Attending Hospital Outpatient Clinics Research Articles

Optimal care of people with brain cancer in the emergency department: A cross-sectional survey of outpatient perceptions

ObjectivePeople diagnosed with brain cancer commonly present to the emergency department (ED). There is uncertainty about essential components and processes of optimal care from the perspective of consumers, and few guidelines exist to inform practice. This study examined the perceptions of outpatients and their support persons regarding what constitutes optimal care for people with brain cancer presenting to the ED. MethodsA cross sectional descriptive survey study was undertaken. Participants included adults attending hospital outpatient clinics (n ​= ​181, 60% of eligible participants). Participants completed a survey assessing perceptions of optimal care for brain cancer patients presenting to emergency department and socio-demographic characteristics. ResultsThe survey items endorsed as ‘essential’ by participants included that the emergency department team help patients: ‘understand signs and symptoms to watch out for’ (51%); ‘understand the next steps in care and why’ (48%); ‘understand if their medical condition suggests it is likely they will die in hospital’ (47%); ‘ask patients if they have a substitute decision maker and want that person told they are in the emergency department’ (44%); ‘understand the purpose of tests and procedures’ (41%). ConclusionsSymptom management, effective communication and supported decision-making should be prioritised by ED teams. Further research to establish the views of those affected by brain cancer about essential care delivered in the ED setting, and to compare these views with the quality of care that is actually delivered, is warranted.

Increased malaria parasitaemia among adults living with HIV who have discontinued cotrimoxazole prophylaxis in Kitgum district, Uganda.

BackgroundAlthough WHO recommends cotrimoxazole (CTX) discontinuation among HIV patients who have undergone immune recovery and are living in areas of low prevalence of malaria, some countries including Uganda recommend CTX discontinuation despite having a high malaria burden. We estimated the prevalence and factors associated with malaria parasitaemia among adults living with HIV attending hospital outpatient clinic before and after discontinuation of CTX prophylaxis.MethodsBetween March and April 2019, 599 participants aged 18 years and above, and attending Kitgum hospital HIV clinic in Uganda were enrolled in a cross study. A standardized questionnaire was administered and physical examination conducted. A finger-prick blood sample was collected for identification of malaria parasites by microscopy. The prevalence of parasitaemia was estimated and compared among participants on and those who had discontinued CTX prophylaxis, and factors associated with malaria parasitaemia assessed.ResultsOf the enrolled participants, 27 (4.5%) had malaria parasites and 452 (75.5%) had stopped CTX prophylaxis. Prevalence of malaria parasitaemia was significantly higher in participants who had stopped CTX prophylaxis (5.5% versus 1.4% p = 0.03) and increased with increasing duration since the discontinuation of prophylaxis. Compared to participants taking CTX, those who discontinued prophylaxis for 3–5 months and >5 months were more likely to have malaria parasites (adjusted prevalence ratio (aPR) = 1.64, 95% CI 0.37–7.29, p = 0.51, and aPR = 6.06, 95% CI 1.34–27.3, P = 0.02). Low CD4 count (< 250cells/mm3) was also associated with increased risk of having parasites (aPR = 4.31, 95% CI 2.13–8.73, p <0.001).ConclusionPeople from malaria endemic settings living with HIV have a higher prevalence of malaria parasitaemia following discontinuation of CTX compared to those still on prophylaxis. The risk increased with increasing duration since discontinuation of the prophylaxis. HIV patients should not discontinue CTX prophylaxis in areas of Uganda where the burden of malaria remains high. Other proven malaria control interventions may also be encouraged in HIV patients following discontinuation of CTX prophylaxis.

Prevalence, perceived barriers and sociodemographic correlates of advance care planning in a sample of outpatients.

This study aimed to examine the prevalence and perceived barriers to uptake of advance care planning (ACP), including appointment of an enduring guardian (EG) and completion of an advance care directive (ACD) among Australian adults attending hospital outpatient clinics. Sociodemographic correlates of not completing ACP were also assessed. A cross-sectional survey exploring the uptake of ACP was conducted with outpatients and their accompanying persons aged >18 years (n =191) at one regional hospital in New South Wales, Australia. Rates of completion of an ACD and appointment of an EG were 20% (n =37) and 35% (n =67) respectively. The most common reason for non-completion of an ACD and not appointing an EG was: 'didn't think I needed this'. Younger age was associated with not having appointed an EG (OR 3.8, 95% CI 1.2-12.1, P =0.02). No sociodemographic characteristics were significantly associated with non-completion of ACDs. Uptake of ACP is suboptimal among outpatients. Community-based healthcare providers are well positioned to promote ACP with outpatients.

Planning Ahead for Dementia Research Participation: Insights from a Survey of Older Australians and Implications for Ethics, Law and Practice

People with dementia have commonly been excluded from research. The adverse impacts of this exclusion are now being recognized and research literature, position statements, and ethics guidelines increasingly call for inclusion of people with dementia in research. However, few published studies investigate the views of potential participants on taking part in research should they experience dementia-related cognitive impairment. This cross-sectional survey examined the views of people aged sixty and older (n=174) attending hospital outpatient clinics about clinical research participation if they had dementia and impaired decision-making ability. Over 90 percent of respondents were agreeable to participating in a wide range of research activities, such as cognitive testing, physical measurements, imaging procedures, and blood draws. For drug studies, however, agreement dropped to 60 percent. Altruism was a strong motivator for research participation. In regard to who should be involved in decisions about their participation in research during periods of incapacity, respondents mostly preferred the person they appoint as their substitute decision-maker for healthcare matters (88%) or a doctor or health professional on the research team (78%). Over three-quarters (79%) expressed interest in making an advance research directive. The study findings are discussed in relation to law reforms in Australia that aim to strengthen respect and inclusion for people with impaired decision-making capacity, especially by providing frameworks for advance planning for research participation.

Cross-Sectional Study on Knowledge of Chronic Kidney Disease among Patients Attending Hospital Outpatient Clinics in Sabah

Introduction&#x0D; The number of new dialysis acceptance and dialysis prevalence rate in Malaysia has been increasing steadily for the past 10 years, and forecasting models predict that these numbers will continue to increase. Chronic Kidney Disease (CKD) awareness may slow the progression of CKD. As CKD awareness is dependent upon general knowledge of CKD, assessing the knowledge of CKD of the local population is important, to direct future CKD education efforts.

Development and evaluation of a consumer information resource, including Patient Decision Aid, for lung cancer screening: a quasi-experimental study.

Lung cancer screening of high-risk individuals with computed tomography is a promising intervention to reduce lung cancer mortality. Patient Decision Aids (PtDAs) may assist eligible individuals assess the risks and benefits associated with screening. Screening preference is high among lower-risk, screening-ineligible individuals and strategies are needed to reduce screening demand among this group. We developed and evaluated a resource comprising a recruitment pamphlet combined with either a PtDA for screening-eligible individuals or an education pamphlet for screening-ineligible individuals. Quasi-experimental pre-post pamphlet exposure design. Ever-smokers aged 55-80 years attending hospital outpatient clinics were invited. Among screening-eligible participants, the assessed outcome was change in score on the Decisional Conflict Scale (DCS). Among screening-ineligible participants, the assessed outcomes were change in screening preference. In the study 51% (55/107) of invited individuals participated, with mean ± standard deviation age 66.9 ± 6.4 years, 53% (29/55) male, and 65% (36/55) eligible for screening. Median (interquartile range) DCS among screening-eligible participants reduced from 28.9 (22.7-45.3) pre-PtDA to 25 (1.6-29.7) post-PtDA (p < .001), but there was no significant change in the proportion that reached the accepted threshold for decisional certainty (DCS < 25, 10/36 [28%] pre-exposure vs. 14/36 [39%] post-exposure, p = .1). Screening preference among screening-ineligible individuals reduced after viewing the screening-ineligible brochure (pre-exposure median of "Prefer" to post-exposure median of "Unsure," p = .001). Our consumer information pamphlets about lung cancer screening may reduce decisional conflict and improve alignment of screening preference with eligibility.

Advance care planning for patients with advanced illnesses attending hospital outpatient clinics study: a study protocol for a randomised controlled trial

IntroductionIt is unclear whether advance care planning (ACP) undertaken with patients living in the community can improve patient care and avoid unwanted interventions and hospital admissions. We have designed a...

Prevalence and characteristics of breakthrough cancer pain in an outpatient clinic in a Catalan teaching hospital: incorporation of the Edmonton Classification System for Cancer pain into the diagnostic algorithm

BackgroundBreakthrough cancer pain (BTcP) is defined according to its principal characteristics: high intensity, short time interval between onset and peak intensity, short duration, potential recurrence over 24 h and non-responsiveness to standard analgesic regimes. The Edmonton Classification System for Cancer Pain (ECS-CP) is a classification tool that evaluates different dimensions of pain.The aim of this study was to measure prevalence and the main characteristics of BTcP in a sample of advanced cancer patients and to explore the complexity observed when ECS-CP is incorporated into BTcP diagnostics algorithm.MethodsDescriptive prevalence study (Retrospective chart review). Davies’ algorithm was used to identify BTcP and ECS-CP was used to recognize appropriate dimensions of pain. The study was conducted in a sample of advanced cancer patients attending hospital outpatient clinic in Lleida, Spain. 277 patients were included from 01/01/2014 to 31/12/2015. No direct contact was made with participants. The following information was extracted from the palliative care outpatient clinic database: age, gender, civil status, cognitive impairment status, functional performance status and variables related to tumour. Only BTcP cases were included.ResultsPrevalence of BTcP was 39.34% (63.9% men). Mean of age was 68.2 years. Main diagnosis was lung cancer (n = 154; 31.6%). Metastases were diagnosed in 83% of the sample. 138 patients (49.8%) were diagnosed with 1 type of BTcP and 139 (50.2%) were diagnosed with more than one type of BTcP. In total, 488 different types of BTcP were recorded (mean 1.75 ± 0, 9), 244 of these types (50%) presented a component of neuropathic pain. Addictive behaviour, measured through CAGE test, was present in 29.2% (N = 81) of the patients and psychological distress was present in 40.8% (n = 113).ConclusionsPrevalence of BTcP (39.34%) is similar to the one reflected in the existing literature. Study results indicate that the routine use of ECS-CP in a clinical setting allows us to detect more than one type of BTcP as well as additional complexity associated with pain (neuropathic, addictive behavior and psychological distress).

Bloodstream bacterial infection among outpatient children with acute febrile illness in north-eastern Tanzania.

BackgroundFever is a common clinical symptom in children attending hospital outpatient clinics in rural Tanzania, yet there is still a paucity of data on the burden of bloodstream bacterial infection among these patients.MethodsThe present study was conducted at Korogwe District Hospital in north-eastern Tanzania. Patients aged between 2 and 59 months with a history of fever or measured axillary temperature ≥37.5°C attending the outpatient clinic were screened for enrolment into the study. Blood culturing was performed using the BACTEC 9050® system. A biochemical analytical profile index and serological tests were used for identification and confirmation of bacterial isolates. In-vitro antimicrobial susceptibility testing was performed using the Kirby-Bauer disc diffusion method. The identification of Plasmodium falciparum malaria was performed by microscopy with Giemsa stained blood films.ResultsA total of 808 blood cultures were collected between January and October 2013. Bacterial growth was observed in 62/808 (7.7%) of the cultured samples. Pathogenic bacteria were identified in 26/808 (3.2%) cultures and the remaining 36/62 (58.1%) were classified as contaminants. Salmonella typhi was the predominant bacterial isolate detected in 17/26 (65.4%) patients of which 16/17 (94.1%) were from patients above 12 months of age. Streptococcus pneumoniae was the second leading bacterial isolate detected in 4/26 (15.4%) patients. A high proportion of S.typhi 11/17 (64.7%) was isolated during the rainy season. S. typhi isolates were susceptible to ciprofloxacin (n = 17/17, 100%) and ceftriaxone (n = 13/17, 76.5%) but resistant to chloramphenicol (n = 15/17, 88.2%). P. falciparum malaria was identified in 69/808 (8.5%) patients, none of whom had bacterial infection.ConclusionBloodstream bacterial infection was not found to be a common cause of fever in outpatient children; and S. typhi was the predominant isolate. This study highlights the need for rational use of antimicrobial prescription in febrile paediatric outpatients presenting at healthcare facilities in rural Tanzania.

Comparison between exercise performance in asthmatic children and healthy controls – Physical Activity Questionnaire application

BackgroundThe PAQ questionnaire (Physical Activity Questionnaire - Kowalski, Crocker, Donen) is a self-administered 7-day recall validated questionnaire that measures physical activity levels in young people. A final activity score is obtained (1 indicates low and 5 indicates high physical activity level).Our aim was to determine whether there was any difference between the level of physical activity of children with controlled allergic disease and healthy children. Patients and methodsWe used the PAQ questionnaire with a group of asthmatic children attending hospital outpatient clinic and a group of healthy children matched for age. Results155 children with allergic disease (median age of 11 years; 63% males) and 158 healthy controls (median age of 10 years; 46% males) answered the questionnaire.There were no differences in the overall level of physical activity, estimated by PAQ score, between allergic and healthy children (2,40±0,7 vs 2,48±0,62; p=0,32). Performance in physical education classes and after school sports activity was found to be different between the study groups; healthy children were more active (p=0,011) and did more sports between 6 and 10 pm (p=0,036). No other statistically significant differences were found between the study groups. ConclusionDespite the fact that a majority of the parents of allergic children stated that their child's disease was a barrier to physical activity, in our study there seems to be no difference between the level of physical activity of controlled asthmatic children and their healthy peers.

Comparison between exercise performance in asthmatic children and healthy controls – Physical Activity Questionnaire application

BackgroundThe PAQ questionnaire (Physical Activity Questionnaire - Kowalski, Crocker, Donen) is a self-administered 7-day recall validated questionnaire that measures physical activity levels in young people. A final activity score is obtained (1 indicates low and 5 indicates high physical activity level).Our aim was to determine whether there was any difference between the level of physical activity of children with controlled allergic disease and healthy children. Patients and methodsWe used the PAQ questionnaire with a group of asthmatic children attending hospital outpatient clinic and a group of healthy children matched for age. Results155 children with allergic disease (median age of 11 years; 63% males) and 158 healthy controls (median age of 10 years; 46% males) answered the questionnaire.There were no differences in the overall level of physical activity, estimated by PAQ score, between allergic and healthy children (2,40±0,7 vs 2,48±0,62; p=0,32). Performance in physical education classes and after school sports activity was found to be different between the study groups; healthy children were more active (p=0,011) and did more sports between 6 and 10 pm (p=0,036). No other statistically significant differences were found between the study groups. ConclusionDespite the fact that a majority of the parents of allergic children stated that their child's disease was a barrier to physical activity, in our study there seems to be no difference between the level of physical activity of controlled asthmatic children and their healthy peers.

Anti-TNF-Alpha-Adalimumab Therapy Is Associated with Persistent Improvement of Endothelial Function without Progression of Carotid Intima-Media Wall Thickness in Patients with Rheumatoid Arthritis Refractory to Conventional Therapy

To determine whether treatment with the anti-TNF-alpha blocker adalimumab yields persistent improvement of endothelial function and prevents from morphological progression of subclinical atherosclerosis in patients with rheumatoid arthritis (RA) refractory to conventional therapy, a series of 34 consecutive RA patients, attending hospital outpatient clinics and who were switched from disease modifying antirheumatic drug therapy to anti-TNF-alpha-adalimumab treatment because of severe disease, were assessed by ultrasonography techniques before the onset of adalimumab therapy (at day 0) and then at day 14 and at month 12. Values of flow-mediated endothelium-dependent vasodilatation at day 14 and at month 12 were significantly higher (mean ± standard deviation (SD): 6.1 ± 3.9%; median: 5.7% at day 14, and mean ± SD: 7.4 ± 2.8%; median: 6.9% at month 12) than those obtained at day 0 (mean: 4.5 ± 4.0%; median: 3.6%; P = 0.03 and P < 0.001, resp.). Endothelium-independent vasodilatation results did not significantly change compared with those obtained at day 0. No significant differences were observed when carotid artery intima-media wall thickness values obtained at month 12 (mean ± SD: 0.69 ± 0.21 mm) were compared with those found at day 0 (0.65 ± 0.16 mm) (P = 0.3). In conclusion, anti-TNF-alpha-adalimumab therapy has beneficial effects on the development of the subclinical atherosclerosis disease in RA.

4247 POSTER What Do Patients Think About Telephone Aftercare?

BACKGROUND The National Cancer Survivorship Initiative Vision in the UK calls for a shift from the traditional medical model of hospital follow-up for people with cancer to developing alternative strategies that demonstrate real patient benefit and promote self management. Telephone aftercare is one such alternative approach. We have conducted randomised controlled trials (RCT) to demonstrate that telephone aftercare by specialist nurses is beneficial in breast and colorectal cancer, shifting the focus from searching for signs of recurrent disease to meeting the information and support needs of patients using a structured telephone intervention. While RCTs provide evidence of effectiveness, integrating qualitative research into RCTs allows in-depth analysis of how complex interventions work and the perceived impact. METHODS Interviews were conducted with 28 patients with breast cancer, 26 patients with colorectal cancer and five specialist nurses; all had either received or delivered telephone aftercare. Content analysis was used to analyse interview data. RESULTS All patients found telephone aftercare to be a positive experience, comparing favourably with hospital follow-up. The structured intervention was well received and patients felt confident that all relevant questions had been asked and answered and nothing had been “missed”. Patients reported telephone aftercare as convenient, economical and more “normal” than attending hospital outpatient clinics, providing continuity of care and carer. Specialist nurses reported the high level of skill, knowledge and confidence required to deliver the intervention. Specialist nurses perceived that, unlike hospital outpatient care, telephone aftercare met individual needs and enabled patients to self-manage when discharged from hospital follow-up. CONCLUSIONS The addition of qualitative methods to RCT’s of complex interventions advances our understanding of how interventions work. Useful insights were gained into how the intervention could be implemented into everyday clinical practice. Moreover these studies demonstrated that meeting psycho-social needs is essential to help patients who have survived a cancer diagnosis and treatment to self-manage.

Age-Specific Seroprevalence of Merkel Cell Polyomavirus, BK Virus, and JC Virus

We produced capsids of Merkel cell polyomavirus (MCPyV) in a baculovirus expression system and developed a virus-like particle (VLP) enzyme-linked immunosorbent assay (ELISA). To determine age-specific seroprevalence, serum samples were collected from 947 individuals attending hospital outpatient clinics and ranging in age from 1 to 93 years. To evaluate the association between exposure to MCPyV and Merkel cell cancer (MCC), plasma samples were obtained from 33 MCC patients and 37 controls. MCPyV seroprevalence was 45% in children under 10 years of age, increased to 60% in the next decade of life, and peaked at 81% among those 60 to 69 years of age. Levels of MCPyV capsid antibodies were positively correlated with age (P = 0.007). Virus specificity of MCPyV seroreactivity was supported by competitive inhibition of reactivity by MCPyV VLPs and not by BK polyomavirus (BKPyV) VLPs. MCPyV seroprevalence was greater among MCC patients (91%) than controls (68%; age-adjusted P value, 0.32); the mean level of MCPyV antibodies was also greater (P = 0.04). The age-specific seroprevalence of MCPyV shares with previously known polyomaviruses, BKPyV and JC polyomavirus (JCPyV), evidence of widespread exposure in human populations beginning early in life. MCPyV age-specific seroprevalence also has unique features. Seroprevalence among children is higher than that of JCPyV but lower than that of BKPyV. Among older adults, MCPyV seroprevalence remains high, while that of BKPyV declines and that of JCPyV continues to rise. In agreement with results from other studies, we found an association between MCPyV seropositivity and MCC, and higher levels of serum MCPyV capsid antibodies in MCC patients than in controls.

Telephone follow‐up after treatment for breast cancer: views and experiences of patients and specialist breast care nurses

To explore the views of patients and specialist breast care nurses on telephone follow-up after treatment for breast cancer. A recent randomised controlled trial demonstrated that nurse-led telephone follow-up led to high levels of patient satisfaction with no physical or psychological detriment. This study aimed to explore in more detail the views of patients randomised to telephone follow-up and the nurses who conducted telephone appointments. Qualitative. Individual interviews with 28 patients and four specialist breast care nurses. Content analysis was used to analyse the interview data. Telephone follow-up was convenient for patients and provided continuity of care. Speaking on the telephone was perceived as a more 'normal' activity than attending hospital outpatient clinics. A structured approach was appreciated, instilling feelings of confidence that all questions had been asked and no errors had been made. Specialist nurses emphasised the high level of skill required to deliver the intervention and perceived that the telephone approach was well able to meet the individual needs of patients. Positive views on telephone follow-up were reported. An experienced and skilled practitioner, with effective communication skills, is required to deliver the intervention and a period of training is recommended. Nurse-led telephone interventions have a broader applicability to other disease conditions, although more work is needed to develop appropriate interventions and evaluate their effectiveness. Nurses at advanced levels of practice are uniquely placed to deliver such complex interventions. However, a period of initial training with effective peer support and channels for ongoing feedback are essential for administering an intervention that relies on audio rather than visual cues.

SUBCLINICAL ATHEROSCLEROSIS IN PATIENTS WITH PSORIATIC ARTHRITIS: THE IMPACT OF CLASSICAL AND NEW CARDIOVASCULAR RISK FACTORS: PP.10.391

Objective: Increased cardiovascular morbidity and mortality have been observed in several immune mediated rheumatic diseases, including psoriatic arthritis (PsA). We evaluated subclinical atherosclerosis in PsA patients according with hypertensive status by studying non invasively structural and functional properties of arteries. Design and Method: We studied 41 consecutive patients with PsA (of whom, 23 hypertensives) attending hospital outpatient clinics. 40 normotensives healthy subjects (NC) and 19 hypertensives (HT-C) served as controls. We evaluated by B-mode ultrasound the carotid intima media thickness (IMT). Measurements were expressed as mean-IMT (cumulative mean of mean IMT measured in each carotid segment, common, bulb, and internal carotid artery, bilaterally) and as M-MAX (cumulative mean of maximum IMT). Endothelial function was evaluated by post-occlusion flow mediated dilation (FMD) of the brachial artery using high-sensitivity brachial ultrasonography. NO-independent vasodilation was evaluated by the response to sublingual glyceril trinitrate (GTN). Results: PsA had a higher mean-IMT compared to NC. Hypertensive PsA displayed higher M-MAX versus both HT-C (p = 0.007) and normotensive PsA (p = 0.026). FMD was significantly lower in PsA than in NC (8.9%), whereas there was no difference between hypertensive PsA (6.1%), normotensive PsA (5.7%), and HT-C (6.3%). GTN response was similar in all groups. The TNFα level was much higher in PsA patients than in the other groups. In the entire cohort, the IMT parameters were significantly related to TNFα as well as classical risk factors, including blood pressure and lipid profile, whereas FMD was inversely related to TNFα levels and blood pressure but not lipid parameters. Conclusions: Subclinical atherosclerosis is enhanced in PsA compared to NC. In PsA, the hypertensive status proved to exert an additional effect on M-MAX, a parameter of advanced pro-atherogenic remodelling. FMD was reduced in PsA irrespective of hypertensives status. Thus, PsA per se implies a pro-atherogenic remodelling which is enhanced by the hypertensive status. In addition, TNFα seems to play a role in the hampering the functional properties of vascular wall probably through endothelial dysfunction.

Malnutrition ‘self-screening’ with ‘MUST’ in hospital outpatients: concurrent validity and the ease of use

A 19.6% of patients categorised themselves into medium (9.8 %) and high risk (9.8 %) of malnutrition. For the three-category classification of ‘MUST’ (low, medium and high risk) agreement between patient ‘self-screening’ and health-care professional screening was 90 % ( k= 0.70 (within the range of 0.45–0.75 indicative of ‘fair-good’ agreement); SE 0.058; P < 0.001). For two categories (low risk and medium + high risk) agreement was 93 % ( k= 0.78 (within the range of 0.75–1.0, indicative of ‘excellent’ agreement); SE 0.058; P < 0.001). Disagreements between the two methods were not systematically under or over categorised. Of the 14 (7 %) discrepancies associated with the two category classification, five were associated with BMI score, seven with weight loss score and one with acute disease score (one was associated with both weight loss and acute disease effect score). Most patients reported that they were able to complete ‘self-screening’ in less than 5 min (71 %), overall 98 % were able to complete in less than 10 min. Patients found the tool easy or very easy to understand (96%) and complete (98%), with 94 % reporting that they were happy to screen themselves. The mean recorded time for patients to complete screening was 5 min (SD 1 min 54 s). This study of patients attending hospital outpatient clinics shows that ‘self-screening’ involving ‘MUST’ is acceptable to patients, user friendly and with good concurrent validity to health-care professional screening. Further work is required to understand how ‘selfscreening’ and subsequent management can be effectively implemented into routine outpatients, and the wider community.

Abstract 5204: Vascular Remodelling in Patients With Psoriatic Arthritis: The Impact of Blood Pressure

Increased cardiovascular mortality have been observed in several immune mediated rheumatic diseases, including psoriatic arthritis (PsA). We evaluated subclinical atherosclerosis in PsA patients according with hypertensive status by studying non invasively structural and functional properties of arteries. We studied 41 consecutive patients with PsA (of whom, 48% hypertensives) attending hospital outpatient clinics. 40 normotensives healthy subjects (NC) and 18 hypertensives (HT-C) served as controls. We evaluated by B-mode ultrasound the carotid intima media thickness (IMT) expressed as mean-IMT (cumulative mean of mean IMT measured in each carotid segment, common, bulb, and internal carotid artery, bilaterally) and as M-MAX (cumulative mean of maximum IMT). Endothelial function was evaluated by post-occlusion flow mediated dilation (FMD) of the brachial artery using ultrasonography. NO-independent vasodilation was evaluated by the response to sublingual glyceril trinitrate (GTN). PsA had a higher mean-IMT compared to NC. Hypertensive PsA displayed higher M-MAX versus both HT-C (p=0.007) and normotensive PsA (p=0.026). FMD was lower in PsA than in NC, whereas there was no difference between hypertensive PsA, normotensive PsA, and HT-C. GTN response was similar in all groups. In conclusion, our data show that subclinical atherosclerosis is enhanced in PsA compared to NC. In PsA, the hypertensive status proved to exert an additional effect on M-MAX, a parameter of advanced pro-atherogenic remodeling. FMD was reduced in PsA irrespective of hypertensives status. Thus, PsA per se implies a pro-atherogenic remodeling which is enhanced by the hypertensive status.

Left ventricular diastolic dysfunction in elderly hypertensives: results of the APROS-diadys study

A number of patients with chronic heart failure (CHF) have diastolic but not systolic dysfunction. This occurs particularly in the elderly and in hypertension, but the prevalence of diastolic dysfunction in elderly hypertensives without CHF has never been investigated systematically. The Assessment of PRevalence Observational Study of Diastolic Dysfunction (APROS-diadys) project was a cross-sectional observational study on elderly (age >/= 65 years) hypertensives without systolic dysfunction [left ventricular ejection fraction (LVEF) >/= 45%] consecutively attending hospital outpatient clinics in Italy, in order to establish the prevalence of echocardiographic signs of diastolic dysfunction according to various criteria, and to correlate them with a number of demographic and clinical characteristics. Primary criteria for diastolic dysfunction was an E/A ratio (ratio between transmitral peak velocities of E and A waves) < 0.7 or > 1.5 on echocardiographic Doppler examination. Secondary criteria were: E/A < 0.5 and deceleration time (DT) > 280 ms, or isovolumic relaxation time (IVRT) > 105 ms or pulmonary vein (PV) peak systolic/peak diastolic flow (S/D) ratio > 2.5 or PV atrial retrograde flow (PV A) > 35 cm/s. Throughout Italy, 27 447 patients were screened in 107 clinics, with 24 141 excluded according to protocol. Among the remaining 3336 patients, 754 (22.6%) had signs of CHF. After exclusion of 37 protocol violators, 2545 patients (49.0% men, mean age 70.3 years, 95.4% under antihypertensive treatment) were studied ultrasonographically. Diastolic dysfunction (primary criteria) was found in 649 (25.8%) patients. Multiple logistic regression analysis found age, gender, left ventricular mass, systolic and pulse pressures and midwall shortening fraction as significant covariates. Using secondary criteria, the prevalence of diastolic dysfunction was higher (45.6%), mostly because of IVRT > 105 ms or PVA flow > 35 cm/s. CHF and diastolic dysfunction are highly prevalent in elderly hypertensives attending hospital clinics.

Asthma as a Barrier to Children's Physical Activity: Implications for Body Mass Index and Mental Health

The purpose of this work was to identify barriers to physical activity in children with asthma and to compare their customary activity levels, BMI and emotional well-being with that of children with other medical conditions. It was hypothesized that children with asthma would have higher BMI and lower levels of customary activity. We studied children aged 7 to 14 years attending hospital outpatient clinics for either asthma (asthma group: n = 56) or for otorhinolaryngology or dermatological conditions (nonasthma group: n = 61). In this cross-sectional survey, children's weight and height were recorded and their BMI classified according to International Obesity Task Force classification of obesity. Child mental health was assessed by the parent-rated Strengths and Difficulties Questionnaire. The child-rated Physical Activity Questionnaire assessed total sedentary and physical activities during the previous 24 hours. The asthma group had a higher mean BMI (20.78 vs 18.82) and higher rates of obesity (21.4% vs 6.6%). Children with asthma reported fewer physical activities than the nonasthma group (median 4 per day vs 6 per day) but comparable levels of sedentary activities. Asthma was the strongest predictor of lower activity scores, followed by younger age. The asthma group had higher levels of emotional difficulties and, within this group, more active children had better mental health. More parents in the asthma group identified the child's health as a barrier to exercise (60.7% vs 11%). The same was true of children (66.1% vs 11.5%). We found that children attending a hospital clinic for asthma were more likely to be obese and were significantly less active than a comparison group with other medical conditions. Asthma was identified as a barrier to exercise by parents and children. Strategies to promote exercise within pediatric asthma care are needed to protect both mental and physical health.