Efficacy of telemedicine for the management of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND: Telemedicine has been increasingly integrated into chronic disease management through remote patient monitoring and consultation, particularly during the COVID-19 pandemic. We did a systematic review and meta-analysis of studies reporting effectiveness of telemedicine interventions for the management of patients with cardiovascular conditions. METHODS: In this systematic review and meta-analysis, we searched PubMed, Scopus, and Cochrane Library from database inception to Jan 18, 2021. We included randomised controlled trials and observational or cohort studies that evaluated the effects of a telemedicine intervention on cardiovascular outcomes for people either at risk (primary prevention) of cardiovascular disease or with established (secondary prevention) cardiovascular disease, and, for the meta-analysis, we included studies that evaluated the effects of a telemedicine intervention on cardiovascular outcomes and risk factors. We excluded studies if there was no clear telemedicine intervention described or if cardiovascular or risk factor outcomes were not clearly reported in relation to the intervention. Two reviewers independently assessed and extracted data from trials and observational and cohort studies using a standardised template. Our primary outcome was cardiovascular-related mortality. We evaluated study quality using Cochrane risk-of-bias and Newcastle-Ottawa scales. The systematic review and the meta-analysis protocol was registered with PROSPERO (CRD42021221010) and the Malaysian National Medical Research Register (NMRR-20–2471–57236). FINDINGS: 72 studies, including 127 869 participants, met eligibility criteria, with 34 studies included in meta-analysis (n=13 269 with 6620 [50%] receiving telemedicine). Combined remote monitoring and consultation for patients with heart failure was associated with a reduced risk of cardiovascular-related mortality (risk ratio [RR] 0·83 [95% CI 0·70 to 0·99]; p=0·036) and hospitalisation for a cardiovascular cause (0·71 [0·58 to 0·87]; p=0·0002), mostly in studies with short-term follow-up. There was no effect of telemedicine on all-cause hospitalisation (1·02 [0·94 to 1·10]; p=0·71) or mortality (0·90 [0·77 to 1·06]; p=0·23) in these groups, and no benefits were observed with remote consultation in isolation. Small reductions were observed for systolic blood pressure (mean difference –3·59 [95% CI –5·35 to –1·83] mm Hg; p<0·0001) by remote monitoring and consultation in secondary prevention populations. Small reductions were also observed in body-mass index (mean difference –0·38 [–0·66 to –0·11] kg/m(2); p=0·0064) by remote consultation in primary prevention settings. INTERPRETATION: Telemedicine including both remote disease monitoring and consultation might reduce short-term cardiovascular-related hospitalisation and mortality risk among patients with heart failure. Future research should evaluate the sustained effects of telemedicine interventions. FUNDING: The British Heart Foundation

Obesity and chronic disease prevention among old adults (55-74 years): An evidence overview and framework to inform policy and practice

This document is an expansive report detailing the research evidence (to mid-2012) on the rationale, determinants and effective approaches to reduce the prevalence of obesity and chronic disease among community-dwelling older adults, aged 55-74 years. It is designed specifically to contribute to the planning of programs and interventions for obesity and chronic disease prevention in New South Wales, Australia. A summary version of this report can be found at http://hdl.handle.net/2123/9084 Specifically this report: • Examines the available epidemiological evidence on the weight status and obesity-related chronic disease risk profile of older adults in NSW • Considers the behaviours contributing to weight status and chronic disease in this age group • Presents a structured planning framework to identify potential points for intervention based on analysis of contributing factors • Examines the evidence around the effectiveness of potential interventions, considering the strengths, limitations and gaps within the evidence base • Proposes a portfolio of evidence-based and promising intervention approaches for the reduction of obesity and related chronic disease risk

Associations Between Heart Rate Variability and Metabolic Syndrome Risk Factors

Metabolic syndrome (MetS) is a clustering of risk factors for cardiovascular disease (CVD) and type 2 diabetes (T2D) – two major causes of morbidity and mortality worldwide. Heart rate variability (HRV) is a non-invasive measure of cardiac autonomic regulation that predicts mortality and morbidity. Additionally, HRV is reduced in CVD, T2D and MetS. As such, HRV has potential to be a novel cardiometabolic risk factor to be included in clinical risk assessment. Therefore, the purpose of this thesis was to examine the relationships between MetS and HRV. A systematic review of cross-sectional studies examining relationships between HRV and MetS was completed to consolidate existing evidence and to guide future studies. This was followed by a cross-sectional investigation of time and frequency domain and nonlinear HRV in a population with MetS risk factors to determine which MetS risk factors were associated with HRV parameters. A pilot study was then conducted to study the feasibility of conducting a mobile health (mHealth) and exercise intervention in a rural population, which was followed by a 24-week randomized clinical trial to examine the effects of the interactive mHealth exercise intervention compared to standard of care exercise in participants with MetS risk factors. Overall, HRV was reduced in women with MetS compared to those without, though there were no differences in men. Waist circumference and lipid profiles were most commonly related to HRV parameters when studied cross-sectionally. The changes in waist circumference and fasting plasma glucose were associated with the change in HRV parameters when studied longitudinally. Following the intervention period, waist circumference and blood pressure were improved with no other changes in MetS risk factors. HRV parameters indicative of vagal activity were reduced over the intervention period, but there were no changes in other HRV parameters. There were no differences in changes between the intervention and control groups. In conclusion, MetS and HRV are associated in women but not men. However, there were no clear associations between MetS and HRV to suggest that HRV would be a valuable clinical risk factor

Educational technologies designed to promote cardiovascular health in adults: integrative review

Objetivo Investigar as tecnologias educacionais desenvolvidas para promoção da saúde cardiovascular em adultos. Método Revisão integrativa realizada nas bases de dados PubMed, SciELO e LILACS, com a seleção de 15 artigos. Resultados Mais da metade (60%) dos estudos foi de Ensaios Clínicos Randomizados. As tecnologias educacionais desenvolvidas foram programas envolvendo três estratégias e com a duração de um ano, além de tecnologias lúdicas com contação de histórias, programas de computador ou software para smartfones e folheto eletrônico. Essas tecnologias resultaram em redução dos níveis pressóricos, peso, circunferência abdominal, diminuição de internações e aumento dos anos de vida. Conclusão Os estudos com melhores impactos na saúde cardiovascular dos adultos foram os que trouxeram a tecnologia em forma de programa e com a duração de um ano.



Objetivo Investigar las tecnologías educativas desarrolladas para la promoción de la salud cardiovascular en adultos. Método Revisión integrativa llevada a cabo en las bases de datos PubMed, SciELO e LILACS, mediante la selección de 15 artículos. Resultados Más de la mitad (60%) de los estudios fue de Ensayos Clínicos Randomizados. Las tecnologías educativas desarrolladas fueron programas que abarcaban tres estrategias y con duración de un año, además de tecnologías lúdicas mediante el acto de contar historias, programas de computadora o software para smartphones y folleto electrónico. Dichas tecnologías resultaron en la reducción de los niveles presóricos, de peso y de la circunferencia abdominal, y también en la reducción de hospitalizaciones y aumento de los años de vida. Conclusión Los estudios con mejores impactos en la salud cardiovascular de los adultos fueron los que proporcionaron la tecnología a modo de programa y con duración de un año.
Objective Investigating the educational technologies developed for promoting cardiovascular health in adults. Method Integrative review carried out in the databases of PubMed, SciELO and LILACS, with 15 articles selected. Results Over half (60%) of the studies were randomized clinical trials. The developed educational technologies were programs involving three strategies, with duration of one year, use of playful technologies with storytelling, computer programs or software for smartphones, and electronic brochure. These technologies resulted in reduction of blood pressure, weight, waist circumference, decreased hospitalizations and increased years of life. Conclusion The studies with better impact on the cardiovascular health of adults were those who brought the technology in the form of program and duration of one year

Systems and WBANs for Controlling Obesity

According to World Health Organization (WHO) estimations, one out of five adults worldwide will be obese by 2025. Worldwide obesity has doubled since 1980. In fact, more than 1.9 billion adults (39%) of 18 years and older were overweight and over 600 million (13%) of these were obese in 2014. 42 million children under the age of five were overweight or obese in 2014. Obesity is a top public health problem due to its associated morbidity and mortality. This paper reviews the main techniques to measure the level of obesity and body fat percentage, and explains the complications that can carry to the individual's quality of life, longevity and the significant cost of healthcare systems. Researchers and developers are adapting the existing technology, as intelligent phones or some wearable gadgets to be used for controlling obesity. They include the promoting of healthy eating culture and adopting the physical activity lifestyle. The paper also shows a comprehensive study of the most used mobile applications and Wireless Body Area Networks focused on controlling the obesity and overweight. Finally, this paper proposes an intelligent architecture that takes into account both, physiological and cognitive aspects to reduce the degree of obesity and overweight

The effect of whole body vibration training on insulin sensitivity in overweight adolescents: A randomised controlled trial

Clinical insulin resistance (IR), commonly seen in the obese adolescent, precedes a diagnosis of Type 2 diabetes. Paediatric weight management programs improve insulin sensitivity (Si) and metabolic profile. This RCT investigated whether whole body vibration training (WBVT) could enhance Si in obese adolescents, in addition to lifestyle intervention. Secondary outcome measures included change in anthropometry, musculoskeletal and cardiorespiratory fitness (CRF). Participants had central adiposity. Adverse anthropometry was associated with poorer Si, increased weight and BMI. IR correlated with greater inflammation. Acanthosis nigricans, in dark skinned individuals, detected biochemical hyperinsulinaemia. Two thirds were female; males had the highest BMI. The average fasting insulin was 33.8mU/L. The group was highly insulin resistant at baseline with HOMA-IR 7.62 and WBISI 1.74. Metabolic syndrome was prevalent ranging from 23-44%. Males had higher systolic blood pressure z score at baseline. The group had mild elevation in aspart aminotransferase. Triglycerides positively correlated with alanine aminotransaminase, mainly in males. Participants were inactive with increased sedentary times. CRF, muscle force and power generation were reduced. Obese individuals had higher areal bone mineral density (BMD) and content (BMC) for age but normal values for height. Females had a higher BMD and BMC to males. Lean tissue mass was a predictor of BMD. Increased waist circumference negatively affected BMC and BMD. Lifestyle intervention improved BMI z score (-0.8 vs. -0.08, p<0.039) in the lifestyle and WBVT group respectively and was associated with improvements in fasting glucose (-0.3 vs. -0.0, p<0.047). Si showed non-significant improvement. WBVT, increased lean tissue mass by almost 0.5kg. There was no association between bone and mineral turnover and energy homeostasis. Low vitamin D and dark skin were associated with higher fasting insulin, lower WBISI and higher HOMA-IR. Retention to the study was high with dropout of 2.3%, but compliance to the WBVT exercise intervention was poor. This study confirmed lifestyle measures in the management of obesity and insulin resistance and provides evidence of the safety of WBVT as an efficient method of improving lean tissue mass in obese adolescents

Nurse Practitioner Impact on Quantitative Patient Outcomes in Four Healthcare Settings' System Context: A Systematic Review and Meta-Analysis

Nurse Practitioners (NPs) are frequently integrated into interprofessional teams to improve quality and efficiency of healthcare delivery, especially in complex systems. Research on the NP role has grown dramatically, yet an aggregate analysis had never been performed. The purpose of this review was to systematically describe the nature and impact of NP interventions in healthcare settings, to establish a comprehensive understanding of NPs with respect to healthcare delivery, including discovery of information gaps. The specific objectives of the study were to describe the types of: 1) intervention activities that NPs have performed in randomised controlled trials (RCTs); 2) quantitative study endpoints measured in RCTs; and 3) impact of NPs on all quantitative patient outcomes in four settings: primary health care, long term care, outpatient care, and acute care, conducting meta-analysis where possible. Eligible studies included low risk of bias RCTs that tested NP interventions on quantitative endpoints in healthcare settings; data sources included peer reviewed or grey literature in English, from the year 2000 forth. The literature search performed by a professional librarian (MH) yielded 1,188 unique citations. Screening for relevance and risk of bias by two independent reviewers (LT and NL) resulted in a set of included studies comprised of 39 articles (29 different RCTs). Data extraction by LT was cross-checked by the second independent reviewer NL. Findings were systematically summarized according to pre-specified protocol. Out of 89 classes of endpoint-outcomes, results for 43 patient outcome classes (43/89; 48%) were statistically significant, associated with 26/29 (90%) interventions. Meta-analysis was conducted to compare the proportion of hospitalizations between intervention and control groups of two homogenous studies, systematically completing the review’s data analysis. Transparent data presentation within an explicit, reproducible methodology minimizes bias, resulting in reliable findings that were organized, synthesized and summarized in a clear and comprehensive fashion. To the extent of its findings, this systematic review may support improvements in access to quality healthcare, and may provide insight into long term strategies that have potential to contribute toward enhanced balance within the healthcare continuum, from delivery of preventive primary health care services to treatment in acute care

Third-wave cognitive behaviour therapies for weight management: A systematic review and network meta-analysis.

This systematic review and network meta-analysis synthesized evidence on the effects of third-wave cognitive behaviour therapies (3wCBT) on body weight, and psychological and physical health outcomes in adults with overweight or obesity. Studies that included a 3wCBT for the purposes of weight management and measured weight or body mass index (BMI) pre-intervention and ≥ 3 months post-baseline were identified through database searches (MEDLINE, CINAHL, Embase, Cochrane database [CENTRAL], PsycINFO, AMED, ASSIA, and Web of Science). Thirty-seven studies were eligible; 21 were randomized controlled trials (RCT) and included in the network meta-analyses. Risk of bias was assessed using RoB2, and evidence quality was assessed using GRADE. Random-effects pairwise meta-analysis found moderate- to high-quality evidence suggesting that 3wCBT had greater weight loss than standard behavioural treatment (SBT) at post-intervention (standardized mean difference [SMD]: -0.09, 95% confidence interval [CI]: -0.22, 0.04; N = 19; I2 = 32%), 12 months (SMD: -0.17, 95% CI: -0.36, 0.02; N = 5; I2 = 33%), and 24 months (SMD: -0.21, 95% CI: -0.42, 0.00; N = 2; I2 = 0%). Network meta-analysis compared the relative effectiveness of different types of 3wCBT that were not tested in head-to-head trials up to 18 months. Acceptance and commitment therapy (ACT)-based interventions had the most consistent evidence of effectiveness. Only ACT had RCT evidence of effectiveness beyond 18 months. Meta-regression did not identify any specific intervention characteristics (dose, duration, delivery) that were associated with greater weight loss. Evidence supports the use of 3wCBT for weight management, specifically ACT. Larger trials with long-term follow-up are needed to identify who these interventions work for, their most effective components, and the most cost-effective method of delivery.This study is funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research RP-PG-0216-20010. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. ALA and SJG are supported by the Medical Research Council (MC_UU_12015/4). SJG is an NIHR senior investigator. The University of Cambridge has received salary support in respect of SJG from the National Health Service in the East of England through the Clinical Academic Reserve.We want to thank the patient user group panel for assisting with the refinement of the research question, and interpretation of results. We would like to thank individuals within the unit that assisted with article language translation, Eleanor Barker for help in developing the search strategy and Rebecca Jones for assisting with database searches. We would also like to thank all corresponding authors of articles that provided additional information or clarity on their studies

The role of naturopathic medicine in the management of women with polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome or PCOS was first described in 1935 by Irving F. Stein and Michael L. Leventhal as Stein Leventhal Syndrome; ‘women with ovarian hyperthecosis presenting with persistent anovulation, obesity and hirsutism.’ Today, PCOS is the most common reproductive endocrinopathy of women, the most common cause of ovarian infertility and the cause of significant distress. PCOS is associated with serious health risks in the short and long term including significantly increased risks for diabetes, cancer and cardiovascular disease, independent to body weight. For the health care system, the annual cost of PCOS in Australia was conservatively estimated as AU$400 million. The negative personal impact of PCOS on women’s quality of life and self-esteem is well defined and recognised. Current evidence-based medical management emphasises a multidisciplinary approach with lifestyle intervention recommended as first-line treatment. However, the strength of evidence for lifestyle intervention is limited by high attrition in RCTs and the clinical uptake remains impeded by the lack of evidence for optimal dietary and exercise practices. Additional forms of management are often needed. Pharmaceuticals and surgery may be used to regulate menstruation, reduce androgens and treat infertility and hyperinsulinaemia however these have limited capacity to address the range of PCOS symptoms, are often contra-indicated due to increased risk of co-morbidities or have high adverse effect profiles. In addition, women with PCOS have expressed preferences for alternatives to birth control pills and fertility drugs. Naturopathy is a type of complementary medicine with traditional origins in ancient western civilisations. Naturopaths could be described as complementary ‘general practitioners’ as they provide health care for a wide range of conditions using a variety of treatment modalities to enhance well-being and support the natural healing capabilities of the body. The case for naturopathy for PCOS is presented here based on three rationales; first on the basis of a clinical gap in medical management; second based on the clinical potential for naturopathic herbal medicine and nutritional supplements in women’s reproductive pathology, and third based on the increasingly high use and acceptability of complementary medicines by women throughout the world

Evaluation of a physical activity and nutrition program for older people

The aim of the program was to develop, implement and evaluate a low cost, accessible, sustainable, replicable physical activity and nutrition program that would ultimately reduce chronic disease. The thesis demonstrates the importance of evaluation pre, during and post intervention. The program was successful, data from the intervention group improved in areas of physical activity, dietary behaviours, and anthropometric measures, in comparison to the control group participants