Nurses' intention to care of COVID-19 patients in hospitals dedicated to infectious disease in South Korea: application of the theory of planned behavior and verification of the moderating effect of ethical nursing competence.

BACKGROUND: The theory of planned behavior is a conceptual framework of recent studies to identify and explain nurses' intentions to care for patients with emerging infectious diseases. However, correlations between behavioral intentions and variables that explain them have been inconsistent in previous studies. The influence of new variables might be considered in this case. This study aimed to determine moderating effects of ethical nursing competence on nurses' intention to care for COVID-19 patients in hospitals dedicated to infectious diseases based on the theory of planned behavior. METHODS: A cross-sectional survey was conducted. Data on intention to care for COVID-19 patients, perceived behavioral control, attitude toward the behavior, subjective norm, and ethical nursing competence were obtained from 190 nurses in three hospitals dedicated to infectious diseases in South Korea. The moderating effect of ethical nursing competence was analyzed using model I of PROCESS Macro. ETHICAL CONSIDERATIONS: This study was approved by the Institutional Review Board of Ulsan University Hospital, South Korea. Written informed consent was obtained from each subject. RESULTS: The ethical nursing competence was a significant moderator in the relation between perceived behavioral control and the intention to care (B = 0.36, t = 2.16, p = 0.032). Ethical nursing competence did not have a significant interaction with attitude toward behavior or subjective norm. CONCLUSIONS: This study showed that the higher the ethical nursing competence level, the greater the effect of perceived behavioral control on nurses' intention to care for COVID-19 patients. Promoting ethical nursing competence is necessary for nurses who would take care of patients at the frontline of the infectious disease pandemic. Nursing managers should include ethical nursing competence in the assessment of nurses' competence and design educational programs to enhance ethical nursing competence for efficient nursing staffing during a pandemic.

[Effect of an Intervention Using Voice Recording of a Family Member on Patients Undergoing Mechanical Ventilator Weaning Process].

PURPOSE: This study aimed to determine the impact of an intervention using voice recording of family members on pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation. METHODS: A randomized control pre-post experimental design was implemented to 53 participants, with 27 and 26 participants in the experimental and control groups, respectively. A 70-second voice recording of a family member, repeated three times at 10-minute intervals was used as an intervention for the experimental group. Meanwhile, participants in the control group used headset for 30 minutes. Structured instruments were utilized to measure pain, anxiety, agitation, and the weaning process. Wilcoxon Signed Ranks test and the Mann-Whitney U test, or χ² test, were used for data analysis. RESULTS: The experimental group exhibited significant decrease in pain (Z = -3.53, p < .001), anxiety (t = 5.45, p < .001), and agitation (Z = -2.99, p = .003) scores compared with those of the control group. However, there was no significant difference between groups in the weaning process' simplification (χ² = 0.63, p = .727). CONCLUSION: Intervention using family members' voice recording effectively reduces pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation. This can be actively utilized to provide a more comfortable process for patients.

Dietary Antioxidant Insufficiency Is Associated With Increased Inflammatory Markers and Poorer Health-Related Quality of Life in Patients With Heart Failure.

BACKGROUND: Antioxidant insufficiency, elevated inflammatory markers, and poor health-related quality of life (HRQOL) are prevalent in patients with heart failure (HF). OBJECTIVE: The objective of this study was to examine the associations among dietary antioxidant intake, inflammatory markers, and HRQOL in patients with HF. METHODS: This was a secondary analysis of 265 patients with HF who completed a 4-day food diary. We assessed intake of 10 antioxidants: alpha carotene, beta carotene, beta cryptoxanthin, lutein, zeaxanthin, lycopene, vitamins C and E, zinc, and selenium. Antioxidant insufficiency was reflected by a measured level for each antioxidant that was below the estimate average requirement or lower than median for antioxidants without an estimate average requirement. Inflammatory markers including serum C-reactive protein, cytokines (interleukins 6 and 10), tumor necrosis factor-alpha, and soluble receptors (sTNFR1 and sTNFR2) were assessed with enzyme immunoassay. Health-related quality of life was measured using the Minnesota Living with Heart Failure at 12 months. RESULTS: Dietary antioxidant insufficiency predicted C-reactive protein (ß = 0.135, P = .032) and interleukin 10 (ß = -.155, P = .027). Patients with higher antioxidant insufficiency had higher C-reactive protein and lower interleukin 10. Both antioxidant insufficiency (ß = 0.13, P = .049) and higher C-reactive protein (ß = 0.16, P = .019) were independently associated with poorer HRQOL while adjusting for covariates. CONCLUSIONS: Dietary antioxidant insufficiency was associated with increased markers of inflammation and poorer HRQOL. Improvement of diet quality among patients with HF may be a fruitful area of research for enhancing HRQOL.

Communication competence and resilience are modifiable factors for burnout of operating room nurses in South Korea.

BACKGROUND: Burnout negatively impacts the personal and professional life of nurses. Job stress and resilience have been determined to be associated with nurse burnout. Given the importance of communication competence in operating room (OR) nurses, the associations of job stress, resilience, and communication competence with burnout have not been examined. PURPOSE: To determine the relationships of job stress, resilience, and communication competence to burnout of OR nurses in South Korea. METHODS: This was a cross-sectional, descriptive study of 146 OR nurses. A series of self-reported questionnaires was used to assess job stress, resilience, communication competence, and burnout. Pearson correlation coefficient and a hierarchical linear regression were used for data analysis. RESULTS: Communication competence was correlated with resilience (r = 0.65, p < .001) and burnout (r = -0.44, p < .001), and resilience was correlated with burnout (r = -0.48, p < .001). Resilience (ß = -0.22, p = .027) and communication competence (ß = -0.33, p < .001) were associated with burnout of OR nurses in a hierarchical linear regression (F = 6.28, p < .001). CONCLUSIONS: Increased resilience and communication competence were associated with lower burnout of perioperative nurses. To prevent and reduce burnout of OR nurses, it is necessary to develop and implement a program targeting for communication competence and resilience. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders should provide programs fostering communication competence and resilience to OR nurses and encourage them to actively participate in such job trainings.

Relationships among basic psychological needs, organizational commitment, perceived authentic leadership and turnover intention in Korean nurses: A cross-sectional study.

AIM: This study determined the relationships of satisfaction and frustration with basic psychological needs, organizational commitment, perceived authentic leadership and turnover intention in nurses in South Korea. BACKGROUND: Minimizing nurse turnover is essential for improving the quality of nursing care and patient safety. METHODS: This was a cross-sectional, correlational pilot study of 216 nurses at a university hospital in South Korea. Data were collected with a self-report questionnaire, from 1 to 15 September 2020. Collected data were analysed using SPSS 24.0. RESULTS: Multiple regression analysis revealed that clinical experience (3 to 5 years, ß = 2.35, p = .019; 5 to 10 years, ß = 2.23, p = .026), subjective workload (severe, ß = 2.10, p = .036; extreme, ß = 2.84, p = .005), psychological needs frustration (ß = 0.35, p < .001), organizational commitment (ß = -0.17, p = .011) and perceived authentic nurse leadership (ß = -0.14, p = .030) were found to have significant effects on nurses' turnover intention. CONCLUSIONS: The results suggest that it is necessary to create a transparent work environment based on authentic leadership and consider individual frustrations with regard to basic psychological needs and organizational commitments. IMPLICATIONS FOR NURSING MANAGEMENT: This study offers a new approach to reducing nurses' turnover. A strategy is needed for efficient nursing staffing management to assist with reduction of nurses' turnover intentions.

Dietary Vitamin C Deficiency Is Associated With Health-Related Quality of Life and Cardiac Event-free Survival in Adults With Heart Failure.

BACKGROUND: Vitamin C deficiency is prevalent in adults with heart failure (HF). Little is known about the relationship of dietary vitamin C deficiency with health outcomes in adults with HF. OBJECTIVE: The study's aim was to determine the relationships of vitamin C deficiency measured at baseline with health-related quality of life (HRQOL) and cardiac event-free survival in patients with HF measured 1 year later. METHOD: A total of 251 patients with HF completed a 4-day food diary. Dietary vitamin C deficiency was defined as daily intake less than the estimated average requirement from the Institute of Medicine of 75 mg/d for men and 60 mg/d for women. Health-related quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire at 12 months. Patients were followed for a median of 1 year to determine time to the first event of cardiac-related hospitalization or death. Data were analyzed by hierarchical linear and Cox proportional hazards regressions. RESULTS: One hundred patients (40%) had vitamin C deficiency. Dietary vitamin C deficiency was associated with poorer HRQOL at 12 months (ß = 0.16, P = .02) after controlling for demographic and clinical variables. During the follow-up period, 59 patients (24%) had cardiac events. In Cox regression, vitamin C deficiency predicted shorter cardiac event-free survival after adjusting for the same covariates (hazards ratio, 1.95; 95% confidence interval, 1.08-3.51). CONCLUSION: Vitamin C deficiency was associated with poorer HRQOL and shorter cardiac event-free survival in patients with HF. The findings suggest that encouraging patients with HF to consume a diet rich in fruits/vegetables to prevent vitamin C deficiency may lead to better health outcomes.

Micronutrient Deficiency Independently Predicts Time to Event in Patients With Heart Failure.

Background Dietary micronutrient deficiencies have been shown to predict event-free survival in other countries but have not been examined in patients with heart failure living in the United States. The purpose of this study was to determine whether number of dietary micronutrient deficiencies in patients with heart failure was associated with shorter event-free survival, defined as a combined end point of all-cause hospitalization and death. Methods and Results Four-day food diaries were collected from 246 patients with heart failure (age: 61.5±12 years; 67% male; 73% white; 45% New York Heart Association [NYHA] class III / IV ) and analyzed using Nutrition Data Systems for Research. Micronutrient deficiencies were determined according to methods recommended by the Institute of Medicine. Patients were followed for 1 year to collect data on all-cause hospitalization or death. Patients were divided according to number of dietary micronutrient deficiencies at a cut point of ≥7 for the high deficiency category versus <7 for the no to moderate deficiency category. In the full sample, 29.8% of patients experienced hospitalization or death during the year, including 44.3% in the high-deficiency group and 25.1% in the no/moderate group. The difference in survival distribution was significant (log rank, P=0.0065). In a Cox regression, micronutrient deficiency category predicted time to event with depression, NYHA classification, comorbidity burden, body mass index, calorie and sodium intake, and prescribed angiotensin-converting enzyme inhibitors, diuretics, or ß-blockers included as covariates. Conclusions This study provides additional convincing evidence that diet quality of patients with heart failure plays an important role in heart failure outcomes.

Associations of Vitamin D Intake and Sleep Quality With Cognitive Dysfunction in Older Adults With Heart Failure.

BACKGROUND: Low vitamin D intake and poor sleep quality are independently associated with cognitive dysfunction in healthy older adults. However, the relationships among vitamin D intake, sleep quality, and cognitive dysfunction are unknown in older adults with heart failure (HF). PURPOSE: The aim of this study was to determine the relationships of vitamin D intake and sleep quality with cognitive dysfunction in older adults with HF. METHODS: A total of 160 older adults with HF completed the Mini-Mental State Examination to assess cognitive function. Vitamin D deficiency was defined as less than 15 mcg/day of average intake determined using a 3-day food diary and use of dietary supplements. Sleep quality was measured by the Pittsburgh Sleep Quality Index (PSQI). Hierarchical regressions and mediation analysis were used for data analysis. RESULTS: Thirty-four patients (21.2%) had severe cognitive dysfunction (total Mini-Mental State Examination score ≤ 19), 88 (55%) had vitamin D deficiency, and 120 (75%) reported poor sleep quality (total PSQI score > 5). Increased daily vitamin D intake (ß = 0.305, P < .001) and poorer sleep quality indicated by the total PSQI score (ß = -0.312, P < .001) were associated with cognitive function. Vitamin D deficiency was associated with poor sleep quality (odds ratio, 2.22; P = .033). In mediation analysis, the relationship between vitamin D deficiency and cognitive function was mediated by sleep quality among older adults with HF. CONCLUSIONS: Both vitamin D deficiency and poor sleep quality are associated with cognitive dysfunction in older adults with HF. Interventions should be tested to target patients with poor sleep quality to improve cognitive function, particularly in those with vitamin D deficiency.

Racial differences in dietary antioxidant intake and cardiac event-free survival in patients with heart failure.

BACKGROUND: Heart failure is a chronic, burdensome condition with higher re-hospitalization rates in African Americans than Whites. Higher dietary antioxidant intake is associated with lower oxidative stress and improved endothelial function. Lower dietary antioxidant intake in African Americans may play a role in the re-hospitalization disparity between African American and White patients with heart failure. OBJECTIVE: The objective of this study was to examine the associations among race, dietary antioxidant intake, and cardiac event-free survival in patients with heart failure. METHODS: In a secondary analysis of 247 patients with heart failure who completed a four-day food diary, intake of alpha-carotene, beta-carotene, beta-cryptoxanthin, lutein, zeaxanthin, lycopene, vitamins C and E, zinc, and selenium were assessed. Antioxidant deficiency was defined as intake below the estimated average requirement for antioxidants with an established estimated average requirement, or lower than the sample median for antioxidants without an established estimated average requirement. Patients were followed for a median of one year to determine time to first cardiac event (hospitalization or death). Survival analysis was used for data analysis. RESULTS: African American patients had more dietary antioxidant deficiencies and a shorter cardiac event-free survival compared with Whites ( p = .007 and p = .028, respectively). In Cox regression, race and antioxidant deficiency were associated with cardiac event-free survival before and after adjusting for covariates. CONCLUSION: African Americans with heart failure had more dietary antioxidant deficiencies and shorter cardiac event-free survival than Whites. This suggests that encouraging African American patients with heart failure to consume an antioxidant-rich diet may be beneficial in lengthening cardiac event-free survival.

Vitamin D supplements reduce depressive symptoms and cardiac events in heart failure patients with moderate to severe depressive symptoms.

BACKGROUND: Depressive symptoms and vitamin D deficiency predict cardiac events in heart failure patients, but whether vitamin D supplements are associated with depressive symptoms and cardiac events in heart failure patients remains unknown. PURPOSE: The purpose of this study was to compare the association of vitamin D supplement use with depressive symptoms and cardiac events in heart failure patients with mild or moderate to severe depressive symptoms. METHODS: A total of 177 heart failure patients with depressive symptoms (Patient Health Questionnaire-9 score ≥5) completed a three-day food diary to determine dietary vitamin D deficiency. Patients were split into four groups by dietary vitamin D adequacy versus deficiency and vitamin D supplement use versus non-use. The Patient Health Questionnaire-9 was used to reassess depressive symptoms at six months. Data on cardiac events for up to one year and vitamin D supplement use were obtained from patient interview and medical record review. Hierarchical linear and Cox regressions were used for data analysis. RESULTS: Sixty-six patients (37.3%) had dietary vitamin D deficiency and 80 (45.2%) used vitamin D supplements. In patients with moderate to severe depressive symptoms, the group with dietary vitamin D deficiency and no supplements had the highest Patient Health Questionnaire-9 score at six months (ß=0.542, p<0.001) and shortest cardiac event-free survival ( p<0.001) among the four groups, the group with dietary vitamin D deficiency and no supplements didn't have the highest Patient Health Questionnaire-9 score at six months and shortest cardiac event-free survival in patients with mild depressive symptoms. CONCLUSIONS: Vitamin D supplements predicted lower depressive symptoms and reduced cardiac events for patients with moderate to severe depressive symptoms. Vitamin D deficiency was associated with higher risk of shorter cardiac event-free survival in heart failure patients regardless of vitamin D supplementation.

Vitamin C Deficiency, High-Sensitivity C-Reactive Protein, and Cardiac Event-Free Survival in Patients With Heart Failure.

BACKGROUND: Vitamin C is related to lower levels of high-sensitivity C-reactive protein (hsCRP), an inflammatory biomarker that predicts cardiovascular disease. Whether vitamin C deficiency is associated with hsCRP and cardiac events in heart failure (HF) patients has not been examined. PURPOSE: The aim of this study is to determine the relationships among vitamin C intake, serum levels of hsCRP, and cardiac events. METHODS: A total of 200 HF patients completed a 3-day food diary to determine vitamin C deficiency and provided blood to measure serum levels of hsCRP. Patients were followed for 2 years to obtain data on cardiac event-free survival. Moderation analyses with hierarchical logistic and Cox regressions were used for the data analysis. RESULTS: Seventy-eight patients (39%) had vitamin C deficiency and 100 (50%) had an hsCRP level higher than 3 mg/L. Vitamin C deficiency was associated with an hsCRP level higher than 3 mg/L in the hierarchical logistic regression (odds ratio, 2.40; 95% confidence interval, [1.13-5.10]; P = .023). Vitamin C deficiency (hazard ratio, 1.68; 95% CI, 1.05-2.69, P = .029) and hsCRP level higher than 3 mg/L (hazard ratio, 1.79; 95% CI, 1.07-3.01; P = .027) predicted shorter cardiac event-free survival in hierarchical Cox regression. The interaction of hsCRP level higher than 3 mg/L and vitamin C deficiency produced a 2.3-fold higher risk for cardiac events (P = .002) in moderation analysis. Higher level of hsCRP predicted shorter cardiac event-free survival only in patients with vitamin C deficiency (P = .027), but not in those with vitamin C adequacy. CONCLUSION: Vitamin C deficiency moderated the relationship between inflammation and cardiac events in patients with HF. Future study is required to determine whether adequate intake of vitamin C could play a protective role against the impact of inflammation on cardiac events in HF patients.

Micronutrient Deficiency Independently Predicts Adverse Health Outcomes in Patients With Heart Failure.

BACKGROUND: Despite growing evidence on the important role of micronutrients in prognosis of heart failure (HF), there has been limited research that micronutrient deficiency predicts health outcomes in patients with HF. PURPOSE: The aim of this study was to determine whether micronutrient deficiency independently predicts adverse health outcomes. METHODS: A total of 113 consecutive outpatients with HF completed a 3-day food diary to measure intake of 15 micronutrients. The Computer Aided Nutrition Analysis Program for Professionals was used to analyze the food diaries and determine dietary micronutrient deficiencies. Patients completed the Minnesota Living With HF Questionnaire to assess health-related quality of life (HRQoL) and were followed up for 1 year to determine cardiac-related hospitalization or cardiac death. Hierarchical multiple linear regressions and Cox proportional hazard regressions were used to determine whether micronutrient deficiencies predicted health outcomes. RESULTS: Fifty-eight patients (51%) had at least 3 micronutrient deficiencies (range, 0-14). Calcium, magnesium, and vitamin D were the most common micronutrient deficiencies. Micronutrient deficiency was independently associated with worse HRQoL (ß = .187, P = .025) in hierarchical multiple linear regression. Thirty-nine patients were hospitalized or died during 1-year follow-up because of cardiac problems. The number of micronutrient deficiencies independently predicted cardiac event-free survival (hazard ratio, 1.14; 95% confidence interval, 1.02-1.28). CONCLUSIONS: These findings show that micronutrient deficiency independently predicted poor HRQoL and earlier cardiac event-free survival in patients with HF. Further research is needed to provide for specific dietary guidelines for better health outcomes in HF patients.

The Relationship of Depressive Symptoms and Vitamin D Intake to Cardiac Event-Free Survival in Patients With Heart Failure.

BACKGROUND: Low vitamin D and depressive symptoms are associated with inflammation activation that predicts cardiovascular disease. Little is known about the relationships among vitamin D intake, depressive symptoms, and cardiac events in heart failure (HF). PURPOSE: The aim of this study is to determine the relationships among vitamin D deficiency, depressive symptoms, and cardiac events. METHODS: A total of 204 HF patients completed a 3-day food diary to determine average daily intake of vitamin D. Patients completed the Patient Health Questionnaire-9 to assess somatic and cognitive depressive symptoms and were split into 2 groups using the Patient Health Questionnaire-9 cut-point score of 10 (< 10, no depressive symptoms; ≥ 10, depressive symptoms). Data on cardiac events during 1 year were obtained through medical record review. Hierarchical Cox and logistic regressions were used for data analyses. RESULTS: Sixty patients (29.4%) had depressive symptoms and 106 (52.0%) had vitamin D deficiency. Depressive symptoms (hazard ratio [HR], 1.93; P = .031) and vitamin D deficiency (HR, 1.84, P = .036) predicted shorter cardiac event-free survival in Cox regression. Depressive symptoms predicted shorter cardiac event-free survival in patients with vitamin D deficiency (HR, 2.16; P = .038), but not those with vitamin D adequacy. Somatic depressive symptoms were associated with vitamin D deficiency (odds ratio, 1.12; P = .028) in logistic regression, whereas cognitive depressive symptoms were not. CONCLUSIONS: Vitamin D deficiency and depressive symptoms predicted shorter cardiac event-free survival. Depressive symptoms did not predict cardiac events in HF patients with vitamin D adequacy. Somatic depressive symptoms predicted vitamin D deficiency, but cognitive depressive symptoms did not. Additional research is necessary to determine the protective role of vitamin D in the link between somatic depressive symptoms and cardiac events.

Prehospital Delay, Precipitants of Admission, and Length of Stay in Patients With Exacerbation of Heart Failure.

BACKGROUND: Factors that precipitate hospitalization for exacerbation of heart failure provide targets for intervention to prevent hospitalizations. OBJECTIVES: To describe demographic, clinical, behavioral, and psychosocial factors that precipitate admission for exacerbation of heart failure and assess the relationships between precipitating factors and delay before hospitalization, and between delay time and length of hospital stay. METHODS: All admissions in 12 full months to a tertiary medical center were reviewed if the patient had a discharge code related to heart failure. Data on confirmed admissions for exacerbation of heart failure were included in the study. Electronic and paper medical records were reviewed to identify how long it took patients to seek care after they became aware of signs and symptoms, factors that precipitated exacerbation, and discharge details. RESULTS: Exacerbation of heart failure was confirmed in 482 patients. Dyspnea was the most common symptom (92.5% of patients), and 20.3% of patients waited until they were severely dyspneic before seeking treatment. The most common precipitating factor was poor medication adherence. Delay times from symptom awareness to seeking treatment were shorter in patients who had a recent change in medicine for heart failure, renal failure, or poor medication adherence and longer in patients with depressive symptoms and hypertension. CONCLUSIONS: Depressive symptoms, recent change in heart failure medicine, renal failure, poor medication adherence, and hypertension are risk factors for hospitalizations for exacerbation of heart failure.

Prognostic Importance of Sleep Quality in Patients With Heart Failure.

BACKGROUND: Poor sleep quality is common and is associated with poor quality of life and health status in patients with heart failure. However, few investigators have focused on the impact of impaired sleep quality on survival in heart failure. OBJECTIVE: To examine whether self-reported sleep quality is associated with prognosis in patients with heart failure. METHODS: The study sample consisted of 204 patients with heart failure. Sleep quality was measured with the Pittsburgh Sleep Quality Index. Poor sleepers were defined as patients with scores greater than 5 on the index. Patients were followed up for a median of 364 days to determine cardiac events (a composite of cardiac death, hospitalizations, or emergency department visits for cardiac reasons). Multivariable Cox proportional hazard regression was used to examine whether poor sleepers were at a higher risk than good sleepers for shorter cardiac event-free survival after covariates were adjusted for. RESULTS: Of 204 patients, 129 (63%) reported poor sleep quality. Poor sleepers were 2.5 times more likely to have a shorter cardiac event-free survival (95% CI, 1.164-5.556) than were good sleepers after covariates were controlled for. CONCLUSIONS: Impaired sleep quality was prevalent in patients with heart failure and was associated with poor cardiac event-free survival. Clinicians should assess and manage sleep quality in patients with heart failure to improve outcomes.

Self-reported Adherence to a Low-Sodium Diet and Health Outcomes in Patients With Heart Failure.

BACKGROUND: Most clinicians rely on patients' self-report of following a low-sodium diet to determine adherence of patients with heart failure (HF). Whether self-reported adherence to a low-sodium diet is associated with cardiac event-free survival is unclear. PURPOSES: To determine (1) whether self-reported is concordant with adherence to a low-sodium diet measured by food diaries and 24-hour urinary sodium excretion and (2) whether self-reported adherence to a low-sodium diet predicts cardiac event-free survival. METHODS: Adherence to a low-sodium diet was measured using 3 measures in 119 HF patients: (1) self-reported adherence, 1 item from the Self-care of Heart Failure Index scale; (2) a 3-day food diary; (3) 24-hour urinary sodium excretion. Patients were followed up for a median of 297 days to determine cardiac hospitalization or emergency department visit. One-way analysis of variance and Cox regression were used to address our purposes. RESULTS: Self-reported adherence was concordant with adherence to a low-sodium diet measured by food diaries and 24-hour urinary sodium excretion. Thirty-one patients who reported they always follow a low-sodium diet had an average sodium intake less than 3 g/d (F = 5.07, P = .002) and 3.3 g of a mean 24-hour urinary sodium excretion (F = 3.393, P = .020). Patients who reported they never or rarely follow a low-sodium diet had 4.7 times greater risk of having cardiac events than did those who always followed a low-sodium diet (P = .017). CONCLUSION: Self-reported adherence to a low-sodium diet predicted cardiac event-free survival demonstrating clinicians can use this as an indicator of adherence.

Association of Depressive Symptoms and Micronutrient Deficiency With Cardiac Event-Free Survival in Patients With Heart Failure.

BACKGROUND: Depressive symptoms and malnutrition independently predict cardiac events in heart failure (HF) patients. However, the relationships among depressive symptoms, nutritional intake, and cardiac event-free survival have not been examined. METHODS AND RESULTS: A total of 232 patients with HF completed the Patient Health Questionnaire 9 (PHQ-9) to measure depressive symptoms and a 3-day food diary to determine the number of micronutrient deficiencies. Patients were followed for 2 years to collect data on cardiac event-free survival. Patients were divided into 4 groups by a PHQ-9 score of 10 and the median value of micronutrient deficiencies. Cox regressions were used to determine the relationships among depressive symptoms, micronutrient deficiency, and cardiac event-free survival. Depressive symptoms conferred greater risk of cardiac events in patients with a high number of micronutrient deficiencies than in those with a low number of micronutrient deficiencies. Patients with a PHQ-9 score ≥10 and number of micronutrient deficiencies >5 had 2.4 times higher risk for cardiac events compared with patients with a PHQ-9 score <10 and micronutrient deficiency ≤5 (P = .005). CONCLUSIONS: There was a synergistic effect on the association of depressive symptoms with cardiac event-free survival in HF patients that differed by micronutrient deficiency.

Type D personality, self-efficacy, and medication adherence in patients with heart failure-A mediation analysis.

BACKGROUND: Type D personality is associated with medication non-adherence. Both Type D personality and non-adherence are predictors of poor outcomes. Self-efficacy, which is modifiable, is also associated with medication adherence. OBJECTIVES: To determine the relationships among Type D personality, self-efficacy, and medication adherence in 84 heart failure patients. METHODS: Self-efficacy, Type D personality, medication adherence, demographic and clinical data were collected. Hierarchical linear regression was used. RESULTS: Type D patients were more likely to have lower self-efficacy (p = .023) and medication non-adherence (p = .027) than non-Type D patients. Low self-efficacy was associated with medication non-adherence (p < .001). Type D personality didn't predict medication adherence after entering self-efficacy in the model (p = .422), demonstrating mediation. CONCLUSIONS: Self-efficacy mediates the relationship between Type D personality and medication adherence. Developing and applying interventions to enhance self-efficacy may help to sever the link between Type D personality and poor outcomes.

The association between regular symptom monitoring and self-care management in patients with heart failure.

BACKGROUND: Symptom monitoring is considered the first step toward self-care management (actions to manage altered symptom status) to avert worsening heart failure (HF). However, empirical evidence demonstrating that symptom monitoring leads to adequate self-care management is lacking. We examined the relationship of adherence to regular symptom monitoring with adequate self-care management in HF patients. METHODS AND RESULTS: A total of 311 HF patients (60 years, 35% women) were divided into 3 groups by adherence to 2 symptom monitoring behaviors (monitoring daily weights and lower extremity edema). Patients who were adherent to both symptom monitoring behaviors formed the adherent group (15.1%). Those adherent to either of the symptom monitoring behaviors formed the partially adherent group (28.9%). Those adherent to neither of the symptom monitoring behaviors formed the nonadherent group (56.0%). The adjusted odds of performing adequate self-care management were increased by 225% (95% confidence interval, 1.13-4.48) and 344% (95% confidence interval, 1.55-7.62) for the partially adherent and adherent symptom monitoring groups, respectively, compared with the nonadherent group. CONCLUSION: Adequacy of self-care management was predicted by adherence to symptom monitoring behaviors. This finding suggests that regular symptom monitoring facilitates performance of adequate self-care management, which may contribute to a decrease in preventable hospitalizations in HF.

The Impact of Body Mass Index on the Link Between Depressive Symptoms and Health Outcome in Patients With Heart Failure.

BACKGROUND: Depressive symptoms are predictors of shorter cardiac event-free survival, whereas increased body mass index (BMI) is associated with longer cardiac event-free survival in patients with heart failure (HF). However, the impact of BMI on the link between depressive symptoms and cardiac event-free survival is unexplored. The purpose of this study was to determine whether the relationship between depressive symptoms and cardiac event-free survival differs among HF patients stratified by BMI tertiles. METHODS: A total of 297 outpatients with HF completed the Patient Health Questionnaire-9 to assess depressive symptoms. Body mass index was calculated as weight in kilograms divided by height in meters squared. Patients were followed for 1 year to determine cardiac event-free survival. Cox proportional hazard regression with survival curves was used to determine the relationships among depressive symptoms, BMI, and cardiac event-free survival. RESULTS: Both depressive symptoms (P < .001) and lower BMI (P = .002) are independent predictors of shorter cardiac event-free survival after controlling for age, gender, etiology, total comorbidity scores, ejection fraction, New York Heart Association functional class, and prescribed medications. Patients with depressive symptoms had shorter cardiac event-free survival compared with patients without depressive symptoms in the lowest (P = .001) and middle (P = .036) BMI tertiles. There was no difference in cardiac event-free survival between patients with and without depressive symptoms in the highest tertile (P = .894). CONCLUSIONS: Higher BMI has a protective role in the adverse effect of depressive symptoms on health outcomes in patients with HF.