Comprehensive symptom assessment using Integrated Palliative care Outcome Scale in hospitalized heart failure patients.

AIMS: Patients with heart failure (HF) may have variable unrecognized symptom burdens. We sought to investigate the details, determinants, and prognostic significance of symptom burden in hospitalized patients with HF. METHODS AND RESULTS: We prospectively evaluated consecutive hospitalized patients with HF as primary diagnosis at our institution using the Integrated Palliative care Outcome Scale (IPOS) both on admission and at discharge. The IPOS, which is a well-validated multi-dimensional symptom assessment scale among advanced illness, consists of 17 questions for enquiring about physical symptoms (10 items), emotional symptoms (4 items) and communication and practical issues (3 items) using a 5-point Likert scale (0 [best]-4 [worst] points). Clinically relevant symptoms were defined as ≥2 points for each IPOS item. Worsening symptom burden was defined as the total IPOS score at discharge being poorer than that on admission. Of 294 patients (mean age: 77.5 ± 12.0 years, male: 168 patients, New York Heart Association class IV: 96 patients, mean left ventricular ejection fraction [LVEF]: 44%, and median N-terminal pro B-type natriuretic peptide [NT-proBNP] level: 4418 ng/L), the median (IQR) total IPOS score on admission was 19 (12, 27) and they were widely distributed (minimum: 0 - maximum: 52). The total IPOS score on admission was not correlated with the HF severity, including LVEF (Spearman's ρ = -0.05, P = 0.43), NT-proBNP levels (Spearman's ρ = 0.08, P = 0.20) or in-hospital mortality prediction model (GWTG-HF risk score) (Spearman's ρ = 0.01, P = 0.90). Total IPOS scores significantly decreased during hospitalization as a whole (median [IQR]: 13 [6, 21] at discharge; P < 0.001 vs. those on admission). All of the four emotional symptoms (patient anxiety, depression, family anxiety and feeling at peace) remained in the top 5 of clinically relevant symptoms at discharge, whereas none of 10 physical symptoms were nominated. Worsening symptom burden was noted in 28% of the patients during hospitalization, and was independently associated with higher all-cause mortality after discharge (hazard ratio: 2.28, 95% confidence interval: 1.02-5.09; P = 0.044) even after adjustment by age and HF mortality prediction model (MAGGIC risk score). CONCLUSIONS: We revealed that hospitalized patients with HF had multi-dimensional symptom burdens which varied among individuals and were not correlated with the disease severity. Emotional symptoms, such as anxiety and depression, were the main clinically relevant symptoms at discharge. A worsening IPOS score was noted in a quarter of patients with HF and was associated with a poor prognosis, suggesting the importance of holistic symptom assessment during the course of hospitalization for HF.

Prevalence, Temporal Change, and Determinants of Anxiety and Depression in Hospitalized Patients With Heart Failure.

BACKGROUND: Anxiety and depression may be under-recognized in patients with heart failure (HF). We therefore investigated the prevalence and temporal change of these symptoms in hospitalized patients with HF. METHODS AND RESULTS: We prospectively evaluated consecutive hospitalized patients with HF using the Hospital Anxiety and Depression Scale (HADS) on admission and at discharge. The HADS-A (anxiety) and HADS-D (depression) scores were categorized as follows; 0-7, no symptoms; 8-10, mild; and 11-21, significant anxiety or depression. Symptom worsening was defined as the HADS category at discharge being poorer than that on admission. Of 224 patients (mean age 77.5 years), 35 (16%) and 62 (28%) had significant symptoms of anxiety and depression, respectively. During hospitalization, the HADS-A significantly decreased (on admission; median 6 [interquartile range (IQR) 3-9] vs at discharge; median 4 [IQR 2-7], P < .01), whereas the HADS-D did not improve (on admission; median 8 [IQR 5-11] vs at discharge; median 8 [IQR 4-11], P =.82). Anxiety and depression worsened during hospitalization in 19 (10%) and 40 (21%) patients, respectively. Advanced age, higher natriuretic peptide levels, and acute-on-chronic HF were associated with worsening anxiety, and longer hospitalization length was associated with worsening depression. CONCLUSIONS: Anxiety and depression were common and depression persisted during HF hospitalization.

Photostability studies on (±)-tramadol in a liquid formulation.

BACKGROUND: Tramadol ((±)-TRA) is recommended for the treatment of mild to moderate cancer pain by the World Health Organization. An oral liquid formulation of (±)-TRA is preferable for patients with a compromised swallowing function. However, the stability of (±)-TRA in aqueous solution has yet to be determined in a clinical setting. The aim of this study was to evaluate the photostability of (±)-TRA in aqueous solution in a clinical setting. METHODS: We improved high performance liquid chromatography (HPLC) method for the enantiomeric separation of (±)-TRA, and then the (±)-TRA concentration was determined using HPLC method. We investigated the photodegradation of (±)-TRA in an aqueous solution irradiated with ultraviolet (UV) light: UV-A, UV-B, and UV-C. We also evaluated the stability of liquid formulations of (±)-TRA in a clinical setting by keeping (±)-TRA aqueous solution in normal dispensing bottles and in light-shading dispensing bottles under conditions of both sunlight and diffused light in a room. Samples were collected sequentially over time. RESULTS: (±)-TRA in aqueous solution was degraded the most rapidly when irradiated with UV-C, but was not affected by irradiation with UV-A. No significant difference was observed in the photodegradation behavior of (+)-TRA and (-)-TRA with UV-A, UV-B, and UV-C irradiation. The residual percentages of (±)-TRA were 94.6-104.3% after 14 days in the presence of either sunlight or diffused light in a room, with or without protection from light. CONCLUSIONS: These results demonstrated the stability of (±)-TRA in aqueous solution to both sunlight and diffused light in a room. Therefore, liquid formulations of TRA are preserved at room temperature for up to 2 weeks, with or without protection from light. Our results provide additional treatment options with tramadol for pain control.