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PubMed1993

[Unexplained syncope. Likelihood of inducing sustained ventricular tachycardia with electrophysiologic examination].

In patients with unexplained syncope and documented nonsustained VT or complex premature ventricular beats indication for programmed ventricular stimulation (PVS) should be considered. However, the variables derived from noninvasive methods that predict diagnostic yield of PVS are incompletely defined. The purpose of this study was to elucidate the role of noninvasive testing variables in predicting inducible monomorphic sustained ventricular tachycardia (SVT) in 116 patients (pts) presenting with syncope. The study group consisted of 45 pts with remote Q wave myocardial infarction. 5 pts with non-Q wave myocardial infarction, 21 pts with another heart disease and 45 pts without organic heart disease. All pts underwent standard ECG, Holter monitoring, echocardiography, signal-averaged ECG and PVS with 1, 2 and 3 extrastimuli at three basic cycle lengths. Nonsustained VT, low ejection fraction, prolongation of QTc interval, abnormal Q waves in postinfarction pts (Q-MI) and late potentials (LP) indicate a greatly increased probability of inducible SVT. Inducible SVT was present in 15 of 45 (33%) pts with Q-MI. Although in the group of 71 pts without Q-MI, nonsustained VT on Holter monitoring was detected in 20 pts, LP in 16 pts, prolongation of QTc interval in 3 pts and low ejection fraction in 2 pts, the positive yield of PVS was documented in only one case (1%). The combination of Q-MI and LP best predicted inducible SVT showing a sensitivity of 75%, specificity of 93%, overall predictive accuracy of 91%, predictive value of positive response of 63% and negative response of 69% to identify pts who would have inducible SVT. Thus, the combination of Q-MI and LP variables was shown as the best predictor of inducible SVT in pts with unexplained syncope. In pts without Q-MI the noninvasive testing variables have considerably less value in selection of pts to PVS, because inducible SVT is very rare in this population.

Adult↗
PubMed1988

Exercise testing in patients with life-threatening ventricular tachyarrhythmias: results and correlation with clinical and arrhythmia factors.

The results of exercise treadmill stress testing were analyzed in 64 consecutive patients presenting with either ventricular fibrillation (42%) or hemodynamically significant ventricular tachycardia (58%). Underlying diseases included coronary artery disease (55%), dilated cardiomyopathy (16%), and miscellaneous disorders (29%). Patients were additionally studied with ambulatory electrocardiographic monitoring and programmed stimulation. During exercise testing, 22 patients (34%) had nonsustained and five (8%) had sustained ventricular tachycardia. No patient experienced ventricular fibrillation or a major complication during exercise testing. Patients with a history of ventricular fibrillation were significantly less likely to have exercise-induced ventricular tachycardia than those with a history of ventricular tachycardia. Other clinical factors were not associated with the results of exercise testing. The results of programmed stimulation did not correlate with the results of exercise testing. Ventricular tachycardia was commonly documented during ambulatory monitoring (72%), but this was not predictive of ventricular tachycardia during exercise. However, patients who did not have ventricular tachycardia during ambulatory monitoring were predictably unlikely to have it during exercise testing (p less than 0.002). Thus exercise testing is safe and can provoke ventricular tachycardia in a significant proportion of patients with life-threatening arrhythmias.

Cardiac Pacing, Artificial↗
PubMed1983

Disopyramide: evaluation of electrophysiologic effects and clinical efficacy in patients with sustained ventricular tachycardia or ventricular fibrillation.

The efficacy of disopyramide in the management of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) was evaluated in 50 patients by programmed ventricular stimulation: 38 patients had coronary artery disease (16 with left ventricular aneurysm), 8 had other cardiac diseases, and 4 had no apparent heart disease. Disopyramide was administered orally for 72 hours (dosage 400 to 1,600 mg/day), resulting in a plasma level of 3.6 +/- 1.2 micrograms/ml (mean +/- standard deviation [SD]). Disopyramide prevented induction of sustained ventricular tachyarrhythmias in 17 patients (34%) and failed to prevent induction in 33 patients (66%). Plasma levels were not significantly different regardless of response to disopyramide. The VT cycle length in patients responding to disopyramide was shorter than in nonresponding patients (225 +/- 51 ms versus 281 +/- 70 ms, p = 0.005). Disopyramide increased VT cycle length in those patients in whom it was ineffective (failed to prevent induction) from 281 +/- 70 ms to 347 +/- 64 ms (p less than 0.001). Ventricular refractory periods, QRS, and QTc durations significantly increased after disopyramide administration. Of the 17 patients in whom tachyarrhythmias were noninducible on disopyramide, 11 were discharged on disopyramide and followed up for 19 +/- 9 months; 9 of them remained free of VT. Heart failure developed in 2 of these patients. One other patient in whom disopyramide was ineffective had irreversible heart failure and died. It is concluded that disopyramide (1) prevents induction of ventricular tachyarrhythmias in one third of patients studied and remains clinically effective in approximately 80%, (2) is more frequently effective in rapid tachycardias, (3) prolongs the VT cycle length when ineffective, and (4) may produce marked hemodynamic embarrassment in patients with significant left ventricular dysfunction.

Adult↗
PubMed1995

Metoprolol versus sotalol in the treatment of sustained ventricular tachycardia.

The efficacy of sotalol in the treatment of sustained ventricular arrhythmias has been proved; however, whether its antiarrhythmic effect is due to a beta-blocking activity, a class III antiarrhythmic activity, or a combination of both is not known. We conducted a prospective randomized study to compare the effects of metoprolol, a "pure" beta-blocking agent, and of sotalol, a beta-blocking agent with additional class III antiarrhythmic properties, in 34 consecutive patients with documented sustained monomorphic ventricular tachycardia (VT) unrelated to transient causes. After undergoing baseline programmed electrical stimulation (PES-1) to assess arrhythmia inducibility, the patients were randomly assigned to a (double-blind) treatment of either metoprolol (16 patients) or sotalol (18 patients). Before the chronic regimen was initiated, arrhythmia inducibility was reassessed after the intravenous administration of either 0.15 mg/kg metoprolol or 1.5 mg/kg sotalol (PES-2), according to drug assignment. During the chronic oral regimen, a third PES (PES-3) was performed after a median follow-up of 72 days. Resting and exercise ECG, Holter monitoring and echocardiography were performed at baseline and during follow-up. During a 2-year follow-up, a non-fatal arrhythmia recurred in 1 patient of the metoprolol arm and in 5 patients of the sotalol arm; 1 patient in the latter group died suddenly 2 months after the recurrence, while receiving amiodarone therapy. Intention-to-treat analysis showed no difference in the incidence of arrhythmia recurrence, sudden death, or total mortality between the two groups. During PES-1, a sustained ventricular arrhythmia was inducible in 18 of 34 patients (53%), 8 in the metoprolol and 10 in the sotalol arm.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed2001

Prince Edward Island Heart Health Dissemination Research Project: establishing a sustainable community mobilization initiative.

This paper provides an overview of the Prince Edward Island Heart Health Program (PEIHHP) Dissemination Research Project. Prince Edward Island (PEI) is a small province in the Atlantic region of Canada with a population of 137,980. The Island's economy is dependent on the fishery, agriculture, and tourism industries. Although unemployment rates are high (14.4%), Prince Edward Island has the lowest poverty rate in the country at 15.2%, high levels of social support (86%), and the second lowest rate of high chronic stress (Report on the Health of Canadians, 1996, 1999).

Cardiovascular Diseases↗
PubMed2001

A multicentre, double-blind randomized crossover comparative study on the efficacy and safety of dofetilide vs sotalol in patients with inducible sustained ventricular tachycardia and ischaemic heart disease.

BACKGROUND: Antiarrhythmic drugs are still used for the treatment of ventricular tachyarrhythmias, in combination with implantable cardioverter-defibrillators or without them. AIM OF THE STUDY: In a double-blind randomized crossover design, the short- and long-term efficacy and safety of oral dofetilide or oral sotalol were compared in 135 patients with ischaemic heart disease and inducible sustained ventricular tachycardia. METHODS: The inducibility of ventricular tachycardia was determined by programmed electrophysiological stimulation at baseline. Patients were then blindly randomized to receive either oral dofetilide 500 microg twice daily or oral sotalol 160 mg twice daily, for 3 to 5 days. Suppression of inducible ventricular tachycardia on the drug was then assessed by programmed electrophysiological stimulation. After a wash-out period of at least 2.5 days, the patients received the alternative treatment for 3 to 5 days. Suppression of inducible ventricular tachycardia on the alternate drug was again determined by programmed electrophysiological stimulation. Selection of long-term treatment was allocated blindly according to programmed electrophysiological stimulation results. RESULTS: During the acute phase, 128 patients received both dofetilide and sotalol. Sixty-seven patients were responders to either drug. Forty-six patients (35.9%) were responders to dofetilide compared with 43 (33.6%) to sotalol (P=ns). Only 23 patients responded to both dofetilide and sotalol. Adverse events, deemed to be treatment related, were seen in 2.3% of patients receiving dofetilide and 8.6% of patients receiving sotalol (P=0.016). Three patients on dofetilide had torsade de pointes. Two patients receiving sotalol died during the acute phase (one was arrhythmic death, and the other was due to heart failure). During the long-term phase, two of 42 patients (4.8%) receiving dofetilide and three of 27 patients (11.1%) receiving sotalol withdrew from treatment due to lack of efficacy. Overall, during the long-term phase, 23.8% of the patients receiving dofetilide and 37.0% of the patients receiving sotalol, withdrew from treatment with a similar pattern of withdrawals for the two drugs. CONCLUSION: Dofetilide was as efficacious as sotalol in preventing the induction of sustained ventricular tachycardia. There was no concordance in the response rate in two-thirds of the patients. Dofetilide was significantly better tolerated during the acute phase than sotalol. Both dofetilide and sotalol were well tolerated during the long term with no statistically significant difference in the adverse events.

Adult↗
PubMed1990

Programmed ventricular stimulation using up to two extrastimuli and repetition of double extrastimulation for induction of ventricular tachycardia: a new highly sensitive and specific protocol.

The sensitivity and specificity of a new protocol of programmed ventricular stimulation were evaluated in 71 consecutive patients who were divided into 2 groups: group 1 included 41 patients, of whom 25 had sustained ventricular tachycardia (VT) not associated with cardiac arrest and 16 had ventricular fibrillation (VF) not precipitated by any obvious factor; group 2 included 30 patients without demonstrable heart disease and no suspected or documented sustained ventricular tachyarrhythmias. The study consisted of a standard protocol (up to 2 extrastimuli given only once for each extrastimulus prematurity, 2 right ventricular sites and 3 basic pacing cycle lengths, as well as rapid ventricular pacing) in which double extrastimulation at the shortest coupling intervals that allowed ventricular capture was repeated 10 times. A stimulus current of 3 mA was used. Sustained ventricular tachyarrhythmias were induced in 23 of 25 (92%) patients who presented with sustained VT, 14 of 16 (88%) patients who presented with VF and 2 of 30 (7%) group 2 patients. Eighteen of 25 (72%) patients with sustained VT but only 4 of 16 (25%) with VF had arrhythmias inducible at "immediate" trials of single or double extrastimulation (p less than 0.01). Repetition of double extrastimulation increased the yield of inducible sustained ventricular tachyarrhythmia to 92% in patients with sustained VT (+20%, p = 0.14) and 75% (+50%, p = 0.013) in patients with VF. Rapid right ventricular pacing added a 13% increase in the overall yield in patients with VF. This new protocol of programmed ventricular stimulation has both high sensitivity (90%) and specificity (93%) for induction of sustained VT.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Pacing, Artificial↗
PubMed1996

Exercise participation in a frail elderly population.

A low-intensity exercise demonstration project was developed jointly by researchers, social service practitioners, and program participants to actively involve frail older people in their own health maintenance. This article describes this collaborative process and its impact on the success of the health promotion program, which was conducted at three senior centers serving a low-income, urban elderly population. Participants were predominantly sedentary women over age 70 with multiple chronic conditions. The program was conducted with peer leaders to facilitate its continuation after the research demonstration phase. In addition to positive health outcomes related to functional mobility, blood pressure maintenance, and overall well-being, this intervention was successful in sustaining active participation in regular physical activity through the use of peer leaders selected by the program participants. The planning, implementation, and outcomes of this project illustrate the benefits and challenges of combining research and practice perspectives in conducting health promotion interventions with older populations.

Black or African American↗
PubMed1990

Cigarette smoking: the clinician's role in cessation, prevention, and public health.

Cigarette smoking is the most important preventable cause of illness and death in the United States, responsible for 390,000, or one sixth, of all deaths. Although smoking prevalence has decreased among adults, from 40% in 1965 to 29% in 1987, 49 million Americans continue to smoke. Smoking rates have declined at a slower rate among blacks, women, young people, and the less educated, groups that must be targeted for tobacco use prevention interventions. The clinician is uniquely positioned to reduce the enormous health toll from cigarette smoking. As a first step, physicians are urged to assess tobacco use during every patient visit by making smoking status a new vital sign. Although 85% of all smokers quit on their own, physicians can greatly facilitate this process. A brief intervention for physicians to help their smoking patients quit, based on a program of the National Cancer Institute, is presented. This program includes asking about smoking status during every clinic visit, advising all smoking patients to quit, assisting smokers by setting a quit date and using nicotine gum, if appropriate, and arranging follow-up with smokers who try to quit. Cessation rates of 5% to 25%, sustained for at least 1 year, are consistent with a successful, physician-mediated intervention program. Physicians are also urged to prevent smoking initiation among adolescents, particularly young girls and those not aspiring to attend college. Physicians can also reduce the enormous toll of tobacco use by acting at the public health and public policy levels. Recording tobacco use as a contributing or the underlying cause on death certificates, if appropriate, will assist in public health surveillance. Also, clinicians are urged to work at the organizational, community, and governmental levels to promote tobacco-free environments.

Health Policy↗
PubMed2006

Mass immunization programs: principles and standards.

Mass immunization involves delivering immunizations to a large number of people at one or more locations in a short interval of time. Good mass immunization programs apply planning and quality standards that maximize return on resources invested and provide the greatest individual benefits when immunizing many people in a short period of time. These programs can be used to counter contagious outbreaks, adopted as a repeated means of sustained healthcare delivery, or applied where many people move through a specific place in a short interval of time. Relevant quality standards address appropriate facilities and supplies, training of professional and paraprofessional staff, education of potential vaccinees and methods to screen them for contraindications to immunization, safeguards against anaphylaxis and syncope, documentation, safety surveillance, and a quality-improvement program. Successful mass immunization programs require early planning that builds on existing competencies. As the number of available vaccines increases, prioritizing which vaccines to administer during mass campaigns requires consideration of effectiveness, safety, and a cost-benefit equation from both the individual and community perspectives. Mass immunization campaigns aim to maximize the health of a population, but such campaigns need to be customized based on individual contraindications to immunization. Mass immunization programs need to be conducted ethically, with considerations of benefit versus risk and the need for detailed education of healthcare workers and vaccinees.

Health Education↗
PubMed1998

[Influence of time (4 years) on the results of programmed ventricular stimulation].

The reproducibility of programmed ventricular stimulation has been previously demonstrated for periods of a few hours to several months. It has not been studied over longer intervals. The aim of this study was to assess the reproducibility of the method at long-term (> 2 years). Forty-six patients with underlying cardiac disease underwent two programmed ventricular stimulations in the absence of antiarrhythmic treatment at intervals of 2 to 6 years (mean 4 years). None of the patients had myocardial infarction or cardiac surgery during this period. The protocol was identical: up to 3 extra-stimuli were delivered in the two right ventricular sites over 3 cycles. Twenty-eight patients had inducible sustained monomorphic ventricular tachycardia during the first investigation (Group I): the investigation was negative in the remaining 18 patients (Group II). During the second investigation, 26 of the 28 patients in Group I had inducible ventricular tachycardia, the rate of which decreased from 206 +/- 50 bpm to 196 +/- 54 bpm. The induced ventricular tachycardia was slower in 15 patients and faster in 5 patients. The mode of induction was different in 12 cases. In Group II, 4 patients (22%) had inducible sustained ventricular tachycardia at the second investigation. The authors conclude that the reproducibility of programmed ventricular stimulation remains good in the long-term in subjects within inducible tachycardia, demonstrating the stability of the arrhythmogenic substrate; the frequency of this tachycardia is generally slower. In subjects with an abnormal initial investigation who became symptomatic, it may be useful to repeat programmed ventricular stimulation.

Adult↗
PubMed1993

Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs.

OBJECTIVE: To determine the effects of the Arthritis Self-Management Program 4 years after participation in it. METHODS: Valid self-administered instruments were used to measure health status, psychological states, and health service utilization. RESULTS: Pain had declined a mean of 20% and visits to physicians 40%, while physical disability had increased 9%. Comparison groups did not show similar changes. Estimated 4-year savings were $648 per rheumatoid arthritis patient and $189 per osteoarthritis patient. CONCLUSION: Health education in chronic arthritis may add significant and sustained benefits to conventional therapy while reducing costs.

Aged↗
PubMedDate not supplied

A proposal for a foster grandmother intervention program to prevent child abuse.

The incidence of child abuse and neglect is epidemic. Many abused children have sustained lifelong injuries. Often they become perpetrators of abuse, continuing the cycle into future generations. Studies have indicated that mothers who are likely to abuse their children can be identified by a predictive method during the prenatal and postpartum periods. Pilot studies have indicated that mothers who are identified by the method and who receive early intervention, consisting of home visits by registered nurses, show a significantly lower rate of verified cases of child abuse. The author proposes a strategy for early intervention to prevent child abuse and neglect and to help infants and children attain their appropriate developmental milestones. The strategy calls for training and employing women from the Foster Grandparent Program. Foster grandmothers would be a valuable resource for high-risk mothers, providing role models for parenting skills in the home setting. Participating foster grandmothers would be trained and supervised in an interdisciplinary team setting. Evaluation of the program would compare the target population of infants and children whose mothers received the proposed intervention with a similar high-risk group that received only traditional interventions.

Aged↗
PubMed1996

Successful atrial defibrillation with very-low-energy shocks by means of temporary epicardial wire electrodes.

Sustained atrial fibrillation is very common after cardiac surgical procedures. We hypothesized that atrial defibrillation could be accomplished consistently and safely by means of low-energy shocks delivered by temporary stainless steel wire electrodes placed at the time of the operation. Sterile pericarditis was created in five mongrel dogs (20.9 +/- 2.1 kg), and pairs of standard temporary stainless steel wire electrodes were placed on the right atrial appendage, on Bachmann's bundle, and on the right ventricular apex for pacing, sensing, and recording. Temporary stainless steel wire electrodes, insulated except for the distal 6 cm and used to deliver defibrillation shocks, were placed adjacent to both atrial free walls and secured to the pericardium. All electrodes were brought out through the skin, and the sternotomy was closed. Dogs were tested in the conscious state on postoperative day 2. Sustained atrial fibrillation was induced by rapid atrial pacing. A customized software program was used to control the defibrillator, which delivered R wave-synchronous biphasic shocks to the atria through the temporary defibrillation electrodes. The shock intensity began at 50 volts and was increased by 10-volt increments until atrial fibrillation was terminated. Atrial fibrillation was terminated in all dogs at 112 +/- 7 volts, with an energy of 0.42 +/- 0.07 joule and an impedance of 67.8 +/- 4 ohms (all values mean +/- standard error of the mean). The mean percent success for atrial defibrillation at this minimal threshold was 49%. Thus at low-threshold voltages atrial fibrillation could be terminated with every other shock. A 25% increase in the minimal threshold voltage improved the conversion rate to 73% (mean energy 0.66 +/- 0.19 joule and mean impedance of 67 +/- 3.8 ohms). No complications were detected with the use of the electrodes or after their removal on the seventh postoperative day. One instance of electrode migration on the right atrial free wall was detected by roentgenography, but this did not adversely affect atrial defibrillation threshold. No ventricular arrhythmias or hemodynamic complications were noted during shock delivery. We conclude that successful conversion of atrial fibrillation to sinus rhythm can be achieved consistently with shock energies below 0.5 joule delivered with temporary epicardial defibrillation wire electrodes in this canine pericarditis model. These results suggest that this approach to the management of sustained atrial tachyarrhythmias has considerable promise in the management of atrial fibrillation in patients who have had cardiac operations.

Animals↗
PubMed2004

Building a foundation for systems change: increasing access to physical activity programs for older adults.

Although 25% of U.S. adults are physically inactive, this percentage increases dramatically for older adults. Organizational change theory guided a state health department in identifying system gaps and developing strategies to expand programming for seniors. A survey of provider agencies in New Jersey assessed (a) capacity for physical activity programs for older adults, (b) accessibility of programs, and (c) barriers to providing programs. One hundred sixty agencies provided physical activity programs to almost 184,000 individuals annually. Fewer than one half of the agencies provided exercise programs for people with disabilities, and only 44% provided in-home programs. Eighty-two percent of program providers wanted to expand programming but cited lack of trained instructors and peer leaders, inadequate facility space, insufficient funding, and limited transportation resources as barriers. Sustaining older adult behavior change requires infrastructure that will ensure access to diverse physical activities. This article provides strategies to expand access to physical activity programs for older adults.

Aged↗
PubMedDate not supplied

Narrowing the gap in health status of minority populations: a community-academic medical center partnership.

A major challenge in the United States is to narrow the gap in the excess morbidity and mortality rates of minority populations. This article presents a synthesis of the 15-year results of a collaborative program between the Johns Hopkins Medical Institutions and an African-American community with the highest rates of premature disease and death in Maryland. The program began with an efficacious disease prevention clinical trial with patients and ended with effective population approaches. We transferred key components to community ownership and formally trained community health workers who provided health promotion counseling, monitoring, linkage, and referral services. Results indicated significant decreases in morbidity and mortality as a result of improved control of hypertension. This program has begun to decrease the health status gap in an African-American population and has demonstrated long-term sustainability. Current joint activities are directed at several major causes of excess morbidity and mortality, including smoking, obesity, hyperlipidemia, and hypertension, and at plans for programs to control diabetes, substance abuse, and breast and cervical cancer.

Black or African American↗
PubMed2005

Developing a national indicator of soil quality on U.S forestlands: methods and initial results.

The Montreal Process was formed in 1994 to develop an internationally agreed upon set of criteria and indicators for the conservation and sustainable management of temperate and boreal forests. In response to this initiative, the Forest Inventory and Analysis (FIA) and Forest Health Monitoring (FHM) programs of the United States Department of Agriculture Forest Service have implemented soil measurements as part of a national monitoring program to address specific questions related to the conservation of soil and water resources. Integration of soil assessments into the national FIA program provides for systematic monitoring of soil properties across all forested regions of the U.S. using standardized collection, laboratory, and statistical procedures that are compatible with existing forest inventory data. The resulting information will provide quantitative benchmarks for regional, national, and international reporting on sustainable forest management and enhance our understanding of management effects on soil quality. This paper presents an overview of the FIA soil monitoring program, outlines the field and laboratory protocols as currently implemented, and provides examples of how these data may be used to assess indicators of sustainable management as defined by the Montreal Process.

Conservation of Natural Resources↗
PubMed2004

Alaska telemedicine: growth through collaboration.

The last thirty years have brought the introduction and expansion of telecommunications to rural and remote Alaska. The intellectual and financial investment of earlier projects, the more recent AFHCAN Project and the Universal Service Administrative Company Rural Health Care Division (RHCD) has sparked a new era in telemedicine and telecommunication across Alaska. This spark has been flamed by the dedication and collaboration of leaders at he highest levels of organizations such as: AFHCAN member organizations, AFHCAN Office, Alaska Clinical Engineering Services, Alaska Federal Health Care Partnership, Alaska Federal Health Care Partnership Office, Alaska Native health Board, Alaska Native Tribal health Consortium, Alaska Telehealth Advisory Council, AT&T Alascom, GCI Inc., Health care providers throughout the state of Alaska, Indian Health Service, U.S. Department of Health and Human Services, Office of U.S. Senator Ted Steens, State of Alaska, U.S. Department of Homeland Security--United States Coast Guard, United States Department of Agriculture, United States Department of Defense--Air Force and Army, United States Department of Veterans Affairs, University of Alaska, and University of Alaska Anchorage. Alaska now has one of the largest telemedicine programs in the world. As Alaska moves system now in place become self-sustaining, and 2) collaborating with all stakeholders in promoting the growth of an integrated, state-wide telemedicine network.

Alaska↗