Richard H. Glazier

Aerobic exercise interventions for adults living with HIV/AIDS

BACKGROUNDnAccess to combination antiretroviral therapy has turned HIV into a chronic and manageable disease for many. This increased chronicity has been mirrored by increased prevalence of health-related challenges experienced by people living with HIV (Rusch 2004). Exercise is a key strategy for people living with HIV and by rehabilitation professionals to address these disablements; however, knowledge about the effects of exercise among adults living with HIV still is emerging.nnnOBJECTIVESnTo examine the safety and effectiveness of aerobic exercise interventions on immunologic and virologic, cardiopulmonary, psychologic outcomes and strength, weight, and body composition in adults living with HIV.nnnSEARCH STRATEGYnSearches of MEDLINE, EMBASE, SCIENCE CITATION INDEX, CINAHL, HEALTHSTAR, PsycINFO, SPORTDISCUS and Cochrane Review Group Databases were conducted between 1980 and June 2009. Searches of published and unpublished abstracts and proceedings from major international and national HIV/AIDS conferences were conducted, as well as a handsearch of reference lists and tables of contents of relevant journals and books.nnnSELECTION CRITERIAnWe included studies of randomised controlled trials (RCTs) comparing aerobic exercise interventions with no aerobic exercise interventions or another exercise or treatment modality, performed at least three times per week for at least four weeks among adults (18 years of age or older) living with HIV.nnnDATA COLLECTION AND ANALYSISnData on study design, participants, interventions, outcomes, and methodological quality were abstracted from included studies by two reviewers. Meta-analyses, using RevMan 5 computer software, were performed on outcomes when possible.nnnMAIN RESULTSnA total of 14 studies met inclusion criteria for this review and 30 meta-analyses over several updates were performed. Main results indicated that performing constant or interval aerobic exercise, or a combination of constant aerobic exercise and progressive resistive exercise for at least 20 minutes at least three times per week for at least five weeks appears to be safe and may lead to significant improvements in selected outcomes of cardiopulmonary fitness (maximum oxygen consumption), body composition (leg muscle area, percent body fat), and psychological status (depression-dejection symptoms). These findings are limited to participants who continued to exercise and for whom there were adequate follow-up data.nnnAUTHORS CONCLUSIONSnAerobic exercise appears to be safe and may be beneficial for adults living with HIV. These findings are limited by the small sample sizes and large withdrawal rates described in the studies. Future research would benefit from participant follow-up and intention-to-treat analysis. Further research is required to determine the optimal parameters in which aerobic exercise may be most beneficial for adults living with HIV.

Effects of progressive resistive exercise in adults living with HIV/AIDS: systematic review and meta-analysis of randomized trials

Abstract This systematic review examined the effectiveness and safety of progressive resistive exercise (PRE) interventions on immunological/virological, cardiopulmonary, weight, and body composition, strength and psychological outcomes in adults living with HIV. Using Cochrane Collaboration protocol, we included randomized controlled trials from 1980–2006 comparing PRE interventions with no PRE or another intervention. Ten studies met inclusion criteria. Seventeen meta-analyses were performed. Results indicated that PRE or a combination of PRE and aerobic exercise may lead to statistically significant increases in weight (WMD: 2.68 kg; 95%CI: 0.40, 4.97) and arm and thigh girth (WMD: 7.91 cm; 95%CI: 2.18, 13.65) among exercisers versus non-exercisers. Trends toward improvement in submaximum heart rate and exercise time also were found. Individual studies suggested that PRE contributed to improved strength and psychological status. Findings are limited to participants who continued to exercise. Progressive resistive exercise appears to be safe and may be beneficial for medically-stable adults living with HIV.

Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial

BackgroundTo determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting.MethodsA prospective cluster randomized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto. Preventive Care Checklist Forms© were created to be used by family physicians at adult health check-ups over a five-month period. The sex-specific forms incorporate evidence-based recommendations on preventive health services and documentation space for routine procedures such as physical examination. The forms were used in two intervention clinics and two control clinics. Rates and relative risks (RR) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to-date preventive health services delivered per patient were compared between the two groups.ResultsRandomly-selected charts were reviewed at baseline (n = 509) and post-intervention (n = 608). Baseline rates for provision of preventive health services ranged from 3% (fecal occult blood testing) to 93% (blood pressure measurement), similar to other settings. The percentage of up-to-date preventive health services delivered per patient at the end of the intervention was 48.9% in the control group and 71.7% in the intervention group. This is an overall 22.8% absolute increase (p = 0.0001), and 46.6% relative increase in the delivery of preventive health services per patient in the intervention group compared to controls. Eight of thirteen preventive health services showed a statistically significant change (p < 0.05) in favor of the intervention (adjusted RR (95% C.I.)): counseling on brushing/flossing teeth (9.2 (4.3–19.6)), folic acid counseling (7.5 (2.7–20.8)), fecal occult blood testing (6.7 (1.9–24.1)), smoking cessation counseling (3.9 (2.2–7.2)), tetanus immunization (3.0 (1.7–5.2)), history of alcohol intake (1.33 (1.2–1.5)), history of smoking habits (1.28 (1.2–1.4)) and blood pressure measurement (1.05 (1.00–1.10)).ConclusionThis simple, low cost, clinically relevant intervention improves the delivery of preventive health services by prompting physicians of evidence-based recommendations in a checklist format that incorporates existing practice patterns. Periodic updates of the Preventive Care Checklist Forms© will allow a feasible and easy-to-use tool for primary care physicians to provide evidence-based preventive health services to adults at routine health check-ups. The forms can also be incorporated into an electronic health record. The Preventive Care Checklist Forms© are accessible in English and French at the College of Family Physicians of Canada web site.

Geographic Methods for Understanding and Responding to Disparities in Mammography Use in Toronto, Canada

OBJECTIVE: To use spatial and epidemiologic analyses to understand disparities in mammaography use and to formulate interventions to increase its uptake in low-income, high-recent immigration areas in Toronto, Canada.DESIGN: We compared mammography rates in four income-immigration census tract groups. Data were obtained from the 1996 Canadian census and 2000 physician billing claims. Risk ratios, linear regression, multilayer maps, and spatial analysis were used to examine utilization by area for women age 45 to 64 years.SETTING: Residential population of inner city Toronto, Canada, with a 1996 population of 780,000.PARTICIPANTS: Women age 45 to 64 residing in Toronto’s inner city in the year 2000.MEASUREMENTS AND MAIN RESULTS: Among 113,762 women age 45 to 64, 27,435 (24%) had received a mammogram during 2000 and 91,542 (80%) had seen a physician. Only 21% of women had a mammogram in the least advantaged group (low income-high immigration), compared with 27% in the most advantaged group (high income-low immigration) (risk ratio, 0.79; 95% confidence interval, 0.75 to 0.84). Multilayer maps demonstrated a low income-high immigration band running through Toronto’s inner city and low mammography rates within that band. There was substantial geographic clustering of study variables.CONCLUSIONS: We found marked variation in mammography rates by area, with the lowest rates associated with low income and high immigration. Spatial patterns identified areas with low mammography and low physician visit rates appropriate for outreach and public education interventions. We also identified areas with low mammography and high physician visit rates appropriate for interventions targeted at physicians.

Neighbourhood chronic stress and gender inequalities in hypertension among Canadian adults: a multilevel analysis

Background A growing body of literature regarding the contextual influences of ‘place’ effects on health increasingly demonstrates that living in neighbourhoods with high levels of deprivation is associated with worse cardiovascular outcomes; however, little research has explored whether neighbourhood deprivation has a differential impact on the cardiovascular health of men and women. The purpose of this study was to explore gender differences in the association between neighbourhood deprivation and the prevalence of hypertension among non-institutionalised Canadian adults. Methods Individual-level data from the Canadian Community Health Survey (2000–2005) were combined with area-level data from the 2001 Canada Census to assess the relationship between gender, neighbourhood deprivation and hypertension using multilevel regression. Results Of the 103u2009419 respondents, 20u2009705 reported having hypertension (17.6%). In multilevel models, neighbourhood deprivation was significantly associated with hypertension and this effect remained significant after adjusting for individual-level demographic, socioeconomic and lifestyle characteristics (OR 1.12, 95% CI 1.10 to 1.15). Neighbourhood deprivation appears to be a stronger predictor of hypertension among women, such that women living in areas of high deprivation were 10% more likely to report having hypertension in comparison with men living in the same neighbourhoods and with women living in the least impoverished neighbourhoods. Conclusions Although future research is needed to determine whether interventions at the area-level are effective in reducing inequalities in health outcomes across neighbourhoods, policies aimed at reducing area-level deprivation may have a differential benefit on the cardiovascular health of men and women.

Beta2‐agonists for acute bronchitis

BACKGROUNDnThere are no clearly effective treatments for the cough of acute bronchitis. Beta2-agonists are often prescribed, perhaps because clinicians suspect many patients also have reversible airflow restriction contributing to the symptoms.nnnOBJECTIVESnTo determine whether beta2-agonists improve acute bronchitis symptoms in patients with no underlying pulmonary disease.nnnSEARCH STRATEGYnWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1 which contains the Acute Respiratory Infections Groups Specialised Register, MEDLINE (January 1966 to February week 1, 2011) and EMBASE (1974 to February 2011).nnnSELECTION CRITERIAnRandomised controlled trials (RCTs) in which patients (adults, or children over two years of age) with acute bronchitis or acute cough and without known pulmonary disease were allocated to beta2-agonist versus placebo, no treatment or alternative treatment.nnnDATA COLLECTION AND ANALYSISnThree review authors independently selected outcomes and extracted data while blinded to study results. Two review authors independently assessed each trial for risk of bias. We analysed trials in children and adults separately.nnnMAIN RESULTSnTwo trials in children (n = 109) with no evidence of airway obstruction did not find any benefits from oral beta2-agonists. Five trials in adults (n = 418) had mixed results but overall summary statistics did not reveal any significant benefits from oral (three trials) nor inhaled (two trials) beta2-agonists. There were no significant differences in daily cough scores nor in the percentage of adults still coughing after seven days (control group 73%; risk ratio (RR) 0.77, 95% confidence interval (CI) 0.54 to 1.09). in one trial, subgroups with evidence of airflow limitation had lower symptom scores if given beta2-agonists. The trials that noted quicker resolution of cough with beta2-agonists were those with a higher proportion of wheezing patients at baseline. Adults given beta2-agonists were more likely to report tremor, shakiness or nervousness (RR 7.94, 95% CI 1.17 to 53.94; number needed to treat to harm (NNTH) 2.3).nnnAUTHORS CONCLUSIONSnThere is no evidence to support the use of beta2-agonists in children with acute cough who do not have evidence of airflow obstruction. There is also little evidence that the routine use of beta2-agonists is helpful for adults with acute cough. These agents may reduce symptoms, including cough, in people with evidence of airflow obstruction. However, this potential benefit is not well-supported by the available data and must be weighed against the adverse effects associated with their use.

The Neighbourhood Effects on Health and Well-being (NEHW) study.

Many cross-sectional studies of neighbourhood effects on health do not employ strong study design elements. The Neighbourhood Effects on Health and Well-being (NEHW) study, a random sample of 2412 English-speaking Toronto residents (age 25-64), utilises strong design features for sampling neighbourhoods and individuals, characterising neighbourhoods using a variety of data sources, measuring a wide range of health outcomes, and for analysing cross-level interactions. We describe here methodological issues that shaped the design and analysis features of the NEHW study to ensure that, while a cross-sectional sample, it will advance the quality of evidence emerging from observational studies.

Serious Preeclampsia Among Different Immigrant Groups

OBJECTIVEnResearch conducted outside Canada suggests that preeclampsia (PET) may be more common among certain ethnic groups. A limitation to prior studies is that they did not distinguish between immigrant and non-immigrant women; they also included women with mild PET arising near term, the clinical importance of which is debatable. We created the term serious PET to describe a diagnosis of severe PET, eclampsia, or any degree of PET with concomitant preterm delivery, fetal death, or maternal hospitalization of seven days or more, and evaluated its risk in association with world region of origin among recent immigrants to Ontario.nnnMETHODSnUsing the federal Landed Immigrant Data System database (LIDS), we completed a population-based study of 118 849 women who immigrated to Ontario between 1985 and 2000. The LIDS was linked to the Canadian Institute for Health Informations Discharge Abstracts Database, thereby capturing all hospitalizations with subsequent delivery in Ontario between April 1, 2002, and March 31, 2009. Rates for serious PET were determined according to maternal world region of birth, and odds ratios were adjusted for maternal age, number of live births, multifetal pregnancy, diabetes mellitus status, level of formal education, place of residence, neighbourhood income quintile, duration of residence in Canada, and fiscal year of delivery.nnnRESULTSnImmigrant women from the Caribbean (6.8 per 1000; OR 3.34; 95% CI 2.25 to 4.96), Sub-Saharan Africa (6.8 per 1000; OR 3.14; 95% CI 2.04 to 4.83) and Hispanic America (5.9 per 1000; OR 3.11; 95% CI 1.97 to 4.88) were at highest risk of serious PET relative to immigrant women from industrialized nations. The ORs were either unchanged or higher when restricted to women without a prior live birth.nnnCONCLUSIONnWe identified immigrant groups at higher risk of serious PET, whose consequences would presumably include greater financial costs for hospital care and a negative impact on maternal and newborn well-being.

Geomatics in injury prevention: the science, the potential and the limitations

Background: Geomatics describes the activities involved in acquiring and managing geographical data and producing geographical information for scientific, administrative and technical endeavors. As an emerging science, geomatics has a great potential to support public health. Geomatics provides a conceptual foundation for the development of geographic information systems (GIS), computerized tools that manage and display geographical data for analytical applications. As descriptive epidemiology typically involves the examination of person, place and time in the occurrence of disease or injury, geomatics and GIS can play an important role in understanding and preventing injury. Aim: This article provides a background to geomatics for those in the injury prevention field who are unfamiliar with spatial analysis. We hope to stimulate researchers and practitioners to begin to use geomatics to assist in the prevention of injury. Methods: The authors illustrate the potential benefits and limitations of geomatics in injury prevention in a non-technical way through the use of maps and analysis. Results: By analysing the location of patients treated for fall injuries in Central Toronto using GIS, some demographic and land use variables, such as household income, age, and the location of homeless shelters, were identified as explanatory factors for the spatial distribution. Conclusion: By supporting novel approaches to injury prevention, geomatics has a great potential for efforts to combat the burden of injury. Despite some limitations, those with an interest in injury prevention could benefit from this science.

Taking the next steps in goal ascertainment: a prospective study of patient, team, and family perspectives using a comprehensive standardized menu in a geriatric assessment and treatment unit

Objectives: To examine the performance of an expanded menu of goals in a geriatric rehabilitation setting incorporating patient, family, and team perspectives.