Seasonal cold, excursional behaviour, clothing protection and physical activity in young and old subjects.

Previous reports indicate that everyday excursional exposures may play a part in increased winter mortality (Donaldson et al 1997) and that the avoidance of cold stress is associated with low indices of cold related mortality in Europe (Eurowinter Group 1997). However, few prospective data have been reported on excursional data and risk factors for arterial disease. In a field study carried out on 21 young (mean age 23.5) and 24 elderly healthy subjects (mean age 73.6) there were no significant differences between winter and summer in the number or duration of outside excursions. Never the less, elderly subjects had significantly more clothing insulation (clo), both indoors and outdoors in the winter than in the summer (p < or = 0.001) and this was also the case for young subjects. The urine temperature of the elderly in the winter was significantly lower (p < or = 0.01) than in the summer but this was not seen in the young. Elderly physical activity was significantly higher in the winter than in the summer (p < or = 0.05) but not for the young. Thus, elderly subjects showed no material change in excursional behaviour in the winter, even though clothing protection was arguably inadequate in view of lower body temperature, accompanied by increased physical activity. Blood pressure was significantly higher in the winter (p < or = 0.01) in the elderly, though the extent to which activity levels contributed to this contrast is uncertain from these data.

A stage-theory model of cognitive development.

A model of the proportions of the population at various stages of cognitive development as a function of age is proposed. It is shown that a number of weaknesses in an earlier model proposed by Eckstein & Shemesh (1992a) are avoided. The new model accounts well for empirical data for the age range 13-18 years. The uses of such models in research are discussed.

Home-based versus hospital-based rehabilitation after myocardial infarction: A randomized trial with preference arms--Cornwall Heart Attack Rehabilitation Management Study (CHARMS).

BACKGROUND: Participation in cardiac rehabilitation after acute myocardial infarction is sub-optimal. Offering home-based rehabilitation may improve uptake. We report the first randomized study of cardiac rehabilitation to include patient preference. AIM: To compare the clinical effectiveness of a home-based rehabilitation with hospital-based rehabilitation after myocardial infarction and to determine whether patient choice affects clinical outcomes. DESIGN: Pragmatic randomized controlled trial with patient preference arms. SETTING: Rural South West England. METHODS: Patients admitted with uncomplicated myocardial infarction were offered hospital-based rehabilitation classes over 8-10 weeks or a self-help package of six weeks' duration (the Heart Manual) supported by a nurse. Primary outcomes at 9 months were mean depression and anxiety scores on the Hospital Anxiety Depression scale, quality of life after myocardial infarction (MacNew) score and serum total cholesterol. RESULTS: Of the 230 patients who agreed to participate, 104 (45%) consented to randomization and 126 (55%) chose their rehabilitation programme. Nine month follow-up data were available for 84/104 (81%) randomized and 100/126 (79%) preference patients. At follow-up no difference was seen in the change in mean depression scores between the randomized home and hospital-based groups (mean difference: 0; 95% confidence interval, -1.12 to 1.12) nor mean anxiety score (-0.07; -1.42 to 1.28), mean global MacNew score (0.14; -0.35 to 0.62) and mean total cholesterol levels (-0.18; -0.62 to 0.27). Neither were there any significant differences in outcomes between the preference groups. CONCLUSIONS: Home-based cardiac rehabilitation with the Heart Manual was as effective as hospital-based rehabilitation for patients after myocardial infarction. Choosing a rehabilitation programme did not significantly affect clinical outcomes.

Home-based cardiac rehabilitation versus hospital-based rehabilitation: a cost effectiveness analysis.

BACKGROUND: Home-based cardiac rehabilitation offers an alternative to traditional, hospital-based cardiac rehabilitation. AIM: To compare the cost effectiveness of home-based cardiac rehabilitation and hospital-based cardiac rehabilitation. METHODS: 104 patients with an uncomplicated acute myocardial infarction and without major comorbidity were randomized to receive home-based rehabilitation (n=60) i.e. nurse facilitated, self-help package of 6 weeks' duration (the Heart Manual) or hospital-based rehabilitation for 8-10 weeks (n=44). Complete economic data were available in 80 patients (48 who received home-based rehabilitation and 32 who received hospital-based rehabilitation). Healthcare costs, patient costs, and quality of life (EQ-5D4.13) were assessed over the 9 months of the study. RESULTS: The cost of running the home-based rehabilitation programme was slightly lower than that of the hospital-based programme (mean (95% confidence interval) difference - 30 pounds sterling (- 45 pounds sterling to - 12 pounds sterling) [-44 euro, -67 euro to -18 euro] per patient. The cost difference was largely the result of reduced personnel costs. Over the 9 months of the study, no significant difference was seen between the two groups in overall healthcare costs (78 pounds sterling, - 1102 pounds sterling to 1191 pounds sterling [-115 euro, -1631 euro to -1763 euro] per patient) or quality adjusted life-years (-0.06 (-0.15 to 0.02)). The lack of significant difference between home-based rehabilitation and hospital-based rehabilitation did not alter when different costs and different methods of analysis were used. CONCLUSIONS: The health gain and total healthcare costs of the present hospital-based and home-based cardiac rehabilitation programmes for patients after myocardial infarction appear to be similar. These initial results require affirmation by further economic evaluations of cardiac rehabilitation in different settings.

Seasonal cold and circadian changes in blood pressure and physical activity in young and elderly people.

AIM: To test the hypothesis that there is no association between seasonal cold and the circadian responses of blood pressure, deep-body temperature and physical activity in healthy young and elderly men. METHODS: 25 healthy elderly (aged 70-82 years) and 21 young volunteers (aged 20-30 years) participated in a 3-year prospective cross-seasonal study. RESULTS: Ambulatory day-time blood pressures in the older men were higher in the winter than in the summer and higher in both seasons than in the young people. The seasonally related differences were associated with lower outdoor and indoor temperatures, lower body temperature and higher activity levels in the elderly group in the winter. The older but not the younger group had higher blood pressure and levels of physical activity at certain times of the day in the winter compared with the summer. CONCLUSION: Time-of-day winter increases in blood pressure in older people may be related to increased activity as well as to levels of ambient temperature. Although it is generally advantageous for older people to be physically active in order to prevent circulatory disease, there may be a rationale for advising that that they should avoid intense activity at certain times of the day, especially in the winter.

Myocardial infarction: a comparison between home and hospital care for patients.

To compare the results of home and hospital treatment in men aged under 70 years who had suffered acute myocardial infarction within 48 hours 1895 patients were considered for study in four centres in south-west England. Four-hundred-and-fifty patients were randomly allocated to receive care either at home by their family doctor or in hospital, initially in an intensive care unit. The randomised treatment groups were similar in age, history of cardiovascular disease, and incidence of hypotension when first examined. They were followed up for up to a year after onset. The mortality rate at 28 days was 12% for the random home group and 14% for the random hospital group; the corresponding figures at 330 days were 20% and 27%. On average, older patients and those without initial hypotension fared rather better under home care. The patients who underwent randomisation were similar to those whose place of care was not randomised, except that the non-randomised group contained a higher proportion of initially hypotensive patients, whose prognosis was poor wherever treated. These results confirm and extend our preliminary findings. Home care is a proper form of treatment for many patients with acute myocardial infarction, particularly those over 60 years and those with an uncomplicated attack seen by general practitioners.

Acute myocardial infarction: home and hospital treatment.

This is a preliminary report of a co-operative study of 1,203 episodes of acute myocardial infarction in men under 70 years in four centres in the south west of England. The mortality at 28 days was 15%. A comparison is made between home care by the family doctor and hospital treatment initially in an intensive care unit: 343 cases were allocated at random. The randomized groups do not differ significantly in composition with respect to age; past history of angina, infarction, or hypertension; or hypotension when first examined. The mortality rates of the random groups are similar for home and hospital treatment. The group sent electively to hospital contained a higher proportion of initially hypotensive patients whose prognosis was bad wherever treated; those who were not hypotensive fared rather worse in hospital.For some patients with acute myocardial infarction seen by their general practitioner home care is ethically justified, and the need for general admission to hospital should be reconsidered.