Home-Based Cardiac Rehabilitation Among Patients Unwilling to Participate in Hospital-Based Programs.

PURPOSE: Asynchronous home-based cardiac rehabilitation (HBCR) is a viable alternative to center-based cardiac rehabilitation (CBCR). However, to achieve significant functional improvement, a high level of adherence and activity must be achieved. The effectiveness of HBCR among patients who actively avoid CBCR has not been effectively investigated. This study aimed to investigate the effectiveness of the HBCR program among patients unwilling to participate in CBCR. METHODS: A randomized prospective study enrolled 45 participants to a 6-mo HBCR program and the remaining 24 were allocated to regular care. Both groups were digitally monitored for physical activity (PA) and self-reported outcomes. Change in peak oxygen uptake (VO 2peak ), the primary study outcome, was measured by the cardiopulmonary exercise test, immediately before program start and 4 mo thereafter. RESULTS: The study included 69 patients, 81% men, aged 55.9 ±12 yr, enrolled in a 6-mo HBCR program to follow a myocardial infarction (25.4%) or coronary interventions (41.3%), heart failure hospitalization (29%), or heart transplantation (10%). Weekly aerobic exercise totaled a median of 193.2 (110.2-251.5) min (129% of set exercise goal), of which 112 (70-150) min was in the heart rate zone recommended by the exercise physiologist.After 4 mo, VO 2peak improved by 10.2% in the intervention group versus -2.7% in the control group (+2.46 ± 2.67 vs -0.72 ± 3.02 mL/kg/min; P < .001). CONCLUSION: The monthly PA of patients in the HBCR versus conventional CBCR group were well within guideline recommendations, showing a significant improvement in cardiorespiratory fitness. Risk level, age, and lack of motivation at the beginning of the program did not prevent achieving goals and maintaining adherence.

Israel's first national remote cardiac rehabilitation program: A retrospective analysis.

Aims: Cardiac rehabilitation is an essential component of secondary prevention consistently unexploited by most eligible patients. Accordingly, the remote cardiac rehabilitation program (RCRP) was developed to create optimal conditions for remote instruction and supervision for patients to enable successful completion of the program. Methods: This study comprised 306 patients with established coronary heart disease who underwent a 6-month RCRP. RCRP involves regular exercise, monitored by a smartwatch that relays data to the operations center and a mobile application on the patient's smartphone. A stress test was performed immediately before the RCRP and repeated after 3 months. The aims were to determine the effectiveness of the RCRP in improving aerobic capacity, and correlating the program goals and first-month activity, with attaining program goals during the last month. Results: Participants were mostly male (81.5%), aged 58 ± 11, enrolled in the main after a myocardial infarction or coronary interventions. Patients exercised aerobically for 183 min each week, 101 min (55% of total exercise) at the target heart rate. There was a significant improvement in exercise capacity, assessed by stress tests, metabolic equivalents which increased from 9.5 ± 3 to 11.4 ± 7(p < 0.001). Independent predictors of RCRP goals were older age and more minutes of aerobic exercise during the first program month (p < 0.05). Conclusion: Participants succeeded in performing guideline recommendations, resulting in a significant improvement in exercise capacity. Older age and increased volume of first month of exercise were significant factors associated with a greater likelihood to attain program goals.

The First National Program of Remote Cardiac Rehabilitation in Israel-Goal Achievements, Adherence, and Responsiveness in Older Adult Patients: Retrospective Analysis.

BACKGROUND: Remote cardiac rehabilitation (RCR) after myocardial infarction is an innovative Israeli national program in the field of telecardiology. RCR is included in the Israeli health coverage for all citizens. It is generally accepted that telemedicine programs better apply to younger patients because it is thought that they are more technologically literate than are older patients. It has also previously been thought that older patients have difficulty using technology-based programs and attaining program goals. OBJECTIVE: The objectives of this study were as follows: to study patterns of physical activity, goal achievement, and improvement in functional capacity among patients undergoing RCR over 65 years old compared to those of younger patients; and to identify predictors of better adherence with the RCR program. METHODS: A retrospective study of patients post-myocardial infarction were enrolled in a 6-month RCR program. The activity of the patients was monitored using a smartwatch. The data were collected and analyzed by a special telemedicine platform. RCR program goals were as follows: 150 minutes of aerobic activity per week, 120 minutes of the activity in the target heart rate recommended by the exercise physiologist, and 8000 steps per day. Models were created to evaluate variables predicting adherence with the program. RESULTS: Out of 306 patients, 80 were older adults (mean age 70 years, SD 3.4 years). At the end of the program, there was a significant improvement in the functional capacity of all patients (P=.002). Specifically, the older adult group improved from a mean 8.1 (SD 2.8) to 11.2 (SD 12.6). The metabolic equivalents of task (METs) and final MET results were similar among older and younger patients. During the entire program period, the older adult group showed better achievement of program goals compared to younger patients (P=.03). Additionally, we found that younger patient age is an independent predictor of early dropout from the program and completion of program goals (P=.045); younger patients were more likely to experience early program dropout and to complete fewer program goals. CONCLUSIONS: Older adult patients demonstrated better compliance and achievement of the goals of the remote rehabilitation program in comparison with younger patients. We found that older age is not a limitation but rather a predictor of better RCR program compliance and program goal achievement.

Blood lipid levels and treatment following an acute coronary syndrome or coronary intervention - Journey from hospital to cardiac rehabilitation.

Background: A significant number of coronary artery disease patients do not attain guideline recommended LDL levels. Participating in a cardiac rehabilitation (CR) program has been shown to improve adherence to medical therapy. Objectives: Evaluate the specific lipid lowering therapy (LLT) prescribed and percent of subjects achieving LDL levels of <70 mg/dL before and after 3 months following CR program initiation. Methods: From May 2017 to April 2019, we prospectively recruited patients referred to our CR program and compared 1015 of them at 4 time points; (P1) just prior to the index hospitalization, (P2) during the index hospitalization, (P3) upon entering the CR program, roughly 3 months after the index hospitalization, and (P4) 3 months into the CR program. Included in the analysis were parameters of lipid levels, the dispensed medication given, as well as patient adherence to treatment. Results: At CR intake, LDL goals were partially achieved with 57% of patients below 70 mg/dL. After completion of 3 months of CR, 63% of patients had LDL levels below 70 mg/dL, despite the fact that the majority (95%) were prescribed high-dose potent statins. Aside from the LDL levels at CR intake, we found no other independent predictors for not attaining the lipid goals at 6 months. Conclusions: A significant treatment gap is present even in a selected population participating in CR, with the vast majority receiving guideline recommended LLT. In order to improve goals, we need to intensify LLT treatment, and increase patient adherence to therapy.

Metastatic Neoplasms to the Vulva-A Review.

INTRODUCTION: Metastatic neoplasms to the vulva are rare and can pose a diagnostic dilemma. As identification of the primary site can influence patient treatment and prognosis, correct diagnosis is important. METHODS: PubMed was searched for applicable publications using the terms vulva, vulvar neoplasms, metastasis, and vulvar metastasis. RESULTS: Most neoplasms metastatic to the vulva originate from other genital sources; however, extragenital primary neoplasms can also metastasize to the vulva. Vulvar metastases often occur in the setting of widespread disease. CONCLUSIONS: It is important to consider biopsy for appropriate histologic and immunohistochemical studies, as well as consider patient history to establish the primary site of metastatic lesions to the vulva, allowing optimal therapy.

Evaluation of PROMIS Preference Scoring System (PROPr) in Patients Undergoing Hemodialysis or Kidney Transplant.

BACKGROUND AND OBJECTIVES: A preference-based health utility score (PROPr) can be calculated using Patient-Reported Outcomes Measurement Information System domain scores. We assessed the construct validity of PROPr among patients treated with KRT (hemodialysis or kidney transplant). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We performed a secondary analysis of data collected in multicenter, cross-sectional studies of adults treated with KRT, recruited between April 2016 to March 2020 in Toronto, Canada. All participants provided informed consent. The outcome was the PROPr score. Coadministered outcome variables included the Short-Form Six-Domain (SF-6D) and EuroQol Five-Domain Five-Level (EQ-5D-5L) scores. Socioeconomic and clinical variables included age, sex, diabetes, eGFR, serum albumin, hemoglobin, KRT, and Charlson Comorbidity Index. Construct validity was assessed through correlations between PROPr and SF-6D or EQ-5D-5L, and associations between PROPr and other exposure variables. Health-condition impact estimates (coefficients for health conditions compared with a referent category, e.g., dialysis versus kidney transplant) were calculated using multivariable linear regression. RESULTS: The mean (SD) age of the 524 participants was 57 (17) years, 58% were male, and 45% were White. Median (interquartile range) score was 0.39 (0.24-0.58) for PROPr, 0.69 (0.58-0.86) for SF-6D, and 0.85 (0.70-0.91) for EQ-5D-5L. Large correlations were observed between PROPr versus SF-6D (0.79; 95% confidence interval [95% CI], 0.76 to 0.82) and EQ-5D-5L (0.71; 95% CI, 0.66 to 0.75). Both PROPr and the other utility indices demonstrated health-condition impact in the expected direction. For example, the estimate for PROPr was -0.17 (95% CI, -0.13 to -0.21) for dialysis (versus kidney transplant), -0.05 (95% CI, -0.11 to 0.01; P=0.08) for kidney transplant recipients with an eGFR of <45 versus ≥45 ml/min per 1.73 m2, and -0.28 (95% CI, -0.22 to -0.33) for moderate/severe versus no/mild depressive symptoms. CONCLUSIONS: Our results support the validity of PROPr among patients treated with KRT.

Clinical Outcomes After Percutaneous Patent Ductus Arteriosus Closure in Adults.

BACKGROUND: There is little published data regarding percutaneous patent ductus arteriosus (PDA) closure in adults. We aim to describe the outcomes of adult patients undergoing PDA closure at a single tertiary referral centre. METHODS: All adults who underwent device PDA closure at our centre from 2001 to 2017 were identified and enrolled in the study. Available clinical data and imaging data were reviewed. RESULTS: At total of 141 patients were identified, with a mean age of 43 ± 15 years. Left ventricular dilation was present in 27% and pulmonary hypertension in 36% of the patients. Most ducts (74%) were of type A morphology. Mean ductal diameter at the pulmonary artery end was 4.1 ± 1.9 mm and mean length was 10.0 ± 4.7 mm. Wire passage from the pulmonary artery was achieved in 79%. Procedural success rate was 100%, and an Amplatzer duct occluder was deployed in all successful cases (ADO1 device in 97%). There was a small residual shunt in 6% at the time of closure, and only 2 patients had a residual leak on echocardiography at a median 3 months' follow-up. No major complications occurred. CONCLUSIONS: Transcatheter PDA closure with the use of an Amplatzer duct occluder is very effective in adults across all duct morphologies and associated with a very low complication rate.

Multidisciplinary analysis of Finnish esker sediment in radon source identification.

In order to define the naturally-occurring radioactive materials that are the source of radon in natural environments, a comprehensive analytical (geochemical, physical and chemical) methodology was employed to study sand samples from the Hollola esker in the city of Hollola (Lahti area, Finland). Techniques such as gamma-spectrometry, emanation measurements, sequential chemical extraction, scanning electron microscopy (SEM), electron probe microanalyses (EPMA) and inductively-coupled plasma mass spectrometry (ICP-MS) were used to determine the potential source of radon. Monazite and xenotime, uranium- and thorium-bearing minerals and potential radon sources, occurred in significant amounts in the samples and were also the main reason for the distribution of uranium and thereby radium in separate grain-size fractions. Following deposition, the esker sand has been exposed to no significant weathering, and radium has not therefore been much separated from uranium. However, considering its non-compatibility with crystal lattices, it was recognized rather in easily leachable species (44% of the total (226)Ra) than uranium (21% of the total (238)U) in our analyses. The smallest grain-size fraction of the esker sand had a higher emanation power (0.24) than the other fractions (around 0.17). Due to the small relative proportion of this fraction, however, it contributed only slightly to the total emanation (4%). The emanation power of the leachable species was about three times higher (ca. 0.20) than that of the species tightly bound to the crystal lattice (ca. 0.07).