Interventions to promote patient utilisation of cardiac rehabilitation

Background: International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation. Objectives: First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations. Search methods: Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index ‐ Science (CPCI‐S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions. Selection criteria: We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity. Data collection and analysis: Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random‐effects meta‐regression for each outcome and explored prespecified study characteristics. Main results: Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation. Low‐quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta‐regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face‐to‐face; P = 0.01) were influential in increasing enrolment. Low‐quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home‐based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate‐quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi‐centre studies were less effective than those given in single‐centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small‐study bias for enrolment (insufficient studies to test for this in the other outcomes). With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women‐tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment. Authors' conclusions: Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face‐to‐face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion

Evaluation of the AR4 CMIP3 and the AR5 CMIP5 model and projections for precipitation in northeast Brazil

This article compares the sensitivity of IPCC CMIP3-AR4 and CMIP5-AR5 models used on the latest reports from the Intergovernmental Panel on Climate Change (IPCC) in representing the annual average variations (austral summer and autumn) on three regions in Northeastern Brazil (NNEB) for the periods 1979–2000 using the CMAP (Climatology Merged Analysis of Precipitation) data as reference. The three areas of NNEB chosen for this analysis were the semiarid, eastern, and southern regions. The EOF analysis was performed to investigate how the coupled models resolve the temporal variability of the spatial modes in the Tropical Atlantic Sea Surface Temperature (SST), which drives the interannual variations of the rainfall in the Northeastern Brazil. CMIP3-AR4 and CMIP5-AR5 models presented a good representation of the annual cycle of precipitation. Results from correlation and mean absolute error analysis indicate that both CMIP3 and CMIP5 models produce large errors and barely capture the interannual rainfall variance during austral summer and autumn in Northeast Brazil, this features is closely related to the poor representation of the modes of SST variability in the Tropical Atlantic Ocean. For the summer and autumn rainfall projections (2040–2070) in the semiarid region, there was no convergence between the CMIP3 and CMIP5 models. During the summer and autumn in the eastern sector, both the CMIP3 and CMIP5 models projected rainfall above the mean for the 2040–2070 period

Theoretical/practical teaching in nursing graduation for mental health / Ensino teórico/prático na graduação em enfermagem para atuação em saúde mental

Objetivo: analisar o ensino teórico/prático em Saúde Mental e Psiquiatria recebido durante a graduação em enfermagem. Método: estudo quantitativo, desenvolvido com 44 enfermeiros de uma Rede de Atenção Psicossocial do Município de São Paulo por meio de questionário validado. Resultados: 72,7% dos enfermeiros se sentem despreparados para lidar com Saúde Mental pela primeira vez, 68,2% consideram que o conteúdo foi pouco explorado e 84,1% tem interesse em fazer cursos na área. Conclusão: há dualidade no ensino teórico/prático ofertado pelas instituições de ensino superior, configurando a necessidade de que a formação seja revista para que enfermeiros generalistas consigam atender as demandas de Saúde Mental nos diversos campos de atuação profissional de acordo com o paradigma da Reforma Psiquiátrica e dos pressupostos da Reabilitação Psicossocial.

Measurements of differential production cross sections for a Z boson in association with jets in pp collisions at root s=8 TeV

Peer reviewe

Searches for invisible decays of the Higgs boson in pp collisions at root S=7, 8, and 13 TeV

Peer reviewe

Search for leptophobic Z ' bosons decaying into four-lepton final states in proton-proton collisions at root s=8 TeV

Peer reviewe