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PubMed1984

Sustained ventricular tachycardia in patients with idiopathic dilated cardiomyopathy: electrophysiologic testing and lack of response to antiarrhythmic drug therapy.

Eleven consecutive patients with idiopathic dilated cardiomyopathy and spontaneous, sustained ventricular tachycardia (VT) of uniform morphology underwent programmed ventricular stimulation and serial antiarrhythmic drug testing. The mean ejection fraction was 30 +/- 6.4%. Sustained VT was induced by programmed electrical stimulation in all 11 patients. A mean of 3.7 +/- 2.4 antiarrhythmic drugs were evaluated by programmed stimulation, including at least one experimental agent in eight patients. In nine of 11 patients VT remained inducible on all drug therapy. During a mean follow-up period of 21 +/- 14 months there were four sudden deaths and two patients with recurrences of VT. In all six patients with sudden death or recurrence of VT, the arrhythmia remained inducible on drug therapy. Three patients who died suddenly had a hemodynamically stable, induced tachycardia on antiarrhythmic therapy. Of eight patients treated with amiodarone, only two were successfully treated. We conclude that in patients with sustained VT and idiopathic dilated cardiomyopathy, VT can be induced by programmed electrical stimulation. VT will usually remain inducible on antiarrhythmic therapy, and sudden death can occur despite slowing and improved tolerance of the induced arrhythmia. Amiodarone may have limited efficacy, and more aggressive therapy, such as surgery or implantation of an automatic internal defibrillator, should be considered in this patient population.

Adult↗
PubMed1980

Initiation and termination of ventricular tachycardia by supraventricular stimuli. Incidence and electrophysiologic determinants as observed during programmed stimulation of the heart.

In 7 of 43 patients in whom a sustained ventricular tachycardia could be induced during programmed electrical stimulation by a single ventricular premature stimulus, an identical tachycardia could also be initiated by a single atrial premature stimulus. This phenomenon was observed only in those patients in whom the ventricular tachycardia could be induced by a single ventricular extrastimulus having a prematurity index (ratio between the longst ventricular premature stimulus interval resulting in tachycardia and th duration of the basic cycle length of the paced ventricular rhythm) above 54 percent. No single instance of initiation of ventricular tachycardia by atrial premature stimuli was observed in patients with a ventricular prematurity index below 54 percent or requiring more than one consecutive ventricular extrastimulus to have tachycardia initiated. Other features of patients showing initiation of ventricular tachycardia by atrial premature stimuli were a right bundle branch block configuration of the QRS complex during tachycardia in all seven patients and a relatively slow rate during tachycardia. In one patient ventricular tachycardia was terminated by a conducted atrial premature stimulus.

Adult↗
PubMed1997

A decade's experience at Tufts with a four-year combined curriculum in medicine and public health.

The absence of a good working relationship between medicine and public health is a cardinal feature of the health care system in the United States. Nowhere has the "uneasy alliance" between proponents of care for the individual versus those who advocate greater attention to the health needs of the population been more apparent than within medical schools. This article chronicles ten years of experience at the Tufts University School of Medicine where, for a limited number of students, the Combined MD-MPH (Master of Public Health) Program has been created and sustained and continues to produce professionals trained and credentialed in both public health and medicine. The four-year program has graduated over 75 students and provides a medical-school-based model that combines education in medicine with a comprehensive, prevention-oriented, population-based approach to health. The Program is described, and experience-based suggestions are offered for medical schools interested in developing training opportunities that address both the care of the individual patient and the care of populations. The Tufts experience shows that a four-year program that combines rigorous education in medicine and public health does not require drastic changes in medical school admission policy or major revisions in curricula. The introduction of combined MD-MPH programs can better serve the changing needs of medical practitioners and their patients while also fostering the health of the public.

Adult↗
PubMed2006

An institutional approach to maintenance of excellent outcomes for carotid endarterectomy in a setting with moderate-to-low procedure volume.

BACKGROUND: Institutions and surgeons with high procedure volumes have been reported to have lower morbidity and mortality rates for patients undergoing carotid endarterectomy. Demonstrating comparable results is essential for centers with moderate or low volume. If comparable results cannot be demonstrated, a low- to moderate-volume center should not perform the procedure. STUDY DESIGN: A prospective study of a program to achieve and sustain excellent outcomes after carotid endarterectomy was conducted at a single institution with low-to-moderate volumes. Results of this effort from January 1997 through December 2005 are reported. Key features of our approach include institutional control over which and how many surgeons can perform carotid endarterectomy. Surgeons must be experienced carotid surgeons and consistently perform more than 12 procedures annually and be continuously monitored. Surgical outcomes were independently audited through a mandated institutional carotid endarterectomy data registry. Surgeons with poor outcomes are barred from doing carotid endarterectomies; and annually updated outcomes data are posted on the Internet. RESULTS: This approach was used for 555 carotid endarterectomies in 503 patients. Our outcomes-with total death and disabling stroke rate of 1.6%-compare favorably with, and are not statistically different from, published benchmarks, despite volumes at our institution ranging from 44 to 81 patients annually and the participation of 8 surgeons during the study period. CONCLUSIONS: Surgeons should perform carotid endarterectomies only if excellent outcomes can be demonstrated. We conclude that by using an approach like ours, even institutions with moderate-to-low carotid endarterectomy volumes can achieve excellent outcomes. We propose that all institutions should assume responsibility for ensuring excellent carotid endarterectomy outcomes using a comprehensive outcomes-based approach with independent auditing similar to that presented here.

Aged↗
PubMed1987

Correlation between signal-averaged electrocardiogram and programmed stimulation in patients with and without spontaneous ventricular tachyarrhythmias.

This study examined the incidence of delayed ventricular activation on signal-averaged electrocardiograms and the incidence of inducible sustained ventricular tachycardia (VT) at programmed stimulation (1 or 2 extrastimuli) in patients with and patients without spontaneous ventricular tachyarrhythmias. The correlation between delayed ventricular activation and inducible VT was investigated in 371 patients with acute myocardial infarction (AMI). In 32 patients with no ventricular disease and no spontaneous arrhythmias (group I), ventricular activation time averaged 115 +/- 2 ms, compared with 166 +/- 3 ms (p less than 0.001) for 65 patients with spontaneous ventricular tachyarrhythmias late after AMI (group II). In AMI patients with no spontaneous arrhythmias, ventricular activation time averaged 133 +/- 2 ms for 306 patients studied 1 to 4 weeks after AMI (group III) and 130 +/- 2 ms for 67 patients studied 3 to 12 months after AMI (group IV). The values for group III and group IV patients were each significantly higher than for group I (p less than 0.001), but lower than that for group II (p less than 0.001). The incidence of delayed ventricular activation was 89% for group II, 26% for group III and 18% for group IV. Sustained VT was not inducible in group I patients, but was inducible in 78% of group II (p less than 0.001 vs group I) and 20% of group III (p less than 0.05 vs group I; p less than 0.001 vs group II) (group IV was not studied).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1987

Comparative efficacy of pirmenol and procainamide in a drug-resistant population with ventricular tachycardia.

The acute antiarrhythmic properties of pirmenol were studied in 12 patients who failed clinical oral drug therapy with a history of a cardiac arrest or sustained ventricular tachycardia (VT). Programmed electrical stimulation studies were performed in ten men and two women with a mean age of 63 +/- 2 years. All patients had inducible ventricular tachycardia by programmed electrical stimulation when they were off all antiarrhythmic therapy. Patients were then tested on procainamide, 1000 mg, administered intravenously, and ventricular tachycardia could be provoked in nine of twelve patients. Pirmenol was given intravenously, 1.1 mg/kg bolus followed by 40 micrograms/kg/min over 40 minutes prior to drug testing. Pirmenol did not significantly change the baseline heart rate, blood pressure, or measured electrocardiographic values from control values. Ten of 12 patients were still inducible to ventricular tachycardia on pirmenol. Procainamide protected one of nine patients against VT induction. In patients still inducible on drug therapy, the VT rate was significantly slowed from 221 beats/min to 166 beats/min on pirmenol and to 200 beats/min on procainamide. The effects of this new antiarrhythmic agent were similar to procainamide in this drug-resistant study population.

Anti-Arrhythmia Agents↗
PubMed2006

Realigning clinical and economic incentives to support depression management within a medicaid population: the Colorado access experience.

The authors describe their experiences in developing an economically sustainable depression care management program within Colorado Access, a non-profit Medicaid health plan. They describe high rates of mental health issues, medical comorbidities, and psychosocial barriers to care within the plan's Medicaid population. They discuss how the company redirected resources to incorporate depression care management into an intensive care management program focused on high-cost members with multiple chronic medical conditions. This strategy allowed Colorado Access to cost effectively care manage a targeted group of high-cost Medicaid recipients across multiple primary care physician (PCP) practices without requiring changes in provider workflow.

Colorado↗
PubMed2000

Are implantable cardioverter- defibrillators cost-effective?

Sudden cardiac deaths account for a large number of cardiovascular deaths, and ventricular tachyarrhythmias are implicated in many of these. In survivors of sudden cardiac deaths and other selected groups of patients, implantable cardioverter-defibrillators (ICDs) have been shown to have significant survival benefits in randomized controlled trials. The incremental costs for each extra year of survival conferred by ICDs were compared to the cost of antiarrhythmic drug therapy in some of these trials. In patients with nonsustained ventricular tachycardia with low ejection fraction (< 35%) and inducible sustained ventricular tachycardia on programmed electrical stimulation (nonsuppressible by procainamide), the incremental costs of ICD therapy amounted to $27,000 per life-year saved, compared with drug therapy. These costs may be acceptable increments for adaptation of the new technology in view of the definite survival advantage conferred by ICDs. Evolving technology may further reduce these costs by development of better devices with longer battery life.

Amiodarone↗
PubMed1989

The effect of thromboxane inhibition on vulnerability to ventricular fibrillation in the acute and chronic feline infarction models.

Inhibition of the enzyme that synthesizes thromboxanes may protect against the development of ventricular fibrillation (VF) during acute myocardial ischemia. This study was carried out to test this hypothesis with a new thromboxane synthetase inhibitor, and to extend the studies to alternative animal models of myocardial infarction. In a series of acute experiments, 19 cats were pretreated with 10 mg/kg of U-63557A (a dose that produced greater than 75% reduction in thromboxane B2 [TxB2] levels) or saline before abrupt left anterior descending coronary artery occlusion. Seven of the nine control animals suffered spontaneous VF associated with a 77% fall in VF threshold compared with the treated animals, of which 2 of 10 had spontaneous VF and in which VF threshold fell by only 45% (p less than 0.025). Despite a similar extent of TxB2 inhibition in another set of nine animals, U-63557A failed to protect against a fall in VF threshold during coronary reperfusion. Finally, chronic changes in VF threshold and inducibility of sustained ventricular tachycardia by programmed stimulation were assessed in a group of eight animals. The lowering of VF threshold and inducibility of ventricular tachycardia seen in the control state were not influenced by treatment with U-63557A. Thus protection against infarct-related VF by TxB2 inhibition is a property shared by more than one pharmacologic agent. Arrhythmias generated by reperfusion or induced in a more chronic setting may not be thromboxane-dependent. These results have important implications for the planning of studies designed to assess the antiarrhythmic potential of drugs that inhibit thromboxane synthesis.

Acute Disease↗
PubMed1985

Electrophysiologic evaluation of the antiarrhythmic effects of N-acetylprocainamide for ventricular tachycardia secondary to coronary artery disease.

Antiarrhythmic properties of N-acetylprocainamide (NAPA), an active metabolite of procainamide, were studied in 12 patients with coronary artery disease who presented with cardiac arrest or documented sustained ventricular tachycardia (VT). Programmed electrical stimulation (PES) studies were performed in 10 men and 2 women, aged 52 to 80 years (mean 63), who had a left ventricular ejection fraction of 16 to 69% (mean 33). All patients tested had inducible VT provoked by PES without antiarrhythmic therapy. Patients were then tested with procainamide, 1,000 mg administered intravenously. VT could be provoked after procainamide treatment in 8 of 10 patients. Twenty-four to 36 hours later NAPA was administered, 18 mg/kg body weight intravenously, and PES was performed after 20 minutes. NAPA did not significantly change heart rate, mean arterial blood pressure, electrocardiographic intervals and AH or HV conduction times. The QT interval lengthened, but not significantly. The mean serum NAPA levels were 15.7 +/- 4 micrograms/ml in the group protected by NAPA and 16.2 +/- 4 micrograms/ml in the group not protected by NAPA. Five patients were discharged with NAPA therapy, 1.5 g orally every 8 hours. Two patients have been maintained with chronic NAPA therapy (10 +/- 3 months), and 2 patients had breakthrough VT on follow-up Holter monitoring and alternative therapy was given. One patient died while taking oral therapy. NAPA demonstrates antiarrhythmic efficacy in preventing induction of VT by PES in a high-risk group of patients. During chronic oral therapy in some patients, NAPA appears to be well tolerated, with antiarrhythmic efficacy that may be enhanced with further upward dose titration.

Acecainide↗
PubMed1995

Follow-up of 30 pregnancies after embryo cryopreservation.

OBJECTIVE: In an observational follow-up study, the pregnancy outcome of the first 30 women who conceived after transfer of cryopreserved embryos was evaluated. STUDY DESIGN: The main outcome measures were duration and complications of pregnancy, mode of delivery, complications during and after childbirth, birthweight, Apgar score, and congenital anomalies. RESULTS: Twenty-six pregnancies ended in birth of one (n = 22) or more (n = 4) infants with a cesarean section rate of 23%. Of the singleton pregnancies 77% were uncomplicated, but there was a high incidence of breech presentation (14%). Infant birthweight tended to be above average with 45% of singletons weighing more than the 75th centile of weight for gestation. There were no major congenital deformations. CONCLUSION: The results of our embryo cryopreservation program are encouraging, but sustained follow-up of such pregnancies and infants is needed.

Adult↗
PubMed1994

Cariogenic microflora in patients with Hodgkin's disease before and after mantle field radiotherapy.

Because mantle field radiotherapy is associated with partial xerostomia in patients with Hodgkin's disease, the purpose of this study was to evaluate their cariogenic microflora before and after completion of radiotherapy. We obtained samples of oral saline solution rinse from 40 patients with Hodgkin's disease before radiotherapy and from 31 patients with Hodgkin's disease who had survived 1 to 24 years after radiotherapy. We also evaluated caries experience and history of fluoride gel use for caries prevention in these patients. Mutans streptococci and lactobacilli levels were significantly higher in the postradiotherapy patients with carious teeth, particularly in those with limited home use of fluoride gels. In the postradiotherapy group, caries parameters were significantly higher (p < 0.05) than in the preradiotherapy group. Within the postradiotherapy group, both caries and microbial parameters tended to be higher in patients who were less compliant about using the recommended 0.4% stannous fluoride "brush-in" technique than in those who used the gel regularly at home. This study indicates that for patients with Hodgkin's disease who receive mantle field irradiation during the management of their disease, a sustained brush-in program with stannous fluoride gel can be of benefit for caries prevention and for limitation of oral levels of cariogenic mutans streptococci.

Adolescent↗
PubMed1991

Paired comparisons of efficacy of intravenous and oral procainamide in patients with inducible sustained ventricular tachyarrhythmias.

Thirty-eight patients who had inducible sustained ventricular tachycardia during baseline programmed electrical stimulation underwent electrophysiologic testing after both intravenous and oral administration of procainamide. Each had presented clinically with documented sustained ventricular tachycardia or out of hospital cardiac arrest not associated with acute myocardial infarction. In 23 patients (61%) (Group I) the arrhythmia became noninducible during an intravenous infusion of procainamide. Oral procainamide was subsequently administered and retesting was carried out after dose titration to match plasma concentration at the end of the intravenous study. Among the 23 patients in Group I the mean (+/- SD) plasma procainamide level was 7.2 +/- 2.8 micrograms/ml after intravenous dosing and 7.9 +/- 2.5 micrograms/ml after oral dosing (p = 0.09). In 15 (65%) of the 23 patients, sustained ventricular arrhythmia was inducible on oral therapy with comparable plasma procainamide levels (intravenous = 6.3 +/- 2.1 micrograms/ml, oral = 7.5 +/- 2.1 micrograms/ml). The other eight patients (35%) had concordant responses to repeat testing with comparable intravenous (mean 9.0 +/- 3.3 micrograms/ml) and oral (8.8 +/- 3.1 micrograms/ml) plasma procainamide levels. In the additional 15 patients (Group II) sustained ventricular tachyarrhythmia remained inducible on intravenous procainamide therapy and the patients were retested on oral therapy with similar plasma concentration (p = 0.05). In seven patients (47%) sustained ventricular tachyarrhythmia was noninducible on treatment with oral procainamide (mean plasma level 7.6 +/- 2.7 micrograms/ml) after failure of intravenous procainamide (mean plasma level 10.3 +/- 2.3 micrograms/ml).(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed2005

Transport of the critically ill: the Northwest MedStar experience.

This article provides a description of Northwest MedStar, a fully integrated, self-sustained critical care transport program that provides transport services to over 70 hospitals and 350 emergency medical service agencies in the inland Northwest region of the United States. By providing transport and educational support to these agencies, Northwest MedStar assists in providing optimal emergency and critical care services for the patients in their communities.

Accreditation↗
PubMed2003

Sustaining new parents in home visitation services: key participant and program factors.

OBJECTIVES: As prevention efforts have adopted more intensive service models, concerns over initial enrollment and retention rates have become more salient. This study examines the participant, provider and program factors that contribute to a longer length of stay and greater number of home visits for new parents enrolling in one national home visitation program. METHODS: Retrospective data were collected on a random sample of 816 participants served by one of 17 Healthy Families America (HFA) program sites around the country. Using case record reviews, research staff documented each participant's characteristics and service experiences. To capture relevant staff and program information, research staff collected basic descriptive information from published documents and interviews with program managers. All home visitors who had contact with sample families also completed a self-assessment instrument regarding personal and professional characteristics. Hierarchical linear modeling allowed us to examine the unique role of participant, provider and program characteristics while recognizing the lack of independence among these three sets of variables. RESULTS: The combined provider and program levels in the HLM model accounted for one-third of the variance in service duration and one-quarter of the variance in the number of home visits. Older participants, those unemployed, and those who enrolled in the program early in their pregnancy were more likely to remain in services longer and to complete a greater number of home visits. Compared to White participants, African Americans and Hispanics were significantly more likely to remain in services longer and, in the case of African Americans, to receive a greater number of home visits. Participants who were enrolled in school were more likely to remain in services longer. Age was the only consistent provider characteristic associated with positive results in both models, with younger home visitors performing better. Prior experience showed a significant relationship only in the service dosage model and African American workers demonstrated greater success than White home visitors did in retaining families in service. At the program level, programs with lower caseloads and greater success in matching their participants and providers on parenting status and race/ethnicity were significantly more likely to demonstrate stronger enrollment patterns.

Adult↗
PubMed2005

An overview of the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program: 1997-2004.

This overview provides a summary of the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program over an 8-year period from 1997 to 2004. The evolution of the MYSTIC Program is described, as well as its design compared with other surveillance programs. In addition, the global MYSTIC Program data, published to date, are summarized, and the empiric use of carbapenems, their current indications, and meropenem usage versus resistance was discussed. From 1997 to 2004, 120 medical centers that were actively prescribing meropenem in 32 countries worldwide participated in the program. The MYSTIC Program results demonstrate the sustained potency and continued effectiveness of meropenem globally against clinically relevant Gram-negative and Gram-positive pathogens including extended spectrum beta-lactamase- and AmpC beta-lactamase-producing organisms, which may also display resistance to the fluoroquinolones and/or aminoglycosides. Furthermore, in centers actively prescribing meropenem, resistance to meropenem is not increasing despite greater resistance among the comparator antimicrobial agents. Thus, antipseudomonal carbapenems such as meropenem and imipenem remain an effective treatment option.

Anti-Bacterial Agents↗
PubMedDate not supplied

Mental health correlates of healthy lifestyle attitudes, beliefs, choices, and behaviors in overweight adolescents.

INTRODUCTION: A tripling in the number of overweight adolescents has occurred during the past two decades, with type 2 diabetes reaching epidemic proportions. Although obesity has been identified as a correlate of depression and low self-esteem in adolescents, the relationships among key cognitive/mental health variables and healthy attitudes, beliefs, choices, and behaviors in overweight teens have yet to be explored. Therefore, the aim of this study was to describe these relationships so that an effective intervention program to promote and sustain healthy lifestyle behaviors could be implemented. METHODS: A descriptive correlational study was conducted with 23 overweight teens. Key variables measured included depressive symptoms, state and trait anxiety, self-esteem, beliefs/confidence about engaging in a healthy lifestyle, perceived difficulty in leading a healthy lifestyle, and healthy attitudes, choices, and behaviors. FINDINGS: Teens with higher state and trait anxiety as well as depressive symptoms had less healthy lifestyle beliefs, and teens with higher self-esteem had stronger beliefs about their ability to engage in a healthy lifestyle. Stronger beliefs about the ability to engage in healthy lifestyles were related to healthier living attitudes and healthier lifestyle choices. Teens who perceived healthy lifestyles as more difficult had less healthy attitudes and reported less healthier choices and behaviors. DISCUSSION: Including a strong cognitive behavioral skills building component into clinical interventions with overweight teens may be key in boosting their beliefs/confidence about being able to engage in healthy behaviors and lessening their perceived difficulty in performing them, which should result in healthier choices and lifestyle behaviors.

Adaptation, Psychological↗
PubMed2006

The impact of routine infant immunization with Haemophilus influenzae type b conjugate vaccine in Malawi, a country with high human immunodeficiency virus prevalence.

Malawi has extreme poverty and a high-human immunodeficiency virus (HIV) prevalence. Following Haemophilus influenzae type b (Hib) conjugate vaccine introduction during 2002, we evaluated vaccine impact by reviewing hospital surveillance data for acute bacterial meningitis in Blantyre district among children age 1-59 months admitted during 1997-2005. Documented annual Hib meningitis incidence rates decreased from 20-40/100,000 to near zero among both rural and urban residents despite no change in pneumococcal meningitis incidence rates. Before vaccine introduction, an average of 10 children/year had Hib meningitis and HIV infection compared to 2/year during 2003-2004 and none during 2005. Vaccine effectiveness was high following two or more doses of vaccine. The most urgent future need is for a sustainable routine infant immunization program, including a less expensive vaccine that preferably is delivered in a multivalent form.

Age Factors↗