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PubMedDate not supplied

Functional correlates in the rehabilitation of occupational low back pain.

The aim of this preliminary report was to identify physiological parameters related to functional improvement in industrial workers with occupational low back pain (LBP) undergoing an intensive rehabilitation program. Four able-bodied and four LBP industrial workers were evaluated before and after a 4-week rehabilitation program. Dynamic and static strength tests, namely sustained isometric contractions, were performed in conjunction with surface electromyographic (EMG) measurements. Significant pre-rehabilitation differences were found between the two groups. Measured forces changed significantly in LBP subjects immediately after rehabilitation. No significative changes were found in the control subjects after the rehabilitation program. After rehabilitation, the slope of decay of the median frequency of the EMG power spectrum at L4 level, during a 60-sec isometric submaximal (60% MVC) contraction, decreased significantly (p < 0.02) indicating a lower fatigue level.

Adult↗
PubMed1992

[Correlations between the different criteria of late potentials and results of programmed ventricular stimulation after myocardial infarction].

Five to ten per cent of survivors of acute myocardial infarction die within two years. The majority of these deaths are sudden and are attributed to a lethal ventricular arrhythmia. This is usually ventricular tachycardia degenerating to ventricular fibrillation. These post-infarction tachycardias are generally due to reentry. They require an anatomic arrhythmogenic substrate, a zone of delayed conduction. This can be detected as late potentials on signal averaged ECG. The triggering of a significant ventricular arrhythmia by ventricular stimulation is closely correlated to the occurrence of a severe ventricular arrhythmia in the months following infarction. Programmed ventricular stimulation could, therefore, help to identify patients requiring close follow-up and/or preventive antiarrhythmic therapy, but cannot be offered to all patients because of its invasive nature. Seventy nine post-infarction patients were studied prospectively. All underwent coronary angiography, signal averaging electrocardiography, and programmed ventricular stimulation at least 15 days after infarction. Fifty five patients had at least one criterion of late potentials (QRS duration > or = 110 ms and/or amplitude of the last 40 ms < 27 microV and/or duration of potentials of under 40 microV > 37 ms). Twenty four patients had no late potentials. The results of programmed stimulation were estimated to be positive when sustained or unsustained monomorphic ventricular tachycardia was triggered, and negative when ventricular fibrillation, ventricular flutter unsustained polymorphic ventricular tachycardia or no arrhythmia could be induced. Programmed ventricular pacing triggered 15 significant events, 17 unsustained polymorphic ventricular tachycardias, 13 ventricular flutters and 11 ventricular fibrillations. The exploration was negative in 23 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Action Potentials↗
PubMedDate not supplied

The role of strategic alliances in ensuring health care quality: a health care system perspective.

The Chronic Illness Management Research and Development Project (CIMRDP) was created as part of an effort to implement clinical process improvements in HealthSystems Minnesota, a vertically integrated care system in Minneapolis. CIMRDP's objective is to introduce sustainable improvements in the management of chronic illness. These types of quality improvement efforts require fundamental change at the organizational level, which often does not occur, and the programs do not continue beyond the initial stage. Using CIMRDP as a model for a sustainable chronic illness management program, this paper explores the process of implementing clinical guidelines for the management of chronic illness and contending with the complex problem of initiating change at an organizational level. It reviews factors critical to the success of such a program, including the use of focus groups to ensure a patient-centered approach, the advantage of hiring an outside consultant, the question of whether to accept external funding, and an evaluation outline of the six main tasks the program requires. Methods for marketing and integration are also presented.

Chronic Disease↗
PubMed1994

[Diagnostic value of exercise test in the evaluation of sustained ventricular arrhythmia].

The authors undertook a prospective study comparing exercise testing and programmed ventricular stimulation in order to assess the diagnostic value and risks of exercise stress testing in patients with sustained ventricular arrhythmias. Fifty-five consecutive patients (47 men and 8 women) with an average age of 47 +/- 15 years were included. The initial condition requiring investigation was sustained ventricular tachycardia (47 cases) and ventricular fibrillation (8 cases). The patients had ischaemic heart disease (N = 18), dilated cardiomyopathy (N = 9), valvular heart disease (N = 4) and congenital heart disease (N = 3). Six patients presented with arrhythmogenic right ventricular dysplasia and 15 patients had apparently normal hearts. Four episodes of sustained ventricular tachycardia (7.3%) and 10 non-sustained ventricular tachycardia (18.2%) were induced by exercise testing. One poorly tolerated episode of ventricular tachycardia required cardioversion. No signs of myocardial ischaemia were observed in association with the induced ventricular tachycardia Patients with ventricular tachycardia induced by exercise were significantly younger (39.5 +/- 12.5 vs 49.5 +/- 15.4 years; p = 0.04) and attained a lower predicted maximal heart rate (82.2 +/- 14.6 vs 91.4 +/- 14.4%; p = 0.04), but the underlying pathologies were the same, as were the initial arrhythmias and the level of exercise attained. With respect to the clinical circumstances of induction of the initial ventricular arrhythmia, patients with ventricular tachycardia induced by exercise had an increased tendency to arrhythmias during effort or stress (7/14 vs 8/41; p = 0.06). Programmed ventricular stimulation induced more ventricular tachycardias than exercise testing (36/55 vs 14/55; p < 0.0001). The results of exercise testing were not correlated to those of programmed stimulation (p = 0.38).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Predictive value of early electrophysiologic testing in determining long-term outcome with amiodarone treatment in patients with sustained ventricular tachycardia.

This prospective study sought to determine whether programmed ventricular stimulation before hospital dismissal in patients who had received a loading dose of amiodarone would identify those at risk for recurrent ventricular arrhythmias. Between January 1985 and January 1989, 64 patients (55 men and 9 women; mean age, 64 years) with a history of sustained ventricular tachycardia (VT) or ventricular fibrillation were referred to our institution for electrophysiologic testing. Of these patients, 52 had coronary artery disease, 11 had dilated cardiomyopathy, and 1 had hypertrophic cardiomyopathy. Of the 64 patients, 47 had baseline tests while no drugs were administered and repeated electrophysiologic testing after 10 days of amiodarone loading (1.2 g/day). The other 17 patients had no baseline study because of instability of their arrhythmias but underwent electrophysiologic testing after amiodarone loading. Follow-up ranged from 7 to 1,536 days (mean, 652 days). During the follow-up period, recurrent arrhythmias were detected in 22 patients. Of the 64 patients, 14 had suppression of VT. Of 43 patients in whom the cycle lengths of VT were determined both at baseline and after amiodarone therapy, 20 had an increase of 100 ms or more, and 23 had no substantial change. The mean ejection fraction was 31%. Of a total of 16 deaths in the series, 8 were sudden. Suppression of VT during amiodarone therapy suggested a lower rate of fatal and nonfatal recurrent arrhythmias, but the difference was not statistically significant. An increase in the cycle length of VT did not predict an improved outcome. The age of the patient and the presence of a left ventricular aneurysm were slightly predictive of mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1998

Kinetics of gentamicin uptake in the inner ear of Chinchilla langier after middle-ear administration in a sustained-release vehicle.

The search for a safe, effective treatment for the vertigo associated with Meniere's disease has long been an important topic in otolaryngology. In recent years many groups have begun using intratympanic gentamicin to treat this vertigo. Although reported cure rates are as high as 90%, many questions remain regarding this type of treatment. Current limitations are the necessity for repeated treatments and a lack of clear dosing guidelines. In addition, the gentamicin must be delivered in a manner that allows maximal vestibulotoxic effect without injury to hearing. Until investigators can control the exact amount of medicine that is placed in the ear and have an understanding of the kinetics of gentamicin absorption, adequate dosing guidelines will be difficult to establish, and therapy will continue to rely on empiric data. We describe the use of a fibrin-based sustained-release vehicle, impregnated with gentamicin, injected into the middle ear of chinchillas. This allows for a prolonged effect without repeated dosing. Using this model, we studied the absorption kinetics of gentamicin at time points ranging from 8 hours to 1 week after injection. We used our findings to create a kinetics curve of gentamicin absorption. We discuss the shape and characteristics of this kinetics curve and examine the effects of the fibrin-based sustained-release vehicle and gentamicin on the middle ear. We noted no absorption in the contralateral (untreated ear) or blood. Through better understanding of the actions of gentamicin in this animal model, we hope to facilitate safer use of intratympanic medicines in our patient population and initiate programs for the use of this sustained-release vehicle in human beings.

Animals↗
PubMed2000

School-based mental health services: a research review.

This paper provides a synthetic review of research on school-based mental health services. Schools play an increasingly important role in providing mental health services to children, yet most school-based programs being provided have no evidence to support their impact. A computerized search of references published between 1985 and 1999 was used to identify studies of school-based mental health services for children. Study inclusion was determined by (i) use of randomized, quasi-experimental, or multiple baseline research design; (ii) inclusion of a control group; (iii) use of standardized outcome measures; and (iv) baseline and postintervention outcome assessment. The application of these criteria yielded a final sample of 47 studies on which this review is based. Results suggest that there are a strong group of school-based mental health programs that have evidence of impact across a range of emotional and behavioral problems. However, there were no programs that specifically targeted particular clinical syndromes. Important features of the implementation process that increase the probability of service sustainability and maintenance were identified. These include (i) consistent program implementation; (ii) inclusion of parents, teachers, or peers; (iii) use of multiple modalities; (iv) integration of program content into general classroom curriculum; and (v) developmentally appropriate program components. Implications of these findings and directions for future research are discussed.

Affective Symptoms↗
PubMed2003

Interests in HIV prevention topics of HIV-seropositive men who have sex with men.

As improved medical treatments have extended the lives of persons with HIV, prevention programs increasingly address these persons' ability to adopt and sustain HIV risk reduction behavior. Little is known about which HIV-seropositive persons would most likely use prevention programs or what program topics would best meet the needs of this population. A diverse sample of HIV-seropositive men who have sex with men (MSM, N = 206) rated their interest in a variety of program topics addressing physical and mental health issues. Topics specific to HIV prevention were of interest to most MSM, but the level of interest was generally lower than for other topics. Compared with White MSM, African American MSM had higher overall interest in programs addressing safer sex and programs addressing serostatus disclosure. Higher active coping was related to more interest in a broad range of program topics for HIV-seropositive men, programs addressing safer sex, and programs addressing serostatus disclosure. Risk behavior was not associated with program interests. Gaining a better understanding of interest in a variety of program topics among persons living with HIV is an important step in enhancing HIV transmission prevention programs.

Adult↗
PubMedDate not supplied

Systems collaborate for a healthier community. A Community Health Advisory Board focuses on immunization.

The Community Health Advisory Board (CHAB), Pierce County, WA, involves four healthcare systems--Franciscan Health System, MultiCare Medical Center, Group Health Cooperative of Puget Sound, and Good Samaritan Hospital--that have joined forces with other providers in an innovative attempt to better serve their community. An evaluation by representatives of New York University's Hospital Community Benefit Standard Program prompted St. Joseph Medical Center, Tacoma, WA, to bring major providers together in a coordinated effort that could reach community residents in need. At their first meeting in November 1992, CHAB members agreed on a purpose: to facilitate collaboration between healthcare providers throughout the county to develop programs and services that improve the health status of community residents. In January 1993 CHAB members selected a "quick success" project: a program aimed at increasing immunization levels to 90 percent for two-year-old children in the county. In February 1993 CHAB members committed the "best and brightest" to the Immunization Task Force, naming experts in planning, nursing, community health, education, and marketing. When the Immunization Task Force assessed the project, they realized that the "quick success" program would not be accomplished so quickly. CHAB has had to address underlying problems to make higher immunization levels sustainable. In March 1994 members will evaluate the immunization program's process, status, and structure; data on immunization levels; and the group's demonstrated ability to cooperate.

Child, Preschool↗
PubMed1995

Evaluation of the Navy's obesity treatment program.

This study evaluated the overall effectiveness of the Navy's three-tiered obesity treatment program and compared effectiveness across the three treatment levels. Height, weight, and body circumference measurements were obtained from 369 program participants at baseline and follow-up (6 weeks, 6 months, 12 months). Results demonstrated a significant and sustained reduction in percent body fat in all three program tiers, but the absolute losses at the end of 12 months were small: -3.7% fat for men, -4.5% fat for women. The level III tier, which employs a multidimensional approach to treatment, was the most effective program, even after differences in enrollees' initial percent body fat were taken into account. Changes in the approach to treatment and development of a supportive, long-term, behaviorally based aftercare program are recommended.

Female↗
PubMedDate not supplied

Interpreting science in the real world for sustainable land application.

Today's land application practices are designed to effectively treat wastes, and have evolved from earlier practices that centered on cheap disposal with less regard for environmental protection. The major objectives of this paper are to (i) review how current land application practices, and our understanding of them, have evolved over time and (ii) explore how science is used (and sometimes misused or ignored) in the development of design, regulation, and management of sustainable land application. Land treatment technologies have been used effectively for the treatment and recycling of many types of wastewaters and organic residuals for many years. Extensive research and demonstration efforts, as well as experience with pilot- and field-scale projects, have provided the information about soil reactions with contaminants in wastewater and organic residuals needed to design and operate sustainable land application projects. Still, systematic research programs are as important today as ever to support studies aimed at producing information on how soil-based treatment and recycling systems work, to address new areas of concerns as they arise, and continue to improve the overall design, performance, and reliability of land application systems as sustainable soil treatment and recycling systems.

Animals↗
PubMed1991

Routine programmed electrical stimulation in survivors of acute myocardial infarction for prediction of spontaneous ventricular tachyarrhythmias during follow-up: results, optimal stimulation protocol and cost-effective screening.

Of 3,286 consecutive patients treated for acute myocardial infarction, electrophysiologic testing was performed in 1,209 survivors (37%) free of significant complications at the time of hospital discharge to determine their risk of spontaneous ventricular tachyarrhythmias during follow-up. Sustained monomorphic ventricular tachycardia was inducible by programmed electrical stimulation in 75 (6.2%). Antiarrhythmic therapy was not routinely prescribed regardless of the test results. During the 1st year of follow-up, 14 infarct survivors (19%) with inducible ventricular tachycardia experienced spontaneous ventricular tachycardia or fibrillation in the absence of new ischemia compared with 34 (2.9%) of those without inducible ventricular tachycardia (p less than 0.0005). During the extended follow-up period (median 28 months) of those with inducible ventricular tachycardia, 19 (25%) had a spontaneous electrical event; 37% of these first events were fatal. These results suggest that the most cost-effective strategy for predicting arrhythmia will be obtained by restricting electrophysiologic testing to infarct survivors whose left ventricular ejection fraction is less than 40% and using a stimulation protocol containing four extrastimuli. Electrophysiologic testing is the single best predictor of spontaneous ventricular tachyarrhythmias during follow-up in infarct survivors. The majority (94%) with a negative test benefit from the more reliable reassurance that all is well, whereas the 25% risk of electrical events in those with inducible ventricular tachycardia justifies a prospective trial of effective prophylactic antiarrhythmic interventions.

Anti-Arrhythmia Agents↗
PubMed1990

Day to day reproducibility of electrically inducible ventricular arrhythmias in survivors of acute myocardial infarction.

Day to day reproducibility of the response to programmed ventricular stimulation has not been evaluated in survivors of acute myocardial infarction. Programmed ventricular stimulation was performed prospectively on 2 consecutive days in 56 patients on an average of 12 +/- 5 days (range 7 to 29) after an acute myocardial infarction. No patient had a history of documented or suspected sustained ventricular tachycardia or fibrillation occurring greater than 48 h after infarction. During initial programmed ventricular stimulation, 21 patients had induction of sustained ventricular tachycardia or fibrillation (Group I), and 35 patients had induction of either nonsustained ventricular tachycardia or no ventricular tachycardia (Group II). Repeat programmed ventricular stimulation in Group I patients induced sustained ventricular tachycardia or fibrillation in 16 of 21 patients (reproducibility 76%); the maximal induced response in the other 5 patients was nonsustained ventricular tachycardia in 2 patients and fewer than six repetitive ventricular responses in 3 patients. The day to day reproducibility was significantly higher for inducible sustained ventricular tachycardia of cycle length greater than or equal to 240 ms compared with rapid sustained ventricular tachycardia of cycle length less than 240 ms (100% versus 44%, p less than 0.009) or ventricular fibrillation (100% versus 43%, p less than 0.009). Repeat programmed ventricular stimulation in Group II patients did not induce sustained ventricular arrhythmias in 31 of 35 patients (reproducibility 89%). Thus, in survivors of acute myocardial infarction, inducible slow sustained ventricular tachycardia was a highly reproducible finding, whereas inducibility of rapid sustained ventricular tachycardia and ventricular fibrillation showed a significant day to day variability.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1998

Initiating sequences in exercise induced idiopathic ventricular tachycardia of left bundle branch-like morphology.

Initiating sequences for VT may infer the underlying arrhythmogenic mechanisms. This study examines the initiating sequences of exercise induced idiopathic VT of left bundle branch block-like (LBBB-like) morphology and makes an attempt to relate these to clinical aspects and the mechanisms of arrhythmia. Thirty-two patients (mean age 33.4 +/- 13.2 years; 18 men) with exercise induced VT in the absence of structural cardiac abnormality on history, clinical examination, and noninvasive and invasive investigations were divided into two groups on the basis of the initiating sequence of VT on exercise. Group I consisted of patients with long-short sequence of RR intervals prior to the onset of VT (initiating/preinitiating cycle length ratio < or = 0.78). Group II consisted of patients without changes in cycle length prior to VT. Group I mechanism would suggest delayed afterdepolarizations (DADs) or reentry whereas group II mechanism triggered activity due to early afterdepolarizations. Fourteen patients (group I) had long-short sequence and 18 patients (group II) were without cycle length changes prior to VT initiated during exercise. VT axis was inferior in all 18 patients in group II but only in 9 patients in group I (P = 0.02). In these predefined patient groups, sustained monomorphic VT could not be initiated by programmed stimulation in any patient in group I, whereas four patients in group II had inducible VT. Patients in group II also had higher incidence of sustained VT on ambulatory monitoring (P < 0.05). The two groups did not differ in other respects. This study demonstrates the existence of at least two possible mechanisms of initiation of exercise induced idiopathic VT of LBBB-like morphology. VT initiated without cycle length changes is more common, more likely to have an inferior axis suggesting an outflow tract origin, and is probably related to triggered activity secondary to DADs. VT initiated with a long-short sequence is more often nonsustained and may have a superior axis suggesting an origin from the body or septal region of the ventricle. The two groups, therefore, exhibit differences in electrophysiological characteristics that may aid classification and therapy of this arrhythmia.

Adult↗
PubMed2005

Mechanism of sudden cardiac death in pigs with viable chronically dysfunctional myocardium and ischemic cardiomyopathy.

Pigs with viable chronically dysfunctional myocardium and ischemic cardiomyopathy are at high risk of sudden cardiac death (SCD). We sought to identify the arrhythmic mechanism of SCD, the relation to changes in left ventricular (LV) function, and inducibility of malignant arrhythmias before SCD. Juvenile pigs (n = 72) were instrumented with chronic stenoses on proximal left anterior descending and circumflex arteries. Survival was only 29% 3 mo after instrumentation, and all deaths were sudden and without prodromal symptoms of heart failure. Triphenyltetrazolium chloride staining demonstrated necrosis in only nine animals averaging 2.3 +/- 0.9% of the LV, with no difference between SCD animals and survivors. Implantable loop recorders (n = 13) documented both ventricular fibrillation (n = 6) and bradyasystole (n = 2) as the arrhythmic mechanism of death. Although regional and global function were depressed [anteroseptal wall thickening 1.8 +/- 0.2 vs. 4.2 +/- 0.2 mm in Sham animals (P < 0.001); fractional shortening 21 +/- 2 vs. 31 +/- 1% in Sham animals (P < 0.01)], there were no differences between SCD animals and survivors. LV mass increased in animals with ischemic cardiomyopathy and was greater in animals with SCD (4.0 +/- 0.2 vs. 3.1 +/- 0.1 g/kg in survivors; P < 0.001). Serial programmed ventricular stimulation failed to induce any sustained arrhythmias. We conclude that pigs with viable dysfunctional myocardium and globally reduced LV function have a high rate of SCD with a spectrum of arrhythmias similar to patients with ischemic cardiomyopathy. The risk is independent of necrosis but appears to increase with LV hypertrophy. Like patients with ischemic cardiomyopathy, programmed stimulation is insensitive to predict SCD when viable dysfunctional myocardium is the pathological substrate.

Animals↗
PubMed2004

Institutionalization of a community action program targeting licensed premises in Stockholm, Sweden.

The objective of this article is to evaluate the level of institutionalization of a community action program targeting licensed premises in Stockholm. Five key factors were identified for institutionalization: adoption, sustainability, key leader support, structural changes, and compliance. A scale was developed to assess the strength of each factor. The results indicate a high degree of institutionalization (score 13 on a scale from 5 to 15). The authors conclude that the program activities have been sustained at a high level. A written agreement ensures that the participating organizations take responsibility for the continuing work.

Alcoholic Beverages↗
PubMed1985

Flecainide: electrophysiologic and antiarrhythmic properties in refractory ventricular tachycardia.

Twenty-two patients with coronary artery disease and spontaneous ventricular tachycardia (VT) or ventricular fibrillation (VF) underwent intracardiac electrophysiologic evaluation and, when possible, ambulatory monitoring before and after therapy with flecainide (mean dose 418 +/- 87 mg [mean +/- standard deviation]). An average of 4 antiarrhythmic agents were used and were unsuccessful before therapy with flecainide was begun. During 64 +/- 16 hours of control Holter monitoring in 16 patients, all had 1 or more salvos of VT, as well as ventricular premature complexes (VPCs). Programmed stimulation during the control period induced VT in 17 of 22 patients. After flecainide therapy, Holter monitoring showed elimination of all forms of VT in all but 1 patient, as well as significant reduction of paired VPCs by 95% (p less than 0.03) and single VPCs by 70% (p less than 0.005). Electrophysiologic study during flecainide therapy showed significant increases in AH, HV, PR, QRS and QTc intervals, and the ventricular effective refractory period. Programmed stimulation in 17 patients taking flecainide, with a mean plasma level of 1,075 +/- 521 ng/ml, showed ablation of inducible VT in only 2 patients, a worsening in 5 and continued VT inducibility in 10. Adverse effects that required drug withdrawal were infrequent and encountered in patients who received higher drug levels: 1 patient with congestive heart failure and 1 with severe sinus bradycardia. Thus, although flecainide suppresses complex ventricular arrhythmias on Holter recordings, it rarely alters the response to programmed stimulation. Caution is recommended in its use for recurrent sustained VT or VF and in the interpretation of electrophysiologic studies until the predictive value of programmed stimulation with flecainide therapy is established.

Adult↗
PubMed1998

One-year followup of patients with osteoarthritis of the knee who participated in a program of supervised fitness walking and supportive patient education.

OBJECTIVE: To determine whether gains in functioning observed immediately following participation in an 8-week program of supervised fitness walking for patients with knee osteoarthritis were sustained at 1-year followup. METHODS: Twenty-nine (61.1%) of 47 original intervention program patients and 23 (51.1%) of 45 original control patients were interviewed by telephone at 1-year followup. Patients completed the Arthritis Impact Measurement Scales physical activity, arthritis impact, pain, medication use, and general health perceptions subscales, as well as a separate visual analog pain scale and measures of perceived self-efficacy to cope with arthritis pain and other symptoms. RESULTS: Adherence to walking was low, and there were no statistically significant differences between intervention and control patients at one year. CONCLUSIONS: The failure of intervention patients to maintain regular walking resulted in loss of functional benefits that were observed at 8 weeks in the original study. Long-term adherence to walking is critical to maintenance of initial gains in functional outcomes.

Activities of Daily Living↗