Comprehensive rehabilitation in chronic heart failure - better psycho-emotional status related to quality of life, brain natriuretic peptide concentrations, and clinical severity of disease

To evaluate the effects of a comprehensive outpatient rehabilitation program in chronic heart failure (CHF) on quality of life (QoL) in relation to emotional status and clinical severity of disease.

Effects of a comprehensive rehabilitation program on quality of life in patients with chronic heart failure

This evaluation was performed to assess the effects of a new, comprehensive outpatient rehabilitation program on generic and disease-specific quality of life related to exercise tolerance in stable chronic heart failure patients. Fifty-one patients (aged 59+/-11 years; 84% men) were treated for 12 weeks. Patients underwent optimized drug treatment, exercise training, and counseling and education. At baseline and at the end of the program, functional status, exercise capacity, and quality of life were assessed using the Medical Outcomes Study 36-item Short-Form Health Survey and the Minnesota Living with Heart Failure Questionnaire. Left ventricular ejection fraction and New York Heart Association functional class, as well as measures of physical fitness and walking distance covered in 6 minutes, improved significantly (by 11%-20% and by 58% on average, respectively). Physical functioning (effect size, 0.38; p<0.0001), role functioning (effect size, 0.17; p<0.05), and mental component score (effect size, 0.47; p<0.0001) on the questionnaire improved significantly. Disease-specific quality of life improved in sum score (effect size, 0.24; p<0.0001) and physical component score (effect size, 0.35; p<0.0001). The latter was inversely correlated to improvement in peak power output (r= -0.31; p<0.05). In patients with stable chronic heart failure, significant improvements in both generic and disease-specific quality of life related to improved exercise tolerance can be achieved within 12 weeks of comprehensive rehabilitation.

Effects of interventions in health care settings on physical activity or cardiorespiratory fitness

Introduction: This paper reviews studies of physical activity interventions in health care settings to determine effects on physical activity and/or fitness and characteristics of successful interventions. Methods: Studies testing interventions to promote physical activity in health care settings for primary prevention (patients without disease) and secondary prevention (patients with cardiovascular disease [CVD]) were identified by computerized search methods and reference lists of reviews and articles. Inclusion criteria included assignment to intervention and control groups, physical activity or cardiorespiratory fitness outcome measures, and, for the secondary prevention studies, measurement 12 or more months after randomization. The number of studies with statistically significant effects was determined overall as well as for studies testing interventions with various characteristics. Results: Twelve studies of primary prevention were identified, seven of which were randomized. Three of four randomized studies with short-term measurement (4 weeks to 3 months after randomization), and two of five randomized studies with long-term measurement (6 months after randomization) achieved significant effects on physical activity. Twenty-four randomized studies of CVD secondary prevention were identified; 13 achieved significant effects on activity and/or fitness at twelve or more months. Studies with measurement at two time points showed decaying effects over time, particularly if the intervention were discontinued. Successful interventions contained multiple contacts, behavioral approaches, supervised exercise, provision of equipment, and/or continuing intervention. Many studies had methodologic problems such as low follow-up rates. Conclusion: Interventions in health care settings can increase physical activity for both primary and secondary prevention. Long-term effects are more likely with continuing intervention and multiple intervention components such as supervised exercise, provision of equipment, and behavioral approaches. Recommendations for additional research are given.

Concienciación para la conservación del patrimonio urbano : los instrumentos de gestión para la recuperación del barrio madrileño de Embajadores

La tesis trata la evolución de la conciencia de la conservación de los centros históricos y de los instrumentos de gestión utilizados en las políticas de rehabilitación del casco antiguo de Madrid, desde las primeras experiencias de los años ‘80 hasta el perfeccionamiento del complejo mecanismo contemporáneo. El proceso de rehabilitación ha demostrado ser extremadamente coherente en cuanto a los objetivos y en cuanto al tema de los instrumentos ha seguido la tendencia de diversificar y flexibilizar. En Madrid se ha utilizado el concepto de rehabilitación en sentido integral, abarca una amplia gama de acciones que implican por una parte, intervenciones directas sobre los edificios y por otra, la valorización del espacio público, de los edificios representativos, la introducción de dotaciones y también un componente social. El tema se analizará desde la perspectiva del barrio de Embajadores, un área muy especial del casco antiguo de la ciudad. Desde 1998 hasta la actualidad allí funciona el Área de Rehabilitación Integral con el nombre de Lavapiés. El barrio de Embajadores representa un caso de extrema complejidad dada su tradición, que mantiene hasta el momento, de barrio popular que ha tenido como consecuencia negativa un grave estado de deterioro de los edificios y de sus estructuras urbanas. Además, presenta una composición socio-cultural muy heterogénea ya que siempre ha alojado oleadas de inmigrantes que llegaban a la capital tanto de las provincias como del extranjero. Los ‘80 marcan en Madrid el inicio de la preocupación por la rehabilitación urbana y de los primeros intentos de definir unos mecanismos. Durante este período el barrio de Embajadores es escenario de los primeros proyectos piloto de rehabilitación. Se sientan las bases del sistema de subvenciones, que empujará hacia un modelo de rehabilitación generalizada. A principios de los años ‘90, la insatisfacción dejada por de los resultados obtenidos, la Administración decide reorganizar la estrategia y se procede a la rehabilitación integral por áreas, concentrando los esfuerzos geográfica y temporalmente. La idea ya se había utilizado diez años antes, pero sin encontrar nunca la voluntad política de aplicarla. En comparación con el casco antiguo, el barrio de Embajadores se dejó para el final del proceso para verificar los métodos en zonas más restringidas en cuanto a superficie y con menos problemas. Desde 1998 hasta hoy, período en que funciona el Área de Rehabilitación Integral de Lavapiés, los distintos tipos de actuaciones, de producción arquitectónica, urbanística y sociocultural, han mostrado su eficacia, de forma que los cambios que aportaron al barrio son evidentes para todos. Mientras que las Áreas de Rehabilitación del centro una vez alcanzados los objetivos, se preparan para su clausura, a nivel administrativo se están definiendo nuevas direcciones y nuevos objetivos para el casco antiguo: subastas para incentivar intervenciones de mejoramiento energético y del nivel de sostenibilidad de los edificios madrileños. La primera parte de la tesis establece las premisas presentando algunos puntos relevantes relativos al desarrollo histórico de los documentos y normativas más importantes que tendrán eco en el proceso de concienciación de la cultura de la conservación del patrimonio urbano de los centros históricos. Después, se habla de la experiencia de rehabilitación urbana en Europa, en España en general y en Madrid en particular, con referencia a los modelos de enfoque, al marco legislativo y a las experiencias relacionadas con el casco antiguo, y en definitiva a la creación de la conciencia de la rehabilitación y conservación de los centros de las ciudades. La segunda parte se centra en el caso de estudio, el barrio de Embajadores. En primer lugar, se presenta en detalle el barrio: ubicación, datos característicos, edificios representativos y flujos que generan, trama urbana, datos sobre la formación histórica, tipologías y características de construcción de los edificios y, para finalizar, algún dato demográfico para introducir la compleja problemática social. Más adelante se exponen las primeras experiencias de rehabilitación: dos proyectos piloto de intervención sobre las viviendas realizados en los años ‘80, uno privado y el otro público. La parte central del trabajo trata sobre la fase intensiva de rehabilitación, proceso puesto en marcha en el año ’98 y que corresponde al período en el que Embajadores es Área de Rehabilitación Integral. Se presentan y analizan los objetivos de la rehabilitación y luego los instrumentos de orden administrativo, normativo y legal que regulan las actuaciones en el barrio. Sucesivamente se afronta la rehabilitación de la parte residencial, en régimen privado y público, que fue el modelo principal que la Administración llevó a cabo. Se presenta todo el proceso, desde la decisión sobre el tipo de rehabilitación, las subvenciones y las soluciones técnicas adoptadas así como la rehabilitación de casos especiales de edificios, que por sus características, el alto nivel de degradación o porque ocupados por inquilinos con dificultades económicas, se realizó con intervención pública. Las enormes dificultades derivadas de la complicada gestión y de las incongruencias de las normativas también se analizan en este trabajo. El autor presenta un dosier de una veintena de trabajos llevados a cobo en el Barrio de Embajadores a lo largo de más de 15 años de experiencia profesional propia. Se intenta, en primer lugar, evaluar la actuación pública en comparación con la privada en cuanto a los modelos propuestos, a las problemáticas que generan y a los resultados obtenidos. Una segunda línea de argumentación se refiere a la relación que se establece entre los instrumentos que se promueven y los que obligan a la conservación y a la rehabilitación de los edificios. Quizás el elemento más interesante, por su conocida innovación, de la experiencia de la obligación de conservación a cargo de los propietarios y la introducción de una revisión periódica del estado de los edificios (ITE), que conduce a su mantenimiento permanente a lo largo del tiempo. El ultimo instrumento aparecido y de por si el más novedoso se refiere a la política de rehabilitación energética iniciada en los últimos años por el Ayuntamiento de Madrid. ABSTRACT Starting from the early experiences of the ‘80s and tackling the complex and improved contemporary techniques of development, the present thesis focuses on raising awareness of the conservation of urban heritage and deals with the evolution of rehabilitation policies adopted in the historical center of Madrid. The rehabilitation process has proven to be extremely coherent in terms of its objectives and, consequently, the subject of the instruments has forged ahead a trend of diversification and flexibility. Madrid has used the concept of rehabilitation in a comprehensive manner, encompassing a wide range of actions, which involved on the one hand, direct interventions on buildings and on the other, the appreciation of the public space with its representative edifices and endowments. Confident that the social components have not been neglected during the rehabilitation proceedings, the topic will be analysed in relation to the neighbourhood of Embajadores, an authentic area of the old town. From 1998 onwards, this quarter serves as a Comprehensive Rehabilitation Area under the name of Lavapies. Considering the tradition and popularity of the district, Embajadores represents a challenging case for rehabilitation projects, aiming to improve the severe state of deterioration of buildings and urban structures. Having a heterogeneous sociocultural dynamic, the neighbourhood has always hosted waves of immigrants who come to the capital both from other provinces and abroad. The 1980s in Madrid marked the beginning of concerns with urban regeneration and the first attempts to define feasible restoration techniques. During this period, the district of Embajadores has benefited from various pilot projects. The financial investments have significant effects on the overall environment, so the model of general rehabilitation has been encouraged throughout the years. In the early 90s, left by the dissatisfaction of the results obtained, the authorities proposed to reorganise the strategy and proceed to the full rehabilitation of areas, concentrating efforts geographically and temporally. The idea had already been used ten years before, but never encountered the political force to be implemented. Compared to the old town, the Embajadores neighbourhood has been left for the end of the process, which focused on verifying the methods in more restricted areas that caused fewer disruptions. For the Comprehensive Rehabilitation Area of Lavapies, the various types of administrative implementations from architectural to urban and socio-cultural productions have proved effective. The improvements experienced by the neighbourhood from 1998 are obvious to all. However, while the areas of rehabilitation of the city centre have achieved their objectives and prepare for closure, the administration is still generating new directions and new targets for the ancient surroundings: auctions to encourage the improvement of energy interventions and the sustainability level for the buildings of Madrid. Therefore, the first part of the thesis establishes the premises and introduces some relevant points concerning the entire city. It describes the historical development of urban projects, indicating the events that will echo in the rehabilitation process. This paper then turns to discuss the experience of urban regeneration in Spain, emphasising the case of Madrid with reference to models of approach, legislative frameworks and appreciation of the old structures. The second part reveals an in depth case study of the district of Embajadores. At first, the thesis provides insights into the neighbourhood: location, general data on representative buildings and propagated trends, urban, historical data on training, building typologies and characteristics. The section introduces some demographic data to complete the portrait of the elaborate social problems encountered in this district, also outlining the first experiences of rehabilitation: two pilot projects on housing intervention made in the 80s, one private and one public. The central part of the thesis deals with the intensive phase of rehabilitation developments launched in the year '98 when Embajadores joined the Comprehensive Rehabilitation Area. It analyses the goals of rehabilitation and the instruments of administrative, regulatory and governing legal proceedings of the neighbourhood. The following chapter addresses the privately and publicly founded plan of residential rehabilitation that constituted the main model conducted by the authorities. It describes the entire process: deciding the type of restoration, subsidies and technical solutions as well as the degree of rehabilitation for special buildings, which either have a high level of degradation or require public intervention when tenants face financial difficulties. The administrative difficulties caused by the enormous bureaucratic machinery and the inconsistencies in regulations are also discussed in this paper. Thus, a just evaluation of the public and private performances regarding the proposed models of rehabilitation, along with the problems they generate and the results obtained is desired throughout the thesis. A second line of argument concerns the relationship established between the instruments that are promoted and requiring conservation and the building restoration. Perhaps the most interesting and innovative element of the new rehabilitation policies is the owners' obligation to preserve their properties and the introduction of a periodic review for the state of the buildings (ITE). These thorough and meticulous regulations lead to an ongoing maintenance of constructions, preventing them from severe or sudden deteriorations.

La Ordenación del Territorio en las Ciudades Globales Europeas: El caso de Madrid

En la Comunidad de Madrid el modelo de ocupación del territorio en las dos últimas décadas ha obedecido a factores de oferta del mercado y no a las necesidades de la población, ello provoca un consumo de suelo y de recursos que conducen a una sobrexplotación insostenible. Las metrópolis globales están experimentando rápidas e intensas transformaciones, basadas en los paradigmas emergentes de la globalización, la gobernanza, la metropolizacion y la dispersión de las actividades en el territorio y a través de ellos se abordan los planes de Londres, París y las tentativas de Madrid. La globalización provoca la pérdida de soberanía de las administraciones publicas y la competitividad entre las ciudades globales en Europa, Londres, Paris y Madrid, son centros de poder, de concentración y crecimiento donde se produce la dualización del espacio y donde la desigualdad participa de la restructuración urbana, concentración de pobreza frente a espacios de la nueva clase emergente en donde dominan los sectores de servicios y las tecnologías de la información. Frente al desarrollo urbano neoliberal de regulación a través del mercado y basada en criterios de eficiencia de la Nueva Gestión Pública, se vislumbra la posibilidad de que la sociedad se administre a si misma por medio de acciones voluntarias y responsables que promuevan los intereses colectivos mediante el reconocimiento de su propia identidad, introduciendo el concepto de gobernanza. Frente, a la explotación del territorio por parte de la sociedad extractiva que genera corrupcion, se propone un modelo de cooperación público-privada basado en la confianza mutua, un marco regulador estable, la transparencia y la información a cuyo flujo más homogéneo contribuirán sin duda las TICs. En todo este proceso, las regiones metropolitanas en Europa se erigen como motores del crecimiento, donde los límites administrativos son superados, en un territorio cada vez más extendido y donde los gobiernos locales tienen que organizarse mediante un proceso de cooperación en la provisión de servicios que ayuden a evitar los desequilibrios territoriales. El fenómeno de la dispersión urbana en desarrollos de baja densidad, los centros comerciales periféricos, la expulsión hacia la periferia de las actividades de menor valor añadido y la concentración de funciones directivas en el centro, conducen a una fragmentación del territorio en islas dependientes del automóvil y a procesos de exclusión social por la huida de las rentas altas y la expulsión de las rentas bajas de los centros urbanos. Se crean fragmentos monofuncionales y discontinuos, apoyados en las autovías, lugares carentes de identidad y generadores de despilfarro de recursos y una falta de sostenibilidad ambiental, económica y social. El estudio de la cultura de la planificación en Europa ayuda a comprender los diferentes enfoques en la ordenación del territorio y el proceso de convergencia entre las diferentes regiones. Los documentos de la UE se basan en la necesidad de la competitividad para el crecimiento europeo y la cohesión social y en relación al territorio en los desarrollos policéntricos, la resolución del dualismo campo-ciudad, el acceso equilibrado a las infraestructuras, la gestión prudente de la naturaleza, el patrimonio y el fomento de la identidad. Se proponen dos niveles de estudio uno actual, los últimos planes de Londres y Paris y el otro la evolución de las tentativas de planes en la Región madrileña siempre en relación a los paradigmas emergentes señalados y su reflejo en los documentos. El Plan de Londres es estratégico, con una visión a largo plazo, donde se confiere un gran interés al proceso, al papel del alcalde como líder y su adaptación a las circunstancias cambiantes, sujeto a las incertidumbres de una ciudad global. El desarrollo del mismo se concibe a través de la colaboración y cooperación entre las administraciones y actores. La estructura del documento es flexible, establece orientaciones y guías indicativas, para la redacción de los planes locales, no siendo las mismas vinculantes y con escasa representación grafica. El Plan de París es más un plan físico, similar al de otros centros europeos, trabaja sobre los sectores y sobre los territorios, con información extensa, con características de “Plan Latino” por la fuerza de la expresión gráfica, pero al mismo tiempo contiene una visión estratégica. Es vinculante en sus determinaciones y normativas, se plantea fomentar, pero también prohibir. Ambos planes tratan la competitividad internacional de sus centros urbanos, la igualdad social, la inclusión de todos los grupos sociales y la vivienda como una cuestión de dignidad humana. Londres plantea la gobernanza como cooperación entre sector público-privado y la necesaria cooperación con las regiones limítrofes, en París las relaciones están más institucionalizadas resaltando la colaboración vertical entre administraciones. Ambos plantean la densificación de nodos servidos por transporte público, modos blandos y el uso los TODs y la preservación de la infraestructura verde jerarquizada, la potenciación de la red azul y la mejora del paisaje de las periferias. En las “tentativas” de planes territoriales de Madrid se constata que estuvieron sujetas a los ciclos económicos. El primer Documento las DOT del año 1984, no planteaba crecimiento, ni económico ni demográfico, a medio plazo y por ello no proponía una modificación del modelo radio concéntrico. Se trataba de un Plan rígido volcado en la recuperación del medio rural, de la ciudad, el dimensionamiento de los crecimientos en función de las dotaciones e infraestructuras existentes. Aboga por la intervención de la administración pública y la promoción del pequeño comercio. Destaca el desequilibrio social en función de la renta, la marginación de determinados grupos sociales, el desequilibrio residencia/empleo y la excesiva densidad. Incide en la necesidad de viviendas para los más desfavorecidos mediante el alquiler, la promoción suelo público y la promoción del ferrocarril para dar accesibilidad al espacio central. Aboga por el equipamiento de proximidad y de pequeño tamaño, el tratamiento paisajístico de los límites urbanos de los núcleos y el control de las actividades ilegales señalando orientaciones para el planeamiento urbano. Las Estrategias (1989) contienen una visión: la modificación del modelo territorial, mediante la intervención pública a través de proyectos. Plantea la reestructuración económica del territorio, la reconversión del aparato productivo, la deslocalización de actividades de escaso valor añadido y una mayor ubicuidad de la actividad económica. Incide en la difusión de la centralidad hacia el territorio del sur, equilibrándolo con el norte, tratando de recomponer empleo y residencia, integrando al desarrollo económico las periferias entre sí y con el centro. Las actuaciones de transporte consolidarían las actuaciones, modificando el modelo radio concéntrico facilitando la movilidad mediante la red de cercanías y la intermodalidad. El plan se basaba en el liderazgo del Consejero, no integrando sectores como el medio ambiente, ni estableciendo un documento de seguimiento de las actuaciones que evaluara los efectos de las políticas y su aportación al equilibrio territorial, a través de los proyectos realizados. El Documento Preparatorio de las Bases (1995), es más de un compendio o plan de planes, recoge análisis y propuestas de los documentos anteriores y de planes sectoriales de otros departamentos. Presenta una doble estructura: un plan físico integrador clásico, que abarca los sectores y territorios, y recoge las Estrategias previas añadiendo puntos fuertes, como el malestar urbano y la rehabilitación el centro. Plantea la consecución del equilibrio ambiental mediante el crecimiento de las ciudades existentes, la vertebración territorial basada en la movilidad y en la potenciación de nuevas centralidades, la mejora de la habitabilidad y rehabilitación integral del Centro Urbano de Madrid, y la modernización del tejido productivo existente. No existe una idea-fuerza que aglutine todo el documento, parte del reconocimiento de un modelo existente concentrado y congestivo, un centro urbano dual y dos periferias al este y sur con un declive urbano y obsolescencia productiva y al oeste y norte con una dispersión que amenaza al equilibrio medioambiental. Señala como aspectos relevantes, la creciente polarización y segregación social, la deslocalización industrial, la aparición de las actividades de servicios a las empresas instaladas en las áreas metropolitanas, y la dispersión de las actividades económicas en el territorio por la banalización del uso del automóvil. Se plantea el reto de hacer ciudad de la extensión suburbana y su conexión con el sistema metropolitano, mediante una red de ciudades integrada y complementaria, en búsqueda de un mayor equilibrio y solidaridad territorial. Las Bases del PRET (1997) tenían como propósito iniciar el proceso de concertación en que debe basarse la elaboración del Plan. Parte de la ciudad mediterránea compacta, y diversa, y de la necesidad de que las actividades económicas, los servicios y la residencia estén en proximidad, resolviéndolo mediante una potente red de transporte público que permitiese una accesibilidad integrada al territorio. El flujo de residencia hacia la periferia, con un modelo ajeno de vivienda unifamiliar y la concentración del empleo en el centro producen desequilibrio territorial. Madrid manifiesta siempre apostó por la densificación del espacio central urbanizado, produciendo su congestión, frente al desarrollo de nuevos suelos que permitieran su expansión territorial. Precisa que es necesario preservar los valores de centralidad de Madrid, como generador de riqueza, canalizando toda aquella demanda de centralidad, hacia espacios más periféricos. El problema de la vivienda no lo ve solo como social, sino como económico, debido a la pérdida de empleos que supone su paralización. Observa ya los crecimientos residenciales en el borde de la region por el menor valor del suelo. Plantea como la política de oferta ha dado lugar a un modelo de crecimiento fragmentado, desequilibrado, desestructurado, con fuertes déficits dotacionales y de equipamiento, que inciden en la segregación espacial de las rentas, agravando el proceso de falta de identidad morfológica y de desarraigo de los valores urbanos. El plan señalaba que la presión sobre el territorio creaba su densificación por las limitaciones de espacio, Incidía en limitar el peso de la intervención pública, no planteando propuestas de cooperación público-privado. La mayor incoherencia estriba en que los objetivos eran innovadores y coinciden en su mayoría con las propuestas estudiadas de Londres o Paris, pero se intentan implementar a través de un cambio hacia un modelo reticulado homogéneo, expansivo sobre el territorio, que supone un consumo de suelo y de infraestructuras para solucionar un problema inexistente, la gestión de la densidad. Durante las dos últimas décadas en ausencia de un plan regional, la postura neoliberal fue la de un exclusivo control de legalidad del planeamiento, los municipios entraron en un proceso de competencia para aprovechar las iniciales ventajas económicas de los crecimientos detectados, que proporcionaban una base económica “sólida” a unos municipios con escasos recursos en sus presupuestos municipales. La legislación se modifica a requerimiento de grupos interesados, no existiendo un marco estable. Se pierde la figura del plan no solo a nivel regional, si no en los sectores y el planeamiento municipal donde los municipios tiende a basarse en modificaciones puntuales con la subsiguiente pérdida del modelo urbanístico. La protección ambiental se estructura mediante un extenso nivel de figuras, con diversidad de competencias que impide su efectiva protección y control. Este proceso produce un despilfarro en la ocupación del suelo, apoyada en las infraestructuras viarias, y un crecimiento disperso y de baja densidad, cada vez más periférico, produciéndose una segmentación social por dualización del espacio en función de niveles de renta. Al amparo del boom inmobiliario, se produce una falta de política social de vivienda pública, más basada en la dinamización del mercado con producción de viviendas para rentas medias que en políticas de alquiler para determinados grupos concentrándose estas en los barrios desfavorecidos y en la periferia sur. Se produce un incremento de la vivienda unifamiliar, muchas veces amparada en políticas públicas, la misma se localiza en el oeste principalmente, en espacios de valor como el entorno del Guadarrama o con viviendas más baratas por la popularización de la tipología en la frontera de la Región. El territorio se especializa a modo de islas monofuncionales, las actividades financieras y de servicios avanzados a las empresas se localizan en el norte y oeste próximo, se pierde actividad industrial que se dispersa más al sur, muchas veces fuera de la región. Se incrementan los grandes centros comerciales colgados de las autovías y sin población en su entorno. Todo este proceso ha provocado una pérdida de utilización del transporte público y un aumento significativo del uso del vehículo privado. En la dos últimas décadas se ha producido en la región de Madrid desequilibrio territorial y segmentación social, falta de implicación de la sociedad en el territorio, dispersión del crecimiento y un incremento de los costes ambientales, sociales y económicos, situación, que solo, a través del uso racional del territorio se puede reconducir, apoyado en una planificación integrada sensible y participativa. ABSTRACT In Madrid the model of land occupation in the past two decades has been driven by market supply factors rather than the needs of the population. This results in a consumption of land and resources that leads to unsustainable overexploitation. Addressing this issue must be done through sensitive and participatory integrated planning. Global cities are experiencing rapid and intense change based on the emerging paradigms of globalization, governance, metropolization and the dispersion of activities in the territory. Through this context, a closer look will be taken at the London and Paris plans as well as the tentative plans of Madrid. Globalization causes the loss of state sovereignty and the competitiveness among global cities in Europe; London, Paris and Madrid. These are centres of power, concentration and growth where the duality of space is produced, and where inequality plays a part in urban restructuration. There are concentrated areas of poverty versus areas with a new emerging class where the services sector and information technologies are dominant. The introduction of ICTs contributes to a more homogeneous flow of information leading, us to the concept of governance. Against neoliberal urban development based on free market regulations and efficiency criteria as established by the “New Public Management”, emerge new ways where society administers itself through voluntary and responsible actions to promote collective interests by recognizing their own identity. A new model of public-private partnerships surfaces that is based on mutual trust, transparency, information and a stable regulatory framework in light of territorial exploitation by the “extractive society” that generates corruption. Throughout this process, European metropolitan regions become motors of growth where administrative boundaries are overcome in an ever expanding territory where government is organized through cooperative processes to provide services that protect against regional imbalances. Urban sprawl or low-density development as seen in peripheral shopping centres, the off-shoring of low added-value activities to the periphery, and the concentration of business and top management functions in the centre, leads to a fragmentation of the territory in automobile dependent islands and a process of social exclusion brought on by the disappearance of high incomes. Another effect is the elimination of low income populations from urban centres. In consequence, discontinuous expansions and mono-functional places that lack identity materialize supported by a highway network and high resource consumption. Studying the culture of urban planning in Europe provides better insight into different approaches to spatial planning and the process of convergence between different regions. EU documents are based on the need of competitiveness for European growth and social cohesion. In relation to polycentric development territory they are based on a necessity to solve the dualism between field and city, balanced access to infrastructures, prudent management of nature and solidifying heritage and identity Two levels of study unfold, the first being the current plans of London and Île-de-France and the second being the evolution of tentative plans for the Madrid region as related to emerging paradigms and how this is reflected in documents. The London Plan is strategic with a long-term vision that focuses on operation, the role of the mayor as a pivotal leader, and the adaptability to changing circumstances brought on by the uncertainties of a global city. Its development is conceived through collaboration and cooperation between governments and stakeholders. The document structure is flexible, providing guidance and indicative guidelines on how to draft local plans so they are not binding, and it contains scarce graphic representation. The Plan of Paris takes on a more physical form and is similar to plans of other European centres. It emphasizes sectors and territories, using extensive information, and is more characteristic of a “Latin Plan” as seen in its detailed graphic expression. However, it also contains a strategic vision. Binding in its determinations and policy, it proposes advancement but also prohibition. Both plans address the international competitiveness of urban centres, social equality, inclusion of all social groups and housing as issues of human dignity. London raises governance and cooperation between public and private sector and the need for cooperation with neighbouring regions. In Paris, the relations are more institutionalized highlighting vertical collaboration between administrations. Both propose nodes of densification served by public transportation, soft modes and the use of TOD, the preservation of a hierarchical green infrastructure, and enhancing the landscape in urban peripheries. The tentative territorial plans for the Madrid region provide evidence that they were subject to economic cycles. The first document of master guidelines (1984) does not address either economic or demographic growth in the mid term and therefore does not propose the modification of the radio-concentric model. It is a rigid plan focused on rural and urban recovery and the dimensioning of growth that depends on endowments and infrastructures. It advocates government intervention and promotes small business. The plan emphasizes social imbalance in terms of income, marginalization of certain social groups, the imbalance of residence/employment and excessive density. It stresses the need for social rent housing for the underprivileged, promotes public land, and the supports rail accessibility to the central area. It backs facilities of proximity and small size, enhancing the landscaping of city borders, controlling illegal activities and draws out guidelines for urban planning. The strategies (1989) contain a vision: Changing the territorial model through public intervention by means of projects. They bring to light economic restructuring of territory, the reconversion of the productive apparatus, relocation of low value-added activities, and greater ubiquity of economic activity. They also propose the diffusion of centrality towards southern territories, balancing it with the north in an attempt to reset employment and residence that integrates peripheral economic development both in the periphery and the centre. Transport would consolidate the project, changing the radius-concentric model and facilitating mobility through a commuter and inter-modality network. The plan derives itself from the leadership of the minister and does not integrate sectors such as environment. It also does not incorporate the existence of a written document that monitors performance to evaluate the effects of policies and their contribution to the territorial balance. The Preparatory Document of the Bases, (1995) is more a compendium, or plan of plans, that compiles analysis and proposals from previous documents and sectorial plans from other departments. It has a dual structure: An integrating physical plan covering the sectors and territories that includes the previous strategies while adding some strengths. One such point is the urban discomfort and the rehabilitation of the centre. It also poses the achievement of environmental balance through the growth of existing cities, the territorial linking based on mobility, strengthening new centres, improving the liveability and comprehensive rehabilitation of downtown Madrid, and the modernization of the existing production network. There is no one powerful idea that binds this document. This is due to the recognition of an existing concentrate and congestive model, a dual urban centre, two eastern and southern suburbs suffering from urban decay, and an obsolescent productive north and west whose dispersion threatens the environmental balance. Relevant aspects the document highlights are increasing polarization and social segregation, industrial relocation, the emergence of service activities to centralized companies in metropolitan areas and the dispersion of economic activities in the territory by the trivialization of car use. It proposes making the city from the suburban sprawl and its connection to the metropolitan system through a network of integrated and complementary cities in search of a better balance and territorial solidarity. The Bases of PRET (1997) aims to start the consultation process that must underpin the development of the plan. It stems from a compact and diverse Mediterranean city along with the need for economic activities, services and residences that are close. To resolve the issue, it presents a powerful network of public transport that allows integrated accessibility to the territory. The flow of residence to the periphery based on a foreign model of detached housing and an employment concentration in the centre produces territorial imbalance. Madrid always opted for the densification of the central space, producing its congestion, against the development of new land that would allow its territorial expansion. The document states that the necessity to preserve the values of the housing problem is not only viewed as social, but also economic due to the loss of jobs resulting from their paralysis. It notes the residential growth in the regional border due to the low price of land and argues that the policy of supply has led to a fragmented model of growth that is unbalanced, unstructured, with strong infrastructure and facility deficits that affect the spatial segregation of income and aggravate the lack of morphological identity, uprooting urban values. The pressure on the territory caused its densification due to space limitation; the proposed grid model causes land consumption and infrastructure to solve a non-problem, density. Focusing on limiting the weight of public intervention, it does not raise proposals for public-private cooperation. The biggest discrepancy is that the targets were innovative and mostly align with the proposals in London and Paris. However, it proposes to be implemented through a shift towards a uniform gridded model that is expansive over territory. During the last two decades, due to the absence of a regional plan, a neoliberal stance held exclusive control of the legality of urban planning. The municipalities entered a competition process to take advantage of initial economic benefits of such growth. This provided a “solid” economic base for some municipalities with limited resources in their municipal budgets. The law was amended without a legal stable framework at the request of stakeholders. The character of the plan is lost not only regionally, but also in the sectors and municipal planning. This tends to be based on specific changes with the loss of an urban model. Environmental protection is organized through an extensive number of protection figures with diverse competencies that prevent its effective protection. This process squanders the use of the land, backed by increasing road infrastructure, dispersed occupations with low-density growth causing a social segmentation due to space duality based on income levels. During the housing boom, there is a reduction in social public housing policy mostly due to a boost in the market of housing production for average incomes than in rental policies for needy social groups that focus on disadvantaged neighbourhoods and southern suburbs. As a result, there is an increase in single-family housing, often protected by public policy. This is located primarily in the west in areas of high environmental value such as Guadarrama. There is also cheaper housing due to the popularization of typology in the border region. There, territory works as a mono-functional islands. Financial activities and advanced services for companies are located to the north and west where industrial activity is lost as it migrates south, often outside the region. The number of large shopping centres hanging off the highway infrastructure with little to no surrounding population increases. This process leads to the loss of dependency on public transport and a significant increase in the use of private vehicles. The absence of regional planning has produced more imbalance, more social segmentation, more dispersed growth and a lot of environmental, social and economic costs that can only be redirected through rational territorial.

Technical guide for determining income and allowances for the HOME program.

"HUD-1470-CPD"--P. [4] of cover.

[Stress tolerance and quality of life--effect of a comprehensive ambulatory rehabilitation program for patients with chronic heart failure]

Chronic heart failure (CHF) impairs quality of life (QoL) much stronger than other chronic diseases. The objective of this evaluation was to assess the effect of a new integrated comprehensive outpatients rehabilitation program on somatic parameters and quality of life in 51 patients with stable CHF. After rehabilitation, left ventricular ejection fraction, NYHA class, and parameters of sub-maximum and maximum exercise capacity improved significantly between 11 and 20%, and 6-minute walking distance by 58% on average (p < 0.0001). Non-disease specific QoL (Short Form-36 questionnaire) improved in only 2 of 8 subscales (physical functioning [effect size 0.38, p < 0.001], and role functioning [effect size 0.17, p < 0.05]), and a mental component score [effect size 0.47, p < 0.0001]. Disease-specific QoL (Minnesota Living with Heart Failure questionnaire) improved in terms of sum score [effect size 0.24, p < 0.0001], and physical component score [effect size 0.35, p < 0.0001]. Improvement in exercise capacity correlated significantly with improvements in parameters of disease-specific QoL.

Long-term Results of a 12-Week Comprehensive Ambulatory Cardiac Rehabilitation Program

PURPOSE: To evaluate the long-term outcome of a 12-week outpatient cardiac rehabilitation (CR) program. METHODS: In a prospective single-center interventional cohort study, 201 consecutive patients (133 patients after acute coronary syndrome, 32 patients after heart surgery, and 36 patients with heart failure) attending a 12-week comprehensive outpatient CR program were evaluated for exercise capacity, cardiovascular risk factors (CvRFs), and quality of life at entry, end, and 1.4 years after completion of the program (followup). RESULTS: Physical exercise capacity improved significantly from program entry to program end and remained at this level at followup (P ≤ .006). CvRFs at followup were significantly reduced with regard to smoking prevalence and blood lipids (P < .001). At program end and followup, MacNew heart disease–specific emotional, physical, and social quality of life were improved significantly compared with those at program entry (P < .001). Use of cardioprotective medication remained equally high over the entire study period. However, significantly fewer patients reached blood pressure (<140/90 mm Hg, P = .034) and body mass index (<30 kg/m2, P = .017) goals at followup than at program end. CONCLUSION: The 12-week comprehensive outpatient CR program was successful at reducing important CvRFs long-term.

Effect of comprehensive cardiac rehabilitation after heart valve surgery (CopenHeartVR): study protocol for a randomised clinical trial

Background Heart valve diseases are common with an estimated prevalence of 2.5% in the Western world. The number is rising due to an ageing population. Once symptomatic, heart valve diseases are potentially lethal, and heavily influence daily living and quality of life. Surgical treatment, either valve replacement or repair, remains the treatment of choice. However, post surgery, the transition to daily living may become a physical, mental and social challenge. We hypothesise that a comprehensive cardiac rehabilitation programme can improve physical capacity and self-assessed mental health and reduce hospitalisation and healthcare costs after heart valve surgery. Methods A randomised clinical trial, CopenHeartVR, aims to investigate whether cardiac rehabilitation in addition to usual care is superior to treatment as usual after heart valve surgery. The trial will randomly allocate 210 patients, 1:1 intervention to control group, using central randomisation, and blinded outcome assessment and statistical analyses. The intervention consists of 12 weeks of physical exercise, and a psycho-educational intervention comprising five consultations. Primary outcome is peak oxygen uptake (VO2 peak) measured by cardiopulmonary exercise testing with ventilatory gas analysis. Secondary outcome is self-assessed mental health measured by the standardised questionnaire Short Form 36. Also, long-term healthcare utilisation and mortality as well as biochemistry, echocardiography and cost-benefit will be assessed. A mixed-method design is used to evaluate qualitative and quantitative findings encompassing a survey-based study before the trial and a qualitative pre- and post-intervention study. Discussion The study is approved by the local regional Research Ethics Committee (H-1-2011-157), and the Danish Data Protection Agency (j.nr. 2007-58-0015).

Medicare certified rehabilitation programs : outpatient physical therapy, speech pathology, occupational therapy, comprehensive outpatient rehabilitation facility /

A directory of Medicare certified rehabilitation service providers in Illinois.

Rehabilitation outcomes following percutaneous coronary interventions (PCI)

This prospective study evaluated the effect of an individualized, comprehensive, home-based cardiac rehabilitation program combining exercise training with risk factor modification and psychosocial counseling on risk factors, psychological wellbeing, functional capacity, and work resumption in 99 post-percutaneous coronary interventions (PCI) patients randomized to control (standard care plus telephone follow-up, n = 49) or intervention (individualized, comprehensive, home-based cardiac rehabilitation, n = 50) groups. Data were collected at time 1 (T-1) during hospital admission, time 2 (T-2) approximately 2 months post-PCI, and time 3 (T-3) approximately 12 months post-PCI. Results suggest that the allocation to an individualized, comprehensive, home-based cardiac rehabilitation program provided more advantageous outcomes. At both follow-ups, the intervention group showed within-group improvement in serum cholesterol levels (P < 0.02; P < 0.01) and exercise participation (P < 0.001; P < 0.001) with differences in exercise participation favoring the intervention group (P < 0.01) at T-2 Repeated measures ANOVA showed significant improvements over time in body mass index (BMI) (P < 0.01), psychological well-being (P < 0.001), and functional capacity (P < 0.001) for both groups. More patients in the intervention group had returned to work at T-2 (P < 0.001) and did so more quickly (P < 0.01). These findings suggest that an individualized, comprehensive, home-based cardiac rehabilitation program improves risk factor profiles and work resumption patterns for patients following PCI. (C) 2001 Elsevier Science Ireland Ltd. All rights reserved.

Audit and comprehensive health assessment programme in the primary healthcare of adults with intellectual disability: a pilot study

International research has demonstrated significant shortcomings in the health of adults with intellectual disability (ID). Because general practitioners (GPs) are the main providers of primary healthcare for this population, strategies to improve general practice care are an important aspect of rectifying these shortcomings. The present pilot study aimed to determine the effect of various interventions on health maintenance activities and to assess their acceptability to GPs, with a view to informing larger scale studies. The GPs were recruited through an earlier questionnaire-based postal survey. The GPs identified all their adult patients with ID, then obtained consent for participation from three patients randomly selected by the investigators. The GPs completed two self-evaluation forms and case note audits 12 months apart, read a synopsis of the relevant literature provided by the researchers, and completed a comprehensive health assessment (CHA) of their three patients. Forty-five GPs agreed to participate in the CHA programme (CHAP), and 15 completed the project. Thirty-eight patients completed the project. The number of patient-GP dyads who completed the project was too small to demonstrate statistically significant changes in health issues over time. The GPs found that the synopsis of the literature was the best intervention for increasing knowledge and was also the most practical to use in general practice. The CHAP was the intervention that prompted the most action from the GP which would not have been undertaken otherwise. The CHAP appeared to provide a superior review process compared to the other interventions used in the present study. The numbers of health maintenance activities found to be overdue and the number of health issues detected as a result of the process were considerable. The CHAP served as a communication tool and an educative instrument, providing a basis for future studies and strategies to improve the general practice care of adults with ID.

South American Guidelines for Cardiovascular Disease Prevention and Rehabilitation

In this document, the Inter-American Committee of Cardiovascular Prevention and Rehabilitation, together with the South American Society of Cardiology, aimed to formulate strategies, measures, and actions for cardiovascular disease prevention and rehabilitation (CVDPR). In the context of the implementation of a regional and national health policy in Latin American countries, the goal is to promote cardiovascular health and thereby decrease morbidity and mortality. The study group on Cardiopulmonary and Metabolic Rehabilitation from the Department of Exercise, Ergometry, and Cardiovascular Rehabilitation of the Brazilian Society of Cardiology has created a committee of experts to review the Portuguese version of the guideline and adapt it to the national reality. The mission of this document is to help health professionals to adopt effective measures of CVDPR in the routine clinical practice. The publication of this document and its broad implementation will contribute to the goal of the World Health Organization (WHO), which is the reduction of worldwide cardiovascular mortality by 25% until 2025. The study group's priorities are the following: • Emphasize the important role of CVDPR as an instrument of secondary prevention with significant impact on cardiovascular morbidity and mortality; • Join efforts for the knowledge on CVDPR, its dissemination, and adoption in most cardiovascular centers and institutes in South America, prioritizing the adoption of cardiovascular prevention methods that are comprehensive, practical, simple and which have a good cost/benefit ratio; • Improve the education of health professionals and patients with education programs on the importance of CVDPR services, which are directly targeted at the health system, clinical staff, patients, and community leaders, with the aim of decreasing the barriers to CVDPR implementation.