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PubMed1992

Pharmacodynamic monitoring of cyclosporin.

The efficacy of cyclosporin as an immunosuppressive agent is largely based on clinical indicators such as graft survival, rejection or nephrotoxicity. Therapeutic monitoring is necessary to evaluate the efficacy of cyclosporin therapy. The most widely used method for monitoring cyclosporin therapy is the measurement of predose through blood concentrations of the drug. The relationship of a single or multiple blood cyclosporin concentration to slowly evolving outcomes is difficult to establish. Some investigators have found a good correlation between cyclosporin trough concentrations on the one hand and cyclosporin toxicity and rejection on the other, but others have not. Therapeutic monitoring of cyclosporin may be enhanced using some biological assays for immunosuppression (pharmacodynamic monitoring) in addition to cyclosporin trough concentrations (pharmacokinetic monitoring). However, direct monitoring of the immune response to cyclosporin therapy using a clinically applicable biological assay is difficult. Some pharmacodynamic parameters have been suggested as biological markers in the clinical monitoring of cyclosporin.

Biomarkers↗
PubMed1999

The evolving role of ambulatory arrhythmia monitoring in general clinical practice.

PURPOSE: To evaluate the efficacy of various ambulatory electrocardiographic monitors for the diagnosis of arrhythmia-related disorders and to provide recommendations for their use in clinical practice. DATA SOURCES: Studies published since 1988 were identified through search of the MEDLINE database. STUDY SELECTION: Studies that met methodologic criteria for minimal bias and had clinical relevance were selected. DATA EXTRACTION: Descriptive and analytic data from each study. DATA SYNTHESIS: Ambulatory electrocardiographic monitors, specifically transtelephonic continuous-loop event recorders, are highly effective for establishing a diagnosis in patients with palpitations but are less effective for establishing a diagnosis in patients with syncope. Clinicians may use these devices to monitor for nonsustained ventricular tachycardia in patients at potentially high risk for sudden arrhythmic death; however, few data are available to support this practice. Ambulatory monitors are useful for assessment of the safety and efficacy of antiarrhythmic medications and the recurrence of symptomatic supraventricular arrhythmias. New ambulatory arrhythmia monitoring devices are being developed that may facilitate outpatient management of chronic cardiac disease. CONCLUSIONS: Ambulatory electrocardiographic monitors, particularly transtelephonic continuous-loop event recorders, aid in the diagnosis of symptomatic arrhythmias. These devices are also useful for monitoring the effectiveness and safety of antiarrhythmic medications. Guidelines are lacking for use of these devices to assess prognosis in patients at potential risk for sudden arrhythmic death.

Algorithms↗
PubMed1998

Relationship between ambulatory blood pressure monitoring and response of blood pressure in male hypertensive adolescents to exercise.

BACKGROUND: High blood pressure in the young has been related to the development of hypertension in adults; hence the importance of identifying adolescents with the risk of developing it.OBJECTIVE: To investigate the relationship between 24 h ambulatory blood pressure monitoring and the response of blood pressure in adolescents to exercise. DESIGN: A prospective and cross-sectional study. METHODS: We classified 101 men aged 13-18 years as obese hypertensive, lean hypertensive, obese normotensive, and lean normotensive. Mean blood pressure and variability were measured with ambulatory blood pressure monitoring, and expressed as 24 h, awake, and sleeping periods. Treadmill tests were also performed. RESULTS: Hypertensives and obese normotensives had higher ambulatory blood pressure monitoring values (P< 0.0001). Systolic blood pressure during sleep in obese subjects was significantly higher than that in lean usbjects (119.9 +/- 9 versus 113.6 +/- 8 mmHg, P < 0.001, obese hypertensives versus lean hypertensives; and 113.6 +/- 2 versus 103.0 +/- 2 mmHg, P < 0.002, obese normotensives versus lean normotensives) and nocturnal drop of systolic blood pressure was lower in obese subjects. We found a significant correlation between systolic blood pressure during ambulatory blood pressure monitoring and systolic blood pressure during moderate and maximal exercise for all periods (P < 0.0001). Blood pressure variability during awake period was higher in subjects with maximum exercise systolic blood pressure >/= 200 mmHg (7.4 +/- 2 versus 6.4 +/- 2%, P < 0.01).CONCLUSION: Systolic blood pressure measured by ambulatory blood pressure monitoring is related to response of systolic blood pressure to exercise and ambulatory blood pressure monitoring can identify groups of subjects at greater than normal risk through their higher blood pressure during sleep. Greater than normal blood pressure variability in adolescents is an indicator of the risk of reaching abnormal exercise values of systolic blood pressure. Higher casual blood pressure than ambulatory blood pressure monitoring values for adolescents should be considered abnormal.

Journal Article↗
PubMed1996

Accuracy of the SpaceLabs 90207 ambulatory blood pressure monitor in children and adolescents.

OBJECTIVE: To determine the accuracy of the SpaceLabs 90207 ambulatory blood pressure monitor for measurement of systolic and Korotkoff phases IV and V diastolic blood pressures in children aged 6-18 years. DESIGN: Monitor evaluation was performed using the 1990 British Hypertension Society (BHS) protocol, adapted for use in children. METHODS: Three SpaceLabs 90207 monitors were evaluated according to the five phases of the 1990 BHS protocol: observer training and assessment; before-use interdevice variability assessment; in-use (field) assessment; after-use interdevice variability assessment; and device validation. Outcome was classified according to the criteria from the BHS (1990) and Association for the Advancement of Medical Instrumentation (AAMI) protocols. RESULTS: During in-use assessment, the monitor failed to achieve the required 70% valid readings on four of 25 recording days. On three of four failed days, kinked tubing errors were noted, possibly caused by excess tubing length. After adjustment of tubing length to body size, criteria were satisfied on 24 additional recording days. During validation, the monitor achieved BHS grade C for systolic blood pressure and satisfied AAMI criteria with a mean difference of 5.0+/- 6.4 mmHg. The monitor received grade D for Korotkoff phase IV and V diastolic blood pressure and failed to satisfy AAMI criteria with a mean difference of -7.2+/- 11.0 mmHg for Korotkoff phase IV and 0.8+/-11.1 mmHg for Korotkoff phase V. CONCLUSION: The SpaceLabs 90207 monitor satisfied the minimum accuracy criteria for measurement of systolic, but not diastolic, blood pressure in children aged 6-18 years.

Journal Article↗
PubMed1997

Clinical use of ambulatory blood pressure monitoring in a Veteran's Medical Center.

BACKGROUND: The lack of prospective data on the relative value of ambulatory blood pressure compared with office blood pressure as well as concern about increased costs have led to cautious endorsement of such monitoring in the clinical arena. Several consensus bodies have reviewed the scientific evidence and have suggested appropriate and limited clinical indications for ambulatory blood pressure monitoring. OBJECTIVE: To evaluate the ordering habits of the clinicians in regard to the recent introduction of such a monitoring service at our Veteran's Administration Medical Center and to assess its influence on practice.METHODS: During the 18 months after the introduction of ambulatory blood pressure monitoring, 95 successful blood pressure recordings were performed. These studies were requested for patients typical of the aging World War II veteran population in the USA. The blood pressure monitoring test was ordered mostly by attending physicians (44%) but physician extenders (34%) and medical residents (22%) also ordered a significant proportion of the tests. The main indication for ambulatory blood pressure monitoring was suspicion of white-coat hypertension in untreated patients and suspicion of white-coat effect in treated hypertensives (45%). RESULTS: The results had an important impact on the management of patients, 42% of untreated patients remained without pharmacologic treatment whereas, for 36% of treated patients, increases in medication were avoided. With the 73 patients for whom complete follow-up blood pressure data were obtained, there was a significant decline both in office systolic (by 8 +/- 15 mmHg, P = 0.001) and in office diastolic blood pressure (by 6 +/- 8 mmHg, P = 0.001) after 3 months. CONCLUSION: Clinical providers in a Veteran's Administration Medical Center used ambulatory blood pressure monitoring appropriately after its introduction and found the information provided to be of clinical value.

Journal Article↗
PubMedDate not supplied

[New techniques used to monitor cerebral function in the newborn].

INTRODUCTION: Continuous display four channels EEG monitoring and near infrared spectroscopy (NIRS) are relatively new and valuable techniques used for continuous brain monitoring in the neonatal period. Supporting the value of continuous display four channels EEG monitoring in the evaluation of neonates with paroxysmal motor events is a study recently conducted at Miami Children s Hospital. DEVELOPMENT: In this study 30 events were captures in 88 hours of simultaneous continuous display four channels EEG monitoring and continuous video EEG telemetry recording in five patients. Fourteen of the events were consider epileptic and 16 were considered non epileptic after evaluation of the continuous display four channels EEG monitoring printed epochs. RESULTS: The continuous video EEG telemetry confirmed the diagnosis for all the events. Several studies attest to the usefulness of NIRS in neonates and in older children with pathologies similar to those seeing in neonates. CONCLUSIONS: 1. NIRS is the best method to monitor regional cerebral oxygen saturation; 2. Regional cerebral oxygen saturation values are primarily those of the venous circulation in the subcortical white matter below the sensor; 3. Values of regional oxygen saturation should be considered not independently but only relative as a change over time; 4. Decreased regional cerebral oxygen saturation may be a sign of impending or established hypoxemia or hypotension, increased cerebral metabolic demands, or a cerebral oxygenation or perfusion problem that involve only brain, and 5. NIRS should be used in conjunction with arterial oxygen saturation and pressure monitoring (to detect hypoxemia and hypotension), with EEG to detect increased cerebral metabolic demands (electroencephalographic seizures) and with anterior cerebral artery Doppler ultrasound to detect perfusion (decreased flow velocity) and oxygenation (constant flow velocity) problems that involve only the brain.

Cerebrovascular Circulation↗
PubMed2003

Monitoring equity in health and healthcare: a conceptual framework.

This paper aims at articulating a conceptual framework for monitoring equity in health and healthcare. The focus is on four main questions: What is health equity? What is monitoring? What are the essential components of a system for monitoring health equity? and Why monitor health equity? Monitoring equity in health and healthcare requires comparing indicators of health and its social determinants among social groups with different levels of underlying social advantage, i.e. groups who occupy different positions in a social hierarchy. A framework is presented for formulating the key questions, defining the social groups to be compared, and selecting the health indicators and measures of disparity that are fundamental to monitoring health equity. Although monitoring health equity is a scientific endeavour, its fundamental objective is guided by values; technical challenges should be addressed as part of a broader strategy to confront the political obstacles to greater equity.

Health Care Rationing↗
PubMed2005

Public health monitoring tools for multiple data streams.

INTRODUCTION: In concert with increased concerns regarding both biologic terrorism and new natural infectious disease threats (e.g., severe acute respiratory syndrome [SARS] and West Nile virus), as a result of advances in medical informatics, various data sources are available to epidemiologists for routine, prospective monitoring of public health. The synthesis of this evidence requires tools to find anomalies within various data stream combinations while maintaining manageable false alarm rates. OBJECTIVES: The objectives of this report are to establish statistical hypotheses to define the compound multivariate problem of surveillance systems, present statistical methods for testing these hypotheses, and examine results of applying these methods to simulated and actual data. METHODS: Canonical problems of parallel monitoring and consensus monitoring are considered in this report. Modified Bonferroni methods are examined for parallel monitoring. Both multiple univariate and multivariate methods are applied for consensus monitoring. A multivariate adaptation of Monte Carlo trials, using the injection of epidemic-curve-like signals in the multiple data streams of interest, is presented for evaluation of the various tests. RESULTS: The Monte Carlo test results demonstrate that the multiple univariate combination methods of Fisher and Edgington provide the most robust detection performance across the scenarios tested. As the number of data streams increases, methods based on Hotelling's T2 offer added sensitivity for certain signal scenarios. This potential advantage is clearer when strong correlation exists among the data streams. CONCLUSION: Parallel and consensus monitoring tools must be blended to enable a surveillance system with distributed sensitivity and controlled alert rates. Whether a multiple univariate or multivariate approach should be used for consensus monitoring depends on the number and distribution of useful data sources and also on their covariance structure and stationarity. Strong, consistent correlation among numerous sources warrants the examination of multivariate control charts.

Algorithms↗
PubMed2002

Monitoring tissue gas tensions in critical illness.

OBJECTIVE: To review the technology and the role of monitoring tissue oxygenation in critical illness. DATA SOURCES: Articles and published peer review abstracts on monitoring tissue oxygenation. SUMMARY OF REVIEW: Miniaturised optodes and electrode systems are the commonly used technology for measurement of tissue gas tensions. Reductions in tissue perfusion frequently leads to a decrease in tissue PO2 and an increase in tissue PCO2 which has been confirmed in a number of animal and human trials in hypovolaemic shock. Monitoring tissue oxygenation has also enabled the delineation of cytopathic hypoxia, which is one of the important pathophysiological mechanisms of sepsis. Although these devices have improved our understanding of pathophysiological mechanisms of critical illness, at a clinical level titrating oxygen therapy to tissue oxygen tensions has only been shown to be useful in patients with impaired wound healing. A number of questions remain unanswered in relation to the monitoring of tissue oxygenation in critical illness. These include establishing normal values of PO2 and PCO2 in humans at the various tissue beds, establishing dysoxic thresholds for the various tissues, identifying optimal sites for monitoring and improving measurement accuracy. Furthermore, the nature of microcirculatory blood flow and tissue gas exchange in critical illness is complex and incompletely understood, limiting our ability to interpret changes from the baseline. Knowing critical tissue PO2 thresholds will provide the clinician with practical resuscitation endpoints in hypoxia and shock, and may even modify the practice of 'permissive hypoxia' in severe respiratory failure. These questions need answers in the years to come. CONCLUSIONS: Monitoring of tissue oxygenation is largely a research tool. For its application in the critically ill patient there needs to be a greater understanding of normal values of PO2 and PCO2 at the various tissue beds, dysoxic thresholds for the various tissues and optimal sites for monitoring.

Journal Article↗
PubMed1999

Continuous Intra-arterial Blood Gas Monitoring.

OBJECTIVE: To review the technology and the role of continuous intra-arterial blood gas monitoring in critical illness. DATA SOURCES: Articles and published peer review abstracts on continuous intra-arterial blood gas monitoring. SUMMARY OF REVIEW: The history of intermittent and continuous blood gas analysis and the development of technology of continuous blood gas monitoring are reviewed. A summary of the various clinical trials on the evaluation of continuous blood gas monitoring systems, and the various factors which might affect the performance characteristics in the clinical setting is also presented. The potential role and future applications of this technology in critical illness are described. CONCLUSIONS: Over the last 10 years, a number of continuous intra-arterial blood gas monitoring systems have been developed. Only a few have reached commercial availability. While the performance characteristics of these systems are comparable, the levels of accuracy of these systems obtained in vitro are not consistently obtained in clinical trials. Arterial blood flow, wrist movement, wall effect and variability of blood gas analysers are some of the factors which determine the accuracy and reproducibility of these systems. Evidence to support the clinical usefulness of these monitors exists only in the form of case studies. Controlled studies demonstrating an improvement in outcome with the use of these monitors are lacking.

Journal Article↗
PubMed2006

Does adherence monitoring reduce controlled substance abuse in chronic pain patients?

BACKGROUND: Opioids are used extensively for chronic pain management in the United States. The frequency of opioid use prior to presenting to interventional pain management settings and in interventional pain management settings has been shown to be above 90%. Given that controlled substance abuse and illicit drug use are prevalent phenomena, adherence monitoring of patients that are prescribed opioids is becoming common. Adherence monitoring is carried out by an appropriate history, periodic evaluation of appropriate intake of drugs, random drug testing, and pill counts. Crucial to adherence monitoring is an initial controlled substance agreement and repeated review of the terms of this agreement with on-going education. However, the effect of adherence monitoring on drug abuse is unclear. OBJECTIVE: To identify controlled substance abuse through implementation of the terms of a controlled substance agreement, including periodic review and monitoring outside the organization. STUDY DESIGN: Prospective evaluation with historical controls. METHODS: Five hundred consecutive patients receiving prescription controlled substances were followed in a prospective manner. The evaluation consisted of a chart review to monitor controlled substance intake, with special attention to drugs obtained from outside the organization. Data collection for this purpose included information from records, pharmacies, referring physicians, and all the physicians involved in the treatment of the patient. RESULTS: Results from 500 consecutive patients were evaluated. Controlled substance abuse was seen in 9% of patients; overall, 5% of patients were obtaining controlled substances from other physicians, and 4% from illegal sources. CONCLUSION: Adherence monitoring, including controlled substance agreements and various periodic measures of compliance was associated with a 50% reduction in opioid abuse.

Analgesics, Opioid↗
PubMed2002

[Neuromuscular monitoring during anesthesia.].

OBJECTIVE: Muscle relaxants are very important in anesthetic practice but must be used with great care. Studies have shown that 17-40% of patients in postanesthesia care units (PACU) have residual muscle weakness. The purpose of this study was to evaluate whether the use of neuromuscular monitors during anesthesia could reduce the incidence of muscle weakness in the postoperative period. MATERIALS AND METHOD: Eighty patients operated for laparoscopic cholecystectomy or lumbal disc prolapse given muscle relaxants during anesthesia were studied, randomly allocated to four groups. Fourty of these patients were monitored with neuromuscular monitor (TOF-guard") during anesthesia and the set point was a TOF-ratio of at least 70% before extubating the patients. Fourty patients were monitored by usual clinical signs (spontaneus breathing, cough and muscle movement). Twenty patients in each group were given vecuronium as muscle relaxant and 20 patients recieved pancuronium, again patients were randomly selected. In the PACU all patients were evaluated and the "5-sec headlift test" was used to find patients with muscle weakness. Hand grip strength was also measured before anesthesia and in the PACU. Glascow Coma Score (GCS) was used to evaluate if patients were too drowsy to co-operate and patients with GCS < 12 were excluded. Measurements were made after arrival to the PACU and every 30 minutes thereafter until headlift was at least 5 sec. RESULTS: The incidence of restcurarization was 15% on arrival to the PACU. No statistically significant difference was found between those monitored with neuromuscular monitors and those that were not. Similarily no statistical difference was found between short acting neuromuscular blocking agents and longer acting agents. CONCLUSION: Although we didn t find any benefit from neuromuscular monitoring or using shorter acting drugs, the use of nervestimulators and short acting drugs is still recommended, especially for high risk patients. The generally accepted train-of-four (TOF-) ratio of 70% has been questioned by some authors, recommending a higher ratio (85%). Further studies using a higher TOF-ratio are therefore recommended.

English Abstract↗
PubMed2006

[The cerebral function monitoring in severe cerebral vascular disease].

OBJECTIVE: To evaluate the value of combined evoked potential, continuous EEG with transcranial Doppler to monitor the cases of severe cerebral vascular disease. METHODS: 32 cases of severe cerebral vascular disease were admitted to the hospital and divided into severe or moderate groups based on the GCS (< or = or > 8) when the patients were admitted. BAEP and SEP were used to for monitoring of brain and brainstem functions. The BAEP and SEP results were divided into grade I, grade II and grade III according to Cant's classification. Continuous EEG monitored all patients by bedside. The EEG findings were divided into 6 grades based on Young's criteria. TCD monitoring by using bilateral 2 MHz Probes with probe holder were lasted at least 30 minutes per day through temporal windows and eye windows to explore the velocity of cerebral artery. The patients were classified into three groups according to the velocities, i.e. (1) the group with elevated velocity, (2) the group with reduced velocity, and (3) the group with normal velocity. The association among the brain and brain stem function, cortex function and cerebral flow velocity was analyzed with patient outcome in the two groups. RESULTS: (1) The mortality of the patients in the severe group was 42.86%, significantly higher than that in the group of moderate symptom (22.22%). The survivors with good outcome accounted for 33.33% in the moderate group, and those with independent disability accounted for 44.44% in the moderate group, much better than those in the severe group. (2) The numbers of the patients with III grade SEP and BAEP results in the severe group were higher than those in the moderate group. The mortality of the patients with III grade SEP and BAEP results was high and the most of survivors were found with obvious disability in outcome. The patients with grade I SEP and BAEP results showed a better outcome. (3) 32 patients of cerebral vascular disease were monitored with continuous EEG monitoring by bedside. The results revealed that the mortality of the patients with grade II EEG results was much higher than that of the patients with grade I EEG results. (4) The association of the brain blood flow velocity, either increased or decreased or within normal range was uncertain (all P > 0.05). CONCLUSION: The cerebral function of patients of severe cerebral vascular disease may be estimated precisely and objectively by using continuous monitoring of SEP, BAEP and EEG at bedside, which will provide valuable information about patient's prognosis and treatment.

Aged↗
PubMed1991

Centralized telemetry monitoring: implementation and management.

Baptist Memorial Hospital in Memphis, Tennessee has implemented a newly designed cardiac arrhythmia monitoring system. Management engineers worked closely with nurses and physicians in the design process which led to development and implementation of a centralized telemetry monitoring system. Changes in the work distribution, improvement of the work environment, efficient use of nursing personnel and upgrades of monitoring equipment are several of the objectives addressed by this new centralized monitoring system. The backbone of the centralized telemetry monitoring system is an effective communication system that fully addresses staff needs during emergency situations. This paper presents the communication system features as well as the operational, functional and technical considerations necessary to support a centralized telemetry monitoring system. Some topics covered in detail include communication system selection, staff scheduling, selection, training, and supervision of staff members, ergonomic workstation design parameters and centralized telemetry monitoring system benefits. One benefit observed was that an additional 35 minutes per nurse per shift was made available to provide additional patient care activities.

Arrhythmias, Cardiac↗
PubMed1986

Movement training: when trainer initiated reinforcement and self-monitoring are not enough.

Trainer initiated reinforcement and client self-monitoring have been used successfully to increase the vocational productivity of individuals with moderate and severe mental retardation. Some previous research, however, has reported cases in which reinforcement strategies had minimal influence on productivity. The current study introduced reinforcement and self-monitoring sequentially in an attempt to improve the productivity levels of five clients with moderate and severe mental retardation in an adult development center. In a subsequent alternating treatments phase, the self-monitoring was compared to self-monitoring with movement training--prompting through a task analysis of the most efficient movements to perform a task. In a final phase, the most effective treatment of the alternating treatments for each subject was replicated across sessions. Four of the five subjects responded minimally to trainer initiated reinforcement or self-monitoring but showed improvement with movement training. This increase was replicated across sessions for three of these four subjects. A fifth subject increased productivity substantially with reinforcement, maintained the increase with self-monitoring, and replicated the increase across sessions with self-monitoring alone. This fifth subject did not increase productivity with movement training.

Adult↗
PubMed1981

[Biochemical monitoring of postoperative glioma (author's transl)].

Extention of the survival period and suppression of the recurrence of neurological symptoms during postoperative progression free intervals have become the most important problems in the treatment of gliomas. In the outpatient clinic, neurological and neuroradiological monitoring, including sequential CT scans, are especially valuable. In addition to each conventional monitoring methods, immunological and biochemical monitoring methods have been introduced as precise and noninvasive methods. In this paper, wer have discussed about the biochemical monitoring. In biochemical monitoring cystic fluid was repeatedly obtained through Ommaya's reservoir and chemically analysed during the postoperative period of eight cases of glioblastoma showed complete remission either clinically or chemically during the monitoring period. Chemical progression, especially a gradual increase in LDH, was detected in three cases of anaplastic astrocytoma prior to the clinical and radiological deterioration. In the remaining two cases of glioblastoma, neither clinical nor chemical regression was obtained in spite of postoperative adjuvant treatments. In biochemical monitoring of gliomas, total cholesterol, LDH and LDH isozyme values of cystic fluid were especially valuable.

Adolescent↗
PubMed1981

[Quality control of computer-assisted arrhythmia monitoring].

In the management of coronary care patients, continuous ECG analysis is best performed by a computerized monitoring system. For more than 2 years all the patients in this CCU have been monitored by the 78220 Hewlett-Packard arrhythmia monitoring system. As a quality control of the system the data of 15,068 alarm situations in 300 patients were first analyzed: the specificity of the system varied from 3% to 83% according to type and severity of arrhythmias. To evaluate the sensitivity of the system the amount of VES registered by Holter monitoring was then compared with the analysis by computerized monitoring during the same period of time: in a total of over 10,000 VES in 14 patients the sensitivity was 90%. Although the personnel of a CCU still have to deal with a large number of false positive alarms, a computerized arrhythmia monitoring system offers a higher degree of security for the patient than conventional monitoring.

Arrhythmias, Cardiac↗
PubMed1980

Clinical value of ambulatory rhythm monitoring.

(1) Ambulatory (Holter monitor) electrocardiography is currently one of the most important noninvasive cardiac diagnostic tests in our daily practice. (2) The primary purpose of Holter monitor electrocardiography is to diagnose various cardiac arrhythmias with accuracy, especially when the routine 12-lead electrocardiogram fails to record the arrhythmia because of its transient and episodic nature. (3) A precise etiology of a dizzy spell or a fainting episode can be confirmed by the Holter monitor ECG, when various symptoms are directly related to either tachyarrhythmias or bradyarrhythmias. (4) Another very important role of the Holter monitor ECG is to assess the efficacy of various antiarrhythmic agents, digitalis, and antianginal drugs. (5) Another purpose for obtaining the Holter monitor ECG is to document ischemic events by recognizing S-T segment and/or T wave abnormalities, especially at rest or during sleep. This is particularly valuable when the chest pain is atypical and when the exercise electrocardiogram is equivocal. Conversely, the patient's complaints may be totally unrelated to ischemic manifestations or any cardiac arrhythmias. (6) In addition, the status of artificial pacemaker function can be assessed by the Holter monitor ECG. (7) Many other clinical applications of the Holter monitor ECG have been described also.

Ambulatory Care↗