Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis.

OBJECTIVE: To determine whether patient- and family-centered care interventions in the ICU improve outcomes. DATA SOURCES: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016. STUDY SELECTION: We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs. DATA EXTRACTION: We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes. DATA SYNTHESIS: There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis. CONCLUSIONS: Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.

Association Between Right Ventricular Dysfunction and Adverse Outcomes in Peripartum Cardiomyopathy: Insights From the BRO-HF Quebec Cohort Study.

Background: Peripartum cardiomyopathy (PPCM) is associated with severe morbidity and mortality, and the significance of right ventricular (RV) involvement is unclear. We sought to determine whether RV systolic dysfunction or dilatation is associated with adverse clinical outcomes in women with PPCM. Methods: We conducted a multicentre retrospective cohort study examining the association between echocardiographic RV systolic dysfunction or dilatation at the time of PPCM diagnosis and clinical outcomes. Clinical endpoints of interest were the need for mechanical support, recovery of left ventricular ejection fraction at follow-up, and a combined endpoint of hospitalization for heart failure, cardiac transplant, or death. Results: A total of 67 women, median age 30 years (interquartile range: 7), were diagnosed with PPCM between 1994 and 2015 in 17 participating centres. Twin pregnancies occurred in 11%; 62% of women were multiparous; and 24% had preeclampsia. RV systolic function was impaired in 18 (27%) and dilated in 8 (12%). Seven women required ventricular assistance, and 8 experienced the composite outcome during follow-up (25 [interquartile range 61] months). RV dysfunction was associated with the need for mechanical support (odds ratio 10.10 (95% confidence interval: 1.86-54.81), P = 0.007), but neither RV dysfunction nor dilatation was associated with left ventricular ejection fraction recovery, the need for cardiac transplant, heart failure hospitalization, or death. Conclusions: RV dysfunction is associated with the need for mechanical support in women with PPCM. These findings may improve risk stratification of complications and clinical management.

Introduction: La cardiomyopathie du péripartum (CMP-PP) est associée à la morbidité grave et à la mortalité, mais on ignore l'importance de l'atteinte ventriculaire droite (VD). Nous avons cherché à déterminer si la dysfonction systolique ou la dilatation VD sont associées aux résultats cliniques défavorables chez les femmes atteintes de CMP-PP. Méthodes: Nous avons mené une étude de cohorte rétrospective multicentrique sur l'association entre la dysfonction systolique ou la dilatation VD à l'échographie au moment du diagnostic de CMP-PP et les résultats cliniques. Les critères cliniques d'intérêt étaient la nécessité d'une assistance mécanique, la récupération de la fraction d'éjection ventriculaire gauche (FEVG) au suivi et un critère combiné d'hospitalisation liée à l'insuffisance cardiaque (IC), la transplantation cardiaque ou la mort. Résultats: Un total de 67 femmes, dont l'âge médian était de 30 ans (écart interquartile [EI] : 7), ont reçu un diagnostic de CMP-PP entre 1994 et 2015 dans 17 centres participants. Les grossesses gémellaires sont survenues chez 11 % ; 62 % de femmes étaient multipares ; et 24 % souffraient de prééclampsie. La fonction systolique VD était compromise chez 18 (27 %) femmes et le VD, dilaté, chez huit (12 %) femmes. Sept femmes ont eu besoin d'une assistance ventriculaire, et huit ont subi le critère composite durant le suivi (25 [EI : 61] mois). La dysfonction VD a été associée à la nécessité d'une assistance mécanique (rapport de cotes 10,10 [intervalle de confiance à 95 % : 1,86-54,81], P = 0,007), mais ni la dysfonction ni la dilatation VD n'ont été associées à la récupération de la FEVG, à la nécessité d'une transplantation cardiaque, à une hospitalisation liée à l'IC ou à la mort. Conclusions: La dysfonction VD est associée à la nécessité d'une assistance mécanique chez les femmes atteintes de CMP-PP. Ces conclusions peuvent permettre d'améliorer la stratification des risques de complications et la prise en charge clinique.

Association between sepsis survivorship and long-term cardiovascular outcomes in adults: a systematic review and meta-analysis.

PURPOSE: We aimed to determine the association between sepsis and long-term cardiovascular events. METHODS: We conducted a systematic review of observational studies evaluating post-sepsis cardiovascular outcomes in adult sepsis survivors. MEDLINE, Embase, and the Cochrane Controlled Trials Register and Database of Systematic Reviews were searched from inception until April 21st, 2021. Two reviewers independently extracted individual study data and evaluated risk of bias. Random-effects models estimated the pooled crude cumulative incidence and adjusted hazard ratios (aHRs) of cardiovascular events compared to either non-septic hospital survivors or population controls. Primary outcomes included myocardial infarction, stroke, and congestive heart failure; outcomes were analysed at maximum reported follow-up (from 30 days to beyond 5 years post-discharge). RESULTS: Of 12,649 screened citations, 27 studies (25 cohort studies, 2 case-crossover studies) were included with a median of 4,289 (IQR 502-68,125) sepsis survivors and 18,399 (IQR 4,028-83,506) controls per study. The pooled cumulative incidence of myocardial infarction, stroke, and heart failure in sepsis survivors ranged from 3 to 9% at longest reported follow-up. Sepsis was associated with a higher long-term risk of myocardial infarction (aHR 1.77 [95% CI 1.26 to 2.48]; low certainty), stroke (aHR 1.67 [95% CI 1.37 to 2.05]; low certainty), and congestive heart failure (aHR 1.65 [95% CI 1.46 to 1.86]; very low certainty) compared to non-sepsis controls. CONCLUSIONS: Surviving sepsis may be associated with a long-term, excess hazard of late cardiovascular events which may persist for at least 5 years following hospital discharge.

Patient and Family Engagement in Care in the Cardiac Intensive Care Unit.

Hospitalization in the cardiac intensive care unit can be a stressful experience for patients and families. Family members often feel overwhelmed by the severity of their loved one's illness, powerless to affect their care, and struggle to comprehend information regarding their loved one's current health status and treatment plan. Consequently, up to half of family members might develop psychological symptoms (depression, generalized anxiety, and post-traumatic stress disorder) and a syndrome of enduring psychological, cognitive, or emotional disturbances. Patient and family engagement (PFE) is an emerging approach that empowers family members to become essential and active partners in care delivery and research. In the patient care context, the goal of PFE is to improve the care experience and achieve better outcomes for patients and family members. As a result of societal trends, family members increasingly wish to directly participate in their relative's care and be informed and involved in decision-making. There is growing evidence that engaging family members in care improves patient- and family-important outcomes after acute and critical illness. Although the role for PFE in care and research has been explored in the general critical care context, efforts to inform clinicians who manage patients with acute cardiovascular disease about the relevance of PFE are limited. In this review, we describe opportunities for PFE in the cardiac intensive care unit, outline the current evidence base for PFE in patient care, identify barriers to PFE and how to overcome them, and highlight knowledge gaps and areas for future investigations.

The Basics of ARDS Mechanical Ventilatory Care for Cardiovascular Specialists.

The ongoing COVID-19 pandemic has placed pressure on health care systems and intensive care unit capacity worldwide. Respiratory insufficiency is the most common reason for hospital admission in patients with COVID-19. The most severe form of respiratory failure is acute respiratory distress syndrome (ARDS), which is associated with significant morbidity and mortality. Patients with ARDS are often treated with invasive mechanical ventilation according to established evidence-based and guideline recommended management strategies. With growing strain on critical care capacity, clinicians from diverse backgrounds, including cardiovascular specialists, might be required to help care for the growing number of patients with severe respiratory failure and ARDS. The aim of this article is to outline the fundamentals of ARDS diagnosis and management, including mechanical ventilation, for the nonintensivist. In the absence of mechanical ventilation trials specifically in patients with COVID-19-associated ARDS, the information presented is on the basis of general ARDS trials.

National Interhospital Transfer for Patients With Acute Cardiovascular Conditions.

BACKGROUND: Treatment of ST-elevation myocardial infarction (STEMI) in Canada is protocolized, and timely patient transfer can improve outcomes. Population-based processes of care in Canada for other cardiovascular conditions remain less clear. We aimed to describe the interhospital transfer of Canadian patients with acute cardiovascular disease. METHODS: We reviewed the Canadian Institute for Health Information Discharge Abstract Database for adult patients hospitalized with acute cardiovascular disease between 2013 and 2018. We compared patient characteristics and clinical outcomes based on transfer status (transferred, nontransferred) and presenting hospital (teaching, large community, medium community, and small community hospitals). The primary outcome of interest was in-hospital mortality. RESULTS: There were 476,753 patients with primary acute cardiovascular diagnoses, 48,579 (10.2%) of whom were transferred. Transferred patients were more frequently younger, male, and had fewer comorbidities. The most common diagnoses among transferred patients were non-STEMI (44.2%), STEMI (29.0%), and congestive heart failure (9.4%). Using teaching hospitals as a reference, transfer to large and medium community hospitals was associated with lower hospital mortality (adjusted odds ratio: 0.83, 95% confidence interval: 0.75-0.91 and 0.45, 95% confidence interval: 0.39-0.52, respectively). CONCLUSIONS: Approximately 10% of patients with acute cardiovascular conditions are transferred to another hospital. Patient transfer may be associated with lower in-hospital mortality, with possible variability based on diagnosis, comorbidities, hospital of origin, and destination hospital. Further investigation into the optimization of care for patients with acute cardiovascular disease, including transfer practices, is warranted as regionalized care models continue to develop.

INTRODUCTION: Au Canada, le traitement de l'infarctus du myocarde avec sus-décalage du segment ST (STEMI) découle d'un protocole qui prévoit au moment opportun le transfert des patients pour permettre d'améliorer les résultats cliniques. On n'en sait encore peu sur les processus de soins auprès de la population canadienne en ce qui concerne les autres maladies cardiovasculaires. Nous avions pour objectif de décrire les transferts interhospitaliers de patients canadiens atteints d'une maladie cardiovasculaire aiguë. MÉTHODES: Nous avons passé en revue les résumés de la base de données de l'Institut canadien d'information sur la santé sur les congés des patients hospitalisés atteints d'une maladie cardiovasculaire aiguë entre 2013 et 2018. Nous avons comparé les caractéristiques des patients et les résultats cliniques en fonction du statut du transfert (patients transférés ou non transférés) et de l'hôpital de destination (hôpitaux d'enseignement, grands hôpitaux communautaires, hôpitaux communautaires moyens et petits hôpitaux communautaires). Le principal critère étudié était la mortalité intrahospitalière. RÉSULTATS: Parmi les 476 753 patients qui avaient un diagnostic principal de maladie cardiovasculaire aiguë, 48 579 (10,2 %) ont été transférés. Les patients transférés étaient plus fréquemment jeunes, de sexe masculin, et avaient peu de comorbidités. Les diagnostics les plus fréquents parmi les patients transférés étaient les non-STEMI (44,2 %), les STEMI (29,0 %) et l'insuffisance cardiaque congestive (9,4 %). En utilisant comme référence les hôpitaux d'enseignement, les transferts vers de grands hôpitaux communautaires et des hôpitaux communautaires moyens étaient associés à une plus faible mortalité intrahospitalière (ratio d'incidence approché ajusté : 0,83, intervalle de confiance à 95 %, 0,75-0,91 et 0,45, intervalle de confiance à 95 %, 0,39-0,52, et ce, respectivement). CONCLUSIONS: Approximativement 10 % des patients atteints d'une maladie cardiovasculaire aiguë sont transférés vers un autre hôpital. Le transfert des patients peut être associé à une plus faible mortalité intrahospitalière et montrer une variabilité en fonction du diagnostic, des comorbidités, de l'hôpital d'origine et de l'hôpital de destination. D'autres études liées à l'optimisation des soins des patients atteints d'une maladie cardiovasculaire aiguë, qui porteront de plus sur les pratiques de transfert, sont justifiées puisque l'élaboration de modèles de soins régionaux se poursuit.

Association of Surrogate Decision-making Interventions for Critically Ill Adults With Patient, Family, and Resource Use Outcomes: A Systematic Review and Meta-analysis.

Importance: Physicians often rely on surrogate decision-makers (SDMs) to make important decisions on behalf of critically ill patients during times of incapacity. It is uncertain whether targeted interventions to improve surrogate decision-making in the intensive care unit (ICU) reduce nonbeneficial treatment and improve SDM comprehension, satisfaction, and psychological morbidity. Objective: To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) to determine the association of such interventions with patient- and family-centered outcomes and resource use. Data Sources: A search was conducted of MEDLINE, Embase, and other relevant databases for potentially relevant studies from inception through May 30, 2018. Study Selection: Randomized clinical trials studying interventions that were targeted at SDMs or family members of critically ill adults in the ICU were included. Key search terms included surrogate or substitute decision-maker, critically ill, randomized controlled trials, and their respective related terms. Data Extraction and Synthesis: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent, blinded reviewers independently screened citations and extracted data. Random effects models with inverse variance weighting were used to pool outcomes data when possible and otherwise present findings qualitatively. Main Outcomes and Measures: Outcomes of interest were divided into 3 categories: (1) patient-related clinical outcomes (mortality, length of stay [LOS], duration of life-sustaining therapies), (2) SDM and family-related outcomes (comprehension, major change in goals of care, incident psychological comorbidities [posttraumatic stress disorder, anxiety, depression], and satisfaction with care), and (3) use of resources (cost of care and health care resource use). Results: Of 3735 studies screened, 13 RCTs were included, comprising a total of 10 453 patients. Interventions were categorized as health care professional led (n = 6), ethics consultation (n = 3), palliative care consultation (n = 2), and media (n = 1 pamphlet and 1 video). No association with mortality was observed (risk ratio, 1.03; 95% CI, 0.98-1.08; P = .22). Intensive care unit LOS was significantly shorter among patients who died (mean difference, -2.11 days; 95% CI, -4.16 to -0.07; P = .04), but not in the overall population (mean difference, -0.79 days; 95% CI, -2.33 to 0.76 days; P = .32). There was no consistent difference in SDM-related outcomes, including satisfaction with care or perceived quality of care (n = 6 studies) and incident psychological comorbidities (depression: ratio of means, -0.11; 95% CI, -0.29 to 0.08; P = .26; anxiety: ratio of means, -0.08; 95% CI, -0.25 to 0.08; P = .31; or posttraumatic stress disorder: ratio of means: -0.04; 95% CI, -0.21 to 0.13; P = .65). Among 6 trials reporting effects on health care resource use, only 1 nurse-led intervention observed a significant reduction in costs ($75 850 control vs $51 060 intervention; P = .04). Conclusions and Relevance: Systematic interventions aimed at improving surrogate decision-making for critically ill adults may reduce ICU LOS among patients who die in the ICU, without influencing overall mortality. Better understanding of the complex processes related to surrogate decision-making is needed.

The effect of bromocriptine on left ventricular functional recovery in peripartum cardiomyopathy: insights from the BRO-HF retrospective cohort study.

AIMS: Bromocriptine is thought to facilitate left ventricular (LV) recovery in peripartum cardiomyopathy (PPCM) through inhibition of prolactin secretion. However, this potential therapeutic effect remains controversial and was incompletely studied in diverse populations. METHODS AND RESULTS: Consecutive women with new-onset PPCM (n = 76) between 1994 and 2015 in Quebec, Canada, were classified according to treatment (n = 8, 11%) vs. no treatment (n = 68, 89%) with bromocriptine. We assessed LV functional recovery at mid-term (6 months) and long-term (last follow-up) and compared outcomes among groups. Women treated with bromocriptine experienced better mid-term left ventricular ejection fraction (LVEF) recovery from 23 ± 10% at baseline to 55 ± 12% at 6 months, compared with a change from 30 ± 12% at baseline to 45 ± 13% at 6 months in women treated with standard medical therapy (P interaction < 0.01). At long-term, a similar positive association was found with bromocriptine (9% greater LVEF variation, P interaction < 0.01). In linear regressions adjusted for obstetrical, clinical, echocardiographic, and pharmacological variables, treatment with bromocriptine was associated with a greater improvement in LVEF [ß coefficient (standard error), 14.1 (4.4); P = 0.03]. However, there was no significant association between bromocriptine use and the combined occurrence of all-cause death and heart failure events (hazard ratio, 1.18; 95% confidence interval, 0.15 to 9.31), using univariable Cox regressions based over a cumulative follow-up period of 285 patient-years. CONCLUSIONS: In women newly diagnosed with PPCM, treatment with bromocriptine was independently associated with greater LV functional recovery.

Systematic review and directors survey of quality indicators for the cardiovascular intensive care unit.

BACKGROUND: Quality indicators (QIs) are increasingly used in cardiovascular care as measures of performance but there is currently no consensus on indicators for the cardiovascular intensive care unit (CICU). METHODS: We searched Medline, CINAHL, EMBASE, and COCHRANE databases from inception until October 2016 and websites for organizations involved in quality measurement for QIs relevant to cardiovascular disease in an intensive or critical care setting. We surveyed 14 expert cardiac intensivist-administrators (7 European; 7 North American) on the importance and relevance of each indicator as a measure of CICU care quality using a scale of 1 (=lowest) to 10 (=highest). Indicators with a mean score ≥8/10 for both importance and relevance were included in the final set. RESULTS: Overall, 108 QIs (70 process, 18 structural, 18 outcome, 1 patient engagement, and 1 covering multiple domains) were identified in 30 articles representing 23 agencies, organizations, and societies. Disease-specific QIs included myocardial infarction (n = 37), heart failure (n = 31), atrial fibrillation (n = 11), and cardiac rehabilitation (n = 1); general QIs represented about one-quarter (n = 28) of all measures. Fifteen QIs were selected for the final QI set: 7 process, 2 structural, and 6 outcome measures, including 6 general and 9 disease-specific measures. Outcome measures chosen to evaluate general CICU performance included overall CICU mortality, length of stay, and readmission rate. CONCLUSIONS: Numerous QIs relevant to the CICU have been recommended by a variety of organizations. The indicators chosen by the cardiac intensivist-administrators could serve as a basis for future efforts to develop a standardized set of quality measures for the CICU.

Muscle Mass and Mortality After Cardiac Transplantation.

BACKGROUND: Frailty assessment is recommended to evaluate the candidacy of adults referred for orthotopic heart transplantation (OHT). Psoas muscle area (PMA) is an easily measured biomarker for frailty. There has yet to be a study examining the prognostic impact of PMA in OHT patients. METHODS: In this retrospective study, preoperative and postoperative computed tomography (CT) scans were retrieved for adults transplanted between 2000 and 2015 at a tertiary care hospital. Psoas muscle area was measured on a single axial image. Outcomes of interest were all-cause mortality over 6 years and a composite of in-hospital mortality or major morbidity (prolonged ventilation, stroke, dialysis, mediastinitis, or reoperation). RESULTS: Of 161 adult patients transplanted, 82 had at least 1 abdominal CT scan. At baseline, mean PMA was 25.7 ± 5.8 cm in men and 16.0 ± 3.6 cm in women, and decreased by 8% from the first to the last available CT scan. Adjusting for age, sex, body mass index, and cardiomyopathy etiology, every 1-cm increase in PMA was found to be associated with a 9% reduction in long-term mortality (hazard ratio, 0.91; 95% confidence interval [CI], 0.83-0.99; P = 0.031) and a 17% reduction in in-hospital mortality or major morbidity (odds ratio, 0.83; 95% CI, 0.72-0.96; P = 0.014). When PMA was smaller than the sex-specific median, the risk of mortality or major morbidity increased fourfold (odds ratio, 4.29; 95% CI, 1.19-15.46; P = 0.026). CONCLUSIONS: Muscle mass is an independent predictor of mortality and major morbidity after OHT. Further research is needed to determine whether frail OHT patients with low PMA may benefit from muscle-building interventions to improve outcomes.

Understanding the patient perspective on research access to national health records databases for conduct of randomized registry trials.

BACKGROUND: Use of health administrative databases is proposed for screening and monitoring of participants in randomized registry trials. However, access to these databases raises privacy concerns. We assessed patient's preferences regarding use of personal information to link their research records with national health databases, as part of a hypothetical randomized registry trial. METHODS AND RESULTS: Cardiology patients were invited to complete an anonymous self-reported survey that ascertained preferences related to the concept of accessing government health databases for research, the type of personal identifiers to be shared and the type of follow-up preferred as participants in a hypothetical trial. A total of 590 responders completed the survey (90% response rate), the majority of which were Caucasians (90.4%), male (70.0%) with a median age of 65years (interquartile range, 8). The majority responders (80.3%) would grant researchers access to health administrative databases for screening and follow-up. To this end, responders endorsed the recording of their personal identifiers by researchers for future record linkage, including their name (90%), and health insurance number (83.9%), but fewer responders agreed with the recording of their social security number (61.4%, p<0.05 with date of birth as reference). Prior participation in a trial predicted agreement for granting researchers access to the administrative databases (OR: 1.69, 95% confidence interval: 1.03-2.90; p=0.04). CONCLUSION: The majority of Cardiology patients surveyed were supportive of use of their personal identifiers to access administrative health databases and conduct long-term monitoring in the context of a randomized registry trial.

Implications of Frailty in Elderly Patients With Electrophysiological Conditions.

A growing number of complex older adults are referred for electrophysiological conditions and age alone is insufficient to guide management decisions such as implantable cardioverter-defibrillator (ICD) implantation or atrial fibrillation anticoagulation. The concept of frailty has emerged as a geriatric vital sign to gain insight into physiological reserve and prognostic risk beyond chronological age and comorbidities. To date, a number of published studies have evaluated frailty in patients with electrophysiological conditions. These studies collectively demonstrate that frail patients have an increased prevalence of atrial fibrillation, lower use of oral anticoagulation, higher risk of bleeding complications from oral anticoagulation, and higher risk of stroke and mortality. A paucity of studies have explored frailty in the setting of device implantation, with a signal suggesting that frail heart failure patients may have a lower likelihood of being considered for ICD and cardiac resynchronization therapy devices, and a higher risk of fatal and nonfatal events after ICD and cardiac resynchronization therapy implantation. Whether frailty modulates the risks and benefits of these devices is a critical knowledge gap for which further study is clearly warranted.

Therapeutic interventions for frail elderly patients: part II. Ongoing and unpublished randomized trials.

There is increasing momentum to measure frailty in clinical practice given its proven value as a predictor of outcomes, particularly in elderly patients with cardiovascular disease. The number of randomized clinical trials targeting frail older adults has been modest to date. Therefore, we systematically searched the ClinicalTrials.gov registry in order to review the frailty intervention trials that had been actively initiated or completed but not yet published. The interventions studied were exercise training in 2 trials, nutritional supplementation in 3 trials, combined exercise plus nutritional supplementation in 5 trials, pharmaceutical agents in 5 trials, multi-dimensional programs in 2 trials, and home-based services in 3 trials. Their respective study designs, populations, interventions, and planned outcomes are presented in this article.

Therapeutic interventions for frail elderly patients: part I. Published randomized trials.

The body of literature for frailty as a prognostic marker continues to grow, yet the evidence for frailty as a therapeutic target is less well defined. In the setting of cardiovascular disease, the prevalence of frailty is elevated and its impact on mortality and major morbidity is substantial. Therapeutic interventions aimed at improving frailty may impart gains in functional status and survival. Randomized clinical trials that tested one or more therapeutic interventions in a population of frail older adults were reviewed. The interventions studied were exercise training in 13 trials, nutritional supplementation in 4 trials, combined exercise plus nutritional supplementation in 7 trials, pharmaceutical agents in 8 trials, multi-dimensional programs in 5 trials, and home-based services in 1 trial. The main findings of these trials are explored along with a discussion of their relative merits and limitations.