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PubMed1996

A guide for planning community-oriented health care: the health sector resource allocation model.

The objective of this study was to demonstrate the value of a planning model for the design and evaluation of community health services. The health status of Washtenaw County, Michigan was modeled. Data were obtained from the Michigan Department of Public Health, Medstat Systems, and the medical literature for 32 diseases or conditions, representing approximately 85% of causes of death and 56% of medical payments (excluding medication costs). An expanded life-table approach was used for 16 age-and sex-matched cohorts exposed to a disease attack rate, access-to-care rate, case fatality rate, morbidity, and costs. Rates can be modified to reflect changes due to treatment, secular trends, or prevention programs. Two alternative delivery methods were considered to show the potential impact of reducing cardiovascular deaths (worksite initiative), or increasing utilization of services (lay health promotion) on county health status and costs over time. Deaths, bed days, and annual medical payments were the main outcome measurements. Cardiovascular and cancer conditions are and will be the primary causes of death in this population. The most important causes of bed days are musculoskeletal conditions, chronic obstructive pulmonary disease, accidents, strokes, and depression. The major health-care payments are for angina pectoris and/or other cardiac conditions, musculoskeletal conditions, accidents, prenatal care, and/or childbirth, and depression. The two alternative scenarios illustrate how reductions in mortality are not necessarily equated with similar improvements in morbidity or costs. This model presents an overview of the current and projected health status of a community. With such a planning tool, a community can better understand the impact of potential prevention or intervention programs, and help design its health-care system within the constraints of available resources.

Cause of Death↗
PubMed1985

Doppler echocardiographic measurement of cardiac output using the mitral orifice method.

Cardiac output was determined in 20 patients with various cardiac conditions by measuring the cross sectional area of the mitral orifice by echocardiography and the transmitral flow by the Doppler technique. Cardiac output was calculated by multiplying the corrected mitral orifice area by the maximum diastolic velocity integral recorded by the pulsed mode. The results were compared with that obtained by the Fick method. The correlation for cardiac output by the two techniques was high in the whole group, particularly in patients without mitral regurgitation. There was also a good correlation for stroke volume determined by the two methods. Cardiac output was significantly overestimated by the continuous mode and in patients with mitral regurgitation. These results show that the mitral orifice method provides a new and reliable approach to the non-invasive measurement of cardiac output.

Adolescent↗
PubMed2002

BioGlue Surgical Adhesive--an appraisal of its indications in cardiac surgery.

BACKGROUND: The recent emergence of BioGlue Surgical Adhesive has widened the field of surgical adhesives for the cardiac surgeon. We believe the present series, in a wider spectrum of cardiac conditions, is the first larger scale evaluation of the use of this new adhesive. METHODS: BioGlue was used in 115 consecutive patients (90 male and 25 female, age range 5 days to 87 years) from September 9, 1998 to March 12, 2001. Preoperative, intraoperative, and postoperative data were examined to establish its use, indications, and outcomes in patients undergoing cardiac surgical procedures. RESULTS: The most common underlying pathologic conditions were aortic dissections (30 patients) and aortic aneurysms (39 patients). The procedures carried out were aortic root replacement (36 patients), aortic wall replacement (39), ascending aorta repair (2), coronary artery bypass grafting (28), valve procedures (11), ventricular aneurysm repair (6), repair of postinfarct ventricular septal defect (2), and correction of congenital conditions (13 patients). The indications for BioGlue use were hemostasis in 79 patients, tissue adherence in 21, and tissue strengthening in 30. The hospital mortality was 10.1% (11 patients). Only 1 patient required a late reoperation for dehiscence of a suture line with formation of a false aneurysm. The mean postoperative blood loss at 12 hours was 702 mL. Ten patients developed a cerebrovascular accident postoperatively, which was considered to be unrelated to the use of BioGlue. CONCLUSIONS: All surgeons in this study believed that BioGlue facilitated the operation. Future follow-up of patients is required to validate our early promising results and to assess the long-term outcome of patients treated with BioGlue.

Adolescent↗
PubMed1997

Purification of endothelin from a conditioned medium of cardiac fibroblastic cells using beating rate assay of myocytes cultured in a serum-free medium.

A conditioned medium from cardiac fibroblastic cells stimulated the beating of quiescent cardiac myocytes cultured in a serum-free medium. The aim of this study was to isolate and characterize the myocyte beat-stimulating activity of the conditioned medium of fibroblastic cells. Cardiac myocytes and fibroblastic cells were isolated individually from neonatal rats. The fibroblastic cells were grown in a growth medium until they became confluent, then serum-free conditioned medium was obtained from them. For the beating-rate assay, the cardiac myocytes were cultured in a completely serum-free medium. The beat-stimulating factor of myocytes in the conditioned medium was purified by reverse-phase liquid chromatographies and gel filtration, and was characterized by measuring the molecular weight of the activity and a pharmacological antagonistic study. The beat-stimulating activity in the conditioned medium was purified into two active fractions. Both of the activities have a molecular weight of 2.5 kDa, and the activities were abolished similarly by FR139317, an endothelin type-A receptor antagonist. These results indicate that cardiac fibroblastic cells secrete endothelin and that this may contribute in part to the functional abnormalities of the heart in patients with myocardial fibrosis.

Animals↗
PubMed2005

Common issues in sports cardiology.

Many cardiac conditions found in athletes are amenable to athletic participation if well-managed. As always, a respect for the causes of sudden cardiac death in athletes is paramount. Although rare, sudden cardiac death in athletes is frequently preventable by careful pre-participation screening. The authors hope that more athletes will undergo screening, and that basic investigations, including but not limited to electrocardiography, will become more widespread. A high degree of surveillance for cardiac pathology in athletes is the duty of any sports medicine practitioner.

Arrhythmias, Cardiac↗
PubMed2002

Antimicrobial prophylaxis for gastrointestinal procedures: current practices in North American academic pediatric programs.

BACKGROUND: Guidelines for the use of antibiotic prophylaxis in children are based on a small number of studies that assess the risk of infection associated with performing endoscopic procedures. The American Heart Association (AHA) and the American Society of Gastroenterological Endoscopy (ASGE) have established guidelines that identify conditions and procedures that place a child at greater risk for infectious complications. Because data on bacteremia and sepsis associated with endoscopy in children are very limited, we reviewed the practices of 15 large academic pediatric gastroenterology services to see if patterns of practice and safety could be determined. METHODS: A questionnaire was sent to 15 academic gastroenterology centers in the United States and Canada asking about antibiotic prophylaxis for endoscopic procedures for children with six conditions. These included three conditions related to congenital heart disease based on negligible, moderate, and high risk for endocarditis; immune compromise; the presence of a central venous line; and the presence of a ventriculo-peritoneal shunt. Six procedures were evaluated, including esophagogastroduodenoscopy with biopsy, flexible sigmoidoscopy or colonoscopy with biopsy, endoscopic retrograde cholangiopancreatography, esophageal sclerotherapy, esophageal dilation, and percutaneous endoscopic gastrostomy (PEG) tube placement. RESULTS: The patterns of reported practice generally conform to the AHA and ASGE guidelines. The six conditions and six procedures yielded 36 response categories for the participating centers. The majority of centers reported routine use of antibiotic prophylaxis in about half (17) of the response categories, which represented three distinct situations. These included children with congenital heart disease having moderate or high risk for bacterial endocarditis for almost all procedure categories and children undergoing PEG tube placement regardless of underlying condition. In all other combinations of underlying conditions and procedures, the majority of centers did not use routine prophylaxis. The majority of centers did not use antibiotic prophylaxis for cardiac conditions with a negligible risk of infectious complication or for children with immunocompromise, central venous lines, or ventriculo-peritoneal shunts for any procedure except PEG placement. CONCLUSIONS: These results indicate that the routine use of antibiotic prophylaxis is limited in pediatric academic centers to a few very specific conditions and procedures. The results also provide indirect evidence that the risk of infectious complications associated with endoscopic procedures appears to be exceedingly low.

Antibiotic Prophylaxis↗
PubMed1982

Role of external cardiac compression in truncal trauma.

External cardiac compression (ECC) was originally developed for patients with nontraumatic cardiac conditions, but it is now used for a wide variety of emergency conditions. As an integral part of cardiopulmonary resuscitation (CPR), ECC coupled with forced pulmonary ventilation may NOT be applicable to cases of cardiac arrest following penetrating and blunt thoracic and abdominal trauma. Review of 100 patients with penetrating or blunt truncal trauma who received CPR and ECC more than 3 minutes prehospital revealed NO survivors despite continued aggressive resuscitative efforts in 49 of the patients upon arrival at a trauma center. Major cardiovascular disruption was found at thoracotomy or autopsy in all patients. In another 12 patients receiving forced ventilation and prehospital ECC, air embolism to the coronary arteries was the cause of death. CPR by paramedics, physicians, nurses, or lay persons does not appear to be of value in patients who have sustained cardiac arrest from truncal trauma.

Abdominal Injuries↗
PubMed2005

Inhaled beta2-adrenoceptor agonists: cardiovascular safety in patients with obstructive lung disease.

Although large surveys have documented the favourable safety profile of beta(2)-adrenoceptor agonists (beta(2)-agonists) and, above all, that of the long-acting agents, the presence in the literature of reports of adverse cardiovascular events in patients with obstructive airway disease must induce physicians to consider this eventuality. The coexistence of beta(1)- and beta(2)-adrenoceptors in the heart clearly indicates that beta(2)-agonists do have some effect on the heart, even when they are highly selective. It should also be taken into account that the beta(2)-agonists utilised in clinical practice have differing selectivities and potencies. beta(2)-agonist use has, in effect, been associated with an increased risk of myocardial infarction, congestive heart failure, cardiac arrest and sudden cardiac death. Moreover, patients who have either asthma or chronic obstructive pulmonary disease may be at increased risk of cardiovascular complications because these diseases amplify the impact of these agents on the heart and, unfortunately, are a confounding factor when the impact of beta(2)-agonists on the heart is evaluated. Whatever the case may be, this effect is of particular concern for those patients with underlying cardiac conditions. Therefore, beta(2)-agonists must always be used with caution in patients with cardiopathies because these agents may precipitate the concomitant cardiac disease.

Administration, Inhalation↗
PubMed1993

Depression and its treatment in cardiac patients.

In general medical-surgical hospital services, depression is the most common reason for seeking psychiatric consultation in behalf of patients with cardiovascular disease. The nontreatment of depression or the use of a psychotropic agent mismatched to a patient's particular cardiac condition or individual sensitivities has considerable negative impact. Therefore, a systematic approach should be used in the differential diagnosis of depression in cardiac patients, to eliminate other psychiatric disorders and to assure the correct treatment strategy. Physicians can develop an appropriate rationale for the use of a psychopharmacologic regimen in cardiovascular settings through recognition of the diagnostic criteria for depression and through comprehensive knowledge of the pharmacologic properties and possible cardiovascular effects of these vital treatments. Standard and alternative pharmacotherapies for depression in cardiac patients are reviewed.

Antidepressive Agents↗
PubMed2004

[Right ventricular arrhythmias].

Right ventricular arrhythmias predominantly occur in young patients with rare cardiac diseases. Underlying cardiac conditions include idiopathic right ventricular outflow-tract tachycardia (RVOT-VT), arrhythmogenic right ventricular cardiomyopathy (ARVC), Brugada syndrome, and postoperative congenital heart disease (i.e. tetralogy of Fallot). According to the underlying cardiac disease, there are significant differences in the diagnostic and therapeutic management and prognosis which is mainly determined by life-threatening ventricular arrhythmia recurrences and sudden cardiac death. To provide optimal treatment for affected patients, a detailed diagnostic evaluation and risk stratification is mandatory. Tailored treatment strategies aim at the suppression or effective termination of recurrent ventricular tachyarrhythmias and prevention of sudden death by antiarrhythmic drug therapy, catheter ablation, and the implantation of cardioverter-defibrillators. This review summarizes the current knowledge on pathogenesis, diagnosis, treatment and prognosis of those conditions that are associated with arrhythmias originating from the right ventricle.

Arrhythmias, Cardiac↗
PubMed2004

Virtual cardiac symposia: Worldwide, Internet-based, educational forums for cardiologists.

In this study, we detail our recent experience with 2 successful Internet-based virtual cardiac symposia that focused on the Brugada syndrome and the long QT syndrome. The responses from cardiologists around the world exceeded our expectations, and clearly, this approach answered an unmet need and has major educational potential. Although we initiated the Virtual Cardiac Symposia with the idea of assisting cardiologists caring for patients with relatively infrequent cardiac conditions, we believe that this Internet-based educational approach will have similar applicability and value for cardiologists caring for patients with common cardiac disorders.

Bundle-Branch Block↗
PubMed2004

Fibrosis in hypertensive heart disease: role of the renin-angiotensin-aldosterone system.

Structural homogeneity of cardiac tissue is governed by mechanical and humoral factors that regulate cell growth, apoptosis, phenotype, and extracellular matrix turnover. ANGII has endocrine, autocrine, and paracrine properties that influence the behavior of cardiac cells and matrix by AT1 receptor binding. Various paradigms have been suggested, including ANGII-mediated up-regulation of collagen types I and III formation and deposition in cardiac conditions, such as HHD. A growing body of evidence, however, deals with the potential role of aldosterone, either local or systemic, in inducing cardiac fibrosis. Aldosterone might also mediate the profibrotic actions of ANGII. To reduce the risk of heart failure that accompanies HHD, its adverse structural remodeling (eg, myocardial hypertrophy and fibrosis) must be targeted for pharmacologic intervention. Cardioprotective agents must reverse not only the exaggerated growth of cardiac cells, but also regress existing abnormalities in fibrillar collagen. Available experimental and clinical data suggest that agents interfering with ACE, the AT1 receptor, or the mineralocorticoid receptor may provide such a cardioprotective effect.

Aldosterone↗
PubMed1991

Thalamic short-term plasticity in the auditory system: associative returning of receptive fields in the ventral medial geniculate body.

The effects of classical conditioning on frequency receptive fields (RFs) in the ventral, tonotopic part of the guinea pig (Cavia porcellus) medial geniculate ventral body (MGv) during cardiac conditioning to a single tone frequency were studied. Associative frequency-specific plasticity, in which the RF was returned to the frequency of the conditioned stimulus (CS), developed if the CS frequency was within 0.125 octave of the pretraining best frequency. Otherwise, a general increase across the RF developed. Sensitization training also produced general increased responses. The frequency-specific plasticity was short-term and observed only immediately after training, whereas the general effects were maintained. These results suggest that frequency-specific RF plasticity in the MGv may be a substrate of short-term mnemonic processes that could participate in long-term storage of information and modification of the representation of the CS at the auditory cortex.

Animals↗
PubMed1988

Haemodynamic and regional blood flow changes after acute pulmonary microembolism in conscious rabbits.

The central and peripheral haemodynamic effects of pulmonary embolisation with microspheres were measured in conscious rabbits in which the autonomic and central nervous systems were functioning normally. Sufficient microspheres were given to reduce cardiac output (measured by thermodilution) by one half. This fall in cardiac output was accompanied by a severe fall in arterial pressure and an increase in heart rate and right atrial pressure. Under these conditions cardiac output responded less than normally to an increased right atrial pressure imposed by an infusion of saline. Changes in regional blood flow and resistance were measured with radioactive microspheres injected into the left ventricle. Myocardial blood flow was unaffected by pulmonary embolisation. Cerebral flow was slightly increased. Renal, intestinal, dermal, and skeletal muscle blood flows were all reduced. Myocardial and cerebral tissue vascular resistances decreased; splenic and dermal vascular resistances increased; and renal and skeletal muscle vascular resistances were unchanged.

Animals↗
PubMed1994

[Congenital heart defects: prevalence and course during the school years (8 to 16 years)].

In continuation of former studies regarding the first year of life and the preschool period, the prevalence and course of congenital heart disease in children during compulsory schooling has been studied. Compared with the preschool period, few cardiac defects are discovered, the prevalence up to 16 years of age being 9.9/1000. The mortality rate (2.7%) and also the rate of spontaneous normalization (4%) is significantly lower (compared to 18.7% and 21% respectively in the preschool period). Medical measures are needed less frequently, with 10 times fewer operations and 15 times fewer heart catheterizations being performed. Apart from the decline of hospital stays, checkups in the outpatient clinic also declined 3-4 times in comparison with the period between birth and school entry. School performance is very good. Only 4% of the children are unable to attend a normal school for cardiac reasons, and the percentage of pupils attending secondary school is higher than normal. In 5% of the children exercise tolerance is decreased due to the cardiac condition. In 85%, the quality of life is normal during the compulsory school period. Impairment is most often caused by additional non-cardiac malformations or very severe heart disease.

Abnormalities, Multiple↗
PubMed2003

Intravenous nitro-glycerine versus general anaesthesia for placental extraction--a sequential comparison.

BACKGROUND: Postpartum haemorrhage due to retained placenta is one of the commonest life-threatening conditions during the third stage of labour. Uterine relaxation is usually required to facilitate placental removal. 'Full-stomach' obstetric patients (which includes those who delivered within 48 h), parturients with a history of antepartum or recurrent postpartum hemorrhage, grand multiparity, twin pregnancy, and those with cardiac abnormalities may benefit from an alternative to volatile-based general anaesthesia for uterine relaxation to avoid complications associated with the technique (e.g. aspiration pneumonitis and cardiovascular compromise). CASE REPORT: A 34-year-old gravida 4, para 3 parturient with rheumatic valvular heart disease presented with retained placenta and postpartum haemorrhage on two consecutive deliveries and had the placenta removed manually by the same surgeon under two different anaesthetic techniques. On the first occasion, general anaesthesia was administered whereas only i.v. fentanyl and nitro-glycerine were used on the second occasion. The postoperative course was uneventful on both occasions. CONCLUSIONS: The use of nitro-glycerine was found to be efficacious for manual removal of placenta with minimal haemodynamic perturbations, avoiding the use (and associated risks) of general anaesthesia for uterine relaxation. The ability of nitro-glycerine to reduce spontaneous uterine activity, induce uterine relaxation, coupled with its short duration of action and high efficacy, may render it a safe alternative to general anaesthesia for facilitating intrauterine manoeuvres. Nitro-glycerine may be useful especially in patients with associated co-morbid chronic cardiac conditions, e.g. rheumatic heart disease, which is characterised by impaired haemodynamics and cardiac reserves.

Anesthesia, General↗
PubMed2003

The meaning of the turning point of the index of motor current amplitude curve in controlling a continuous flow pump or evaluation of left ventricular function.

In this series, we investigated the meaning of the t-point of index of motor current amplitude (ICA) curve from a point of view of flow rate on in vitro and in vivo studies. On mock circulation loop and left ventricular assist device (LVAD)-equipped pigs, we detected the t-point and compared the pump flow at the t-point with the simultaneous cardiac output. The pump flow at the t-point showed high correlation against the simultaneous cardiac output for in vitro or in vivo study. By detection of the t-point of the ICA curve and measuring or estimating the pump flow at t-point, the cardiac output may be assessed without any sensor in various cardiac conditions.

Animals↗