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We determined the effects of 2 years of exercise training and soy isoflavone supplementation on bone mass and lipids in postmenopausal women provided with calcium and vitamin D. Women were randomized to four groups: exercise training (Ex); isoflavone supplementation (Iso: 165 mg/d [105 mg/d aglycone equivalent]); combined Ex and Iso (ExIso); and placebo (control). Exercise included resistance training (2 days/week) and walking (4 days/week). Our primary outcomes were lumbar spine and hip bone mineral density (BMD). Secondary outcomes included hip geometry, tibia and radius speed of sound (SOS), dynamic balance (6 m backward tandem walking), blood lipids, mammography, and endometrial thickness. A total of 351 women (Ex = 86, Iso = 90, ExIso = 87, control = 88) were randomized, with 298 analyzed at 2 years (Ex = 77, Iso = 76, ExIso = 72, control = 73). There was a significant interaction for total hip BMD ( p < 0.001) such that ExIso had a greater rate of decrease (absolute change [95% confidence interval] = −0.018 [−0.024, −0.012] g/cm2) than either the Ex or Iso groups alone (−0.005 [−0.01, 0.001] and −0.005 [−0.011, 0.001] g/cm2, respectively). There were no differences between groups for changes in lumbar spine BMD and minimal significant changes in hip geometric properties and bone SOS. Exercise groups improved dynamic balance as measured by a decrease in backward tandem walking time over 6 m ( p = 0.017). Isoflavone groups decreased low density lipoproteins (Iso: −0.20 [−0.37, −0.02] mmol/L; ExIso: −0.23 [−0.40, −0.06] mmol/L; p = 0.003) compared to non-isoflavone groups (Ex: 0.01 [−0.16, 0.18] mmol/L; control: −0.09 [−0.27, 0.08] mmol/L) and had lower adverse reports of menopausal symptoms (14% versus 33%; p = 0.01) compared to non-isoflavone groups. Isoflavone supplementation did not increase endometrial thickness or abnormal mammograms. We conclude exercise training and isoflavone supplementation maintain hip BMD compared to control, but these two interventions interfere with each other when combined. Isoflavone supplementation decreased LDL and adverse events related to menopausal symptoms. © 2013 American Society for Bone and Mineral Research. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the utility of dual-energy X-ray absorptiometry (DXA)-derived fat mass indices for predicting blood lipid profile in postmenopausal women. A secondary purpose was to determine whether waist circumference is comparable with DXA-derived measurements in predicting blood lipid profile. Subjects were 423 postmenopausal women (age 58.1 ± 6.3 years). Fat mass was assessed at abdomen, trunk, and total body using DXA. Anthropometric measurements included BMI and waist circumference. Blood samples were analyzed for total cholesterol (TC), triglyceride (TAG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and cholesterol/HDL ratio. Of the DXA-derived measures, abdominal-fat mass was the best predictor of blood lipid profiles. DXA-derived abdominal fat mass and waist girth explained 20 and 16.5% of variation in TC/HDL ratio, respectively, in univariate analysis, with no difference between the slopes of the regression coefficients. Eighty-four percent of subjects were common to the top quartiles of waist circumference and abdominal fat mass, and blood lipid profiles generally worsened across increasing quartiles. DXA-derived abdominal fat mass and waist circumference are of equivalent utility for predicting alterations in blood lipids. Waist circumference is, therefore, ideal as an inexpensive means in primary health-care services for predicting risk of cardiovascular diseases in postmenopausal women.Obesity (2009) 17 8, 1635–1640. doi:10.1038/oby.2009.80 [ABSTRACT FROM AUTHOR]

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Integrated care pathways (ICPs) for atrial fibrillation and congestive heart failure have been examined in the literature. Systematic study, however, of provider experiences with implementation of pathways for these conditions is lacking. Given the pivotal role of nurses in the care of these chronic heart conditions, this information may be valuable for cardiovascular nurses who use pathways for these chronic heart conditions. In this study, qualitative methods were used to systematically examine providers' experiences with the implementation of integrated care pathways for these conditions. Nurses, physicians, and pharmacists provided feedback on their experiences. Analyses revealed that pathways were perceived by providers to have strengths (e.g., improved communication, knowledge, transition, patient involvement and review), but also multiple challenges (e.g., education, timelines, complexity, interest, ownership, coordination, and documentation) when implemented for these complex chronic medical conditions. Provider recommendations for pathway implementation with these conditions are shared in this study. This information may facilitate cardiovascular nurses in implementing lCPs in other centres. [ABSTRACT FROM AUTHOR]

Background: Breaks in continuity of care occur during the care of patients with cardiac conditions, such as congestive heart failure (CHF) and atrial fibrillation (AF), during their hospitalization, the discharge process or follow-up care. Recently, to measure continuity of care for such patients, a comprehensive questionnaire was developed to reflect the cardiac patient's perspective on multifaceted aspects of continuity of care., Objective: To examine the psychometric properties of an in-person interview questionnaire for the measurement of continuity of care in patients recently hospitalized with CHF or AF., Methods: The Heart Continuity of Care Questionnaire (HCCQ) was administered to 350 cardiac patients (176 with CHF and 174 with AF) at least six months after discharge from hospitals in two urban centres. The questionnaire was assessed by item and principal components analysis. Factors derived from principal components analysis were assessed for internal consistency and construct validity against variables of comorbidity, health status and symptom severity., Results: A principal components analysis produced three subscales. These subscales were internally consistent, and demonstrated construct validity through expected correlations with other variables and theoretical constructs., Conclusion: The present study supports the reliability and validity of the HCCQ for measuring continuity of care. The HCCQ subscales correspond to the theoretical components of continuity of care that have been proposed, namely relational, informational and management continuity. The HCCQ subscales may be of value for identifying problems in continuity of care and for evaluating interventions aimed at improving continuity of care for cardiac patients after hospital discharge.

Background: Continuity of care can be a challenge for cardiac patients, many of whom require chronic and complex management from a variety of health care personnel in multiple settings. For health services research, measures are needed that encompass the multifaceted nature of continuity of care for cardiac patients., Objective: To assess continuity of care from the patient's perspective, a comprehensive self-report instrument of continuity of care for patients with congestive heart failure and atrial fibrillation was developed and validated., Methods: Based on published work, patient interviews and provider input, the Heart Continuity of Care Questionnaire (HCCQ) was developed to assess various aspects of care in the transition from hospital to home. The HCCQ covered a variety of content areas relevant to cardiac care. The HCCQ and either the Continuity of Care Index (CCI) or the Minnesota Living with Heart Failure Questionnaire (MLHFQ) were completed by 83 patients who had been discharged for at least six months., Results: Most items had good response rates. The subscales, defined a priori, had good reliability (subscales alpha ranged from 0.80 to 0.93). The HCCQ and its subscales had strong correlations with the CCI but not the MLHFQ. The HCCQ subscales demonstrated better known group validity than the CCI., Conclusions: In this preliminary study, the HCCQ appears to be a comprehensive, reliable and valid measure of continuity of care from the patient perspective. Further studies of the validity, generalizability and use are needed.

The telephone provides an easy-to-use, reliable and cheap computer interface. We review computer telephony applications for patient care, clinical research and medical education. We describe uses at our academic health sciences centre and discuss strengths and weaknesses of this technology. Until more sophisticated interfaces, for example personal digital assistants with wireless Internet access, are commonplace, we believe computer telephony can play a useful role in electronic healthcare.

Continuity of care, defined as the patient experiencing coherent care over time and place, is challenged when a rural senior with multiple medical problems is transferred to a regional hospital for acute care. From an illustrative case of an older patient with pneumonia and atrial fibrillation, we catalogue potential breaks in continuity of care. Optimal continuity of care is characterised not only by regular contact with the providers who establish collaboration with patients and their caregivers, but also by communication, co-ordination, contingency, convenience, and consistency. Because it is not possible to have the same providers continuously available (relational continuity), for continuity of care, there is a need for integrative system approaches, such as: (1) policy and standards, disease management programs, integrated clinical pathways (management continuity), (2) electronic health information systems and telecommunications technology (communication continuity). The evaluation of these approaches requires measures that account for the multi-faceted nature of continuity of care.

Cardiovascular disease remains the most common cause of premature death in end-stage renal disease (ESRD). Although several predictors of cardiac death have been reported, identifying individuals most at risk remains difficult. Previous studies in nonuremic populations have associated cardiac mortality, in particular sudden death, with increased QT dispersion (QTd); defined as the difference between the maximal and minimal QT interval on a standard electrocardiogram. The present study aimed to determine the prognostic value of QTd and corrected QTd (QTdc) in predicting total, cardiovascular, and arrhythmia-related mortality in ESRD patients initiating dialysis. The study was a retrospective cohort of adult ESRD patients starting peritoneal dialysis or hemodialysis between 1990 and 1994. Statistical analysis was by Cox proportional hazard modeling and Kaplan-Meier analysis. Primary study endpoints were total, cardiovascular, and arrhythmia-related mortality. Nonfatal cardiovascular events were a secondary endpoint. A total of 147 patients were studied for a period of 5 to 9 years. In Cox modeling, QTdc was an independent predictor of total (relative risk [RR] = 1.53; difference for RR = 50 msec; P = 0.0001) and cardiovascular mortality (RR = 1.57; difference for RR = 50 msec; P = 0.028) and trended toward arrhythmia-related mortality (P = 0.061). Total mortality also was predicted independently by lack of renal transplantation, radiographic cardiomegaly, and predialysis serum albumin. In multivariate analysis, QTdc was associated weakly with serum calcium, mean QT interval, and presence of diabetes mellitus. QTdc may be a useful marker for identifying dialysis patients at an increased risk for overall and cardiovascular mortality., (Copyright 2002 by the National Kidney Foundation, Inc.)