Traditional versus extended hybrid cardiac rehabilitation based on the continuous care model for coronary artery bypass surgery patients in a middle-income country: an embedded mixed method

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac rehabilitation (CR) is a proven method to reduce the risk of disease, but unfortunately in low-and middle-income countries (LMICs), it is either unavailable or done in small quantities.

Purpose

To compare traditional (1-month supervised) vs hybrid cardiac rehabilitation (CR; usual care) with an additional 3 months offered remotely based on the continuous care model (intervention) in patients who have undergone coronary artery bypass graft (CABG).

Methods

The embedded method has been used for the conduction of this study in two phases. The first phase of the study was carried out using a randomised clinical trial. Of 107 eligible patients who were referred to CR during the period of study, 82.2% (N=88) were enrolled (target sample size). Participants were randomly assigned 1:1 (concealed; 44 per parallel arm). After CR, participants were given a mobile application and communicated biweekly with the nurse from months 1-4 to control risk factors. Quality of life (QOL, Short Form-36, primary outcome); functional capacity (treadmill test); and the Depression, Anxiety and Stress Scale were evaluated pre-CR, after 1 month, and 3 months after CR (end of intervention), as well as re-hospitalisation. In the second phase, a qualitative study was conducted using the conventional content analysis method. 17 patients from the intervention group and 3 members of their families were interviewed.

Results

The results of the quantitative stage showed the analysis of variance interaction effects for the physical and mental component summary scores of QOL were <.001, favoring intervention (per protocol); there were also significant increases from pre-CR to 1 month, and from 1 month to the final assessment in the intervention arm (P<.001), with change in the control arm only to 1 month. The effect sizes were 0.115 and 0.248, respectively. Similarly, the interaction effect for functional capacity was significant (P<.001), with a clinically significant 1.5 metabolic equivalent of task increase in the intervention arm. There were trends for group effects for the psychosocial indicators, with paired t tests revealing significant increases in each at both assessment points in the intervention arm. At 4 months, there were 4 (10.3%) re-hospitalisations in the control arm and none in intervention (P=.049). Intended theoretical mechanisms were also affected by the intervention. From the analysis of qualitative data, 20 subcategories, 6 categories, and three themes, including promotion and continuity of self-care, self-efficacy enhancement, belief, and lifestyle modification were extracted. Finally, qualitative findings supported quantitative findings.

Conclusions

Extending CR in this accessible manner, rendering it more comprehensive was effective in improving outcomes. Therefore, using the CCM can greatly reduce the gap due to cardiac rehabilitation in LMICs.

Digital health technologies for osteopaths and allied healthcare service providers: A scoping review

Background

Digital health technologies are poised to revolutionise the healthcare industry by improving accessibility to services and patient outcomes. The novel coronavirus disease-19 (COVID-19) pandemic has presented unprecedented challenges for the delivery of allied healthcare and has catalysed rapid adoption of telehealth. As such, allied healthcare consumers and providers stand to benefit from the capabilities of the digital health movement, ultimately justifying a scoping review of current and emerging technologies.

Objective

To provide decision makers with up-to-date information on the allied health applications of new and emerging digital health technologies; their evidence of efficacy, scope of use, and limitations.

Methods

A scoping review of the literature was conducted, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. To synthesise original research, MEDLINE, CINAHL, and EMBASE databases were searched from 2010 to June 2020 and reference lists were examined for randomised control trials analysing the efficacy of these technologies in allied health applications.

Results

A total of 14 articles were included with a focus on common musculoskeletal conditions managed by allied health service providers. Studies were selected for data extraction after abstract and full-text screening by three independent reviewers. The results of this review indicate that telehealth technology effectively monitors and progresses patient care, while mobile health applications provide remote support and enable data collection.

Conclusion

Emerging trends suggest that digital technologies serve as promising adjuncts to allied healthcare. Further research is warranted regarding the safety and efficacy of digital health technologies in this context.

A systematic review of visual processing and associated treatments in body dysmorphic disorder

OBJECTIVE

Recent advances in body dysmorphic disorder (BDD) have explored abnormal visual processing, yet it is unclear how this relates to treatment. The aim of this study was to summarize our current understanding of visual processing in BDD and review associated treatments.

METHOD

The literature was collected through PsycInfo and PubMed. Visual processing articles were included if written in English after 1970, had a specific BDD group compared to healthy controls and were not case studies. Due to the lack of research regarding treatments associated with visual processing, case studies were included.

RESULTS

A number of visual processing abnormalities are present in BDD, including face recognition, emotion identification, aesthetics, object recognition and gestalt processing. Differences to healthy controls include a dominance of detailed local processing over global processing and associated changes in brain activation in visual regions. Perceptual mirror retraining and some forms of self-exposure have demonstrated improved treatment outcomes, but have not been examined in isolation from broader treatments.

CONCLUSION

Despite these abnormalities in perception, particularly concerning face and emotion recognition, few BDD treatments attempt to specifically remediate this. The development of a novel visual training programme which addresses these widespread abnormalities may provide an effective treatment modality.

Clinical and sociodemographic correlates of referral for cardiac rehabilitation following cardiac revascularization in Ontario

OBJECTIVES

Describe rates of, and examine factors affecting, referral to cardiac rehabilitation (CR) following revascularization in Ontario.

BACKGROUND

CR reduces mortality following cardiac revascularization, but is largely underutilized, partly due to poor referral rates.

METHODS

In this retrospective study, the sample consisted of all CR-indicated patients who underwent revascularization at the Cardiac Care Network of Ontario hospitals between October 2011 through March 2012. Referral rates were described, and multivariate analyses performed to identify disparities.

RESULTS

Of the 3739 patients included, 51.8% were referred to CR. Patients aged ≥85 or requiring a translator, and patients with hyperlipidemia, heart failure, or comorbid pulmonary, renal or peripheral vascular disease, were significantly less likely to be referred. Patients with a history of smoking or myocardial infarction, or who underwent coronary artery bypass graft surgery, were significantly more likely.

CONCLUSIONS

A national policy statement recommends 85% referral of indicated patients to CR, a target currently missed by almost 35%.

Opposite Ends of the Same Stick? Multi-Method Test of the Dimensionality of Individualism and Collectivism

The construct of individualism–collectivism (IND-COL) has become the definitive standard in cross-cultural psychology, management, and related fields. It is also among the most controversial, in particular, with regard to the ambiguity of its dimensionality: Some view IND and COL as the opposites of a single continuum, whereas others argue that the two are independent constructs. We explored the issue through seven different tests using original individual-level data from 50 studies and meta-analytic data from 149 empirical publications yielding a total of 295 sample-level observations that were collected using six established instruments for assessing IND and COL as separate constructs. Results indicated that the dimensionality of IND-COL may depend on (a) the specific instrument used to collect the data, (b) the sample characteristics and the cultural region from which the data were collected, and (c) the level of analysis. We also review inconsistencies, deficiencies, and challenges of conceptualizing IND-COL and provide guidelines for developing and selecting instruments for measuring the construct, and for reporting and meta-analyzing results from this line of research.

Physical activity behavior two to six years following cardiac rehabilitation: a socioecological analysis

BACKGROUND

Cardiac rehabilitation (CR) promotes long-term positive health behaviours, such as physical activity (PA), in patients following a cardiovascular event. We have limited knowledge of long-term PA and its correlates. Therefore, this research examined both PA behaviour and socioecological correlates among elderly graduates 2-6 years following CR.

HYPOTHESIS

CR graduates will have a moderate PA level in the long term. Greater PA will be associated with various multilevel correlates.

METHODS

This was a retrospective, cross-sectional study which quantified PA using the Physical Activity Scale for the Elderly (PASE) and collected information about socioecological correlates at the intrapersonal, interpersonal and health service levels. Both univariate and multivariate analyses assessed PA and PA correlates.

RESULTS

The majority of the 584 participants were older (69.8 ± 9.8), male (80.3%), and well educated (75.4% ≥ some post-secondary). Average time since CR graduation was 41.5 ± 11.5 months. Seventy five percent of CR graduates reported current weekly PA levels that met, or exceeded, Canadian PA guidelines (>150 minutes of moderate-vigorous PA). Univariate analyses identified 13 PASE score correlates. Multivariate analyses identified age, PA enjoyment, current work status, CR staff support, location of primary residence, and perceived health as significantly associated with higher PASE scores (p < 0.001).

CONCLUSIONS

Three and a half years post-CR graduates had high PA levels. Greater PA was associated with several modifiable multilevel correlates at all levels of influence. Understanding correlates of long-term PA behaviour among CR graduates will help identify groups at risk for nonadherence and assist with continued program development.

Practitioner-client relationships in integrative medicine clinics in Australia: a contemporary social phenomenon

OBJECTIVES

The increasing use of complementary and alternative medicine (CAM) in developed countries has been attributed more to contemporary cultural trends than to inherent problems in mainstream medicine. The aim of this study was to examine the impact of post-modern values on relationships between practitioners and clients in integrative medicine (IM) clinics in Australia.

DESIGN

This research used hermeneutic phenomenology to uncover experiences of practitioner-client relationships in IM and the meanings clients and practitioners attached to these relationships. Data were collected using cumulative case studies, focus groups and key informant interviews. Data analysis consisted of reading and re-reading texts derived from interview transcripts and field notes and constantly comparing texts to identify meanings and patterns. Themes extracted from the data set were continually refined, discarded and elaborated until meta-themes emerged.

SETTING

Australian IM clinics where general medical practitioners and CAM practitioners were co-located.

RESULTS

Post-modern values were evident in practitioner-client relationships in Australian IM clinics and were manifested in two ways. (1) Clients did not bring an expectation that they would receive prescriptive treatment regimens. They regarded consultations as opportunities for obtaining information or advice, or for monitoring their health. (2) Practitioners valued clients' knowledge and judgments and respected clients' right to choose and direct their health care.

CONCLUSIONS

In the IM clinics in this research, the traditional role of the practitioner as sole possessor of expertise had changed. Practitioners had become one among a number of resources that informed clients used when designing personal health care plans or negotiating health care with practitioners.

A comprehensive view of sex-specific issues related to cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.

Antenatal risk factors for postpartum depression: a synthesis of recent literature

Postpartum nonpsychotic depression is the most common complication of childbearing, affecting approximately 10-15% of women and, as such, represents a considerable health problem affecting women and their families. This systematic review provides a synthesis of the recent literature pertaining to antenatal risk factors associated with developing this condition. Databases relating to the medical, psychological, and social science literature were searched using specific inclusion criteria and search terms, in order to identify studies examining antenatal risk factors for postpartum depression. Studies were identified and critically appraised in order to synthesize the current findings. The search resulted in the identification of two major meta-analyses conducted on over 14,000 subjects, as well as newer subsequent large-scale clinical studies. The results of these studies were then summarized in terms of effect sizes as defined by Cohen. The findings from the meta-analyses of over 14,000 subjects, and subsequent studies of nearly 10,000 additional subjects found that the following factors were the strongest predictors of postpartum depression: depression during pregnancy, anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, low levels of social support, and a previous history of depression. Critical appraisal of the literature revealed a number of methodological and knowledge gaps that need to be addressed in future research. These include examining specific risk factors in women of lower socioeconomic status, risk factors pertaining to teenage mothers, and the use of appropriate instruments assessing postpartum depression for use within different cultural groups.

Cytomegalovirus-specific cellular immune responses and viremia in recipients of allogeneic stem cell transplants

The immune suppression inherent in allogeneic stem cell transplantation (SCT) offers a favorable environment for infection by opportunistic agents, such as human cytomegalovirus (CMV). Despite the application of potent antiviral prophylaxis, patients remain at risk for CMV infection until adequate immunity is restored. CMV-specific CD8(+) T cell counts were monitored, using HLA-A2 tetrameric complexes, to establish the level of immune response to the viral phosphoprotein UL83 in patients after allogeneic SCT. Correlating this with viral replication and clinical status shows that the level of tetramer-positive T cells provides an assessment of CMV immune reconstitution after stem cell transplantation. Most patients with seropositive donors did reconstitute long-term CMV immunity, unless prolonged immunosuppression to control graft-versus-host disease was induced. Together with polymerase chain reaction testing, this technique provides measurable parameters that can be a guide to therapeutic decision making and can form the basis of CMV immunotherapy.

Sequential annual administration of purified fusion protein vaccine against respiratory syncytial virus in children with cystic fibrosis

BACKGROUND

We recently showed the clinical benefit of the PFP-2 vaccine for respiratory syncytial virus (RSV) for children with cystic fibrosis (CF).

OBJECTIVE

To determine the safety and immunogenicity of yearly sequential administration of the PFP-2 vaccine in CF children.

STUDY DESIGN

Twenty-nine of the 34 CF children who participated in the previous study were enrolled in this open label vaccine study. All of the CF children ages 2.6 to 8.9 years received the PFP-2 vaccine, the PFP/PFP group received the PFP-2 vaccine in 1993 and 1994 and the saline/PFP group received the vaccine for the first time in 1994. At entry demographic data and measurements of lung function and nutrition were collected. Microneutralization test, enzyme-linked immunosorbent assay to F protein and Western blot assay were performed on plasma drawn before and 4 weeks after vaccination and at the end of the RSV season. During the study weekly telephone calls were made and acute respiratory illnesses were evaluated.

RESULTS

Baseline measurements were similar between groups. Systemic and local vaccine reactions were mild and similar for both groups. A 4-fold or greater neutralizing antibody rise to RSV occurred in 4 of 14 (28.6%) and 9 of 14 (64.3%) in PFP/PFP and saline/PFP groups (P = 0.13), respectively. Four children in the PFP/PFP group and 7 in the saline/PFP group were infected with RSV. A reduction in lower respiratory illnesses (1.0 vs. 2.0), antibiotic courses (2.5 vs. 5.6) and days of illnesses (37.3 vs. 93.1) was observed in the PFP/PFP vaccinees infected with RSV compared with the saline/PFP group (t test; P < or = 0.05). One death occurred in the PFP/PFP group; the cause of death was consistent with septic shock and unrelated to vaccination or RSV infection.

CONCLUSION

Sequential annual PFP-2 vaccination was safe and not associated with exaggerated respiratory disease.

Purified fusion protein vaccine protects against lower respiratory tract illness during respiratory syncytial virus season in children with cystic fibrosis

OBJECTIVE

To test in a double blind, placebo-controlled study a purified fusion protein (PFP-2) vaccine against respiratory syncytial virus (RSV) in RSV-seropositive children with cystic fibrosis (CF).

METHODS

Seventeen CF children, mean age 4.5 years, received PFP-2 vaccine and 17 CF children, mean age 5.8 years, received a saline vaccine. At enrollment the Shwachman clinical score, Brasfield radiographic score, oxygen saturation (SpO2), anthropometric indices and other variables were recorded. After vaccination the reactions were assessed daily for 7 days. During the RSV season weekly telephone interviews were performed and children with an acute respiratory illness were evaluated and cultured for RSV. Serum was drawn before vaccination, 1 month after vaccination and at the end of the RSV season and tested for antibodies to RSV.

RESULTS

Other than age the baseline measurements at enrollment were similar between groups. The PFP-2 vaccine produced mild local reactions and induced a significant neutralizing antibody response in two-thirds of the vaccinees and a significant enzyme-linked immunosorbent assay-fusion glycoprotein antibody response in nearly all the PFP-2 vaccinees. Vaccine-enhanced disease was not observed in PFP-2 vaccines infected with RSV. Protection against RSV infection was not observed; however, a significant reduction (t test, P < 0.01) in mean number of lower respiratory tract illnesses (0.8 vs. 2.1), antibiotic courses (2.2 vs 4.5) and days ill (30.5 vs. 67) occurred among RSV-infected PFP-2 vaccinees.

CONCLUSIONS

Efficacy of the PFP-2 vaccine against lower respiratory tract illness during the RSV season was shown in RSV-seropositive children with CF.

The use of mouse serum and the presence of non-adherent cells for the culture of mouse macrophages

Mouse serum (MS) was investigated as an alternative to fetal calf serum (FCS) as a medium supplement for the culture of murine macrophages. Peritoneal macrophages were successfully cultured in medium supplemented with 1-20% MS and were able to produce superoxide anions in response to stimulation with phorbol myristate acetate (PMA) and to phagocytose antibody-coated erythrocytes effectively. Macrophages cultured in the presence of 5% or 20% FCS showed a generally augmented response to PMA, raising the possibility that they had been 'primed' by constituents or contaminants of FCS. Lipopolysaccharide-elicited macrophages initially showed vigorous in vitro responses to PMA which decreased with increasing culture time in MS-supplemented medium. This 'de-differentiation' of elicited macrophages could be due to the absence of LPS contamination and foreign protein when autologous serum is used as a medium supplement. In all cultures the presence of non-adherent cells for the first 24 h increased the number and superoxide response of adherent cells. MS is a convenient, reliable and inexpensive alternative to FCS as a medium supplement for murine macrophage cultures.

Kaposi's sarcoma in Zimbabwe. II. Peripheral lymphocytes, immunoglobulin G levels and HIV antibody positivity

Patients with Kaposi's Sarcoma (KS) were grouped according to their clinical symptoms into "indolent", "locally aggressive", "endemic generalised aggressive" and "epidemic generalised aggressive" disease. Only the patients in the epidemic generalised aggressive disease group had serum antibodies to HIV. Complete peripheral blood counts, including lymphocyte subsets, and serum IgG assays were performed on all patients before treatment was initiated. In all the aggressive disease groups there was evidence of immune deficiency in that T helper/inducer (T4) cells were reduced leading to reduced T4,T8 (suppresser/cytotoxic) ratio. All patient groups had increased levels of serum IgG. Although immune deficiency and aggressive KS can be explained in the HIV infected patients no underlying cause has been found in the HIV negative patients with aggressive KS.

Relationship between non-antigen-specific immunodepression and persisting immune complexes induced by pertussis in mice

A temporal relationship has been demonstrated between persisting immune complexes and non-antigen-specific immunodepression. Mice were given intraperitoneal injections of Bordetella pertussis at weekly intervals. After 7 weeks they developed circulating immune complexes, the levels of which increased with continued administration of pertussis. The increase in immune complex levels was accompanied by a diminished primary immune response to intraperitoneally injected sheep erythrocytes (SRBC) as judged by a reduction in their direct and indirect plaque-forming cell response and serum agglutination titres. Spleen cells from immunodepressed pertussis-treated mice were transferred to irradiated normal recipients and displayed a normal response to SRBC. By contrast, spleen cells transferred from normal donors to irradiated pertussis-treated recipients had an impaired response to SRBC. Thus, the immunodepression caused by pertussis treatment is a property of the environment and not the lymphocytes themselves. It is considered that chronic circulating immune complexes induced by pertussis administration may cause non-antigen-specific immunodepression.

Examination of the solvent perturbation technique as a method to identify enzyme catalytic groups

The present study was undertaken for the purpose of evaluating the solvent perturbation technique as a method to identify enzyme catalytic residues. For establishment of expected directions and sizes of pKa perturbations for different types of acids in different classes of solvents, a study of the pKa of a series of acids in mixed solvent systems was carried out. Consistent with previous findings, the presence of organic solvents (25% v/v) increased the pKa values of neutral acids while it decreased or did not change the pKa values of cationic acids. The size of the perturbation observed was dependent on the nature of the organic solvent and on the polarity of the neutral form of the acid. The solvent perturbation studies were then extended to the catalytic aspartate residue of yeast hexokinase. The pKa of this residue was determined from the MgATP V/K profile measured in the presence and absence of organic solvents (25% v/v). While dimethylformamide and methanol induced small but perhaps significant increases in the observed pKa, dimethyl sulfoxide and propylene glycol did not. The pKa values, from the MgATP V/K profiles measured in the presence of fully saturating glucose, were not significantly increased by the organic solvents. The pKi vs. pH profile for the competitive inhibitor lyxose was also measured in the presence and absence of organic solvents. While methanol (25% v/v), dimethylformamide (25% v/v), and dioxane (17.5% v/v) induced a large increase in the pKa, propylene glycol and dimethyl sulfoxide (25% v/v) did not. The results from this investigation indicate that the solvent perturbation technique should not be relied upon indiscriminately.

Segmental gastric antral resection in experimental peptic ulceration

In using the technique of histamine in beeswax peptic ulceration in dogs, these experimental preparations were studied as to their efficacy to protect against ulceration: laparotomy controls; bilateral truncal vagotomy and pyloroplasty; a 50 per cent gastrectomy and vagotomy plus a Billroth II gastrojejeunostomy; a 50 per cent segmental resection of the gastric antrum and corplus plus bilateral truncal vagotomy and pyloroplasty; a 75 per cent gastrectomy and Billroth II gastrojejeunostomy, and a 75 per cent segmental resection of the gastric antrum and corpus and bilateral truncal vagotomy and pyloroplasty. Only a 75 per cent gastrectomy Billroth II and a 75 per cent segmental resection of the antrum and corpus plus vagotomy and pyloroplasty consistently protected against histamine in beeswax induced ulceration.