BARRIERS FOR CARDIAC REHABILITATION IN HEART FAILURE: HOW TO IMPROVE ADHERENCE

Introdução: Apesar da disponibilidade de terapias farmacológicas e de dispositivos para o tratamento da insuficiência cardíaca (IC), os doentes com IC ainda apresentam um mau prognóstico e uma qualidade de vida reduzida. Modificações no estilo de vida, a reabilitação cardíaca (RC) e exercício físico regular, ajudam a controlar os sintomas da IC e melhorar a função cardíaca. No entanto, apesar de todas as evidências científicas e recomendações clínicas, a RC é subutilizada no tratamento da IC. As razões para a subutilização dos programas de RC são multifatoriais e incluem fatores relacionados com o sistema de saúde, os profissionais de saúde ou ainda barreiras relacionadas ao doente. É importante identificar estas barreiras para aumentar a participação e adesão aos programas de RC de modo a garantir que todos os que possam se beneficiar deste tipo de programa tenham a oportunidade de participar. Desta forma, a RC domiciliária isoladamente ou em combinação com a RC supervisionada, tem o potencial de abordar algumas barreiras, como flexibilidade de horário, distância do centro de RC, custos e a preferência do doente. Além disso, o maior grau de auto monitorização exigido em programas domiciliários pode promover uma transição favorável para a mudança comportamental sustentável e o autocuidado da doença. A adesão a longo prazo ao exercício físico após a fase II da RC pode ser desafiadora, mas é fundamental para manter a saúde cardiovascular e reduzir o risco de futuros eventos cardíacos. Assim, considerando a importância dos programas de RC no tratamento dos doentes com IC, a baixa acessibilidade e adesão a esse tipo de programa, bem como a adesão subótima em longo prazo, é preciso entender os motivos dessa subutilização no contexto da população portuguesa. Objetivo: No presente trabalho propomos-nos: i) descrever e comparar as barreiras à participação num programa de RC hospitalar versus domiciliar em doentes com IC num hospital público em Portugal; ii) investigar a relação entre as barreiras reportadas e a adesão ao programa de RC; iii) verificar a efetividade de um programa de RC domiciliário em relação a adesão a longo prazo à atividade física e aos níveis de aptidão física após um programa de RC fase 2; iv) comparar os efeitos a longo prazo de uma intervenção de RC domiciliária versus uma intervenção de RC hospitalar; e v) propor um programa comunitário especializado de RC fase III visando auxiliar doentes cardíacos a alcançarem um estilo de vida saudável, a controlar os fatores de risco cardiovascular e promover o bem-estar após a fase II de RC. Métodos: Para alcançar os objetivos propostos, avaliamos 87 doentes com IC no Estudo I e 54 pacientes com IC no Estudo II. No estudo I, foi utilizado o questionário de Barreiras na Reabilitação Cardíaca para avaliar a perceção dos doentes em relação ao grau em que diferentes barreiras afetam sua participação no programa de RC. Além disso, foram coletados dados de adesão dos registos das sessões de exercícios e da monitorização de frequência cardíaca. No Estudo II, os doentes foram avaliados quanto à atividade física (IPAQ versão curta e o monitor de frequência cardíaca, modelo POLAR M200) e aptidão física (teste de caminhada de 6 minutos, teste de 8-foot-up-and-go, teste de força de preensão manual e teste de sentar e levantar por 30 segundos). O Estudo III é um protocolo de fase III para ser implementado dentro da comunidade Resultados: No Estudo I, os nossos dados indicam que "outros problemas de saúde" são a principal barreira à RC para doentes com IC na população estudada. Comparando com o grupo RC hospitalar, os doentes do grupo RC domiciliário identificaram duas principais barreiras como principais, nomeadamente, "mau tempo" e "tenho pouco tempo", mas isso não se refletiu nas taxas de adesão. No Estudo II, nossos dados sugerem que o programa domiciliar não resultou em melhor adesão à atividade física a longo prazo ou níveis de aptidão física em comparação ao programa hospitalar. Por fim, no Estudo III, propomos a implementação de um programa de RC fase III na comunidade, com alocação em grupos de acordo com a preferência do doente, a fim de abordar desafios de saúde e sociais não atendidos relacionados à manutenção após a fase II de RC. Conclusões: Os nossos dados sugerem que, após identificar as barreiras relacionadas à participação e adesão à RC, programas individualizados que incorporem as barreiras específicas do doente poderão ter um impacto na participação nestes programas. Além disso, 12 semanas de um programa de RC domiciliária ou hospitalar parecem não ser suficientes para promover uma transição para uma mudança de comportamento sustentável no tempo. Por fim, são necessários novos programas especializados de RC de fase III baseados na comunidade para ajudar os doentes cardíacos a alcançarem um estilo de vida saudável e sustentável, auxiliar no controle dos fatores de risco cardiovascular e promoverem o bem-estar após a RC de fase II. Palavras-chave: reabilitação cardíaca, insuficiência cardíaca, domiciliar, barreiras, adesão, efeitos a longo prazo, doentes cardíacos, fase III, comunidade.Introduction: Despite a variety of pharmacological and device therapies for heart failure (HF), patients still have a poor prognosis and quality of life. Lifestyle modifications, cardiac rehabilitation (CR) and regular exercise, have been shown to help manage HF symptoms and improve cardiac function. However, despite all the scientific evidence and clinical recommendations, CR is underutilized in the treatment of HF. The reasons for the underutilization of CR programs are multifactorial and include health system, health professionals or patient barriers. It is important to address these barriers to increase participation and adherence to ensure that everyone who could benefit from CR has the opportunity to participate. In light of this, home-based CR (HBCR) alone or in combination with clinical-based CR (CBCR), have the potential to address some barriers such as schedule flexibility, time commitment, travel distance, cost and patient preference. In addition, the higher degree of self-monitoring/management required in home-based programs, may promote a favorable transition to sustainable behavioral change and disease self-management. Long-term adherence to exercise training after CR phase 2 can be challenging, but it is critical to maintaining cardiovascular health and reducing the risk of future cardiac events. Thus, considering the importance of CR programs in the treatment of patients with HF, the low accessibility and adherence to this type of program, as well the long-term adherence, it is necessary to understand the reasons for this underutilization in the context of the Portuguese population. Objective: In the present work we propose: i) to describe and compare the barriers to participation in a clinical versus home-based CR program in patients with HF in a public hospital in Portugal; ii) to investigate whether these barriers were related to adherence to the CR program; iii) to assess the effectiveness of the home-based CR on exercise adherence and physical fitness after phase II CR in HF patients; iv) to compare long-term effects of a home-based vs clinical-based CR intervention; and v) to propose the implementation of a specialized community phase III CR program to help cardiac patients achieve a healthy lifestyle, manage optimal cardiovascular risk factors, and promote wellness after phase II CR. Methods: To achieve the proposed objectives, we evaluated 87 patients with HF in Study I and 54 patients with HF in Study II. In study I, the Barriers to Cardiac Rehabilitation Scale questionnaire was used to assess patients' perception of the degree to which different barriers affected their participation in a CR program. In addition, adherence data were collected from exercise session records and the heart rate monitor device. In Study II, patients were assessed for physical activity (IPAQ short version and the heart rate monitor, model POLAR M200) and physical fitness (6-minute-walking test (6MWT), 8-foot-up-and-go test, handgrip and 30-second sit-to-stand test). Study III is a phase III CR protocol to be implemented within the community. Results: In Study I, our data indicate that other health problems are the main barrier for patients with HF. Comparing with CBCR group, the HBCR participants rated two main barriers significantly higher, such as "bad weather" and "I have little time", but it not reflected in adherence rates. In Study II, our data suggests that HBCR program did not resulted in better adherence to long-term physical activity or fitness levels compared with the CBCR intervention. Finally, in Study III, we propose a phase III CR program within the community, with group allocation according to preference, to respond to unmet health and social challenges regarding maintenance after phase II CR. Conclusions: Our data suggest that after identifying barriers related with CR participation and adherence, an individualized CR programs that incorporates patient's-specific barriers would impact on CR participation. In addition, 12 weeks of a HBCR or CBCR program appears to be not enough to promote a transition to sustainable behavior change over time. Finally, new a specialized community-based phase III CR programs are needed to help cardiac patients achieve a sustainable healthy lifestyle, manage optimal cardiovascular risk factors, and promote wellness after phase II CR

Efekti 5-tjednog funkcionalnoga i tradicionalnoga treninga s opterećenjem na antropometrijske karakteristike i motoričke sposobnosti

Functional training (FT) refers to exercise training programs designed to imitate the activities and movement patterns that occur in an athlete’s characteristic activity. Its purpose is to make training adaptations more specific and applicable. There is a lack of studies on the effects of FT in young and previously trained subjects. The aim of this study was to determine the training-specific effects of FT and traditional strength training (TRT) on a subset of anthropometric measures, explosive strength, agility, and sprint performance in young (22-25 years of age), previously trained male subjects (N=23) that were divided randomly into two groups (FT, n=11; TRT, n=12). The variables included anthropometric measures (body height, body weight, body fat percentage, lean body mass, and total body water), two agility tests (5-10-5 meter shuttle run and the hexagon test – HEXAGON), jumping ability (air time, peak power – PEAKPWR, jump height, ground contact time – GCT), throwing ability tests (standing overarm medicine ball throw (SMB) and lying medicine ball throw), and sprint variables (10m and 20m dash and 10-20m split time results). The training program consisted of tree either FT or TRT training sessions per week through 5 weeks. Pre- and post-training intragroup differences were established using the dependent samples t-test. The independent samples t-test was calculated to detect inter-group differences. Anthropometric variables did not change significantly during the training period. Intra-group comparisons revealed significant improvements in the SMB and HEXAGON values for FT group, whereas TRT significantly improved GCT, PEAKPWR, and HEXAGON performance but decreased achievement in SMB. In conclusion, FT and TRT influenced differently the explosive strength and agility variables. More precisely, the results demonstrated that TRT increased the energetic potential of trained musculature, which resulted in an overall increase in power qualities, while FT improved postural control and precise coordination. Certain limitations of the study are noted.Funkcionalni trening je trenažni program oblikovan tako da imitira aktivnosti i kretne strukture koje se pojavljuju u karakterističnoj sportskoj aktivnosti. Cilj mu je izazvati adaptaciju na trening što specifičniju za sport te zato primjenjiviju u konkretnom sportu. Evidentan je nedostatak znanstvenih studija koje su proučavale efekte funkcionalnoga treninga u mladih, treniranih ispitanika. Cilj je ovoga istraživanja bio utvrditi specifične efekte funkcionalnoga treninga (FT) i tradicionalnoga treninga snage (TTS) na sklopu antropometrijskih varijabli, varijabli eksplozivne snage, agilnosti i na rezultatima sprinta mladih (22-25 godina), prethodno treniranih muških ispitanika (N=23) koji su nasumično bili podijeljeni u dvije grupe (FT, n=11; TTS, n=12). Uzorak varijabli je uključivao varijable antropometrijskih karakteristika (tjelesna visina, tjelesna težina, postotak masnoga tkiva, bezmasna masa i ukupna tjelesna voda), dvije varijable za procjenu agilnosti (5-10-5 metara shuttle run i heksagon test - HEXAGON), varijable za procjenu skakačkih sposobnosti (vrijeme leta, vršna snaga - PEAKPWR, visina skoka i vrijeme kontakta sa tlom - GCT), testove snage tipa bacanja (bacanje medicinske lopte jednom rukom stojeći - SMB, bacanje medicinske lopte iz ležanja) te varijable za procjenu eksplozivne snage tipa sprinta (sprint na 10m i 20m te međuvrijeme trčanja između 10. i 20. metra). Eksperimentalni program treninga trajao je 5 tjedana, a obje grupe provodile su 3 eksperimentalne trenažne jedinice tjedno. Razlike između inicijalnih i finalnih stanja unutar grupa utvrđene su t-testom za zavisne uzorke. Za utvrđivanje razlika između grupa korišten je t-test za nezavisne uzorke. Varijable antropometrijskih karakteristika nisu se statistički značajno promijenile tijekom primjene eksperimentalnog trenažnog programa. Značajni pozitivni efekti uočeni su unutar grupe FT za varijable SMB i HEXAGON, dok su unutar grupe TTS uočeni pozitivni efekti u varijablama GCT, PEAKPWR i HEXAGON, ali i negativni efekti za varijablu SMB. Zaključno, FT i TTS utječu diferencijalno na eksplozivnu snagu i agilnost. TTS povećava energetske potencijale trenirane muskulature, što rezultira ukupnim povećanjem parametara snage, dok FT trening pretežno djeluje na posturalnu kontrolu i poboljšanje koordinacije. Određena ograničenja ovoga istraživanja su zabilježena u članku

Coordinated Transit Response Planning and Operations Support Tools for Mitigating Impacts of All-Hazard Emergency Events

This report summarizes current computer simulation capabilities and the availability of near-real-time data sources allowing for a novel approach of analyzing and determining optimized responses during disruptions of complex multi-agency transit system. The authors integrated a number of technologies and data sources to detect disruptive transit system performance issues, analyze the impact on overall system-wide performance, and statistically apply the likely traveler choices and responses. The analysis of unaffected transit resources and the provision of temporary resources are then analyzed and optimized to minimize overall impact of the initiating event

Effects and Optimal Dose of Exercise on Endothelial Function in Patients with Heart Failure: A Systematic Review and Meta‑Analysis

Background Exercise-based cardiac rehabilitation (CR) is considered an effective treatment for enhancing endothelial function in patients with heart failure (HF). However, recent studies have been published and the optimal “dose” of exercise required to increase the benefits of exercise-based CR programmes on endothelial function is still unknown. Objectives (a) To estimate the effect of exercise-based CR on endothelial function, assessed by flow-mediated dilation (FMD), in patients with HF; (b) to determine whether high-intensity interval training (HIIT) is better than moderate-intensity training (MIT) for improving FMD; and (c) to investigate the influence of exercise modality (i.e. resistance exercise vs. aerobic exercise and combined exercise vs. aerobic exercise) on the improvement of endothelial function. Methods Electronic searches were carried out in PubMed, Embase, and Scopus up to February 2022. Random-effects models of between-group mean differences were estimated. Heterogeneity analyses were performed by means of the chi-square test and I2 index. Subgroup analyses and meta-regressions were used to test the influence of potential moderator variables on the effect of exercise. Results We found a FMD increase of 3.09% (95% confidence interval [CI] = 2.01, 4.17) in favour of aerobic-based CR programmes compared with control groups in patients with HF and reduced ejection fraction (HFrEF). However, the results of included studies were inconsistent (p < .001; I2 = 95.2%). Higher FMD improvement was found in studies which were randomised, reported radial FMD, or performed higher number of training sessions a week. Moreover, HIIT enhanced FMD to a greater extent than MIT (2.35% [95% CI = 0.49, 4.22]) in patients with HFrEF. Insufficient data prevented pooled analyses for the effect of exercise in patients with HF and preserved ejection fraction and the influence of exercise modality on the improvement of endothelial function. Conclusion Aerobic-based CR is a non-pharmacological treatment for enhancing endothelial function in patients with HFrEF. However, higher training frequency and HIIT induce greater adaptation of endothelial function in these patients, which should betaken into consideration when designing exercise-based CR programmes. Trial registration The protocol was prospectively registered on the PROSPERO database (CRD42022304687)

Increasing Transit Ridership: Lessons from the Most Successful Transit Systems in the 1990s, MTI Report-01-22

This study systematically examines recent trends in public transit ridership in the U.S. during the 1990s. Specifically, this analysis focuses on agencies that increased ridership during the latter half of the decade. While transit ridership increased steadily by 13 percent nationwide between 1995 and 1999, not all systems experienced ridership growth equally. While some agencies increased ridership dramatically, some did so only minimally, and still others lost riders. What sets these agencies apart from each other? What explains the uneven growth in ridership

Integration of a palliative approach into heart failure care: a European Society of Cardiology Heart Failure Association position paper

The Heart Failure Association of the European Society of Cardiology has published a previous position paper and various guidelines over the past decade recognizing the value of palliative care for those affected by this burdensome condition. Integrating palliative care into evidence-based heart failure management remains challenging for many professionals, as it includes the identification of palliative care needs, symptom control, adjustment of drug and device therapy, advance care planning, family and informal caregiver support, and trying to ensure a 'good death'. This new position paper aims to provide day-to-day practical clinical guidance on these topics, supporting the coordinated provision of palliation strategies as goals of care fluctuate along the heart failure disease trajectory. The specific components of palliative care for symptom alleviation, spiritual and psychosocial support, and the appropriate modification of guideline-directed treatment protocols, including drug deprescription and device deactivation, are described for the chronic, crisis and terminal phases of heart failure

THE BOETHIAN VISION OF ETERNITY IN OLD, MIDDLE, AND EARLY MODERN ENGLISH TRANSLATIONS OF DE CONSOLATIONE PHILOSOPHI

While this analysis of the Old, Middle, and Early Modern English translations of De Consolatione Philosophiandamp;aelig; provides a brief reception history and an overview of the critical tradition surrounding each version, its focus is upon how these renderings present particular moments that offer the consolation of eternity, especially since such passages typify the work as a whole. For Boethius, confused and conflicting views on fame, fortune, happiness, good and evil, fate, free will, necessity, foreknowledge, and providence are only capable of clarity and resolution to the degree that one attains to knowledge of the divine mind and especially to knowledge like that of the divine mind, which alone possesses a perfectly eternal perspective. Thus, as it draws upon such fundamentally Boethian passages on the eternal Prime Mover, this study demonstrates how the translators have negotiated linguistic, literary, cultural, religious, and political expectations and forces as they have presented their own particular versions of the Boethian vision of eternity. Even though the text has been understood, accepted, and appropriated in such divergent ways over the centuries, the Boethian vision of eternity has held his Consolations arguments together and undergirded all of its most pivotal positions, without disturbing or compromising the philosophical, secular, academic, or religious approaches to the work, as readers from across the ideological, theological, doctrinal, and political spectra have appreciated and endorsed the nature and the implications of divine eternity. It is the consolation of eternity that has been cast so consistently and so faithfully into Old, Middle, and Early Modern English, regardless of form and irrespective of situation or background. For whether in prose and verse, all-prose, or all-verse, and whether by a Catholic, a Protestant, a king, a queen, an author, or a scholar, each translation has presented the texts central narrative: as Boethius the character is educated by the figure of Lady Philosophy, his eyes are turned away from the earth and into the heavens, moving him and his mind from confusion to clarity, from forgetfulness to remembrance, from reason to intelligence, and thus from time to eternity

Special Program Issue October 12-15, 1994

Special Program Issu

Functional training improves peak oxygen consumption and quality of life of individuals with heart failure : a randomized clinical trial

Background: Functional training may be an effective non-pharmacological therapy for heart failure (HF). This study aimed to compare the effects of functional training with strength training on peak VO2 and quality of life in individuals with HF. Methods: A randomized, parallel-design and examiner-blinded controlled clinical trial with concealed allocation, intention-to-treat and per-protocol analyses. Twenty-seven participants with chronic HF were randomly allocated to functional or strength training group, to perform a 12-week physical training, three times per week, totalizing 36 sessions. Primary outcomes were the difference on peak VO2 and quality of life assessed by cardiopulmonary exercise testing and Minnesota Living with Heart Failure Questionnaire, respectively. Secondary outcomes included functionality assessed by the Duke Activity Status Index and gait speed test, peripheral and inspiratory muscular strength, assessed by hand grip and manovacuometry testing, respectively, endothelial function by brachial artery flow-mediated dilation, and lean body mass by arm muscle circumference. Results: Participants were aged 60 ± 7 years, with left ventricular ejection fraction 29 ± 8.5%. The functional and strength training groups showed the following results, respectively: peak VO2 increased by 1.4 ± 3.2 (16.9 ± 2.9 to 18.6 ± 4.8 mL.kg-1.min-1; p time = 0.011) and 1.5 ± 2.5 mL.kg-1.min-1 (16.8 ± 4.0 to 18.6 ± 5.5 mL.kg-1.min-1; p time = 0.011), and quality of life score decreased by 14 ± 15 (25.8 ± 14.8 to 10.3 ± 7.8 points; p time = 0.001) and 12 ± 28 points (33.8 ± 23.8 to 19.0 ± 15.1 points; p time = 0.001), but no difference was observed between groups (peak VO2: p interaction = 0.921 and quality of life: p interaction = 0.921). The functional and strength training increased the activity status index by 6.5 ± 12 and 5.2 ± 13 points (p time = 0.001), respectively, and gait speed by 0.2 ± 0.3 m/s (p time = 0.002) in both groups. Conclusions: Functional and strength training are equally effective in improving peak VO2, quality of life, and functionality in individuals with HF. These findings suggest that functional training may be a promising and innovative exercise-based strategy to treat HF