The impact and experience of cardiac cachexia in advanced heart failure patients and their caregivers

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Northern Ireland Chest Heart & Stroke

Background

Cardiac cachexia is a multifactorial wasting syndrome, which is characterised by unintentional weight loss, a reduction in skeletal muscle mass, and reduced quality of life. There is a paucity of qualitative research outlining the impact and experience of cardiac cachexia in advanced heart failure patients and their caregivers. Research in this area may promote a better understanding of the syndrome, enhance current treatment strategies, and highlight priorities for patient care.

Purpose

To qualitatively investigate the impact and experience of cardiac cachexia in advanced heart failure patients and their caregivers.

Methods

Semi-structured interviews were performed with advanced heart failure (NYHA functional class III-IV) patients meeting diagnostic criteria for cardiac cachexia (number (n) = 8) and their caregivers (n = 5). Interview questions followed a "laddered style approach", with a focus on determining the experience of cachexia for patients and carers, and its impact on their daily lives. Interviews were digitally recorded and transcribed verbatim. Average interview duration was 43 (15-64) minutes. Data were thematically analysed, using the 6-step approach of Braun & Clarke. Themes were developed and refined by several members of the research team to ensure rigor.

Results

Four key themes were developed from the data. 1) "Changed relationship with food and eating": patients with cachexia referred to eating as something they now ‘make’ themselves do without enjoyment, often just to placate their caregiver. Caregivers noted this change in habit and were concerned about inadequate nutritional intake due to the patient’s lack of interest in food. 2) "Not me in the mirror": patients struggled with their appearance and had a negative perception of themselves, linked to their weight loss. Caregivers were similarly aware of the physical changes in their loved ones and emotionally impacted. 3) "Lack of understanding regarding cachexia": despite the patient and caregivers’ concerns, they had a perception that healthcare professionals were just ‘fobbing you off’. Even though weight loss was noted and distressing to patients and caregivers, there was little clinical recognition of it, nor any advice or support from the clinical team regarding management. 4) "Uncertainty regarding the future": patients and caregivers recognised cachexia as a bad sign, and many expressed concerns about their future health and prognosis.

Conclusion

These novel qualitative findings highlight the severe impact of cardiac cachexia on the daily lives of patients and caregivers, and demonstrate their limited understanding of the syndrome. To improve care, professionals need to recognise and discuss cachexia with heart failure patients and caregivers, supporting them to cope with prognostic implications and develop more effective management strategies.

Decreased regional cerebral blood flow in medial prefrontal cortex during trauma-unrelated stressful imagery in Vietnam veterans with post-traumatic stress disorder

BACKGROUND

Neuroimaging research has demonstrated medial prefrontal cortex (mPFC) hyporesponsivity and amygdala hyperresponsivity to trauma-related or emotional stimuli in post-traumatic stress disorder (PTSD). Relatively few studies have examined brain responses to the recollection of stressful, but trauma-unrelated, personal events in PTSD. In the current study, we sought to determine whether regional cerebral blood flow (rCBF) abnormalities in mPFC and amygdala in PTSD could be observed during the recollection of trauma-unrelated stressful personal events.

METHOD

Participants were 35 right-handed male combat veterans (MCVs) and female nurse veterans (FNVs) who served in Vietnam: 17 (seven male, 10 female) with current military-related PTSD and 18 (nine male, nine female) with no current or lifetime PTSD. We used positron emission tomography (PET) and script-driven imagery to study rCBF during the recollection of trauma-unrelated stressful versus neutral and traumatic events.

RESULTS

Voxelwise tests revealed significant between-group differences for the trauma-unrelated stressful versus neutral comparison in mPFC, specifically in the anterior cingulate cortex (ACC). Functional region of interest (ROI) analyses demonstrated that this interaction in mPFC represented greater rCBF decreases in the PTSD group during trauma-unrelated stressful imagery relative to neutral imagery compared to the non-PTSD group. No differential amygdala activation was observed between groups or in either group separately.

CONCLUSIONS

Veterans with PTSD, compared to those without PTSD, exhibited decreased rCBF in mPFC during mental imagery of trauma-unrelated stressful personal experiences. Functional neuroanatomical models of PTSD must account for diminished mPFC responses that extend to emotional stimuli, including stressful personal experiences that are not directly related to PTSD.

Psychophysiologic assessment of posttraumatic stress disorder in Vietnam nurse veterans who witnessed injury or death

This study examined whether witnessing death and injury could produce psychophysiologically responsive posttraumatic stress disorder (PTSD). Participants consisted of medication-free female Vietnam nurse veterans with a diagnosis of current PTSD (n = 17) and who never had PTSD (n = 21), related to their military service. Individualized scripts describing personal traumatic military nursing events, a standard military nursing event, and other life events were tape recorded and played back to the participant while heart rate, skin conductance, and facial electromyograms were recorded. Nurses with PTSD showed significantly larger physiologic responses than non-PTSD nurses only during imagery of military-related nursing events. The groups' self-reported emotional responses did not differ during imagery. Psychophysiologic results support the proposition that witnessing death and serious injury to others is sufficiently stressful to cause PTSD.

The impact of a relaxation technique on the lipid profile

The purpose of this research was to test the effect of a relaxation technique on blood lipid levels. Sixty outpatient males with known hyperlipidemia were recruited to the study. All participants were stabilized on an American Heart Association Step I diet for 8 weeks. After stabilization, participants were randomly assigned to relaxation or reading groups and received in-depth follow-up and support over another 8-week period. Monthly follow-up continued for an additional 8 months. Although both groups demonstrated decreased weight, total cholesterol, and triglycerides, no group differences were detected over time. This suggests that relaxation training may not be an effective technique for long-term clinical management of clients with dyslipidemias.

Prolactinoma: a review and case study

Prolactinomas are often characterized by a slow, insidious onset of symptoms. This case study highlights the need for a thorough understanding of the endocrine system and reinforces the importance of history taking and detailed nursing assessment.

Prolactinoma: a review and case study

Prolactinomas are often characterized by a slow, insidious onset of symptoms. This case study highlights the need for a thorough understanding of the endocrine system and reinforces the importance of history taking and detailed nursing assessment.

Hormone-induced changes in the in vitro DNA-binding activity of the chicken progesterone receptor

Previous analyses have indicated that steroid hormone receptors undergo an allosteric change in structure upon binding by the steroid ligand. This structural change was envisioned as an intramolecular unmasking of the protein's DNA-binding domain, thus allowing the receptor to function in gene regulation. We report an analysis of the effect of hormone on the DNA-binding activity of the chicken progesterone receptor. Using an isocratic elution of DNA affinity columns we show that unliganded receptor (aporeceptor) can bind a 23-basepair progesterone response element with high affinity and a high degree of sequence preference. Hormone causes a 1.5-fold increase in affinity for the PRE sequence and a 2-fold decrease in affinity for non-specific DNA. Kinetic analysis of the off-rate of receptor-DNA complexes is consistent with this minor effect of hormone. In addition, gel retardation analysis of receptor-progesterone response element complexes further substantiates that hormone is not required for sequence-specific DNA binding. These results indicate that hormone is not necessary for the progesterone receptor to fold into a conformation that recognizes specific gene regulatory sequences.

Structure-function relationships of the chicken progesterone receptor

To define the functional domains of the chicken progesterone receptor (CPR) and to establish the origin of the receptor A and B proteins, we have cloned and sequenced the complete cDNA encoding the CPR. The receptor A and B proteins arise by alternate initiation of translation from a single mRNA transcript. Using deletion mutants in the receptor A cDNA, we have determined that the DNA binding and gene activator regions reside in the central portion of the protein, while the hormone binding domain is located in the C-terminal region. The target gene activator site of the receptor is modulated by interaction with the hormone binding domain.

The effect of a relaxation technique on coronary risk factors

This study examined the effect of a relaxation technique on plasma lipids, weight, blood pressure, and blood glucose. Sixteen outpatient males were randomly assigned to control or experimental groups. The experimental group was taught a relaxation technique that they used throughout the study. The control group was started in a reading program. Subjects were followed by a nurse practitioner and dietitian for eight weeks. Results revealed a significant reduction in systolic blood pressure and a marginally significant reduction in low density lipoprotein (LDL) cholesterol in the experimental group. Both control and experimental groups self-reported high compliance with diet and adherence to prescribed intervention. State anxiety was found to be inversely related to changes in total cholesterol and LDL cholesterol.

Structure-function properties of the chicken progesterone receptor A synthesized from complementary deoxyribonucleic acid

The chicken progesterone receptor (PR) cDNA has been cloned and sequenced in our laboratory. Functional receptor A was synthesized from cDNA in two independent systems, by transient transfection of receptor-negative COS M6 cells and by in vitro transcription and translation. These receptors exhibited DNA and hormone binding properties similar to the native PR from oviduct. The ability of receptor to induce target gene transcription was measured by cotransfection of receptor-negative CV-1 cells with expression vectors containing the receptor A cDNA and a progesterone-inducible promotor linked to the chloramphenicol acetyl transferase (CAT) gene. In these assays, receptor A produced hormone-dependent induction of CAT activity. In order to define the functional domains of receptor A, expression constructs coding for C-terminal deletion proteins were prepared. Deletion of the C-terminus resulted in loss of hormone binding activity as well as a loss of CAT induction. However, when 290 amino acids were removed from the C-terminus, this severely truncated receptor protein produced hormone-independent target gene activation. Mutant receptor proteins which retained the highly conserved cysteine-rich (C1) region were able to bind to DNA-cellulose, although removal of 290 amino acids from the C-terminus resulted in reduced affinity for DNA. Deletion of part or all of the C1 region resulted in loss of both DNA-binding and transcriptional activation capacities. These results confirm that C1 functions in DNA binding and transcriptional activation and that hormone binding activity can be localized to the C-terminal half of the protein.

Coordinate regulation of phosphatidylserine decarboxylase activity and phospholipid N-methylation in yeast

Membranes isolated from Saccharomyces cerevisiae, strain ATCC 26615, catalyze the decarboxylation of exogenous phosphatidylserine added as an aqueous dispersion in detergent. Active preparations of the decarboxylase can be obtained by extracting salt-washed membranes with 0.5% Cutscum . The properties of the phosphatidylserine decarboxylase activity associated with a particulate fraction and the detergent extracts have been characterized by assaying the enzymatic conversion of exogenous [14C]phosphatidylserine to [14C]phosphatidylethanolamine. The yeast decarboxylase does not require a divalent cation and is inhibited by hydroxylamine and p-hydroxymercuribenzoate. The rate of decarboxylation of exogenous phosphatidylserine catalyzed by membranes prepared from cells grown in the presence of choline is reduced by approximately 60% compared to membranes from cells grown in a choline-deficient medium. Relatively smaller reductions in phosphatidylserine decarboxylase activity are also seen in cells grown in the presence of mono- or dimethylethanolamine. In vitro incorporation studies with [14C]serine demonstrate that endogenous, prelabeled phosphatidylserine can be utilized for the biosynthesis of phosphatidylcholine by the coupled action of the hydroxylamine-sensitive decarboxylase and the phospholipid N-methyltransferases in the presence of 2 mM S-adenosylmethionine. A similar comparative enzymatic study shows that the rates of synthesis and decarboxylation of [14C]phosphatidylserine, as well as phospholipid N-methylation, are lower for membranes prepared from cells grown in the presence of choline relative to identical preparations from cells grown in the absence of choline. These studies describe the properties of particulate and detergent-solubilized phosphatidylserine decarboxylase activity in S. cerevisiae and provide evidence that its activity is regulated in coordination with other enzymes in the pathway for phosphatidylcholine biosynthesis involving N-methylation.

Control of phosphatidylethanolamine metabolism in yeast: diacylglycerol ethanolaminephosphotransferase and diacylglycerol cholinephosphotransferase are separate enzymes

Membrane preparations from Saccharomyces cerevisiae catalyze the transfer of phosphoethanolamine and phosphocholine from the cytidine dinucleotide derivatives to endogenous and exogenous 1,2-diacylglycerols. Utilizing CDP-[14C]ethanolamine and CDP-[14C]choline as isotopic substrates, diacylglycerol ethanolaminephosphotransferase (EPT) and diacylglycerol cholinephosphotransferase (CPT) have been characterized in vitro. Both enzymes (i) require Mn2+; (ii) are stimulated by exogenous 1,2-diacylglycerols; and (iii) are inhibited by p-hydroxymercuribenzoate and CMP. Yeast EPT and CPT can be clearly distinguished on the basis of their different (i) pH optima; (ii) thermal sensitivities at 50 degrees C; (iii) concentration-dependent inhibition by CMP; and (iv) sensitivities to the hypolipidemic drug, DH-990. Reversibility experiments demonstrate that CDP-ethanolamine can be resynthesized by enzymatic reactions involving CMP and phosphatidylethanolamine (PE) formed from the cytidine dinucleotide derivative or by the decarboxylation of phosphatidylserine (PS). Similarly, CDP-choline can be reformed by the reaction of CMP with PC synthesized from CDP-choline or by the sequential N-methylation of PE. A double-isotope experiment provides evidence that PE molecules synthesized via CDP-ethanolamine or by the decarboxylation of PS are converted to phosphatidylcholine (PC) by the methylation pathway at similar, if not identical, rates. The N-methylation of the metabolically specific pool of PE, synthesized from CDP-ethanolamine, is drastically reduced in membranes prepared from choline-grown cells. Neither EPT nor CPT appear to be induced by the addition of ethanolamine or choline, respectively, to the growth medium. However, the addition of 10 mM choline to the growth medium results in a 46% reduction in EPT activity. This change in EPT activity may be a regulatory response to lower rates of PE N-methylation in choline-grown cells.

Characterization of brain phosphatidylserine decarboxylase: localization in the mitochondrial inner membrane

A membranous fraction from calf brain, sedimenting at 10,000g, catalyzes the decarboxylation of exogenous phosphatidyl[14C]serine presented in an aqueous dispersion in detergent. The product formed by the enzymatic decarboxylation reaction is chemically and chromatographically identical to phosphatidyl[14C]ethanolamine. The calf brain decarboxylase activity: (1) did not require divalent cations; (2) was optimally active at neutral pH; (3) exhibited maximal activity in the presence of 0.1% Cutscum or sodium taurocholate; (4) was inhibited by hydroxylamine or p-hydroxymercuribenzoate; and (5) has an apparent Km = 2.4 mM for the phospholipid substrate. When this fraction was further separated by metrizamide density centrifugation, 90% of the phosphatidylserine decarboxylase activity was associated with the mitochondria. Resolution of the inner and outer membranes of the mitochondria revealed that greater than 99% of the decarboxylase activity was bound to the inner membrane. In contrast to this result, diacylglycerol ethanolaminephosphotransferase, another enzyme responsible for phosphatidylethanolamine biosynthesis in brain, was greatly enriched in the microsomal fraction. The highest level of phospholipid N-methyltransferase activity was also localized in the microsomal fraction. Thus, phosphatidylethanolamine formation via cytidine diphosphate ethanolamine in brain occurs at a membrane site where it should be available for the biosynthesis of phosphatidylcholine by stepwise methylation. In order for phosphatidylethanolamine formed by the decarboxylation reaction to be available for N-methylation, translocation from mitochondria to the microsomal site would be required.

Properties of particulate and solubilized phosphatidylserine synthase activity from Saccharomyces cerevisiae. Inhibitory effect of choline in the growth medium

When radiolabeled serine is incubated with a particulate fraction from Saccharomyces cerevisiae, radioactivity is incorporated initially into phosphatidylserine and gradually appears in phosphatidylethanolamine. Because decarboxylation of phosphatidylserine is blocked by hydroxylamine, phosphatidylserine synthase can be assayed separately. The yeast phosphatidylserine synthase activity 1) exhibits a divalent cation requirement; 2) is stimulated by exogenous CDP-diolein (apparent Km = 0.17 mM); 3) has an apparent Km = 4 mM for L-serine; 4) has a neutral pH optimum; 5) is inhibited by p-hydroxymercuribenzoate; and 6) is reversible in the presence of 5'-CMP, but not 2'-CMP, 3'-CMP, or 5'-AMP. The phospholipid-synthesizing activity is solubilized with Triton X-100 and the enzymatic parameters have been compared with the particulate form of the enzyme. Detergent extracts catalyze the conversion of exogenous purified [31P]CDP-diglyceride to [32P]phosphatidylserine in the presence of Mn2+ and L-serine. Enzyme preparations from cells grown in the presence of choline, that have reduced phospholipid methylation activity (Waechter, C. J., Steiner, M. R., and Lester, R. L. (1969) J. Biol. Chem. 244, 3419-3422), also have substantially less phosphatidylserine synthase activity compared to identical preparations grown in the absence of choline. When choline, phosphocholine, CDP-choline, and phosphatidylcholine are present in vitro, there is no direct inhibitory effect on phosphatidylserine synthase activity. While the inclusion of choline in the growth medium caused a significant reduction in phosphatidylserine synthase activity, it did not appreciably effect the apparent Km values for L-serine and CDP-diglyceride. These results are consistent with choline-grown cells containing less phosphatidylserine synthase activity because of lower amounts of enzyme present or perhaps less active enzyme due to covalent modification.