Evaluation of implementation of the ParkFit program: A multifaceted intervention aimed to promote physical activity in patients with Parkinson's disease

Objectives

We recently completed the ParkFit study, a two-year randomized controlled trial including 586 sedentary Parkinson's disease (PD) patients, that evaluated a multifaceted intervention (ParkFit program) to promote physical activity. The results showed that the ParkFit program enables PD patients to become physically more active, suggesting that this intervention should now be further implemented into clinical practice. To facilitate this process, we here evaluate the implementation of the ParkFit program.

Methods

The ParkFit program was evaluated in three ways: (a) experiences of patients and physiotherapists, as investigated using interviews and questionnaires; (b) factors associated with changed activity levels; and (c) subgroup analyses to identify differential effects in subgroups of patients based on baseline physical activity level, age, gender, disease severity, disease duration, and mobility.

Results

The ParkFit program was well received: 73% of patients indicated they would recommend the program to other patients, and 90% of physiotherapists indicated they wanted to use the ParkFit program in other patients. Multiple forward regression analysis resulted in a model with two variables: less baseline physical activity, and better mobility were associated with larger changes in levels of physical activity (R² = 38%). The program was effective in almost all subgroups. In women, most sedentary patients and patients with higher disease severity, the estimated effect size was largest.

Conclusion

We conclude that the ParkFit program was effective in almost all specific subgroups. Therapists and patients experienced no major hurdles. Suggestions for improvement are: (1) improve education for therapists with respect to theories about behavioral change; (2) formulate concrete and specific examples of exercise goals; and (3) pay more specific attention to patients with co morbidities, cognitive dysfunction and a lack of motivation during education     

Fluid overload in hemodialysis patients: a cross-sectional study to determine its association with cardiac biomarkers and nutritional status

Background

Chronic fluid overload is associated with higher mortality in dialysis patients; however, the link with cardiovascular morbidity has not formally been established and may be influenced by subclinical inflammation. We hypothesized that a relationship exists between fluid overload and [i] cardiovascular laboratory parameter as well as between fluid overload and [ii] inflammatory laboratory parameters. In addition, we aimed to confirm whether volume status correlates with nutritional status.

Methods

We recorded baseline characteristics of 244 hemodialysis patients at three hemodialysis facilities in Vienna (Austria) and determined associations with volume measurements using the body composition monitor (Fresenius/Germany). In one facility comprising 126 patients, we further analyzed cardiovascular, inflammatory and nutritional parameters.

Results

We detected predialysis fluid overload (FO) in 39% of all patients (n?=?95) with FO defined as ≥15% of extracellular water (ECW). In this subgroup, the absolute FO was 4.4 +/-1.5 L or 22.9?±?4.8% of ECW. A sub-analysis of patients from one center showed that FO was negatively associated with body mass index (r?=?-0.371; p?=?<0.001), while serum albumin was significantly lower in fluid overloaded patients (p?=?0.001). FO was positively associated with D-Dimer (r?=?0.316; p?=?0.001), troponin T (r?=?0.325; p?<?0.001), and N-terminal pro-B-type natriuretic peptide (r?=?0.436; p?<?0.001), but not with investigated inflammatory parameters.

Conclusions

Fluid overload in HD patients was found to be lower in patients with high body mass index, indicating that dry weight was inadequately prescribed and/or difficult to achieve in overweight patients. The association with parameters of cardiovascular compromise and/or damage suggests that fluid overload is a biomarker for cardiovascular risk. Future studies should determine if this applies to patients prior to end-stage renal disease.

     

Validation of virtual reality simulators: Key to the successful integration of a novel teaching technology into minimal access surgery

Minimal access surgery (MAS) requires additional training in the surgical curriculum, as skills needed to perform MAS are quite different from those used in open surgery. Moreover, residents do not seem to experience ample opportunity to gain such skills in the current surgical curriculum. Virtual reality (VR) simulation offers an interesting opportunity to train such skills in a safe, supporting environment. As with any new development, one should be careful about integrating costly technology into practice before it has been properly validated.

This article outlines the requirements for a valid and integrated approach towards the integration of novel VR simulation systems in minimal access surgery.     

Ärzte und Ärztinnen für Allgemeinmedizin als potenzielle Schnittstelle zwischen Patient(inn)en und Psychotherapeut(inn)en in Bezug auf psychische und psychosomatische Probleme

This study deals with the role played by general practitioners in referring patients to psychotherapists. On the basis of the assumption that general practitioners are frequently the first "port of call" when patients suffer from psychological or emotional problems, this study sets out to explore how physicians and psychotherapists cooperate. In May 2005, 66 general practitioners were interviewed by using semistructured questionnaires. These expert interviews focused on the question of how often, according to the physicians polled, psychological or psychosomatic problems that require treatment occur in their patients and which measures these findings entail on the part of these physicians. The study revolves around modalities of cooperating with psychotherapists. Furthermore, it addresses the issue of satisfaction with psychotherapy and the provision of information relating to it. The study also gauges the general practitioners' attitude towards psychotherapy.     

Radiographic features of small intestinal injury in human graft-versus-host disease

Graft-versus-host disease (GVHD) is one of the life-threatening complications of allogeneic bone marrow transplantation; it is probably due to an immunological reaction mounted by engrafted lymphocytes against the host. Symptoms of involvement of the gastrointestinal tract in GVHD are abdominal cramps and diarrhea, accompanied by a variety of functional derangements. The histologic changes, most marked in the ileum and colon, consist of necrosis of crypt epithelium leading to glandular depopulation.The radiographic features in the small intestine were studied in 7 patients with gastrointestinal GVHD. Characteristic was the disappearance of mucosal folds in a substantial part of the small bowel, most marked distally. Furthermore, there was thickening of the bowel wall and a very rapid transit of contrast material.The findings are compared with findings in the literature.     

Large-scale preparation of γ-crystallin and fractionation by chromatofocusing

Large quantities of calf γ-crystallin can be prepared by a single and rapid salting-out procedure. The final product is indistinguishable from the γ-crystallin fraction obtained after gel filtration of a 15000 g lens protein supernatant over Sephadex G 200. Further fractionation is achieved by the mild procedure of chromatofocusing yielding six to eight subfractions. The latter have been characterized by polyacrylamide gel electrophoresis (PAGE) in 6 m-urea, SDS-gel electrophoresis, partial digestion with Staphylococcus aureus protease and amino acid analysis.     

Quantitative T*2‐mapping based on multi‐slice multiple gradient echo flash imaging: Retrospective correction for subject motion effects

Numerous clinical and research applications for quantitative mapping of the effective transverse relaxation time T*₂ have been described. Subject motion can severely deteriorate the quality and accuracy of results. A correction method for T*₂ maps acquired with multi‐slice multiple gradient echo FLASH imaging is presented, based on acquisition repetition with reduced spatial resolution (and consequently reduced acquisition time) and weighted averaging of both data sets, choosing weighting factors individually for each k‐space line to reduce the influence of motion. In detail, the procedure is based on the fact that motion artifacts reduce the correlation between acquired and exponentially fitted data. A target data set is constructed in image space, choosing the data yielding best correlation from the two acquired data sets. The k‐space representation of the target is subsequently approximated as linear combination of original raw data, yielding the required weighting factors. As this method only requires a single acquisition repetition with reduced spatial resolution, it can be employed on any clinical system offering a suitable sequence with export of modulus and phase images. Experimental results show that the method works well for sparse motion, but fails for strong motion affecting the same k‐space lines in both acquisitions. Magn Reson Med, 2011. © 2011 Wiley‐Liss, Inc.     

Delayed formation of actin filaments in the outer pillar head plate of VASP-/- mice

Pillar cells with their rich network of tubulin and actin filaments have been reported to contribute to the rigidity of the organ of Corti. As the earliest expression of the actin filament enhancer vasodilator-stimulated phosphoprotein (VASP) in the outer pillar head plate has been found to be associated with the onset of hearing, we tested hearing development in VASP-/- compared to wild-type mice. Performing measurements of auditory brainstem responses on postnatal days (P) P14 and P21, we detected statistically significantly higher thresholds in VASP-/- compared to wild-type mice at P14, but no hearing differences at P21. Staining for prestin and synaptophysin at P12 in morphologically regularly developed cochleae of VASP-/- mice provided an immature prestin protein pattern but no evidence of developmental delay in hair cell innervations. Regularly intense staining of actin filaments in the outer pillar head plate was found only in wild-type but not in VASP-/- mice at P14. At P21, intensive actin filament staining was also observed in the outer pillar head plates of VASP-/- mice. The delayed hearing development in VASP-/- mice is supposed to be caused by a delayed formation of actin filaments in the outer pillar head plate indicating the importance of appropriate pillar cell stiffness in cochlear mechanics.     

Risk factors and impact of major bleeding in critically ill patients receiving heparin thromboprophylaxis

Purpose

Bleeding frequently complicates critical illness and may have serious consequences. Our objectives are to describe the predictors of major bleeding and the association between bleeding and mortality in medical–surgical critically ill patients receiving heparin thromboprophylaxis.

Methods

We prospectively studied patients from 67 intensive care units and six countries enrolled in a thromboprophylaxis trial (NCT00182143) comparing dalteparin with unfractionated heparin. Patients with trauma, orthopedic surgery or neurosurgery were excluded. Trained research coordinators used a validated tool to document bleeding, which underwent duplicate independent blinded adjudication. Major bleeding was defined as hypovolemic shock, bleeding into critical sites, requiring an invasive intervention or transfusion of at least two units of red blood cells, or associated with hypotension or tachycardia in the absence of other causes. Adjusted Cox proportional hazard regression analysis was used to identify major bleeding predictors and the association between bleeding and mortality.

Results

Among 3,746 patients, bleeding occurred in 208 [5.6 %, 95 % confidence interval (CI) 4.9–6.3 %]. Time-dependent predictors were prolonged activated partial thromboplastin time [hazard ratio (HR) 1.10, 1.05–1.14 per 10 s increase], lower platelet count (HR 1.16, 1.09–1.24 per 50 × 10⁹/L decrease), therapeutic heparin (HR 3.26, 1.72–6.17), antiplatelet agents (HR 1.38, 1.02–1.88), renal replacement therapy (HR 1.75, 1.20–2.56), and recent surgery (HR 1.64, 1.01–2.65). Type of pharmacologic thromboprophylaxis was not associated with bleeding. Patients with bleeding had a higher risk of in-hospital death (HR 2.09, 1.69–2.57).

Conclusions

As major bleeding has modifiable risk factors and is associated with in-hospital mortality, strategies to mitigate these factors should be evaluated in critically ill patients.