BACKGROUND: In a study of Italian heart failure patient-caregiver dyads, greater caregiver strain significantly predicted lower patient clinical event risk. OBJECTIVE: The purpose of this secondary analysis was to examine this relationship in a sample from the United States. METHODS: Data came from 92 dyads who participated in a self-care intervention. Logistic regression was used to test the relationship between baseline strain (Bakas Caregiving Outcomes Scale, divided into tertiles) and patient likelihood of events (heart failure hospitalization/emergency visit or all-cause mortality) over 8 months. RESULTS: Nearly half of patients (n = 40, 43.5%) had an event. High (vs low) caregiver strain was associated with a 92.7% event-risk reduction, but with substantial variability around the effect (odds ratio, 0.07; 95% confidence interval, 0.01-0.63; P = .02). CONCLUSIONS: Although findings were similar to the Italian study, the high degree of variability and contrasting findings to other studies signal a level of complexity that warrants further investigation.

Background: Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management. Objective: Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED. Methods: This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED-HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30-day cardiovascular death and/or heart failure-related events. Results: Of the 491 subjects included in the GUIDED-HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54-70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval,  0.49-2.01, P = 0.994). Conclusion: If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.

BACKGROUND: Cardiometabolic risk (CMR) factors including hypertension, overweight/obesity, diabetes mellitus, and hyperlipidemia are high among United States ethnic minorities, and the immigrant population continues to burgeon. METHODS AND RESULTS: Hypothesizing that acculturation (length of residence) would be associated with a higher prevalence of CMR factors, the authors analyzed data on 54, 984 US immigrants in the 2010-2014 National Health Interview Surveys. The main predictor was length of residence. The outcomes were hypertension, overweight/obesity, diabetes mellitus, and hyperlipidemia. The authors used multivariable logistic regression to examine the association between length of US residence and these CMR factors.The mean (SE) age of the patients was 43 (0.12) years and half were women. Participants residing in the United States for ≥10 years were more likely to have health insurance than those with <10 years of residence (70% versus 54%, P<0.001). After adjusting for region of birth, poverty income ratio, age, and sex, immigrants residing in the United States for ≥10 years were more likely to be overweight/obese (odds ratio [OR], 1.19; 95% CI, 1.10-1.29), diabetic (OR, 1.43; 95% CI, 1.17-1.73), and hypertensive (OR, 1.18; 95% CI, 1.05-1.32) than those residing in the United States for <10 years. CONCLUSIONS: In an ethnically diverse sample of US immigrants, acculturation was associated with CMR factors. Culturally tailored public health strategies should be developed in US immigrant populations to reduce CMR.

Purpose: Patients with cancer experience acute and chronic symptoms caused by their underlying disease or by the treatment. While numerous studies have examined the impact of various treatments on symptoms experienced by cancer patients, there are inconsistencies regarding the symptoms measured and reported in treatment trials. This article presents a systematic review of the research literature of the prevalence and severity of symptoms in patients undergoing cancer treatment. Methods: A systematic search for studies of persons receiving active cancer treatment was performed with the search terms of "multiple symptoms" and "cancer" for studies involving patients over the age of 18 years and published in English during the years 2001 to 2011. Search outputs were reviewed independently by seven authors, resulting in the synthesis of 21 studies meeting criteria for generation of an Evidence Table reporting symptom prevalence and severity ratings. Results: Data were extracted from 21 multi-national studies to develop a pooled sample of 4,067 cancer patients in whom the prevalence and severity of individual symptoms was reported. In total, the pooled sample across the 21 studies was comprised of 62 % female, with a mean age of 58 years (range 18 to 97 years). A majority (62 %) of these studies assessed symptoms in homogeneous samples with respect to tumor site (predominantly breast and lung cancer), while 38 % of the included studies utilized samples with mixed diagnoses and treatment regimens. Eighteen instruments and structured interviews were including those measuring single symptoms, multi-symptom inventories, and single symptom items drawn from HRQOL or health status measures. The MD Anderson Symptom Inventory was the most commonly used instrument in the studies analyzed (n = 9 studies; 43 %), while the Functional Assessment of Cancer Therapy, Hospital Anxiety and Depression Subscale, Medical Outcomes Survey Short Form-36, and Symptom Distress Scale were each employed in two studies. Forty-seven symptoms were identified across the 21 studies which were then categorized into 17 logical groupings. Symptom prevalence and severity were calculated across the entire cohort and also based upon sample sizes in which the symptoms were measured providing the ability to rank symptoms. Conclusions: Symptoms are prevalent and severe among patients with cancer. Therefore, any clinical study seeking to evaluate the impact of treatment on patients should consider including measurement of symptoms. This study demonstrates that a discrete set of symptoms is common across cancer types. This set may serve as the basis for defining a "core" set of symptoms to be recommended for elicitation across cancer clinical trials, particularly among patients with advanced disease.

CT is routinely used for radiotherapy planning with organs and regions of interest being segmented for diagnostic evaluation and parameter optimization. For cardiac segmentation, many methods have been proposed for left ventricular segmentation, but few for simultaneous segmentation of the entire heart. In this work, we present a convolutional neural networks (CNN)-based cardiac chamber segmentation method for 3D CT with 5 classes: left ventricle, right ventricle, left atrium, right atrium, and background. We achieved an overall accuracy of 87.2% ± 3.3% and an overall chamber accuracy of 85.6 ± 6.1%. The deep learning based segmentation method may provide an automatic tool for cardiac segmentation on CT images.

Cardiovascular disease is a leading cause of death in the United States. The identification of cardiac diseases on conventional three-dimensional (3D) CT can have many clinical applications. An automated method that can distinguish between healthy and diseased hearts could improve diagnostic speed and accuracy when the only modality available is conventional 3D CT. In this work, we proposed and implemented convolutional neural networks (CNNs) to identify diseased hears on CT images. Six patients with healthy hearts and six with previous cardiovascular disease events received chest CT. After the left atrium for each heart was segmented, 2D and 3D patches were created. A subset of the patches were then used to train separate convolutional neural networks using leave-one-out cross-validation of patient pairs. The results of the two neural networks were compared, with 3D patches producing the higher testing accuracy. The full list of 3D patches from the left atrium was then classified using the optimal 3D CNN model, and the receiver operating curves (ROCs) were produced. The final average area under the curve (AUC) from the ROC curves was 0.840 ± 0.065 and the average accuracy was 78.9% ± 5.9%. This demonstrates that the CNN-based method is capable of distinguishing healthy hearts from those with previous cardiovascular disease.

Objectives Determine if family functioning influences response to family-focused interventions aimed at reducing dietary sodium by heart failure (HF) patients. Background Lowering dietary sodium by HF patients often occurs within the home and family context. Methods Secondary analysis of 117 dyads randomized to patient and family education (PFE), family partnership intervention (FPI) or usual care (UC). Dietary sodium measures were obtained from 3-day food record and 24-hour urine samples. Results In the poor family functioning groups, FPI and PFE had lower mean urine sodium than UC (p<.05) at 4 months, and FPI remained lower than UC at 8 months (p<.05). For good family functioning groups, FPI and PFE had lower mean sodium levels by 3-day food record at 4 and 8 months. Conclusion Optimizing family-focused interventions into HF clinical care maybe indicated.

Aim: Persons with concomitant heart failure (HF) and diabetes mellitus (DM) have complicated, competing, self-care expectations and treatment regimens that may reduce quality of life (QOL). This randomized controlled trial tested an integrated self-care intervention on outcomes of HF and DM QOL, physical function and physical activity (PA). Methods: Participants with HF and DM (n=134, mean age 57.4 ± 11 years, 66% men, 69% minority) were randomized to usual care attention control (control) or intervention groups. The control group received standard HF and DM educational brochures with follow up phone contact; Intervention received education/counseling on combined HF and DM self-care (diet, medications, self-monitoring, symptoms, and PA) with follow up home visit and phone counseling. Measures including questionnaires for HF and DM-specific, and overall QOL; Physical activity frequency; and physical function (6 minute walk test; 6MWT) were obtained at baseline, 3 and 6 months. Analysis included mixed models with a priori post-hoc tests. Results: Adjusting for age, body mass index, and comorbidity, the intervention group improved HF total (p=.002) and physical (p<.001) QOL scores at 3 months with retention of improvements at 6 months, improved emotional QOL scores compared to control at 3 months (p=.04), and improved health status ratings (p=.04) at 6 Months compared to baseline. The intervention group improved 6MWT distance (924 feet vs 952 feet, p=. 03) while control declined (834 vs 775 feet) (F1, 63=6.86, p=.01). The intervention group increased self-reported PA between baseline and 6M (p=.01). Conclusions: An integrated HF and DM self-care intervention improved perceived HF and general QOL but not DM QOL. Improved physical functioning and self-reported PA were also observed with the integrated self-care intervention. Further study of the HF and DM integrated self-care intervention on other outcomes such as hospitalization and cost is warranted.

Background: Persons with concomitant heart failure (HF) and diabetes mellitus constitute a growing population whose quality of life is encumbered with worse clinical outcomes as well as high health resource use (HRU) and costs. Methods and Results: Extensive data on HRU and costs were collected as part of a prospective cost-effectiveness analysis of a self-care intervention to improve outcomes in persons with both HF and diabetes. HRU costs were assigned from a Medicare reimbursement perspective. Patients (n = 134) randomized to the self-care intervention and those receiving usual care/attention control were followed for 6 months, revealing significant differences in the number of hospitalization days and associated costs between groups. The mean number of inpatient days was 3 with bootstrapped bias-corrected (BCa) confidence intervals (CIs) of 1.8-4.4 d for the intervention group and 7.3 d (BCa CI 4.1-10.9 d) in the control group: P =.044. Total direct HRU costs per participant were an estimated $9,065 (BCa CI $6,496-$11,936) in the intervention and $16,712 (BCa CI 8,200-$26,621) in the control group, for a mean difference of -$7,647 (BCa CI -$17,588 to $809; P =.21) in favor of the intervention, including intervention costs estimated to be $130.67 per patient. Conclusions: The self-care intervention demonstrated dominance in lowering costs without sacrificing quality-adjusted life-years.

Background and Research Objective Several heart failure (HF) knowledge tools have been developed and tested over the past decade; however, they vary in content, format, psychometric properties, and availability. This article details the development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test (A-HFKT) as a standardized instrument for both the research and clinical settings. Participants and Methods Development and psychometric testing of the A-HFKT were undertaken with 116 New York Heart Association (NYHA) class II and III community-dwelling HF patients and their family members (FMs) participating in a family intervention study. Internal consistency, reliability, and content validity were examined. Construct validity was assessed by correlating education level, literacy, dietary sodium ingestion, medication adherence, and healthcare utilization with knowledge. Results Content validity ratings on relevance and clarity ranged from 0.55 to 1.0, with 81% of the items rated from 0.88 to 1.0. Cronbach α values were .84 for patients, .75 for FMs, and .73 for combined results. Construct validity testing revealed a small but significant correlation between higher patient and FM knowledge on sodium restriction questions and lower ingested sodium, r = −0.17, P = .05 and r = −0.19, P = .04, respectively, and between patient knowledge and number of days that medications were taken correctly (diuretics: r = 0.173, P < .05, and angiotensin-converting enzyme: r = 0.223, P = .01). Finally, patients seeking emergency care or requiring hospitalization in the 4 months before study entry were found to have significantly lower FM knowledge using both t test and logistic regression modeling. Conclusions The A-HFKT was revised using the content and construct validity data and is available for use with HF patients and FMs. The construct validity testing indicates that patient knowledge has a significant relationship to aspects of self-care. Furthermore, family knowledge may influence patient adherence with sodium restriction and healthcare utilization behavior.