carried by the following research question: ¿What is the psychosocial diagnosis in a cohort of patients managed in a heart failure program and its correlation with clinical parameters measured by functional class, NT-proBNP and Left Ventricular Ejection Fraction %?. Conclusions: In patients with chronic heart failure, psychosocial factors are related to clinical and prognostic factors, in our cohort we demonstrate the relation between affective state and NT-proBNP levels and a direct relation between quality of life and NYHA functional class. Evaluation of psychosocial function through validated scales , should be strength in the setting of Heart Failure Units, in order to identify social high risk patients and implement multidisciplinary interventions to improve their prognosis.

Cultivares, espaçamento entrelinhas e programas de aplicação de fungicidas no controle de Phakopsora pachyrhizi Sidow em soja / Cultivars, row spacing and fungicide application programs on Phakopsora pachyrhizi Sydow control in soybean

Com este trabalho, buscou-se avaliar a resposta de cultivares de soja, em duas safras, submetidas a diferentes espaçamentos entrelinhas e programas de controle sob pressão natural de Phakopsora pachyrhizi Sidow. Nas safras 07/08 e 08/09, os espaçamentos entrelinhas de 40, 50 e 60cm representavam as parcelas principais, as cultivares 'A 8000 RG' e 'A 6001 RG', as subparcelas e os programas de controle, as subsubparcelas. A redução do espaçamento entrelinhas permitiu melhores condições para o estabelecimento e progresso da ferrugem asiática para as duas cultivares e menor eficácia de controle. A melhor resposta de controle foi verificada com a utilização do programa após uma aplicação no estádio de desenvolvimento R1 e uma segunda aplicação 25 dias após a primeira. O espaçamento de 60cm entrelinhas proporcionou menores valores de doença acumulada e maior produtividade.

This study aimed to assess in two seasons, the response of soybean cultivars subjected to different row spacings and control programs under Phakopsora pachyrhizi Sidow natural pressure. The research was carried out at the seasons 07/08 and 08/09. The main plots were composed of the row spacings of 40, 50 and 60cm and the split plots corresponded to the cultivars A 8000 RG and A 6001 RG. The control programs were the split split plots.The reduction of row spacing allowed more conditions for the rust establishment and progress for both cultivars and less effective control. The best control response was verified using the program with an application in R1 and a second application, 25 days after the first one. The row spacing of 60cm gave lower AUDPC values and higher productivity.

Cultivares, espaçamento entrelinhas e programas de aplicação de fungicidas no controle de Phakopsora pachyrhizi Sidow em soja

This study aimed to assess in two seasons, the response of soybean cultivars subjected to different row spacings and control programs under Phakopsora pachyrhizi Sidow natural pressure. The research was carried out at the seasons 07/08 and 08/09. The main plots were composed of the row spacings of 40, 50 and 60cm and the split plots corresponded to the cultivars A 8000 RG and A 6001 RG. The control programs were the split split plots.The reduction of row spacing allowed more conditions for the rust establishment and progress for both cultivars and less effective control. The best control response was verified using the program with an application in R1 and a second application, 25 days after the first one. The row spacing of 60cm gave lower AUDPC values and higher productivity.

Com este trabalho, buscou-se avaliar a resposta de cultivares de soja, em duas safras, submetidas a diferentes espaçamentos entrelinhas e programas de controle sob pressão natural de Phakopsora pachyrhizi Sidow. Nas safras 07/08 e 08/09, os espaçamentos entrelinhas de 40, 50 e 60cm representavam as parcelas principais, as cultivares 'A 8000 RG' e 'A 6001 RG', as subparcelas e os programas de controle, as subsubparcelas. A redução do espaçamento entrelinhas permitiu melhores condições para o estabelecimento e progresso da ferrugem asiática para as duas cultivares e menor eficácia de controle. A melhor resposta de controle foi verificada com a utilização do programa após uma aplicação no estádio de desenvolvimento R1 e uma segunda aplicação 25 dias após a primeira. O espaçamento de 60cm entrelinhas proporcionou menores valores de doença acumulada e maior produtividade.

Cultivares, espaçamento entrelinhas e programas de aplicação de fungicidas no controle de Phakopsora pachyrhizi Sidow em soja

This study aimed to assess in two seasons, the response of soybean cultivars subjected to different row spacings and control programs under Phakopsora pachyrhizi Sidow natural pressure. The research was carried out at the seasons 07/08 and 08/09. The main plots were composed of the row spacings of 40, 50 and 60cm and the split plots corresponded to the cultivars A 8000 RG and A 6001 RG. The control programs were the split split plots.The reduction of row spacing allowed more conditions for the rust establishment and progress for both cultivars and less effective control. The best control response was verified using the program with an application in R1 and a second application, 25 days after the first one. The row spacing of 60cm gave lower AUDPC values and higher productivity.

Com este trabalho, buscou-se avaliar a resposta de cultivares de soja, em duas safras, submetidas a diferentes espaçamentos entrelinhas e programas de controle sob pressão natural de Phakopsora pachyrhizi Sidow. Nas safras 07/08 e 08/09, os espaçamentos entrelinhas de 40, 50 e 60cm representavam as parcelas principais, as cultivares 'A 8000 RG' e 'A 6001 RG', as subparcelas e os programas de controle, as subsubparcelas. A redução do espaçamento entrelinhas permitiu melhores condições para o estabelecimento e progresso da ferrugem asiática para as duas cultivares e menor eficácia de controle. A melhor resposta de controle foi verificada com a utilização do programa após uma aplicação no estádio de desenvolvimento R1 e uma segunda aplicação 25 dias após a primeira. O espaçamento de 60cm entrelinhas proporcionou menores valores de doença acumulada e maior produtividade.

Cultivares, espaçamento entrelinhas e programas de aplicação de fungicidas no controle de Phakopsora pachyrhizi Sidow em soja

This study aimed to assess in two seasons, the response of soybean cultivars subjected to different row spacings and control programs under Phakopsora pachyrhizi Sidow natural pressure. The research was carried out at the seasons 07/08 and 08/09. The main plots were composed of the row spacings of 40, 50 and 60cm and the split plots corresponded to the cultivars A 8000 RG and A 6001 RG. The control programs were the split split plots.The reduction of row spacing allowed more conditions for the rust establishment and progress for both cultivars and less effective control. The best control response was verified using the program with an application in R1 and a second application, 25 days after the first one. The row spacing of 60cm gave lower AUDPC values and higher productivity.

Com este trabalho, buscou-se avaliar a resposta de cultivares de soja, em duas safras, submetidas a diferentes espaçamentos entrelinhas e programas de controle sob pressão natural de Phakopsora pachyrhizi Sidow. Nas safras 07/08 e 08/09, os espaçamentos entrelinhas de 40, 50 e 60cm representavam as parcelas principais, as cultivares 'A 8000 RG' e 'A 6001 RG', as subparcelas e os programas de controle, as subsubparcelas. A redução do espaçamento entrelinhas permitiu melhores condições para o estabelecimento e progresso da ferrugem asiática para as duas cultivares e menor eficácia de controle. A melhor resposta de controle foi verificada com a utilização do programa após uma aplicação no estádio de desenvolvimento R1 e uma segunda aplicação 25 dias após a primeira. O espaçamento de 60cm entrelinhas proporcionou menores valores de doença acumulada e maior produtividade.

Exacerbation rate, health status and mortality in COPD--a review of potential interventions.

COPD is prevalent in Western society and its incidence is rising in the developing world. Acute exacerbations of COPD, about 50% of which are unreported, lead to deterioration in quality of life and contribute significantly to disease burden. Quality of life deteriorates with time; thus, most of the health burden occurs in more severe disease. COPD severity and frequent and more severe exacerbations are all related to an increased risk of mortality. Inhaled corticosteroids (ICS) have similar effects on quality of life but ICS/long-acting bronchodilator combinations and the long-acting antimuscarinic tiotropium all improve health status and exacerbation rates and are likely to have an effect on mortality but perhaps only with prolonged use. Erythromycin has been shown to decrease the rate of COPD exacerbations. Pulmonary rehabilitation and regular physical activity are indicated in all severities of COPD and improve quality of life. Noninvasive ventilation is associated with improved quality of life. Long-term oxygen therapy improves mortality but only in hypoxic COPD patients. The choice of an inhaler device is a key component of COPD therapy and this requires more attention from physicians than perhaps we are aware of. Disease management programs, characterized as they are by patient centeredness, improve quality of life and decrease hospitalization rates. Most outcomes in COPD can be modified by interventions and these are well tolerated and have acceptable safety profiles.