Where have we come from and where are we going? The paediatric HIV programme in Johannesburg, South Africa, from 2004 to 2018: A retrospective analysis of programme trends.

BACKGROUND: The paediatric HIV treatment programme in South Africa (SA) has grown since its inception in 2004. Despite this impressive scale-up of antiretroviral therapy (ART) in children, the proportion of children started on ART and retained in care remains unacceptably low, with only 47% of the 340 000 HIV-positive children in SA on ART in 2020. Johannesburg is one of the districts in SA with the largest number of children living with HIV who are not on ART, and is a priority district for paediatric case finding and retention. OBJECTIVES: To describe the dynamics of the paediatric HIV programme in Johannesburg, SA. METHODS: A secondary analysis was conducted on patient-level HIV treatment data from TIER.Net, the nationally mandated HIV/ART database. Children aged <15 years who received ART between January 2004 and June 2019 at public health facilities in Johannesburg were included. We reported the number of children on ART and the number who entered and exited the programme by age group over time, and analysed the trends of these indicators. RESULTS: By December 2018, 7 630 children aged <15 years remained in Johannesburg's paediatric ART programme: 82.5% were aged 5 - <15 years, with 54.1% of these being 10 - <15 years old. During the study period, 19 850 children were newly initiated on ART. New initiations slowed from 2013, to range from 1 172 to 1 373 yearly. In 2018, 34.2% of initiators were aged <1 year, 24.2% 1 - <5 years and 41.6% 5 - <15 years. Despite these initiations, the number of children on ART only grew by 97 in 2018, owing to programme losses. In 2018, 924  children (12.1%) aged out, 35 (0.5%) died and 983 (12.9%) were lost to follow-up (LTFU), the latter having increased from 10.7% in 2017. Of children who aged out of the paediatric ART programme, 56.3% remained in care at the same facility. CONCLUSION: Early in the SA ART roll-out, many children were found to be HIV infected and started on ART. This number started to slow in 2013, after which the growth rate of the paediatric HIV programme also began to slow. Scale-up of methods for identifying older children with HIV is needed. While ageing out of the paediatric programme is a consideration, the number of children LTFU remains unacceptably high. Further interrogation of barriers to paediatric retention is needed to help realise the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90:90:90 goals for children in SA.

Effect of COVID-19 on HIV, tuberculosis, and prevention of mother-to-child transmission of HIV indicators in Mopani district, South Africa.

BACKGROUND: To prevent the spread of SARS-CoV-2, many countries instituted lockdown measures. As the virus was initially slow to spread to rural areas in South Africa, Mopani district in Limpopo Province did not experience a high incidence of COVID-19 until the second wave in December 2020. Until then, lockdown measures were more likely than SARS-CoV-2 infections to have an adverse impact on health services. OBJECTIVES: To analyse HIV, tuberculosis (TB) and prevention of mother-to-child transmission of HIV (PMTCT) indicator trends in Mopani during the COVID-19 lockdown and two COVID-19 waves. METHODS: Using monthly data from the District Health Information System from February 2019 to December 2020, we conducted a retrospective review of data elements and indicators that fall into the following domains: primary healthcare head count (HC), HIV, antiretroviral treatment (ART), PMTCT and TB. Aggregated data were analysed, and an interrupted time series analysis was conducted. We assessed percentage changes between the January - March 2020 and April - June 2020 periods, and differences in means for the period April - December 2019 v. the period April - December 2020 were assessed for statistical significance. RESULTS: At the start of the first wave in April 2020, a statistically significant decline of 10% was recorded for total HC utilisation rates (p=0.1). We also found declines of 665 HIV tests (from 1 608 to 942) and 22 positive HIV tests (from 27 to 4) for children between the ages of 18 months and 14 years (p=0.05), with no recovery. Significant declines were also recorded for children aged <15 years starting (change from 35 to 21) and remaining (change from 4 032 to 3 986) on ART, as well as for adults starting ART (change from 855 to 610) at the onset of the first wave (p=0.01). No significant change was detected in PMTCT and TB indicators during the first wave. Pronounced decreases in HC were recorded in December, during the country's second wave (change from 237 965 to 227 834). CONCLUSION: Declines were recorded for most indicators in Mopani, with HC being affected the most at the start of the first wave and not showing any significant recovery between waves. Strategies are required to mitigate the effects of future COVID-19 waves and encourage positive health-seeking behaviour.

Rapid review of the effects of cloth and medical masks for preventing transmission of SARS-CoV-2 in community and household settings.

BACKGROUND: Evidence on mask use in the general population is needed to inform SARS-CoV-2 responses. OBJECTIVES: To assess the effectiveness of cloth and medical masks for preventing SARS-CoV-2 transmission in community settings. METHODS: Two rapid reviews were conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and two clinical trials registries on 30 and 31 March 2020. RESULTS: We screened 821 records and assessed nine full-text articles for eligibility. One and seven RCTs were included for cloth and medical mask reviews, respectively. No SARS-CoV-2-specific RCTs and no cloth mask RCTs in community settings were identified. A single hospital-based RCT provided indirect evidence that, compared with medical masks, cloth masks probably increase clinical respiratory illnesses (relative risk (RR) 1.56; 95% confidence interval (CI) 0.98 - 2.49) and laboratory-confirmed respiratory virus infections (RR 1.54; 95% CI 0.88 - 2.70). Evidence for influenza-like illnesses (ILI) was uncertain (RR 13.00; 95% CI 1.69 - 100.03). Two RCTs provide low-certainty evidence that medical masks may make little to no difference to ILI infection risk versus no masks (RR 0.98; 95% CI 0.81 - 1.19) in the community setting. Five RCTs provide low-certainty evidence that medical masks may slightly reduce infection risk v. no masks (RR 0.81; 95% CI 0.55 - 1.20) in the household setting. CONCLUSIONS: Direct evidence for cloth and medical mask efficacy and effectiveness in the community is limited. Decision-making for mask use may consider other factors such as feasibility and SARS-CoV-2 transmission dynamics; however, well-designed comparative effectiveness studies are required.

Primary healthcare workers at risk during COVID-19: An analysis of infections in HIV service providers in five districts of South Africa.

BACKGROUND: Protecting healthcare workers (HCWs) from COVID-19 is a global priority. Anova Health Institute (Anova) is the PEPFAR (US President's Emergency Plan for AIDS Relief) District Support Partner for the Johannesburg, Cape Town, Sedibeng, Capricorn and Mopani districts in South Africa, operating in public sector primary healthcare facilities. At the time of the emergence of COVID-19, Anova employed close to 4 000 people: 41% community health workers (CHWs), 23% data staff, 20% nurses and doctors, 12% management/support and 5% allied HCWs. OBJECTIVES: To describe rates of COVID-19 diagnosis in Anova-employed HCWs in five districts. METHODS: Employees exposed to, tested for or diagnosed with COVID-19 were required to report the event. These reports were compiled into a database to monitor the impact of COVID-19 on the workforce. We kept a timeline of key events occurring at national and district level, including Anova's policies and their implementation, that was used to describe organisational response. We described the number of confirmed cases, cumulative incidence rates and testing rates, broken down by district and job category. We estimated expected deaths and the effect on time off work. RESULTS: Of Anova employees, 14% (n=562) were diagnosed with COVID-19 by the end of September 2020. Cumulative incidence was highest in Sedibeng (29%) and lowest in Mopani (5%). All HCWs experienced high incidences: data staff 17%, allied HCWs 16%, CHWs 14%, nurses and doctors 13%, and management/support 11%. At the peak of the epidemic, for 5 weeks, >5% of employees were unable to work owing to exposure or infection, significantly disrupting service delivery. The additional administrative burden on managers was substantial. CONCLUSIONS: It is critical that all cadres of HCWs are protected in the workplace, including in primary care settings, where better structuresare needed to perform risk assessments and conduct outbreak investigations. CHWs and data staff may be at higher risk owing to poor infrastructure, limited power to negotiate working conditions, and limited experience of infection prevention and control. Their working conditions must be improved to reduce their risk.

Time to oxygenation for cannula- and scalpel-based techniques for emergency front-of-neck access: a wet lab simulation using an ovine model.

Emergency front-of-neck access to achieve a percutaneous airway can be a life-saving intervention, but there is debate about the preferred technique. This prospective, observational study was designed to compare the two most common emergency surgical airway techniques in a wet lab simulation using an ovine model. Forty-three doctors participated. After providing standardised reading, a lecture and dry lab benchtop training, participants progressed to a high-fidelity wet lab simulation. Participants entered an operating theatre where a 'cannot intubate, cannot oxygenate' situation had been declared and were directed to perform emergency front-of-neck access: first with a cannula technique (14-gauge cannula insertion with ventilation using a Rapid-O2® cricothyroidotomy insufflation device); and subsequently, a scalpel-bougie technique (surgical incision, bougie insertion into trachea and then tracheal tube passed over bougie, with ventilation using a self-inflating bag). The primary end-point was time from declaration of 'cannot intubate, cannot oxygenate' to delivery of oxygen via a correctly placed percutaneous device. If a cannula or tracheal tube was not placed within 240 s, the attempt was marked as a failure. There was one failure for the cannula approach and 15 for the scalpel-bougie technique (OR 0.07 (95%CI 0.00-0.43); p <0.001). Median (IQR [range]) time to oxygenation, if successful, was 65 (57-78 [28-160]) s for the cannula approach and 90 (74-115 [40-265]) s for the scalpel-bougie technique (p=0.005). In this ovine model, emergency front-of-neck access using a cannula had a lower chance of failure and (when successful) shorter time to first oxygen delivery compared with a scalpel-bougie technique.

Hormone-secreting adrenal tumours cause severe hypertension and high rates of poor pregnancy outcome; a UK Obstetric Surveillance System study with case control comparisons.

OBJECTIVE: To examine the management and outcomes of adrenal tumours in pregnancy. DESIGN: A national observational, cohort study over 4 years using the UK Obstetric Surveillance System (UKOSS). SETTING: Consultant-led obstetric units. PATIENTS: Women with phaeochromocytoma, primary aldosteronism or Cushing's syndrome diagnosed before or during pregnancy. METHODS: Clinical features of UKOSS cases were compared with those of women with adrenal tumours reported from 1985-2015. Nested case-control comparisons involving the UKOSS cases as well as those identified in the literature were performed for pregnancy outcome data using UKOSS controls with uncomplicated singleton (n = 2250) pregnancy and data from the Office of National Statistics (ONS). MAIN OUTCOME MEASURES: Incidence, management and frequency of adverse maternal and offspring outcomes of adrenal tumours in pregnancy. RESULTS: Fifteen pregnant women met the inclusion criteria: ten phaeochromocytoma, three primary aldosteronism and two Cushing's syndrome. All of the tumours had an incidence rate <2 per 100 000 pregnancies. Clinical symptoms were similar to those in non-pregnant women due to the hormones released. All women had severe hypertension, and in those diagnosed in pregnancy prior to conception. There was a significantly increased risk of adverse pregnancy outcomes in affected women, with increased rates of stillbirth, preterm labour and operative delivery. CONCLUSIONS: Adrenal tumours are associated with increased risks for pregnant women and their babies. Data on these tumours to inform practice are limited and international collaborative efforts are likely to be needed. TWEETABLE ABSTRACT: Study of hormone-secreting adrenal tumours in pregnancy linked with high BP and high rates of fetal morbidity.

The impact of implementing a Xpert MTB/RIF algorithm on drug-sensitive pulmonary tuberculosis: a retrospective analysis.

Xpert MTB/RIF (Xpert) is the preferred first-line test for all persons with tuberculosis (TB) symptoms in South Africa in line with a diagnostic algorithm. This study evaluates pre- and post-implementation trends in diagnostic practices for drug-sensitive, pulmonary TB in adults in an operational setting, following the introduction of the Xpert-based algorithm. We retrospectively analysed data from the national TB database for Greater Tzaneen sub-district, Limpopo Province. Trends in a number of cases, diagnosis and outcome and characteristics associated with death are reported. A total of 8407 cases were treated from 2008 until 2015, with annual cases registered decreasing by 31·7% over that time period (from 1251 to 855 per year). After implementation of Xpert, 69·9% of cases were diagnosed by Xpert, 29·4% clinically, 0·6% by smear microscopy and 0·1% by culture. Cases with a recorded microbiological test increased from 76·2% to 96·4%. Cases started on treatment without confirmation, but with a negative microbiological test increased from 7·1% to 25·7%. Case fatality decreased from 15·0% to 9·8%, remaining consistently higher in empirically treated groups, regardless of HIV status. Implementation of the algorithm coincided with a reduced number of TB cases treated and improved coverage of microbiological testing; however, a substantial proportion of cases continued to start treatment empirically.

Periglacial fires and trees in a continental setting of Central Canada, Upper Pleistocene.

Fire is a key factor controlling global vegetation patterns and carbon cycling. It mostly occurs under warm periods during which fuel builds up with sufficient moisture, whereas such conditions stimulate fire ignition and spread. Biomass burning increased globally with warming periods since the last glacial era. Data confirming periglacial fires during glacial periods are very sparse because such climates are likely too cold to favour fires. Here, tree occurrence and fires during the Upper Pleistocene glacial periods in Central Canada are inferred from botanical identification and calibrated radiocarbon dates of charcoal fragments. Charcoal fragments were archived in sandy dunes of central Saskatchewan and were dated >50000-26600 cal BP. Fragments were mostly gymnosperms. Parallels between radiocarbon dates and GISP2-δ¹8O records deciphered relationships between fire and climate. Fires occurred either hundreds to thousands of years after Dansgaard-Oeschger (DO) interstadial warming events (i.e., the time needed to build enough fuel for fire ignition and spread) or at the onset of the DO event. The chronological uncertainties result from the dated material not precisely matching the fires and from the low residual ¹4C associated with old sample material. Dominance of high-pressure systems and low effective moisture during post-DO coolings likely triggered flammable periglacial ecosystems, while lower moisture and the relative abundance of fuel overshadowed lower temperatures for fire spread. Laurentide ice sheet (LIS) limits during DO events are difficult to assess in Central Canada due to sparse radiocarbon dates. Our radiocarbon data set constrains the extent of LIS. Central Saskatchewan was not covered by LIS throughout the Upper Pleistocene and was not a continental desert. Instead, our results suggest long-lasting periods where fluctuations of the northern tree limits and fires after interstadials occurred persistently.

Parent-only interventions in the treatment of childhood obesity: a systematic review of randomized controlled trials.

BACKGROUND: An effective and cost-effective treatment is required for the treatment of childhood obesity. Comparing parent-only interventions with interventions including the child may help determine this. METHODS: A systematic review of published and ongoing studies until 2013, using electronic database and manual searches. INCLUSION CRITERIA: randomized controlled trials, overweight/obese children aged 5-12 years, parent-only intervention compared with an intervention that included the child, 6 months or more follow-up. Outcomes included measures of overweight. RESULTS: Ten papers from 6 completed studies, and 2 protocols for ongoing studies, were identified. Parent-only groups are either more effective than or similarly effective as child-only or parent-child interventions, in the change in degree of overweight. Most studies were at unclear risk of bias for randomization, allocation concealment and blinding of outcome assessors. Two trials were at high risk of bias for incomplete outcome data. Four studies showed higher dropout from parent-only interventions. One study examined programme costs and found parent-only interventions to be cheaper. CONCLUSIONS: Parent-only interventions appear to be as effective as parent-child interventions in the treatment of childhood overweight/obesity, and may be less expensive. Reasons for higher attrition rates in parent-only interventions need further investigation.

Healthcare professionals' views on two computer-based decision aids for women choosing mode of delivery after previous caesarean section: a qualitative study.

OBJECTIVE: To explore healthcare professionals' views about decision aids, developed by the DiAMOND study group, for women choosing mode of delivery after a previous caesarean section. DESIGN/METHODS: A qualitative focus group study. Data were analysed thematically. SETTING: Two city maternity units, surrounding community midwife units and general practitioner (GP) practices in southwest England. SAMPLE: Twenty-eight healthcare professionals, comprising obstetricians, hospital and community midwives and GPs, who participated in six focus groups. RESULTS: Participants were generally positive about the decision aids. Most thought they should be implemented during early pregnancy in the community, but should be accessible throughout pregnancy, with any arising questions discussed with an obstetrician nearer to term. Perceived barriers to implementation included service issues (e.g. time pressure, cost and access), computer issues (e.g. computer literacy) and people issues (e.g. women's prior delivery preferences and clinician preference). Facilitators to implementation included access to more standardised and reliable information and empowerment of the user. Self-accessing the aids, increased awareness of decision aids among healthcare professionals and incorporation of aids into usual care were suggested as possible ways to improve implementation success. CONCLUSIONS: This study gives insight into healthcare professionals' views on the role of decision aids for women choosing a mode of delivery after a prior caesarean section. It highlights potential obstacles to their implementation and ways to address these. Such aids could be a useful adjunct to current antenatal care.

Dietary advice for reducing cardiovascular risk.

BACKGROUND: Changes in population diet are likely to reduce cardiovascular disease and cancer, but the effect of dietary advice is uncertain. OBJECTIVES: To assess the effects of providing dietary advice to achieve sustained dietary changes or improved cardiovascular risk profile among healthy adults. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials, DARE and HTA databases on The Cochrane Library (Issue 4 2006), MEDLINE (1966 to December 2000, 2004 to November 2006) and EMBASE (1985 to December 2000, 2005 to November 2006). Additional searches were done on CAB Health (1972 to December 1999), CVRCT registry (2000), CCT (2000) and SIGLE (1980 to 2000). Dissertation abstracts and reference lists of articles were checked and researchers were contacted. SELECTION CRITERIA: Randomised studies with no more than 20% loss to follow-up, lasting at least 3 months involving healthy adults comparing dietary advice with no advice or minimal advice. Trials involving children, trials to reduce weight or those involving supplementation were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Thirty-eight trials with 46 intervention arms (comparisons) comparing dietary advice with no advice were included in the review. 17,871 participants/clusters were randomised. Twenty-six of the 38 included trials were conducted in the USA. Dietary advice reduced total serum cholesterol by 0.16 mmol/L (95% CI 0.06 to 0.25) and LDL cholesterol by 0.18 mmol/L (95% CI 0.1 to 0.27) after 3-24 months. Mean HDL cholesterol levels and triglyceride levels were unchanged. Dietary advice reduced blood pressure by 2.07 mmHg systolic (95% CI 0.95 to 3.19) and 1.15 mmHg diastolic (95% CI 0.48 to 1.85) and 24-hour urinary sodium excretion by 44.2 mmol (95% CI 33.6 to 54.7) after 3-36 months. Three trials reported plasma antioxidants where small increases were seen in lutein and beta-cryptoxanthin, but there was heterogeneity in the trial effects. Self-reported dietary intake may be subject to reporting bias, and there was significant heterogeneity in all the following analyses. Compared to no advice, dietary advice increased fruit and vegetable intake by 1.25 servings/day (95% CI 0.7 to 1.81). Dietary fibre intake increased with advice by 5.99 g/day (95% CI 1.12 to 10.86), while total dietary fat as a percentage of total energy intake fell by 4.49 % (95% CI 2.31 to 6.66) with dietary advice and saturated fat intake fell by 2.36 % (95% CI 1.32 to 3.39). AUTHORS' CONCLUSIONS: Dietary advice appears to be effective in bringing about modest beneficial changes in diet and cardiovascular risk factors over approximately 10 months but longer term effects are not known.

Impact of ectomycorrhizal colonization of hybrid poplar on the remediation of diesel-contaminated soil.

Infection by ectomycorrhizal (ECM) fungi may benefit hybrid poplar growing in contaminated soils by providing greater access to water and nutrients and possibly protecting the trees from direct contact with toxic contaminants. The objective of this research was to determine the effect of colonization of the ECM fungus Pisolithus tinctorius (Pers.) Coker & Couch on hybrid poplar fine root production, biomass and N and P uptake when grown in diesel-contaminated soil (5000 mg diesel fuel kg soil(-1)). Commercially available Mycogrow Tree Tabs were the source of inoculum. A minirhizotron camera was used to provide the data necessary for estimating fine root production. Colonization of hybrid poplar roots (P. deltoides x [P. laurifolia x P. nigra] cv. Walker) by P. tinctorius increased total fine root production in diesel-contaminated soil to 56.58 g m(-2) compared to 22.59 g m(-2) in the uncolonized, diesel-contaminated treatment. Hybrid poplar leaf N and P concentrations were significantly greater in the diesel-contaminated/ECM-colonized treatment compared to the diesel-contaminated/uncolonized treatment after 12 wk, while significantly less diesel fuel was recovered from the soil of the uncolonized treatment compared to the colonized treatment. Both planted treatments removed more contaminants from the soil than an unplanted control. Significantly greater concentrations of total petroleum hydrocarbons (TPH) were found sequestered in hybrid poplar root/fungal-sheath complexes from the colonized treatment compared to the roots of the uncolonized treatment. The results of this study indicate that over a 12-wk growth period, ECM colonization of hybrid poplar in diesel-contaminated soils increased fine root production and whole-plant biomass, but inhibited removal of TPH from the soil.

Caring for people who are dying on renal wards: a retrospective study.

Unfortunately, there is still a high mortality rate among patients with end-stage renal disease (ESRD). If the decision is made to activate non-dialytic management of the patient with ESRD, it should be made jointly by the patient and responsible consultant nephrologist after consultation with relatives, the family doctor and other relevant members of the caring team. This paper discusses the establishment of a new renal supportive care service for patients opting not to have dialysis and focuses on the results of a 'death audit' carried out on this patient population. Recommendations for practice resulting from analysis of the audit results include, the use of advance directives, identification and prompt treatment of symptoms, increased staff education, timely referral to the palliative care team and expansion and further integration of the renal supportive care team.

Dietary advice for reducing cardiovascular risk.

BACKGROUND: Changes in population diet are likely to reduce cardiovascular disease and cancer, but the effect of dietary advice is uncertain. OBJECTIVES: To assess the effects of providing dietary advice to achieve sustained dietary changes or improved cardiovascular risk profile among healthy adults. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register on The Cochrane Library (Issue 2 2000), MEDLINE (January 1966 to December 2000), EMBASE (January 1985 to December 2000), DARE (December 2000), CAB Health (December 1999), dissertation abstracts, and reference lists of articles. We contacted researchers in the field. SELECTION CRITERIA: Randomised studies with no more than 20% loss to follow-up, lasting at least three months involving healthy adults comparing dietary advice with no advice or less intensive advice. Trials involving children, trials to reduce weight or those involving supplementation were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Twenty-three trials with 29 intervention arms (comparisons) comparing dietary advice with no advice were included in the review. Dietary advice reduced total serum cholesterol by 0.13 mmol/l (95% CI 0.03 to 0.23) and LDL cholesterol by 0.13 mmol/l (95% CI 0.01 to 0.25) after 3-12 months. Mean HDL cholesterol levels were unchanged. Dietary advice reduced blood pressure by 2.10 mmHg systolic (95% CI 1.37 to 2.83) and 1.63 mmHg diastolic (95% CI 0.56 to 2.71) and 24-hour urinary sodium excretion by 44.2 mmol (95% CI 33.6 to 54.7) after 3-36 months. Plasma triglycerides, ss-carotene and red cell folate were each measured in one small study which suggested no significant effect. Self-reported dietary intake may be subject to reporting bias, and there was significant heterogeneity in all the following analyses. Compared to no advice, dietary advice increased fruit and vegetable intake by 1.24 servings/day (95% CI 0.43 to 2.05). Dietary fibre intake increased with advice by 7.22 g/day (95% CI 2.84 to 11.60), while total dietary fat as a percentage of total energy intake fell by 6.18 % (95% CI 4.00 to 8.36) with dietary advice and saturated fat intake fell by 3.28 % (95% CI 1.92 to 4.64). AUTHORS' CONCLUSIONS: Dietary advice appears to be effective in bringing about modest beneficial changes in diet and cardiovascular risk factors over approximately 9 months but longer term effects are not known.

Provision, uptake and cost of cardiac rehabilitation programmes: improving services to under-represented groups.

OBJECTIVES: To estimate UK need for outpatient cardiac rehabilitation, current provision and identification of patient groups not receiving services. To conduct a systematic review of literature on methods to improve uptake and adherence to cardiac rehabilitation. To estimate cost implications of increasing uptake of cardiac rehabilitation. DATA SOURCES: Hospital Episode Statistics (England). Hospital Inpatient Systems (Northern Ireland). Patients Episode Database for Wales. British Association for Cardiac Rehabilitation/British Heart Foundation surveys. Cardiac rehabilitation centres. Patients from general hospitals. Electronic databases. REVIEW METHODS: The study analysed hospital discharge statistics to ascertain the population need for outpatient cardiac rehabilitation in the UK. Surveys of cardiac rehabilitation programmes were conducted to determine UK provision, uptake and audit activity, and to identify local interventions to improve uptake. Data were also examined from a trial estimating eligibility for cardiac rehabilitation and non-attendance. A systematic review of interventions to improve patient uptake, adherence and professional compliance in cardiac rehabilitation was conducted. Estimated costs of improving uptake were identified from national survey, systematic review and sampled cardiac rehabilitation programmes. RESULTS: In England, Wales and Northern Ireland nearly 146,000 patients discharged from hospital with primary diagnosis of acute myocardial infarction, unstable angina or following revascularisation were potentially eligible for cardiac rehabilitation. In England in 2000, 45-67% of these patients were referred, with 27-41% attending outpatient cardiac rehabilitation. If all discharge diagnoses of ischaemic heart disease were considered, nearly 299,000 patients would be potentially eligible and in England rates of attendance and referral would be 22-33% and 13-20% respectively. Rates of referral and attendance were similar in Wales, but somewhat lower in Northern Ireland. It was found that referral and attendance of older people and women at cardiac rehabilitation tended to be low. It was also suggested that patients from ethnic minorities and those with angina or heart failure were less likely to be referred to or join programmes. A wide range of local interventions suggested awareness of the problem of uptake. In an NHS-funded randomised controlled trial, possibly representing more optimal protocol-led care, medical and nursing staff identified 73-81% of patients with acute myocardial infarction as eligible for cardiac rehabilitation. Excluded patients tended to be older with more severe presentation of cardiac disease. Experiences of patients suggested that uptake may be improved by addressing issues of motivation and relevance of rehabilitation to future well-being, co-morbidities, site and time of programme, transport and care for dependents. Systematic review of studies supported the use of letters, pamphlets or home visits to motivate patients and the use of trained lay visitors. Self-management techniques showed some value in promoting adherence to lifestyle changes. Studies examining professional compliance found that professional support for practice nurses may have value in the coordination of postdischarge care. Average costs in 2001 of cardiac rehabilitation to the health service per patient completing a cardiac rehabilitation programme were about GBP350 (staff only) and GBP490 (total). If services were modelled on an intermediate multidisciplinary configuration with three to five key staff, approximately 13% more patients could be treated with the same budget. Depending on staffing configuration an approximate 200-790% budget increase would be required to provide cardiac rehabilitation to all potentially eligible patients. CONCLUSIONS: Provision of outpatient cardiac rehabilitation in the UK is low and little is known about the capacity of cardiac rehabilitation centres to increase this provision. There is an uncoordinated approach to audit data collection and few interventions aimed at improving the situation have been formally evaluated. Motivational communications and trained lay volunteers may improve uptake of cardiac rehabilitation, as may self-management techniques. Experience of low-cost interventions and good practice exists within rehabilitation centres, although cost information frequently is not reported. Increased provision of outpatient cardiac rehabilitation will require extra resources. Further trials are required to compare the cost-effectiveness of comprehensive multidisciplinary rehabilitation with simpler outpatient programmes, also research is needed into economic and patient preference studies of the effects of different methods of using increased funding for cardiac rehabilitation. An evaluation of a range of interventions to promote attendance in all patients and under-represented groups would also be useful. The development of standards is suggested for audit methods and for eligibility criteria, as well as regular and comprehensive data collection to estimate the need for and provision of cardiac rehabilitation. Further areas for intervention could be identified through qualitative studies, and the extension of low-cost interventions and good practice within rehabilitation centres. Regularly updated systematic reviews of relevant literature would also be useful.

Exercise based rehabilitation for heart failure.

BACKGROUND: The prevalence of chronic heart failure is increasing, and increases with increasing age. Major symptoms include breathlessness and restricted activities of daily living due to reduced functional capacity, which in turn affects quality of life. Exercise training has been shown to be effective in patients with coronary heart disease and has been proposed as an intervention to improve exercise tolerance in patients with heart failure. OBJECTIVES: To determine the effectiveness of exercise based interventions compared with usual medical care on the mortality, morbidity, exercise capacity and health related quality of life, of patients with heart failure. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (The Cochrane Library Issue 2, 2001), MEDLINE (2000 to March 2001), EMBASE (1998 to March 2001), CINAHL (1984 to March 2001) and reference lists of articles. We also sought advice from experts. SELECTION CRITERIA: RCTs of exercise based interventions. The comparison group was usual medical care as defined by the study, or placebo. Adults of all ages with chronic heart failure. Only those studies with criteria for diagnosis of heart failure (based on clinical findings or objective indices) have been included. DATA COLLECTION AND ANALYSIS: Studies were selected, and data were abstracted, independently by two reviewers. Authors were contacted where possible to obtain missing information. MAIN RESULTS: Twenty-nine studies met the inclusion criteria, with 1126 patients randomised. The majority of studies included both patients with primary and secondary heart failure, NYHA class II or III. None of the studies specifically examined the effect of exercise training on mortality and morbidity as most were of short duration. Exercise training significantly increased VO(2) max by (WMD random effects model) 2.16 ml/kg/min (95% CI 2.82 to 1.49), exercise duration increased by 2.38 minutes (95% CI 2.85 to 1.9), work capacity by 15.1 Watts (95% CI 17.7 to 12.6) and distance on the six minute walk by 40.9 metres (95% CI 64.7 to 17.1). Improvements in VO(2) max were greater for training programmes of greater intensity and duration. HRQoL improved in the seven of nine trials that measured this outcome. REVIEWERS' CONCLUSIONS: Exercise training improves exercise capacity and quality of life in patients mild to moderate heart failure in the short term. There is currently no information regarding the effect of exercise training on clinical outcomes. The findings are based on small-scale trials in patients who are unrepresentative of the total population of patients with heart failure. Other groups (more severe patients, the elderly, women) may also benefit. Large-scale pragmatic trials of exercise training of longer duration, recruiting a wider spectrum of patients are needed to address these issues.

Psychological interventions for coronary heart disease.

BACKGROUND: Psychological interventions can form part of comprehensive cardiac rehabilitation programmes (CCR). These interventions may include stress management interventions, which aim to reduce stress, either as an end in itself or to reduce risk for further cardiac events in patients with heart disease. OBJECTIVES: To determine the effectiveness of psychological interventions, in particular stress management interventions, on mortality and morbidity, psychological measures, quality of life, and modifiable cardiac risk factors, in patients with coronary heart disease (CHD). SEARCH STRATEGY: We searched CCTR to December 2001 (Issue 4, 2001), MEDLINE 1999 to December 2001 and EMBASE 1998 to the end of 2001, PsychINFO and CINAHL to December 2001. In addition, searches of reference lists of papers were made and expert advice was sought. SELECTION CRITERIA: RCTs of non-pharmacological psychological interventions, administered by trained staff, either single modality interventions or a part of CCR with minimum follow up of 6 months. Adults of all ages with CHD (prior myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty, angina pectoris or coronary artery disease defined by angiography). Stress management (SM) trials were identified and reported in combination with other psychological interventions and separately. DATA COLLECTION AND ANALYSIS: Studies were selected, and data were abstracted, independently by two reviewers. Authors were contacted where possible to obtain missing information. MAIN RESULTS: Thirty six trials with 12,841 patients were included. Of these, 18 (5242 patients) were SM trials. Quality of many trials was poor with the majority not reporting adequate concealment of allocation, and only 6 blinded outcome assessors. Combining the results of all trials showed no strong evidence of effect on total or cardiac mortality, or revascularisation. There was a reduction in the number of non-fatal reinfarctions in the intervention group (OR 0.78 (0.67, 0.90), but the two largest trials (with 4809 patients randomized) were null for this outcome, and there was statistical evidence of publication bias. Similar results were seen for the SM subgroup of trials. Provision of any psychological intervention or SM intervention caused small reductions in anxiety and depression. Few trials reported modifiable cardiac risk factors or quality of life. REVIEWERS' CONCLUSIONS: Overall psychological interventions showed no evidence of effect on total or cardiac mortality, but did show small reductions in anxiety and depression in patients with CHD. Similar results were seen for SM interventions when considered separately. However, the poor quality of trials, considerable heterogeneity observed between trials and evidence of significant publication bias make the pooled finding of a reduction in non-fatal myocardial infarction insecure.