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PubMed1998

Effect of heart rate on T wave alternans.

INTRODUCTION: T wave alternans (TWA) is a promising technique for detecting arrhythmia vulnerability. Previous studies in animals demonstrated that the magnitude of TWA is dependent on heart rate. However, the effects of heart rate on TWA in humans and the clinical relevance of this effect remain controversial. METHODS AND RESULTS: This was a prospective evaluation of pacing rate and monitoring lead configuration on TWA in subjects undergoing electrophysiologic study. Measurements of TWA were performed on 45 patients in the absence of antiarrhythmic drugs. Recordings were made in normal sinus rhythm and during atrial pacing at 100 and 120 beats/min. Sustained monomorphic ventricular tachycardia (VT) was induced in 29 patients with programmed stimulation. TWA in the vector magnitude lead increased with heart rate, independent of VT inducibility (0.4 +/- 0.7 microV, 1.6 +/- 1.9 microV, and 2.4 +/- 2.1 microV in sinus rhythm and at 100 and at 120 beats/min, respectively; P < 0.001). In addition, the diagnostic performance of TWA for inducible VT was dependent on heart rate (sensitivity 4%, 42%, and 65%, and specificity 100%, 93%, and 63% at 77, 100, and 120 beats/min, respectively). By analyzing orthogonal leads rather than the vector magnitude lead, the sensitivity is increased from 42% to 59% at 100 beats/min, but the specificity is reduced from 93% to 72%. CONCLUSION: These results indicate that TWA in humans is strongly dependent on heart rate with regard to both magnitude and diagnostic performance. The optimal heart rate for the measurement of TWA is between 100 and 120 beats/min and multiple leads should be monitored.

Cardiac Pacing, Artificial↗
PubMed1989

Control of diarrheal diseases.

The tremendous advances made in the control of diarrheal diseases in the past few years indicate what more can be achieved. Even though the lives of an estimated three quarters of a million children are being saved each year, over three million children are still dying from readily preventable diarrheal disease. The challenge is to build on the successes thus far, to learn from experience, to promote changes in health habits that will prevent diarrhea, and to make all of these activities sustainable. From this analysis, we have three specific recommendations for CDD programs in the next decade. 1. ORT programs should move strongly toward promoting home treatment, building on local traditions of giving food-based preparations, with ORS available from health workers and health facilities for those who need it. Local assessment of people's beliefs and practices in caring for diarrhea should lead to simple methods of adapting ORT preparations that are culturally acceptable. Most of these traditional preparations have adequate amounts of the proteins and starches that are now being shown to produce better clinical results than the glucose in the standard ORS formula. Usually, the main change needed is more precision in the quantity of sodium added. Education of parents can then focus simply on how to make these adapted preparations, on starting rehydration early, and on replacing fluid volume as it is lost. The use of ORS packets in health facilities should continue, but the main indicator of progress in CDD should be ORT use including home solutions. Every packet of ORS should have printed on it the locally recommended formula for home ORT. 2. Nutritional support is just as important as rehydration. Diarrhea precipitates and accelerates the progression of malnutrition, which lowers resistance and increases the duration of diarrhea. Nutritional support through continued breast feeding and improved weaning practices using high density, easily digestible, local foods is especially important during and after episodes of diarrhea. 3. For long-term prevention, breaking the transmission cycles of the many common pathogens that cause diarrhea will be necessary. The most immediate preventive impact can be achieved by promoting hand washing with soap. Priority should also continue to be given to improving water supply, sanitation, and excreta control, especially of childrens' stools. Even with the great progress of recent years, the Child Survival and Development Revolution has just begun.

Child↗
PubMed1991

Exercise and body composition.

We assessed changes in body composition in 41 young adults who engaged in various exercise and/or training programs on ad libitum diets. Most of those who gained weight sustained an increase in lean body mass (LBM), and most of those who lost weight lost LBM as well as fat. The change in LBM was directly related to the change in weight, with a regression slope of 0.500. An analysis of published data confirms these findings and, in concert with our data, provides the additional information that the magnitude of the change in body composition in exercising individuals is influenced by body fat content, just as it is for nonexercising individuals.

Adipose Tissue↗
PubMed2000

Anisotropic reentry in a perfused 2-dimensional layer of rabbit ventricular myocardium.

BACKGROUND: Anisotropy creates nonuniformity in electrical propagation and may contribute to the occurrence of unidirectional conduction block and reentry. We describe the characteristics of reentrant tachycardia in a 2D layer of anisotropic ventricular myocardium. METHODS AND RESULTS: A Langendorff-perfused epicardial sheet (1.0+/-0.4 mm, n=35) was created by freezing the intramural layers of the rabbit left ventricle. Epicardial activation maps were constructed by use of different high-resolution mapping arrays connected to a mapping system. In 5 experiments, monophasic action potentials were recorded. In the intact left ventricle, no arrhythmias except VF could be induced. After freezing, programmed electrical stimulation or rapid pacing led to the induction of sustained VT (cycle length 130+/-11 ms). VT was caused by reentry around a functional line of block oriented parallel to the epicardial fiber direction. Action potential recordings demonstrated that the central line of block was kept refractory by electrotonic currents generated by the depolarization waves propagating at either side of the line of block. At the pivot points of the line of block, the pronounced curvature of the turning wave and abrupt loading changes created an excitable gap of 30 ms in the reentrant pathway. CONCLUSIONS: In uniform anisotropic myocardium, reentry around a functional Z-shaped line of block may occur. The core of the circuit is kept refractory by electrotonic currents. The pronounced wave-front curvature and abrupt loading changes at the pivot points cause local conduction delay and create a small excitable gap.

Action Potentials↗
PubMed1988

Resetting of ventricular tachycardia with electrocardiographic fusion: incidence and significance.

The incidence and significance of fusion of the QRS complex during resetting of sustained ventricular tachycardias (VTs) was determined in 53 VTs induced by programmed stimulation in 46 patients with prior myocardial infarction. All 53 VTs were reset with one or two extrastimuli delivered at the right ventricular apex (RVA); 29 (54.7%) demonstrated fusion of the VT QRS complex coincident with the extrastimulus resetting the VT. Activation time at the RVA during VT (measured from the onset of the VT QRS complex to the first rapid deflection of the RVA electrogram) was longer in VT reset with fusion compared with those without fusion (91 +/- 30 vs 33 +/- 32 msec; p less than .001). A right bundle branch block VT QRS morphology and a rightward and inferior axis were more common in VT reset with electrocardiographic (ECG) fusion. Additionally, the shortest return cycle following the extrastimulus resetting the VT was shorter in VT reset with ECG fusion compared with those without (327 +/- 66 vs 423 +/- 84 msec; p less than .001). Fusion of the endocardial electrogram recorded at the site of VT origin was noted in 11 of 15 VTs that were reset while a recording catheter was positioned at this site, including all eight VTs with evidence of surface ECG fusion and three of seven VTs without fusion. Seventeen VTs were reset from the right ventricular outflow tract as well as the RVA; eight demonstrated QRS fusion at both sites, five from the right ventricular outflow tract only, and four from neither site.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Pacing, Artificial↗
PubMedDate not supplied

AV fistula rates: changing the culture of vascular access.

PURPOSE: Data from the United States Renal Data System show about 30% of prevailing hemodialysis (HD) patients use arteriovenous fistulae (AVF), which falls far short of the Kidney Disease Outcomes Quality Initiative (K/DOQI) goals of 40-50%. Recent initiatives to increase the use of AVF in HD patients have been criticized as unachievable under realistic practice conditions. METHODS: A multidisciplinary effort to increase AVF use was undertaken at an outpatient HD center beginning in 1998. Strategies focused on education and recruitment of patients in both inpatient and outpatient settings, preservation of veins, pre-operative vein mapping, and education of staff. RESULTS: AVF rates increased from 32%, to 72% over 6 years. The percentage of prosthetic grafts decreased from 40% to 13%. Central venous catheters fell from 28% to 15%. Among residual patients with catheters, 77% had maturing fistulae, as well. Infection rates in the dialysis unit decreased by 39%. Bacteremia declined by 47%. These improvements have been sustainable over the past 12 months. CONCLUSIONS: Adherence to a strategic program similar to the Fistula First Initiative can increase fistula rates under ordinary practice conditions. High fistula rates can be achieved in male and female patients. Unanimous commitment among all members of the health care team is needed. Reduction in the risks of infection, bacteremia, endocarditis, and death may be derived from achievable changes in practice.

Journal Article↗
PubMed2006

Integrating asthma prevention and control: the roles of the coalition.

Activities addressing pediatric asthma are often fragmented. Allies coalitions promoted integration, the alignment of concurrent asthma control activities across and within sectors. Systems integration describes activities from an organizational perspective. Activities included developing a shared vision, promoting consistency in asthma education and self-management support, improving adherence to clinical guidelines, advocating jointly for policy change, and seeking funds collaboratively. Service integration describes activities focused on ensuring seamless, comprehensive services through coordination within and across organizations. Activities included use of community health workers (CHWs) and nurses for care coordination, program cross-referral, and clinical quality improvement. Integration is a sustainable role for coalitions as it requires fewer resources than service delivery and results in institutionalization of system changes. Organizations that seek integration of asthma control may benefit.

Asthma↗
PubMed2006

The promise of a community-based approach to managing severe malnutrition: A case study from Ethiopia.

BACKGROUND: Community-based therapeutic care (CTC) is a new strategy in the arsenal of techniques to manage complex nutritional emergencies in rural communities. The CTC approach uses a newly developed ready-to-use therapeutic food, Plumpynut, to rehabilitate severely malnourished children in their home communities. Emerging literature has suggested the CTC strategy yielded results that were superior to those of programs limited to therapeutic feeding centers, as measured by rates of coverage and numbers of children rehabilitated. OBJECTIVE: To compare the effectiveness of the CTC strategy in combination with conventional treatments for acute malnutrition. The expectation was that this program would support the growing consensus on the effectiveness of CTC strategies. METHODS: Data from monitoring the initial phase of program implementation were reviewed to ascertain program impact. The number of children participating and the outcome of their participation were assessed. RESULTS: Families became key participants in the rehabilitation of their children, and communities became strengthened through the mobilization of local networks and the improved knowledge base of local health workers. Recovery rates were comparable with international standards, and coverage far exceeded that of traditional center-based care. CONCLUSIONS: CTC is an important tool to effectively address nutritional emergencies and may be a valuable entry point for long-term development, since it fosters capacity building and improvement in local communities. CTC programs may eventually be viewed as the entry point for more sustained development-oriented interventions, thus helping make the transition from relief to development.

Child↗
PubMed1995

Washington State Health Services Act: implementing comprehensive health care reform.

In 1993, Washington State enacted the Health Services Act of 1993 (HSA) to guarantee universal access to health care through an employer mandate, with caps on premiums as the primary cost-control mechanism. The HSA represents the Nation's first formal experiment with managed competition. This article reports the results of a case study of the HSA's implementation. The study concludes that the Washington State initiative can be replicated in other States, but that implementation is complex, requires sustained public education, and requires cooperation from the Federal Government through program waivers. A major implementation challenge is to facilitate competition and minimize regulation.

Competitive Medical Plans↗
PubMed1995

Enhancing student practicum opportunities: the outbreak investigation option.

An outbreak investigation practicum option for graduate students at the University of Washington School of Public Health and Community Medicine has three goals of education, scientific investigation, and exposure to operations of public health agencies. Over a six-year period, 48 students performed 40 outbreak investigations in collaboration with adjunct faculty based in local public health agencies. An outbreak investigation practicum at Yale University had similar goals, but the rapid-response team approach there generally involved one regular faculty member and a team of graduate students. In either program, the level of faculty involvement necessary for outbreak investigations is sustainable only if the faculty value public health practice as part of the school's mission. Since public health students need to acquire many practical skills, a short outbreak investigation practicum experience should not be viewed in isolation, but rather should be one of a variety of practicum offerings available to students at schools of public health.

Curriculum↗
PubMed1980

Sustaining board trains future trustees.

The sustaining board of fellows of Mount Sinai Medical Center, Miami Beach, FL, serves as a training ground for future members of the hospital's board of trustees. The sustaining board also sponsors numerous hospital projects, including a student scholarship program and various community outreach programs.

Allied Health Personnel↗
PubMed1999

Childhood farm injuries.

During a recent 6-year period (1991-1997), 143 children and adolescents less than 18 years of age were admitted to a Level I trauma center for agriculture-related trauma. Mechanized pieces of equipment were responsible for half of the injuries. The pattern of injury was clearly seasonal and a daytime occurrence. Half of the patients came from the scene and half from rural hospital emergency rooms, with only 25 per cent being transported via advanced life support. Rural geography led to both long distance (mean, 55 miles) and long transport time to definitive care (mean, 2 hours, 15 minutes). There was a predilection for fractures, amputations, head injuries, and soft-tissue infections. Operative intervention was required immediately in two-thirds, and one-third were admitted to an intensive care unit. Whereas hospital mortality was low at 1.4 per cent, most childhood farm deaths during the study period occurred in the field. Severe permanent disability was present in one-third of children, and 7 per cent incurred a second injury during the study period. Using this review, prevention programs have been developed to minimize death and disability in children sustaining farm injuries.

Accidents↗
PubMed2003

[Epidemiology of falling].

It has been only some 10 years since the study of falls among old people was initiated in Japan. The incidence of falls depends on age, sex, health condition including underlying diseases, and extrinsic factors (e.g. living environment). The incidence of falls among community-dwelling elderly in Japan varies from approximately 10 to 25%, however, that among the elderly people in medical or care institutions is approximately 20 to 35%, being lower than that in US and European countries. The incidence of falls was higher in women than in men, and that it increased sharply with advancing age. Fall experience within one year preceding the survey was one of the major significant predicting factors. The available literature showed that exercise programs have beneficial effects. The exercises need to be regular and sustainable.

English Abstract↗
PubMed2006

Mobile phone and young people. A survey pilot study to explore the controversial aspects of a new social phenomenon.

AIM: Aim of this paper is to report the results of a pilot study as a part of a program addressed to health promotion and to improve the culture of sustainability in the school. METHODS: A 15-items structured questionnaire was administered to 1 011 students (aged 9-18 years) in order to explore the entity of the phenomenon of mobile telephony among the young and qualitatively esteem the level of exposure to the potential adverse health and social effects of such dominant form of electronically mediate communication. This preliminary information was then deepened by in-group interviews focused to clarify the cultural basis of the phenomenon. RESULTS: The survey-study confirmed that the penetration of mobile telephony among the young matches with the national trend: 96% of 14-18-teens own at least one mobile phone; 22% of them own multiple mobile phones. In addition, most of them use mobile phone all the day; a third makes calls over 6 minutes long; half is poorly informed about the potential health risks related to ''electromagnetic pollution''. CONCLUSIONS: Despite the most perceive mobile phone like something noxious, only 23% holds it far from body; a very small percentage uses a hands-free kit. Most declared to suffer from a sort of addiction towards mobile phone. In the light of a growing literature and of a supposed more vulnerability of children and adolescents towards toxicants than adults, we believe that health and school operators should inform parents and the young about the possible risks linked to the abuse of technology and promote a more critic and responsible approach to mobile phone.

Adolescent↗
PubMed1991

[The prognostic significance and correlation of ventricular late potentials with programmed electrical stimulation in patients after myocardial infarction].

Seventeen patients (pts) after myocardial infarction (MI) were studied with signal-averaged electrocardiograph and cardiac programmed electrical stimulation (PES). In 7 pts with late potentials (LPs), sustained ventricular tachycardia (SVT) was induced in 6 cases (6/7, 85.7%); while it was induced only in 3 cases the 10 pts without LPs (3/10, 30%). Both have significant difference (P less than 0.01). During following observation, pts with LPs and SVT induced 5 of the 6 appeared clinical SVT or ventricular fibrillation (VF) repetitiously, and 1 died from sudden cardiac death. They also have significant difference (P less than 0.001) with pts without LPs and SVT not induced. These results suggests that LPs is a significant index for predicting future events and its combination with PES is helpful to screen high-risk pts after MI.

Adult↗
PubMed1990

[Comparative evaluation of the results of Holter monitoring and programmed ventricular stimulation in patients with ischemic heart disease].

24-hour ECG Holter monitoring and programmed ventricular stimulation were performed in 81 patients (64 males and 17 females aged 35-65). No ++anti-arrhythythmic agents nor beta-blockers were administrated. 58 patients suffered from myocardial infarction in the past, and 38 had a history of ventricular tachycardia. Right atrial and ventricular stimulation (in 7 patients also left ventricular stimulation) was performed using stimuli of a 2 ms pulse width. 24-hour ECG Holter monitoring was recorded on a magnetic tape from two bipolar precordial leads. Both examinations results were compared to assess correlation between ECG Holter monitoring parameters and inducibility of VT or VF by programmed stimulation. Significant correlation was stated among occurrence of: 1) spontaneous sustained ventricular tachycardia and induced by stimulation monomorphic sustained VT (p less than 0.005) as well as estimated both sustained and nonsustained VT (p less than 0.010) 2) spontaneous nonsustained VT and induced by stimulation sustained or nonsustained monomorphic VT (p less than 0.025). There was no correlation between spontaneous ventricular arrhythmias estimated by Lown and Wolf's classification and possibility to induce monomorphic VT as well as between any of ECG Holter monitoring parameters and polymorphic VT or ventricular fibrillation induced by stimulation. Aggressiveness extent of stimulation protocol necessary to induce monomorphic VT was similar in patients with or without VT recorded by Holter method.

Adult↗
PubMedDate not supplied

Maternal health services--the developing world.

Women in developing nations run 100 to 200 times the risk of dying in pregnancy and childbirth compared to women in affluent countries. The vast majority of these deaths are preventable. We examine 3 models of health development for their potential impact on maternal mortality. Although universal primary maternal health care would be ideal, resource limitations render its implementation impractical in many regions. The nonavailability of transport and referral services limits the impact of community-based programs. Selective primary health interventions have some role, but more costly and complex services are required to deal with hemorrhage, the complications of illegal abortion and to provide operative deliveries. Public health workers should focus on intersectoral programs at the community level which mobilize women around health issues. Sustainable development has the greatest potential to produce lasting changes in the risks of childbearing.

Developing Countries↗
PubMed1987

Fitness assessment using step tests.

The current interest in physical conditioning has resulted, to a large degree, from the desire of many individuals to improve their ability to sustain physical activity without fatigue. To safely participate in a conditioning program, an individual should first learn his initial fitness level. The step test is simple and accurate and is found in many laboratories and physicians' offices. The physical exercise should last long enough to adjust the individual's circulation and respiration to that of the level of exercise, usually three to four minutes. In addition, the work rate should be sufficiently stressful to result in a steady-state heart rate greater than 120 and less than 170 beats per minute. For most untrained adolescents and adults, this intensity of effort can be achieved using a single-stage step test of 16 in and a stepping frequency of 20 to 25 steps per minute. The single-stage step test can be used to assess more fit individuals simply by increasing stepping frequency (raising the height above 16 in is not recommended because of premature leg fatigue in heavy individuals and those of short stature). Multistage step tests are based on the same requirements as those of the single-stage test except that the multistage test provides a gradual increase in work rate and a termination level that often exceeds the exertional level experienced in a single-stage test. The multistage test can be used not only for providing reliable measurements of cardiovascular fitness but also, with the appropriate equipment, for the diagnosis of cardiovascular abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise Test↗