Kyoung Suk Lee

Transcutaneous electrical nerve stimulation reduces pain, fatigue and hyperalgesia while restoring central inhibition in primary fibromyalgia

Summary Pain and fatigue during movement, but not at rest, are reduced by a onetime 30‐m treatment with active transcutaneous electrical nerve stimulation (TENS) in individuals with fibromyalgia. Abstract Because transcutaneous electrical nerve stimulation (TENS) works by reducing central excitability and activating central inhibition pathways, we tested the hypothesis that TENS would reduce pain and fatigue and improve function and hyperalgesia in people with fibromyalgia who have enhanced central excitability and reduced inhibition. The current study used a double‐blinded randomized, placebo‐controlled cross‐over design to test the effects of a single treatment of TENS with people with fibromyalgia. Three treatments were assessed in random order: active TENS, placebo TENS and no TENS. The following measures were assessed before and after each TENS treatment: pain and fatigue at rest and in movement; pressure pain thresholds, 6‐m walk test, range of motion; 5‐time sit‐to‐stand test, and single‐leg stance. Conditioned pain modulation was completed at the end of testing. There was a significant decrease in pain and fatigue with movement for active TENS compared to placebo and no TENS. Pressure pain thresholds increased at the site of TENS (spine) and outside the site of TENS (leg) when compared to placebo TENS or no TENS. During active TENS, conditioned pain modulation was significantly stronger compared to placebo TENS and no TENS. No changes in functional tasks were observed with TENS. Thus, the current study suggests TENS has short‐term efficacy in relieving symptoms of fibromyalgia while the stimulator is active. Future clinical trials should examine the effects of repeated daily delivery of TENS, similar to the way in which TENS is used clinically on pain, fatigue, function, and quality of life in individuals with fibromyalgia.

Symptom clusters in men and women with heart failure and their impact on cardiac event-free survival

Background:Because patients with heart failure (HF) experience multiple symptoms simultaneously, it is necessary to explore symptom clusters rather than individual symptoms to determine their impact on outcomes. Given gender differences in symptom experience, examination of potential gender differences in clusters is reasonable. Objective:The objective of the study was to compare symptom clusters between men and women with HF, differences in patient characteristics among symptom clusters, and the impact of symptom clusters on cardiac event-free survival. Methods:A total of 331 patients with HF recruited from HF clinics were included (35% were female and 62% were of New York Heart Association classes III/IV). Cluster analysis was used to identify symptom clusters between men and women based on ratings of distress related to 7 symptoms. Analysis of variance or &khgr;2 test was used to compare characteristics of patient groups that were divided by the median split of total distress scores of each cluster. Cox proportional hazards regression was used to determine whether total scores of symptom distress in symptom clusters predicted time to first cardiac event. Results:Two identical symptom clusters were identified in men and women: a physical symptom cluster composed of dyspnea, fatigue/increased need to rest, fatigue/low energy, and sleep disturbances and an emotional/cognitive symptom cluster composed of worrying, feeling depressed, and cognitive problems. Patients with higher distress from the physical symptom cluster were primarily females and of New York Heart Association classes III and IV (P < .05). Patients with higher distress from the emotional/cognitive symptom cluster were younger than those with lower distress (P < .05). The total symptom distress score in the emotional/cognitive cluster, but not the physical cluster, was an independent predictor of cardiac event-free survival (hazard ratio, 1.18; 95% confidence interval, 1.03-1.37). Conclusion:Although distress for individual symptoms may differ between men and women, they both experienced identical symptom clusters. Only the emotional/cognitive cluster predicted a higher risk for a cardiac event. These results suggested that interventions should be developed that consider symptom clusters. Targeting patients who have high distress from emotional/cognitive symptoms may be particularly important as they may be most vulnerable for adverse outcomes.

Psychometrics of the PHQ-9 as a measure of depressive symptoms in patients with heart failure

Background Depression in patients with heart failure commonly goes undiagnosed and untreated. The Patient Health Questionnaire-9 (PHQ-9) is a simple, valid measure of depressive symptoms that may facilitate clinical assessment. It has not been validated in patients with heart failure. Aims To test the reliability, and concurrent and construct validity of the PHQ-9 in patients with heart failure. Methods A total of 322 heart failure patients (32% female, 61 ± 12 years, 56% New York Heart Association class III/IV) completed the PHQ-9, the Beck Depression Inventory-II (BDI-II), and the Control Attitudes Scale (CAS). Results Cronbach’s alpha of .83 supported the internal consistency reliability of the PHQ-9 in this sample. Inter-item correlations (range .22–.66) and item-total correlation (except item 9) supported homogeneity of the PHQ-9. Spearman’s rho of .80, (p < .001) between the PHQ-9 and the BDI-II supported the concurrent validity as did the agreement between the PHQ-9 and the BDI-II (Kappa = 0.64, p < .001). At cut-off score of 10, the PHQ-9 was 70% sensitive and 92% specific in identifying depressive symptoms, using the BDI-II scores as the criterion for comparison. Differences in PHQ-9 scores by level of perceived control measured by CAS (t318 = −5.05, p < .001) supported construct validity. Conclusion The PHQ-9 is a reliable, valid measure of depressive symptoms in patients with heart failure.

‘It could be worse … lot's worse!’ Why health-related quality of life is better in older compared with younger individuals with heart failure

BACKGROUND health-related quality of life (HRQOL) is markedly impaired in patients with heart failure (HF). Despite worse prognosis and physical status, older patients have better HRQOL than younger patients. OBJECTIVE to determine reasons for differences in HRQOL in older compared with younger HF patients. METHODS a mixed methods approach was used. HRQOL was assessed using the Minnesota Living with HF Questionnaire and compared among HF patients (n = 603) in four age groups (≤ 53, 54-62, 63-70 and ≥ 71 years). Socio-demographic/clinical and psychological factors related to HRQOL were determined in four groups using multiple regressions. Patients (n = 20) described their views of HRQOL during semi-structured interviews. RESULTS HRQOL was worse in the youngest group, and best in the two oldest groups. The youngest group reported higher levels of depression and anxiety than the oldest group. Anxiety, depression and functional capacity predicted HRQOL in all age groups. Qualitatively, patients in all age groups acknowledged the negative impact of HF on HRQOL; nonetheless older patients reported that their HRQOL exceeded their expectations for their age. Younger patients bemoaned the loss of activities and roles, and reported their HRQOL as poor. CONCLUSIONS better HRQOL among older HF patients is the result, in part, of better psychosocial status. The major factor driving better HRQOL among older patients is a change with advancing age in expectations about what constitutes good HRQOL.

Identification of symptom clusters among patients with heart failure: An international observational study

BACKGROUND Virtually all patients with heart failure experience multiple symptoms simultaneously, yet clinicians and researchers usually consider symptoms in isolation. Recognizing and responding early to escalating symptoms is essential to preventing hospitalizations in heart failure, yet patients have considerable difficulty recognizing symptoms. Identification of symptom clusters could improve symptom recognition, but cultural differences may be present that must be considered. OBJECTIVES To identify and compare symptom clusters in heart failure patients from the United States, Europe and Asia. DESIGN Cross-sectional, observational study. SETTINGS In- and out-patient settings in three regions of the world: Asia (i.e., China and Taiwan); Europe (i.e., the Netherlands and Sweden); and the United States. PARTICIPANTS A total of 720 patients with confirmed heart failure. Propensity scoring using New York Heart Association Classification was used to match participants from each of the three regions. METHODS Symptoms were identified using the Minnesota Living with Heart Failure Questionnaire. To identify symptom clusters we used cluster analysis with the hierarchical cluster agglomerative approach. We used the Euclidean distance to measure the similarity of variables. Proximity between groups of variables was measured using Wards method. The resulting clusters were displayed with dendrograms, which show the proximity of variables to each other on the basis of semi-partial R-squared scores. RESULTS There was a core group of symptoms that formed two comparable clusters across the countries. Dyspnea, difficulty in walking or climbing, fatigue/increased need to rest, and fatigue/low energy were grouped into a cluster, which was labeled as a physical capacity symptom cluster. Worrying, feeling depressed, and cognitive problems were grouped into a cluster, which was labeled as an emotional/cognitive symptom cluster. The symptoms of edema and trouble sleeping were variable among the countries and fell into different clusters. CONCLUSION Despite the diversity in cultures studied, we found that symptoms clustered similarly among the cultural groups. Identification of similar symptoms clusters among patients with heart failure may improve symptom recognition in both patients and healthcare providers.

Symptom Variability, Not Severity, Predicts Rehospitalization and Mortality in Patients with Heart Failure

Background: Inability of heart failure (HF) patients to recognize worsening symptoms that herald an exacerbation is a common reason for HF readmissions. Aims: To examine the relationship between patterns of HF symptom variability, and HF event-free survival. Methods: Patients with HF (N = 71) rated HF symptoms daily for 30 days. Symptoms were rated on a 10 point scale anchored at the extreme ends by “worst symptom could be” and “best symptom could be”. Patients were followed for an average of 1 year to track HF and cardiac rehospitalizations and all-cause mortality. Results: Cox regression comparing event-free survival between patients who had highly variable symptom ratings across the 30-days and those whose symptoms were less variable revealed worse event-free survival in patients with more variable symptoms of shortness of breath or edema. Symptom variability predicted event-free survival independently of severity of symptoms, ejection fraction, comorbidities, age and gender. Symptom severity did not predict rehospitalization or mortality. Conclusion: Regardless of symptom severity, patients whose symptoms fluctuated in an improving and worsening pattern were at substantially greater risk for poorer event-free survival. These patients may become accustomed to this pattern such that they expect symptoms to improve and thus do not seek treatment with worsening symptoms.

The Association of Co-morbid Symptoms of Depression and Anxiety With All-Cause Mortality and Cardiac Rehospitalization in Patients With Heart Failure

BACKGROUND Patients with heart failure (HF) experience multiple psychologic symptoms. Depression and anxiety are independently associated with survival. Whether co-morbid symptoms of anxiety and depression are associated with outcomes in patients with HF is unknown. OBJECTIVE To determine whether co-morbid symptoms of depression and anxiety are associated with all-cause mortality or rehospitalization for cardiac causes in patients with HF. METHOD A total of 1260 patients with HF participated in this study. Cox regression analysis was used to determine whether co-morbid symptoms of depression and anxiety independently predicted all-cause mortality and cardiac rehospitalization. Anxiety and depression were treated first as continuous-level variables, then as categorical variables using standard published cut points. Patients were then divided into 4 groups based on the presence of anxiety and depression symptoms. RESULTS When entered as a continuous variable, the interaction between anxiety and depression (hazard ratio = 1.02; 95% CI: 1.01-1.03; p = 0.002) was a significant predictor of all-cause mortality in patients with HF. When entered as a categorical variable, co-morbid symptoms of depression and anxiety (vs no symptoms or symptoms of anxiety or depression alone) independently predicted all-cause mortality (hazard ratio = 2.59; 95% CI: 1.49-4.49; p = 0.001). None of the psychologic variables was a predictor of cardiac rehospitalization in patients with HF whether using the continuous or categorical level of measurement. CONCLUSION To improve mortality outcomes in patients with HF, attention must be paid by health care providers to the assessment and management of co-morbid symptoms of depression and anxiety.

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.

Association of Physical versus Affective Depressive Symptoms with Cardiac Event-Free Survival in Patients with Heart Failure

Objective To determine whether physical depressive symptoms inflate the association between depressive symptoms as measured with the nine-item Patient Health Questionnaire (PHQ-9) and cardiac event–free survival in patients with heart failure (HF). Methods A total of 210 patients with HF were recruited from HF clinics affiliated with two academic medical centers. The PHQ-9 was used to assess levels of depressive symptoms. Cardiac event–free survival data (cardiac death, cardiac hospitalization, or cardiac emergency department visit) were collected for a median follow-up of 360 days. Cox proportional hazards regression analyses were performed separately for physical and affective depressive symptom dimensions of the PHQ-9 to examine predictive ability for time to the first cardiac event. Results Scores of both physical and affective depressive symptom dimensions of the PHQ-9 predicted time to the first cardiac event in separate unadjusted models. However, scores of the physical depressive symptom dimension did not predict time to the first cardiac events, whereas scores of the affective depressive symptom dimension remained as an independent predictor (hazard ratio = 1.12, 95% confidence interval = 1.03–1.22) after controlling for health status (comorbidities and the New York Heart Association functional class) and clinical and sociodemographic factors. Conclusions Affective depressive symptoms, not physical depressive symptoms, predicted time to the first cardiac event independent of health status and clinical and sociodemographic characteristics. The use of the full PHQ-9 does not inflate the relationship of depressive symptoms to cardiac event–free survival. Thus, clinicians can use the PHQ-9 to assess depressive symptoms in their patients with HF without concern that the instrument overestimates the relationship between depressive symptoms and outcomes. Abbreviations HF = heart failure PHQ-9 = nine-item Patient Health Questionnaire

Psychometric testing of the Duke Activity Status Index in patients with heart failure.

Background: Patients with heart failure (HF) experience difficulty performing activities of daily living. As impaired functional status is adversely associated with outcomes, it is important to accurately evaluate patient functional status. The Duke Activity Status Index (DASI) is a 12-item, self-administered questionnaire to measure functional status. However, its psychometric properties have not been determined in patients with HF. The purpose of this study was to examine the psychometric properties of the DASI in patients with HF. Methods and results: We used data from 297 patients with a diagnosis of HF (age 61±11 years, 31% female) for psychometric testing. Internal consistency reliability of the DASI was high (Cronbach’s alpha=0.86). Criterion-related validity was supported by significantly different DASI scores for each New York Heart Association classification. Construct validity was supported by significant correlation of DASI scores with health-related quality of life (r = −0.64), depressive symptoms (r = −0.44), and N-terminal B-type natriuretic peptide (r = −0.14). Conclusion: Our data support the psychometric properties of the DASI as a measure of functional status in patients with HF. This instrument can be used to evaluate functional status and enhance health care provider understanding of functional status related to daily living from the patient perspective.