Telecommunication for Advance Care Planning in Heart Failure

Heart failure is a chronic illness that carries a significant burden for patients, caregivers and health systems alike. The integration of palliative care and telehealth is a growing area of interest in heart failure management to help alleviate these burdens. This review focuses on the incorporation of advance care planning for complex decision-making in heart failure in the setting of increasing virtual care and telehealth. The review will also consider the role of virtual education for advance care planning and serious illness communication. Telecommunication for clinical care and clinical education are both described as non-inferior to in-person methods. Nevertheless, more research is needed to discern best practices and the optimal integration of methods

Perioperative Neurocognitive Disorder: State of the Preclinical Science.

The purpose of this article is to provide a succinct summary of the different experimental approaches that have been used in preclinical postoperative cognitive dysfunction research, and an overview of the knowledge that has accrued. This is not intended to be a comprehensive review, but rather is intended to highlight how the many different approaches have contributed to our understanding of postoperative cognitive dysfunction, and to identify knowledge gaps to be filled by further research. The authors have organized this report by the level of experimental and systems complexity, starting with molecular and cellular approaches, then moving to intact invertebrates and vertebrate animal models. In addition, the authors' goal is to improve the quality and consistency of postoperative cognitive dysfunction and perioperative neurocognitive disorder research by promoting optimal study design, enhanced transparency, and "best practices" in experimental design and reporting to increase the likelihood of corroborating results. Thus, the authors conclude with general guidelines for designing, conducting and reporting perioperative neurocognitive disorder rodent research

Influence of depression and gender on symptom burden among patients with advanced heart failure: Insight from the pain assessment, incidence and nature in heart failure study

Introduction Patients with advanced heart failure (HF) experience many burdensome symptoms that increase patient suffering. Methods Comparative secondary analysis of 347 patients with advanced HF. Symptom burden was measured with the Memorial Symptom Assessment Scale-HF. Depression was measured using the Patient Health Questionnaire-9. Results Mean number of symptoms was 13.6. The three most frequent symptoms were non-cardiac pain, shortness of breath, and lack of energy. Patients with depression reported higher symptom burden. Symptom burden differed when compared by gender. Women reported higher symptom burden for other pain, dry mouth, swelling of the arms and legs, sweats, feeling nervous, nausea, and vomiting. Men reported higher symptom burden with sexual problems. Conclusions Given the high rates of symptoms and distress, interventions are needed to alleviate the symptom burden of patients with advanced HF. Reported symptom burden in patients with advanced heart failure was higher when depressive symptoms were present. Women reported varied number and severity of symptoms than men

Perioperative Factors Associated With Postoperative Delirium in Patients Undergoing Noncardiac Surgery:An Individual Patient Data Meta-Analysis

IMPORTANCE: Postoperative delirium (POD) is a common and serious complication after surgery. Various predisposing factors are associated with POD, but their magnitude and importance using an individual patient data (IPD) meta-analysis have not been assessed.OBJECTIVE: To identify perioperative factors associated with POD and assess their relative prognostic value among adults undergoing noncardiac surgery.DATA SOURCES: MEDLINE, EMBASE, and CINAHL from inception to May 2020.STUDY SELECTION: Studies were included that (1) enrolled adult patients undergoing noncardiac surgery, (2) assessed perioperative risk factors for POD, and (3) measured the incidence of delirium (measured using a validated approach). Data were analyzed in 2020.DATA EXTRACTION AND SYNTHESIS: Individual patient data were pooled from 21 studies and 1-stage meta-analysis was performed using multilevel mixed-effects logistic regression after a multivariable imputation via chained equations model to impute missing data.MAIN OUTCOMES AND MEASURES: The end point of interest was POD diagnosed up to 10 days after a procedure. A wide range of perioperative risk factors was considered as potentially associated with POD.RESULTS: A total of 192 studies met the eligibility criteria, and IPD were acquired from 21 studies that enrolled 8382 patients. Almost 1 in 5 patients developed POD (18%), and an increased risk of POD was associated with American Society of Anesthesiologists (ASA) status 4 (odds ratio [OR], 2.43; 95% CI, 1.42-4.14), older age (OR for 65-85 years, 2.67; 95% CI, 2.16-3.29; OR for &gt;85 years, 6.24; 95% CI, 4.65-8.37), low body mass index (OR for body mass index &lt;18.5, 2.25; 95% CI, 1.64-3.09), history of delirium (OR, 3.9; 95% CI, 2.69-5.66), preoperative cognitive impairment (OR, 3.99; 95% CI, 2.94-5.43), and preoperative C-reactive protein levels (OR for 5-10 mg/dL, 2.35; 95% CI, 1.59-3.50; OR for &gt;10 mg/dL, 3.56; 95% CI, 2.46-5.17). Completing a college degree or higher was associated with a decreased likelihood of developing POD (OR 0.45; 95% CI, 0.28-0.72).CONCLUSIONS AND RELEVANCE: In this systematic review and meta-analysis of individual patient data, several important factors associated with POD were found that may help identify patients at high risk and may have utility in clinical practice to inform patients and caregivers about the expected risk of developing delirium after surgery. Future studies should explore strategies to reduce delirium after surgery.</p

Medical decision making for older adults: an international perspective comparing the United States and India

There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutaneous revascularization, mechanical circulatory support, and transcatheter valvular therapies. While advancing therapies may add significant longevity, they also bring about new end-of-life decision-making challenges for patients and their families who also must weigh the advantages of reduced mortality to the possibility of longer lives consisting of high morbidity, frailty, pain, and poor quality of living. Advance care entails options of withholding or withdrawing therapies, and has become a familiar part of cardiovascular care for older patients in Western countries. However, as advanced cardiovascular practices extend to developing countries, the interrelated concept of advance care is rarely straight forward as it is affected by local cultural traditions and mores, and can lead to very different inferences and use. This paper discusses the concepts of advance care planning, surrogate decision-making, orders for resuscitation and futility in patients with cardiac disease with comparisons of West to East, focusing particularly on the United States versus India

Frequency and predictors of falls among adults with heart failure : A prospective study

Objective Adults with heart failure (HF) may be at high risk for falling due to age, comorbidities and frailty; however, few studies have examined falls in HF. The purpose of this study was to quantify the frequency and predictors of falls over 1 year among adults with HF. Methods We conducted a prospective study of adults with New York Heart Association (NYHA) functional class I–IV HF. After baseline assessment of physical frailty and clinical characteristics, participants self-reported falls every 3 months during 1 year. Comparative statistics were used to identify baseline differences between those who fell vs those who did not. A stepwise negative binomial regression model was used to identify predictors of fall rate over 1 year. Results The sample (n = 111) was 63.4 ± 15.7 years old, 48% were women, 28% had HF with preserved ejection fraction, and 41% were frail. Over 1 year, 43 (39%) of participants reported at least 1 fall and 28 (25%) of participants reported 2+ falls. Among those who fell, 29 (67%) reported injurious falls. Those who fell had significantly higher body mass indexes and were more likely to have NYHA class III/IV, type 2 diabetes and HF with preserved ejection fraction and to meet slowness and physical exhaustion criteria than those who did not fall. The fall rate was elevated among those with type 2 diabetes and those meeting the slowness and physical exhaustion criteria for physical frailty. Conclusions Nearly 40% of adults with HF experienced a fall within 1 year. Screening for comorbidities, slowness and exhaustion may help to identify those at risk for a fall

Perioperative Neurocognitive Disorder: State of the Preclinical Science.

The purpose of this article is to provide a succinct summary of the different experimental approaches that have been used in preclinical postoperative cognitive dysfunction research, and an overview of the knowledge that has accrued. This is not intended to be a comprehensive review, but rather is intended to highlight how the many different approaches have contributed to our understanding of postoperative cognitive dysfunction, and to identify knowledge gaps to be filled by further research. The authors have organized this report by the level of experimental and systems complexity, starting with molecular and cellular approaches, then moving to intact invertebrates and vertebrate animal models. In addition, the authors goal is to improve the quality and consistency of postoperative cognitive dysfunction and perioperative neurocognitive disorder research by promoting optimal study design, enhanced transparency, and best practices in experimental design and reporting to increase the likelihood of corroborating results. Thus, the authors conclude with general guidelines for designing, conducting and reporting perioperative neurocognitive disorder rodent research

Investigating pain in heart failure patients: The pain assessment, incidence, and nature in heart failure (PAIN-HF) study

Background: Patients with advanced heart failure (HF) have high rates of pain and other symptoms that diminish quality of life. We know little about the characteristics and correlates of pain in patients with advanced HF. Methods and Results: We identified pain prevalence, location, character, severity, frequency, and correlates in 347 outpatients with advanced HF enrolled from hospices and clinics. We evaluated the correlation of pain with HF-related quality of life, mortality, symptoms and health problems, and current treatments for pain. Pain at any site was reported by 293 patients (84.4%), and 138 (39.5%) reported pain at more than one site. The most common site of pain was the legs below the knees (32.3% of subjects). Pain interfered with activity for 70% of patients. Pain was severe or very severe for 28.6% of subjects with chest pain, and for 38.9% of those with other sites of pain. The only medication reported to provide pain relief was opioids, prescribed for 34.1% of subjects (P =.001). The strongest predictors of pain were degenerative joint disease (DJD) (odds ratio [OR] 14.95, 95% confidence interval [CI] 3.9-56.0; P \u3c.001), other arthritis (OR 2.8, 95% CI 1.20-6.62; P =.017), shortness of breath (OR 3.27, 95% CI 1.47-7.28; P =.004), and angina pectoris (OR 3.38, 95% CI 1.30-8.81; P =.013). Conclusions: Pain occurred at multiple sites in patients with advanced HF. Pain correlated with DJD or other arthritis, shortness of breath, and angina. Only opioid analgesics provided relief of pain. Future research should evaluate the etiology of and interventions to manage pain in patients with HF. © 2012 Elsevier Inc. All rights reserved