Provision of professional interpreters and Heart School attendance for foreign-born compared with native-born myocardial infarction patients in Sweden.

Objective: Interactive patient education, referred to as Heart School (HS), is an important part of cardiac rehabilitation (CR) after myocardial infarction (MI), which has been associated with improved outcomes. Little is known about HS attendance among foreign-born patients. The aims were to assess; 1) HS attendance in foreign-born versus native-born patients, 2) the association between the provision of professional interpreters and HS attendance, and 3) secondary prevention goal attainment after MI based on HS attendance. Methods: The provision of professional interpreters during post-MI follow-up was assessed by a questionnaire sent to all 78 Swedish CR sites. Patient-specific data was retrieved from the SWEDEHEART registry. The association between the provision of professional interpreters and HS attendance was estimated with logistic regression models. HS attendance and attainment of secondary prevention goals by country of birth were investigated. Results: In total, 8377 patients < 75 years (78 % male) were included. Foreign-born (19.8 %) had a higher prevalence of cardiovascular risk factors and were less likely to attend HS (33.7 vs 51.3 %, p < 0.001), adjusted odds ratio (OR) 0.59 (95 % confidence interval (CI) 0.52-0.68), compared with native-born patients. CR centers providing professional interpreters had higher HS attendance among foreign-born (adjusted OR 1.55, 95 % CI 1.20-2.01) but not among native-born patients. Attending HS was similarly associated with improved secondary prevention goal attainment in both groups. Conclusions: Despite similar positive association between HS attendance and attainment of secondary prevention goals, foreign-born patients attended HS less often. With the provision of professional interpreters, HS attendance increased in foreign-born patients.

Swedish multimodal cohort of patients with anxiety or depression treated with internet-delivered psychotherapy (MULTI-PSYCH).

PURPOSE: Depression and anxiety afflict millions worldwide causing considerable disability. MULTI-PSYCH is a longitudinal cohort of genotyped and phenotyped individuals with depression or anxiety disorders who have undergone highly structured internet-based cognitive-behaviour therapy (ICBT). The overarching purpose of MULTI-PSYCH is to improve risk stratification, outcome prediction and secondary preventive interventions. MULTI-PSYCH is a precision medicine initiative that combines clinical, genetic and nationwide register data. PARTICIPANTS: MULTI-PSYCH includes 2668 clinically well-characterised adults with major depressive disorder (MDD) (n=1300), social anxiety disorder (n=640) or panic disorder (n=728) assessed before, during and after 12 weeks of ICBT at the internet psychiatry clinic in Stockholm, Sweden. All patients have been blood sampled and genotyped. Clinical and genetic data have been linked to several Swedish registers containing a wide range of variables from patient birth up to 10 years after the end of ICBT. These variable types include perinatal complications, school grades, psychiatric and somatic comorbidity, dispensed medications, medical interventions and diagnoses, healthcare and social benefits, demographics, income and more. Long-term follow-up data will be collected through 2029. FINDINGS TO DATE: Initial uses of MULTI-PSYCH include the discovery of an association between PRS for autism spectrum disorder and response to ICBT, the development of a machine learning model for baseline prediction of remission status after ICBT in MDD and data contributions to genome wide association studies for ICBT outcome. Other projects have been launched or are in the planning phase. FUTURE PLANS: The MULTI-PSYCH cohort provides a unique infrastructure to study not only predictors or short-term treatment outcomes, but also longer term medical and socioeconomic outcomes in patients treated with ICBT for depression or anxiety. MULTI-PSYCH is well positioned for research collaboration.

Comparing three neuropsychological subgrouping approaches in subjective and mild cognitive impairment from a naturalistic multicenter study.

Subjective cognitive impairment (SCI) and mild cognitive impairment (MCI) are two clinical groups with an increased risk to develop dementia, but they are highly heterogeneous. This study compared three different approaches to subgroup SCI and MCI patients and investigated their capacity to disentangle cognitive and biomarker heterogeneity. We included 792 patients from the MemClin-cohort (142 SCI and 650 MCI). Biomarkers included cerebrospinal fluid measures of beta-amyloid-42 and phosphorylated tau, as well as visual ratings of medial temporal lobe atrophy and white matter hyperintensities on magnetic resonance imaging. We found that a more inclusive approach identified individuals with a positive beta-amyloid-42 biomarker; a less inclusive approach captured individuals with higher medial temporal lobe atrophy; and a data-driven approach captured individuals with high white matter hyperintensities burden. The three approaches also captured some neuropsychological differences. We conclude that choice of approach may differ depending on the purpose. This study helps to advance our current understanding of the clinical and biological heterogeneity within SCI and MCI, particularly in the unselected memory clinic setting.

Association of anxiety or depression with risk of recurrent cardiovascular events and death after myocardial infarction: A nationwide registry study.

BACKGROUND: Depression and anxiety are risk factors for patients with myocardial infarction (MI). However, the association of a previous psychiatric diagnosis of anxiety or depression, or only such self-reported symptoms, with cardiovascular outcomes and mortality post-MI has not been previously examined in the same nationwide cohort. METHODS: We linked demographic, socioeconomic and clinical data from four nationwide Swedish registries for patients enrolled in cardiac rehabilitation (CR) after first-time MI (2006-2015, N = 45,096). After multiple imputation, we applied Cox regression to estimate the post-MI outcome risk for patients with a previous psychiatric diagnosis of anxiety/depression (Diagnosis), patients with no formal diagnosis but self-reported symptoms of anxiety/depression (Symptoms), versus patients with neither Diagnosis nor Symptoms (Reference). RESULTS: During one-year follow-up, fully adjusted models showed that patients with Diagnosis had a higher risk (hazard ratio [95%CI]) of all-cause mortality (1.86 [1.36, 2.53]), reinfarction (1.14 [1.06, 1.22]), their composite (1.15 [1.07, 1.23]), and an extended cardiovascular composite (1.19 [1.12, 1.26]), versus Reference, even though 77% reported no symptoms at the time of MI. In patients with Symptoms, estimates were also elevated yet somewhat attenuated compared to Reference. Findings were overall robust across multiple sensitivity analyses. CONCLUSIONS: Both a previous diagnosis, and present self-reported symptoms of anxiety or depression are associated with an increased risk of death and recurrent cardiovascular events in adults with first-time MI. Only screening for present symptoms is inadequate for assessing this excessive risk. Assessment of both psychiatric history and self-reported symptoms seems warranted for these patients.

The Association Between Temporal Atrophy and Episodic Memory Is Moderated by Education in a Multi-Center Memory Clinic Sample.

BACKGROUND: Cognitive reserve (CR) is hypothesized to partially explain the discrepancy between Alzheimer's disease related brain pathology and cognitive performance. Educational attainment is often used as a proxy for CR. OBJECTIVE: To examine the association of years of education and the relationship between atrophy in the medial temporal lobe and episodic memory, in a cross-sectional ecological multi-center memory clinic cohort. METHODS: Included patients (n = 702) had undergone memory clinic examination and were diagnosed with subjective cognitive impairment (n = 99), mild cognitive impairment (n = 471), or dementia (n = 132). Total years of education were used as a moderating variable and neuropathology was operationalized as visual ratings of medial temporal lobe atrophy (MTA) on magnetic resonance imaging and computer tomography images. Weighted least squares regression and multiple regression were used to analyze moderation and the effect of education separately by diagnostic group. A composite score of two episodic memory tests constituted the dependent variable. RESULTS: After controlling for age and gender the interaction term between MTA and years of education was significant indicating moderation. In particular, the regression model showed that at low levels of MTA, high education individuals had better episodic memory performance. However, at higher MTA levels, high education individuals had the lowest episodic memory performance. Education had a significant positive effect on episodic memory in SCI and MCI, but not dementia. CONCLUSION: These results extend the findings of education moderating the effect of MTA on cognition to a naturalistic memory clinic setting. Implications of the findings for theories on CR are discussed.

Characterization of exhaustion disorder and identification of outcomes that matter to patients: Qualitative content analysis of a Swedish national online survey.

Fatigue is a common presenting problem in healthcare settings, often attributed to chronic psychosocial stress. Understanding of fatigue and development of evidence-based treatments is hampered by a lack of consensus regarding diagnostic definitions and outcomes to be measured in clinical trials. This study aimed to map outcome domains of importance to the Swedish diagnosis stress-induced exhaustion disorder (ED; ICD-10, code F43.8 A). An online survey was distributed nationwide in Sweden to individuals who reported to have been diagnosed with ED and to healthcare professionals working with ED patients. To identify outcome domains, participants replied anonymously to four open-ended questions about symptoms and expectations for ED-treatment. Qualitative content analysis was conducted of a randomized subsample of respondents, using a mathematical model to determine data saturation. Six hundred seventy participants (573 with reported ED, 97 healthcare professionals) completed the survey. Qualitative content analysis of answers supplied by 105 randomized participants identified 87 outcomes of importance to ED encompassing physical, cognitive, and emotional symptoms as well as functional disability. Self-rating scales indicated that many ED participants, beyond reporting fatigue, also reported symptoms of moderate to severe depression, anxiety, insomnia, poor self-rated health, and sickness behavior. This study presents a map of outcome domains of importance for ED. Results shed light on the panorama of issues that individuals with ED deal with and can be used as a step to further understand the condition and to reach consensus regarding outcome domains to measure in clinical trials of chronic stress and fatigue. Preregistration: Open Science Framework (osf.io) with DOI https://doi.org/10.17605/OSF.IO/4VUAG.

Empirically Defining Treatment Response and Remission in Obsessive-Compulsive Disorder Using the Obsessive-Compulsive Inventory-Revised.

In clinical trials of obsessive-compulsive disorder (OCD), clinical outcomes are generally measured using lengthy clinician-administered interviews. However, in routine clinical practice, many clinicians lack the time to administer such instruments. This study evaluated cutoffs for treatment response and remission in OCD using the self-rated Obsessive-Compulsive Inventory-Revised (OCI-R). Data from 349 patients in three clinical trials of cognitive-behavioral therapy for OCD were pooled for analysis. The OCI-R was compared to gold-standard criteria for response and remission based on the clinician-administered Yale-Brown Obsessive Compulsive Scale and the Clinical Global Impression Scale. The results showed that a ≥40% reduction on the OCI-R was the optimal cutoff for treatment response, with a sensitivity of 0.72 and a specificity of 0.79. For remission status, the optimal cutoff was ≤8 points on the OCI-R, with a sensitivity of 0.57 and specificity of 0.83. Results from additional analyses using the 12-item version of the OCI were similar. These cutoffs provide a simple and time-efficient way to help determine treatment response and remission in OCD when the administration of clinician-administered instruments is unfeasible.

Pre-pregnancy participation and performance in world's largest cross-country ski race as a proxy for physical exercise and fitness, and perinatal outcomes: Prospective registry-based cohort study.

OBJECTIVE: Investigate associations between pre-pregnancy participation and performance in a demanding cross-country ski race (proxy for exercise volume and fitness) and perinatal outcomes. Pre-registered protocol: osf.io/aywg2. DESIGN: Prospective cohort study. SETTING: Based on entire overlap between the Vasaloppet registry and the population-based Swedish Pregnancy Register. SAMPLE: All female Vasaloppet participants 1991-2017 with subsequent singleton delivery (skiers), and age- and county-matched non-skiers. METHODS: We calculated odds ratios (ORs) for non-skiers versus skiers (model 1) and, among skiers, by performance (model 2), in Bayesian logistic regressions adjusted for socio-demographics, lifestyle factors, and comorbidities. We repeated calculations adjusting for early pregnancy body mass index (potential mediator) and explored robustness (selection/exposure settings; multiple comparisons correction). MAIN OUTCOME MEASURES: Twenty-nine important perinatal outcomes, predefined based on existing expert consensus. RESULTS: Non-skiers (n = 194 384) versus skiers (n = 15 377) (and slower versus faster performance, not shown) consistently had higher odds of gestational diabetes mellitus (GDM) (OR 1.70, 95% highest density interval: 1.40-2.09), excessive gestational weight gain (GWG) (1.28, 1.22-1.38), psychiatric morbidity (1.60, 1.49-1.72), any caesarean section (CS) (1.34, 1.28-1.40), elective CS (1.39, 1.29-1.49), and large-for-gestational-age babies (>90th percentile, 1.11, 1.04-1.18); lower odds of inadequate GWG (0.83, 0.79-0.88); and no associations with fetal/neonatal complications (e.g. preterm birth [1.09, 0.98-1.20], small for gestational age [SGA] [1.23, 1.05-1.45]). Adjustment for body mass index attenuated associations with excessive (1.20, 1.14-1.30) and inadequate GWG (0.87, 0.83-0.92) and large for gestational age (1.07, 1.00-1.13). CONCLUSION: Non-skiers compared with skiers, and slower versus faster performance, consistently displayed higher odds of GDM, excessive GWG, psychiatric morbidity, CS and large-for-gestational-age babies; and lower odds of inadequate GWG, after adjustment for socio-demographic and lifestyle factors and comorbidities. There were no associations with fetal/neonatal complications.

Executive functioning in body dysmorphic disorder and obsessive-compulsive disorder.

OBJECTIVE: To assess executive functions (EFs) in patients with body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD) compared with healthy controls. METHODS: Adults diagnosed with BDD (n = 26) or OCD (n = 29) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and healthy controls (n = 28) underwent validated and computerized neuropsychological tests, spatial working memory (SWM), intra-extra-dimensional set shifting (IED), and stop signal task (SST), from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Test performance was compared between groups, and correlated with standardized symptom severity of BDD and OCD. Significance level was set to P < .05. RESULTS: There were no statistically significant between-group differences on key outcome measures in SWM, IED, or SST. There was a weak positive correlation between symptom severity and test errors on SWM and IED in both OCD and BDD groups; increased clinical severity was associated with more errors in these tests. Furthermore, there was a negative correlation between symptom severity and SST in the BDD group. CONCLUSIONS: Patients with BDD or OCD did not differ from healthy control subjects in terms of test performance; however, there were several statistically significant correlations between symptom severity and performance in those with BDD or OCD. More studies on EFs in BDD and OCD are required to elucidate if there are differences in EFs between these two disorders.

Organizational and patient-level predictors for attaining key risk factor targets in cardiac rehabilitation after myocardial infarction: The Perfect-CR study.

BACKGROUND: Benefits of cardiac rehabilitation (CR) programme components on attaining risk factor targets post-myocardial infarction (MI) and their predictive strength relative to patient characteristics remain unclear. We aimed to identify organizational and patient-level predictors of risk factor target attainment at one-year post-MI. METHODS: In this observational study data on CR organization at 78 Swedish CR centres was collected and merged with patient-level registry data (n = 7549). Orthogonal partial least squares discriminant analysis identified predictors (Variables of Importance for the Projection (VIP) values >0.8) of attaining low-density lipoprotein-cholesterol (LDL-C) <1.8 mmol/L, blood pressure (BP) <140/90 mmHg and smoking abstinence. RESULTS: The strongest predictors (VIP [95% CI]) for attaining LDL-C and BP targets were offering psychosocial management (2.14 [1.78-2.50]; 2.45 [1.91-2.99]), having a psychologist in the CR team (1.62 [1.36-1.87]; 2.05 [1.67-2.44]), extended opening hours (2.13 [2.00-2.27]; 1.50 [0.91-2.10]), adequate facilities (1.54 [0.91-2.18]; 1.89 [1.38-2.40]), and having a medical director (1.70 [0.91-2.48]; 1.46 [1.04-1.88]). The strongest patient-level predictors of attaining LDL-C and/or BP targets were low baseline LDL-C (3.95 [3.39-4.51]) and having no history of hypertension (2.93 [2.60-3.26]), respectively, followed by exercise-based CR participation (1.38 [0.66-2.10]; 1.46 [1.14-1.78]). For smoking abstinence, the strongest organizational predictor was varenicline being prescribed by CR physicians (1.88 [0.95-2.80]) and patient-level predictors were participation in exercise-based CR (2.47 [2.07-2.88]) and group education (1.92 [1.43-2-42]), and no cardiovascular disease history (2.13 [1.78-2.48]). CONCLUSIONS: We identified multiple CR organizational and patient-level predictors of attaining risk factor targets post-MI. These results may influence the future design of comprehensive CR programmes.

Exhaustion disorder: scoping review of research on a recently introduced stress-related diagnosis.

BACKGROUND: Symptoms related to chronic stress are prevalent and entail high societal costs, yet there is a lack of international consensus regarding diagnostics and treatment. A new stress-related diagnosis, exhaustion disorder, was introduced into the Swedish version of ICD-10 in 2005. Since then, use of the diagnosis has increased rapidly. AIMS: To create the first comprehensive synthesis of research on exhaustion disorder to report on the current state of knowledge. Preregistration: Open Science Framework (http://www.w3.org/1999/xlink">osf.io), doi 10.17605/OSF.IO/VFDKW. METHOD: A PRISMA-guided scoping review of all empirical studies of exhaustion disorder was conducted. Searches were run in the MEDLINE, PsycInfo and Web of Science databases. Data were systematically charted and thematically categorised based on primary area of investigation. RESULTS: Eighty-nine included studies were sorted into six themes relating to lived experience of exhaustion disorder (n = 9), symptom presentation and course (n = 13), cognitive functioning (n = 10), biological measures (n = 24), symptom measurement scales (n = 4) and treatment (n = 29). Several studies indicated that individuals with exhaustion disorder experience a range of psychiatric and somatic symptoms beyond fatigue, but robust findings within most thematic categories were scarce. The limited number of studies, lack of replication of findings and methodological limitations (e.g. small samples and scarcity of specified primary outcomes) preclude firm conclusions about the diagnostic construct. CONCLUSIONS: More research is needed to build a solid knowledge base for exhaustion disorder. International collaboration regarding the conceptualisation of chronic stress and fatigue is warranted to accelerate the growth of evidence.

Predicting remission after internet-delivered psychotherapy in patients with depression using machine learning and multi-modal data.

This study applied supervised machine learning with multi-modal data to predict remission of major depressive disorder (MDD) after psychotherapy. Genotyped adult patients (n = 894, 65.5% women, age 18-75 years) diagnosed with mild-to-moderate MDD and treated with guided Internet-based Cognitive Behaviour Therapy (ICBT) at the Internet Psychiatry Clinic in Stockholm were included (2008-2016). Predictor types were demographic, clinical, process (e.g., time to complete online questionnaires), and genetic (polygenic risk scores). Outcome was remission status post ICBT (cut-off ≤10 on MADRS-S). Data were split into train (60%) and validation (40%) given ICBT start date. Predictor selection employed human expertise followed by recursive feature elimination. Model derivation was internally validated through cross-validation. The final random forest model was externally validated against a (i) null, (ii) logit, (iii) XGBoost, and (iv) blended meta-ensemble model on the hold-out validation set. Feature selection retained 45 predictors representing all four predictor types. With unseen validation data, the final random forest model proved reasonably accurate at classifying post ICBT remission (Accuracy 0.656 [0.604, 0.705], P vs null model = 0.004; AUC 0.687 [0.631, 0.743]), slightly better vs logit (bootstrap D = 1.730, P = 0.084) but not vs XGBoost (D = 0.463, P = 0.643). Transparency analysis showed model usage of all predictor types at both the group and individual patient level. A new, multi-modal classifier for predicting MDD remission status after ICBT treatment in routine psychiatric care was derived and empirically validated. The multi-modal approach to predicting remission may inform tailored treatment, and deserves further investigation to attain clinical usefulness.

Association between ß-blocker dose and quality of life after myocardial infarction: a real-world Swedish register-linked study.

BACKGROUND: ß-blockers are routinely administered to patients following myocardial infarction (MI), yet their potential effect on health-related quality of life (HRQoL) is not entirely understood. We investigated the relationship between two different doses of ß-blockers with HRQoL following MI. METHODS AND RESULTS: This nationwide observational study used Swedish national registries to collate sociodemographic, clinical, medication, and HRQoL {the latter operationalized using EuroQol [European Quality of Life Five Dimensions Questionnaire (EQ-5D)]}. Estimates at 6-10 weeks and 12-14 months post-MI follow-up from pooled linear and logistic models were calculated after multiple imputation. We identified 35 612 patients with first-time MI, discharged with ß-blockers, and enrolled in cardiac rehabilitation between 2006 and 2015. Upon discharge, patients were either dispensed <50% [24 082 (67.6%)] or ≥50% [11 530 (32.4%)] of the target dosage, as defined in previous trials. After adjusting for pre-defined covariates, neither the EQ-5D Index nor the Emotional Distress items were statistically different between groups. The EQ-VAS score was significantly lower in patients treated with ≥50% target ß-blocker dose than those treated with <50% of the target dose [-0.87 [-1.23, -0.46], P < .001]. Results were similar at the 12-month follow-up and across sub-groups separated by sex and age. CONCLUSION: No difference in HRQoL was found among patients taking <50% vs. ≥50% of the target ß-blocker dose, except for the EQ-VAS in which higher scores were reported in those taking a lower dose. The clinical meaningfulness of this statistical significance is likely low.

Improving smoking cessation after myocardial infarction by systematically implementing evidence-based treatment methods.

We compared the odds of smoking cessation at 2-months post-myocardial infarction (MI), before and after implementing routines optimizing use of evidence-based smoking cessation methods, with start during admission. The following routines were implemented at six Swedish hospitals: cardiac rehabilitation nurses offering smokers consultation during admission, optimizing nicotine replacement therapy and varenicline prescription, and contacting patients by telephone during the 1st week post-discharge. Using logistic regression, odds for smoking cessation at 2-months before (n smokers/n admitted = 188/601) and after (n = 195/632) routine implementation were compared. Secondary outcomes included adherence to implemented routines and assessing the prognostic value of each routine on smoking cessation. After implementation, a larger proportion of smokers (65% vs. 54%) were abstinent at 2-months (OR 1.60 [1.04-2.48]). Including only those counselled during admission (n = 98), 74% were abstinent (2.50 [1.42-4.41]). After implementation, patients were more often counselled during admission (50% vs. 6%, p < 0.001), prescribed varenicline (23% vs. 7%, p < 0.001), and contacted by telephone post-discharge (18% vs. 2%, p < 0.001). Being contacted by telephone post-discharge (adjusted OR 2.74 [1.02-7.35]) and prescribed varenicline (adjusted OR 0.39 [0.19-0.83]) predicted smoking cessation at 2-months. In conclusion, readily available methods for aiding smoking cessation can be implemented effectively in routine practice, with beneficial effects for post-MI patients.

Self-perceived cognitive status and cognitive challenges associated with cardiac rehabilitation management: experiences of elderly myocardial infarction patients.

PURPOSE: The study aimed to explore the self-perceived cognitive status and cognitive challenges associated with lifestyle changes in cardiac rehabilitation among elderly myocardial infarction (MI) patients (≥65 years). Further, the study explored coping strategies developed to manage these challenges in the everyday life. METHODS: Nine patients were included in the study. Data were collected by telephone or in person, between 6 and 12 weeks post MI, using semi-structured interviews. Data were analysed inductively, using thematic analysis. RESULTS: Four major themes were identified, highlighting elderly MI patients' experiences of their cognitive status and cardiac rehabilitation management: (1) A change in cognition over time, (2) Situating the MI within a challenging and changing life context, (3) Navigating the hurdles of cardiac rehabilitation, and (4) Being seen within the healthcare system. CONCLUSION: Elderly MI patients are situated in a complex life context, dealing with a transition to retirement, multiple health issues and age-related cognitive decline. In this context, the MI experience is marginalised, and cognitive decline normalized. By adopting individually tailored interventions and improving healthcare provider continuity and accessibility, cognitive challenges associated with cardiac rehabilitation could be easier to overcome.IMPLICATIONS FOR REHABILITATIONSelf-perceived cognitive impairment, in particular regarding memory, seems fairly common among elderly MI patients and should likely be identified prior to hospital discharge in order to optimize the prospects of self-care.There seems to exist an unmet need to implement the practice of individually adapted education and information further, in accordance with current recommendations for elderly cardiac patients.The overall health and cognitive status, social network and the objective living conditions (e.g., distance from service and housing) should be taken into account when planning the patient's cardiac rehabilitation management.Healthcare providers likely need to strengthen the continuity of care and increase its accessibility for elderly MI patients, in particular following the transfer from hospital care to local health centres.

Cognitive dedifferentiation as a function of cognitive impairment in the ADNI and MemClin cohorts.

The cause of cognitive dedifferentiation has been suggested as specific to late-life abnormal cognitive decline rather than a general feature of aging. This hypothesis was tested in two large cohorts with different characteristics. Individuals (n = 2710) were identified in the Alzheimer's Disease Neuroimaging Initiative (ADNI) research database (n = 1282) in North America, and in the naturalistic multi-site MemClin Project database (n = 1223), the latter recruiting from 9 out of 10 memory clinics in the greater Stockholm catchment area in Sweden. Comprehensive neuropsychological testing informed diagnosis of dementia, mild cognitive impairment (MCI), or subjective cognitive impairment (SCI). Diagnosis was further collapsed into cognitive impairment (CI: MCI or dementia) vs no cognitive impairment (NCI). After matching, loadings on the first principal component were higher in the CI vs NCI group in both ADNI (53.1% versus 38.3%) and MemClin (33.3% vs 30.8%). Correlations of all paired combinations of individual tests by diagnostic group were also stronger in the CI group in both ADNI (mean inter-test r = 0.51 vs r = 0.33, p < 0.001) and MemClin (r = 0.31 vs r = 0.27, p = 0.042). Dedifferentiation was explained by cognitive impairment when controlling for age, sex, and education. This finding replicated across two separate, large cohorts of older individuals. Knowledge that the structure of human cognition becomes less diversified and more dependent on general intelligence as a function of cognitive impairment should inform clinical assessment and care for these patients as their neurodegeneration progresses.

Internet-Based Cognitive Behavioral Therapy for Patients Reporting Symptoms of Anxiety and Depression After Myocardial Infarction: U-CARE Heart Randomized Controlled Trial Twelve-Month Follow-up.

BACKGROUND: The U-CARE Heart trial was one of the first randomized controlled trials to evaluate the effect of internet-based cognitive behavioral therapy on self-reported symptoms of anxiety or depression for patients with a recent myocardial infarction. While the effects of internet-based cognitive behavioral therapy on Hospital Anxiety and Depression Scale (HADS) scores at 14 weeks postbaseline were not significant, in this study, we investigated possible long-term effects of treatment. OBJECTIVE: The aim of this study was to evaluate the long-term effectiveness of internet-based cognitive behavioral therapy on self-reported symptoms of anxiety and depression in patients 12 months after a myocardial infarction and to explore subsequent occurrences of cardiovascular disease events. METHODS: Shortly after acute myocardial infarction, 239 patients (33% female, mean age 59.6 years) reporting mild-to-moderate symptoms of anxiety or depression were randomized to 14 weeks of therapist-guided internet-based cognitive behavioral therapy (n=117) or treatment as usual (n=122). Data from national registries were used to explore group differences in clinical outcomes such as cardiovascular disease and cardiovascular-related mortality for a follow-up period of up to 5 years: group differences in HADS total score 1 year post-myocardial infarction, the primary outcome, was analyzed using multiple linear regression. Secondary outcomes, such as HADS anxiety and depression subscales and the Cardiac Anxiety Questionnaire total score (CAQ), which measures heart-focused anxiety, were analyzed in the same way. Multiple imputation was used to account for missing data, and a pooled treatment effect was estimated. Adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) for data pertaining to registry outcomes. RESULTS: Both groups reported lower HADS total scores 1 year after myocardial infarction than those at baseline. HADS total scores were not significantly different between the treatment and control groups 1 year after myocardial infarction (ß=-1.14, 95% CI -2.73 to 0.45, P=.16). CAQ was the only measure improved significantly by internet-based cognitive behavioral therapy when compared with treatment as usual (ß=-2.58, 95% CI -4.75 to -0.42, P=.02) before adjusting for multiple comparisons. The composite outcome of nonfatal cardiovascular events and cardiovascular-related mortality did not differ between groups but was numerically higher in the internet-based cognitive behavioral therapy group, who were at slightly greater risk (HR 1.8, 95% CI 0.96 to 3.4, P=.07). Adjusting for previous myocardial infarction and diabetes attenuated this estimate (HR 1.5, 95% CI 0.8 to 2.8, P=.25). CONCLUSIONS: Internet-based cognitive behavioral therapy was not superior in reducing self-reported symptoms of depression or anxiety compared to treatment as usual at the 1-year follow-up after myocardial infarction. A reduction in cardiac-related anxiety was observed but was not significant after adjusting for multiple comparisons. There was no difference in risk of cardiovascular events between the treatment groups. Low treatment adherence, which might have affected treatment engagement and outcomes, should be considered when interpreting these results. TRIAL REGISTRATION: ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-015-0689-y.

Association between ß-blocker dose and cardiovascular outcomes after myocardial infarction: insights from the SWEDEHEART registry.

AIMS: Dose-dependent effects of ß-blockers on survival and cardiovascular outcomes after myocardial infarction (MI) are not well understood. We investigated the long-term risk of cardiovascular events in patients with different doses of ß-blockers after MI. METHODS AND RESULTS: This was a nationwide observational study linking morbidity, mortality, socioeconomic, and medication data from Swedish national registries. Between 2006 and 2015, 97 575 unique patients with first-time MI were included. In total, 33 126 (33.9%) patients were discharged with ≥50% of the target ß-blocker dose and 64 449 (66.1%) patients with <50% of the target ß-blocker dose used in previous randomized trials. The primary composite endpoint was re-infarction or all-cause death within 1 year from discharge. Multivariable adjusted 1-year follow-up estimates using mixed effects Cox regression [HR (95% CI)] showed that patients treated with ≥50% of the target dose had a similar risk of the composite endpoint [1.03 (0.99-1.08)] and a somewhat higher risk when stroke, atrial fibrillation, or heart failure hospitalization were added to the composite endpoint [1.08 (1.04-1.12)], compared with patients on <50% of the target ß-blocker dose. Results remained similar up to 5 years of follow-up and consistent across relevant patient subgroups, including patients who developed heart failure during the index hospitalization. CONCLUSIONS: In contrast to doses of ß-blockers used in previous trials, ≥50% of the target ß-blocker dose was not associated with superior cardiovascular outcomes up to 5 years as compared with <50% of the target dose. Contemporary randomized clinical trials are needed to clarify the optimal dose of ß-blockers after MI.