Kathryn A. Wood

Effect of an implantable cardioverter defibrillator with atrial detection and shock therapies on patient-perceived, health-related quality of life.

BACKGROUND This study used a device (DDD implantable cardioverter defibrillator [ICD]) capable of delivering pacing and shock therapies to restore normal sinus rhythm in patients with atrial tachycardias or atrial fibrillation (AF). The purpose of this study was to assess the effect of the device on patient-perceived, health-related quality of life (QOL). METHODS The DDD ICD was implanted in 267 patients with drug refractory, symptomatic AF from 45 centers across Europe, the United States, and Canada. Patients completed self-reported, validated QOL assessments at baseline and at 3- and 6-month follow-up visits (The Medical Outcomes Short Form 36 [SF-36] and the Symptom Checklist [SCL]). RESULTS The mean age of the study group was 62 +/- 12 years, and 73% of the patients were male. A total of 150 patients completed SF-36 assessments, and 138 patients completed SCL assessments at all 3 times. Baseline scores were more impaired (P <.05) on most SF-36 scales compared with norms for a general population, but were similar to a comparison group of patients with AF who were referred to tertiary care centers. The role-physical, physical functioning, vitality, mental health, and social functioning scales all improved significantly with time (all P <.04). Similarly, symptom frequency and severity (SCL) also improved significantly from baseline to 6 months (both P <.01). Shock therapy was delivered in 86 of the 150 patients (57%) with complete SF-36 evaluations. There was no evidence that receiving shocks decreased the relative improvement in QOL associated with implantation of the device. CONCLUSIONS In a 6-month period, QOL improves after implantation of a DDD ICD with atrial shock and pacing therapies. These improvements were not attenuated by receipt of shocks.

Psychopathology and symptoms of atrial fibrillation: implications for therapy.

Psychopathology and Symptoms of Atrial Fibrillation. Introduction: Current guidelines recommend that the choice of AF management strategy be guided by the symptomatic status of the patient when in AF. However, little is known regarding what drives AF symptoms. Several limited studies suggest that psychological distress may be linked with AF symptom severity.

Women versus men with chronic atrial fibrillation: insights from the Standard versus Atrial Fibrillation spEcific managemenT studY (SAFETY)

Background Gender-based clinical differences are increasingly being identified as having significant influence on the outcomes of patients with cardiovascular disease (CVD), including atrial fibrillation (AF). Objective To perform detailed clinical phenotyping on a cohort of hospitalised patients with chronic forms of AF to understand if gender-based differences exist in the clinical presentation, thrombo-embolic risk and therapeutic management of high risk patients hospitalised with chronic AF. Methods We are undertaking the Standard versus Atrial Fibrillation spEcific managemenT studY (SAFETY) - a multi-centre, randomised controlled trial of an AF-specific management intervention versus usual care. Extensive baseline profiling of recruited patients was undertaken to identify gender-specific differences for risk delineation. Results We screened 2,438 patients with AF and recruited 335 into SAFETY. Of these, 48.1% were women who were, on average, 5 years older than their male counterparts. Women and men displayed divergent antecedent profiles, with women having a higher thrombo-embolic risk but being prescribed similar treatment regimens. More women than men presented to hospital with co-morbid thyroid dysfunction, depression, renal impairment and obesity. In contrast, more men presented with coronary artery disease (CAD) and/or chronic obstructive pulmonary disease (COPD). Even when data was age-adjusted, women were more likely to live alone (odds ratio [OR] 2.33; 95% confidence interval [CI] 1.47 to 3.69), have non-tertiary education (OR 2.69; 95% CI 1.61 to 4.48) and be symptomatic (OR 1.93; 95% CI 1.06 to 3.52). Conclusion Health care providers should be cognisant of gender-specific differences in an attempt to individualise and, hence, optimise the management of patients with chronic AF and reduce potential morbidity and mortality.

Patient perception of symptoms and quality of life following ablation in patients with supraventricular tachycardia

OBJECTIVES It remains unclear which symptom experiences and aspects of quality of life (QOL) change after ablation in patients with supraventricular tachycardia (SVT). To determine how patient perceptions of symptoms and QOL change after ablation, we used a single group pretest-posttest design. METHODS Patients with SVT (n=52; mean age 41+/-17 years; 65% female) completed generic and disease-specific measures at baseline and 1 month after ablation. RESULTS Significant improvement after ablation was noted on virtually all measures (P <.05). Patients reported decreases from baseline regarding frequency and duration of episodes, number of symptoms, and impact of SVT on routine activities. All symptoms decreased in prevalence; however, no symptoms were completely eliminated at 1-month follow-up. Women, more so than men, reported larger changes in symptom and QOL scores after ablation. CONCLUSIONS Despite the small sample, statistically significant improvement was found after ablation in a variety of patients with different symptoms and QOL indices.

Gender-related differences in outcomes and resource utilization in patients undergoing radiofrequency ablation of supraventricular tachycardia: results from Patients' Perspective on Radiofrequency Catheter Ablation of AVRT and AVNRT Study

AIMS The aim of this study was to describe gender-related differences in clinical presentation, radiofrequency ablation (RFA) outcomes, and healthcare resource utilization in a group of patients with atrioventricular nodal reciprocating tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT). METHODS AND RESULTS This was a single-centre, prospective, cohort study which enroled 82 patients undergoing RFA of AVNRT or AVRT. At baseline, all patients received a clinical assessment and completed questionnaires concerning: socioeconomic status, disease-specific symptoms (Patient Perception of Arrhythmia Questionnaire; PPAQ), health-related quality of life (HRQoL) (EQ-5D-3L), and healthcare resource utilization. Two months after RFA, the clinical assessment was repeated and subjects completed PPAQ and EQ-5D-3L. Follow-up was completed by 64 patients, 41 (64%) women. At baseline, there were no significant differences in baseline characteristics, except AVNRT prevalence, and HRQoL by gender but women reported higher severity of symptoms on PPAQ than men (2.8 vs. 2.4 points, P < 0.001). At 2 months after RFA, women still reported higher severity of symptoms (1.8 vs. 0 points; P = 0.02) on PPAQ and more heart skipping than men (54 vs. 13%; P = 0.0014); differences in EQ-5D-3L index and EQ-VAS were insignificant. There was no significant difference in healthcare resource utilization during the year preceding RFA, but antiarrhythmic drugs were significantly more often prescribed to women pre-procedure (30 vs. 8%; P = 0.022). CONCLUSION There is a small but significant gender-related difference in outcome of RFA in patients with AVNRT or AVRT measured with a disease-specific instrument. No significant difference in HRQoL or access to healthcare resources between women and men was found.

Development and initial psychometric evaluation of the Patient Perspective of Arrhythmia Questionnaire.

There are no disease-specific questionnaires to measure patient sensitive outcomes in arrhythmia patients. We report the development and preliminary psychometric testing of the Patient Perception of Arrhythmia Questionnaire (PPAQ). The PPAQ was developed using formative research, exploratory factor analysis, expert review, pilot study, and regression. The PPAQ measures frequency and duration of episodes, symptoms, impact on daily activities, and restricted activity days. After preliminary content validation, the sensitivity of the PPAQ was tested in 103 arrhythmia patients. The measures showed good sensitivity and reliability. Preliminary construct validation was supported by significant differences (p < .001) among groups of arrhythmia patients consistent with clinical patterns. Preliminary evidence from patients with supraventricular arrhythmias suggests that the questionnaire has acceptable psychometrics and could be useful in future studies of arrhythmia patients.

Implementing shared medical appointments for heart failure patients in a community cardiology practice: A pilot study

OBJECTIVE To examine patient and staff satisfaction, billing charges, and programmatic feasibility of shared medical appointments (SMA) in a nurse practitioner-managed heart failure (HF) clinic in a community cardiology practice. METHODS Twenty patients were scheduled among four SMAs for this pilot study. All aspects of a usual clinic appointment were utilized during the SMA, but an additional 20-minute teaching session was presented. All patients completed a satisfaction questionnaire. The office staff completed satisfaction questionnaires about the SMA. Billing charges, cancellations and missed appointments without cancellation for SMAs were compared to usual clinic appointment days. RESULTS Satisfaction was high among patients and office staff. Rates for no-shows were similar for SMAs versus usual appointments (15% versus 5.5%), but there were fewer cancellations among SMAs (0% versus 28%). This may be a reflection of the personalized appointment reminder calls that were made to the patients scheduled for SMAs. Billing charges were not significantly different for SMAs versus usual appointments. CONCLUSION SMAs are a feasible option in a community cardiology practice.

Patient reported outcome measures for cardiac ablation procedures: a multicentre pilot to develop a new questionnaire

Aim To assess the feasibility of administering Patient Reported Outcomes Measures (PROMs) in patients treated with ablation for cardiac arrhythmias, and to conduct the first stage of development and testing of a new PROM tool. Methods and results A new tool was developed by a multidisciplinary team and tested alongside an adaptation of the patient perception of arrhythmia questionnaire (PPAQ) and EQ-5D-5L in a multicentre retrospective audit involving 791 consecutive cardiac arrhythmia patients treated with catheter ablation at three UK centres over 13 months. Data were recorded in the National Cardiac Rhythm Management Database, part of the National Institute for Cardiovascular Outcomes Research. The response rate was 71.9% (n = 569). Patients reported significant improvements across all outcomes and impacts, with reductions in symptoms of 51.7% (heart racing), 33.9% (fatigue) 31.8% (heart flutters), 43.5% (dizziness), 38.6% (breathlessness), 44.2% (chest pressure), 33.1% (trouble concentrating), 15.9% (headache), 28.3% (neck pressure), and 23.4% (fainting) (P < 0.001). The mean number of social days affected reduced by 7.49 days/month (P < 0.001); mean work/school days affected/month reduced by 6.26 (P < 0.001); mean GP/hospital visits reduced by 1.36 days/month (P < 0.001). The procedure met patient expectations in 72% of responders. Conclusions The high response rate suggests that the use of PROMs in this patient group is feasible, with rates equalling those of the National PROMs Programme. The results showed that patients experienced significant improvements in their quality of life following ablation, while feedback allowed the tools to be improved. Further work is required to validate these tools; however, the findings suggest that PROMs could be useful in the audit of ablation techniques.

The Impact of Nurses on Neglected Tropical Disease Management

Although Neglected Tropical Diseases (NTDs) are largely endemic in the developing nations of Africa, Asia, and South and Central America, they are reemerging with increasing frequency in developed countries. Their diagnosis, treatment, and control are an increasing public health concern that requires a different awareness by health care providers. Neglected tropical diseases (NTDs) are chronic infectious diseases which disproportionately burden poor, rural, and marginalized populations with significant mortality and high morbidity (disability, disfigurement, impaired childhood growth and cognitive development, increased vulnerability to coinfection) that reinforces their poverty. What can we learn from the nurses in developing countries already battling NTDs that could be useful in the developed world? This article provides an overview of distribution, pathophysiology, symptoms, and management of 13 NTDs, with particular attention to the role of nurses in delivering cost-effective integrated interventions. Case studies of schistosomiasis, Chagas disease, and leishmaniasis address recognition and treatment of infected individuals in developed nations where NTD infection is limited primarily to immigrants and travelers.

Surveillance of tobacco retail density in Beirut, Lebanon using electronic tablet technology

BackgroundLebanon has alarmingly high rates of tobacco use. The objective of this study is to examine the density of tobacco retail outlets and distance to schools as well as to survey retail pricing in a large district of Beirut, Lebanon.FindingsWe observed 100 tobacco retail outlets and collected data using iPad® technology. Store locations were recorded with Global Positioning System coordinates. The distances between all pairs of tobacco retail outlets and all schools were calculated. For 52% of tobacco outlets, the nearest distance to other tobacco retail outlets was < 50 meters and 17% were within a 100-meter radius of a school. We found a high proportion of tobacco retailers with close proximity to schools. The overall retailer density was 1.25 stores per 1,000 people.ConclusionsThese findings call for additional regulation including the establishment of strict density standards.