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Development of drug delivery systems for use in treatment of narcotic addiction.

The long term goal of the NIDA narcotic antagonist program of developing an implantable, biodegradable, naltrexone/PLGA matrix system which will sustain the delivery of naltrexone to biological systems for one month has been achieved. The dosage forms which provide the desired delivery characteristics are 1.5 mm diameter beads composed of 70% by weight naltrexone base in 40,000 molecular weight, 90L/10G poly (L(+)-lactic-co-glycolic acid). Other dosage forms, including 1.5 mm diameter rods which provide 6 months' naltrexone release, finely divided injectable powders which provide up to 30 days' naltrexone release, and 1.5 mm diameter rods which provide 2 weeks' sustained delivery of morphine, have also been investigated. In vitro and in vivo release rates have been determined by measuring chemical concentrations in pH 7 buffer solution and urine, respectively. In vivo efficacy of naltrexone sustained delivery devices has been measured by direct challenge with morphine (Dewey-Harris mouse tail-flick test) and inhibition of morphine self-administration in monkeys. Good Manufacturing Practices documentation has been developed and used to produce a large batch of the 1.5 mm diameter naltrexone bead dosage forms at an FDA-registered pharmaceutical manufacturer. These beads, produced at the University of North Carolina School of Pharmacy, are awaiting use in human clinical trials.

Animals↗

[Sustained ventricular tachycardia: an evaluation of long-term prognosis].

The authors analysed the clinical and paraclinical variables of 116 patients admitted to the Hôpital Cardiologique de Lyon between 1986 and 1990 with sustained ventricular tachycardia without cardiocirculatory arrest in order to determine the long-term outcome and the prognostic factors of death and recurrence. The average age of the patients was 56 +/- 15 years (mean +/- SD) and 83% were men. The mean ejection fraction was 39 +/- 15%. Sixty-five had previous myocardial infarction (group I); 30 (group II) had dilated cardiomyopathy (n = 21), right ventricular dysplasia (n = 4), hypertrophic cardiomyopathy (n = 2), congenital (n = 2) or valvular (n = 1) heart disease. Group III comprised 21 patients with no apparent cardiac disease or isolated mitral valve prolapse. Brief syncope was reported in 12 cases. The paraclinical investigations showed 46 patients (66%) with at least two criteria of positivity for ventricular late potentials; Holter recording showed doublets or runs of VES in 46% of cases and sustained or non-sustained VT was induced during exercise testing in 16 patients (22%). Programmed ventricular stimulation triggered VT in 85%, 79% and 61% of patients in groups I, II and III respectively. The patients were treated with amiodarone in 65 cases, a betablocker in 25 cases, catheter ablation of the origin of the tachycardia in 12 cases, antiarrhythmic surgery in 6 cases, coronary bypass grafting in 5 cases (with an associated antiarrhythmic procedure in 3 cases). An automatic defibrillator was implanted in 9 patients. The average follow-up period was 32 months (range: 17 days to 65 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

[Environmental exposure factors and the concentrations of blood lead in Mexico City children].

Risk factors that contribute to high blood lead concentrations were determined in 113 infants, aged 3 to 7 years old, that attended pediatric consultation at the American British Cowdray Hospital (ABC) from May 1991 to October 1992. The range of blood lead concentrations was 4 to 45 micrograms/dl, with an average value of 15.6 micrograms/dl (DE = 7.0), and a geometric mean of 14.2 micrograms/dl (IC 95% = 11.9-16.5). Seventy six percent of the children presented blood lead concentrations of over 10 micrograms/dl. The main predictors of blood lead levels were the use of glazed pottery for cooking rice (ANOVA, p = 0.0000) and the storage of food in glazed pottery (t-test, p = 0.005). There was a significant association between the use of glazed pottery for cooking rice and blood lead concentrations (tendency p = 0.000). The attributable risk of this population due to the use of glazed pottery was 81 per cent. This study sustains the need to develop and enforce public health policies for programs of lead poisoning prevention.

Adolescent↗

[Sustained monomorphic ventricular tachycardia in non ischemic heart diseases].

Sustained ventricular tachycardia in the absence of coronary artery disease is mainly observed in diffuse left ventricular cardiomyopathy especially dilated but sometimes hypertrophic, and in right sided cardiomyopathies such as ventricular dysplasia, more difficult to diagnose. More rarely, other localised abnormalities, mitral valve prolapse, cardiac tumour and idiopathic aneurysm, may give rise to this arrhythmia. Irrespective of the case, sustained ventricular tachycardia carries a poor prognosis during the most advanced stages of a myocardial disease. The therapeutic strategy remains the same as that of other cases of sustained ventricular tachycardia, drug therapy generally orientated by the results of programmed ventricular stimulation with the exception of Class I antiarrhythmics when the ejection fraction is under 30%, and non-pharmacological methods when drug therapy fails.

Anti-Arrhythmia Agents↗

[Primary ventricular fibrillation].

In the absence of autopsy studies, the etiological diagnosis of this form of ventricular fibrillation (VF) depends on the exclusion of cardiac disease by all available invasive and non-invasive diagnostic methods. Primary VF is rare and affects young adults. There are few clinical markers and published electrophysiological data indicates that sustained ventricular tachycardia or VF is unlikely to be induced by programmed ventricular stimulation. The underlying mechanism of the arrhythmia is poorly understood. However, a possible arrhythmogenic substrate has been suggested in small zones of fibrosis within normal Purkinje tissues, as encountered in some minor forms of arrhythmogenic right ventricular dysplasia. Also, the role played by the autonomic nervous system in triggering VF seems to be particularly important. Some described cases resemble curiously "torsades de pointes" with a short coupling interval. The "cardiac" prognosis of resuscitated patients is usually good. However, arrhythmic recurrences are common, and, classically, antiarrhythmic drugs are usually ineffective. The indication for implantation of an automatic defibrillator is therefore justified in patients surviving primary VF. The lack of understanding of this condition is an argument in favour of setting up a French register of patients with primary VF in order to establish its clinical features.

Arrhythmias, Cardiac↗

[Physical exercise and its effects on the cardiovascular system in elderly subjects].

Physical capacity and exercise tolerance decrease in the elderly because of derangements of the cardiovascular and musculoskeletal systems. It is increasingly apparent that many of these alterations are not necessarily connected to ageing but rather to physical inactivity. Rehabilitation programs adapted to the individual capacities of each patient permit prevention and even reversal of organic and functional deficits of the two systems, which are sometimes at the onset of serious invalidity. The recognition of the usefulness of such programs should lead the practitioner to persuade his elderly patients to sustain a physical activity adapted to their state of health.

Aged↗

Quantitation of day to day variability in mode of induction of ventricular tachyarrhythmias by programmed stimulation.

Spontaneous day to day variability in the mode of induction of ventricular tachycardia at programmed stimulation in the drug-free state has been described but not quantitated. To quantitate this variability, this study employed a new protocol of programmed stimulation in which the number of extrastimuli required for tachycardia induction was the only major stimulation variable. This protocol was applied to 18 consecutive patients with previously documented sustained ventricular tachyarrhythmia due to coronary artery disease. One to seven extrastimuli were available for arrhythmia induction if required. Each patient underwent programmed stimulation in the absence of antiarrhythmic drugs on 3 separate days with a mean interval of 5 +/- 2.7 days between studies. A sustained ventricular tachyarrhythmia was inducible in all studies with less than or equal to 4 extrastimuli; the mean number of extrastimuli required was 2.4 +/- 0.8. Day to day variability in the number of extrastimuli required for tachycardia induction was observed in the majority of patients (72%). Eleven patients (61%) varied by one extrastimulus over the three control studies, and two patients (11%) varied by two extrastimuli. At analysis of variance, the 95% confidence interval for the degree of day to day variability was +/- 1 extrastimulus from the mean number required in the three studies. Multiple configurations of induced ventricular tachycardia were frequently observed at repeat studies and occurred in 15 patients (83%). In conclusion, spontaneous day to day variability in mode of induction of ventricular tachycardia in the absence of drugs is common.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Arrhythmia Agents↗

Healthy country: healthy people? Exploring the health benefits of indigenous natural resource management.

OBJECTIVE: Decades of health-related research have produced a large body of knowledge describing alarming rates of morbidity, mortality and social/cultural disruption among Indigenous Australians, but have failed to deliver sustainable interventions to arrest the deepening spiral of ill-health. This paper explores the potential of Indigenous natural resource management (NRM) activities to promote and preserve Indigenous health in remote areas of northern Australia. METHOD: A literature review of the health, social science and ecology peer-reviewed journals and secondary literature. CONCLUSIONS AND IMPLICATIONS: Effective interventions in Indigenous health will require trans-disciplinary, holistic approaches that explicitly incorporate Indigenous health beliefs and engage with the social and cultural drivers of health. Aboriginal peoples maintain a strong belief that continued association with and caring for ancestral lands is a key determinant of health. Individual engagement with 'country' provides opportunities for physical activity and improved diet as well as boosting individual autonomy and self-esteem. Internationally, such culturally congruent health promotion activities have been successful in programs targeting substance abuse and chronic diseases. NRM is fundamental to the maintenance of biodiversity of northern Australia. Increased support for Indigenous involvement in land and sea NRM programs would also deliver concrete social benefits for communities including opportunities for sustainable and culturally apt regional employment, applied education and economic development. NRM may also reinvigorate societal/cultural constructs, increasing collective esteem and social cohesion.

Anthropology, Cultural↗

Inefficacy and proarrhythmic effects of flecainide and encainide for sustained ventricular tachycardia and ventricular fibrillation.

OBJECTIVE: To assess the efficacy of encainide and flecainide in treating patients with sustained ventricular arrhythmias. DESIGN: Patients were treated with encainide or flecainide. Efficacy was assessed by comparing the results of programmed ventricular stimulation while patients received therapy with the results while they were drug free. SETTING: The electrophysiology laboratory of the University of California at San Francisco. PATIENTS: Forty-nine patients with spontaneous or inducible sustained ventricular tachycardia or ventricular fibrillation for whom treatment with at least one class IA antiarrhythmic agent had failed. INTERVENTIONS: Patients were treated with encainide, 35 to 50 mg three or four times daily, or flecainide, 100 to 200 mg twice daily. RESULTS: Arrhythmia worsened early in 5 of 16 patients receiving encainide and 3 of 33 patients receiving flecainide. Patients with poor left ventricular function were more likely to exhibit proarrhythmia (P = 0.02). Nine of eleven patients receiving encainide and 23 of 28 patients receiving flecainide who had repeat programmed ventricular stimulation while receiving drug therapy still had inducible, poorly tolerated ventricular tachycardia. CONCLUSION: Encainide and flecainide have a low efficacy rate and a high incidence of worsening of arrhythmia in patients with sustained ventricular arrhythmias, particularly when this condition is associated with poor left ventricular function.

Adult↗

Development of ventricular tachyarrhythmias in the conscious canine during the recovery phase of experimental ischemic injury: effect of bethanidine administration.

The antiarrhythmic and antifibrillatory actions of bethanidine were evaluated in two conscious canine models which are capable of developing ventricular tachyarrhythmias during the recovery phase of myocardial infarction. In the first model, nonsustained (n = 3) or sustained (n = 12) ventricular tachycardia (cycle length, 165 +/- 6 ms; mean +/- SD) was initiated by programmed electrical stimulation, 4-9 days after experimental myocardial infarction. Bethanidine was administered in cumulative doses of 2, 4, 8, and 16 mg/kg and programmed stimulation repeated. Bethanidine, in doses of 4, 8, and 16 mg/kg, slowed the cycle length of the tachycardia and allowed slower rates of ventricular pacing to produce equivalent delays at epicardial sites in the ischemic zone. Despite these changes, induction of sustained ventricular tachycardia was prevented in only two of 13 animals. Bethanidine (8 mg/kg i.v. every 8 h, n = 4; 16 mg/kg i.v. every 8 h, n = 5) failed to prevent the development of premature ventricular beats, ventricular tachycardia, and ventricular fibrillation which developed in response to a transient ischemic episode superimposed on the heart that had a previous acute myocardial infarction. No differences in survival at 24 h were observed between saline- (10%, n = 10) and bethanidine-treated (0%, n = 9) groups. These results suggest that bethanidine acts to increase the refractory period and depresses conduction velocity in ischemically injured tissue, slowing the rate of ventricular tachycardia. However, the drug fails to suppress the development of ventricular arrhythmias and ventricular fibrillation in both canine models.

Animals↗

Impact of smoking, physical training and weight reduction on FVII, PAI-1 and hemostatic markers in sedentary men.

The variations of FVII, PAI-1, TAT complexes, fibrinopeptide A, D-Dimers and beta thromboglobulin plasma levels were studied on 30 sedentary men, smokers and non-smokers, who were admitted to a 6 months' program of physical training and smoking cessation. After 3 months of intervention, sustained physical training was associated with the decrease of FVII and PAI-1 levels. Mild exercise performed during a second 3-month period could maintain normal FVII and PAI-1 activities but participants who stopped the training increased their FVII and PAI-1 plasma levels. FVII was not influenced by smoking habits. Smoking cessation seemed to slightly potentiate the decrease of PAI-1 levels associated with mild exercise. Overweight, FVII and PAI-1 levels were correlated and the weight reduction induced by training was related to the changes in the factors. In smokers, physical exercise was associated with a significant increase of hemostatic markers. This exercise-induced variation disappeared after 3 months of intervention in participants who stopped smoking and reappeared in those who smoked again after 6 months of intervention. This finding was not influenced by the physical training program.

Antithrombin III↗

APA/HRSA National Faculty Development Scholars Program: community-based teaching track.

OBJECTIVES: Goals and objectives of the APA/HRSA National Faculty Development Scholars Program are described in a companion article in this supplement. Program objectives of the Community-Based Teaching Track were to 1) identify individuals with faculty development skills to serve as regional leaders, conducting local and regional workshops; 2) create a national network of leaders, thereby promoting sustainability; and 3) increase educational contributions of office-based preceptors. Participant objectives were to 1) meet expectations of the program; 2) possess knowledge, skills, and attitudes needed to recruit and retain community-based preceptors; 3) possess knowledge and skills needed to conduct faculty development workshops for practitioners; and 4) form local and national collegial networks. METHODS: Academicians and practitioners were selected to form 2 cohorts, starting in 1999 (N = 20) and 2000 (N = 22), respectively. Workshops were developed on the basis of projected needs and iterative needs assessments of the participants. Each participant was required to conduct workshops between meetings, first locally and then regionally or nationally. OUTCOMES: Forty-two participants conducted 307 workshops attended by 3815 individuals. Participants reported specific knowledge and skills gained from the program and increases in multiple areas of competence. Networks were formed, leading to collaborative regional and national presentations and formation of an APA Faculty Development Special Interest Group. Participants reported increased recruitment of training sites and preceptors, with enhanced relationships. CONCLUSION: Program and participant objectives of the Community-Based Teaching Track were met, including implementation of multiple new workshops, development of skills, and creation of a support network to enhance the sustainability of that success.

Ambulatory Care↗

Physical activity and health promotion for older adults in public housing.

INTRODUCTION: Designing health promotion and disease prevention (HPDP) programs for older residents of public housing is hampered by a lack of information about residents' needs and interests. This study addressed whether residents have greater needs for lifestyle modification or for preventive care and assessed interest in programs emphasizing physical activity. METHODS: Older residents (n = 199) of public housing facilities in Seattle were surveyed to assess HPDP needs. A comparison of residents with older HMO enrollees (n = 2,289) identified which needs were relatively greater in residents of public housing. Residents' interest in physical activity programs was assessed by interviewing residents and by observing their interest in an exercise class. RESULTS: The majority of residents could benefit from physical activity programs (75% of residents reported less than 60 minutes per week of exercise); fewer residents could benefit from smoking cessation programs (21%) and alcohol counseling (4%). The largest difference between residents and HMO enrollees was the greater need of residents for physical activity promotion. Residents and HMO enrollees reported similar use of preventive care services. Though residents seldom identified physical inactivity as a major concern, residents demonstrated interest in physical activity programs. Eighteen (41%) of 44 residents participated regularly or irregularly in an exercise class offered at their facility. When the class was scheduled to be discontinued, residents successfully lobbied city government to sustain the class. CONCLUSIONS: The results suggest promoting physical activity should be a major goal of HPDP programs for older residents of public housing.

Aged↗

Bethanidine sulfate in paroxysmal ventricular tachycardia: toxicity and antifibrillatory actions.

Programmed ventricular stimulation was used to test oral bethanidine sulfate in 10 patients with life-threatening ventricular arrhythmias. These patients had previously documented, recurrent, sustained ventricular tachycardia (VT) and/or ventricular fibrillation (VF) complicating stable heart disease. During control electrophysiologic studies, VT could be induced in all 10 patients: 6 with nonsustained VT, 3 with sustained VT, and 1 with VT/VF. After control, bethanidine 20-30 mg/kg was administered orally and beginning 60 minutes later, programmed ventricular stimulation was repeated. After bethanidine administration, VT could be induced in nine patients; in four, the VT was essentially unchanged from that induced during control studies. In four others, worse VT was induced after bethanidine. The remaining two patients had a potentially beneficial response to the drug. Bethanidine was poorly tolerated: seven patients had symptomatic orthostatic hypotension that persisted for several days despite concurrent protriptyline therapy. Furthermore, in four patients, spontaneous VT or VT/VF occurred 3-8 hours after the last dose. Nausea, vomiting, flushing, and blood pressure elevation were also noted. Bethanidine sulfate in the dosages used usually does not prevent the induction of VT by programmed ventricular stimulation and frequently causes serious toxicity. These findings suggest that the drug would be ineffective and poorly tolerated for long-term therapy in patients with serious ventricular arrhythmias.

Administration, Oral↗

[Circumferential laser thermo-exclusion of post-infarction ventricular tachycardia. Apropos of 11 cases].

Circumferential laser thermoexclusion was assessed in the treatment of postinfarction ventricular tachycardia resistant to drug therapy in 11 patients between December 1986 and April 1989. There were 10 men and 1 woman with an average age of 63.7 +/- 5.6 years whose ventricular tachycardia occurred 10.7 +/- 7.5 years after infarction. All had left ventricular aneurysm or an akinetic plaque. Circumferential thermoexclusion was carried out by Mesnildrey's method, systematically associated with resection of the aneurysm or, when this was not feasible, with coronary revascularisation. Programmed ventricular stimulation was performed before and after surgery in 8 patients. Sustained ventricular tachycardia remained inducible in 4 patients after surgery but the prescription of antiarrhythmic drugs in 2 of these cases resulted in tachycardia becoming non-inducible. The increase in the left ventricular ejection fraction after surgery was not statistically significant (36.9 +/- 9.4% to 44.4 +/- 12.8%). After an average follow-up of 16.7 +/- 10.6 months, there were 2 cardiac deaths not related to arrhythmias (18%), 1 early at the 20th postoperative day and 1 late, 10 months after surgery. There were 2 recurrences of tachycardia (18%) controlled by antiarrhythmic therapy. Late ventricular potentials were recorded in 9 out of the 11 patients before surgery but in only 3 of these cases (33%) after surgery. Circumferential laser thermoexclusion guided visually in the border zone of the infarct scar would seem to be a simple, safe, rapid and therefore attractive, surgical antiarrhythmic technique, the efficacy of which should be evaluated by programmed ventricular stimulation. This should be undertaken on a large scale in order to define the indications and results of this method.

Aged↗

City of Fort Worth Consumer Health Division-2004 Crumbine Award Winner.

Historically, the Fort Worth CHD has striven to provide the highest level of service toward the assurance of consumer safety. The burgeoning growth of the city, however, combined with limited resources, has challenged this capability. The response by CHD was to develop a long-term, orchestrated plan to not only maintain but also improve performance. To succeed, a multiyear, integrated plan to develop programming, personnel management, and budgeting was adopted. In accordance with this plan, the past five years have witnessed the cultivation and integration of strategic initiatives into a comprehensive and effective consumer safety program. The program has succeeded in improving inspections, lowering violation recidivism, maintaining compliance, and orchestrating activities to sustain improvements well into the future. CHD is proud of these accomplishments and of its service to the citizens of Fort Worth. In this spirit, CHD is happy to accept the 2004 Crumbine Award, which recognizes the dedication to consumer safety underlying this program.

Awards and Prizes↗

Validity of serum total cholesterol level obtained within 24 hours of acute myocardial infarction.

The relation of a serum cholesterol level obtained during acute myocardial infarction (AMI) to the patient's usual baseline level is unclear. Many physicians tend to ignore cholesterol levels measured during AMI and will wait several months before obtaining a repeat cholesterol measurement; in many instances this delays interventional programs. Using the Framingham study cohort of patients, the records of all persons sustaining AMI were reviewed. Eighty-three patients were identified who had total cholesterol (TC) levels recorded within 2 years of AMI, within 24 hours of hospitalization for AMI and within 2 years after hospital discharge. In these persons, there was no statistically significant difference in the TC values measured at these 3 times. Thus, TC levels drawn within the first 24 hours of AMI accurately reflect a baseline level and can be used in instituting intervention programs.

Cholesterol↗

Combined use of time and frequency domain variables in signal-averaged ECG as a predictor of inducible sustained monomorphic ventricular tachycardia in myocardial infarction.

BACKGROUND: Time and frequency domain analyses of signal-averaged ECG (SAECG) have several individual limitations, and the results of the two methods sometimes vary considerably. The purpose of this study was to determine whether the combined use of time and frequency domain variables facilitates identification of patients who will have ventricular tachycardia (VT) induced during programmed ventricular stimulation (PVS). METHODS AND RESULTS: Nine myocardial infarction (MI) patients with clinically documented sustained monomorphic VT (SMVT), 40 MI patients without clinical VT, and 30 normal healthy control subjects were evaluated. PVS using three extrastimuli and SAECG recording were performed in the MI patients on day 36 +/- 4 after infarction. Of 40 MI patients, SMVT was inducible in 14, sustained polymorphic VT in three, nonsustained monomorphic VT in three, nonsustained polymorphic VT in two, and no inducible arrhythmia was obtained in 18. There were significant differences between MI patients with inducible SMVT and without inducible SMVT in the following SAECG variables: filtered QRS durations (high-pass filter setting, 25, 40, and 80 Hz); low-amplitude signal durations (LAS) under 10, 20, 30, and 40 microV (high-pass filter setting, 40 and 80 Hz); root-mean-square voltages (RMS) of the terminal 20, 30, 40, 50, and 60 msec (high-pass filter setting, 40 and 80 Hz); area ratio (area 20-50 Hz/area 0-20 Hz x 10(5)) of a 120-msec sampling interval starting 20 msec before QRS offset; factor of normality on lead X; and minimum value of the variables on lead X, Y, or Z. Stepwise logistic regression analysis selected only LAS under 30 microV (high-pass filter setting, 80 Hz) and area ratio as independent predictors of inducible SMVT. With these two variables, the predicted probability of inducible SMVT [p(VT)] was expressed as p(VT) = 1/[1+exp (6.2-0.11 LAS-0.01 area ratio)]. This function had 93% sensitivity, 81% specificity, 72% positive predictive value, 95% negative predictive value, and 85% predictive accuracy with greater than or equal to 0.3 as the criterion of a positive test. CONCLUSIONS: The combined use of time and frequency domain analysis of SAECG can enhance the accuracy of this technique as a screening test for results of PVS in MI patients without clinical VT.

Aged↗