Factors determining choice of complementary and alternative medicine in acute and chronic diseases.

Background Systematic analysis of the determinants of choice of a treatment modality aids to the understanding of decision process of healthcare utilization. The revealed preference of a single modality may differ according to the nature of disease. Existing studies have not integrated possible causal factors in a model with respect to diseases. This study identifies major determinants and formulates their integral effect on choice of a particular modality on acute and chronic diseases in accordance to socio-behavioural model. Methodology A cross-sectional study on 300 samples using a 30-point questionnaire, developed in Likert scale and dichotomous scale. Possible determinants are tested on choice of CAM in case of acute disease and of chronic disease separately. Results Revealed single modality treatment preference (of CAM) varies widely between acute disease (13%) and chronic disease (58.67%). Bivariate associations are significant for gender (For, overall CAM preference, p=0.001, acute disease, p<0.001, chronic disease, p=0.024), Disease burden (overall and chronic: p<0.001, acute: p=0.008) and previous CAM usage (overall and chronic: p<0.001, acute: p=0.016). Social factor individually has significant influence on choosing CAM both acute (OR=1.096, p<0.001) and chronic disease (OR=1.036, p<0.001). Ideation of philosophical need factor, guided by philosophical congruence with CAM (OR=1.047, p<0.001) is a novel finding of this study. While with multiple logistic regression male gender (p=0.03), social factor (p<0.001), perception of CAM efficacy (p=0.02) and negative ideation about CAM cost-effectiveness (p=0.002) are found to be important in Acute disease; choosing CAM in chronic disease is guided by female gender (p=0.001), making decision in-group (p=0.001), low disease burden (p<0.001), philosophical need factor (p=0.001), and perception of CAM efficacy (p<0.001). Conclusion Demographic, social, cognitive and philosophical factors are important determinants of choosing CAM as a treatment modality over conventional medicine, but they act differently on CAM preference in acute and chronic diseases.

Impact of Nutrition Therapy and Rehabilitation on Acute and Critical Illness: A Systematic Review.

There have been no reviews describing the efficacy of the combination of both rehabilitation and nutritional treatments. This systematic review aimed to assess the effects of nutritional therapy on patients with an acute and critical illness undergoing rehabilitation. Online searches using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, EMBASE (ELSEVIER), and Ichu-shi Web databases identified 986 articles, and 16 additional articles were found through other sources. Each trial assessed for the risk of bias using the Cochrane Collaboration's tool, and the quality of the body of evidence with The Grading of Recommendations Assessment, Development and Evaluation approach. Two randomized controlled trials were included in this review. Jones et al reported that with an enhanced rehabilitation program, there was no effect of nutritional intervention on quality of life (standardized mean difference [SMD] 0.55, 95% confidence intervals [CI] -0.05 to 1.15; P = 0.12). However, Hegerova et al reported positive effects of physical therapy and oral supplements on muscle mass (0.65; 95% CI, 0.36 to 0.93; P < 0.00001) and activities of daily living (SMD 0.28, 95% CI 0.00 to 0.56; P = 0.05). Strengthened nutritional intervention with enhanced rehabilitation treatment for patients with acute and critical illness may possibly be effective for increasing muscle mass, as well as for improving activities of daily living within a short period after discharge.

Protein-enriched, milk-based supplement to counteract sarcopenia in acutely ill geriatric patients offered resistance exercise training during and after hospitalisation: study protocol for a randomised, double-blind, multicentre trial.

INTRODUCTION: Age-related loss of muscle mass and strength, sarcopaenia, burdens many older adults. The process is accelerated with bed rest, protein intakes below requirements and the catabolic effect of certain illnesses. Thus, acutely ill, hospitalised older adults are particularly vulnerable. Protein supplementation can preserve muscle mass and/or strength and, combining this with resistance exercise training (RT), may have additional benefits. Therefore, this study investigates the effect of protein supplementation as an addition to offering RT among older adults while admitted to the geriatric ward and after discharge. This has not previously been investigated. METHODS AND ANALYSIS: In a block-randomised, double-blind, multicentre intervention study, 165 older adults above 70 years, fulfilling the eligibility criteria, will be included consecutively from three medical departments (blocks of n=20, stratified by recruitment site). After inclusion, participants will be randomly allocated (1:1) to receive either ready-to-drink, protein-enriched, milk-based supplements (a total of 27.5 g whey protein/day) or isoenergetic placebo products (<1.5 g protein/day), twice daily as a supplement to their habitual diet. Both groups will be offered a standardised RT programme for lower extremity muscle strength (daily while hospitalised and 4×/week after discharge). The study period starts during their hospital stay and continues 12 weeks after discharge. The primary endpoint is lower extremity muscle strength and function (30 s chair-stand-test). Secondary endpoints include muscle mass, measures of physical function and measures related to cost-effectiveness. ETHICS AND DISSEMINATION: Approval is given by the Research Ethic Committee of the Capital Region of Denmark (reference no. H-16018240) and the Danish Data Protection Agency (reference no. HGH-2016-050). There are no expected risks associated with participation, and each participant is expected to benefit from the RT. Results will be published in peer-reviewed international journals and presented at national and international congresses and symposiums. TRIAL REGISTRATION NUMBER: NCT02717819 (9 March 2016).

Paciente con EPOC grave, insuficiencia respiratoria crónica y agudización cardiorrespiratoria tratado con la asociación CDB-SWEETraining / Patient with severe COPD, chronic respiratory failure and cardiopulmonary exacerbation treated with a combination of CDB-SWEETraining

Objetivo: Evaluar el tratamiento combinado del comprehensive directed breathing con el programa de entrenamiento Square Wave Endurance Exercise Test en cicloergómetro con oxigenoterapia en el ejercicio en un paciente con EPOC grave, insuficiencia respiratoria crónica y agudización cardiorrespiratoria. Metodología: Se evalúa clínica y funcionalmente tras el alta médica a un paciente de 61 años con EPOC grave. Inicia entrenamiento tipo Square Wave Endurance Exercise Test combinado con ventilación dirigida contrastada (Comprehensive Directed Breathing) y oxigenoterapia en el ejercicio. Tras 40 sesiones de 90min se analizan parámetros físicos (frecuencia cardiaca, respiratoria y SaO2) en reposo y tras el ejercicio, funcionales (disnea de reposo y esfuerzo) y espirométricos. Resultados: Tras 8 semanas de entrenamiento se objetivan mejoras en la frecuencia cardiorrespiratoria, la SaO2, la disnea de reposo y esfuerzo, la gasometría y la espirometría (PEF 4,8L/s [+98%] y PIF 3,9L/s [+48%]), manteniéndose a los 6 meses, uno y 3 años. Conclusión: El tratamiento combinado comprehensive directed breathing -Square Wave Endurance Exercise Test con oxigenoterapia durante el ejercicio supervisado mejora la frecuencia cardiorrespiratoria, la SaO2, la disnea, la gasometría y la espirometría, manteniéndose a los 6 meses, uno y 3 años

Objective: To evaluate the effect of combined treatment with comprehensive directed breathing and Square Wave Endurance Exercise Test in cycle ergometer associated with oxygen therapy on exercise in a patient with severe COPD, chronic respiratory failure and cardiopulmonary exacerbation. Methods: Treatment with Square Wave Endurance Exercise Test, comprehensive directed breathing, and oxygen therapy during exercise was implemented in a 61-year-old patient with severe COPD. After 40 sessions of 90min, an analysis was performed on the physical parameters, including heart and respiratory rate, oxygen saturation, gasometry, and spirometry. Results: After 8 weeks of training, improvement were obtained in heart and respiratory rates, oxygen saturation, dyspnoea, gasometry, and spirometry (PEF 4.8L/s [+98%] and PIF 3.9L/s [+48%]) at 6 month and one and 3 years. Conclusion: Comprehensive directed breathing -Square Wave Endurance Exercise Test and oxygen therapy during exercise improved clinical and functional parameters at 6 months, and one and 3 years

[Acute Care Rehabilitation is the First Link in a Chain of Rehabilitation Interventions]. / Frührehabilitation ist erstes Glied einer nahtlosen Rehabilitationskette.

An early, intensive rehabilitative therapy accelerates the recovery of the functions of patients. It contributes to a reduction in the complication rate as well as an improvement in physical and social functioning/participation in the long-term follow-up. Early rehabilitation must be strengthened on the basis of the existing structures: the creation and maintenance of adequately qualified early-stage rehabilitation facilities, at least in hospitals with priority and maximum supply contracts. Patients with long-term intensive care and polytrauma must be rehabilitated as soon as possible (intensive medical rehabilitation).Specialists in physical and rehabilitative medicine, rehabilitative geriatrists, neurologists, orthopaedists and accident surgeons and other regional physicians must cooperate in a targeted manner. Exclusion criteria using corresponding OPS codes must be canceled. Additional specialist physician groups (anesthetists and intensive care physicians, general practitioners, accident and thoracic surgeons, internists) must be sensitized to the importance of early rehabilitation.In the case of more than 500,000 hospital beds, 25,000 beds should be identified as age- and diagnosis-independent early-care beds in the country-specific bed-care plans. A cost-covering financing of the different, personal and cost-intensive early rehabilitation must be ensured. A phase model similar to the BAR guidelines for neurological-neurosurgical early rehabilitation is to be considered for other disease entities.In order to make the rehabilitation process as successful as possible, medical (acute) treatment, medical rehabilitation, occupational integration and social integration have to be understood as a holistic event and are effectively interrelated, as a continuous process which accompanies the entire disease phase-wise. For this purpose, a continuous case management or a rehabilitation guidance has to be established.

Identifying effective and feasible interventions to accelerate functional recovery from hospitalization in older adults: A randomized controlled pilot trial.

Hospitalization induces functional decline in older adults. Many geriatric patients fail to fully recover physical function after hospitalization, which increases the risk of frailty, disability, dependence, re-hospitalization, and mortality. There is a lack of evidence-based therapies that can be implemented following hospitalization to accelerate functional improvements. The aims of this Phase I clinical trial are to determine 1) the effect size and variability of targeted interventions in accelerating functional recovery from hospitalization and 2) the feasibility of implementing such interventions in community-dwelling older adults. Older patients (≥65years, n=100) will be recruited from a single site during hospitalization for an acute medical condition. Subjects will be randomized to one of five interventions initiated immediately upon discharge: 1. protein supplementation, 2. in-home rehabilitation plus placebo supplementation, 3. in-home rehabilitation plus protein supplementation, 4. single testosterone injection, or 5. isocaloric placebo supplementation. Testing will occur during hospitalization (baseline) and at 1 and 4weeks post-discharge. Each testing session will include measures of muscle strength, physical function/performance, body composition, and psychological function. Physical activity levels will be continuously monitored throughout study participation. Feasibility will be determined through collection of the number of eligible, contacted, and enrolled patients; intervention adherence and compliance; and reasons for declining enrollment and study withdrawal. This research will determine the feasibility of post-hospitalization strategies to improve physical function in older adults. These results will also provide a foundation for performing larger, multi-site clinical trials to improve physical function and reduce readmissions in geriatric patents.

Valor pronóstico del diagnóstico principal en ancianos ingresados en una unidad geriátrica de agudos al alta y al año / Prognostic value of the primary diagnosis in elderly patients admitted to an acute geriatric unit at discharge and one year later

Objetivo. Analizar la asociación entre el diagnóstico principal que motiva el ingreso hospitalario en una unidad geriátrica de agudos (UGA) y el riesgo de mortalidad intrahospitalaria y al año del alta. Material y métodos. Estudio longitudinal de los pacientes que ingresaron en la UGA del Hospital Central de la Cruz Roja de Madrid durante 2009. El diagnóstico de ingreso se agrupó por grupos relacionados por el diagnóstico (GRD). La fecha de fallecimiento fue recogida del informe médico y del Índice Nacional de Defunciones del Ministerio de Sanidad. Como variable resultado se analizó la asociación entre diagnósticos al ingreso y deterioro funcional al alta (medido como una pérdida de 10 o más puntos entre el Índice de Barthel al alta respecto al previo al ingreso), mortalidad durante el ingreso, a los 3 meses y al año del alta. El análisis se ajustó por edad, sexo, comorbilidad, situación funcional y cognitiva, y niveles de albúmina sérica. Resultados. Se estudiaron 1.147 pacientes, con una edad media de 86,7 años (DE: ± 6,7), 66% eran mujeres. Fallecieron durante el ingreso un 10,1% y presentaron deterioro funcional al alta el 36,6%. La mortalidad postalta fue del 25,5% a los 3 meses y el 42,2% al año. La frecuencia de los principales diagnósticos al ingreso (entre paréntesis su mortalidad intrahospitalaria y al año) fueron insuficiencia cardiaca 21,4% (8,1 y 37,4%), neumonía no aspirativa 13,3% (12,3 y 46,4%) y neumonía aspirativa 4,7% (27,5 y 71%), bronconeumopatías 13,3% (6,6 y 38,2%), infección urinaria 10,2% (5,1 y 42,7%) e ictus (excluyendo AIT) 9,9% (13,3 y 46,9%). En el análisis multivariante solo el ingreso por neumonía aspirativa se asociaba de forma independiente con mayor riesgo de mortalidad intrahospitalaria (odds ratio-2,23; IC95% = 1,13-44,42) y el ingreso por ictus a la presencia de deterioro funcional al alta (odds ratio-6,01; IC95% = 3,42-10,57). Ningún diagnóstico se asoció de manera independiente con aumento del riesgo de muerte a los 3 meses y al año. Conclusiones. El ingreso por neumonía aspirativa conlleva un mayor riesgo de muerte en ancianos hospitalizados por patología médica aguda. Tras el alta, el riesgo aumentado de muerte debe ser atribuido a otros factores diferentes al diagnóstico (AU)

Objective. To analyse the relationship between the primary diagnosis on admission to an Acute Geriatric Unit (AGU) and the risk of hospital mortality and one year after discharge. Material and methods. A longitudinal study was conducted on patients admitted to the Central Hospital AGU Red Cross in Madrid in 2009. The admission diagnosis was grouped by Diagnosis Related Groups (DRGs). The date of death was collected from the medical charts and the National Death Index Ministry of Health report. The main outcome of study was the association between diagnoses on admission and functional impairment at discharge (measured as a loss of 10 or more points between the Barthel Index at discharge and that on admission), mortality during hospitalization, at 3 months and one year after discharge. The multivariate analysis was adjusted for age, sex, comorbidity, functional and cognitive status, and serum albumin. Results. The study included1147 patients, with a mean age of 86.7 years (SD ± 6.7), and 66% were women. During admission, 10.1% of patients died and 36.6% had functional impairment at discharge. After discharge, 25.5% died at 3 months, and 42.2% at one year. The distribution of the primary diagnoses at admission (between parentheses hospital mortality and at year) were heart failure, 21.4% (8.1% and 37.4%), pneumonia,13.3% (12.3% and 46.4%), and aspiration pneumonia, 4.7% (27.5%, y 71%), respiratory diseases,13.3% (6.6% and 38.2%), urinary infection,10.2% (5.1% and 42.7%), and stroke (excluding AIT), 9.9% (13.3% and 46.9%). In the multivariate analysis, only admissions due to aspiration pneumonia were independently associated with increased risk of hospital mortality (odds ratio, 2.23; 95% CI = 1.13 to 44.42), and stroke with increased risk of functional impairment at discharge (odds ratio, 6.01; 95% CI = 3.42-10.57). No diagnosis was independently associated with increased risk of death at 3 months and at year. Conclusions. Admission from aspiration pneumonia carries an increased risk of death in elderly patients hospitalised for acute medical conditions. After discharge, the risk of death must be attributed to factors other than the admission diagnosis (AU)

[Postacute care]. / Cuidados postagudos.

The aging of the population and changes in family and social structures have led to increasing care needs for elderly persons following an acute disease or accident, with consequent concerns regarding costs and sustainability within the public health system. The main objective of postacute care (PAC) is to restore the functional capabilities of the patient after an acute event and contribute to determine the patient's outcome and future healthcare requirements. With this background, we carried out a systematic review of the published literature from 1990 to 2011 focused on the following aspects of PAC: a) objectives; b) estimations of the need and the indicators for access to it, and c) transfer strategies from acute care to PAC. The results of this review indicate that PAC is an efficient approach to improve patients' quality of life and to sustain the public healthcare system. The choice of candidates for PAC should be based on both health and social indicators, and the overall process viewed in a cross-sectional manner in order to avoid increases in total cost.

[The influence of "dry" bi-carbonate baths on the circadian profile of arterial pressure in patients who suffered acute myocardial infarction].

The objective of this study was to evaluate effect of "dry" bi-carbonate baths (DBB) on the circadian profile of arterial pressure (AP) in patients who suffered acute myocardial infarction (AMI). Diurnal AP profiles were analysed in all patients after AMI. The patients comprising group 1 were treated with the use of DBB while the remaining ones received a sham treatment. 24 hour AP monitoring was performed before and after therapy. The study revealed a reduction in the frequency of hypotensive diastolic values at the daytime and in the duration of night-time hypertensive episodes under the influence of therapy with the use of DBB. Variability of systolic AP throughout 24 hours and of diastolic AP at daytime also decreased. Generally speaking, patients with elevated AP showed a more pronounced effect of DBB on the night AP profile. It is concluded that therapy with the use of DBB after AMI has beneficial effect on the clinical state of the patients and reduces the risk of cardiovascular complications.

A qualitative examination of the experience of 'depression' in hospitalized medically ill patients.

BACKGROUND: Research into depression in the medically ill has progressed without sufficient attention being given to the validity, in this group, of the taxonomic categories. We aimed to describe, using qualitative interviews, the experience of 'being depressed', separating experiences that are unique to depression from experiences that are common to being ill and in hospital. METHOD: Forty-nine patients hospitalized for medical illness underwent a 30-min interview in which they were asked to 'Describe how you have been unwell and, in particular, how that has made you feel.' From the transcripts, a 'folk' taxonomy was constructed using a phenomenological framework involving four steps: frame elicitation to identify the important themes, componential analysis to systematically cluster the attributes into domains, a comparison of the experiences of patients screening depressed and not-depressed, and a theoretical analysis comparing the resulting taxonomy with currently used theoretical constructs. RESULTS: Experiences common to all patients were being in hospital, being ill or in pain, adjusting to not being able to do things, and having time to think. In addition, all participants described being depressed, down or sad. Patients who were identified by screening as being depressed described unique experiences of depression, which included 'having to think about things' (a forceful intrusive thinking), 'not being able to sleep', 'having to rely on others', 'being a burden' to others (with associated shame and guilt), feelings of 'not getting better' and 'feeling like giving up'. Theoretical analysis suggested that this experience of depression fitted well with the concept of demoralization described by Jerome Frank. CONCLUSIONS: Demoralization, which involves feelings of being unable to cope, helplessness, hopelessness and diminished personal esteem, characterizes much of the depression seen in hospitalized medically ill patients.

[Structures of acute rheumatic care]. / Strukturen der akutstationären rheumatologischen Versorgung.

Severe rheumatological systemic diseases demand high levels of diagnostic and therapeutic measures and differentiated and complex methods of care. In Germany, specialised rheumatologists and, if hospitalisation is indicated, specialised rheumatology hospitals or departments are responsible for the treatment of these patients. Early rehabilitation procedures, provided by a multidisciplinary therapeutic team, are an important component of the treatment concept in these facilities. Early rehabilitation is integrated into the patients acute medical treatment plan, with careful consideration of the patients current health problems and functional capabilities (body functions and structures, activities and participation as outlined in the ICF), thereby providing a comprehensive, integrated therapy strategy which has long been acknowledged as necessary for the successful treatment of rheumatoid patients. This article presents an analysis concerning the development, organisation, facilities and processes of the acute medical in-patient care for patients with rheumatological disorders in Germany. In total there are 4188 beds in 88 acute hospitals exclusively available for rheumatological in-patients in Germany at present. There is at least one facility specialised in rheumatology in every German federal state. The density of care in the German federal states varies between 131.8 beds per 1 million inhabitants in Bremen and 9 beds per 1 million inhabitants in Saxony. In most regions of Germany the acute in-patient care for patients with rheumatological disorders is provided by hospitals specialised in rheumatology. Rheumatological patients are treated in a variety of hospital departments. In the year 2000 only 47% of the inpatients with rheumatoid arthritis, 56% of those with ankylosing spondylitis and 28% of those with systemic lupus erythematosus were treated in a ward specialising in rheumatology. Rheumatoid arthritis, with a total share of nearly 30%, was the most frequently treated rheumatic disease in wards specialising in rheumatology, followed by soft tissue disorders (e.g. fibromyalgia), diseases with systemic involvement of connective tissue and inflammatory spinal disorders such as ankylosing spondylitis.

Managing musculoskeletal complaints with rehabilitation therapy: summary of the Philadelphia Panel evidence-based clinical practice guidelines on musculoskeletal rehabilitation interventions.

OBJECTIVE: The Philadelphia Panel recently formulated evidence-based guidelines for selected rehabilitation interventions in the management of low back, knee, neck, and shoulder pain. STUDY DESIGN: The guidelines were developed with the use of a 5-step process: define the intervention, collect evidence, synthesize results, make recommendations based on the research, and grade the strength of the recommendations. POPULATION: Outpatient adults with low back, knee, neck, or shoulder pain without vertebral disk involvement, scoliosis, cancer, or pulmonary, neurologic, cardiac, dermatologic, or psychiatric conditions were included in the review. OUTCOMES MEASURED: To prepare the data, systematic reviews were performed for low back, knee, neck, and shoulder pain. Therapeutic exercise, massage, transcutaneous electrical nerve stimulation, thermotherapy, ultrasound, electrical stimulation, and combinations of these therapies were included in the literature search. Studies were identified and analyzed based on study type, clinical significance, and statistical significance. CONCLUSIONS: The Philadelphia Panel guidelines recommend continued normal activity for acute, uncomplicated low back pain and therapeutic exercise for chronic, subacute, and postsurgical low back pain; transcutaneous electrical nerve stimulation and exercise for knee osteoarthritis; proprioceptive and therapeutic exercise for chronic neck pain; and the use of therapeutic ultrasound in the treatment of calcific tendonitis of the shoulder.

Feasibility of gait training for acute stroke patients using FNS with implanted electrodes.

Following stroke, many patients do not regain a normal, safe gait pattern even after receiving conventional physical therapy. One promising technique is functional neuromuscular stimulation (FNS) with intramuscular (IM) electrodes (FNS-IM). Five subjects were admitted into the study at 3 weeks to 3 months following the stroke. For each subject, electrodes were placed intramuscularly at the motor point of up to seven lower extremity paretic muscles. Subjects were treated for 6 months, twice weekly with FNS-IM for exercise and gait training. The stimulator and software provided individualized stimulation patterns, with flexible stimulus parameters and activation timings of multiple muscles. Outcome measures were active joint movement, coordination (Fugl-Meyer scale), balance (Tinetti scale), gait (Tinetti scale), activities of daily living (functional independence measure), and therapist and subject satisfaction (survey instrument). Subjects tolerated well the placement of IM electrodes with no adverse effects, and subjects lost no conventional rehabilitation time. Therapists and subjects were satisfied with the FNS-IM system as a rehabilitation tool. Post treatment, subjects demonstrated improvements in impairment and disability in active joint movement, coordination, balance, gait and activities of daily living. Considered together with prior research for chronic stroke subjects, this research suggests that FNS-IM can be successfully and efficaciously utilized for gait training for those with acute stroke.

Impacto en kinesiología: necesidad de definir y evaluar / Impact in physical therapy: needs to define and assess

Los cada vez más exigentes estándares de atención en salud han conducido al desarrollo de metodologías para la evaluación del impacto del tratamiento kinesiológico en el proceso de la rehabilitación del paciente. Para ello se ha adoptado, entre otros, como herramienta la clasificación propuesta por la Organización Mundial de la Salud, en la cual se reconocen tres esferas durante el proceso de recuperación: deterioro, discapacidad y handicap. El adoptarlas posibilita priorizar la atención y esclarecer los objetivos del tratamiento. Si bien la literatura al respecto es escasa, y con resultados muchas veces poco favorables, cada día aumenta el interés por investigar. Por esta razón se propone continuar buscando escalas de evaluación de manera de abrir un nuevo camino de discusión para el quehacer kinésico