Limited availability of cardiac rehabilitation for heart failure patients in the United Kingdom: findings from a national survey

Background: Participation of patients with heart failure in cardiac rehabilitation in the UK is low. This study investigated the availability of cardiac rehabilitation services for patients with heart failure in the UK and the views of service coordinators on ideal service models. Design: Our study was a cross-sectional national postal survey that was mailed to 342 service coordinators in the UK between April and June 2009. Methods: We developed a 38-item questionnaire to survey all cardiac rehabilitation service coordinators on theNational Audit of Cardiac Rehabilitation register in the UK in 2009. Results: The survey response rate was 71% (244/342). Forty three per cent (105/244) of coordinators did not accept patients with heart failure to their cardiac rehabilitation services. Most coordinators who did accept patients with heart failure offered their services to patients with a variety of cardiac conditions, though referral criteria and models of care varied widely. Services inconsistently used New York Heart Association classes and left ventricular ejection fraction measures to select patients. Few offered separate dedicated heart failure programmes (14%; 33/244) but where these existed they ran for longer than programmes which included patients with heart failure alongside other cardiac patients (10.9 vs 8.5 weeks; F=4.04; p=0.019). Few offered home-based options for patients with heart failure (11%; 27/244). Coordinators accepting patients with heart failure to their cardiac rehabilitation services tended to agree that patients with heart failure should be included in services alongside other cardiac patients (X2=6.2; p=0.013). Conclusions: There is limited access for patients with heart failure to cardiac rehabilitation in the UK. Local policies on referral and selection criteria differ and reflect coordinators views rather than clinical guidance. © The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav

Prevalence and correlates of frailty among older adults: findings from the German health interview and examination survey

Background: Despite having the third highest proportion of people aged 60 years and older in the world, Germany has been recently reported as having the lowest prevalence of frailty of 15 European countries. The objective of the study is to describe the prevalence of frailty in a large nationwide population-based sample and examine associations with sociodemographic, social support and health characteristics. Methods: We performed a cross-sectional analysis of the first wave of the German Health Interview and Examination Survey for Adults (DEGS1) conducted 2008–2011. Participants were 1843 community-dwelling people aged 65–79 years. Frailty and pre-frailty were defined, according to modified Fried criteria, as 3 and more or 1–2 respectively, of the following: exhaustion, low weight, low physical activity, low walking speed and low grip strength. The Oslo-3 item Social Support Scale (OSS-3) was used. Patient Health Questionnaire (PHQ-9) measured depressive symptoms and the Digit Symbol Substitution Test (DSST) measured cognition. Associations between participants’ characteristics and frailty status were examined using unadjusted and adjusted multinomial logistic regression models estimating relative risk ratios (RRR) of frailty and pre-frailty. Results: The prevalence of frailty among women was 2.8% (CI 1.8-4.3) and pre-frailty 40.4% (CI 36.3-44.7) and among men was 2.3% (CI 1.3-4.1) and 36.9% (CI 32.7-41.3) respectively. Independent determinants of frailty, from unadjusted models, included older age, low socioeconomic status, poor social support, lower cognitive function and a history of falls. In adjusted models current depressive symptoms (RRR 12.86, CI 4.47-37.03), polypharmacy (RRR 7.78, CI 2.92-20.72) and poor hearing (RRR 5.38, CI 2.17-13.35) were statistically significantly associated with frailty. Conclusions: Frailty prevalence is relatively low among community-dwelling older adults in Germany. Modifiable characteristics like low physical activity provide relevant targets for individual and population-level frailty detection and intervention strategies

Changes in physical functioning among men and women aged 50–79 years in Germany: an analysis of National Health Interview and Examination Surveys, 1997–1999 and 2008–2011

Background: This study examines changes in physical functioning among adults aged 50-79 years in Germany based on data from two German National Health Interview and Examination Surveys conducted in 1997–1999 (GNHIES98) and 2008–2011 (DEGS1). Methods Using cross-sectional data from the two surveys (GNHIES98, n = 2884 and DEGS1, n = 3732), we examined changes in self-reported physical functioning scores (Short Form-36 physical functioning subscale (SF-36 PF)) by sex and age groups (50–64 and 65–79 years). Covariables included educational level, living alone, nine chronic diseases, polypharmacy (≥5 prescribed medicines), body mass index, sports activity, smoking and alcohol consumption. Multimorbidity was defined as ≥2 chronic diseases. Multivariable models were fitted to examine consistency of changes in physical functioning among certain subgroups and to assess changes in mean SF-36 PF scores, adjusting for changes in covariables between surveys. Results: Mean physical functioning increased among adults aged 50–79 years between surveys in unadjusted analyses, but this change was not as marked among men aged 65–79 years who experienced rising obesity (20.6 to 31.5%, p = 0.004) and diabetes (13.0 to 20.0%, p = 0.014). Prevalence of multimorbidity and polypharmacy use increased among men and women aged 65–79 years. In sex and age specific multivariable analyses, changes in physical functioning over time were consistent across subgroups. Gains in physical functioning were explained by improved education, lower body mass index and improved health-related behaviours (smoking, alcohol consumption, sports activity) in women, but less so among men. Conclusions: Physical functioning improved in Germany among adults aged 50–79 years. Improvements in the population 65–79 years were less evident among men than women, despite increases in multimorbidity prevalence among both sexes. Changes in health behaviours over time differed between sexes and help explain variations in physical functioning. Targeted health behaviour interventions are indicated from this study

The Polarity Protein Scribble Regulates Myelination and Remyelination in the Central Nervous System

The development and regeneration of myelin by oligodendrocytes, the myelin-forming cells of the central nervous system (CNS), requires profound changes in cell shape that lead to myelin sheath initiation and formation. Here, we demonstrate a requirement for the basal polarity complex protein Scribble in CNS myelination and remyelination. Scribble is expressed throughout oligodendroglial development and is up-regulated in mature oligodendrocytes where it is localised to both developing and mature CNS myelin sheaths. Knockdown of Scribble expression in cultured oligodendroglia results in disrupted morphology and myelination initiation. When Scribble expression is conditionally eliminated in the myelinating glia of transgenic mice, myelin initiation in CNS is disrupted, both during development and following focal demyelination, and longitudinal extension of the myelin sheath is disrupted. At later stages of myelination, Scribble acts to negatively regulate myelin thickness whilst suppressing the extracellular signal-related kinase (ERK)/mitogen-activated protein kinase (MAP) kinase pathway, and localises to non-compact myelin flanking the node of Ranvier where it is required for paranodal axo-glial adhesion. These findings demonstrate an essential role for the evolutionarily-conserved regulators of intracellular polarity in myelination and remyelination

Prevalence and correlates of DSM-IV-TR major depressive disorder, self-reported diagnosed depression and current depressive symptoms among adults in Germany

Background: While standardized diagnostic interviews using established criteria are the gold standard for assessing depression, less time consuming measures of depression and depressive symptoms are commonly used in large population health surveys. We examine the prevalence and health-related correlates of three depression measures among adults aged 18–79 years in Germany. Methods: Using cross-sectional data from the national German Health Interview and Examination Survey for Adults (DEGS1) (n=7987) and its mental health module (DEGS1-MH) (n=4483), we analysed prevalence and socio-demographic and health-related correlates of (a) major depressive disorder (MDD) established by Composite International Diagnostic Interview (CIDI) using DSM-IV-TR criteria (CIDI–MDD) in the last 12 months, (b) self-reported physician or psychotherapist diagnosed depression in the last 12 months, and (c) current depressive symptoms in the last two weeks (PHQ-9, score ≥10). Results: Prevalence of 12-month CIDI–MDD was 4.2% in men and 9.9% in women. Prevalence of 12-month self-reported health professional-diagnosed depression was 3.8% and 8.1% and of current depressive symptoms 6.1% and 10.2% in men and women, respectively. Case-overlap between measures was only moderate (32–45%). In adjusted multivariable analyses, depression according to all three measures was associated with lower self-rated health, lower physical and social functioning, higher somatic comorbidity (except for women with 12-month CIDI–MDD), more sick leave and higher health service utilization. Limitations: Persons with severe depression may be underrepresented. Associations between CIDI–MDD and correlates and overlap with other measures may be underestimated due to time lag between DEGS1 and DEGS1-MH. Conclusions: Prevalence and identified cases varied between these three depression measures, but all measures were consistently associated with a wide range of adverse health outcomes

Prevalence, trends, patterns and associations of analgesic use in Germany

Background: Despite the public health relevance of analgesic use, large-scale studies on this topic in Germany are lacking. This study describes the prevalence, trends, associations and patterns of use of prescription and over-the-counter (OTC) analgesics, focusing on five of the most common agents: aspirin, diclofenac, ibuprofen, naproxen and paracetamol. Methods: Data from two representative population-based surveys: The German National Health Interview and Examination Survey 1998 (GNHIES98 n = 7099) and the German Health Interview and Examination Survey for Adults 2008–2011 (DEGS1 n = 7091) was investigated. Information on all medicines consumed in the previous 7 days was collected via computer-assisted personal interviews with adults aged 18–79 years. Associations between analgesic use and socio-demographic and health-behaviour factors were analysed using logistic regression models. Results: Analgesic use has increased over the last decade from 19 to 21 %. This was exclusively due to the rise in OTC analgesic use from 10.0 to 12.2 %. Prescribed analgesic use remained constant (7.9 %). Findings from DEGS1 indicate that ibuprofen is the most commonly used analgesic followed by aspirin and paracetamol. OTC analgesic use is higher among women and smokers, but lower among older adults (65–79 years). Prescribed analgesics use is higher among women, older adults, smokers and obese adults with medium or high socio- economic status. Adults performing more than 2 h/week of physical exercise use fewer analgesics. Discussion: Among the adult population of Germany, the prevalence of OTC analgesic use has significantly increased over the last decade. We found differences between adults consuming OTC and prescribed analgesics (or both) concerning their health behaviour and health conditions. International direct comparison between prevalence rates of analgesic use was limited due to varying availability of analgesics between countries and to methodological differences. Conclusions: About one in five community dwelling adults aged 18–79 years in Germany use analgesics in a given week. Considering the potential harms of analgesic use, monitoring of prevalence, patterns and determinants of use at the population level are important steps to inform disease prevention and health promotion policies

Improving prioritization processes for clinical practice guidelines: new methods and an evaluation from the National Heart Foundation of Australia

Abstract Background Releasing timely and relevant clinical guidelines is challenging for organizations globally. Priority-setting is crucial, as guideline development is resource-intensive. Our aim, as a national organization responsible for developing cardiovascular clinical guidelines, was to develop a method for generating and prioritizing topics for future clinical guideline development in areas where guidance was most needed. Methods Several novel processes were developed, adopted and evaluated, including (1) initial public consultation for health professionals and the general public to generate topics; (2) thematic and qualitative analysis, according to the International Classification of Diseases (ICD-11), to aggregate topics; (3) adapting a criteria-based matrix tool to prioritize topics; (4) achieving consensus through a modified-nominal group technique and voting on priorities; and (5) process evaluation via survey of end-users. The latter comprised the organization’s Expert Committee of 12 members with expertise across cardiology and public health, including two citizen representatives. Results Topics (n = 405; reduced to n = 278 when duplicates removed) were identified from public consultation responses (n = 107 respondents). Thematic analysis synthesized 127 topics that were then categorized into 37 themes using ICD-11 codes. Exclusion criteria were applied (n = 32 themes omitted), resulting in five short-listed topics: (1) congenital heart disease, (2) valvular heart disease, (3) hypercholesterolaemia, (4) hypertension and (5) ischaemic heart diseases and diseases of the coronary artery. The Expert Committee applied the prioritization matrix to all five short-listed topics during a consensus meeting and voted to prioritize topics. Unanimous consensus was reached for the topic voted the highest priority: ischaemic heart disease and diseases of the coronary arteries, resulting in the decision to update the organization’s 2016 clinical guidelines for acute coronary syndromes. Evaluation indicated that initial public consultation was highly valued by the Expert Committee, and the matrix tool was easy to use and improved transparency in priority-setting. Conclusion Developing a multistage, systematic process, incorporating public consultation and an international classification system led to improved transparency in our clinical guideline priority-setting processes and that topics chosen would have the greatest impact on health outcomes. These methods are potentially applicable to other national and international organizations responsible for developing clinical guidelines