Psychological Aspects of Cardiac Care and Rehabilitation: Time to Wake Up to Sleep?

Psychological and psychosocial factors have long been linked to cardiovascular disease. These psychosocial factors, including low socioeconomic status, social support/isolation, stress and distress, personality, and sleep disturbance increase risk of cardiovascular events and negatively impact quality of life. These factors may have direct effects on cardiovascular disease via immune or neuroendocrine pathways, or more indirect effects, by, for example, limiting adherence to recommended therapies and cardiac rehabilitation. Most psychosocial risk factors can be assessed relatively easily using standardised tools. Sleep disturbance, in particular, is gaining evidence for its importance and may be crucial to address. While the management of certain psychosocial risk factors is an ethical requirement for care and improves quality of life, unfortunately there is little evidence that such strategies impact on 'hard' endpoints such as recurrent myocardial infarction. A comprehensive biopsychosocial approach to management of these psychosocial factors is required to maximise the benefits patients derive from cardiac care.

Depression interventions for individuals with coronary artery disease - Cost-effectiveness calculations from an Irish perspective.

BACKGROUND: A substantial proportion of individuals with coronary artery disease experience moderate or severe acute depression that requires treatment. We assessed the cost-effectiveness of four interventions for depression in individuals with coronary artery disease. METHODS: We assessed effectiveness of pharmacotherapy, psychotherapy, collaborative care and exercise as remission rate after 8 and 26 weeks using estimates from a recent network meta-analysis. The cost assessment included standard doses of antidepressants, contact frequency, and staff time per contact. Unit costs were calculated as health services' purchase price for pharmaceuticals and mid-point staff salaries obtained from the Irish Health Service Executive and validated by clinical staff. Incremental cost-effectiveness ratios were calculated as the incremental costs over incremental remissions compared to usual care. High- and low-cost scenarios and sensitivity analysis were performed with changed contact frequencies, and assuming individual vs. group psychotherapy or exercise. RESULTS: After 8 weeks, the estimated incremental cost-effectiveness ratio was lowest for group exercise (€526 per remission), followed by pharmacotherapy (€589), individual psychotherapy (€3117) and collaborative care (€4964). After 26 weeks, pharmacotherapy was more cost-effective (€591) than collaborative care (€7203) and individual psychotherapy (€9387); no 26-week assessment for exercise was possible. Sensitivity analysis showed that group psychotherapy could be most cost-effective after 8 weeks (€519) and cost-effective after 26 weeks (€1565); however no group psychotherapy trials were available investigating its effectiveness. DISCUSSION: Large variation in incremental cost-effectiveness ratios was seen. With the current assumptions, the most cost-effective depression intervention for individuals with coronary artery disease after 8 weeks was group exercise.

The impact of enriched environment and transplantation of murine cortical embryonic stem cells on recovery from controlled cortical contusion injury.

PURPOSE: The effectiveness of embryonic stem cell (eSC) therapy has been explored in many models of neurological disease and several research groups have shown that eSC treatment leads to improved outcomes in pre-clinical models of traumatic brain injury (TBI). Though functional recovery occurs, few surviving eSCs appear to develop neuronal characteristics; instead the majority of the surviving eSC express glial phenotypes. Additionally, researchers have shown that enriching the post-surgical environment of the subject promotes functional recovery following TBI. The purpose of the current project was to determine if post-surgical environmental enrichment (EE) impacts the survival, migration, and integration of eSCs in a rodent model of TBI and if the presence of these cells lead to improved outcomes. METHODS: In the current study, the medial frontal cortex (MFC) of rats was injured using a controlled cortical impact (CCI) device. Immediately following injury the rats were placed into either EE or standard environment (SE) housing and then seven days post-injury rats received either murine cortical eSC or media. Behavioral testing consisted of the Morris water maze (MWM), Barnes Maze (BM), and Rotarod tasks (RR). RESULTS: On the MWM task, TBI/eSC/EE animals performed as well as the Sham/SE and Sham/EE groups. The TBI/eSC/SE, TBI/Media/EE, and TBI/Media/SE groups were impaired compared to the controls. By the end of training on the BM there were no differences between the Sham, TBI/Media/EE, and TBI/eSC/EE groups. On the RR task all animals placed in the EE performed equally well and significantly better than their SE housed counterparts. By the end of training on the RR task, the TBI/eSC/EE group performed as well as the sham counterparts, and though not significant they also surpassed the performance of the injured animals that received enrichment or eSC treatment alone. CONCLUSIONS: Combing therapeutic strategies with enriching the post-injury environment is likely to be an important addition to determining the efficacy of pre-clinical therapies.