Dr Phillip Newton

Background. The study aimed to determine whether the addition of cognitive impairment, depression, or both, to the assessment of physical frailty (PF) is associated with the risk of lung transplant (LTX) waitlist mortality. Methods. Since March 2013, all patients referred for LTX evaluation underwent PF assessment. Cognition was assessed using the Montreal Cognitive Assessment and depression assessed using the Depression in Medical Illness questionnaire. We assessed the association of 4 composite frailty measures: PF =3 of 5 = frail, cognitive frailty (CogF =3 of 6 = frail), depressive frailty (DepF =3 of 6 = frail), and combined frailty (ComF =3 of 7 = frail) with waitlist mortality. Results. The prevalence of PF was 78 (22%), CogF 100 (28%), DepF 105 (29%), and ComF 124 (34%). Waitlist survival in the non-PF group was 94% ± 2% versus 71% ± 7% in the PF group (P < 0.001). Cox proportional hazards regression analysis demonstrated that PF (adjusted hazard ratio [HR], 4.88; 95% confidence interval [CI], 2.06-11.56), mild cognitive impairment (adjusted HR, 3.03; 95% CI, 1.05-8.78), and hypoalbuminemia (adjusted HR, 0.89; 95% CI, 0.82-0.97) were independent predictors of waitlist mortality. There was no significant difference in the area under the curve of the 4 frailty measures. Conclusions. The addition of cognitive function and depression variables to the PF assessment increased the number of patients classified as frail. However, the addition of these variables does not strengthen the association with LTX waitlist mortality compared with the PF measure.

Nurses represent the largest sector of the healthcare workforce, and it is established that they are faced with ongoing physical and mental demands that leave many continuously stressed. In turn, this chronic stress may affect cardiac autonomic activity, which can be non-invasively evaluated using heart rate variability (HRV). The association between neurocognitive parameters during acute stress situations and HRV has not been previously explored in nurses compared to non-nurses and such, our study aimed to assess these differences. Neurocognitive data were obtained using the Mini-Mental State Examination and Cognistat psychometric questionnaires. ECG-derived HRV parameters were acquired during the Trier Social Stress Test. Between-group differences were found in domain-specific cognitive performance for the similarities (p¿=.03), and judgment (p¿=.002) domains and in the following HRV parameters: SDNNbaseline, (p¿=.004), LFpreparation (p¿=.002), SDNNpreparation (p¿=.002), HFpreparation (p¿=.02), and TPpreparation (p¿=.003). Negative correlations were found between HF power and domain-specific cognitive performance in nurses. In contrast, both negative and positive correlations were found between HRV and domain-specific cognitive performance in the non-nurse group. The current findings highlight the prospective use of autonomic HRV markers in relation to cognitive performance while building a relationship between autonomic dysfunction and cognition.

Introduction: The autonomic nervous system plays a vital role in the modulation of many vital bodily functions, one of which is sleep and wakefulness. Many studies have investigated the link between autonomic dysfunction and sleep cycles; however, few studies have investigated the links between short-term sleep health, as determined by the Pittsburgh Quality of Sleep Index (PSQI), such as subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction, and autonomic functioning in healthy individuals. Aim: In this cross-sectional study, the aim was to investigate the links between short-term sleep quality and duration, and heart rate variability in 60 healthy individuals, in order to provide useful information about the effects of stress and sleep on heart rate variability (HRV) indices, which in turn could be integrated into biological models for wearable devices. Methods: Sleep parameters were collected from participants on commencement of the study, and HRV was derived using an electrocardiogram (ECG) during a resting and stress task (Trier Stress Test). Result: Low-frequency to high-frequency (LF:HF) ratio was significantly higher during the stress task than during the baseline resting phase, and very-low-frequency and high-frequency HRV were inversely related to impaired sleep during stress tasks. Conclusion: Given the ubiquitous nature of wearable technologies for monitoring health states, in particular HRV, it is important to consider the impacts of sleep states when using these technologies to interpret data. Very-low-frequency HRV during the stress task was found to be inversely related to three negative sleep indices: sleep quality, daytime dysfunction, and global sleep score.

Stress is an inherent part of the normal human experience. Although, for the most part, this stress response is advantageous, chronic, heightened, or inappropriate stress responses can have deleterious effects on the human body. It has been suggested that individuals who experience repeated or prolonged stress exhibit blunted biological stress responses when compared to the general population. Thus, when assessing whether a ubiquitous stress response exists, it is important to stratify based on resting levels in the absence of stress. Research has shown that stress that causes symptomatic responses requires early intervention in order to mitigate possible associated mental health decline and personal risks. Given this, real-time monitoring of stress may provide immediate biofeedback to the individual and allow for early self-intervention. This study aimed to determine if the change in heart rate variability could predict, in two different cohorts, the quality of response to acute stress when exposed to an acute stressor and, in turn, contribute to the development of a physiological algorithm for stress which could be utilized in future smartwatch technologies. This study also aimed to assess whether baseline stress levels may affect the changes seen in heart rate variability at baseline and following stress tasks. A total of 30 student doctor participants and 30 participants from the general population were recruited for the study. The Trier Stress Test was utilized to induce stress, with resting and stress phase ECGs recorded, as well as inter-second heart rate (recorded using a FitBit). Although the present study failed to identify ubiquitous patterns of HRV and HR changes during stress, it did identify novel changes in these parameters between resting and stress states. This study has shown that the utilization of HRV as a measure of stress should be calculated with consideration of resting (baseline) anxiety and stress states in order to ensure an accurate measure of the effects of additive acute stress.

Recently, there has been an increase in the production of devices to monitor mental health and stress as means for expediting detection, and subsequent management of these conditions. The objective of this review is to identify and critically appraise the most recent smart devices and wearable technologies used to identify depression, anxiety, and stress, and the physiological process(es) linked to their detection. The MEDLINE, CINAHL, Cochrane Central, and PsycINFO databases were used to identify studies which utilised smart devices and wearable technologies to detect or monitor anxiety, depression, or stress. The included articles that assessed stress and anxiety unanimously used heart rate variability (HRV) parameters for detection of anxiety and stress, with the latter better detected by HRV and electroencephalogram (EGG) together. Electrodermal activity was used in recent studies, with high accuracy for stress detection; however, with questionable reliability. Depression was found to be largely detected using specific EEG signatures; however, devices detecting depression using EEG are not currently available on the market. This systematic review highlights that average heart rate used by many commercially available smart devices is not as accurate in the detection of stress and anxiety compared with heart rate variability, electrodermal activity, and possibly respiratory rate.

Introduction: Lung transplantation is an effective treatment for certain types of end-stage lung disease. Frailty is a complex clinical syndrome associated with decreased physiological reserve and an increased risk for suboptimal health outcomes. Area covered: This article reviews the current literature on frailty in lung transplantation, with an emphasis on frailty measures, prevalence and impact of frailty on morbidity and mortality prior to and following lung transplantation. Pubmed, EMBASE, CINAHL and Cochrane systematic review databases were searched to September 2019. The search included the MeSH terms ¿frail elderly¿ or ¿frailty¿ or ¿sarcopenia¿ and ¿lung disease¿ or ¿lung transplantation¿. Studies were included if: the population were undergoing evaluation for, listed for or received a lung transplant; frailty was prospectively assessed during lung transplant evaluation using systematically defined criteria; used human subjects and; published in English. The prevalence of frailty varied from 0% - 58%. The frailty phenotype and short physical performance battery were the most common measures. Frailty was associated with delisting and death pre-transplantation. Frailty was associated with an increased risk of early mortality post-lung transplantation. Expert opinion: Frailty is identified often in lung transplant candidates and is associated with adverse pre and post-transplantation outcomes. Further research is necessary to identify potential frailty interventions.

Aortic regurgitation (AR), mitral regurgitation (MR), and tricuspid regurgitation (TR) after continuous-flow left ventricular assist device (LVAD) are common and may increase with prolonged LVAD support. The aim of this study was to simulate severe valvular regurgitation (AR, MR, and TR) within a 4-elemental pulsatile mock circulatory loop (MCL) and observe their impact on isolated LVAD and biventricular assist device (BiVAD) with HeartWare HVAD. Aortic regurgitation, MR, and TR were achieved via the removal of one leaflet from bileaflet mechanical valve from the appropriate valves of the left or right ventricles. The impact of alteration of LVAD pump speed (LVAD 2200-4000 RPM, right ventricular assist device [RVAD] 2400 RPM) and altered LVAD preload (10-25 mm Hg) was assessed. With each of the regurgitant valve lesions, there was a decrease in isolated LVAD pump flow pulsatility. Isolated LVAD provided sufficient support in the setting of severe MR or TR compared with control, and flows were enhanced with BiVAD support. In severe AR, there was no benefit of BiVAD support over isolated LVAD, and actual loop flows remained low. High LVAD flows combined with low RVAD flows and dampened aortic pressures are good indicators of AR. The 4-elemental MCL successfully simulated several control and abnormal valvular conditions using various pump speeds. Current findings are consistent with conservative management of MR and TR in the setting of mechanical support, but emphasize the importance of the correction of AR.

Individuals with chronic heart failure have high utilisation of hospital-related services towards the end of life and receive treatments that provide symptom relief without improving life expectancy. The aim of this discussion paper is to determine chronic heart failure patients¿ use of acute hospital-based services in their last year of life and to discuss the potential for palliative care to reduce service utilisation. A systematic search of the literature was conducted. Medline, Cumulative Index for Nursing and Allied Health (CINAHL) and SCOPUS databases were used to systematically search for literature from database commencement to September 2016. Specific inclusion criteria and search terms were used to identify relevant studies on heart failure patients¿ use of hospital services in their last year of life. There were 12 studies that evaluated the use of hospital-based services by chronic heart failure patients at the end of life. In all studies, it was found that chronic heart failure patients used acute hospital-based services as death approached. However, only two studies examined if palliative care consultations were obtained by patients, and neither study assessed the impact that these consultations had on service utilisation in the last year of life. Heart failure negatively impacts health status, and this is a predictor of service utilisation. Further research is needed to determine the efficacy of both primary and secondary palliative care in reducing resource use towards the end of life and improving the quality of end of life care.

Background: Chronic heart failure is a complex and multifaceted syndrome characterised by an unpredictable trajectory, high symptom burden and reduced quality of life. Although palliative care is recommended, patient, provider and system factors limit access. Aim: To examine the knowledge, attitudes and perspectives of health care professionals towards end of life care and palliative care for patients with chronic heart failure. Design: This is an integrative review. Data sources: CINAHL, Academic Search Complete and SCOPUS were searched. Specific inclusion criteria and search terms were used. The integrative review method entailed analysing data from primary articles using the constant comparison method and then synthesising data. Results: Twenty-six (26) articles were selected that explored health care professionals¿ perspectives towards end of life care and palliative care. The categories that emerged were grouped into patient, provider and system issues. Most health care professionals involved in providing care to heart failure patients have misperceptions of palliative care, often confusing it with end of life and hospice care. This hinders patients¿ access to palliative care as determining the end of life period in heart failure is difficult. Conclusions: Exploring health care professionals¿ perspectives towards the delivery of end of life care and palliative care is important for understanding how their practice influences the delivery of palliative care for heart failure patients. Emphasis on increasing awareness of the principles of palliative care in the health care community, as well as addressing organisational issues will improve the care delivered to these patients.

Purpose of Review: The study aims (1) to provide a contemporary description of frailty assessment in heart failure and (2) to provide an overview of multi-domain frailty assessment in heart failure. Recent Findings: Frailty assessment is an important predictive measure for mortality and hospitalisation in individuals with heart failure. To date, there are no frailty assessment instruments validated for use in heart failure. This has resulted in significant heterogeneity between studies regarding the assessment of frailty. The most common frailty assessment instrument used in heart failure is the Frailty Phenotype which focuses on five physical domains of frailty; the appropriateness a purely physical measure of frailty in individuals with heart failure who frequently experience decreased exercise tolerance and shortness of breath is yet to be determined. A limited number of studies have approached frailty assessment using a multi-domain view which may be more clinically relevant in heart failure. Summary: There remains a lack of consensus regarding frailty assessment and an absence of a validated instrument in heart failure. Despite this, frailty continues to be assessed frequently, primarily for research purposes, using predominantly physical frailty measures. A more multidimensional view of frailty assessment using a multi-domain approach will likely be more sensitive to identifying at risk patients.

Background. We recently reported that frailty is independently predictive of increased mortality in patients with advanced heart failure referred for heart transplantation (HTx). The aim of this study was to assess the impact of frailty on short-term outcomes after bridge-to-transplant ventricular assist device (BTT-VAD) implantation and/or HTx and to determine if frailty is reversible after these procedures. Methods. Between August 2013 and August 2016, 100 of 126 consecutive patients underwent frailty assessment using Fried¿s Frailty Phenotype before surgical intervention: 40 (21 nonfrail, 19 frail) BTT-VAD and 77 (60 nonfrail, 17 frail) HTx¿including 17 of the 40 BTT-VAD supported patients. Postprocedural survival, intubation time, intensive care unit, and hospital length of stay were compared between frail and nonfrail groups. Twenty-six frail patients were reassessed at 2 months or longer postintervention. Results. Frail patients had lower survival (63 ± 10% vs 94 ± 3% at 1 year, P = 0.012) and experienced significantly longer intensive care unit (11 vs 5 days, P = 0.002) and hospital (49 vs 25 days, P = 0.003) length of stay after surgical intervention compared with nonfrail patients. Twelve of 13 frail patients improved their frailty score after VAD (4.0 ± 0.8 to 1.4 ± 1.1, P < 0.001) and 12 of 13 frail patients improved their frailty score after HTx (3.2 ± 0.4 to 0.9 ± 0.9, P < 0.001). Handgrip strength and depression improved postintervention. Only a slight improvement in cognitive function was seen postintervention. Conclusions. Frail patients with advanced heart failure experience increased mortality and morbidity after surgical intervention with BTT-VAD or HTx. Among those who survive frailty is partly or completely reversible underscoring the importance of considering this factor as a dynamic not fixed entity.

Background Heart failure is a complex clinical syndrome with high demands for self-care. The Self-care of Heart Failure Index (SCHFI) was developed to measure self-care and has demonstrated robust psychometric properties across populations. Aim To assess the psychometric properties of the Arabic version of the SCHFI (A-SCHFI). Discussion The scores of the A-SCHFI administered to 223 Lebanese patients with heart failure were used to validate this instrument. Face and content validity, assessed by a panel of experts, were found sufficient. The three constructs of the A-SCHFI explained 37.5% of the variance when performing exploratory factor analysis. Adequate fit indices were achieved using the modification procedure of controlling error terms with the confirmatory factor analysis. The reliability coefficient was adequate in the maintenance, management and confidence scales. Conclusion Following adaptation, the modified A-SCHFI was shown to be a valid and reliable measure of self-care among the Lebanese population. Implications for practice Cross-cultural adaptation is a rigorous process involving complex procedures and analyses. The adaptation of the A-SCHFI should be further analysed, including sensitivity and test-retest analysis, with methods to assess the degree of agreement among the panel.

Background Emerging evidence suggests that some people living with non-communicable diseases (NCDs) have integrated energy healing into their self-management strategy, however little is known about its efficacy. Purpose To identify energy healing interventions that impacted positively on the symptom management outcomes for patients living in the community with various NCDs. Methods A systematic review of energy healing interventions for the management of non-communicable disease related symptoms, conducted between 01 January 2000 and 21 April 2015, published in an English peer-reviewed journal. This review conforms to the PRISMA statement. Results Twenty seven studies were identified that evaluated various energy healing interventions involving 3159 participants. Thirteen of the energy healing trials generated statistically significant outcomes. Conclusions Energy healing has demonstrated some improvement in illness symptoms, however high level evidence consistently demonstrating efficacy is lacking. Further more robust trials are required to better understand which elements of energy healing interventions are associated with positive outcomes.

The uptake of complementary and alternative medicine (CAM) is common, especially among patients with chronic illness. However, the use of CAM by women with cardiovascular disease and how this influences the interface with conventional medicine is poorly understood. To examine the relation between heart disease, hypertension, and diabetes and the use of CAM and conventional medicine in a cohort of women, data were taken from the 2010 survey (n = 9,748) of the 1946 to 1951 cohort of the Australian Longitudinal Study on Women's Health (ALSWH). Analyses focused on women who had been diagnosed or treated for heart disease, diabetes, and/or hypertension. The outcome measures were the use of conventional or CAM treatments in the previous year. Most women had hypertension only (n = 2,335), and few (n = 78) reported having heart disease, hypertension, and diabetes. Women with hypertension were less likely (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.74 to 0.91) to consult with a CAM practitioner and less likely (OR 0.86, 95% CI 0.77 to 0.97) to use self-prescribed CAM, while women with diabetes were also less likely (OR 0.66, 95% CI 0.54 to 0.81) to consult with a CAM practitioner and less likely (OR 0.68, 95% CI 0.55 to 0.83) to use self-prescribed CAM. In conclusion, compared with studies conducted on CAM use and other chronic illness groups, the use of CAM by women with heart disease, hypertension, and/or diabetes in this study was lower, and future research is needed to explore patients' perceptions of cardiovascular risk and the role of CAM in their self-management in the community, among other issues.

Background A number of composite outcomes have been developed to capture the perspective of the patient, clinician and objective measures of health in assessing heart failure outcomes. To date there has been a limited examination in the composition of these outcomes. Methods and results Three commonly used scoring systems in heart failure trials: Packer's composite, Patient Journey and the African American Heart Failure Trial (A-HeFT) scores were compared in assessing outcomes from the Which heart failure intervention is most cost-effective & consumer friendly in reducing hospital care (WHICH(?)) Trial. Comparability and interpretability of these outcomes and the influence of each component to the final outcome were examined. Despite all three composite outcomes incorporating mortality, hospitalisation and quality of life (QoL), the contribution of each individual component to the final outcomes differed. The component with the most influence in deteriorating condition for the Packer's composite was hospitalisation (67.7%), while in Patient Journey it was QoL (61.5%) and for A-HeFT composite score it was mortality (45.4%). Conclusions The contribution made by each component varied in subtle, but important ways. This study emphasises the importance of understanding the value system of the composite outcomes to enable meaningful interpretation of results.

Acute decompensated heart failure is a common cause of hospitalisation. This is a period of vulnerability both in altered pathophysiology and also the potential for iatrogenesis due to therapeutic interventions. Renal dysfunction is often associated with heart failure and portends adverse outcomes. Identifying heart failure patients at risk of renal dysfunction is important in preventing progression to chronic kidney disease or worsening renal function, informing adjustment to medication management and potentially preventing adverse events. However, there is no working or consensus definition in international heart failure management guidelines for worsening renal function. In addition, there appears to be no concordance or adaptation of chronic kidney disease guidelines by heart failure guideline development groups for the monitoring of chronic kidney disease in heart failure. Our aim is to encourage the debate for an agreed definition given the prognostic impact of worsening renal function in heart failure. We present the case for the uptake of the Acute Kidney Injury Network criteria for acute kidney injury with some minor alterations. This has the potential to inform study design and meta-analysis thereby building the knowledgebase for guideline development. Definition consensus supports data element, clinical registry and electronic algorithm innovation as instruments for quality improvement and clinical research for better patient outcomes. In addition, we recommend all community managed heart failure patients have their baseline renal function classified and routinely monitored in accordance with established renal guidelines to help identify those at increased risk for worsening renal function or progression to chronic kidney disease. © 2014 Elsevier Ireland Ltd.