Maintenance of Gains, Morbidity, and Mortality at 1 Year Following Cardiac Rehabilitation in a Middle‐Income Country: A Wait‐List Control Crossover Trial

Background-—Despite the epidemic of cardiovascular diseases in middle-income countries, few trials are testing the benefits of cardiac rehabilitation (CR). This trial assessed (1) maintenance of functional capacity, risk factor control, knowledge, and hearthealth behaviors and (2) mortality and morbidity at 6 months following CR in a middle-income country. Methods and Results-—Eligible Brazilian coronary patients were initially randomized (1:1:1 concealed) to 1 of 3 parallel arms (comprehensive CR [exercise plus education], exercise-only CR, or wait-list control). The CR programs were 6 months in duration, at which point follow-up assessments were performed. Mortality and morbidity were ascertained from chart and patient or family report (blinded). Controls were then offered CR (crossover). Outcomes were again assessed 6 months later (blinded). ANCOVA was performed for each outcome at 12 months. Overall, 115 (88.5%) patients were randomized, and 62 (53.9%) were retained at 1 year. At 6 months, 23 (58.9%) of those 39 initially randomized to the wait-list control elected to attend CR. Functional capacity, risk factors, knowledge, and heart-health behaviors were maintained from 6 to 12 months in participants from both CR arms (all P>0.05). At 1 year, knowledge was significantly greater with comprehensive CR at either time point (P<0.001). There were 2 deaths. Hospitalizations (P=0.03), nonfatal myocardial infarctions (P=0.04), and percutaneous coronary interventions (P=0.03) were significantly fewer with CR than control at 6 months. Conclusions-—CR participation is associated with lower morbidity, long-term maintenance of functional capacity, risk factors, and heart-health behaviors, as well as with greater cardiovascular knowledge compared with no CR. Clinical Trial Registration-—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02575976. (J Am Heart Assoc. 2019;8: e011228. DOI: 10.1161/JAHA.118.011228.) Key Words: cardiac rehabilitation • coronary disease • morbidity/mortality • rehabilitation • risk factorYork University Librarie

LÓGICA FUZZY NA MODELAGEM DA DESERTIFICAÇÃO NO ESTADO DA BAHIA

A desertificação deriva, sobretudo, do uso massivo das terras em domínios morfoclimáticos sazonais. A Bahia possui 393.056 km2, mais de 69% de seu território no semiárido, o que a insere nas Áreas Suscetíveis à Desertificação/ASD’s, devendo elaborar políticas públicas de mitigação ao processo. Imbuído nessa premissa, este estudo objetiva identificar áreas que apresentem vulnerabilidade à desertificação. Foram utilizadas imagens Spot Vegetation e MODIS, dados de uso agropecuário e classes de vegetação e de solos; analisados e integrados pelo modelador Lógica Fuzzy. Nos mapas produzidos foram selecionados quatro Pólos, para estudos focais, com padrões ambientais de degradação mais aguda, nos quais foram identificadas áreas críticas. Estas atingem 12.894 km2 de superfícies dotadas de tipologias de paisagens com forte potencial para estar desenvolvendo desertificaçã

Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients

Background: Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its’ worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a lowresource setting. Methods: In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. Results: Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). Conclusions: The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed. Keywords: Health care services, Cardiac rehabilitation, Cardiac care facilities, Attitude of health personnelYork University Librarie

Psychosocial well-being over the two years following cardiac rehabilitation initiation & association with heart-health behaviors

The objective of this research was to track psychosocial well-being over 2 years following cardiac rehabilitation (CR) initiation, and its' association with heart-health behaviors. Patients from 3 CR programs were approached at their first visit,and consenters completed a survey. Participants were emailed surveys again 6 months, 1 and 2 years later. Depressive symptoms (PHQ-8) and quality of life were assessed at each point, as were exercise, nutrition, smoking and medication adherence, among other well-being indicators. Of 411 participants, 46.7% were retained at 2 years. Post-CR, there was 70% concordance between participants' desired and actual work status. Depressive symptoms were consistently minimal over time (mean = 3.17 ± 0.37); Quality of life was high, and increased over time (p = .01). At 2 years, 56.9% participants met exercise recommendations, and 5.4% smoked. With adjustment, greater self-regulation was associated with significantly greater exercise at intake; greater exercise self-efficacy was significantly associated with greater exercise at 1 year; greater disease management self-efficacy was significantly associated with greater exercise at 2 years; greater environmental mastery (actual) was significantly associated with greater exercise at 2 years. Lower depressive symptoms were significantly associated with better nutrition at 2 years. CR initiators are thriving, and this relates to better exercise and diet.Social Sciences and Humanities Research Council (SSHRC

Pressões respiratórias máximas: equipamentos e procedimentos usados por fisioterapeutas brasileiros

Measuring maximal respiratory pressures - a method for assessing respiratory muscle strength - is a voluntary, effort-dependent test broadly used for diagnostic and therapeutic purposes. There is a large variety of devices and interfaces available to perform this procedure, which leads to a relative absence of standardization. The aim of this survey was to ascertain devices, procedures and interpretation parameters used in measuring maximal respiratory pressures among Brazilian physical therapists. Nineteen respiratory physical therapists, in charge at 13 institutions in three regions of the country, answered a questionnaire on those issues. Results show prevalence of use of analogue respiratory pressure meters (60%), with a silicon tube (60%) and a cylindrical mouthpiece (53,4%) with 1- to 2-mm diameter air-leak opening, associated to use of nose clip (100%). When measuring, they perform a minimum of three acceptable and reproducible tests (80%), and in analysing pressure values all of them use reference values or predictive equations. Data suggest a relative uniformity in measuring maximal respiratory pressures among Brazilian physical therapists.A mensuração das pressões respiratórias máximas - método de avaliação das condições de força dos músculos respiratórios - é um teste voluntário e esforço-dependente, com aplicações clínicas de ordem diagnóstica e terapêutica. Há uma grande variedade de equipamentos e interfaces para sua execução, o que acarreta uma relativa ausência de padronização. O objetivo deste estudo foi identificar os diferentes equipamentos, procedimentos e forma de interpretar a mensuração das pressões respiratórias máximas entre fisioterapeutas brasileiros. Dezenove fisioterapeutas respiratórios, de 13 diferentes instituições, situadas em três regiões do país, responderam a um questionário sobre esses aspectos. Os resultados mostram que prevaleceu o uso de manovacuômetro analógico (60%), com tubo de silicone (60%) e interface do tipo bocal tubular (53,4%), contendo orifício de fuga de 1 a 2 mm de diâmetro (86,6%), associado ao uso de clipe nasal (100%). Na mensuração, foi observado um número mínimo de três testes aceitáveis e reprodutíveis (80%) e, para a análise dos valores encontrados, todos usam valores de referência ou equações preditivas. Os dados sugerem que existe uma relativa uniformidade em relação à mensuração das pressões respiratórias máximas entre fisioterapeutas brasileiros

Ingresso no Serviço Público Bancário no Brasil: Cumprimento Constitucional?

Concerning public banking institutions, many tenders take place, however “reservation register” retain people in the expectation of being hired, which may not happen. Another institute that compromises the hiring of those is the outsourcing process that is formally constituted, but whose aim is the hiring of cheap and skilled labor not to shoulder the high costs of a public worker. Economic growth, globalization, the informal market, increase banks’ profits at the expenses of people who dedicate their lives to succeed in a public tender while there are those who submit themselves to the precarious work conditions of the outsourcing.No que pertine às instituições bancárias públicas, concursos são realizados, mas o cadastro de reserva deixa os classificados na expectativa de serem chamados, o que pode não acontecer. Outro instituto que compromete o ingresso do concursado é a terceirização, formalmente constituída,  mas  cuja  finalidade  é  contratar  mão-de-obra  barata  e  especializada  em detrimento do alto custo do servidor público. O crescimento econômico, a globalização e o mercado informal aumentam os lucros bancários às custas de pessoas que dedicam suas vidas à  aprovação  em  concurso,  enquanto  há  aquelas  que  esperam  uma  oportunidade  e  se submetem à precarização por meio da terceirização