Exercise training can induce cardiac autophagy at end-stage chronic conditions: Insights from a graft-versus-host-disease mouse model

Chronic graft-versus-host disease (cGVHD) is a frequent cause of morbimortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT), and severely compromises patients' physical capacity. Despite the aggressive nature of the disease, aerobic exercise training can positively impact survival as well as clinical and functional parameters. We analyzed potential mechanisms underlying the recently reported cardiac function improvement in an exercise-trained cGVHD murine model receiving lethal total body irradiation and immunosuppressant treatment (Fiuza-Luces et al., 2013. Med Sci Sports Exerc 45, 1703-1711). We hypothesized that a cellular quality-control mechanism that is receiving growing attention in biomedicine, autophagy, was involved in such improvement. Our results suggest that exercise training elicits a positive autophagic adaptation in the myocardium that may help preserve cardiac function even at the end-stage of a devastating disease like cGVHD. These preliminary findings might provide new insights into the cardiac exercise benefits in chronic/debilitating conditions.

Assessment of depression in medical patients: a systematic review of the utility of the beck depression inventory-II

To perform a systematic review of the utility of the Beck Depression Inventory for detecting depression in medical settings, this article focuses on the revised version of the scale (Beck Depression Inventory-II), which was reformulated according to the DSM-IV criteria for major depression. We examined relevant investigations with the Beck Depression Inventory-II for measuring depression in medical settings to provide guidelines for practicing clinicians. Considering the inclusion and exclusion criteria seventy articles were retained. Validation studies of the Beck Depression Inventory-II, in both primary care and hospital settings, were found for clinics of cardiology, neurology, obstetrics, brain injury, nephrology, chronic pain, chronic fatigue, oncology, and infectious disease. The Beck Depression Inventory-II showed high reliability and good correlation with measures of depression and anxiety. Its threshold for detecting depression varied according to the type of patients, suggesting the need for adjusted cut-off points. The somatic and cognitive-affective dimension described the latent structure of the instrument. The Beck Depression Inventory-II can be easily adapted in most clinical conditions for detecting major depression and recommending an appropriate intervention. Although this scale represents a sound path for detecting depression in patients with medical conditions, the clinician should seek evidence for how to interpret the score before using the Beck Depression Inventory-II to make clinical decisions

Obesity

It is now widely accepted that there are important links between inactivity and lifestyle-related chronic diseases, and that exercise can bring tangible therapeutic benefits to people with long-term chronic conditions. Exercise and Chronic Disease: An Evidence-Based Approach offers the most up-to-date survey currently available of the scientific and clinical evidence underlying the effects of exercise in relation to functional outcomes, disease-specific health-related outcomes and quality of life in patients with chronic disease conditions. Drawing on data from randomized controlled trials and observational evidence, and written by a team of leading international researchers and medical and health practitioners, the book explores the evidence across a wide range of chronic diseases, including:

The hyperthermic patient

Concepts used in this chapter include: Thermoregulation:- Thermoregulation refers to the body’s sophisticated, multi-system regulation of core body temperature. This hierarchical system extends from highly thermo-sensitive neurons in the preoptic region of the brain proximate to the rostral hypothalamus, down to the brain stem and spinal cord. Coupled with receptors in the skin and spine, both central and peripheral information on body temperature is integrated to inform and activate the homeostatic mechanisms which maintain our core temperature at 37oC1. Hyperthermia:- An imbalance between the metabolic and external heat accumulated in the body and the loss of heat from the body2. Exertional heat stroke:- A disorder of excessive heat production coupled with insufficient heat dissipation which occurs in un-acclimated individuals who are engaging in over-exertion in hot and humid conditions. This phenomenon includes central nervous system dysfunction and critical dysfunction to all organ systems including renal, cardiovascular, musculoskeletal and hepatic functions. Non-exertional heat stroke:- In contrast to exertional heatstroke as a consequence of high heat production during strenuous exercise, non-exertional heatstroke results from prolonged exposure to high ambient temperature. The elderly, those with chronic health conditions and children are particularly susceptible.3 Rhabdomylosis:- An acute, sometimes fatal disease characterised by destruction of skeletal muscle. In exertional heat stroke, rhabdomylosis occurs in the context of strenuous exercise when mechanical and/or metabolic stress damages the skeletal muscle, causing elevated serum creatine kinease. Associated with this is the potential development of hyperkalemia, myoglobinuria and renal failure. Malignant hyperthermia:- Malignant hyperthermia is “an inherited subclinical myopathy characterised by a hypermetabolic reaction during anaesthesia. The reaction is related to skeletal muscle calcium dysregulation triggered by volatile inhaled anaesthetics and/or succinylcholine.”4 Presentation includes skeletal muscle rigidity, mixed metabolic and respiratory acidosis, tachycardia, hyperpyrexia, rhabdomylosis, hyperkalaemia, elevated serum creatine kinease, multi-organ failure, disseminated intravascular coagulation and death.5

Estimating the burden of disease attributable to smoking in South Africa in 2000

Objectives To quantify the burden of disease attributable to smoking in South Africa for 2000. Design The absolute difference between observed lung cancer death rate and the level in non-smokers, adjusted for occupational and indoor exposure to lung carcinogens, was used to estimate the proportion of lung cancer deaths attributable to smoking and the smoking impact ratio (SIR). The SIR was substituted for smoking prevalence in the attributable fraction formula for chronic obstructive pulmonary disease (COPD) and cancers to allow for the long lag between exposure and outcome. Assuming a shorter lag between exposure and disease, the current prevalence of smoking was used to estimate the population-attributable fractions (PAF) for the other outcomes. Relative risks (RR) from the American Cancer Society cancer prevention study (CPS-II) were used to calculate PAF. Setting South Africa. Outcome measures Deaths and disability-adjusted life years (DALYs) due to lung and other cancers, COPD, cardiovascular conditions, respiratory tuberculosis, and other respiratory and medical conditions. Results Smoking caused between 41 632 and 46 656 deaths in South Africa, accounting for 8.0 - 9.0% of deaths and 3.7 - 4.3% of DALYs in 2000. Smoking ranked third (after unsafe sex/sexually transmitted disease and high blood pressure) in terms of mortality among 17 risk factors evaluated. Three times as many males as females died from smoking. Lung cancer had the largest attributable fraction due to smoking. However, cardiovascular diseases accounted for the largest proportion of deaths attributed to smoking. Conclusion Cigarette smoking accounts for a large burden of preventable disease in South Africa. While the government has taken bold legislative action to discourage tobacco use since 1994, it still remains a major public health priority.

Assessment of fundamental movement skills in childhood cancer patients

Background The improved treatment protocols and subsequent improved survival rates amongst childhood cancer patients has shifted the focus towards the long-term consequences arising from cancer treatment. Children who have completed cancer treatment are at a greater risk of delayed development, diminished functioning, disability, compromised fundamental movement skill (FMS) attainment and long term chronic health conditions. The aim of the study was to compare FMS of childhood cancer patients with an aged matched healthy reference group. Methods Pediatric cancer patients aged 5-8 years of age (n=26; median age 6.91 years), who completed cancer treatment (<5 years) at the Sydney Children’s Hospital were assessed performing 7 key FMS; sprint, side-gallop, vertical-jump, catch, over-arm throw, kick and leap. Results were compared to the reference group (n=430; 6.56 years). Results Childhood cancer patients scored significantly lower on 3 out of 7 FMS tests when compared to the reference group. These results equated to a significantly lower overall score for FMS. Conclusion This study highlighted the significant deficits in FMS within pediatric patients having completed cancer treatment. In order to reduce the occurrence of significant FMS deficits in this population, FMS interventions maybe warranted to assist in recovery from childhood cancer, prevent late effects and improve the quality of life in survivors of childhood cancer.

Why do Queenslanders seek care in emergency departments? A population study

Objective This study aims to identify the main reasons for which first time and multiple users seek medical care through Queensland emergency departments (ED). Methods A cross-sectional survey was conducted at eight public EDs among presenting patients (n = 911). The questions measured the socio-demographic characteristics of patients, their beliefs and attitudes towards EDs services, and perceptions of health status. Bivariate and binary logistic regression analyses were performed to examine the differences between first time and multiple users of EDs. Results First time and multiple users accounted for 55.5% and 44.5%, respectively. Multiple users themselves believed to be sicker, have poorer health status, and additional and/or chronic health conditions. Multiple users more strongly believed that their condition required treatment at an ED and perceived their condition as being very serious. Multiple users reported weekly household incomes below $600, and half of the multiple users were not working as compared to 35% first time users. Multivariate analysis showed that multiple use was significantly associated with the existence of additional health problems, having chronic condition, lower self-efficacy, and need for ED treatment. Conclusions Patients who sought care for multiple times at EDs more often than first time users suffered from additional and chronic conditions. Their opinion of an ED as the most suitable place to address their current health problem was stronger than first time users. Any proposed demand management strategies need to address these beliefs together with the reasoning of patients to provide effective and appropriate care outside or within ED services.

#20 [updated] Community wide interventions for increasing physical activity - Clinical Version

People who are physically active have higher levels of health related fitness, and a lower risk profile for developing a number of disabling medical conditions and chronic diseases. However, despite considerable evidence of the benefits of regular physical activity, global levels of physical inactivity remain stubbornly high. In response, governments are looking to find ways to increase the physical activity of their populations.

Elimination of axial venous reflux

Chronic venous disease (CVD), including uncomplicated varicose veins and chronic venous insufficiency, is one of the most common medical conditions in the Western world. The central feature of CVD is venous reflux, which may be primary, congenital, or result from an antecedent event, usually an acute deep venous thrombosis (DVT). When the history of DVT is clear, the clinical manifestations of secondary CVD are commonly referred to as the post-thrombotic syndrome. Regardless of the underlying etiology, the final pathway leading to symptoms is ambulatory venous hypertension. The spectrum of symptoms and signs of CVD ranges from minor cosmetic problems to venous ulceration, which results in considerable morbidity and increased medical costs. Aims of this study were to evaluate the outcome of superficial venous surgery performed with or without preoperative duplex evaluation and venous marking with hand-held doppler, to assess short-term outcome of ultrasound-guided foam sclerotherapy in patients with axial superficial venous incompetence, as well as to compare reflux patterns after catheter-directed and systemic thrombolysis of deep ileofemoral venous thrombosis, and to evaluate the long-term outcome of deep venous reconstructions for severe chronic venous insufficiency. The study consists of five separate retrospective projects and includes 315 patients. Of this, 133 patients had undergone superficial venous surgery 2 to 5 years earlier according to preoperative duplex examination and venous marking, or according to clinical evaluation alone, or to a written plan without venous marking. A total of 112 patients had undergone ultrasound-guided foam sclerotherapy 5.5 to 16.5 months before. In addition, 32 patients had received either catheter-directed or systemic thrombolysis for DVT 2 to 3 years earlier, and 38 patients had undergone deep venous reconstructions 2 to 7 years earlier. In the present studies, some venous reflux was present postoperatively irrespective of the method of evaluation or ablation of the reflux. It seemed, however, that preoperative examination with duplex ultrasound and marking of reflux sites before the operation by the operating surgeon improves the outcome of superficial venous surgery. Ultrasound-guided foam sclerotherapy is effective in elimination of venous reflux in selected cases in short-term follow-up. Catheter-directed thrombolysis for deep iliofemoral venous thrombosis reduces later reflux and most probably the development of post-thrombotic syndrome as well. The outcome of deep venous reconstructions, especially for post-thrombotic deep venous incompetence, is poor. Thus, prevention of valvular damage by active treatment of deep venous thrombosis is important.

Brain imaging of chronic pain

Acute pain has substantial survival value because of its protective function in the everyday environment. Instead, chronic pain lacks survival and adaptive function, causes great amount of individual suffering, and consumes the resources of the society due to the treatment costs and loss of production. The treatment of chronic pain has remained challenging because of inadequate understanding of mechanisms working at different levels of the nervous system in the development, modulation, and maintenance of chronic pain. Especially in unclear chronic pain conditions the treatment may be suboptimal because it can not be targeted to the underlying mechanisms. Noninvasive neuroimaging techniques have greatly contributed to our understanding of brain activity associated with pain in healthy individuals. Many previous studies, focusing on brain activations to acute experimental pain in healthy individuals, have consistently demonstrated a widely-distributed network of brain regions that participate in the processing of acute pain. The aim of the present thesis was to employ non-invasive brain imaging to better understand the brain mechanisms in patients suffering from chronic pain. In Study I, we used magnetoencephalography (MEG) to measure cortical responses to painful laser stimulation in healthy individuals for optimization of the stimulus parameters for patient studies. In Studies II and III, we monitored with MEG the cortical processing of touch and acute pain in patients with complex regional pain syndrome (CRPS). We found persisting plastic changes in the hand representation area of the primary somatosensory (SI) cortex, suggesting that chronic pain causes cortical reorganization. Responses in the posterior parietal cortex to both tactile and painful laser stimulation were attenuated, which could be associated with neglect-like symptoms of the patients. The primary motor cortex reactivity to acute pain was reduced in patients who had stronger spontaneous pain and weaker grip strength in the painful hand. The tight coupling between spontaneous pain and motor dysfunction supports the idea that motor rehabilitation is important in CRPS. In Studies IV and V we used MEG and functional magnetic resonance imaging (fMRI) to investigate the central processing of touch and acute pain in patients who suffered from recurrent herpes simplex virus infections and from chronic widespread pain in one side of the body. With MEG, we found plastic changes in the SI cortex, suggesting that many different types of chronic pain may be associated with similar cortical reorganization. With fMRI, we found functional and morphological changes in the central pain circuitry, as an indication of central contribution for the pain. These results show that chronic pain is associated with morphological and functional changes in the brain, and that such changes can be measured with functional imaging.

Prevalência de sintomas depressivos em uma população de idosos usuários de serviços públicos

Esta dissertação pretende estimar a prevalência de sintomas depressivos em idosos segundo três níveis de complexidade de atenção à saúde e estudar a co-ocorrência de sintomas depressivos e incapacidade funcional. No Brasil, a transição demográfica ocorreu de forma rápida e explosiva. À medida que o número de idosos cresce ocorre o aumento da prevalência de doenças crônicas e suas complicações. A habilidade funcional pode ser vista como uma medida de resumo do impacto geral das condições médicas no contexto do ambiente e do sistema de apoio social do indivíduo, e deve ser uma consideração importante em qualquer planejamento de saúde. Uma enfermidade associada a elevado grau de incapacidade funcional é a depressão. Entre os agravos de saúde mental, a depressão é um dos mais comuns e importantes problemas psiquiátricos entre indivíduos idosos. Trata-se de estudo transversal com tamanho amostral de 643 idosos com idade de 65 ou mais anos selecionados aleatoriamente e usuários de três serviços públicos de saúde com níveis crescentes de complexidade (primário, secundário e terciário). A prevalência de sintomas depressivos foi estimada a partir da EDG-15, já traduzida e validada para uso no Brasil. O nível de estado funcional foi definido conforme os escores dos instrumentos SF-36 e HAQ. A prevalência de sintomas depressivos na amostra total foi de 45,2% (IC=41,1 49,3). Estratificando por unidade, a prevalência foi de 35,3% no nível primário, 47,6% no nível secundário e 51,7% no nível terciário (p=0,004). As prevalências encontradas foram altas nos três níveis de complexidade de atendimento, inclusive na população de idosos da unidade básica de saúde, apesar de serem idosos mais independentes e mais saudáveis. A prevalência geral de sintomas depressivos aumentou à medida que o grau de incapacidade funcional também aumentou. A busca ativa por idosos com sintomas depressivos é importante em todos os níveis de complexidade de atendimento do sistema de saúde.

Medication use review in Qatar: Are community pharmacists prepared for the extended professional role?

Background
The incidence of chronic illnesses is increasing globally. Non-adherence to medications and other medication-related problems are common among patients receiving long-term medications. Medication use review (MUR) is a service provision with an accredited pharmacist undertaking structured, adherence-centered reviews with patients receiving multiple medications. MUR services are not yet available in community pharmacies in Qatar.

Objective
The current study aims to evaluate community pharmacists' knowledge, attitudes, and perception towards establishing MUR as an extended role in patient care.

Setting
Private community pharmacies in Qatar including chains and independent pharmacies.

Methodology
A cross-sectional survey using a self-administered questionnaire was conducted among licensed community pharmacists from December 2012 to January 2013. Data analysis was conducted using descriptive and inferential statistics.

Main outcome measures
Knowledge, attitudes, and practices related to MUR concept and services.

Results A total of 123 participants responded to the survey (response rate 56 %). The mean total knowledge score was 71.4 ± 14.7 %. An overwhelming proportion of the participants (97 %) were able to identify the scope of MUR in relation to chronic illnesses and at enhancing the quality of pharmaceutical care. Furthermore, 80 % of the respondents were able to identify patients of priority for inclusion in an MUR program. However, only 43 % of the participants knew that acute medical conditions were not the principal focus of an MUR service, while at least 97 % acknowledged that the provision of MUR services is a great opportunity for an extended role of community pharmacists and that MUR makes excellent use of the pharmacist's professional skills in the community. The participants generally reported concerns about time, dedicated consultation area, and support staff as significant barriers towards MUR implementation.

Conclusion
This study suggests that community pharmacists in Qatar had sufficient knowledge about the concept of MUR and its scope, but there were still important deficiencies that warrant further education. The findings have important implications on policy and practice pertaining to the implementation of MUR as an extended role of pharmacists and as part of Qatar's National Health Strategy to move primary health care forward.

Epidemiology of MPN: What Do We Know?

The myeloproliferative neoplasms, are characterised by overproduction of myeloid cells. Chronic myeloid leukaemia, polycythaemia vera, essential thrombocythaemia, myelofibrosis and the very rare disorders chronic neutrophilic leukaemia, chronic eosinophilic leukaemia not otherwise specified and mastocytosis are all included in the group. Incidence and prevalence rates reported in the worldwide literature are presented in this review. Survival data on each condition is described. Information on the aetiology of the disorders is discussed including body mass index, diet, smoking and alcohol, allergies, associated medical conditions, occupation and environmental exposures with focus on recent new studies. The aetiology of the myeloproliferative neoplasms remains unknown, and this review of the current state of knowledge highlights the need for further comprehensive research.

Incongruence between clinicians’ assessment and self-reported functioning is related with psychopathology among patients diagnosed with gastrointestinal disorders

In a previous exploratory study we observed no relevant differences in psychopathology, personality, and functioning between inpatients diagnosed with gastrointestinal motor disorders (GMDs) or functional gastrointestinal disorders (FGDs) [1]. However, we observed higher levels of incongruence between clinician-assessed performance status and patients’ self-reported levels of functioning among patients diagnosed with FGDs. Likewise, research in other medical conditions has shown incongruences between self-reported and clinician-reported or objective measures [2]. Furthermore, in a study on chronic depression, the authors found that discrepancies between patients’ and physicians’ assessments of medical comorbidities were related to higher levels of depressive symptomatology [3]. In this line, the aim of this study was to explore whether the inconsistencies between clinician-assessed and patient self-reported levels of functioning could be related to psychopathology among patients admitted for evaluation of gastrointestinal motility.

The self-management approach of health education in the treatment of chronic illnesses

Health education is essential to the successful treatment of individuals with chronic illnesses. Self-management is a philosophical model of health education that has been shown to be effective in teaching individuals with chronic arthritis to manage their illness as part of their daily lives. Despite the proven results of arthritis self-management programs, some limitations of this form of health education were apparent in the literature. The present study attempted to address the problems of the self-management approach of health education such as reasons for lack of participation in programs and poor course outcomes. In addition, the study served to investigate the relationship between course outcomes and participation in programs with the theory upon which arthritis self-management programs are based, known as self-efficacy theory. Through a combination of qualitative and quantitative methodologies, data collection, and analysis, a deeper understanding of the self-management phenomenon in the treatment of chronic arthritic conditions was established. Findings of the study confirm findings of previous studies that suggest that arthritis self-management programs result in enhanced levels of self-efficacy and are effective in teaching individuals with arthritis to self-manage their health and health care. Findings of the study suggest that there are many factors that determine the choice of participants to participate in programs and the outcomes for the individuals who do choose to participate in programs. Some of the major determinants of enrollment and outcomes of programs include: the participant's personality, beliefs, attitudes and abilities, and the degree of emotional acceptance of the illness. Other determinants of course enrollment and outcomes included class size and length of time, timing of participation, and ongoing support after the program. The results of the study are consistent with the self-management literature and confirm the relationship between the underlying philosophies of adult education and Freire's model of education and self-management.