Alternative models of cardiac rehabilitation : a systematic review

The traditional hospital-based model of cardiac rehabilitation faces substantial challenges, such as cost and accessibility. These challenges have led to the development of alternative models of cardiac rehabilitation in recent years. The aim of this study was to identify and critique evidence for the effectiveness of these alternative models. A total of 22 databases were searched to identify quantitative studies or systematic reviews of quantitative studies regarding the effectiveness of alternative models of cardiac rehabilitation. Included studies were appraised using a Critical Appraisal Skills Programme tool and the National Health and Medical Research Council's designations for Level of Evidence. The 83 included articles described interventions in the following broad categories of alternative models of care: multifactorial individualized telehealth, internet based, telehealth focused on exercise, telehealth focused on recovery, community- or home-based, and complementary therapies. Multifactorial individualized telehealth and community- or home-based cardiac rehabilitation are effective alternative models of cardiac rehabilitation, as they have produced similar reductions in cardiovascular disease risk factors compared with hospital-based programmes. While further research is required to address the paucity of data available regarding the effectiveness of alternative models of cardiac rehabilitation in rural, remote, and culturally and linguistically diverse populations, our review indicates there is no need to rely on hospital-based strategies alone to deliver effective cardiac rehabilitation. Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual's risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.

Home-based activity program for older people with depressive symptoms: DeLLITE–A randomized controlled trial

PURPOSE We wanted to assess the effectiveness of a home-based physical activity program, the Depression in Late Life Intervention Trial of Exercise (DeLLITE), in improving function, quality of life, and mood in older people with depressive symptoms. METHODS We undertook a randomized controlled trial involving 193 people aged 75 years and older with depressive symptoms at enrollment who were recruited from primary health care practices in Auckland, New Zealand. Participants received either an individualized physical activity program or social visits to control for the contact time of the activity intervention delivered over 6 months. Primary outcome measures were function, a short physical performance battery comprising balance and mobility, and the Nottingham Extended Activities of Daily Living scale. Secondary outcome measures were quality of life, the Medical Outcomes Study 36-item short form, mood, Geriatric Depression Scale (GDS-15), physical activity, Auckland Heart Study Physical Activity Questionnaire, and self-report of falls. Repeated measures analyses tested the differential impact on outcomes over 12 months’ follow-up. RESULTS The mean age of the participants was 81 years, and 59% were women. All participants scored in the at–risk category on the depression screen, 53% had a Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases, Tenth Revision diagnosis of major depression or scored more than 4 on the GDS-15 at baseline, indicating moderate or severe depression. Almost all participants, 187 (97%), completed the trial. Overall there were no differences in the impact of the 2 interventions on outcomes. Mood and mental health related quality of life improved for both groups. CONCLUSION he DeLLITE activity program improved mood and quality of life for older people with depressive symptoms as much as the effect of social visits. Future social and activity interventions should be tested against a true usual care control.

Cardiac parasympathetic reactivation following exercise : implications for training prescription

The objective of exercise training is to initiate desirable physiological adaptations that ultimately enhance physical work capacity. Optimal training prescription requires an individualized approach, with an appropriate balance of training stimulus and recovery and optimal periodization. Recovery from exercise involves integrated physiological responses. The cardiovascular system plays a fundamental role in facilitating many of these responses, including thermoregulation and delivery/removal of nutrients and waste products. As a marker of cardiovascular recovery, cardiac parasympathetic reactivation following a training session is highly individualized. It appears to parallel the acute/intermediate recovery of the thermoregulatory and vascular systems, as described by the supercompensation theory. The physiological mechanisms underlying cardiac parasympathetic reactivation are not completely understood. However, changes in cardiac autonomic activity may provide a proxy measure of the changes in autonomic input into organs and (by default) the blood flow requirements to restore homeostasis. Metaboreflex stimulation (e.g. muscle and blood acidosis) is likely a key determinant of parasympathetic reactivation in the short term (0–90 min post-exercise), whereas baroreflex stimulation (e.g. exercise-induced changes in plasma volume) probably mediates parasympathetic reactivation in the intermediate term (1–48 h post-exercise). Cardiac parasympathetic reactivation does not appear to coincide with the recovery of all physiological systems (e.g. energy stores or the neuromuscular system). However, this may reflect the limited data currently available on parasympathetic reactivation following strength/resistance-based exercise of variable intensity. In this review, we quantitatively analyse post-exercise cardiac parasympathetic reactivation in athletes and healthy individuals following aerobic exercise, with respect to exercise intensity and duration, and fitness/training status. Our results demonstrate that the time required for complete cardiac autonomic recovery after a single aerobic-based training session is up to 24 h following low-intensity exercise, 24–48 h following threshold-intensity exercise and at least 48 h following high-intensity exercise. Based on limited data, exercise duration is unlikely to be the greatest determinant of cardiac parasympathetic reactivation. Cardiac autonomic recovery occurs more rapidly in individuals with greater aerobic fitness. Our data lend support to the concept that in conjunction with daily training logs, data on cardiac parasympathetic activity are useful for individualizing training programmes. In the final sections of this review, we provide recommendations for structuring training microcycles with reference to cardiac parasympathetic recovery kinetics. Ultimately, coaches should structure training programmes tailored to the unique recovery kinetics of each individual.

Cardiac safety concerns for domperidone, an antiemetic and prokinetic, and galactogogue medicine

Introduction: Domperidone is a dopamine D2-receptor antagonist developed as an antiemetic and prokinetic agents. Oral domperidone is not approved in the US, but is used in many countries to treat nausea and vomiting, gastroparesis, and as a galactogogue (to promote lactation). The US Food and Drug Administration (FDA) have issued a warning about the cardiac safety of domperidone. Areas covered: The authors undertook a review of the cardiac safety of oral domperidone. Expert opinion: The data from preclinical studies are unambiguous in identifying domperidone as able to produce marked hERG channel inhibition and action potential prolongation at clinically relevant concentrations. The compound’s propensity to augment instability of action potential duration and action potential triangulation are also indicative of proarrhythmic potential. Domperidone should not be administered to subjects with pre-existing QT prolongation/LQTS, subjects receiving drugs that inhibit CYP3A4, subjects with electrolyte abnormalities or with other risk factors for QT-prolongation. With these provisos, it is possible that domperidone may be used as a galactogogue without direct risk to healthy breast feeding women but more safety information should be sought in this situation. Also, more safety information is required regarding risk to breast feeding infants or before domperidone is routinely used in gastroparesis or gastroesphageal reflux in children.

Biological values of acupuncture and Chinese herbal medicine : impact on the life science

Editorial paper

No sex difference in body fat in response to supervised and measured exercise

It is often reported that females lose less body weight than males do in response to exercise. These differences are suggested to be a result of females exhibiting a stronger defense of body fat and a greater compensatory appetite response to exercise than males do. Purpose This study aimed to compare the effect of a 12-wk supervised exercise program on body weight, body composition, appetite, and energy intake in males and females. Methods A total of 107 overweight and obese adults (males = 35, premenopausal females = 72, BMI = 31.4 ± 4.2 kg·m−2, age = 40.9 ± 9.2 yr) completed a supervised 12-wk exercise program expending approximately 10.5 MJ·wk−1 at 70% HRmax. Body composition, energy intake, appetite ratings, RMR, and cardiovascular fitness were measured at weeks 0 and 12. Results The 12-wk exercise program led to significant reductions in body mass (males [M] = −3.03 ± 3.4 kg and females [F] = −2.28 ± 3.1 kg), fat mass (M = −3.14 ± 3.7 kg and F = −3.01 ± 3.0 kg), and percent body fat (M = −2.45% ± 3.3% and F = −2.45% ± 2.2%; all P < 0.0001), but there were no sex-based differences (P > 0.05). There were no significant changes in daily energy intake in males or females after the exercise intervention compared with baseline (M = 199.2 ± 2418.1 kJ and F = −131.6 ± 1912.0 kJ, P > 0.05). Fasting hunger levels significantly increased after the intervention compared with baseline values (M = 11.0 ± 21.1 min and F = 14.0 ± 22.9 mm, P < 0.0001), but there were no differences between males and females (P > 0.05). The exercise also improved satiety responses to an individualized fixed-energy breakfast (P < 0.0001). This was comparable in males and females. Conclusions Males and premenopausal females did not differ in their response to a 12-wk exercise intervention and achieved similar reductions in body fat. When exercise interventions are supervised and energy expenditure is controlled, there are no sex-based differences in the measured compensatory response to exercise.

Where are all the female participants in sports and exercise medicine research?

The aim of this study is to estimate the ratio of male and female participants in Sports and Exercise Medicine research. Original research articles published in three major Sports and Exercise Medicine journals (Medicine and Science in Sport and Exercise, British Journal of Sports Medicine and American Journal of Sports Medicine) over a three year period were examined. Each article was screened to determine the following: total number of participants, the number of female participants and the number of male participants. The percentage of females and males per article in each of the journals was also calculated. Cross tabulations and Chi square analysis were used to compare the gender representation of participants within each of the journals. Data were extracted from 1, 382 articles involving a total of 6, 076, 705 participants. 2, 366, 998 (39%) participants were female and 3, 709, 707 (61%) male. The average percentage of female participants per article across the journals ranged from 35-37%. Females were significantly under-represented across all of the journals (X2 =23566, df=2, p<0.00001). There were no significant differences between the three journals. In conclusion, Sports and Exercise Medicine practitioners should be cognisant of sexual dimorphism and gender disparity in the current literature.

Alternate healing and medicine : the roles of naturopathy, homeopathy, osteopathy, chiropractic and medical practice in the health system

This thesis is concerned with understanding the roles of four alternate healing systems and medical practice in the community's health behaviour. The four alternate systems are naturopathy, homoeopathy, osteopathy and chiropractic. The research reported developed from work supported by the Committee of Inquiry into Chiropractic, Osteopathy, Homoeopathy and Naturopathy conducted under the chairmanship of Professor E. C. Webb set up by the Australian Government in 1975. The study concentrates on the factors which influence individual clients in their decisions to consult healers for treatment. An underlying assumption is that an analysis of the processes that effect such decisions will lead to further knowledge of the community's attitudes towards the functions of alternate healing and medicine. A review of the historical backgrounds and current status of the four alternate healing systems leads to the conclusion that they differ in a variety of areas. These areas include treatment modalities, historical backgrounds, occupational development and rapprochement with medicine. Homoeopathy, osteopathy and chiropractic emerged as distinct approaches to healing late in the nineteenth century. Naturopathy tends to be a philosophy or style of life as much as a health system in its own right. Their relationships with medicine also vary; osteopathy and naturopathy receive some acceptance, some homoeopaths are tolerated, whilst chiropractic is ostracised and vilified. A common paradigm of treatment underlies all four alternate approaches to healing. They all eschew the use of synthetic pharmaceuticals and invasive treatments and accept an indigenous theory of disease and a belief in the vis medicatrix naturae or the healing power of nature. An inevitable concomitant of this paradigm is that they believe that healing and health must be self-engendered. They rest within the client and his or her actions, not within the hands, skills or power of the healer. It is these characteristics combined with the alternate healers ' claims to espouse a similar scientific rationale for their approaches, and their functioning as parallel healers to medicine, that establishes their special relationship with medicine. This relationship become s more problematic in the face of medicine's hegemony and claim to unique legitimacy as the community's sole healing system. The interaction between these systems and medical practice can be gauged through articles related to the four alternate healing systems that have appeared in the medical literature. Interest has been cyclical but appears to have markedly increased in the past two decades. In this period it has included exploratory and descriptive writing; concern with controlling and/or eradicating the healers; desire to protect an ignorant and vulnerable public and. finally understanding and exploration of what the alternate healers might have to offer. At the same time, the public or institutionalized role has been one of denial and suppression through ostracism and legal constraints. In spite of medicine's position the alternate healing systems have found growing community acceptance so that it is problematical and probably unacceptable now to consider their use as a 'deviant ' health action. Increasing interest in the characteristics of clients has provided a consensus that they are similar to the adult population and are more likely to suffer from musculoskeletal and chronic illnesses. They are no more likely to be neurotic or gullible than the general community, but probably more practical and more oriented towards an active involvement in the healing process. The impact of these issues is explored, through comparing the strategies taken into account when choosing a treatment. These include attending one of the alternate healers exclusively for a condition; attending an alternate healer and a medical practitioner for the same problem; attending a medical practitioner solely or not consulting any healer. Respondents from surveys of alternate healer clients and the general community were classified according to their use of these four strategies, and the influences on their decisions at different stages of the treatment decision making process were compared.

An introduction to radiation protection in medicine

"Combining facets of health physics with medicine, An Introduction to Radiation Protection in Medicine covers the background of the subject and the medical situations where radiation is the tool to diagnose or treat human disease. Encouraging newcomers to the field to properly and efficiently function in a versatile and evolving work setting, it familiarizes them with the particular problems faced during the application of ionizing radiation in medicine. The text builds a fundamental knowledge base before providing practical descriptions of radiation safety in medicine. It covers basic issues related to radiation protection, including the physical science behind radiation protection and the radiobiological basis of radiation protection. The text also presents operational and managerial tools for organizing radiation safety in a medical workplace. Subsequent chapters form the core of the book, focusing on the practice of radiation protection in different medical disciplines. They explore a range of individual uses of ionizing radiation in various branches of medicine, including radiology, nuclear medicine, external beam radiotherapy, and brachytherapy. With contributions from experienced practicing physicists, this book provides essential information about dealing with radiation safety in the rapidly shifting and diverse environment of medicine."--publisher website

Molecular network analysis using reverse phase protein microarrays for patient tailored therapy.

The practice of medicine has always aimed at individualized treatment of disease. The relationship between patient and physician has always been a personal one, and the physician's choice of treatment has been intended to be the best fit for the patient's needs. The necessary pooling/grouping of disease families and their assignment to a number of drugs or treatment methods has, consequently, led to an increase in the number of effective therapies. However, given the heterogeneity of most human diseases, and cancer specifically, it is currently impossible for the treating clinician to effectively predict a patient's response and outcome based on current technologies, much less the idiosyncratic resistances and adverse effects associated with the limited therapeutic options.

Plasmas meet nanoparticles—where synergies can advance the frontier of medicine

Nanoparticles and low-temperature plasmas have been developed, independently and often along different routes, to tackle the same set of challenges in biomedicine. There are intriguing similarities and contrasts in their interactions with cells and living tissues, and these are reflected directly in the characteristics and scope of their intended therapeutic solutions, in particular their chemical reactivity, selectivity against pathogens and cancer cells, safety to healthy cells and tissues and targeted delivery to diseased tissues. Time has come to ask the inevitable question of possible plasma–nanoparticle synergy and the related benefits to the development of effective, selective and safe therapies for modern medicine. This perspective paper offers a detailed review of the strengths and weakenesses of nanomedicine and plasma medicine as a stand-alone technology, and then provides a critical analysis of some of the major opportunities enabled by synergizing nanotechnology and plasma technology. It is shown that the plasma–nanoparticle synergy is best captured through plasma nanotechnology and its benefits for medicine are highly promising.

Mathematical modeling of the cancer cell’s control circuitry : paving the way to individualized therapeutic strategies

Cancer is a disease of signal transduction in which the dysregulation of the network of intracellular and extracellular signaling cascades is sufficient to thwart the cells finely-tuned biochemical control mechanisms. A keen interest in the mathematical modeling of cell signaling networks and the regulation of signal transduction has emerged in recent years, and has produced a glimmer of insight into the sophisticated feedback control and network regulation operating within cells. In this review, we present an overview of published theoretical studies on the control aspects of signal transduction, emphasizing the role and importance of mechanisms such as ‘ultrasensitivity’ and feedback loops. We emphasize that these exquisite and often subtle control strategies represent the key to orchestrating ‘simple’ signaling behaviors within the complex intracellular network, while regulating the trade-off between sensitivity and robustness to internal and external perturbations. Through a consideration of these apparent paradoxes, we explore how the basic homeostasis of the intracellular signaling network, in the face of carcinogenesis, can lead to neoplastic progression rather than cell death. A simple mathematical model is presented, furnishing a vivid illustration of how ‘control-oriented’ models of the deranged signaling networks in cancer cells may enucleate improved treatment strategies, including patient-tailored combination therapies, with the potential for reduced toxicity and more robust and potent antitumor activity.

Perception of prescription medicine sample packs among Australian professional, government, industry, and consumer organizations, based on automated textual analysis of one-on-one interviews

Background Prescription medicine samples provided by pharmaceutical companies are predominantly newer and more expensive products. The range of samples provided to practices may not represent the drugs that the doctors desire to have available. Few studies have used a qualitative design to explore the reasons behind sample use. Objective The aim of this study was to explore the opinions of a variety of Australian key informants about prescription medicine samples, using a qualitative methodology. Methods Twenty-three organizations involved in quality use of medicines in Australia were identified, based on the authors' previous knowledge. Each organization was invited to nominate 1 or 2 representatives to participate in semistructured interviews utilizing seeding questions. Each interview was recorded and transcribed verbatim. Leximancer v2.25 text analysis software (Leximancer Pty Ltd., Jindalee, Queensland, Australia) was used for textual analysis. The top 10 concepts from each analysis group were interrogated back to the original transcript text to determine the main emergent opinions. Results A total of 18 key interviewees representing 16 organizations participated. Samples, patient, doctor, and medicines were the major concepts among general opinions about samples. The concept drug became more frequent and the concept companies appeared when marketing issues were discussed. The Australian Pharmaceutical Benefits Scheme and cost were more prevalent in discussions about alternative sample distribution models, indicating interviewees were cognizant of budgetary implications. Key interviewee opinions added richness to the single-word concepts extracted by Leximancer. Conclusions Participants recognized that prescription medicine samples have an influence on quality use of medicines and play a role in the marketing of medicines. They also believed that alternative distribution systems for samples could provide benefits. The cost of a noncommercial system for distributing samples or starter packs was a concern. These data will be used to design further research investigating alternative models for distribution of samples.