A Review of the Design and Implementation of a Hybrid Cardiac Rehabilitation Program: AN EXPANDING OPPORTUNITY FOR OPTIMIZING CARDIOVASCULAR CARE

PURPOSE

This review describes the considerations for the design and implementation of a hybrid cardiac rehabilitation (HYCR) program, a patient-individualized combination of facility-based cardiac rehabilitation (FBCR) with virtual cardiac rehabilitation (CR) and/or remote CR.

REVIEW METHODS

To help meet the goal of the Millions Hearts Initiative to increase CR participation to 70% by 2022, a targeted review of the literature was conducted to identify studies pertinent to the practical design and implementation of an HYCR program. Areas focused upon included the current use of HYCR, exercise programming considerations (eligibility and safety, exercise prescription, and patient monitoring), program assessments and outcomes, patient education, step-by-step instructions for billing and insurance reimbursement, patient and provider engagement strategies, and special considerations.

SUMMARY

A FBCR is the first choice for patient participation in CR, as it is supported by an extensive evidence base demonstrating effectiveness in decreasing cardiac and overall mortality, as well as improving functional capacity and quality of life. However, to attain the CR participation rate goal of 70% set by the Million Hearts Initiative, CR programming will need to be expanded beyond the confines of FBCR. In particular, HYCR programs will be necessary to supplement FBCR and will be particularly useful for the many patients with geographic or work-related barriers to participation in an FBCR program. Research is ongoing and needed to develop optimal programming for HYCR.

Clinical description & molecular modeling of novel MAX pathogenic variant causing pheochromocytoma in family, supports paternal parent-of-origin effect

The titular member of the MAX network of proteins, MYC-associated factor X (MAX), serves an important regulatory function in transcription of E-box genes associated with cell proliferation, differentiation, and apoptosis. Wild type MAX dimerizes with both MYC and MAD, both of which are members of the MAX network, and can promote or repress cell functions as needed. However, pathogenic variants in MAX are known to upset this balance, leading to uncontrolled oncogenic activity and disease phenotypes such as paragangliomas and pheochromocytomas. We report a 58-year-old male and his 32-year-old daughter, both of which have a history of pheochromocytoma and the unique nonsense MAX variant c.271C>T (p.Q91X). These individuals were diagnosed with pheochromocytomas in their early twenties that were later removed through corrective surgery. The father now presents with recurrent symptoms of hypertension, hyperhidrosis, and headaches, which accompany new pheochromocytomas of his remaining adrenal gland. Pathogenicity of this MAX variant is proven through molecular modeling. The case of this father-daughter pair supports both heritability of pheochromocytoma and the paternal parent-of-origin effect for MAX pathogenic variants.

Type 1 sialidosis presenting with ataxia, seizures and myoclonus with no visual involvement

Sialidosis is an autosomal recessive lysosomal storage disease caused by pathogenic variants in NEU1 which encodes lysosomal sialidase (neuraminidase 1). Lysosomal neuraminidase catalyzes the removal of terminal sialic acid molecules from glycolipids, glycoproteins and oligosaccharides. Sialidosis is classified into two types, based on phenotype and age of onset. Patients with the milder type 1 typically present late, usually in the second or third decade, with myoclonus, ataxia and visual defects. Type 2 is more severe and presents earlier with coarse facial features, developmental delay, hepatosplenomegaly and dysostosis multiplex. Presentation and severity of the disease are related to whether lysosomal sialidase is inactive or there is some residual activity. Diagnosis is suspected based on clinical features and increased urinary bound sialic acid excretion and confirmed by genetic testing showing pathogenic variants in NEU1. We report a patient with type 1 sialidosis who presented mainly with ataxia and both generalized and myoclonic seizures but no visual involvement. Whole exome sequencing of the proband detected compound heterozygous likely pathogenic variants (S182G and G227R) in NEU1.

HCAHPS Scores and Community Factors

The objective was to examine associations between patient experience, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and the sociodemographic, cultural, and access-to-care factors of the surrounding community. Using an empty model, this study found that 27% of the variation in HCAHPS scores was at the level of the county in which the hospital was located. The county factors examined explained about half of this county-level variation. Among community factors most strongly associated with increased HCAHPS scores were higher numbers of primary care physicians per capita, fewer specialists per capita, and smaller percentages of African Americans and Hispanics in the county. A number of community factors beyond the hospitalization experience may influence HCAHPS scores. As HCAHPS gains importance as a measure of quality of care and is linked to higher payments over time, it will be essential to understand the possible effects of community factors.

The Relationship of Engagement in Improvement Practices to Outcome Measures in Large-Scale Quality Improvement Initiatives

Hospital engagement networks (HENs) are part of the largest health care improvement initiative ever undertaken. This article explores whether engagement in improvement activities within a HEN affected quality measures. Data were drawn from 1174 acute care hospitals. A composite quality score was created from 10 targeted topic area measures multiplied by the number of qualifying topics. Scores improved from 5.4 (SD = 6.8) at baseline to 4.6 (5.9) at remeasurement; P < .0001. Hospitals with higher baseline scores demonstrated greater improvement ( P < .0001) than hospitals with lower baseline scores. Hospitals with larger Medicaid populations ( P = .023) and micropolitan ( P = .034) hospitals tended to have greater improvement, whereas hospitals in the West ( P = .0009) did not improve as much as hospitals in other regions. After adjusting for hospital characteristics, hospitals with improvement champions ( P = .008), a higher level of engagement with their state association ( P = .001), and more leadership involvement ( P = .005) in HEN demonstrated greater improvement.

Endpoint comparison for bone mineral density measurements in North Central Cancer Treatment Group cancer clinical trials N02C1 and N03CC (Alliance)

Bone mineral density (BMD) measurement can vary depending upon anatomical site, machine, and normative values used. This analysis compared different BMD endpoints in two clinical trials. Trial results differed across endpoints. Future clinical trials should consider inclusion of multiple endpoints in sensitivity analysis to ensure sound overall study conclusions.

INTRODUCTION

Methodological issues hamper efficacy assessment of osteoporosis prevention agents in cancer survivors. Osteoporosis diagnosis can vary depending upon which bone mineral density (BMD) anatomical site and machine is used and which set of normative values are applied. This analysis compared different endpoints for osteoporosis treatment efficacy assessment in two clinical studies.

METHODS

Data from North Central Cancer Treatment Group phase III clinical trials N02C1 and N03CC (Alliance) were employed involving 774 patients each comparing two treatments for osteoporosis prevention. Endpoints for three anatomical sites included raw BMD score (RawBMD); raw machine-based, sample-standardized, and reference population-standardized T scores (RawT, TSamp, TRef); and standard normal percentile corresponding to the reference population-standardized T score (TPerc). For each, treatment arm comparison was carried out using three statistical tests using change and percentage change from baseline (CB, %CB) at 1 year.

RESULTS

Baseline correlations among endpoints ranged from 0.79 to 1.00. RawBMD and TPerc produced more statistically significant results (14 and 19 each out of 36 tests) compared to RawT (11/36), TSamp (8/36), and TRef (7/36). Spine produced the most statistically significant results (26/60) relative to femoral neck (20/60) and total hip (13/60). Lastly, CB resulted in 44 statistically significant results out of 90 tests, whereas %CB resulted in only 15 significant results.

CONCLUSIONS

Treatment comparisons and interpretations were different across endpoints and anatomical sites. Transforming via sample statistics provided similar results as transforming via reference or machine-based norms. However, RawBMD and TPerc may be more sensitive to change as clinical trial endpoints.

Patient and family engagement: a survey of US hospital practices

Background

Patient and family engagement (PFE) in healthcare is an important element of the transforming healthcare system; however, the prevalence of various PFE practices in the USA is not known.

Objective

We report on a survey of hospitals in the USA regarding their PFE practices during 2013–2014.

Results

The response rate was 42%, with 1457 acute care hospitals completing the survey. We constructed 25 items to summarise the responses regarding key practices, which fell into three broad categories: (1) organisational practices, (2) bedside practices and (3) access to information and shared decision-making. We found a wide range of scores across hospitals. Selected findings include: 86% of hospitals had a policy for unrestricted visitor access in at least some units; 68% encouraged patients/families to participate in shift-change reports; 67% had formal policies for disclosing and apologising for errors; and 38% had a patient and family advisory council. The most commonly reported barrier to increased PFE was ‘competing organisational priorities’.

Summary

Our findings indicate that there is a large variation in hospital implementation of PFE practices, with competing organisational priorities being the most commonly identified barrier to adoption.

Zoledronic Acid for Treatment of Osteopenia and Osteoporosis in Women with Primary Breast Cancer (BC) Undergoing Adjuvant Aromatase Inhibitor (AI) Therapy

Background: Postmenopausal women with significant osteopenia/osteoporosis are at increased risk of fracture, a risk that is exacerbated by the use of Aromatase Inhibitors (AIs). Bisphosphonates may be used for these patients because there is no known interaction with estrogen and/or progesterone receptors (ER, PR). This study evaluated the concurrent use of zoledronic acid in patients with significant osteopenia or osteoporosis who received initial adjuvant letrozole therapy for primary BC, to determine if further bone mineral density (BMD) loss could be prevented.Methods: Postmenopausal women with Stage I-IIIa, ER and/or PR + BC, no evidence of metastatic disease, and a BMD T-score &lt; -2.0 were treated with daily letrozole 2.5 mg/d, vitamin D 400 international units/d, calcium 500 mg twice daily, and 4 mg I.V. zoledronic acid every 6 months (for 5 years). The BMD was measured at baseline and at one year. Kruskall-Wallis p-value methodology was used as the method of statistical analysis. Since this was a single-arm study, the analysis plan was primarily descriptive. The primary endpoint was the mean change in lumbar spine (LS) BMD at 1 year.Results: 60 patients were enrolled; 46 completed 1 year of treatment. Mean patient age was 67 years, with 44% having taken prior tamoxifen. At 1 year (see figure 1), LS BMD increased 2.66% (p=0.01), femoral neck (FN) BMD increased 4.81% (p=0.01), and any measured endpoint (within the LS or FN) increased 4.55% (p=0.0052). 7% of patients experienced a fracture vs.13% with a pre-existing history of fracture before enrollment. No patients had disease recurrence during year 1. Toxicity was minimal with arthralgia as the most common complaint. There were no reports of osteonecrosis of the jaw.Conclusion: Zoledronic acid prevents additional bone loss in postmenopausal women with significant osteopenia or osteoporosis initiating letrozole. Treatment with zoledronic acid was associated with an improvement in BMD.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2103.

Blast-related injuries from terrorism: an international perspective

Terrorism using conventional weapons and explosive devices is a likely scenario and occurs almost daily somewhere in the world. Caring for those injured from explosive devices is a major concern for acute injury care providers. Learning from nations that have experienced conventional weapon attacks on their civilian population is critical to improving preparedness worldwide. In September 2005, a multidisciplinary meeting of blast-related injury experts was convened including representatives from eight countries with experience responding to terrorist bombings (Australia, Colombia, Iraq, Israel, United Kingdom, Spain, Saudi Arabia, and Turkey). This article describes these experiences and provides a summary of common findings that can be used by others in preparing for and responding to civilian casualties resulting from the detonation of explosive devices.

Validity of self-reported colorectal cancer screening behavior

End points for trials promoting cancer screening are often based on self-reported screening behavior. This study was designed to evaluate and optimize the reliability of a computer-assisted telephone interview for collecting self-reported colorectal cancer screening behavior. Cases who had received a fecal occult blood test (FOBT), flexible sigmoidoscopy, and/or colonoscopy, and controls who had no record of colorectal screening were identified among 40-75-year-old members of the Denver Kaiser Permanente Health Care Program and were contacted by telephone. Sensitivities and specificities of self-reported screening were calculated by comparison of subjects' recall with Kaiser Permanente records. The questionnaire was revised based upon results of the pilot phase of the study. Using the revised questionnaire, the sensitivity of self-reported screening was 96.2% for the FOBT, 94.9% for flexible sigmoidoscopy, 88.7% for colonoscopy, and 96.2% for either endoscopic screening test. The specificity of self-reported screening was 85.9% for the FOBT, 92.2% for flexible sigmoidoscopy, 96.8% for colonoscopy, and 92.0% for either endoscopic screening test. No marked differences in the accuracy of the self-reports were detected as a function of gender, age, ethnicity, or family history of colorectal cancer of the participants. Self-reports of colon cancer screening behavior can be reliably used as end points for intervention trials when carefully phrased questions are used.

Promoting cancer screening among the first-degree relatives of breast and colorectal cancer patients: the design of two randomized trials

BACKGROUND

In this paper two large nationwide trials are described, both of which will test a comparable telephone-based counseling intervention to promote cancer screening among the first-degree relatives (FDRs) of breast and colorectal cancer patients. The unit of randomization will be the family unit of eligible FDRs. Access to FDRs will be obtained from their relatives with cancer. Selected intervention and design issues are reviewed, including how both projects will respond to FDRs who exhibit significant levels of cancer-specific anxiety or distress and how potential high-risk cancer families will be accommodated.

METHODS

Pursuant to the development of both studies, two feasibility surveys were conducted to determine whether patients would grant access to their FDRs and whether the FDRS identified by these patients would be receptive to the telephone intervention.

RESULTS

Approximately 80% (106 of 132) of breast cancer patients agreed to provide access to their eligible FDRs when contacted on-site at participating hospitals and clinics. Of those subsequently selected for telephone follow-up (n = 95 or 90%), 80% (n = 76) were successfully contacted by telephone, and of these 97% (n = 74) provided the names and telephone numbers of their FDRs. Among colorectal cancer patients contacted on-site (n = 46), 96% (n = 44) agreed to provide access to their FDRs, and of those contacted by telephone (n = 33 or 75%), 91% (n = 30) provided the requested information about their FDRs. Once contacted, 95% of breast cancer FDRs (55 of 58) and 91% of colorectal cancer patients (51 of 56) endorsed the intervention strategy.

CONCLUSIONS

It is argued that this intervention, if proven effective, could provide an exportable strategy for reaching large numbers of high-risk individuals to promote cancer screening.

Spontaneous pushing during birth. Relationship to perineal outcomes

Vaginal birth is a recognized factor in perineal tissue damage and postpartum perineal pain. This study examined outcomes of 39 primiparous women who had spontaneous vaginal births. In a retrospective survey, women were asked to describe the type of pushing used to give birth and what the level of pain had been in the perineal (or vaginal) area during the first week postpartum. Labor and delivery chart data documented extent of episiotomy and/or laceration sustained. Eleven (28%) women reported using spontaneous bearing down efforts, and the remaining 28 (72%) were directed. Women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations (chi 2 [3, N = 39] = 8.1, P = .043). Other variables, such as maternal age, infant birth weight, length of second stage, provider type, and use of epidural, did not demonstrate a significant difference in perineal outcome. Further analysis showed a significant relationship between the extent of perineal disruption and pain (F [3,30] = 5.08, P = .005).

Storage pool disease in chronic lymphocytic leukemia: abnormal aggregation and secretion without bleeding

Although bleeding complications are relatively common in patients with chronic lymphocytic leukemia, they tend to be related to thrombocytopenia or an acquired clotting factor inhibitor. Chronic lymphocytic leukemia-associated thrombocytopenia, which may also contribute to the hemorrhagic risk, is generally caused by decreased production and immune-mediated destruction. This is the case of a 56-year-old man with longstanding chronic lymphocytic leukemia who developed thrombocytopenia (platelet counts of approximately 50,000/microL) with an associated abnormal platelet morphology. Although the patient did not suffer clinically significant bleeding, several tests of platelet function were grossly abnormal. Electron microscopic examination of the platelets revealed virtually complete absence of dense granules. Platelet aggregation did not occur with adenosine diphosphate (10 microM), collagen (2 micrograms/mL), or ristocetin (1 mg/mL). Doubling the agonist concentrations produced only minimal agglutination with ristocetin. The bleeding time was mildly prolonged at 9.0 and 10.5 minutes. Von Willebrand antigen and ristocetin cofactor levels were normal. Collagen-induced adenosine triphosphate secretion was less than 10% that of a matched normal control. In contrast, platelet force development was virtually normal, reaching 4,800 dynes at 1,200 seconds compared with 5,800 dynes for the healthy control. The patient's clots demonstrated enhanced clot modulus 44,000 dynes/cm2 versus 22,400 dynes/cm2 for the healthy control. The latter finding was primarily because of high fibrinogen concentration. This third report of storage pool disease in a patient with chronic lymphocytic leukemia demonstrates that dense granule release is not required for normal platelet-mediated force development.

Maternal and neonatal characteristics associated with HIV infection in infants of seropositive women

In this prospective study of infants born to human immunodeficiency virus (HIV) seropositive mothers, neonatal and maternal characteristics of infected and noninfected infants were compared to determine the factors that may be associated with or contribute to vertical transmission of HIV. Of 134 infants entered as newborns in the study, 31 have definite serological and/or clinical evidence of infection and 103 are considered noninfected (transmission rate, 23.1%). Significantly more of the infected infants had birth weights below 2,500 g (48.4% versus 22.3%), and more infected infants were found to be small for gestational age (16.2% versus 5.8%). A greater number of infected infants experienced two or more problems in the neonatal period than noninfected infants (51.6% versus 24.2%). The incidence of confirmed and suspected bacterial infections was also significantly increased in the infected group. Multiple logistic regression analysis indicated low birth weight had the strongest association with vertical transmission of HIV. There was no significant difference between the two groups in mean maternal age at first pregnancy, mother's marital status, education, type of family, or past history of type of substances abused. Mothers who transmitted HIV to their infants had a trend towards a higher frequency of clinical chorioamnionitis (16.1% versus 5.8%), reported sexually transmitted diseases during pregnancy (45.2% versus 22.3%), and continued illicit drug use (67.7% versus 49.0%). In this group of infants, low birth weight, poor intrauterine growth, neonatal infections and possibly maternal chorioamnionitis, STDs during pregnancy, and continued drug use are associated with vertical transmission of HIV.

Perinatal outcome for women in prison

Pregnancy outcome for 233 women in prison was reviewed. This group of patients presented with multiple perinatal high-risk factors: history of illicit drug use (71%), smoking (70%), and obstetrical (27%), medical (21%), nutritional (20%), and infectious complications (20%). Maternal morbidity was uncommon and the overall cesarean section rate for all prisoners was 16%. There was 1 stillbirth and 236 live-born infants, all of whom were discharged in good health. Prematurity (3%) and delivery of small-for-gestational-age (SGA) (8%) infants was less common among 187 women who received adequate prenatal care than in 46 prisoners with poor or late prenatal care (prematurity 20% and SGA 28%). Good perinatal outcome for women in prison can be achieved if comprehensive prenatal care is available.

Duration of incarceration and perinatal outcome

The number of incarcerated women is increasing, thus pregnancy in prison is no longer uncommon. We reviewed the perinatal outcome of 53 women with short-term incarceration (fewer than 90 days) and of 53 women who experienced long-term incarceration (more than 120 days). Poor prenatal care, history of drug abuse, hepatitis, and poor nutrition were more common among the short-incarceration group. Of infants born to short-incarceration women, 32 (60%) were normal, four (7%) stillborn, eight (15%) premature, six (11%) small for gestational age, and four (7%) septic. Women in the long-incarceration group delivered 48 normal infants (91%), whereas two were offspring of diabetic mothers and three were premature. Birth weight for infants born to smokers in the short-incarceration group was significantly lower than that of infants born to smokers in the long-incarceration group. Women who suffer short incarcerations experience high perinatal mortality and morbidity. In contrast, those incarcerated longer appear to benefit from better prenatal care, improved nutrition, and a structured environment, and thus a more favorable perinatal outcome.

The effect of swimming in asthmatic children--participants in a swimming program in the city of Baltimore

Forty-five asthmatic children were enrolled in a swimming program in Baltimore. After participating in a 2-month swimming session, the children showed significant improvement in all clinical variables including symptoms, hospitalizations, emergency room visits, and school absenteeism compared with their previous medical history or to those of age-matched controls. These health benefits continued to be observed even 12 months after the session had been completed. The implications of these findings and the potential usefulness of adding sports programs as adjunct therapy in the comprehensive care of asthma in children are discussed.

Feather and beak dystrophy and necrosis in cockatoos: clinicopathologic evaluations

Several species of imported and captive-bred southeast Asian cockatoos with feather and beak disease (FBD) were evaluated. In recently emerging stained feathers from affected birds, intracytoplasmic magenta to basophilic inclusions of various sizes were found in macrophages and basophil-like cells within the pulp and feather epidermis. Occasionally, amphophilic intranuclear inclusions were seen within degenerated feather epidermal cells. On the basis of electron microscopic findings, intracytoplasmic inclusions were not membrane bound and consisted of crystalline arrays of viral particles (17 to 22 nm in diameter). On the basis of size and conformation, viral particles most closely resembled those of parvovirus or picornavirus. Consistent hematologic or serum enzyme differences were not found among affected or healthy cockatoos. Compared with findings in healthy cockatoos, cockatoos with FBD had significantly lower serum protein concentrations, and results of serum protein electrophoresis indicated that birds with FBD had significantly lower concentrations of prealbumin and gamma-globulin fractions. Mean pre- and post-ACTH plasma corticosterone concentrations of cockatoos with FBD were not significantly different from those of healthy cockatoos. In 8 of 9 affected cockatoos evaluated, serum T4 concentrations before and after thyrotropin stimulation were considered normal.

The clinical spectrum of autonomic dysfunction

Classic cases of idiopathic autonomic dysfunction are easily recognized, but certain presentations may not immediately suggest the diagnosis. Among 297 cases in the experience of our institutions, eight have been selected as illustrative of the difficulties which may be encountered. The disorder may present as angina pectoris, Parkinsonism, night blindness, nasal stuffiness, malignant hypertension, postprandial fainting, intracerebral hemorrhage and respiratory arrest. About half of the patients with idiopathic orthostatic hypotension manifest supine hypertension. These subjects are extremely sensitive to pressor and depressor agents; those who have angina pectoris complicating their disease are characteristically worsened by nitroglycerin.