The effectiveness of eHealth interventions on physical activity and measures of obesity among working-age women: a systematic review and meta-analysis.

Physical inactivity and obesity are modifiable risk factors for cardiovascular disease, particularly in women. eHealth interventions may increase physical activity and improve obesity-related outcomes among women. The objective of this study was to review the evidence of the effectiveness of eHealth interventions to increase moderate-to-vigorous physical activity among working-age women. The secondary objective was to examine their effectiveness on improving obesity-related outcomes. A comprehensive search strategy was developed for eight electronic databases; through July 2016. All studies consisting of >80% women of working-age (18-65 years) in high income countries were included. Multiple unblinded reviewers determined study eligibility and extracted data. Risk of bias was evaluated using the Cochrane Risk of Bias Tool and data quality using the Grading of Recommendations Assessment, Development and Evaluation approach. Data were pooled using a random-effects model. Sixty studies were included in the review of which 20 were in the meta-analysis. The meta-analysis demonstrated eHealth interventions improved moderate-to-vigorous physical activity (standard mean difference = 1.13, 95% confidence interval: 0.58, 1.68, P < 0.0001); an increase of ~25 min week-1 . No changes were observed in obesity-related outcomes; waist circumference (P = 0.06), body mass (P = 0.05) and body mass index (P = 0.35). eHealth interventions are effective at increasing min week-1 of moderate-to-vigorous physical activity among working-age women from high income countries.

Comparative clinical outcomes with St. Jude Medical, Medtronic Hall and CarboMedics mechanical heart valves.

BACKGROUND AND AIM OF THE STUDY: Whether the St. Jude Medical (SJM), Medtronic Hall (MH) or CarboMedics (CM) heart valves confer any relative benefits to patient outcome remains controversial. While numerous studies have analyzed clinical results with a single brand, and a few studies have compared two brands, there are no single-center trials comparing all three valves. METHODS: Our experience with patients who had either a SJM, MH or CM mechanical valve in isolated aortic valve (AVR) or mitral valve (MVR) replacement was reviewed. AVR was performed in 953 patients (SJM = 394, MH = 314, CM = 245) and MVR in 591 patients (SJM = 193, MH = 264, CM = 134). Survivors were assessed annually; follow up consisted of 3336 patient-years (pt-yr) after AVR and 1693 pt-yr after MVR. RESULTS: Preoperatively, in the AVR group, more MH patients had previous valve surgery (p = 0.001) or were in NYHA class III/IV (p = 0.03), and more CM patients had a concomitant surgical procedure (p = 0.005). The hospital mortality after AVR with SJM, MH and CM valves was 3.8, 4.7 and 5.3%, respectively (p = 0.65). In the MVR group, there were more males in the CM group (p = 0.011), more CM patients had concomitant surgery (p = 0.001), and more MH patients had previous surgery (p = 0.006). The hospital mortality after MVR with SJM, MH and CM valves was 8.3, 10.2 and 6.0%, respectively (p = 0.35). There was no late survival advantage in either the AVR or MVR group according to the valve used (p = 0.24 and p = 0.90, respectively). For the AVR group the five-year actuarial freedom from thromboembolism was: SJM 85.8 +/- 2.5%, MH 80.1 +/- 2.7% and CM 85.9 +/- 3.5% (p = 0.04), and for MVR it was: SJM 84.2 +/- 4.0%, MH 77.5 +/- 3.4% and CM 86.9 +/- 5.2% (p = 0.27). Bleeding occurred with a similar frequency in the AVR (p = 0.36) and MVR (p = 0.70) groups. No cases of structural failure were identified in this study. At follow up, among AVR patients NYHA class III/IV was present in: SJM 5%, MH 6% and CM 3% (p = 0.50), while among MVR patients this was identified in: SJM 7%, MH 10% and CM 4% (p = 0.22). CONCLUSION: It is concluded that the SJM, MH and CM mechanical valves offer similar clinical results when used for isolated AVR or MVR. While there is a suggestion of an advantage with bileaflet valves, any differences detected may simply reflect differences in the preoperative patient variables.

Gender differences in predictors for long-term smoking cessation following physician advice and nicotine replacement therapy.

We evaluated gender differences in demographic, smoking history, nicotine dependence, transtheoretical, and perceived stress variables as predictors of smoking cessation. Participants (n = 381) smoked at least 15 cigarettes per day and were motivated to quit. The outcome variable was 7-day abstinence at 1-year follow-up. Predictor variables included: age, education level, number of years smoking, cigarettes per day, quit attempts, nicotine dependence, stage of change, decisional balance, processes of change, self-efficacy, and perceived stress. Logistic regression analysis was used to derive predictive models for women and men. In women, lower scores for pre- and mid-treatment perceived stress significantly increased the likelihood of being abstinent at follow-up. For men, a higher level of education or number of quit attempts lasting > 24 hours in the past year, along with less frequent use of behavioural processes of change at baseline increased the probability of being abstinent at follow-up.

Determinants of hospital survival following reoperative single valve replacement.

OBJECTIVE: To determine the indicators of risk for hospital death, patients undergoing reoperative valve replacement were analyzed METHODS: Four hundred and eighteen consecutive patients undergoing reoperative valve replacement from 1977 to 1994 were reviewed using univariate and multivariate analysis. RESULTS: Overall hospital mortality was 11.2% with 9.4% mortality with aortic valve replacement and 14.2% with mitral valve replacement (P=0.52). Mortality was 9.7% for patients less than 70 years of age compared with 19.4% for older patients (P=0.03), and was 8.5% for those with anoxia times less than 90 mins versus 21.9% for those with longer anoxia times (P=0.001). For first reoperations, 9.5% of patients died, while for patients undergoing second or more reoperation, mortality was 23.2% (P=0.01). While mortality increased from 8.9% to 19.0% with the addition of a concomitant procedure (P=0.008), it was not affected if the additional procedure was a coronary bypass (P=0. 96). The indication for surgery influenced outcome. Mortality was zero for thromboembolism, 9% for structural failure, 23% for nonstructural failure and 22% for endocarditis (P=0.006). For New York Heart Association (NYHA) functional class I patients, mortality was 1.6% compared with 22.3% for those in NYHA class IV (P=0.006). By multivariate analysis, however, only the indication for surgery and the NYHA functional class influenced survival. CONCLUSIONS: Reoperative valve surgery can be performed with a survival (88.8%) that is similar to the initial procedure (91.2%). The indication for surgery and NYHA functional class alone influenced outcome; therefore, possible early reoperation is indicated before clinical deterioration occurs.

Are older patients with mechanical heart valves at increased risk?

BACKGROUND: Controversy exists regarding the use of mechanical valves in older patients. Many authorities believe that the use of anticoagulants in the elderly is associated with an increased risk of warfarin-related complications. Therefore, we compared the results with mechanical valves in older patients to a cohort of younger patients. METHODS: Aortic (AVR) or mitral valve replacement (MVR) with a mechanical valve was performed in 1,245 consecutive patients who were followed prospectively. They were grouped by age (group 1, < or = 65 years; group 2, > 65 years). The study groups consisted of AVR (group 1, 459 patients; group 2, 323 patients) MVR (group 1, 313 patients; group 2, 150 patients). RESULTS: The average age for the groups was: AVR (group 1, 51 years; group 2, 70 years; p = 0.03) and MVR (group 1, 53 years; group 2, 70 years; p = 0.03). For AVR the incidence of thromboembolism was 0.050 (group 1) and 0.038 (group 2) (p = 0.37) and the actuarial freedom from thromboembolism was 83.0%+/-3.0% and 86.5%+/-1.0%, respectively (p = 0.13). The incidence of bleeding after AVR was 0.021 for group 1 and 0.028 for group 2 (p = 0.49). For MVR the incidence of thromboembolism was 0.059 for group 1 and 0.051 for group 2 (p = 0.75) and the actuarial freedom from thromboembolism was 78.8%+/-3.0% and 75.4%+/-8.7%, respectively (p = 0.71). The incidence of bleeding after MVR was 0.020 for group 1 and 0.027 for group 2 (p = 0.62). CONCLUSIONS: Mechanical valves perform well in selected older patients with no increased risk of bleeding or thromboembolism.

Comparative results with the St. Jude Medical and Medtronic Hall mechanical valves.

This study compared the clinical performance of the St. Jude Medical and Medtronic Hall mechanical valves in isolated aortic or mitral valve replacement. From 1984 to 1993, 349 St. Jude Medical valves (aortic 237, mitral 112) and 465 Medtronic Hall valves (aortic 272, mitral 193) were implanted in 814 patients at the University of Ottawa Heart Institute. The patients had similar preoperative characteristics. The hospital mortality rate for aortic valve replacement was 3.4% with the St. Jude Medical valve and 5.8% with the Medtronic Hall valve (p = 0.26) and the rate for mitral valve replacement was 8.9% with the St. Jude Medical valve and 11.9% with the Medtronic Hall valve (p = 0.54). Actuarial estimates of survival and freedom from complications were calculated. At 5 years the actuarial probability of survival (including hospital deaths) for aortic valve replacement was 86% +/- 3% with the St. Jude Medical valve and 68% +/- 4% with the Medtronic Hall valve (p = 0.0001) and for mitral valve replacement was 75% +/- 7% with the St. Jude Medical valve and 70% +/- 4% with the Medtronic Hall valve (p = 0.54). The most common cause of late death was cardiac failure and no deaths were caused by structural failure. The 5-year probability of freedom from bleeding after aortic valve replacement was 99% +/- 1% with the St. Jude Medical valve and 95% +/- 2% with the Medtronic Hall valve (p = 0.06) and after mitral valve replacement 99% +/- 1% with the St. Jude Medical valve and 97% +/- 2% with the Medtronic Hall valve (p = 0.37). The 5-year probability of freedom from thromboembolism after aortic valve replacement was 88% +/- 4% with the St. Jude Medical valve and 81% +/- 3% with the Medtronic Hall valve (p = 0.08) and after mitral valve replacement was 85% +/- 7% with the St. Jude Medical valve and 77% +/- 5% with the Medtronic Hall valve (p = 0.17). Reoperation was uncommon and there were no cases of structural valve failure. The 5-year actuarial estimate of freedom from reoperation therefore for aortic valve replacement was 99% +/- 1% with the St. Jude Medical valve and 96% +/- 2% with the Medtronic Hall valve (p = 0.09) and for mitral valve replacement was 98% +/- 2% with the St. Jude Medical valve and 95% +/- 3% with the Medtronic Hall valve (p = 0.40).(ABSTRACT TRUNCATED AT 400 WORDS)

Long-term experience with the Ionescu-Shiley pericardial valve.

To determine the long-term durability of the Ionescu-Shiley valve, we analyzed our experience with this valve at the University of Ottawa Heart Institute. To 1988, 780 patients have had aortic valve replacement (AVR = 528) or mitral valve replacement (MVR = 252). Of the aortic valves, 310 were standard profile and 218 were low profile. Of the mitral valves, 143 were standard profile and 109 were low profile. Actuarial survival at 10 years was as follows: AVR, 62% +/- 3%; MVR, 58% +/- 4%; p = 0.42. At 14 years, the results were AVR, 44% +/- 1% and MVR, 46% +/- 5%; p = 0.40. Reoperation was required in 197 patients. Structural failure was present in 85% of these valves, with leaflet tears alone in 69%, tears with calcification in 21%, and calcification alone in 10%. Leaflet tears occurred in 95% after AVR and in 78% after MVR (p = 0.006) and were seen in 95% of low-profile valves and 87% of standard-profile valves (p = 0.16). The actuarial freedom from reoperation at 10 years was: AVR, 58% +/- 3%; MVR, 62% +/- 5%; p = 0.49. At 13 years, these rates were 38% +/- 4% for AVR and 25% +/- 9% for MVR (p = 0.79). For AVR, the 10-year rate of freedom from reoperation was 57% +/- 4% for standard-profile valves and 57% +/- 8% for low-profile valves (p = 1.0). Similarly for MVR, the 10-year freedom from reoperation was 61% +/- 6% for standard-profile valves and 68% +/- 8% for low-profile valves.(ABSTRACT TRUNCATED AT 250 WORDS)

Using an objective structured clinical examination to evaluate competency in sport medicine.

This article discusses the development, format, administration and scoring of the objective structured clinical examination (OSCE) to evaluate competency in sport medicine. The credentials committee of the Canadian Academy of Sport Medicine has developed an examination to evaluate the competency of practicing physicians in the field of sport medicine. The examination is based on a sport medicine matrix that includes five areas: (a) clinical patient care, (b) team and event coverage, (c) medical/legal issues, (d) teaching and administration, and (e) research. The emphasis is on clinical patient care followed by team and event coverage, with the other three areas having a lesser degree of importance. The OSCE format consists of a number of stations or scenarios based on this matrix. The candidates are evaluated on a check list that reflects the emphasis of each station. A typical clinical patient care problem includes check list items related to the history, physical examination, investigations, diagnosis, and treatment. The candidates are also evaluated for their attitudes and techniques on each station. The examination includes volunteer examiners and patients both simulated and real. The candidates are evaluated through the use of checklists that are filled in by the examiners on optical scoring sheets. These are collated and analyzed to generate comparisons between candidates and to determine the psychometric properties of the overall examination. The examination has consistently scored reliability coefficients of 0.8 or greater. The 1993 examination demonstrated reliability coefficients of 0.89-0.97. Interrater reliability was also calculated, and these values ranged from 0.85 to 0.99. The examination also reflects both face and content validity.(ABSTRACT TRUNCATED AT 250 WORDS)

Patterns of failure in Hancock pericardial bioprostheses.

A series of Hancock pericardial valve bioprostheses was reviewed for cases of primary valve failure. Thirteen mitral and 10 aortic valve explants were recovered from 21 adult patients. Mitral valves had been in place for a mean of 56.4 months, and aortic valves for 53.8 months. All valves failed with cusp tears from stents (with a mean of 1.7 for mitral valves and 2.6 for aortic valves) in a predictable pattern, suggesting that wear and stress at cusp stitch sites are important in their pathogenesis. The topography of these tears is illustrated as are the less common associates of primary failure, such as calcification, fibrosis, and thrombosis. Similarities and differences of this valve's failure compared with that of the Ionescu-Shiley pericardial valve are discussed.

Long-term clinical results with the Ionescu-Shiley pericardial xenograft.

From 1977 to 1987, 829 Ionescu-Shiley pericardial valves (Shiley, Inc., Irvine, Calif.) were implanted in 766 patients at the University of Ottawa Heart Institute. There were 476 patients who had aortic valve replacement, 234 who had mitral valve replacement, and 44 who had double valve replacement. The standard-profile design was used in 508 patients and the low-profile design in 321 patients. Follow-up was obtained for 97% of patients, with calculation of event-free probabilities. At 10 years the overall probability of freedom from structural failure was 48% +/- 7% after aortic valve replacement, 44% +/- 15% after mitral valve replacement, and 79% +/- 11% after double valve replacement. Although at 5 years the probability of failure was statistically lower with the low-profile design, this favorability was lost by 6 years. Freedom from structural failure was only 47% +/- 7% for the standard-profile valve at 10 years. Thus the probability of freedom from reoperation was only 46% +/- 7% after aortic valve replacement, 39% +/- 6% after mitral valve replacement, and 65% +/- 20% after double valve replacement at 10 years. Thromboembolism occurred in 69 patients, for a predicted freedom from this complication at 10 years of 79% +/- 3% after aortic, 73% +/- 7% after mitral, and 96% +/- 4% after double valve replacement. There were 31 cases of endocarditis. The 10-year predicted freedom from endocarditis, therefore, was 86% +/- 3% after aortic, 98% +/- 1% after mitral, and 97% +/- 1% after double valve replacement. A total of 221 operative and late deaths were recorded in this series. Prosthetic valve failure accounted for 27% of late deaths. The 10-year survival rates were estimated to be 56% +/- 5% (aortic valve replacement), 54% +/- 6% (mitral valve replacement), and 51% +/- 8% (double valve replacement). We concluded that the Ionescu-Shiley pericardial xenograft provides less than optimal clinical performance and its use has been discontinued.

Heart Murmur in a Football Player With a Normal ECG.

Some athletes, though vigorous in their sports pursuits, may have life-thteatening cardiac anomalies. As this case conference demonstrates, such abnormalities are not always apparent on ECG or radiographic studies.