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Background Few studies have investigated the trajectory of depression and level of physical activity, in patients with heart disease during a psychosocial intervention such as internet based cognitive behavioural therapy (iCBT). For health care professionals in cardiac care it is important to know when an improvement in depression can be expected during iCBT and if this improvement can be associated with physical activity. The aim of this study therefore is, 1) to investigate the trajectory of depression and physical activity during participation in an iCBT program compared to a moderated online discussion forum (ODF). 2) to investigate the association between improvements in depression and physical activity. Method A sub-analysis of data collected in a randomised controlled trial (RCT) that evaluated the effect on depression of a nine-week iCBT program guided by nurse. In the RCT, 144 cardiac patients with at least mild depression were randomised to iCBT or ODF. The iCBT program consisted of seven modules where feedback was provided by nurses. The ODF consisted of nine discussion topics moderated by a nurse. Data for the present analysis was collected at baseline, once weekly during the intervention period, and the follow-up. Depression was measured by Montgomery Åsberg Depression Rating Scale – self rating (MADRS-S). Two modified items from the Physical Activity Questionnaire measured frequency and length of physical activity. Frequency was scored between “none of the days” (0) to “often, 5-7 days” (3). Length was scored from 0 (0 minutes) to 4 (more than 60 minutes). A combined physical activity factor was calculated by multiplying frequency and length scores. Results Figure 1a illustrates the trajectory of depression from baseline assessment until the follow up. There was a significant time and group interaction (F=9.98, p<.001, η2=.106) favouring iCBT. The significant difference in depression between iCBT and ODF started at week six and remained to the follo

Selenium and coenzyme Q10 (SeQ10) are important for normal cellular function. Low selenium intake leads to increased cardiovascular mortality. Intervention with these substances with healthy elderly persons over a period of four years in a double-blind, randomised placebo-controlled prospective study showed reduced cardiovascular mortality, increased cardiac function, and a lower level of NT-proBNP. Therefore, we wanted to evaluate changes in biochemical pathways as a result of the intervention with SeQ10 using metabolic profiling. From a population of 443 healthy elderly individuals that were given 200 µg selenium and 200 mg coenzyme Q10, or placebo daily for four years, we selected nine males on active intervention and nine males on placebo for metabolic profiling in the main study. To confirm the results, two validation studies (study 1 n = 60 males, study 2 n = 37 males) were conducted. Principal component analyses were used on clinical and demographic data to select representative sets of samples for analysis and to divide the samples into batches for analysis. Gas chromatography time-of-flight mass spectrometry-based metabolomics was applied. The metabolite data were evaluated using univariate and multivariate approaches, mainly T-tests and orthogonal projections to latent structures (OPLS) analyses. Out of 95 identified metabolites, 19 were significantly decreased due to the intervention after 18 months of intervention. Significant changes could be seen in the pentose phosphate, the mevalonate, the beta-oxidation and the xanthine oxidase pathways. The intervention also resulted in changes in the urea cycle, and increases in the levels of the precursors to neurotransmitters of the brain. This adds information to previous published results reporting decreased oxidative stress and inflammation. This is the first-time metabolic profiling has been applied to elucidate the mechanisms behind an intervention with SeQ10. The study is small and should be regarded as hy, Funding Agencies|Pharma Nord Aps, Denmark; County Council of Ostergotland, Linkoping University

Genetic counseling services are increasing in demand and limited in access due to barriers such as lack of professional genetic counselors, vast geographic distances, and physical hurdles. This research focuses on an alternative mode of delivery for genetic counseling in Sweden, in order to overcome some of the mentioned barriers. The aim of this study is to identify factors that influence the implementation and use of telegenetic counseling in clinical practice, according to health care professionals in Southeast Sweden. Telegenetic counseling refers to the use of video-conferencing as a means to provide genetic counseling. Qualitative, semi-structured interviews with 16 genetic counseling providers took place and phenomenographic analysis was applied. Significant excerpts were identified in each transcript, which led to sub-categories that constructed the main findings. Three categories emerged from the data: (1) requirements for optimal use, (2) impact on clinical practice, and (3) patient benefits. Each category consists of two or three sub-categories, in total seven sub-categories. These findings could potentially be used to improve access and uptake of telegenetic counseling in Sweden and in other countries with a similar health care system. This could benefit not only remote patient populations, as described in previous research, but also large family groups and patients experiencing obstacles in accessing genetic counseling, such as those with a psychiatric illness or time constraints, and be a useful way to make genetic counseling available in the new era of genomics., Funding Agencies|Centre for Rare Diseases Southeast, Linkoping University Hospital, Linkoping, Sweden

Background: Comorbid psychological distress (i.e. insomnia and depression) is experienced by 20-40% of patients with cardiovascular disease. This has a considerable impact on their health and quality of life, leading to frequent re-hospitalisations, higher healthcare costs and a shorter life expectancy. Internet-based cognitive behavioural therapy shows great potential for treating psychological distress in cardiovascular disease. Effective and feasible treatments can, however, only benefit patients if they are fully implemented in clinical care. Aim: This scoping review aimed to explore the literature for internet-based cognitive behavioural therapy in cardiovascular disease and for strategies to implement the intervention. Methods: We searched electronic databases, journals and internet sources to find original studies about internet-based cognitive behavioural therapy in cardiovascular disease, adhering to scoping methodology guidelines. After identifying 267 titles, we screened 40 abstracts and chose 11 full-text articles for full-text screening. The results sections in four articles were searched for outcomes that related to the effectiveness and implementation of internet-based cognitive behavioural therapy by directed qualitative content analysis using an implementation framework. Results: Three of the four articles fulfilling the inclusion criteria concerned internet-based cognitive behavioural therapy for treating mild to moderate depressive symptoms in cardiovascular disease, and none focused on insomnia. The studies showed evidence for the effectiveness of internet-based cognitive behavioural therapy, and/or described patient factors influencing clinical effectiveness. Our qualitative content analysis showed that many implementation aspects and stakeholder perspectives remain unexplored. Conclusions: Internet-based cognitive behavioural therapy promises to alleviate patient suffering in cardiovascular disease. There is, however, little research about inte, Funding Agencies|Swedish Research Council [2015-02600]

Background: Web-based cognitive behavioral therapy (wCBT) has been proposed as a possible treatment for patients with heart failure and depressive symptoms. Depressive symptoms are common in patients with heart failure and such symptoms are known to significantly worsen their health. Although there are promising results on the effect of wCBT, there is a knowledge gap regarding how persons with chronic heart failure and depressive symptoms experience wCBT. Objective: The aim of this study was to explore and describe the experiences of participating and receiving health care through a wCBT intervention among persons with heart failure and depressive symptoms. Methods: In this qualitative, inductive, exploratory, and descriptive study, participants with experiences of a wCBT program were interviewed. The participants were included through purposeful sampling among participants previously included in a quantitative study on wCBT. Overall, 13 participants consented to take part in this study and were interviewed via telephone using an interview guide. Verbatim transcripts from the interviews were qualitatively analyzed following the recommendations discussed by Patton in Qualitative Research amp; Evaluation Methods: Integrating Theory and Practice. After coding each interview, codes were formed into categories. Results: Overall, six categories were identified during the analysis process. They were as follows: "Something other than usual health care," "Relevance and recognition," "Flexible, understandable, and safe," "Technical problems," "Improvements by real-time contact," and "Managing my life better." One central and common pattern in the findings was that participants experienced the wCBT program as something they did themselves and many participants described the program as a form of self-care. Conclusions: Persons with heart failure and depressive symptoms described wCBT as challenging. This was due to participants balancing the urge for real-time contact with perc, Funding Agencies|Swedish Research Council [2015-02600]; Region Ostergotland, Sweden [LIO-531701, LIO-629211]; Medical Research Council of Southeast Sweden [FORSS-470121]; Swedish Heart and Lung Association [E082/14, E 087/13]; A-L and A Andersson Foundation for psychiatric research [LIO 5611101]

BACKGROUND: Psychological distress such as somatization, fear of body sensations, cardiac anxiety and depressive symptoms is common among patients with non-cardiac chest pain, and this may lead to increased healthcare use. However, the relationships between the psychological distress variables and healthcare use, and the differences in relation to history of cardiac disease in these patients has not been studied earlier. Therefore, our aim was to explore and model the associations between different variables of psychological distress (i.e. somatization, fear of body sensations, cardiac anxiety, and depressive symptoms) and healthcare use in patients with non-cardiac chest pain in relation to history of cardiac disease. METHODS: In total, 552 patients with non-cardiac chest pain (mean age 64 years, 51% women) responded to the Patient Health Questionnaire-15, Body Sensations Questionnaire, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9 and one question regarding number of healthcare visits. The relationships between the psychological distress variables and healthcare visits were analysed using Structural Equation Modeling in two models representing patients with or without history of cardiac disease. RESULTS: A total of 34% of the patients had previous cardiac disease. These patients were older, more males, and reported more comorbidities, psychological distress and healthcare visits. In both models, no direct association between depressive symptoms and healthcare use was found. However, depressive symptoms had an indirect effect on healthcare use, which was mediated by somatization, fear of body sensations, and cardiac anxiety, and this effect was significantly stronger in patients with history of cardiac disease. Additionally, all the direct and indirect effects between depressive symptoms, somatization, fear of body sensations, cardiac anxiety, and healthcare use were significantly stronger in patients with history of cardiac disease. CONCLUSIONS: In, Funding agencies: County Council of Ostergotland, Sweden [LIO-439131]; Medical Research of Southeast Sweden [FORSS-475291]

Background Selenium and coenzyme Q10 are both necessary for optimal cell function in the body. The intake of selenium is low in Europe, and the endogenous production of coenzyme Q10 decreases as age increases. Therefore, an intervention trial using selenium and coenzyme Q10 for four years as a dietary supplement was performed. The main publication reported reduced cardiovascular mortality as a result of the intervention. In the present sub-study the objective was to determine whether reduced cardiovascular (CV) mortality persisted after 12 years, in the supplemented population or in subgroups with diabetes, hypertension, ischemic heart disease or reduced functional capacity due to impaired cardiac function. Methods From a rural municipality in Sweden, four hundred forty-three healthy elderly individuals were included. All cardiovascular mortality was registered, and no participant was lost to the follow-up. Based on death certificates and autopsy results, mortality was registered. Findings After 12 years a significantly reduced CV mortality could be seen in those supplemented with selenium and coenzyme Q10, with a CV mortality of 28.1% in the active treatment group, and 38.7% in the placebo group. A multivariate Cox regression analysis demonstrated a reduced CV mortality risk in the active treatment group (HR: 0.59; 95% CI 0.42-0.81; P = 0.001). In those with ischemic heart disease, diabetes, hypertension and impaired functional capacity we demonstrated a significantly reduced CV mortality risk. Conclusions This is a 12-year follow-up of a group of healthy elderly participants that were supplemented with selenium and coenzyme Q10 for four years. Even after twelve years we observed a significantly reduced risk for CV mortality in this group, as well as in subgroups of patients with diabetes, hypertension, ischemic heart disease or impaired functional capacity. The results thus validate the results obtained in the 10-year evaluation. The protective action was not conf, Funding Agencies|Pharma Nord Aps, Denmark; County Council of Ostergotland, Linkoping University

Background: In an intervention study where 221 healthy elderly persons received selenium and coenzyme Q10 as a dietary supplement, and 222 received placebo for 4 years we observed improved cardiac function and reduced cardiovascular mortality. As fibrosis is central in the aging process, we investigated the effect of the intervention on biomarkers of fibrogenic activity in a subanalysis of this intervention study. Material and Methods: In the present subanalysis 122 actively treated individuals and 101 controls, the effect of the treatment on eight biomarkers of fibrogenic activity were assessed. These biomarkers were: Cathepsin S, Endostatin, Galectin 3, Growth Differentiation Factor-15 (GDF-15), Matrix Metalloproteinases 1 and 9, Tissue Inhibitor of Metalloproteinases 1 (TIMP 1) and Suppression of Tumorigenicity 2 (ST-2). Blood concentrations of these biomarkers after 6 and 42 months were analyzed by the use of T-tests, repeated measures of variance, and factor analyses. Results: Compared with placebo, in those receiving supplementation with selenium and coenzyme Q10, all biomarkers except ST2 showed significant decreased concentrations in blood. The changes in concentrations, that is, effects sizes as given by partial eta(2) caused by the intervention were considered small to medium. Conclusion: The significantly decreased biomarker concentrations in those on active treatment with selenium and coenzyme Q10 compared with those on placebo after 36 months of intervention presumably reflect less fibrogenic activity as a result of the intervention. These observations might indicate that reduced fibrosis precedes the reported improvement in cardiac function, thereby explaining some of the positive clinical effects caused by the intervention. (c) 2017 BioFactors, 44(2):137-147, 2018, Funding Agencies|County Council of Ostergotland; University of Linkoping; Alehagen

Background Insulin-like growth factor-1(IGF-1) has a multitude of effects besides cell growth and metabolism. Reports also indicate anti-inflammatory and antioxidative effects. The concentrations of IGF-1 decrease with age and during inflammation. As selenium and coenzyme Q10 are involved in both the antioxidative defense and the inflammatory response, the present study aimed to examine the effects of supplementation with selenium and coenzyme Q10 on concentrations of IGF-1 and its binding protein IGFBP-1 in a population showing reduced cardiovascular mortality following such supplementation. Methods 215 elderly individuals were included and given the intervention for four years. A clinical examination was performed and blood samples were taken at the start and after 48 months. Evaluations of IGF-1, the age adjusted IGF-1 SD score and IGFBP-1 were performed using group mean values, and repeated measures of variance. Findings After supplementation with selenium and coenzyme Q10, applying group mean evaluations, significantly higher IGF-1 and IGF-1 SD scores could be seen in the active treatment group, whereas a decrease in concentration could be seen of the same biomarkers in the placebo group. Applying the repeated measures of variance evaluations, the same significant increase in concentrations of IGF-1 (F = 68; P amp;gt; 0.0001), IGF-1 SD score (F = 29; P amp;lt; 0.0001) and of IGFBP-1 (F = 6.88; P = 0.009) could be seen, indicating the effect of selenium and coenzyme Q10 also on the expression of IGF-1 as one of the mechanistic effects of the intervention. Conclusion Supplementation with selenium and coenzyme Q10 over four years resulted in increased levels of IGF-1 and the postprandial IGFBP-1, and an increase in the age-corrected IGF-1 SD score, compared with placebo. The effects could be part of the mechanistic explanation behind the surprisingly positive clinical effects on cardiovascular morbidity and mortality reported earlier. However, as the effects of IG, Funding Agencies|Family Erling-Persson Foundation; Medical Research Council; Pharma Nord Aps, Denmark; County Council of Ostergotland; Linkoping University

Background: Patients with non-cardiac chest pain (NCCP) suffer psychological distress such as somatization, fear of body sensations, cardiac anxiety and depressive symptoms, which can increase healthcare use. It is unknown how these variables are related and whether the relationships differ between patients with or without history of cardiac disease. Objective: To explore and model the associations between somatization, fear of body sensations, cardiac anxiety, depressive symptoms, and healthcare use in patients with NCCP with or without history of cardiac disease. Methods: Data were collected in Sweden in 670 patients (mean age 65±16 years, 51% women) within one month from discharge using the Patient Health Questionnaire-15, Body Sensations Questionnaire, Cardiac Anxiety Questionnaire, and Patient Health Questionnaire-9. Structural Equation Modelling analyses were used to explore the relationships between somatization, fear of body sensations, cardiac anxiety, depressive symptoms and healthcare use in NCCP patients with or without history of cardiac disease. Results: About 40% of the NCCP patients had previous diagnosis of cardiac disease. Patients with NCCP and a history of cardiac disease were older (71 vs. 60 years), had more comorbidities (4.7 vs. 2.8), and reported significantly higher scores in somatization (p=0.02), cardiac anxiety (p<0.001), and depressive symptoms (p=0.02), and greater healthcare use (p<0.001). Depressive symptoms were not directly associated with healthcare use (Chi-Square=68.28, df=10, P-value=0.000, RMSEA=0.099, CFI=0.96). In patients with history of cardiac disease, the impact of depressive symptoms on healthcare use was mediated by somatization, fear of body sensations, and cardiac anxiety (Chi-Square=7.61, df=8, P-value=0.48, RMSEA=0.000, CFI=0.99). In patients with no history of cardiac disease, the impact of depressive symptoms on healthcare use was directly mediated by cardiac anxiety (Chi-Square=4.17, df=7, P-value=0.76, RM

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BACKGROUND: Depressive symptoms, and the associated coexistence of symptoms of anxiety and decreased quality of life (QoL), are common in patients with heart failure (HF). However, treatment strategies for depressive symptoms in patients with HF still remain to be established. Internet-based cognitive behavioral therapy (ICBT), as guided self-help CBT programs, has shown good effects in the treatment of depression. Until now, ICBT has not been evaluated in patients with HF with depressive symptoms. OBJECTIVE: The aims of this study were to (1) evaluate the effect of a 9-week guided ICBT program on depressive symptoms in patients with HF; (2) investigate the effect of the ICBT program on cardiac anxiety and QoL; and (3) assess factors associated with the change in depressive symptoms. METHODS: Fifty participants were randomized into 2 treatment arms: ICBT or a Web-based moderated discussion forum (DF). The Patient Health Questionnaire-9 was used to measure depressive symptoms, the Cardiac Anxiety Questionnaire (CAQ) was used to measure cardiac-related anxiety, and the Minnesota Living with Heart Failure questionnaire was used to measure QoL. Data were collected at baseline and at follow-up at the end of the 9-week intervention. Intention-to-treat analysis was used, and missing data were imputed by the Expectation-Maximization method. Between-group differences were determined by analysis of covariance with control for baseline score and regression to the mean. RESULTS: No significant difference in depressive symptoms between the ICBT and the DF group at the follow-up was found, [F(1,47)=1.63, P=.21] and Cohen´s d=0.26. Secondary within-group analysis of depressive symptoms showed that such symptoms decreased significantly in the ICBT group from baseline to the follow-up (baseline M=10.8, standard deviation [SD]=5.7 vs follow-up M=8.6, SD=4.6, t(24)=2.6, P=.02, Cohen´s d=0.43), whereas in the DF group, there was no significant change (baseline M=10.6, SD=5.0, vs follow, Funding agencies: Swedish Heart and Lung Association [E087/13, E08/14]; Medical Research Council of Southeast Sweden [FORSS-374721, FORSS-470121]; Region Ostergotland [LIO-355611, LIO-374831, LIO-443711, LIO-470271]

BACKGROUND: Patients with non-cardiac chest pain (NCCP) suffer from recurrent chest pain and make substantial use of healthcare resources. OBJECTIVE: To explore the prevalence of depressive symptoms, cardiac anxiety, and fear of body sensations in patients discharged with a NCCP diagnosis; and to describe how depressive symptoms, cardiac anxiety, and fear of body sensations are related to each other and to healthcare-seeking behavior. METHODS: Cross-sectional design. Data were collected between late October 2013 and early January 2014 in 552 patients with NCCP from four hospitals in southeast Sweden, using the Patient Health Questionnaire-9, Cardiac Anxiety Questionnaire, and Body Sensations Questionnaire. RESULTS: About 26 % (n = 141) of the study participants reported at least moderate depressive symptoms, 42 % (n = 229) reported at least moderate cardiac anxiety, and 62 % (n = 337) reported some degree of fear of body sensations. We found strong positive relationships between depressive symptoms and cardiac anxiety (r s = 0.49; P < 0.01), depressive symptoms and fear of body sensations (r s = 0.50; P < 0.01), and cardiac anxiety and fear of body sensations (r s = 0.56; P < 0.01). About 60 % of the participants sought care because of chest pain once, 26 % two or three times, and the rest more than three times. In a multivariable regression analysis, and after adjustment for multimorbidity, cardiac anxiety was the only variable independently associated with healthcare-seeking behavior. CONCLUSION: Patients with NCCP and many healthcare consultations had high levels of depressive symptoms and cardiac anxiety, and moderate levels of fear of body sensations. Cardiac anxiety had the strongest relationship with healthcare-seeking behavior and may therefore be an important target for intervention to alleviate suffering and to reduce healthcare use and costs., Funding agencies: County Council of Ostergotland, Sweden; Medical Research of Southeast Sweden (FORSS)

Background: Patients with recurrent episodes of non-cardiac chest pain may experience cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. The purpose of this study was to test the feasibility of a short guided Internet-delivered cognitive behavioural therapy (CBT) program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care. Methods: A pilot randomized controlled study was conducted. Fifteen patients with non-cardiac chest pain with cardiac anxiety or fear of body sensations, aged 22-76 years, were randomized to intervention (n = 7) or control (n = 8) groups. The four-session CBT program contained psychoeducation, physical activity, and relaxation. The control group received usual care. Data were collected before and after intervention. Results: Five of seven patients in the intervention group completed the program, which was perceived as user-friendly with comprehensible language, adequate and varied content, and manageable homework assignments. Being guided and supported, patients were empowered and motivated to be active and complete the program. Patients in both intervention and control groups improved with regard to cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups. Conclusions: The Internet-delivered CBT program seems feasible for patients with non-cardiac chest pain, but needs to be evaluated in larger groups and with a longer follow-up period., Funding Agencies|County Council of Ostergotland, Sweden; Medical Research of Southeast Sweden

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Background: The aims of this study were to: (I) evaluate the effect of a nine-week guided Internet-based Cognitive Behavioral Therapy (ICBT) program on depressive symptoms (DS) in patients with HF; (II) to assess factors associated with the change in DS; and (III) to investigate the effect of the ICBT program on cardiac anxiety and QoL. Methods: Fifty participants were included and randomized into two treatment arms: ICBT or an online moderated discussion forum (DF). Data were collected at baseline and at the nine-week follow-up; the Patient Health Questionnaire- nine, (DS); the Cardiac Anxiety Questionnaire, (cardiac-related anxiety); the Minnesota Living with Heart Failure questionnaire, (QoL). Intention to treat analysis was used. Between group differences were determined by analysis of covariance. Results: In the ICBT-group (n=25), DS improved significantly (P=.02). Also cardiac anxiety in the subscale of fear decreased significantly (P=.04) between baseline and the follow up in the ICBT-group. QoL improved in the ICBT-group by 6 points in the total score and 2.4 points in the physical factor, but this was not significant (P=.09 and P=.12). In the DF-group (n=25) no significant change in the level of DS was found (P=.36). There were no significant differences in the change in DS between the DF- and the ICBT-group (P=.21), nor in cardiac related anxiety (P=.22) or in QoL (total score P=.09, physical factor P=.07). In the ICBT-group, the number of logins to the web-portal correlated significantly with improvement in DS (P=.02), whereas higher age (P=.01) and male sex (P=.048) were associated with less change in DS. Conclusions: Guided ICBT adapted for persons with HF and DS can potentially reduce DS, cardiac anxiety and increase QoL, but is not statistically superior to participation in an online DF.

Background/aim: Fluid restriction has long been considered one of the cornerstones in self-care management of patients with heart failure. The aim of this discussion paper is to discuss fluid restriction in heart failure and propose advice about fluid intake in heart failure patients. Results: Although there have been seven randomised studies on fluid restriction in heart failure patients, the effect of fluid restriction on its own were only evaluated in two studies. In both studies, a stringent fluid restriction compared to a liberal fluid intake was not more beneficial with regard to clinical stability or body weight. In the other studies fluid restriction was part of a larger study intervention including, for example, individualised dietary recommendations and follow-up by telephone. Thus, the effect of fluid restriction on its own has been poorly evaluated. Conclusion: Fluid restriction should not be recommended to all heart failure patients. However, temporary fluid restriction can be considered in decompensated heart failure and/or patients with hyponatremia. Tailored fluid restriction based on body weight (30 ml/kg per day) seems to be most reasonable. To increase adherence to temporary fluid restriction, education, support and planned evaluations can be recommended.

Background: Vitamin D (Vit D) is suggested to play a role in the regulation of physical function as well as in depression. Since, Vit D deficiency is common in patients with heart failure (HF), this study aims to explore if Vit D levels are associated with depressive symptoms and if this association is mediated by the patients physical function. Method: 506 HF patients (mean age 71, 38% women) were investigated. Depressive symptoms and physical function were measured with the Centre for Epidemiological Studies Depression Scale and the physical function scale from the RAND-36. Vit D was measured in blood samples Results: At baseline there was no relationship between depressive symptoms and Vit D levels. However, at 18 months follow-up 29% of patients with Vit D < 50 nmol/l at baseline had depressive symptoms compared 19% of those with Vit D levels >50 nmol/l (p < 0.05). Only in patients with Vit D < 50 nmol/l, Vit D correlated significantly to physical function and depressive symptoms (r = .29, p < 0.001 and r = .20, p < 0.01). In structural equation modelling an indirect association between Vit D and depressive symptoms was found, mediated by physical function (B = 0.20). This association was only found in patients with Vit D levels <50 nmol/l. Conclusion: In HF patients with Vit D < 50 nmol/l, Vit D is associated to depressive symptoms during follow-up and this association is mediated by physical function. This relationship is not found in patients with Vitamin D level >50 nmol/l. (C) 2016 Elsevier Ireland Ltd. All rights reserved., Funding Agencies|Netherlands Heart Foundation [2000Z003]

Background: Telemonitoring of heart failure (HF) patients is increasingly discussed at conferences and addressed in research. However, little is known about actual use in specific countries. Objective: We aimed to (1) describe the use of non-invasive HF telemonitoring, (2) clarify expectations of telemonitoring among cardiologists and nurses, and (3) describe barriers to the implementation of telemonitoring in Japan and Sweden. Methods: This study used a cross-sectional survey of non-invasive HF telemonitoring. A total of 378 Japanese (120 cardiologists, 258 nurses) and 120 Swedish (39 cardiologists, 81 nurses) health care professionals from 165 Japanese and 61 Swedish hospitals/clinics nationwide participated in the study (210 in Japan and 98 in Sweden were approached). Data were collected between November 2013 and May 2014 with a questionnaire that was adapted from a previous Dutch study on telemonitoring. Results: The mean age of the cardiologists and nurses was 47 years and 41 years, respectively. Experience at the current position caring for HF patients was 19 years among the physicians and 15 years among the nurses. In total, 7 Japanese (4.2%) and none of the Swedish health care institutions used telemonitoring. One fourth (24.0%, 118/498) of the health care professionals were familiar with the technology (in Japan: 21.6%, 82/378; in Sweden: 30.0%, 36/120). The highest expectations of telemonitoring (rated on a scale from 0-10) were reduced hospitalizations (8.3 in Japan and 7.5 in Sweden), increased patient self-care (7.8 and 7.4), and offering high-quality care (7.8 and 7.0). The major goal for introducing telemonitoring was to monitor physical condition and recognize signs of worsening HF in Japan (94.1%, 352/374) and Sweden (88.7%, 102/115). The following reasons were also high in Sweden: to monitor effects of treatment and adjust it remotely (86.9%, 100/115) and to do remote drug titration (79.1%, 91/115). Just under a quarter of Japanese (22.4%, 85/378), Funding Agencies|Japan Society for the Promotion Science [25893059]

Background: Chest pain is one of the most common reasons for hospital admissions and more than 50 % of the patients admitted are diagnosed as non-cardiac and discharged without a clear explanation of the underlying cause for the chest pain. A number of patients with non-cardiac chest pain (NCCP) suffer from recurrent chest pain and use a substantial amount of healthcare resources leading to high healthcare and societal costs. Although depressive symptoms, anxiety, and fear of body sensations are prevalent in these patients and may have an impact on patients´ healthcare seeking behaviour, the relationship between these psychological factors and healthcare seeking behaviour is not fully elucidated. Objective: To investigate the prevalence of depressive symptoms, cardiac anxiety and fear of body sensations in patients acutely admitted to hospital due to chest pain and discharged with a NCCP diagnosis. Additionally, to explore how depressive symptoms, cardiac anxiety and fear of body sensations are related to each other and to healthcare seeking behaviour. Methods: Cross-sectional descriptive design. Data were collected from 552 patients diagnosed with NCCP in four Swedish hospitals within one month from discharge using the Patient Health Questionnaire-9, Cardiac Anxiety Questionnaire and Body Sensations Questionnaire. Healthcare seeking behaviour the year before study inclusion (i.e. the number of healthcare contacts) was self-reported by the patients. Results: Of the study population, 141 (26 %) reported at least moderate depressive symptoms, 229 (42 %) reported at least moderate cardiac anxiety, and 337 (62 %) reported some degree of fear of body sensations. There were strong positive relationships between depressive symptoms and cardiac anxiety (rs=.49, p<.01), depressive symptoms and fear of body sensations (rs=.50, p<.01), and cardiac anxiety and fear of body sensations (rs=.56, p<.01). 26 % of the study participants reported 2-3 healthcare contacts and 1

Background: Patients with recurrent episodes of non-cardiac chest pain (NCCP) may suffer from cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. Objective: To test the feasibility of a short guided Internet-delivered CBT intervention and the effects on chest pain, cardiac anxiety, fear of body sensations and depressive symptoms in patients with NCCP compared to usual care. Methods: A pilot randomized controlled study was conducted. Fifteen patients, nine men and six women with a median age of 66 years (range 22-76), were randomly assigned to either intervention (n=7) or control (n=8) group. Patients had recurrent episodes of non-cardiac chest pain and suffered from cardiac anxiety and/or fear of body sensations. The intervention consisted of a four-session guided Internet-delivered CBT program containing psychoeducation, physical activity, and relaxation. The control group received usual care. All patients completed a web-based questionnaire on socio-demographic variables, chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. Results: Five out of the seven patients in the intervention group completed all sessions as planned and two joined only parts of the program. The program was perceived as userfriendly with understandable language, adequate and varied content, and manageable homework assignments. The patients were engaged in the program for about 60 minutes per day and about 22 minutes’ therapist time was required to guide, support and give feedback to each patient through the program. Participating in the program, particularly being guided and supported, empowered and motivated many of the patients to be active and complete the program. In general, patients in both intervention and control groups improved with regard to chest pain frequency, cardiac anxiety, fear of body sensation

INTRODUCTION: Sleep problems are common in patients with heart failure (HF) and might be associated with patient outcomes. AIMS: The aim of this study was to describe the course of sleep problems in HF patients over 1 year and the association between sleep problems and rehospitalization. METHODS: Data from 499 HF patients (mean age, 70 years) were used in this analysis. Sleep problems were assessed with the item "Was your sleep restless" from the Center for Epidemiological Studies Depression Scale during hospitalization for HF (baseline) and after 1 year. RESULTS: A total of 43% of patients (n = 215) reported sleep problems at baseline, and 21% of patients (n = 105), after 1 year. Among the 215 patients with problems with sleep at baseline, 30% (n = 65) continued to have sleep problems over time. Among the 284 patients without sleep problems at baseline, 14% (n = 40) reported sleep problems after 1 year. After adjustments for potential cofounders, patients with continued sleep problems had an almost 2-fold increased risk for all-cause hospitalizations (hazard ratio, 2.1; P = .002) and cardiovascular hospitalizations (hazard ratio, 2.2; P = .004). CONCLUSION: One-third of HF patients with sleep problems at discharge experienced persistent sleep problems at follow-up. Continued sleep problems were associated with all-cause and cardiovascular rehospitalizations.

Sickness behavior is a cluster of symptoms that occur as a response to an infection and alterations in the inflammatory response. Under normal circumstances, sickness behavior is fully reversible once the pathogen has been cleared. Aging and chronic illness such as heart failure are associated with enhanced inflammatory activity that lasts for a long duration and no longer represents an adaptive response. The aim of this study was to explore whether inflammation mediates the relationship between impaired cardiac function and a symptom cluster including anhedonia, fatigue, and sleepiness, which might represent sickness behavior in community-dwelling elders. Structural equation modeling (SEM) showed that the factor impaired cardiac function (i.e., N-terminal fragment of pro-brain natriuretic peptide, left ventricular ejection fraction, and the heart failure medications angiotensin converting enzyme inhibitor, angiotensin receptor blockade, β-blocker, and diuretics) was associated with both inflammation (i.e., C-reactive protein; β = .26) and the symptom cluster (β = .31). Inflammation had a significant direct, but smaller, association with the symptom cluster (β = .21). By this pathway, inflammation also mediated an indirect association between impaired cardiac function and the symptom cluster (β = .05). Including creatinine, blood glucose, ischemic heart disease, previous and current tumor, respiratory disease, age, and body mass index in the SEM model did not change these associations. Our results imply that some aspects of the symptom panorama in elderly individuals with impaired cardiac function or heart failure could represent sickness behavior.

Cardiovascular disease (CVD) and depression are common. Patients with CVD have more depression than the general population. Persons with depression are more likely to eventually develop CVD and also have a higher mortality rate than the general population. Patients with CVD, who are also depressed, have a worse outcome than those patients who are not depressed. There is a graded relationship: the more severe the depression, the higher the subsequent risk of mortality and other cardiovascular events. It is possible that depression is only a marker for more severe CVD which so far cannot be detected using our currently available investigations. However, given the increased prevalence of depression in patients with CVD, a causal relationship with either CVD causing more depression or depression causing more CVD and a worse prognosis for CVD is probable. There are many possible pathogenetic mechanisms that have been described, which are plausible and that might well be important. However, whether or not there is a causal relationship, depression is the main driver of quality of life and requires prevention, detection, and management in its own right. Depression after an acute cardiac event is commonly an adjustment disorder than can improve spontaneously with comprehensive cardiac management. Additional management strategies for depressed cardiac patients include cardiac rehabilitation and exercise programmes, general support, cognitive behavioural therapy, antidepressant medication, combined approaches, and probably disease management programmes.

Long-term adherence to continuous positive airway pressure (CPAP) is low among patients with obstructive sleep apnea (OSA). The potential role of "habit" in sustaining adherence to CPAP use has not been studied. This study aimed to establish the relevance of habit to CPAP adherence, via validation of an adaptation of the Self-Report Habit Index (the CPAP Habit Index-5; CHI-5). Analyses focused on the homogeneity, reliability, and factor structure of the CHI-5 and, in line with theoretical predictions, its utility as a predictor of long-term CPAP adherence in middle-aged patients with OSA. A prospective longitudinal design was used. 117 patients with objectively verified OSA intended for CPAP treatment were recruited. Data was collected via clinical examinations, respiratory recordings, questionnaires, and CPAP devices at baseline, 2 weeks, 6 months, and 12 months. The CHI-5 showed satisfactory homogeneity interitem correlations (0.42-0.93), item-total correlations (0.58-0.91), and reliability ( α = 0.92). CHI-5 data at 6 months showed a one-factor solution and predicted 63% of variance in total CPAP use hours after 12 months. Based on the satisfactory measurement properties and the high amount of CPAP use variance it explained, the CHI-5 can be seen as a useful tool in clinical practice.

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Introduction: Chest pain is a common reason for patients to attend emergency departments and be admitted to coronary care units. However, the cause of pain is non-cardiac in more than 50 % of these patients and many patients remain undiagnosed and symptomatic. Patients with non-cardiac chest pain do not differ from the general population in terms of long-term mortality, but they suffer from recurrent chest pain and frequently seek both primary and emergency care. There is therefore a need for targeted interventions in order to support patients with non-cardiac chest pain and minimize healthcare utilization and costs. Previous studies point out different psychosocial factors to be related to non-cardiac chest pain. However, to date there are few models taking into account the complex relationship between different clinical and psychosocial components that may cause non-cardiac chest pain. Purpose: To study the prevalence of and relationship between pain, depressive symptoms, anxiety, somatization, fear of bodily sensations, illness perception and quality of life in patients with non-cardiac chest pain in order to design a treatment programme. Methods: The study will have a descriptive design. Eligible for the study will be patients over the age of 18 who have been diagnosed with non-cardiac chest pain in four hospitals within a region in southeast Sweden. One thousand patients will be recruited, through patient registers provided by the hospitals, within one month from the day of admission. Data collection will start in the fall of 2013. Study information, written informed consent, all questionnaires, and a pre-stamped envelope will be sent to all eligible patients. Two reminders will be sent to patients who do not respond within 3 weeks from mail-out. Outcomes: The study will report on the relationship between chest pain, depressive symptoms, anxiety, somatization, fear of bodily sensations, illness perception, and quality of life. Data will be collected using the B

Introduction: The majority of the patients seeking medical care due to chest pain are admitted for in-hospital cardiac "rule out" observation, but only one third of all patients have ischemic heart disease. More than half of these patients are diagnosed as "non-cardiac chest pain" (NCCP). Patients with NCCP utilize a substantial amount of healthcare resources, and contribute to high costs for society. Patients with NCCP may be suffering from pain-related fear and inappropriate health beliefs leading to avoidance of physical activities that they think could be harmful to their hearts. We hypothesize that these patients will gain from evaluating the accuracy and usefulness of their thoughts, and shifting their cognitive appraisals from unhealthy and maladaptive to constructive and adaptive. Purpose: To test the feasibility and effectiveness of an intervention based on CBT supporting patients to handle chest pain and related emotions, reactions and thoughts. Methods: A total of twenty patients will be recruited to this randomized controlled pilot study planned to start in April 2014. Eligible for the study will be persons over the age of 18 who during the last 6 months had sought care at least twice due to non-cardiac chest pain, and who screened positive for bodily sensations and/or avoidance of physical activity. The intervention will be a guided 4 weeks internet-based CBT programme with the following content: •Information to increase patients’ knowledge of chest pain and its impact on daily life. •Reflection upon the strategies patients use and how these can change to facilitate management of chest pain, and related emotions, reactions and thoughts. •Tailored moderate physical activity, 30 minutes per day, to get reassured that the heart tolerates physical activity and to decrease pain-related fear. •Relaxation exercise, 15 minutes per day, that can be used to cope with general stress and if appropriate to use in relation to chest pain. The control group will receiv

Purpose Differential item functioning (DIF) is said to exist in an item if a subject’s response to the item is affected by other aspects than that which the test is intended to assess. DIF might affect the validity of a test. The aim of this study was thus to examine whether any of the items in the Epworth Sleepiness Scale (ESS) exhibits DIF regarding age or gender, and if so, to which degree. Methods Using previously collected cross-sectional ESS data from 1,168 subjects with different clinical characteristics (61% males, mean age 67.8 year (SD 12.2 year)), ordinal regression as well as Rasch-based DIF analyses were performed. Results Concerning age, both DIF analyses showed DIF for age in items 3 (inactive in a public place), 4 (passenger in a car), and 8 (in a car that has stopped in traffic). The Rasch model also showed DIF for gender in item 3. The DIF magnitudes as judged by McFadden pseudo-R2 changes were, however, only minor. Conclusions ESS has small but reproducible DIF for age in items 3, 4, and 8. The detected DIF might be worth to consider in large-sample studies, although it probably has no effect on an individual basis.