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Credentials

Education ?

Medical School Score
The University of Texas at San Antonio (1977)
  •  

Awards & Distinctions ?

Associations
American Academy of Ophthalmology
American Board of Ophthalmology

Affiliations ?

Dr. Fisher is affiliated with 2 hospitals.

Hospital Affiliations

  • Veterans Affairs Hosp.-Central Texas
  • Central Texas Veterans Health Care System
    1901 S 1st St, Temple, TX 76504
  • Publications & Research

    Dr. Fisher has contributed to 255 publications.
    Title Advances in Syncope: with Emphasis on Reflex Syncope.
    Date April 2012
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    Syncope is a sudden transient loss of consciousness associated with loss of postural tone, caused by bradycardia, tachycardia, or abnormal autonomic reflexes. Pacing and implantable defibrillators treat but do not cure arrhythmias. Reflex syncope has remained a therapeutic challenge. Remarkably, recent advances in the treatment of the reflex syncopal syndromes are (1) the recognition that many pharmacologic and device-based treatments do not really work, (2) complex subdivisions among the reflex syncope types can be simplified, and (3) effective therapies are often common sense applications of behavioral modifications and physical maneuvers. Many of the treatments have been available for decades and have been supplemented by a renewed interest in the physiologic approach while maintaining a role for evidence-based pharmacologic and device-based therapy. Streamlined workups in dedicated syncope centers may be effective, both economically and therapeutically. In the long term, important advances in syncope are likely to come from the still embryonic field of genetics. Beyond genetic counseling, the greatest benefits lie in the future.

    Title Phase I and Pharmacokinetic Study of Col-3 in Patients with Recurrent High-grade Gliomas.
    Date February 2012
    Journal Journal of Neuro-oncology
    Excerpt

    COL-3 is a chemically modified tetracycline that targets multiple aspects of matrix metalloproteinase regulation. This phase I clinical trial was conducted to determine the maximum tolerated dose (MTD) of COL-3 in adults with recurrent high-grade glioma, to describe the effects of enzyme-inducing antiseizure drugs (EIADs) on its pharmacokinetics, and to obtain preliminary evidence of activity. Adults with recurrent high-grade glioma were stratified by EIAD use. COL-3 was given orally daily without interruption until disease progression or treatment-related dose-limiting toxicity (DLT). Three patients in each EIAD group were evaluated at each dose level beginning with 25 mg/m(2)/day and escalated by 25 mg/m(2)/day. Toxicity, response, and pharmacokinetics were assessed. Thirty-three patients were evaluated. The MTD was 75 mg/m(2)/day in the -EIAD patients while one was not determined in +EIAD patients. The common toxicities observed were anemia, ataxia, diarrhea, hypokalemia, CNS hemorrhage, and myalgia. One partial response was observed. -EIAD patients tended to have a higher steady-state trough concentration that was apparent only at the 100 mg/m(2)/day dose level (P = 0.01). This study suggests that: (a) EIAD use does affect the pharmacokinetics of COL-3 at higher doses; and (b) there was not enough suggestion of single-agent activity to warrant further study in recurrent high-grade gliomas.

    Title Hrs Policy Statement: Clinical Cardiac Electrophysiology Fellowship Curriculum: Update 2011.
    Date January 2012
    Journal Heart Rhythm : the Official Journal of the Heart Rhythm Society
    Title Computer-based Intervention in Hiv Clinical Care Setting Improves Antiretroviral Adherence: the Lifewindows Project.
    Date December 2011
    Journal Aids and Behavior
    Excerpt

    We evaluated the efficacy of LifeWindows, a theory-based, computer-administered antiretroviral (ARV) therapy adherence support intervention, delivered to HIV + patients at routine clinical care visits. 594 HIV + adults receiving HIV care at five clinics were randomized to intervention or control arms. Intervention vs. control impact in the intent-to-treat sample (including participants whose ARVs had been entirely discontinued, who infrequently attended care, or infrequently used LifeWindows) did not reach significance. Intervention impact in the On Protocol sample (328 intervention and control arm participants whose ARVs were not discontinued, who attended care and were exposed to LifeWindows regularly) was significant. On Protocol intervention vs. control participants achieved significantly higher levels of perfect 3-day ACTG-assessed adherence over time, with sensitivity analyses maintaining this effect down to 70% adherence. This study supports the utility of LifeWindows and illustrates that patients on ARVs who persist in care at clinical care sites can benefit from adherence promotion software.

    Title Pilot Test of an Emotional Education Intervention Component for Sexual Risk Reduction.
    Date October 2011
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    Emotions are key predictors of sexual risk behavior but have been largely ignored in theory-based intervention development. The present study aims to evaluate whether the addition of an emotional education intervention component to a traditional social-cognitive safer sex intervention increases intervention efficacy, compared with both a social-cognitive only intervention and a no intervention control condition.

    Title Successful Resuscitation from Cardiopulmonary Arrest Due to Profound Hypothermia Using Noninvasive Techniques.
    Date August 2011
    Journal Pediatric Emergency Care
    Excerpt

    Profound hypothermia is defined as a core body temperature of 20.0 °C or less. Successful resuscitation from this degree of hypothermia is rare. We present a case of successful resuscitation in a 2-year-old boy found in cardiac arrest due to profound hypothermia. Invasive techniques such as cavity lavage, extracorporeal membrane oxygenation, and cardiopulmonary bypass were not used.

    Title An Information-motivation-behavioral Skills Analysis of Diet and Exercise Behavior in Puerto Ricans with Diabetes.
    Date February 2011
    Journal Journal of Health Psychology
    Excerpt

    Frameworks are needed to inform diabetes self-care programs for diverse populations. We tested the Information-Motivation-Behavioral Skills (IMB) model in a sample of Puerto Ricans with Type 2 diabetes (N = 118). Structural equation models evaluated model fit and interrelations between IMB constructs. For diet behavior, information and motivation related to behavioral skills ( r = 0.19, p < .05 and r = 0.39, p < .01, respectively); behavioral skills related to behavior (r = 0.42, p < .01 and r = 0.32, p < .05); and behavior related to glycemic control (r = -0.26, p < .05). For exercise, personal motivation related to behavioral skills (r = 0.53, p < .001), and behavioral skills related to behavior (r = 0.45, p < .001). The IMB model could inform interventions targeting these behaviors in diabetes.

    Title Clinical Spectrum of Shock in the Pediatric Emergency Department.
    Date February 2011
    Journal Pediatric Emergency Care
    Excerpt

    The objective of this study was to describe the clinical spectrum of patients presenting with shock or developing shock in a pediatric emergency department (ED) during an 8-year period.

    Title A Network-individual-resource Model for Hiv Prevention.
    Date January 2011
    Journal Aids and Behavior
    Excerpt

    HIV is transmitted through dyadic exchanges of individuals linked in transitory or permanent networks of varying sizes. A theoretical perspective that bridges key individual level elements with important network elements can be a complementary foundation for developing and implementing HIV interventions with outcomes that are more sustainable over time and have greater dissemination potential. Toward that end, we introduce a Network-Individual-Resource (NIR) model for HIV prevention that recognizes how exchanges of resources between individuals and their networks underlies and sustains HIV-risk behaviors. Individual behavior change for HIV prevention, then, may be dependent on increasing the supportiveness of that individual's relevant networks for such change. Among other implications, an NIR model predicts that the success of prevention efforts depends on whether the prevention efforts (1) prompt behavior changes that can be sustained by the resources the individual or their networks possess; (2) meet individual and network needs and are consistent with the individual's current situation/developmental stage; (3) are trusted and valued; and (4) target high HIV-prevalence networks.

    Title Device Monitoring: Remote and Not So Remote Responsibilities: a Call to the Professional Societies.
    Date August 2010
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Coronary Sinus Left Ventricular Leads: Endocardial or Epicardial?
    Date August 2010
    Journal Pacing and Clinical Electrophysiology : Pace
    Title The Disclosure Processes Model: Understanding Disclosure Decision Making and Postdisclosure Outcomes Among People Living with a Concealable Stigmatized Identity.
    Date June 2010
    Journal Psychological Bulletin
    Excerpt

    Disclosure is a critical aspect of the experience of people who live with concealable stigmatized identities. This article presents the disclosure processes model (DPM)-a framework with which to examine when and why interpersonal disclosure may be beneficial. The DPM suggests that antecedent goals representing approach and avoidance motivational systems moderate the effect of disclosure on numerous individual, dyadic, and social contextual outcomes and that these effects are mediated by three distinct processes: (a) alleviation of inhibition, (b) social support, and (c) changes in social information. Ultimately, the DPM provides a framework that advances disclosure theory and identifies strategies that can assist disclosers in maximizing the likelihood that disclosure will benefit well-being.

    Title Mode of Induction of Ventricular Tachycardia and Prognosis in Patients with Coronary Disease: the Multicenter Unsustained Tachycardia Trial (mustt).
    Date April 2010
    Journal Journal of Cardiovascular Electrophysiology
    Excerpt

    Programmed stimulation is an important prognostic tool in the evaluation of patients with an ejection fraction <or=40% after myocardial infarction. Many believe that ventricular tachycardia (VT) requiring 3 ventricular extrastimuli (VES) for induction is less likely to occur spontaneously and has less predictive value. However, it is unknown whether the mode of VT induction is associated with long-term prognosis.

    Title Insidious Presentation of Pediatric Pneumococcal Meningitis: Alive and Well in the Post Vaccine Era.
    Date January 2010
    Journal The American Journal of Emergency Medicine
    Excerpt

    Routine childhood vaccination against H influenza type b and S pneumoniae has dramatically reduced the incidence of pediatric bacterial meningitis. Because of the decreased incidence of this disease, individual emergency physicians will have limited opportunity to experience the diverse clinical manifestations of this disease. Insidious presentations of this diagnosis still occur but would now be considered rare events for emergency physicians. It is imperative to recognize that young infants with bacterial meningitis can present without fever or irritability and manifest signs and symptoms consistent with many other diagnoses. Careful study of prior cases and sustained clinical vigilance are required to capture these cases. In this report, we present 3 cases of pneumococcal meningitis in young infants presenting with indolent features. None of the patients presented with a chief complaint of irritability, poor feeding, or altered mental status, and no patient had high fever, difficulty consoling, or cirulatory compromise.

    Title Experimental Validation of a Theoretical Model of Cytokine Capture Using a Hemoadsorption Device.
    Date December 2009
    Journal Annals of Biomedical Engineering
    Excerpt

    Sepsis, a systemic inflammatory response in the presence of an infection, is characterized by overproduction of inflammatory mediators called cytokines. Removal of these cytokines using an extracorporeal hemoadsorption device is a potential therapy for sepsis. We are developing a cytokine adsorption device (CAD) filled with microporous polymer beads and have previously published a mathematical model which predicts the time course of cytokine removal by the device. The goal of this study was to show that the model can experimentally predict the rate of cytokine capture associated with key design and operational parameters of the CAD. We spiked IL-6, IL-10, and TNF into horse serum and perfused it through an appropriately scaled-down CAD and measured the change in concentration of the cytokines over time. These data were fit to the mathematical model to determine a single model parameter, Gamma( i ), which is only a function of the cytokine-polymer interaction and the cytokine effective diffusion coefficient in the porous matrix. We compared Gamma( i ) values, which by definition should not change between experiments. Our results indicate that the Gamma( i ) value for a specific cytokine was statistically independent of all other parameters in the model, including initial cytokine concentration, flow rate, serum reservoir volume, CAD size, and bead size. Our results also indicate that competitive adsorption of cytokines and other middle-molecular weight proteins, which is neglected in the model, does not affect the rate of removal of a given cytokine. The model of cytokine capture in the CAD developed in this study will be integrated with a systems model of sepsis to simulate the progression of sepsis in humans and to develop a therapeutic CAD design and intervention protocol that improves patient outcomes in sepsis.

    Title Identifying the Poorest Older Americans.
    Date October 2009
    Journal The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences
    Excerpt

    Public policies target a subset of the population defined as poor or needy, but rarely are people poor or needy in the same way. This is particularly true among older adults. This study investigates poverty among older adults in order to identify who among them is financially worst off.

    Title The Psychological Impact of Implantable Cardioverter-defibrillator Recalls and the Durable Positive Effects of Counseling.
    Date October 2009
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    It is known that patients with lifesaving devices such as implantable cardioverter-defibrillators (ICDs) may be alarmed and worried by recalls or alerts related to their ICDs.

    Title Secondary Prevention of Hiv Infection: the Current State of Prevention for Positives.
    Date July 2009
    Journal Current Opinion in Hiv and Aids
    Excerpt

    To provide a state-of-the-science review of the literature on secondary prevention of HIV infection or 'prevention for positives' (PfP) interventions.

    Title An Agenda for Advancing the Science of Implementation of Evidence-based Hiv Prevention Interventions.
    Date July 2009
    Journal Aids and Behavior
    Excerpt

    In the past 25 years, a tremendous amount of time and resources have been committed to developing evidence-based HIV prevention interventions. More recently, there have been noteworthy efforts to develop an infrastructure and related policies to promote the dissemination (i.e., "the targeted distribution of information and intervention materials to a specific public health or clinical practice audience") of evidence-based interventions. Despite these advances, however, we have had comparatively little success in the effective implementation (i.e., "the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings") of such interventions in everyday practice or community settings. The objective of the current paper is to highlight select and initial areas of research that are critically needed to advance the state-of-the-science of implementation of HIV prevention interventions in our broader efforts to curb the epidemic worldwide.

    Title Systematic Review of Accuracy of Screening Instruments for Predicting Fall Risk Among Independently Living Older Adults.
    Date May 2009
    Journal Journal of Rehabilitation Research and Development
    Excerpt

    The objective of this study was to summarize the evidence on the accuracy of screening tools for predicting falling risk in community-living older adults. This study was designed as a systematic review. Prospective studies of clinical fall risk prediction tools that provided data on the number of participants who sustained falls during follow-up were included. We searched six electronic databases and reference lists of studies and review articles. Data were extracted by two reviewers independently, and methodological quality assessment was performed with a modified version of the Quality Assessment of Diagnostic Accuracy Studies checklist. Twenty-five studies were included. These studies evaluated 29 different screening tools, but only 6 of the tools were evaluated by more than one study. Methodological quality was variable, and many studies were small. No meta-analyses were performed because of heterogeneity. Most tools discriminated poorly between fallers and nonfallers. We found that existing studies are methodologically variable and the results are inconsistent. Insufficient evidence exists that any screening instrument is adequate for predicting falls.

    Title Accuracy of the Stages of Change Algorithm: Sexual Risk Reported in the Maintenance Stage of Change.
    Date May 2009
    Journal Prevention Science : the Official Journal of the Society for Prevention Research
    Excerpt

    The Transtheoretical Model (TTM), which asserts that health behavior change progresses in stages, is often used to explore health risk behaviors and to target and evaluate health promotion interventions. A four-question staging algorithm is often used to measure an individual's health behavior stage of change (SOC), but its accuracy or appropriateness for tailoring interventions or evaluating outcomes has not been established. The current study utilized data from three studies on HIV sexual risk behavior to compare SOC to reports of sexual risk on more detailed risk assessments, measured concurrently. Within each data set, detailed behavioral risk assessments were compared with SOC, with specific emphasis on maintenance staging, to evaluate the correspondence between SOC and reported behavior. Those classified in the maintenance SOC for condom use should, by definition, report no sexual risk events over the matched time period. Across all three studies, 18% of those classified in the maintenance SOC for condom use reported one or more sexual risk behaviors during the matched time period. Because the SOC algorithm is frequently used in intervention design, targeting, and evaluation, the potential for mis-categorization in the most advanced stage of maintenance raises concerns. Results suggest that intervention inclusion or evaluation strategies that use the maintenance stage as a primary outcome should be further qualified by behavioral data.

    Title A National Survey of Services for the Prevention and Management of Falls in the Uk.
    Date March 2009
    Journal Bmc Health Services Research
    Excerpt

    The National Health Service (NHS) was tasked in 2001 with developing service provision to prevent falls in older people. We carried out a national survey to provide a description of health and social care funded UK fallers services, and to benchmark progress against current practice guidelines.

    Title Achieving the Potential of Hiv Prevention Interventions: Critical Global Need for Collaborative Dissemination Efforts.
    Date February 2009
    Journal Aids (london, England)
    Title A Music-based Hiv Prevention Intervention for Urban Adolescents.
    Date December 2008
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    This research examines the process of conducting and evaluating a music-based HIV prevention intervention among urban adolescents, and is informed by the information, motivation, behavioral skills (IMB) model.

    Title High Rates of Unprotected Sex Occurring Among Hiv-positive Individuals in a Daily Diary Study in South Africa: the Role of Alcohol Use.
    Date October 2008
    Journal Journal of Acquired Immune Deficiency Syndromes (1999)
    Excerpt

    OBJECTIVES: The objectives of this study were to assess the prevalence of unprotected sex and to examine the association between alcohol consumption before sex and unprotected sex among HIV-positive individuals in Cape Town, South Africa. METHODS: For 42 days, daily phone interviews assessed daily sexual behavior and alcohol consumption. Logistic and Poisson generalized estimating equation models were used to examine associations between alcohol consumption before sex and subsequent unprotected sex. RESULTS: During the study which yielded 3035 data points, 58 HIV-positive women and 24 HIV-positive men drank an average of 6.13 drinks when they drank and reported 4927 sex events, of which 80.17% were unprotected. More than half (58%) of unprotected sex events were with HIV-negative partners or with partners with unknown HIV status. Extrapolating from the data using likelihood of infection per act estimates, we calculated that an estimated 2.95 incident HIV infections occurred during the study. Drinking alcohol before sex by the female partner or the male partner, or by both partners increased the proportion and number of subsequent unprotected sex events. However, these associations held only when the quantity of alcohol consumed corresponded to moderate or higher risk drinking. CONCLUSIONS: Among HIV positive individuals, engaging in moderate or higher risk drinking before sex increases the likelihood and rate of unprotected sex. Prevention efforts need to address reducing alcohol-involved unprotected sex among HIV-positive persons.

    Title Phase I Safety Study of Escalating Doses of Atrasentan in Adults with Recurrent Malignant Glioma.
    Date October 2008
    Journal Neuro-oncology
    Excerpt

    Atrasentan is an oral selective endothelin-A receptor antagonist that may inhibit cell proliferation and interfere with angiogenesis during glioma growth. We conducted a dose-finding study to assess atrasentan's safety and toxicity and to gather preliminary evidence of efficacy. Patients with recurrent malignant glioma received oral atrasentan at >or=10 mg/day. We increased the dose among cohorts until the maximum tolerated dose (MTD) was defined. Patients were evaluated for response every 8 weeks and remained on the study until the tumor progressed or toxicities occurred. Twenty-five patients were enrolled, with a median age of 53 years (range, 25-70) and a median KPS of 90% (range, 60-100%). Twenty-two patients had glioblastoma multiforme (GBM), 2 had anaplastic astrocytoma, and 1 had an anaplastic oliogodendroglioma; 24 patients had received one prior chemo therapy regimen before being enrolled in the study. The most common atrasentan-related toxicities were grade 1 or 2 rhinitis, fatigue, and edema. One patient developed grade 3 hypoxia and peripheral edema at a dose of 90 mg/day. We observed no dose-limiting toxicities in an expanded cohort of 10 patients at 70 mg/day, which was declared the MTD. Two partial responses (8%) were seen in patients with GBM at the 70- and 90-mg/day dose levels, and 4 patients had stable disease before progressing. Nineteen patients have died, and median survival was 6.0 months (95% confidence interval, 4.2-9.5 months). We conclude that the MTD of daily oral atrasentan in patients with recurrent malignant glioma is 70 mg/day. Further study of atrasentan with radiation therapy and temozolomide in newly diagnosed GBM is warranted to evaluate the efficacy of this novel agent.

    Title Clinic-based Intervention Reduces Unprotected Sexual Behavior Among Hiv-infected Patients in Kwazulu-natal, South Africa: Results of a Pilot Study.
    Date September 2008
    Journal Journal of Acquired Immune Deficiency Syndromes (1999)
    Excerpt

    OBJECTIVE: To evaluate the feasibility, fidelity, and effectiveness of a human immunodeficiency virus (HIV) prevention intervention delivered to HIV-infected patients by counselors during routine clinical care in KwaZulu-Natal, South Africa. METHODS: A total of 152 HIV-infected patients, aged 18 years and older, receiving clinical care at an urban hospital in South Africa, were randomly assigned to intervention or standard-of-care control counselors. Intervention counselors implemented a brief risk reduction intervention at each clinical encounter to help patients reduce their unprotected sexual behavior. Self-report questionnaires were administered at baseline and 6 months to assess number of unprotected sex events in previous 3 months. RESULTS: Intervention was delivered in 99% of routine patient visits and included a modal 8 of 8 intervention steps. Although HIV-infected patients in both conditions reported more vaginal and anal sex events at 6-month follow-up than at baseline, patients who received the counselor-delivered intervention reported a significant decrease over time in number of unprotected sexual events. There was a marginally significant increase in these events among patients in the standard-of-care control condition. CONCLUSIONS: A counselor-delivered HIV prevention intervention targeting HIV-infected patients seems to be feasible to implement with fidelity in the South African clinical care setting and effective at reducing unprotected sexual behavior.

    Title Featured Arrhythmia by Ho and Rhim in the January 2008 Issue of Heart Rhythm.
    Date June 2008
    Journal Heart Rhythm : the Official Journal of the Heart Rhythm Society
    Title The Ambiguous Pulmonary Venoatrial Junction: a New Perspective.
    Date June 2008
    Journal The International Journal of Cardiovascular Imaging
    Excerpt

    The pulmonary venoatrial junction (PVAJ) has recently received attention due to the widespread use of catheter ablation for atrial fibrillation. However, the literature lacks a consensus in the definition of the PVAJ. We aim to review the inconsistent definitions for the PVAJ and related implications in imaging and catheter ablation for atrial fibrillation.

    Title Asymptomatic Anterior Perforation of an Icd Lead into Subcutaneous Tissues.
    Date May 2008
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    A 71-year-old woman underwent routine implantable cardioverter defibrillator implantation. On a predischarge check the next day, electrical signals and thresholds were excellent and similar to those at implant. The chest X-ray was unremarkable and showed good lead position at the right ventricular apex (RVA). At a routine one-month postimplant visit, electrograms were found to be miniscule, and pacing could not be achieved. Chest X-ray and fluoroscopy suggested perforation, then this was confirmed by computed tomography scan. The tip of the lead was estimated to be within 7 mm of the surface of the skin. The system was removed surgically, and the patient continued to do well.

    Title Reasons for Art Non-adherence in the Deep South: Adherence Needs of a Sample of Hiv-positive Patients in Mississippi.
    Date May 2008
    Journal Aids Care
    Excerpt

    HIV prevalence in the American Deep South has reached crisis proportions and greater numbers of patients are enrolling in clinical care and beginning antiretroviral therapy (ART). In order to gain maximum benefit from ART, patients must sustain high levels of adherence to demanding regimens over extended periods of time. Many patients are unable to maintain high rates of adherence and may need assistance to do so, which may be based upon an understanding of barriers to adherence for a given population. The current study sought to gain understanding of barriers to adherence for a mixed urban/rural HIV-positive patient population in Mississippi and to determine whether barriers to adherence may be specific to gender, employment, depressive symptoms or educational attainment status. Seventy-two patients who missed a dose of ART medication over the last three days endorsed the top five reasons for missing a dose as: (1) not having the medication with them, (2) sleeping through the dose time, (3) running out of the medication, (4) being busy with other things and (5) other. Reported barriers were fairly consistent across different groups, although women and those classified as having moderate to severe depressive symptoms reported different patterns of adherence barriers. Results suggest that adherence interventions implemented in the Deep South must take into account specific barriers faced by individuals within this region, where stigma, gender disparities and limited resources are prevalent.

    Title Rate Responsive Pacemakers: a Rapid Assessment Protocol.
    Date May 2008
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    BACKGROUND: Rate responsive (RR) pacemakers are commonly implanted with nominal conservative factory-set responsiveness, which is usually accepted because established exercise protocols are time-consuming. We aimed for efficient assessment of RR pacemaker settings. METHODS: We tested exercise heart rates in controls and paced patients using a brief exercise test that approximates real-life levels of exertion. The test used a nonmotorized treadmill: 30 seconds walking at patient-determined speed followed by 15 seconds brisk exertion. Subjects totaled 110: 26 with RR pacemakers; 22 with non-RR pacers; 27 "sick" nonpaced control patients; and 35 healthy controls. Heart rate (HR) was measured prior to exercise, after 30 seconds of casual walk, after 15 seconds of brisk walk, and 1 minute into recovery. Testing required <5 minutes from set-up to recovery. RESULTS: The 26 RR pacer patients had a mean HR at rest = 74 +/- 10 beats per minute (bpm), walk = 87 +/- 14, and brisk = 94 +/- 18 (increase 27%). Non-RR pacer patients (n = 22): rest = 73 +/- 12 bpm, walk = 88 +/- 14, and brisk = 94 +/- 17 (increase 24.3%, P = 0.60 vs RR patients). "Sick" controls (n = 27): rest = 78 +/- 14 bpm, walk = 102 +/- 17, and brisk = 117 +/- 18 (increase 51.9%, P< 0.001 vs RR pts). For the healthy controls, HRs were at rest 83+/11 bpm, walk = 104 +/- 12, and brisk = 117 +/- 13 (P< 0.001 compared to both paced groups; P = NS vs sick controls). CONCLUSIONS: Nominal RR settings may be suboptimal for many patients. The nonmotorized treadmill test allows quick and inexpensive assessment of RR programming, with the potential for efficient RR optimization.

    Title Prolonged Asystole After Termination of Atrial Arrhythmias: Not So Uncommon?
    Date March 2008
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Multifactorial Assessment and Targeted Intervention for Preventing Falls and Injuries Among Older People in Community and Emergency Care Settings: Systematic Review and Meta-analysis.
    Date March 2008
    Journal Bmj (clinical Research Ed.)
    Excerpt

    To evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings.

    Title The Effect of Enzyme-inducing Antiseizure Drugs on the Pharmacokinetics and Tolerability of Procarbazine Hydrochloride.
    Date November 2007
    Journal Clinical Cancer Research : an Official Journal of the American Association for Cancer Research
    Excerpt

    PURPOSE: Procarbazine hydrochloride (PCB) is one of the few anticancer drugs with activity against high-grade gliomas. This study was conducted to determine if the maximum tolerated dose and pharmacokinetics of PCB are affected by the concurrent use of enzyme-inducing antiseizure drugs (EIASD). EXPERIMENTAL DESIGN: Adults with recurrent high-grade glioma were divided into cohorts who were (+) and were not (-) taking EIASDs. PCB was given orally for 5 consecutive days each month. Six patients were evaluated at each dose level beginning with 200 mg/m2/d and escalated using the modified continual reassessment method. Toxicity and response were assessed. Pharmacokinetic studies were done with a new electrospray ionization mass spectrometry assay. RESULTS: Forty-nine patients were evaluated. The maximum tolerated dose was 393 mg/m2/d for the +EIASD group and the highest dose evaluated in -EIASD patients was 334 mg/m2/d. Myelosuppression was the primary dose-limiting toxicity. Significant hepatic dysfunction occurred in three patients in the +EIASD cohort. Four partial responses (8%) and no complete responses were observed. PCB exhibited linear pharmacokinetics with no significant differences between the two cohorts. A marked increase in peak PCB levels was noted on day 5 relative to day 1, which was not attributable to drug accumulation. CONCLUSIONS: This study suggests that (a) EIASD use does not significantly affect the pharmacokinetics of PCB; (b) changes in the peak plasma concentration of PCB, consistent with decreased apparent oral clearance due to autoinhibition of hepatic metabolism, occur with daily dosing; and (c) severe hepatic dysfunction may accompany this administration schedule.

    Title Relative and Absolute Benefits: Main Results Should Be Reported in Absolute Terms.
    Date November 2007
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Breaking Bad News: Consultants' Experience, Previous Education and Views on Educational Format and Timing.
    Date November 2007
    Journal Medical Education
    Excerpt

    Breaking bad news is a difficult task for health professionals. Senior hospital doctors acknowledge the importance of breaking bad news well, but previous surveys have found them to be sceptical of formal training and disinclined to seek courses in this area. We sought to ascertain if this view was still held.

    Title Limitations of Ejection Fraction for Prediction of Sudden Death Risk in Patients with Coronary Artery Disease: Lessons from the Mustt Study.
    Date October 2007
    Journal Journal of the American College of Cardiology
    Excerpt

    OBJECTIVES: We determined the contribution of multiple variables to predict arrhythmic death and total mortality risk in patients with coronary disease and left ventricular dysfunction. We then constructed an algorithm to predict risk of mortality and sudden death. BACKGROUND: Many factors in addition to ejection fraction (EF) influence the prognosis of patients with coronary disease. However, there are few tools to use this information to guide clinical decisions. METHODS: We evaluated the relationship between 25 variables and total mortality and arrhythmic death in 674 patients enrolled in the MUSTT (Multicenter Unsustained Tachycardia Trial) study that did not receive antiarrhythmic therapy. We then constructed risk-stratification algorithms to weight the prognostic impact of each variable on arrhythmic death and total mortality risk. RESULTS: The variables having the greatest prognostic impact in multivariable analysis were functional class, history of heart failure, nonsustained ventricular tachycardia not related to bypass surgery, EF, age, left ventricular conduction abnormalities, inducible sustained ventricular tachycardia, enrollment as an inpatient, and atrial fibrillation. The model demonstrates that patients whose only risk factor is EF < or =30% have a predicted 2-year arrhythmic death risk <5%. CONCLUSIONS: Multiple variables influence arrhythmic death and total mortality risk. Patients with EF < or =30% but no other risk factor have low predicted mortality risk. Patients with EF >30% and other risk factors may have higher mortality and a higher risk of sudden death than some patients with EF < or =30%. Thus, risk of sudden death in patients with coronary disease depends on multiple variables in addition to EF.

    Title Azithromycin As a Cause of Qt-interval Prolongation and Torsade De Pointes in the Absence of Other Known Precipitating Factors.
    Date October 2007
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    During treatment with azithromycin, a 55 year-old woman developed a newly prolonged QT interval and torsade de pointes in the absence of known risk factors. Female gender and acute renal failure may be considerations in patients treated with azithromycin.

    Title Acoustic Cardiography: Validated Technology Need Not Be Widely Applied.
    Date October 2007
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Pacemaker Pro-arrhythmia: Beyond Spike-on-t and Endless Loop Tachycardia.
    Date September 2007
    Journal Journal of the American College of Cardiology
    Title Failure of an Implantable Cardioverter-defibrillator to Detect Sustained Ventricular Tachycardia: a Consequence of the Latching Phenomenon.
    Date September 2007
    Journal Heart Rhythm : the Official Journal of the Heart Rhythm Society
    Title Designation and Distribution of Events in the Multicenter Unsustained Tachycardia Trial (mustt).
    Date August 2007
    Journal The American Journal of Cardiology
    Excerpt

    Patients with coronary artery disease, depressed left ventricular ejection fraction, and nonsustained ventricular tachycardia (VT) have a high mortality rate due to arrhythmic (arrhythmic death/cardiac arrest) and other cardiac causes. The Multicenter UnSustained Tachycardia Trial (MUSTT) investigated whether electrophysiologic study (EPS) was helpful in choosing drug or defibrillator therapy in patients induced into sustained VT. The events committee attempted to categorize follow-up events in patients in MUSTT and to present a detailed breakdown of events. A derivative of the Hinkle-Thaler classification was used, incorporating lessons from other multicenter studies. The committee was blinded to results of EPS and implantable cardioverter-defibrillator (ICD) or other antiarrhythmic therapy status of patients. The primary end point was cardiac arrest or death from arrhythmia. Secondary end points were death from all causes, cardiac causes, and spontaneous sustained VT. Classifications were death and cardiac arrest. Each was similarly divided as arrhythmic with 14 subcategories, e.g., unwitnessed or related to EPS and nonarrhythmic with 10 subcategories, e.g., ischemia. Terminal VF in progressive heart failure was considered nonarrhythmic. Events were reviewed by 2 members. Disagreements were resolved by the 2 members or, if needed, by the full committee. Of the 2,202 patients in MUSTT, there were 902 deaths. Sustained VT requiring cardioversion occurred in 182 patients. An additional 94 patients had resuscitated cardiac arrests. Events occurred in 1,027 patients, and all were reviewed. The 3 leading events were deaths that were classed as sudden/unwitnessed (23% of 902), due to progressive heart failure (22%), or due to noncardiovascular causes (18%). Arrhythmic deaths or cardiac arrests were highest in inducible patients randomized to no antiarrhythmic therapy; next were inducible patients receiving an ICD; and lowest were in patients who were noninducible. In conclusion, the classification system provided a detailed breakdown of events in consistent categories, showing utility for event analysis and interpretation and development of therapeutic strategies. The classifications assigned by the committee were used in all MUSTT outcomes reports, thus affecting all reported outcomes and overall interpretations of the MUSTT.

    Title Phase Ii Clinical and Pharmacologic Study of Radiation Therapy and Carboxyamido-triazole (cai) in Adults with Newly Diagnosed Glioblastoma Multiforme.
    Date July 2007
    Journal Investigational New Drugs
    Excerpt

    INTRODUCTION: Carboxyamido-triazole (CAI) is a synthetic inhibitor of non-voltage-gated calcium channels that reversibly inhibits angiogenesis, tumor cell proliferation, and metastatic potential. This study examined the efficacy, safety and pharmacokinetics of oral CAI in the treatment of patients with newly diagnosed glioblastoma multiforme (GBM) in an open-label, single arm non-randomized phase 2 trial. METHODS: Eligible patients with histologically confirmed GBM started CAI therapy (250 mg daily) on the first day of radiation (6000 cGy in 30 fractions) and continued until progression, unless side effects became intolerable. The primary outcome was survival compared to historical controls within the NABTT CNS Consortium database. Secondary outcomes included toxicity and pharmacokinetic parameters. RESULTS: Fifty-five patients were enrolled with a median Karnofsky performance status of 90 and age of 56 years. Forty-six (84%) of these patients had debulking surgeries and 52 have died. The median survival was 10.3 months (95% confidence interval (CI), 8.5-12.8) compared to 12.1 months (95% CI, 10.3-13.3) in the NABTT reference group (p = 0.97). Significant toxicities included 2 incidents of reversible vision loss. The mean CAI plasma concentration for patients taking enzyme inducing antiepileptic drugs (EIAED) was 1.35 +/-1.22 compared to 4.06 +/- 1.50 (p < 0.001) for subjects not taking these agents. Overall survival and grade > or = 3 toxicities were comparable by EIAED status. CONCLUSIONS: This study demonstrated that (1) CAI can be administered safely with concomitant cranial irradiation, (2) the pharmacokinetics of CAI are significantly affected by co-administration of EIAED, and (3) the survival of patients with newly diagnosed GBM was not improved with this novel agent, despite achieving adequate drug levels.

    Title Prognostic Factors for Survival in Adult Patients with Recurrent Glioma Enrolled Onto the New Approaches to Brain Tumor Therapy Cns Consortium Phase I and Ii Clinical Trials.
    Date July 2007
    Journal Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology
    Excerpt

    Prognostic factor analyses have proven useful in predicting outcome in patients with newly diagnosed malignant glioma. Similar analyses in patients with recurrent glioma could affect the design and conduct of clinical trials substantially.

    Title Sexual Risk Behaviour Among Hiv-positive Individuals in Clinical Care in Urban Kwazulu-natal, South Africa.
    Date June 2007
    Journal Aids (london, England)
    Excerpt

    We assessed the incidence and predictors of unprotected sex among 152 HIV-positive patients in clinical care in KwaZulu-Natal, South Africa. Nearly 50% were sexually active; 30% of those reported unprotected sex. Alcohol use during sex, reporting forced sex, sex with a perceived HIV-positive partner, and sex with a casual partner predicted more unprotected sex, whereas HIV status disclosure was related to less unprotected sex. These findings highlight the need for linking HIV prevention and care in Africa.

    Title Is the Twist Hazardous to Your Health?
    Date June 2007
    Journal Pacing and Clinical Electrophysiology : Pace
    Title An Information-motivation-behavioral Skills (imb) Model-based Hiv Prevention Intervention for Truck Drivers in India.
    Date June 2007
    Journal Social Science & Medicine (1982)
    Excerpt

    The incidence of HIV/AIDS in India is increasing drastically, and truck drivers are seen as critical sources of HIV transmission due to their high rates of unprotected sex with multiple partners. An intervention based on the Information-Motivation-Behavioral Skills (IMB) model was compared to an information-only control condition in a randomized trial. IMB constructs were assessed among 250 male truck drivers immediately prior to and following implementation of the intervention, and sexual and condom use behaviors were assessed approximately 10 months later. The intervention consisted of a single-session group workshop with 5 interactive activities designed to address HIV prevention-related IMB constructs and to motivate condom use. Findings showed mixed support for the effectiveness of the intervention. There was an effect of the IMB intervention on attitudes, norms, behavioral skills, and intentions specific to condom use with marital partners, but no effects on constructs related to non-marital partners. There was some evidence of greater condom use with marital and non-marital partners at behavioral follow-up for participants in the IMB condition, and effects on condom use with marital partners were mediated by changes in IMB constructs. These findings provide initial evidence for the effectiveness of theoretically-based approaches to HIV prevention in India.

    Title Effects of Cardioactive Medications on Retrograde Conduction: Continuing Relevance for Current Devices.
    Date May 2007
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    INTRODUCTION: Retroconduction (ventriculo-atrial conduction) remains a problem for patients with implanted cardiac rhythm devices. Pacemaker algorithms can detect and terminate endless loop tachycardia (ELT), but actual prevention of ELT may require anti-arrhythmic drugs (AADs). Similarly, AADs can affect ICD rhythm discrimination algorithms that depend on atrio-ventricular ratios. There is concern whether these drugs remain effective during stress situations. METHODS: Electrophysiologic studies that included retroconduction testing using slow ramp pacing were done in 1332 patients. The presence or absence of retroconduction at baseline and with drug was recorded, as was the rate at block. As a stress surrogate, isoproterenol was used to test retroconduction and reversal of drug-induced block. RESULTS: Procainamide, mexiletine, phenytoin, disopyramide, quinidine, beta-blockers, encainide, and amiodarone caused complete retrograde block or decreased the rate at which block occurred (mean 76% of patients, p < 0.008), whereas digoxin, lidocaine, diltiazem, and verapamil did not. Isoproterenol (in the absence of AADs) increased the rate at block in 82% of 404 patients with retroconduction at baseline (p < 0.005). Of 319 patients without retroconduction at baseline, 134 (42%) developed retroconduction after isoproterenol. Isoproterenol reversed retrograde block in 39% of patients with block on an AAD. Amiodarone, digoxin, and the combination of digoxin plus a beta-blocker were most effective at resisting this reversal of ventriculo-atrial block (80%, 68%, and 75% respectively). CONCLUSION: Most of the AADs reviewed increase the cycle length at block or abolish retroconduction, while isoproterenol has the opposite effect. Anti-arrhythmic medications, particularly amiodarone, digoxin, and the combination of digoxin plus a beta-blocker may be considered for a patient with multiple ELT episodes or certain ICD detection problems.

    Title Phase I and Correlative Biology Study of Cilengitide in Patients with Recurrent Malignant Glioma.
    Date May 2007
    Journal Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology
    Excerpt

    PURPOSE: This multi-institutional phase I trial was designed to determine the maximum-tolerated dose (MTD) of cilengitide (EMD 121974) and to evaluate the use of perfusion magnetic resonance imaging (MRI) in patients with recurrent malignant glioma. PATIENTS AND METHODS: Patients received cilengitide twice weekly on a continuous basis. A treatment cycle was defined as 4 weeks. Treatment-related dose-limiting toxicity (DLT) was defined as any grade 3 or 4 nonhematologic toxicity or grade 4 hematologic toxicity of any duration. RESULTS: A total of 51 patients were enrolled in cohorts of six patients to doses of 120, 240, 360, 480, 600, 1,200, 1,800, and 2,400 mg/m2 administered as a twice weekly intravenous infusion. Three patients progressed early and were inevaluable for toxicity assessment. The DLTs observed were one thrombosis (120 mg/m2), one grade 4 joint and bone pain (480 mg/m2), one thrombocytopenia (600 mg/m2) and one anorexia, hypoglycemia, and hyponatremia (800 mg/m2). The MTD was not reached. Two patients demonstrated complete response, three patients had partial response, and four patients had stable disease. Perfusion MRI revealed a significant relationship between the change in tumor relative cerebral blood flow (rCBF) from baseline and area under the plasma concentration versus time curve after 16 weeks of therapy. CONCLUSION: Cilengitide is well tolerated to doses of 2,400 mg/m2, durable complete and partial responses were seen in this phase I study, and clinical response appears related to rCBF changes.

    Title No Place Like Home: Older Adults and Their Housing.
    Date April 2007
    Journal The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences
    Excerpt

    The home is both older Americans' largest asset and their largest consumption good. This article employs new data on the consumption and assets of older Americans to investigate what role the home plays in the economic lives of older adults.

    Title Involving Behavioral Scientists, Health Care Providers, and Hiv-infected Patients As Collaborators in Theory-based Hiv Prevention and Antiretroviral Adherence Interventions.
    Date March 2007
    Journal Journal of Acquired Immune Deficiency Syndromes (1999)
    Excerpt

    Health care providers are often hesitant to attempt health behavior change interventions with patients, although such interventions are frequently needed. When provider-initiated health behavior change interventions are attempted, they are often based on intuition or consist solely of delivering information and are insufficient to change behavior, rather than being based on well-validated and effective behavior change models. We argue that provider-initiated health behavior change interventions are effective and efficient if they are based on appropriate empirically validated theoretical models and developed in collaboration with behavioral scientists and patients. We present a new model for developing such collaborative interventions and initial evidence for its success.

    Title A Lamb in Wolff's Clothing.
    Date March 2007
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    A symptomatic woman with an electrocardiogram (ECG)-based diagnosis of Wolff-Parkinson-White (WPW) syndrome underwent electrophysiologic studies that revealed a likely fasciculo-ventricular tract.

    Title Phase I Trial of Polifeprosan 20 with Carmustine Implant Plus Continuous Infusion of Intravenous O6-benzylguanine in Adults with Recurrent Malignant Glioma: New Approaches to Brain Tumor Therapy Cns Consortium Trial.
    Date February 2007
    Journal Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology
    Excerpt

    PURPOSE: This phase I trial was designed to (1) establish the dose of O6-benzylguanine (O6-BG) administered intravenously as a continuous infusion that suppresses O6-alkylguanine-DNA alkyltransferase (AGT) levels in brain tumors, (2) evaluate the safety of extending continuous-infusion O6-BG at the optimal dose with intracranially implanted carmustine wafers, and (3) measure the pharmacokinetics of O6-BG and its metabolite. PATIENTS AND METHODS: The first patient cohort (group A) received 120 mg/m2 of O6-BG over 1 hour followed by a continuous infusion for 2 days at escalating doses presurgery. Tumor samples were evaluated for AGT levels. The continuous-infusion dose that resulted in undetectable AGT levels in 11 or more of 14 patients was used in the second patient cohort. Group B received the optimal dose of O6-BG for 2, 4, 7, or 14 days after surgical implantation of the carmustine wafers. The study end point was dose-limiting toxicity (DLT). RESULTS: Thirty-eight patients were accrued. In group A, 12 of 13 patients had AGT activity levels of less than 10 fmol/mg protein with a continuous-infusion O6-BG dose of 30 mg/m2/d. Group B patients were enrolled onto 2-, 4-, 7-, and 14-day continuous-infusion cohorts. One DLT of grade 3 elevation in ALT was seen. Other non-DLTs included ataxia and headache. For up to 14 days, steady-state levels of O6-BG were 0.1 to 0.4 micromol/L, and levels for O6-benzyl-8-oxoguanine were 0.7 to 1.3 micromol/L. CONCLUSION: Systemically administered O6-BG can be coadministered with intracranially implanted carmustine wafers, without added toxicity. Future trials are required to determine if the inhibition of tumor AGT levels results in increased efficacy.

    Title Acc/aha/hrs 2006 Key Data Elements and Definitions for Electrophysiological Studies and Procedures: a Report of the American College of Cardiology/american Heart Association Task Force on Clinical Data Standards (acc/aha/hrs Writing Committee to Develop Data Standards on Electrophysiology).
    Date January 2007
    Journal Journal of the American College of Cardiology
    Title Acc/aha/hrs 2006 Key Data Elements and Definitions for Electrophysiological Studies and Procedures: a Report of the American College of Cardiology/american Heart Association Task Force on Clinical Data Standards (acc/aha/hrs Writing Committee to Develop Data Standards on Electrophysiology).
    Date December 2006
    Journal Circulation
    Title An Information-motivation-behavioral Skills Model of Adherence to Antiretroviral Therapy.
    Date December 2006
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    HIV-positive persons who do not maintain consistently high levels of adherence to often complex and toxic highly active antiretroviral therapy (HAART) regimens may experience therapeutic failure and deterioration of health status and may develop multidrug-resistant HIV that can be transmitted to uninfected others. The current analysis conceptualizes social and psychological determinants of adherence to HAART among HIV-positive individuals. The authors propose an information-motivation-behavioral skills (IMB) model of HAART adherence that assumes that adherence-related information, motivation, and behavioral skills are fundamental determinants of adherence to HAART. According to the model, adherence-related information and motivation work through adherence-related behavioral skills to affect adherence to HAART. Empirical support for the IMB model of adherence is presented, and its application in adherence-promotion intervention efforts is discussed.

    Title In Memoriam: Special Tribute to Seymour Furman, M.d. 1931-2006.
    Date October 2006
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Atrial Fibrillation Ablation: Reaching the Mainstream.
    Date October 2006
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    INTRODUCTION AND AIMS: Ablation of atrial fibrillation (AF) has evolved rapidly in the decade since its inception. We aimed to review the results of this evolution as reflected in the published literature. METHODS: Publications through 2005 were reviewed, and data included if there was information on the technique used, and follow-up of at least 6 months. RESULTS: More than 23,000 patients met criteria for inclusion. There has been a steady improvement in reported outcomes (P<0.001). Variations on radiofrequency catheter ablation for pulmonary vein isolation result in apparent elimination ("cure") or improvement of AF in 75%, and surgical techniques are even better. CONCLUSIONS: Catheter ablation of AF is now a mainstream procedure. Continuing technical advances are needed to achieve better results with more uniformity and reduced procedure times.

    Title Adherence to Antiretroviral Therapy: an Empirical Test of the Information-motivation-behavioral Skills Model.
    Date August 2006
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    Consistent and nearly perfect adherence is considered an essential requirement for HIV-positive patients on antiretroviral therapy (ART) to fully realize its life-extending benefits. The current study evaluated a comprehensive model of ART adherence--the information-motivation-behavioral skills (IMB) model. This model views adherence behavior as a function of the interrelations between adherence-related information, motivation, and behavioral skills. It hypothesizes that adherence-related information and motivation work through adherence-related behavioral skills to affect the initiation and maintenance of optimal ART adherence. In a series of structural equation models, the IMB model's critical constructs and assumptions were evaluated with a sample of 100 HIV-positive patients in clinical care. Across all analyses, the authors found support for the assumptions of the IMB model of ART adherence. Consistent with the model, adherence-related information and motivation related significantly to adherence-related behavioral skills, and behavioral skills related significantly to self-reported optimal adherence. Further, as predicted, the effects of information and motivation on self-reported adherence were mediated by adherence-related behavioral skills. Current study results are explored, and implications for adherence promotion interventions based on the model are discussed.

    Title Visual Analog Scale of Art Adherence: Association with 3-day Self-report and Adherence Barriers.
    Date August 2006
    Journal Journal of Acquired Immune Deficiency Syndromes (1999)
    Excerpt

    BACKGROUND: Brief self-reports of antiretroviral therapy adherence that place minimal burden on patients and clinic staff are promising alternatives to more elaborate adherence assessments currently in use. This research assessed the association between self-reported adherence on visual analog scale (VASs) and an existing, more complex self-reported measure of adherence, the AACTG, and the degree to which each method distinguished optimally and suboptimally adherent patients in terms of reported barriers to adherence. METHODS: HIV-infected patients (N = 147) at a southeastern US clinic completed a computerized assessment including an antiretroviral therapy adherence VAS, a modified version of the AACTG, and a measure of adherence. RESULTS: Adherence rates were comparable across the AACTG (81%) and VAS (87%); they significantly correlated (r = 0.585) and produced identical classification of optimal (>90%) or suboptimal (<90%) adherence for 66% of patients. In general, VAS scores tended to be higher than AACTG scores. Suboptimally adherent patients reported more adherence barriers than those classified as optimally adherent, and those so classified by the VAS reported considerably more barriers to adherence than those so classified by the AACTG. CONCLUSIONS: Results generally support the construct validity of the VAS and its use as an easily administered assessment tool that can identify patients with barriers to adherence who might benefit from adherence support interventions.

    Title Experts Outline Ways to Decrease the Decade-long Yearly Rate of 40,000 New Hiv Infections in the Us.
    Date June 2006
    Journal Aids and Behavior
    Excerpt

    This paper presents data from a brief, anonymous, open-ended survey of 50 behavioral research experts in HIV prevention. Responses were received from 31 participants who provided input regarding the primary reasons they believe the rate of the HIV epidemic in the United States has persisted in recent years, and how they believe we can most efficiently decrease the current rate of new HIV infections in the United States. Four clusters of reasons suggested for the persistent rate of new infections: Intervention level reasons, Society level reasons, Person level reasons, and Multiple Risk Factor reasons. Three clusters of strategies suggested for decreasing the current rate: Improved Targeting of HIV Prevention efforts, Larg-Scale Changes to HIV prevention, and Integrating HIV Prevention into more aspects of society. Results are reviewed with the objective of providing a fresh perspective on the potential means for addressing the current HIV epidemic.

    Title Clinician-delivered Intervention During Routine Clinical Care Reduces Unprotected Sexual Behavior Among Hiv-infected Patients.
    Date March 2006
    Journal Journal of Acquired Immune Deficiency Syndromes (1999)
    Excerpt

    OBJECTIVE: To evaluate the effectiveness of a clinician-delivered intervention, implemented during routine clinical care, in reducing unprotected sexual behavior of HIV-infected patients. DESIGN: A prospective clinical trial comparing the impact of a clinician-delivered intervention arm vs. a standard-of-care control arm on unprotected sexual behavior of HIV-infected patients. SETTING: The 2 largest HIV clinics in Connecticut. PARTICIPANTS: A total of 497 HIV-infected patients, aged > or =18 years, receiving HIV clinical care. INTERVENTION: HIV clinical care providers conducted brief client-centered interventions at each clinical encounter that were designed to help HIV-infected patients reduce unprotected sexual behavior. MAIN OUTCOME MEASURES: Unprotected insertive and receptive vaginal and anal intercourse and unprotected insertive oral sex; unprotected insertive and receptive vaginal and anal intercourse only. RESULTS: HIV-infected patients who received the clinician-delivered intervention showed significantly reduced unprotected insertive and receptive vaginal and anal intercourse and insertive oral sex over a follow-up interval of 18 months (P < 0.05). These behaviors increased across the study interval for patients in the standard-of-care control arm (P < 0.01). For the measure of unprotected insertive and receptive vaginal and anal sex only, there was a trend toward a reduction in unprotected sex among intervention arm participants over time (P < 0.09), and a significant increase in unprotected sex in the standard-of-care control arm (P < 0.01). CONCLUSIONS: A clinician-delivered HIV prevention intervention targeting HIV-infected patients resulted in reductions in unprotected sex. Interventions of this kind should be integrated into routine HIV clinical care.

    Title Who Needs a Defibrillator? The Beat Goes On.
    Date December 2005
    Journal Journal of the American College of Cardiology
    Title Atrioventricular and Atriofascicular Accessory Pathways with a Common Atrial Insertion.
    Date December 2005
    Journal Heart Rhythm : the Official Journal of the Heart Rhythm Society
    Title Clinician-initiated Hiv Risk Reduction Intervention for Hiv-positive Persons: Formative Research, Acceptability, and Fidelity of the Options Project.
    Date October 2005
    Journal Journal of Acquired Immune Deficiency Syndromes (1999)
    Excerpt

    OBJECTIVE: To conduct research on levels and dynamics of HIV risk behavior among HIV-positive patients in clinical care, use this research to design a clinician-initiated HIV prevention intervention for HIV-positive patients, and evaluate the acceptability of the intervention to clinicians and patients and the fidelity with which it can be delivered by clinicians. METHODS: Study 1 (elicitation research) involved focus groups with HIV-positive patients and HIV care clinicians to understand the dynamics of HIV risk behavior among HIV-positive patients and how to integrate HIV prevention into routine clinical care. Study 2 (acceptability and intervention fidelity) involved the evaluation of 1455 medical visits by experimental intervention patients (N = 231) for acceptability and fidelity of the clinician-initiated HIV prevention intervention. RESULTS: Elicitation research with patients and clinicians identified critical HIV prevention information, motivation, and behavioral skills deficits in HIV-positive patients as well as risky sexual behavior. These findings were integrated into a theory-based HIV prevention intervention initiated by clinicians that proved acceptable to clinicians and patients and that clinicians were able to implement with adequate fidelity. CONCLUSION: HIV prevention interventions by clinicians treating HIV-positive patients can and should be integrated into routine clinical care.

    Title An Empirical Test of the Information, Motivation and Behavioral Skills Model of Antiretroviral Therapy Adherence.
    Date October 2005
    Journal Aids Care
    Excerpt

    Nearly perfect adherence to demanding antiretroviral therapy (ART) is now recognized as essential for HIV-positive patients to realize its life sustaining benefits. Despite the dire consequences of non-adherence, a large number of patients do not follow their ART regimen. While many factors influence adherence, the literature is dominated by studies on only one or a small set of them. Multivariate, theory-based models of adherence behavior are of great interest. The current study tested one such model, the Information, Motivation and Behavioral Skills (IMB) model of ART adherence (Fisher et al., under review). A sample of HIV-positive patients on ART in clinical care in Puerto Rico (N=200) provided data on adherence-related information, motivation and behavioral skills as well as adherence behavior per se. Structural equation model tests used to assess the propositions of the IMB model of ART adherence provided support for the interrelations between the elements proposed by the model and extended previous work. Implications for future research and intervention development are discussed.

    Title Profound Independent Effects of Left Bundle Branch Block and Heart Rate During Supraventricular Tachycardia.
    Date September 2005
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    Left bundle branch block (LBBB) has negative hemodynamic effects. In the same patient, profound hypotension occurs during supraventricular tachycardia with LBBB but not at the same rate in the absence of LBBB. At slower rates, blood pressure is similar with and without LBBB.

    Title Phase 2 Trial of Copper Depletion and Penicillamine As Antiangiogenesis Therapy of Glioblastoma.
    Date September 2005
    Journal Neuro-oncology
    Excerpt

    Penicillamine is an oral agent used to treat intracerebral copper overload in Wilson's disease. Copper is a known regulator of angiogenesis; copper reduction inhibits experimental glioma growth and invasiveness. This study examined the feasibility, safety, and efficacy of creating a copper deficiency in human glioblastoma multiforme. Forty eligible patients with newly diagnosed glioblastoma multiforme began radiation therapy (6000 cGy in 30 fractions) in conjunction with a low-copper diet and escalating doses of penicillamine. Serum copper was measured at baseline and monthly. The primary end point of this study was overall survival compared to historical controls within the NABTT CNS Consortium database. The 25 males and 15 females who were enrolled had a median age of 54 years and a median Karnofsky performance status of 90. Surgical resection was performed in 83% of these patients. Normal serum copper levels at baseline (median, 130 microg/dl; range, 50-227 microg/dl) fell to the target range of <50 microg/dl (median, 42 microg/dl; range, 12-118 microg/dl) after two months. Penicillamine-induced hypocupremia was well tolerated for months. Drug-related myelosuppression, elevated liver function tests, and skin rash rapidly reversed with copper repletion. Median survival was 11.3 months, and progression-free survival was 7.1 months. Achievement of hypocupremia did not significantly increase survival. Although serum copper was effectively reduced by diet and penicillamine, this antiangiogenesis strategy did not improve survival in patients with glioblastoma multiforme.

    Title Mri: Safety in Patients with Pacemakers or Defibrillators: is It Prime Time Yet?
    Date August 2005
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Long Rp Interval Tachycardia: What is the Mechanism?
    Date June 2005
    Journal Heart Rhythm : the Official Journal of the Heart Rhythm Society
    Title Value of Pre-hospital Discharge Defibrillation Testing in Recipients of Implanted Cardioverter Defibrillators.
    Date June 2005
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Opinions vary regarding the need to perform defibrillation testing prior to hospital discharge in recipients of state-of-the-art cardioverter defibrillators (ICDs). Our protocol is to perform predischarge ICD testing 1 day after implant. This report includes 682 consecutive implants. Adverse observations at testing were grouped into (1) risk of defibrillation failure, (2) surgical complications, (3) sensing/pacing issues or narrow defibrillation margin warranting closer follow-up, or (4) findings correctable by device reprogramming. Among the 682 patients, 63% had single-chamber and 37% dual-chamber or biventricular ICDs. In 48 patients (7%) there were 69 concerns and/or interventions, with overlaps among the four categories, including one failure to defibrillate (0.15%), and six other patients at risk. Surgical complications included 11 hematomas (1.6%), and six lead dysfunctions. Closer follow-up was indicated in 19 patients (2.7%), for high pacing thresholds in seven, sensing issues in seven, and <10 J defibrillation margin in five. Device reprogramming was needed in 31 patients (4.5%), for tachycardia detection and therapy settings in 12, and for pacing/sensing functions in 22 patients. In eight patients ventricular fibrillation could not be induced. There was no morbidity or mortality due to testing. The state-of-the-art ICDs delivering biphasic shocks are remarkably reliable. The routine pre-hospital discharge defibrillation testing of such ICDs may be optional and left to the physicians' discretion.

    Title Oral Sodium Phenylbutyrate in Patients with Recurrent Malignant Gliomas: a Dose Escalation and Pharmacologic Study.
    Date May 2005
    Journal Neuro-oncology
    Excerpt

    We determined the maximum tolerated dose (MTD), toxicity profile, pharmacokinetic parameters, and preliminary efficacy data of oral sodium phenylbutyrate (PB) in patients with recurrent malignant gliomas. Twenty-three patients with supratentorial recurrent malignant gliomas were enrolled on this dose escalation trial. Four dose levels of PB were studied: 9, 18, 27, and 36 g/day. Data were collected to assess toxicity, response, survival, and pharmacokinetics. All PB doses of 9, 18, and 27 g/day were well tolerated. At 36 g/day, two of four patients developed dose-limiting grade 3 fatigue and somnolence. At the MTD of 27 g/day, one of seven patients developed reversible grade 3 somnolence. Median survival from time of study entry was 5.4 months. One patient had a complete response for five years, and no partial responses were noted, which yielded an overall response rate of 5%. Plasma concentrations of 706, 818, 1225, and 1605 muM were achieved with doses of 9, 18, 27, and 36 g/day, respectively. The mean value for PB clearance in this patient population was 22 liters/h, which is significantly higher than the 16 liters/h reported in patients with other malignancies who were not receiving P450 enzyme-inducing anticonvulsant drugs (P = 0.038). This study defines the MTD and recommended phase 2 dose of PB at 27 g/day for heavily pretreated patients with recurrent gliomas. The pharmacology of PB appears to be affected by concomitant administration of P450-inducing anticonvulsants.

    Title Editorial Comment: Tilt Testing Made Easy?
    Date May 2005
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Easy Surgical Approach for Completion of Biventricular Pacing.
    Date April 2005
    Journal Journal of Cardiovascular Electrophysiology
    Excerpt

    Placement of a pacing lead into a branch of the coronary sinus for biventricular pacing sometimes is difficult or impossible. Surgical completion typically has included immediate or subsequent thoracotomy lead placement with hookup to the device at the time of chest surgery. We describe an alternative procedure of complete device-lead hookup and permanent pocket closure in the electrophysiology laboratory. The left ventricular lead is an epicardial type. The lead is tunneled to a position where the surgeon subsequently can recover it using the thoracotomy incision and implant the lead on the epicardium using device-based testing.

    Title Leads Frozen in the Header: a Real Problem or Just Many Solutions?
    Date March 2005
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Pacemakers and Implantable Cardioverter Defibrillators: Device Longevity is More Important Than Smaller Size: the Patient's Viewpoint.
    Date March 2005
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    The size of pacemakers and implantable cardioverter defibrillators (ICDs) has been diminishing progressively. If two devices are otherwise identical in components, features and technology, the one with a larger battery should have a longer service life. Therefore, patients who receive smaller devices may require more frequent surgery to replace the devices. It is uncertain whether this tradeoff for smaller size is desired by patients. We surveyed 156 patients to determine whether patients prefer a larger, longer-lasting device, or a smaller device that is less noticeable but requires more frequent surgery. The effects of subgroups were evaluated; these included body habitus, age, gender, and patients seen at time of pulse generator replacement (PGR), initial implant, or follow-up. Among 156 patients surveyed, 151 expressed a preference. Of these, 90.1% preferred the larger device and 9.9% the smaller device (P <0.0001). Among thin patients, 79.5% preferred a larger device. Ninety percent of males and 89.2% of females selected the larger device. Among younger patients (< or =72 years), 89.6% preferred the larger device, as did 90.5% of older patients (>72 years). Of patients undergoing PGR or initial implants, 95% favored the larger device, as did 86% of patients presenting for follow-up. The vast majority of patients prefer a larger device to reduce the number of potential replacement operations. This preference crosses the spectrum of those with a previously implanted device, those undergoing initial implants, those returning for routine follow-up, and patients of various ages, gender, and habitus.

    Title Electrocardiographic Predictors of Arrhythmic Death and Total Mortality in the Multicenter Unsustained Tachycardia Trial.
    Date February 2005
    Journal Circulation
    Excerpt

    BACKGROUND: Stratifiers of sudden and total mortality risk are needed to optimally target preventive therapies in patients with coronary artery disease and impaired ventricular function. We assessed the prognostic significance of ECG markers of conduction abnormalities and left ventricular hypertrophy in the Multicenter Unsustained Tachycardia Trial (MUSTT). METHODS AND RESULTS: We analyzed the ECGs of 1638 patients from MUSTT who did not receive antiarrhythmic therapy (antiarrhythmic medication or implantable cardioverter-defibrillator). After adjustment for other significant factors, left bundle-branch block and intraventricular conduction delay were associated with a 50% increase in the risk of both arrhythmic and total mortality. Right bundle-branch block was not associated with arrhythmic or total mortality. Left ventricular hypertrophy was the only ECG predictor of arrhythmic (hazard ratio, 1.35; 95% CI, 1.08 to 1.69) but not total mortality. CONCLUSIONS: In patients with coronary artery disease, depressed left ventricular function, and nonsustained ventricular tachycardia, QRS prolongation resulting from left bundle-branch block or intraventricular conduction delay but not right bundle-branch block provided prognostic information about the risk of arrhythmic and total mortality independently of electrophysiological evaluation and ejection fraction. Left ventricular hypertrophy was associated with increased arrhythmic but not total mortality.

    Title A Phase I Open-label, Dose-escalation, Multi-institutional Trial of Injection with an E1b-attenuated Adenovirus, Onyx-015, into the Peritumoral Region of Recurrent Malignant Gliomas, in the Adjuvant Setting.
    Date January 2005
    Journal Molecular Therapy : the Journal of the American Society of Gene Therapy
    Excerpt

    ONYX-015 is an oncolytic virus untested as a treatment for malignant glioma. The NABTT CNS Consortium conducted a dose-escalation trial of intracerebral injections of ONYX-015. Cohorts of six patients at each dose level received doses of vector from 10(7) plaque-forming units (pfu) to 10(10) pfu into a total of 10 sites within the resected glioma cavity. Adverse events were identified on physical exams and testing of hematologic, renal, and liver functions. Efficacy data were obtained from serial MRI scans. None of the 24 patients experienced serious adverse events related to ONYX-015. The maximum tolerated dose was not reached at 10(10) pfu. The median time to progression after treatment with ONYX-015 was 46 days (range 13 to 452 + days). The median survival time was 6.2 months (range 1.3 to 28.0 + months). One patient has not progressed and 1 patient showed regression of interval-increased enhancement. With more than 19 months of follow-up, 1/6 recipients at a dose of 10(9) and 2/6 at a dose of 10(10) pfu remain alive. In 2 patients who underwent a second resection 3 months after ONYX-015 injection, a lymphocytic and plasmacytoid cell infiltrate was observed. Injection of ONYX-015 into glioma cavities is well tolerated at doses up to 10(10) pfu.

    Title Comparison of Rectilinear Biphasic Waveform Energy Versus Truncated Exponential Biphasic Waveform Energy for Transthoracic Cardioversion of Atrial Fibrillation.
    Date January 2005
    Journal The American Journal of Cardiology
    Excerpt

    Success rates of cardioversion with a defibrillator using the truncated exponential biphasic waveform (with a maximum energy of 360 J) and a defibrillator using the rectilinear biphasic waveform (with a maximum energy of 200 J) were randomly compared in 145 patients. Success rates at 50, 100, 150, and 200 J were not significantly different, but 2 patients who did not achieve cardioversion after a 200-J maximum energy shock by the rectilinear device underwent successful cardioversion with a 360-J shock by the truncated exponential device after crossover.

    Title Lead Stuck (frozen) in Header: Salvage by Bone Cutter Versus Other Techniques. Jfisher@montefiore.org.
    Date December 2004
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    It is occasionally difficult to disconnect leads from headers at the time of pulse generator replacement without injuring the fragile leads. Over a 2.5-year period we encountered this problem in six cases (1.7% of pulse generator replacements). The posterior portion of the header was clipped off using an orthopedic bone cutter in four cases. The cut was aligned with the deep end of the lead socket in the header. A metal rod was then used to push the lead out of the socket. Bench testing of alternative methods was done on previously explanted pulse generators that were firmly held in a vice. Motorized microtools were used to drill holes from the end of the header to the deep end of the socket; or with a rotary saw attachment to slice off the back of the header, allowing a retained lead to be pushed out. The latter was also done with a hand held razor saw, and attempts were made with a scalpel. Lead removal in the clinical cases was accomplished quickly in the four cases using the bone-cutter, without trauma to the lead. Bench testing results varied. The bone cutter was the most efficient method for most brands, but was ineffective on one. The motorized tool was difficult to position, produced sprays of plastic particles, and would have been risky in a clinical setting. The razor saw was difficult to use safely, or efficiently, except in some headers that resisted the bone cutter. The scalpel failed except in one "soft header" pacemaker. An orthopedic bone cutter is a useful tool for removing a retained lead from a pulse generator header. Different header designs and materials necessitate knowledge of several lead detachment methods.

    Title Phase I Clinical and Pharmacokinetic Study of Irinotecan in Adults with Recurrent Malignant Glioma.
    Date June 2004
    Journal Clinical Cancer Research : an Official Journal of the American Association for Cancer Research
    Excerpt

    PURPOSE: A preliminary evaluation of the efficacy of irinotecan in patients with malignant glioma demonstrated modest activity. A markedly lower than expected incidence of drug-related toxicity was also noted. This was consistent with pharmacokinetic data indicating that the total body clearance (CL) of irinotecan in this patient population was considerably greater than in colorectal cancer patients. Concomitant medications used chronically in brain cancer patients, especially glucocorticoids and anticonvulsants that induce hepatic enzymes involved in the metabolism or excretion of drugs, were believed to be the cause of the alteration in pharmacokinetic behavior. A Phase I study was therefore undertaken in patients with recurrent malignant gliomas to independently determine the maximum tolerated dose (MTD) of irinotecan in patients stratified according to the use of enzyme-inducing anticonvulsants (EIAs). Experimental Design: Patients with recurrent malignant gliomas received irinotecan as a weekly 90-min i.v. infusion for four consecutive weeks, with additional cycles of treatment repeated every 6 weeks. The starting dose was 125 mg/m(2)/week for both groups of patients (+/-EIA). Groups of >/==" BORDER="0">3 patients were evaluated at each dose level, and the modified continual reassessment method was used for dose adjustments. The plasma pharmacokinetics of irinotecan, its active metabolite, 7-ethyl-10-hydroxy-camptothecin (SN-38), and the glucuronide conjugate of SN-38, SN-38 glucuronide, were determined in all patients during treatment with the first weekly dose. RESULTS: Forty patients were enrolled into the study and treated with a total of 135 cycles of irinotecan. The MTD was determined to be 411 mg/m(2)/week in the +EIA cohort and 117 mg/m(2)/week in the -EIA cohort for the weekly x 4 every 6 weeks schedule. Pharmacokinetic studies showed that the CL of irinotecan was distinctly dose dependent in the patients receiving EIAs, decreasing from approximately 50 liters/h/m(2) at the lower dose levels (125-238 mg/m(2)) to a mean +/- SD value of 29.7 +/- 9.0 liters/h/m(2) (n = 7) at the MTD. The grand mean CL for a group of 13 patients who were not taking EIAs, 18.8 +/- 10.6 liters/h/m(2), was significantly different from the mean CL at the MTD of the +EIA cohort (P = 0.033). Mean values of the AUC of SN-38 (P = 0.4) and SN-38 glucuronide (P = 0.55) were not significantly different at the MTDs for the two cohorts of patients. CONCLUSIONS: The MTD of irinotecan was 3.5 times greater in patients with malignant glioma who were concurrently receiving EIAs than in those who were not. This study has also served to confirm that the concomitant administration of EIAs results in marked enhancement in the CL of irinotecan. These findings have important implications for subsequent clinical trials to further evaluate irinotecan in brain cancer patients and underscore the importance of assessing the potential for pharmacokinetic interactions between concurrent medications and chemotherapeutic agents.

    Title Out-of-hospital Cardiopulmonary Arrest in Children with Croup.
    Date April 2004
    Journal Pediatric Emergency Care
    Excerpt

    Viral laryngotracheobronchitis is a ubiquitous infectious process that has not caused significant mortality in the past 20 years. Bacterial tracheitis and pneumonia can complicate viral laryngotracheobronchitis and markedly increase the risk of bad outcome. Even uncomplicated, properly managed, viral laryngotracheobronchitis can occasionally result in death, particularly in the infant age group.

    Title Presentation Variability of Acute Urolithiasis in School-aged Children.
    Date April 2004
    Journal The American Journal of Emergency Medicine
    Excerpt

    Urolithiasis is not a frequent diagnosis in school-aged children. The clinical presentation can lack many of the clinical clues such as flank pain that are seen in older patients. We present four cases demonstrating this potential diagnostic dilemma.

    Title An Inflatable Balloon Catheter and Liquid 125i Radiation Source (gliasite Radiation Therapy System) for Treatment of Recurrent Malignant Glioma: Multicenter Safety and Feasibility Trial.
    Date September 2003
    Journal Journal of Neurosurgery
    Excerpt

    OBJECT: In this study the authors evaluated the safety and performance of the GliaSite Radiation Therapy System (RTS) in patients with recurrent malignant brain tumors who were undergoing tumor resection. METHODS: The GliaSite is an inflatable balloon catheter that is placed in the resection cavity at the time of tumor debulking. Low-dose-rate radiation is delivered with an aqueous solution of organically bound iodine-125 (lotrex [sodium 3-(125I)-iodo-4-hydroxybenzenesulfonate]), which are temporarily introduced into the balloon portion of the device via a subcutaneous port. Adults with recurrent malignant glioma underwent resection and GliaSite implantation. One to 2 weeks later, the device was filled with Iotrex for 3 to 6 days, following which the device was explanted. Twenty-one patients with recurrent high-grade astrocytomas were enrolled in the study and received radiation therapy. There were two end points: 1) successful implantation and delivery of brachytherapy; and 2) safety of the device. Implantation of the device, delivery of radiation, and the explantation procedure were well tolerated. At least 40 to 60 Gy was delivered to all tissues within the target volume. There were no serious adverse device-related events during brachytherapy. One patient had a pseudomeningocele, one patient had a wound infection, and three patients had meningitis (one bacterial, one chemical, and one aseptic). No symptomatic radiation necrosis was identified during 21.8 patient-years of follow up. The median survival of previously treated patients was 12.7 months (95% confidence interval 6.9-15.3 months). CONCLUSIONS: The GliaSite RTS performs safely and efficiently. It delivers a readily quantifiable dose of radiation to tissue at the highest risk for tumor recurrence.

    Title I-123 Mibg Imaging and Heart Rate Variability Analysis to Predict the Need for an Implantable Cardioverter Defibrillator.
    Date July 2003
    Journal Journal of Nuclear Cardiology : Official Publication of the American Society of Nuclear Cardiology
    Excerpt

    BACKGROUND: Iodine 123 metaiodobenzylguanidine (MIBG) imaging and heart rate variability (HRV) analysis were compared in patients with an implantable cardioverter defibrillator (ICD) who did and did not receive defibrillator discharges. Although the ICD has been shown to abort potentially fatal ventricular arrhythmias, identification of patients who most benefit from this device remains difficult. As the autonomic nervous system has been implicated in the genesis of these arrhythmias, we undertook a pilot study to evaluate local myocardial sympathetic innervation with the use of I-123 MIBG myocardial imaging, as well as central autonomic tone with the use of HRV, in patients with implantable defibrillators. Test results were correlated with the occurrence of ICD discharges. METHODS AND RESULTS: Seventeen patients with previously implanted defibrillators were studied. Of these, 10 had at least 1 appropriate device discharge for ventricular tachyarrhythmias, whereas 7 had no discharge. Patients with a discharge had a significantly lower I-123 MIBG heart-mediastinal tracer uptake ratio, higher I-123 MIBG defect scores, more extensive sympathetic denervation, and significantly reduced values for several HRV parameters, particularly those in the frequency domain. When combined, the I-123 MIBG heart-mediastinal ratio and HRV 5-minute low-frequency variables were highly predictive of defibrillator discharges. All patients with a heart-mediastinal ratio lower than 1.54 and 5-minute low frequency lower than 443 ms(2) had an ICD discharge (4/4), whereas no patient with an uptake ratio greater than 1.54 and 5-minute low frequency greater than 443 ms(2) did (0/3, P =.03). CONCLUSIONS: Cardiac autonomic assessment using a combination of myocardial scintigraphic and neurophysiologic techniques may help select patients who would most benefit from an implantable defibrillator by identifying those at increased risk for potentially fatal arrhythmias.

    Title Simplified Tilt Table Test Protocol with Continuous Upright Position During Medication Administration and No Hydration.
    Date July 2003
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Recommendations for head-up tilt testing (HUT) often include the prolonged abstaining from food and water consumption (nothing by mouth [NPO]) and intravenous fluids administration before HUT. After the baseline test, supine equilibration periods are recommended before and between each dose of medication. The aim of this study was to determine if similar results are obtainable with a simpler protocol. After 2-3 hours NPO, 1,540 HUTs were performed at 70 degrees for 30 minutes unless predetermined endpoints were reached. Then, with the patient remaining in the tilted position, isoproterenol (ISO) (1 microgram/min), titrated every 3 minutes to a maximum of 5 micrograms/min (n = 803 patients), sublingual nitroglycerin (NTG) (300-400 micrograms) (n = 143 patients), or edrophonium (EDP) (5 mg) repeated once after 3 minutes (n = 46 patients) were administered. No aspiration or other adverse effects attributable to the abbreviated fasting period were observed. ISO was well tolerated as doses were increased. Vasovagal manifestations developed in 31% of ISO tests, in 11% with EDP, and in 50% with NTG (P < 0.001). Time consumed with rehydration before and postural changes during HUTs may be avoided when ISO is administered. With NTG the response may be excessive.

    Title Broad Applicability of Ultrarapid Train Stimulation As an Efficient Alternative to Conventional Programmed Electrical Stimulation.
    Date July 2003
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    BACKGROUND AND STUDY OBJECTIVE: Conventional programmed electrical stimulation (PES) is useful for establishing inducibility or noninducibility of clinical ventricular arrhythmias (VA), but is complex and time-consuming. This study compared a standard PES protocol with ultrarapid train stimulation (UTS) in a broad range of patients with and without a history of ventricular arrhythmias or structural heart disease. METHODS: Patients prospectively underwent electrophysiologic testing with both UTS and conventional PES protocols in a randomized, crossover design. RESULTS: The results were concordant in 79% of 150 matched pairs of comparisons in 104 patients (NS). There were no differences related to underlying heart disease or arrhythmia, or antiarrhythmic treatment. Induction of nonclinical arrhythmias with the two methods was similar (P = 0.524). Inhibition phenomena were minor except in some patients receiving amiodarone. Fewer drive-extrastimuli sequences and less time were needed to complete the trains protocol (P < 0.0001). CONCLUSIONS: In cases where the main intent is to induce ventricular arrhythmias, UTS yields results that are similar to those of conventional PES protocols in a shorter length of time.

    Title Prognostic Significance of Nonsustained Ventricular Tachycardia Identified Postoperatively After Coronary Artery Bypass Surgery in Patients with Left Ventricular Dysfunction.
    Date January 2003
    Journal Journal of Cardiovascular Electrophysiology
    Excerpt

    INTRODUCTION: Nonsustained ventricular tachycardia (NSVT) occurs frequently in the postoperative period (< or = 30 days) after coronary artery bypass graft (CABG) surgery, a setting where many factors may play a role in its genesis. The prognosis of NSVT in this setting in patients with left ventricular (LV) dysfunction is unknown. This study was designed to assess its significance. METHODS AND RESULTS: We compared the outcome of untreated patients enrolled in the Multicenter Unsustained Tachycardia Trial with coronary artery disease (CAD), LV dysfunction, and NSVT identified postoperatively after CABG (n = 228; mean age 67 years, 84% males) versus nonpostoperative settings (n = 1,302; mean age 66 years, 85% males). Sustained monomorphic ventricular tachycardia was induced in 27% and 33% (P = 0.046) of patients with postoperative and nonpostoperative NSVT, respectively. The 2- and 5-year rates of arrhythmic events were 6% and 16%, respectively, in postoperative patients versus 15% and 29% in nonpostoperative patients (unadjusted P = 0.0020, adjusted P = 0.0082). The 2- and 5-year overall mortality rates were 15% and 36%, respectively, for postoperative patients versus 24% and 47% for nonpostoperative patients (unadjusted P = 0.0005, adjusted P = 0.027). Patients whose NSVT was identified early (<10 days) versus late (10-30 days) after CABG had significantly lower 2- (13% vs 23%) and 5-year (30% vs 52%) mortality rates (unadjusted P = 0.024, adjusted P = 0.018). CONCLUSION: In this population of patients with CAD and LV dysfunction, the occurrence of postoperative NSVT, especially within 10 days after CABG, portends a far better outcome than when it occurs in nonpostoperative settings. This suggests that in a such setting, NSVT represents a less specific risk factor for future events and should be considered when assigning risk and treatment of similar patients.

    Title Relation of Ejection Fraction and Inducible Ventricular Tachycardia to Mode of Death in Patients with Coronary Artery Disease: an Analysis of Patients Enrolled in the Multicenter Unsustained Tachycardia Trial.
    Date November 2002
    Journal Circulation
    Excerpt

    BACKGROUND: Fifty percent of deaths in patients with coronary disease occur suddenly. Although many factors correlate with increased mortality, there is little information regarding the influence of these factors on mode of death. As such, optimum methods to determine patients most likely to benefit from implantable defibrillator therapy are unclear. METHODS AND RESULTS: We analyzed the relation of ejection fraction and inducible ventricular tachyarrhythmias to mode of death in all 1791 patients enrolled in the Multicenter Unsustained Tachycardia Trial who did not receive antiarrhythmic therapy. Total mortality and arrhythmic deaths/cardiac arrests occurred more frequently in patients with ejection fraction <30% than in those with ejection fraction of 30% to 40%. The percentage of deaths classified as arrhythmic was similar in patients with ejection fraction <30% or > or =30%. The relative contribution of arrhythmic events to total mortality was significantly higher in patients with inducible tachyarrhythmia (58% of deaths in inducible patients versus 46% in noninducible patients, P=0.004). The higher percentage of events that were arrhythmic among patients with inducible tachyarrhythmia appeared more distinct among patients with an ejection fraction > or =30% (61% of events were arrhythmic among inducible patients with ejection fraction > or =30% and only 42% among noninducible patients, P=0.002). CONCLUSIONS: Both low ejection fraction and inducible tachyarrhythmias identify patients with coronary disease at increased mortality risk. Ejection fraction does not discriminate between modes of death, whereas inducible tachyarrhythmia identifies patients for whom death, if it occurs, is significantly more likely to be arrhythmic, especially if ejection fraction is > or =30%.

    Title Information-motivation-behavioral Skills Model-based Hiv Risk Behavior Change Intervention for Inner-city High School Youth.
    Date October 2002
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    This study assessed the effects of 3 theoretically grounded, school-based HIV prevention interventions on inner-city minority high school students' levels of HIV prevention information, motivation, behavioral skills, and behavior. It involved a quasi-experimental controlled trial comparing classroom-based, peer-based, and combined classroom- and peer-based HIV prevention interventions with a standard-of-care control condition in 4 urban high schools (N = 1,532, primarily 9th-grade students). At 12 months postintervention, the classroom-based intervention resulted in sustained changes in HIV prevention behavior. This article discusses why both of the interventions involving peers were less effective than the classroom-based intervention at the 12-month follow-up and, more generally, suggests a set of possible limiting conditions for the efficacy of peer-based interventions.

    Title A Patient with Polymorphic Ventricular Tachycardia (vt) Controlled by Beta-blockers and Atrial Pacing.
    Date October 2002
    Journal Journal of Cardiovascular Electrophysiology
    Title Cardiac Memory, a Surface Electrocardiographic Clue in the Differential Diagnosis of Ongoing Narrow Complex Tachycardia.
    Date September 2002
    Journal The American Journal of Cardiology
    Title Runaway Pulse Generator Malfunction Resulting from Undetected Battery Depletion.
    Date September 2002
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Runaway pacemaker is an uncommon, potentially lethal circuit malfunction characterized by sudden onset of erratic pacing at rapid nonphysiological rates. Two patients with a single chamber pacemaker (Medtronic ST 8331 and 8419) presented with episodic dizziness. ECG revealed recurrent decrescendo amplitude episodes of runaway stimuli at 2,400 and 2,600 ppm, approximately 3 seconds in duration, separated by pacing at 62.5 and 65 ppm, respectively. Fortunately the runaway stimuli were subthreshold and did not result in capture of the ventricle. Emergency pulse generator replacement was uneventful. Both leads were normal and both pulse generators had low battery voltages at 1.488 and 1.78 V, respectively.

    Title Tests of the Mediational Role of Preparatory Safer Sexual Behavior in the Context of the Theory of Planned Behavior.
    Date August 2002
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    The present research details 2 empirical tests within the context of the theory of planned behavior (I. Ajzen & T. Madden, 1986) of the assumption that preparatory behaviors (e.g., discussing safer sex, obtaining condoms) play a mediational role in the relation between psychological variables (e.g., attitudes toward safer sex, social norms about safer sex) and condom use. The assumption of the mediational role of preparatory behaviors is examined in sexually experienced samples from 2 different populations: inner-city high school students (N = 226) and college students (N = 160). The results suggest that the mediational role of preparatory behaviors is a highly significant one. Results indicate no gender differences with regard to the main mediational hypotheses. The methodological, theoretical, and practical implications and importance of these findings are discussed.

    Title Effect of Implantable Defibrillators on Arrhythmic Events and Mortality in the Multicenter Unsustained Tachycardia Trial.
    Date July 2002
    Journal Circulation
    Excerpt

    BACKGROUND: The Multicenter Unsustained Tachycardia Trial (MUSTT) was designed to evaluate an antiarrhythmic treatment strategy, including drugs and implantable defibrillators (ICDs), guided by electrophysiological (EP) testing. We performed several statistical analyses to assess the contribution of defibrillators to the observed treatment benefit. METHODS AND RESULTS: First, the effects of defibrillators were indirectly examined by comparing the randomized treatment arms (EP-guided therapy versus no antiarrhythmic therapy) within subgroups that varied according to ICD usage. Use of ICDs increased during the trial; hence, the randomized treatments were compared according to date of enrollment. There were also site-specific differences in ICD use; hence, the randomized arms were compared within groups of sites defined by level of ICD use. There was a distinct "dose response" in relation to ICD use. Where ICD use was high, EP-guided therapy produced significant reductions in arrhythmic death or cardiac arrest (P<0.004). Where ICD use was low, there was no benefit of EP-guided therapy. Finally, outcomes of EP-guided therapy patients who received an ICD were directly compared with outcomes of other patients using the Cox proportional hazards model with receipt of an ICD as a time-dependent covariate. Adjusted for other prognostic factors, patients who received an ICD had risk reductions of >70% in arrhythmic death or cardiac arrest and >50% in total mortality (P<0.001 for both end points). CONCLUSIONS: The benefit of EP-guided antiarrhythmic therapy observed in MUSTT was due to improved outcomes among patients who received an ICD but not among patients who received antiarrhythmic drugs.

    Title Histopathological Correlation of Ablation Lesions Guided by Noncontact Mapping in a Patient with Peripartum Cardiomyopathy and Ventricular Tachycardia.
    Date July 2002
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    A patient with peripartum cardiomyopathy developed a nearly incessant nonsustained VT. Guided by a noncontact mapping system, the tachycardia was mapped to the mid-septum of the right ventricle and ablated. Despite transient success, the tachycardia recurred and the patient subsequently died of multiorgan failure. Histopathological correlation of the ablation site revealed a nontransmural lesion that may have contributed to the failure of the ablation.

    Title First, Do No Harm: a Call for Emphasizing Adherence and Hiv Prevention Interventions in Active Antiretroviral Therapy Programs in the Developing World.
    Date May 2002
    Journal Aids (london, England)
    Title Determinants of Hiv Risk Among Indian Truck Drivers.
    Date February 2002
    Journal Social Science & Medicine (1982)
    Excerpt

    Although there are very high levels of HIV risk sexual behavior in India, there has been little research on the determinants of this behavior, the psychosocial correlates of condom use, or the potential for effective behavior change interventions. The present research used the information-motivation-behavioral skills model of HIV risk behavior to explore these issues in a sample of Indian truck drivers, a population that comprises an important vector of HIV transmission. This paper presents correlational data on the predictors of HIV risk and preventive behavior in a sample of truck drivers in Chennai, India. The data were collected via detailed individual structured interviews with 300 Indian truck drivers. Results indicated that Indian truck drivers had substantial deficits with respect to HIV prevention information, motivation, and behavioral skills. Consistent with the IMB model, these deficits were often found to be predictive of HIV risk and preventive behavior. The implications of these findings for future intervention are discussed.

    Title Sinus Node Recovery After 25 Years of Atrial Flutter.
    Date December 2001
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    This case report demonstrates that the sinus node can recover relatively quickly even after being suppressed by atrial flutter for 25 years, and that a permanent pacemaker may not always be necessary in all patients with sinus arrest after a successful atrial flutter ablation.

    Title Linear Lesion Radiofrequency Ablation in Canine Vagal Atrial Fibrillation: Effects of Special Catheters Designed for Efficiency, and the Critical Role of Lesions from the Crista Terminalis to the Superior Vena Cava.
    Date October 2001
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    OBJECTIVE: To determine whether specially devised catheters could be used to place radiofrequency (RF) linear lesions quickly and efficiently for termination and/or prevention of atrial fibrillation (AF). METHODS: Two versions of 2 different types of ablating catheters were used in 12 canines with AF induced by rapid pacing during vagal stimulation. 1) Modified basket catheters in two versions, one designed to produce caudo-cranial linear lesions through extended bare electrode-splines in contact with the atrial wall; and the other designed to produce horizontal linear lesions by revolving within the atrium. Together these would form "longitude and latitude" grids in the atrium. 2) The second catheter type was 2 versions of coil electrodes with thermocouples centered under each of the large-area coil electrodes. One version of these deflectable coil electrodes was intended to produce lesions in the tricuspid valve annulus-inferior vena cava (IVC) isthmus; and along the crista terminalis from the superior vena cava (SVC) to the IVC. A different type of deflection angulation on the second version was intended to produce more horizontal lesions from the crista to the tricuspid annulus. Guidance was fluoroscopic, and by electrograms and transesophageal echo. Gross pathologic examinations followed each experiment. Prior to use in canines, all electrode configurations were tested in vitro on fresh bovine preparations suspended in saline at 37 degrees C. RESULTS: The bare spline and coil electrode catheter configurations produced discrete non-perforating non-charring lesions in the in vitro preparations. One dog died of exsanginating hemorrhage. Post mortem examination revealed the lesions to be extremely variable, ranging from no evidence of effective RF delivery to deep lesions with perforation. Seven clinical successes were achieved (6 complete), with the coil electrode catheters accounting for 5 of the 7, although the procedure times were shorter with the baskets. Critical lesions were those from the crista to the SVC. Planned trans-isthmus lesions were not done, but may be needed to prevent atrial flutter not seen prior to effective AF ablation. CONCLUSIONS: Special basket and coil-electrode catheters may be useful but require refinement. The finding that lesions between the crista terminalis and the SVC were critical to success may be applicable to some cases of AF in humans.

    Title Bundle Branch Reentry Tachycardia: Why is the Hv Interval Often Longer Than in Sinus Rhythm? The Critical Role of Anisotropic Conduction.
    Date August 2001
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Title Case Report: is This Svt or Vt? An Exception to the Rule.
    Date July 2001
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    This case illustrates the difficulties sometimes encountered by clinicians when using algorithms in diagnosing a wide-complex tachycardia based on a 12-lead EKG.

    Title Lack of Efficacy of 9-aminocamptothecin in Adults with Newly Diagnosed Glioblastoma Multiforme and Recurrent High-grade Astrocytoma. Nabtt Cns Consortium.
    Date May 2001
    Journal Neuro-oncology
    Excerpt

    9-Aminocamptothecin (9-AC) was administered as a 72-h i.v. infusion every 2 weeks to a total of 99 adults with high-grade astrocytomas. Fifty-one patients with newly diagnosed glioblastoma multiforme received 9-AC treatment prior to radiation therapy and 48 patients with high-grade astrocytomas were treated at the time of tumor recurrence. Upon entrance into these research protocols, all patients had measurable disease that was evaluated on a monthly basis with volumetric CT or MRI scans. A partial response was defined by > or =50% reduction in the contrast enhancing volume on stable or decreasing doses of glucocorticoids. The study specified that all apparent responders would have central review of their radiologic studies and histopathology. The initial patients treated with 9-AC were also receiving anticonvulsants and were noted to have minimal myelosuppression with this chemotherapy. Thus, 9-AC doses were escalated from the previously reported maximum tolerated dose (MTD) of 850 microg/m2/24 h. We then established new MTDs for patients receiving enzyme-inducing anticonvulsants. We defined these MTDs to be 1,776 microg/m2/24 h for newly diagnosed, previously untreated patients and 1,611 microg/m2/24 h for patients with recurrent disease. Twenty-two patients with newly diagnosed glioblastoma multiforme received 9-AC at doses > or =1,776 microg/m2/24 h. Of these, 18 had evaluable disease on central review, and 0 of 18 (0%) demonstrated a partial or complete response. Twenty-one patients with recurrent high-grade astrocytomas were treated at 1,611 microg/m2/24 h; 20 had evaluable disease and 0 of 20 (0%) had a partial or complete response. Thus, the overall response rate in the 38 evaluable patients treated at the MTD was 0 of 38 (0%). Furthermore, of the 51 evaluable patients who were treated at doses less than the MTD, only one partial response was observed, yielding an overall response rate of 2%. Evidence of drug failure was rapid with tumor progression in one-half of patients after 2 drug cycles. 9-AC lacks evidence of substantial activity in patients with newly diagnosed or recurrent high-grade astrocytomas.

    Title Internal Transcardiac Pericardiocentesis for Acute Tamponade.
    Date January 2001
    Journal The American Journal of Cardiology
    Excerpt

    If the catheter is still in the pericardium when tamponade is recognized during catheterization or electrophysiologic procedures, it can be used for definitive aspiration and relief of tamponade. This is physiologically beneficial to the patient, and psychologically beneficial to both patient and medical staff.

    Title Ethyl 5-methyl-4-(2,5,5-trimethyl-1, 3-dioxan-2-yl)isoxazole-3-carboxylate.
    Date November 2000
    Journal Acta Crystallographica. Section C, Crystal Structure Communications
    Excerpt

    The title compound, C(14)H(21)NO(5), possesses an isoxazolyl group in the axial position of the 1,3-dioxanyl ring. The two rings are rotated about the bond joining them such that the two C(methyl)-C(dioxanyl)-C-C torsion angles are 92.1 (2) and -84.1 (2) degrees. In this conformation, neither the methyl nor ethoxycarbonyl substituents on the isoxazole are presented towards the dioxanyl chair.

    Title Transition from Atrioventricular Node Reentry Tachycardia to Atrial Fibrillation Begins in the Pulmonary Veins.
    Date September 2000
    Journal Circulation
    Title Synthesis and Biological Activity of Enantiomeric Pairs of Phosphosulfonate Herbicides.
    Date August 2000
    Journal Journal of Agricultural and Food Chemistry
    Excerpt

    The phosphosulfonates are a new class of soil-active herbicides which control a variety of annual grass and broadleaf weeds. Chirality at the phosphorus atom afforded the opportunity to explore stereospecific requirements for herbicidal activity. Chiral (hydroxymethyl)phosphinate intermediates were enzymatically resolved (Pseudomonas fluorescens lipase) from the racemic mixtures and then used to prepare two pairs of enantiomeric phosphosulfonates. Biological testing of the enantiomeric phosphosulfonate herbicides demonstrated that, in each case, the herbicidal activity was attributed to the (+) enantiomer and that the (+) enantiomer is more active than the racemate.

    Title American College of Cardiology/american Heart Association Expert Consensus Document on Electron-beam Computed Tomography for the Diagnosis and Prognosis of Coronary Artery Disease.
    Date July 2000
    Journal Circulation
    Title Psychosocial Experiences of Cardiac Patients in Early Recovery: a Community-based Study.
    Date July 2000
    Journal Journal of Advanced Nursing
    Excerpt

    OBJECTIVE: To report on the nature, incidence and severity of problems commonly experienced by cardiac patients in the early months of recovery, and to test the hypotheses that there exist differences in the incidences of these problems depending on age and sex. METHODS: 1124 emergency cardiac patients discharged from hospital with acute myocardial infarction, unstable angina, stable angina pectoris, chronic ischaemic heart disease or heart failure were surveyed 4 months after discharge. They were asked to indicate how often during the previous 2 weeks they had experienced each of a range of feelings and problems common to cardiac patients. RESULTS: A large proportion of patients reported experiencing problems in the areas of emotional reactions (70%), physical condition (79%), convalescence (67%) and relating to family and friends (63%). Severe problems were experienced especially in the physical and convalescence areas (43% and 44%, respectively). A greater proportion of patients diagnosed with heart failure experienced problems than those with other diagnoses, and these problems were more severe. Amongst myocardial infarction patients, a greater proportion of females than males reported severe problems in the emotional and physical areas, and patients 65 years and over were more likely than younger patients to report experiencing severe problems with physical condition. CONCLUSIONS: Many cardiac patients are experiencing psychosocial problems 4 months after hospital discharge, especially with physical activities and convalescence. A knowledge of the incidence and nature of these problems may help nurses to assist patients to validate their experiences.

    Title Autonomic Modulation and Atrial Fibrillation in the Wolff-parkinson-white Syndrome.
    Date July 2000
    Journal The American Journal of Cardiology
    Title Hiv Prevention Information, Motivation, Behavioral Skills and Behaviour Among Truck Drivers in Chennai, India.
    Date July 2000
    Journal Aids (london, England)
    Title Electrophysiologic Testing to Identify Patients with Coronary Artery Disease Who Are at Risk for Sudden Death. Multicenter Unsustained Tachycardia Trial Investigators.
    Date June 2000
    Journal The New England Journal of Medicine
    Excerpt

    BACKGROUND: The mortality rate among patients with coronary artery disease, abnormal ventricular function, and unsustained ventricular tachycardia is high. The usefulness of electrophysiologic testing for risk stratification in these patients is unclear. METHODS: We performed electrophysiologic testing in patients who had coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias could be induced were randomly assigned to receive either antiarrhythmic therapy guided by electrophysiologic testing or no antiarrhythmic therapy. The primary end point was cardiac arrest or death from arrhythmia. Patients without inducible tachyarrhythmias were followed in a registry. We compared the outcomes of 1397 patients in the registry with those of 353 patients with inducible tachyarrhythmias who were randomly assigned to receive no antiarrhythmic therapy in order to assess the prognostic value of electrophysiologic testing. RESULTS: Patients were followed for a median of 39 months. In a Kaplan-Meier analysis, two-year and five-year rates of cardiac arrest or death due to arrhythmia were 12 and 24 percent, respectively, among the patients in the registry, as compared with 18 and 32 percent among the patients with inducible tachyarrhythmias who were assigned to no antiarrhythmic therapy (adjusted P<0.001). Overall mortality after five years was 48 percent among the patients with inducible tachyarrhythmias, as compared with 44 percent among the patients in the registry (adjusted P=0.005). Deaths among patients without inducible tachyarrhythmias were less likely to be classified as due to arrhythmia than those among patients with inducible tachyarrhythmias (45 and 54 percent, respectively; P=0.06). CONCLUSIONS: Patients with coronary artery disease, left ventricular dysfunction, and asymptomatic, unsustained ventricular tachycardia in whom sustained ventricular tachyarrhythmias cannot be induced have a significantly lower risk of sudden death or cardiac arrest and lower overall mortality than similar patients with inducible sustained tachyarrhythmias.

    Title Death and Readmission in the Year After Hospital Admission with Cardiovascular Disease: the Hunter Area Heart and Stroke Register.
    Date June 2000
    Journal The Medical Journal of Australia
    Excerpt

    OBJECTIVES: To compare outcomes one year after hospital admission for patients initially discharged with a diagnosis of acute myocardial infarction (AMI), other ischaemic heart disease (other IHD), congestive heart failure (CHF) or stroke. DESIGN: Cohort study. SETTING: Hunter Area Heart and Stroke Register, which registers all patients admitted with heart disease or stroke to any of the 22 hospitals in the Hunter Area Health Service in New South Wales. PATIENTS: 4981 patients with AMI, other IHD, CHF or stroke admitted to hospital as an emergency between 1 July 1995 and 30 June 1997 and followed for at least one year. MAIN OUTCOME MEASURES: Death from any cause or emergency hospital readmission for cardiovascular disease. RESULTS: In-hospital mortality varied from 1% of those with other IHD to 22% of those with stroke. Almost a third of all patients discharged alive (and 38% of those aged 70 or more) had died or been readmitted within one year. This varied from 22% of those with stroke to 49% of those with CHF. The causes of death and readmission were from a spectrum of cardiovascular disease, regardless of the cause of the original hospital admission. CONCLUSIONS: Data from this population register show the poor outcome, especially with increasing age, among patients admitted to hospital with cardiovascular disease. This should alert us to determine whether optimal secondary prevention strategies are being adopted among such patients.

    Title Understanding Condom Use Among Heroin Addicts in Methadone Maintenance Using the Information-motivation-behavioral Skills Model.
    Date April 2000
    Journal Substance Use & Misuse
    Excerpt

    The current study represents the application of a health behavior model to account for unsafe sexual behavior (as opposed to unsafe needle use) among heroin addicts in methadone treatment. The Information-Motivation-Behavioral Skills (IMB) model of HIV preventive behavior asserts that HIV prevention information, motivation, and behavioral skills are fundamental determinants of HIV preventive behavior. Participants (N = 156 heroin-addicted individuals in methadone treatment) completed assessments of their levels of HIV prevention information, motivation, behavioral skills, and safer sexual behavior. Overall measures of fit generated via structural equation modeling indicate that the IMB model adequately fits the data obtained. The constructs of the model accounted for a substantial proportion of the variance in safer sexual behavior, and tests of parameter estimates indicate that while information and motivation had direct and reliable associations with safer sexual behavior in this population, behavioral skills did not. Discussion focuses on the primary roles of HIV prevention information and motivation as determinants of safer sexual behavior in this population, on the lack of a significant contribution of HIV prevention behavioral skills, and on the implications for intervention of this pattern of findings.

    Title Adenosine Induced Atrial Fibrillation Precipitating Polymorphic Ventricular Tachycardia.
    Date February 2000
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    An 86-year-old female developed supraventricular tachycardia 36 hours after a myocardial infarction (MI). She developed atrial fibrillation and polymorphic ventricular tachycardia (PVT) following administration of 12 mg of adenosine. The PVT caused hemodynamic instability with no response to cardioversion, but termination with procainamide. The heart is vulnerable to hemodynamically unstable, possibly lethal, PVT early after MI under some circumstances. This vulnerability may be exposed following administration of adenosine. Extra caution is warranted when using adenosine in the post-MI period.

    Title A Randomized Study of the Prevention of Sudden Death in Patients with Coronary Artery Disease. Multicenter Unsustained Tachycardia Trial Investigators.
    Date December 1999
    Journal The New England Journal of Medicine
    Excerpt

    BACKGROUND: Empirical antiarrhythmic therapy has not reduced mortality among patients with coronary artery disease and asymptomatic ventricular arrhythmias. Previous studies have suggested that antiarrhythmic therapy guided by electrophysiologic testing might reduce the risk of sudden death. METHODS: We conducted a randomized, controlled trial to test the hypothesis that electrophysiologically guided antiarrhythmic therapy would reduce the risk of sudden death among patients with coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias were induced by programmed stimulation were randomly assigned to receive either antiarrhythmic therapy, including drugs and implantable defibrillators, as indicated by the results of electrophysiologic testing, or no antiarrhythmic therapy. Angiotensin-converting-enzyme inhibitors and beta-adrenergic-blocking agents were administered if the patients could tolerate them. RESULTS: A total of 704 patients with inducible, sustained ventricular tachyarrhythmias were randomly assigned to treatment groups. Five-year Kaplan-Meier estimates of the incidence of the primary end point of cardiac arrest or death from arrhythmia were 25 percent among those receiving electrophysiologically guided therapy and 32 percent among the patients assigned to no antiarrhythmic therapy (relative risk, 0.73; 95 percent confidence interval, 0.53 to 0.99), representing a reduction in risk of 27 percent). The five-year estimates of overall mortality were 42 percent and 48 percent, respectively (relative risk, 0.80; 95 percent confidence interval, 0.64 to 1.01). The risk of cardiac arrest or death from arrhythmia among the patients who received treatment with defibrillators was significantly lower than that among the patients discharged without receiving defibrillator treatment (relative risk, 0.24; 95 percent confidence interval, 0.13 to 0.45; P<0.001). Neither the rate of cardiac arrest or death from arrhythmia nor the overall mortality rate was lower among the patients assigned to electrophysiologically guided therapy and treated with antiarrhythmic drugs than among the patients assigned to no antiarrhythmic therapy. CONCLUSIONS: Electrophysiologically guided antiarrhythmic therapy with implantable defibrillators, but not with antiarrhythmic drugs, reduces the risk of sudden death in high-risk patients with coronary disease.

    Title Familial Polymorphic Ventricular Arrhythmias: a Quarter Century of Successful Medical Treatment Based on Serial Exercise-pharmacologic Testing.
    Date December 1999
    Journal Journal of the American College of Cardiology
    Excerpt

    We sought to determine whether objective tests of antiarrhythmic drug efficacy could produce favorable short- and long-term outcomes in a family with idiopathic malignant ventricular arrhythmias.

    Title Cardiac Memory After Radiofrequency Ablation of Accessory Pathways: the Post-ablation T Wave Does Not Forget the Pre-excited Qrs.
    Date December 1999
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    INTRODUCTION: Normalization of the pre-excited QRS following ablation is accompanied by repolarization changes but their directional relationship to changes in ventricular activation has not been well characterized.METHODS: Accordingly, we measured QRS and T wave vectors and QRS-T angles from 12 lead ECG recordings immediately before and after accessory pathway (AP) radiofrequency ablation in 100 consecutive patients. Patients with bundle branch block, intraventricular conduction defect or intermittent pre-excitation were excluded, leaving a study group of 45 patients: 35 with pre-excitation and 10 with concealed APs.RESULTS: With AP ablation, changes occurred in the QRS and T wave vectors and QRS-T angles that were essentially equal and opposite, so that the newly normalized QRS complex and QRS vector were accompanied by a T wave whose vector approximated that of the pre-ablation QRS vector. This tended to maintain a large QRS-T angle: 72 degrees +/- 50 degrees before, and 54 degrees +/- 34 degrees after QRS normalization (p = NS). A QRS-T angle >40 degrees was found before and after ablation in 22/35 patients (63%) with baseline pre-excitation; but never in patients with a concealed AP (p = 0.001). The angle between the pre-excited QRS and the post-ablation T wave was 35 degrees +/- 37 degrees, and </=40 degrees in 25/35 patients (71%). The change in T wave axis with QRS normalization correlated in magnitude with the QRS-T angle before ablation (r = 0.73, p < 0.0001). The change in QRS axis correlated with the QRS-T angle after ablation (r = 0.37, p < 0.03). Shorter AP effective refractory periods (ERPs) correlated with wider QRS-T angles after ablation (r = -0.39, p < 0.03). The ECG leads manifesting these changes depend on AP location. CONCLUSION: T-wave changes after ablation of APs (1) are dependent on anterograde AP conduction at baseline and are not observed with concealed APs; (2) correlate in magnitude directly with the change in QRS axis and inversely with the anterograde AP-ERP; (3) are related to AP location. With termination of pre-excitation secondary repolarization changes immediately disappear and the post ablation T wave axis approximates that of the pre-excited QRS. Recognition of this sequence may prevent unnecessary clinical interventions.

    Title Use of the 12-item Short-form (sf-12) Health Survey in an Australian Heart and Stroke Population.
    Date September 1999
    Journal Quality of Life Research : an International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation
    Excerpt

    The objective of this study was to validate the SF-12 Health Survey in heart and stroke patients using a community-based study. Between November 1995 and August 1996, 3,362 patients were invited to join the Hunter Heart and Stroke Register in New South Wales, Australia and to complete the SF-12 Health Survey. Of the 3,362 patients, 2,341 (70%) returned the SF-12. Of those 2,341 patients, 78% completed all 12 items. Those who did not complete the questionnaire were significantly more likely to be females, older, less educated, have stayed longer in hospital and been admitted on emergency. The SF-12 demonstrated construct validity in an analysis restricted to the 1,831 patients who completed the questionnaire: scores measuring physical and mental health status were statistically significantly higher in men than women, in younger than older, in those who had shorter than longer lengths of stay in hospital, in patients whose hospital admissions were planned than emergencies and in heart than stroke patients. Construct validity of the SF-12 among patients able to complete the SF-12 suggests considerable potential for its use in assessing health status in large-scale surveys. However, caution should be taken with the heart and stroke population because of a relatively high in completion rate.

    Title Understanding and Promoting Sexual and Reproductive Health Behavior: Theory and Method.
    Date June 1999
    Journal Annual Review of Sex Research
    Title Ultrarapid Train Stimulation Versus Conventional Programmed Electrical Stimulation for Induction of Ventricular Arrhythmias in Patients with Coronary Artery Disease.
    Date January 1999
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    Conventional programmed electrical stimulation (PES) of the ventricle is useful for establishing inducibility or noninducibility of clinical ventricular arrhythmias (VA) but is complex and time consuming. The present study was designed to compare a standard PES protocol with an alternative method using ultrarapid train stimulation in patients with VA and coronary artery disease (CAD). A prospective, randomized, crossover design was used. During each session in the electrophysiology laboratory, patients were studied using both the trains and PES protocols in randomized order. In 82 matched pairs of comparisons in 50 patients, results were concordant in 85% (p < 0.0001). There were no differences related to type of clinical arrhythmia or to the presence of antiarrhythmic drugs. There were no significant differences in the induction of nonclinical arrhythmias with the two methods (p < 0.0001 for concordance). There were no significant differences related to the cycle length of the trains (10, 20, or 30 ms, equivalent to 100, 50, or 33 Hz). The number of drive-extrastimuli sequences and the time required to complete the trains protocol was significantly shorter (p < 0.0001) using trains versus PES. Ultrarapid train stimulation provides results in CAD patients that are comparable with those of conventional PES protocols. There is a significant savings in time, adding practical value to intrinsic electrophysiologic interest. Trains may be useful when multiple inductions are desirable, for example, in the setting of antitachycardia pacing parameters in an implantable defibrillator (ICD), during ICD implantation, or in other circumstances where the main question is inducibility of ventricular arrhythmias.

    Title Naspe Expert Consensus Document: Use of I.v. (conscious) Sedation/analgesia by Nonanesthesia Personnel in Patients Undergoing Arrhythmia Specific Diagnostic, Therapeutic, and Surgical Procedures.
    Date June 1998
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Use of IV (Conscious) Sedation/Analgesia by Nonanesthesia Personnel in Patients Undergoing Arrhythmia Specific Diagnostic, Therapeutic, and Surgical Procedures. This article is intended to inform practitioners, payers, and other interested parties of the opinion of the North American Society of Pacing and Electrophysiology (NASPE) concerning evolving areas of clinical practice or technologies or both, that are widely available or are new to the practice community. Expert consensus documents are so designated because the evidence base and experience with the technology or clinical practice are not yet sufficiently well developed, or rigorously controlled trials are not yet available that would support a more definitive statement. This article has been endorsed by the American College of Cardiology, October 1997.

    Title Practical Implementation of a Modified Continual Reassessment Method for Dose-finding Trials.
    Date April 1998
    Journal Cancer Chemotherapy and Pharmacology
    Excerpt

    We describe a practical, reliable, efficient dose-finding design for cytotoxic drugs applied in a multi-institutional setting.

    Title Symptomatic Improvement After Av Nodal Ablation and Pacemaker Implantation for Refractory Atrial Fibrillation and Atrial Flutter.
    Date December 1997
    Journal Angiology
    Excerpt

    Symptomatic Improvement was evaluated in 64 patients with drug-refractory atrial fibrillation or atrial flutter who underwent atrioventricular (AV) nodal ablation and permanent pacemaker implantation. The arrhythmias were chronic in 40 patients and paroxysmal in 24 patients. All were refractory to multiple drugs (3.7 +/- 1.5) and had severe symptoms: palpitations (58 patients), dyspnea (n=58), dizziness (n=38), asthenia (n=37), and chest pain (n=20). All underwent AV nodal ablation and single- (n=39) or dual-chamber (n=25) pacemaker implantation. During follow-up of 20.4 +/- 17.8 months, palpitations improved in 100% of 58 patients who had palpitations before the ablation, dyspnea improved in 75% of 58 patients, chest pain in 95% of 20 patients, asthenia in 75% of 37 patients, and dizziness in 93% of 38 patients. Moderate to significant improvement in these symptoms was reported in 83% of patients and mild improvement in 5%. Before ablation, 77% of patients were in New York Heart Association functional class III or IV. After ablation, 19% of patients were in the same functional classes (P < 0.05). Thus, AV nodal ablation and pacemaker implantation in patients with drug-refractory atrial fibrillation or flutter was associated with significant improvement in presenting symptoms and functional capacity. A randomized, controlled study is needed to compare this form of therapy with other therapeutic modalities.

    Title Butyrate Inhibits Deoxycholate-induced Increase in Colonic Mucosal Dna and Protein Synthesis in Vivo.
    Date December 1997
    Journal Diseases of the Colon and Rectum
    Excerpt

    PURPOSE: Crypt surface hyperproliferation is an intermediate biomarker of colon cancer risk. In vitro studies indicate that the short-chain fatty acid and antineoplastic agent butyrate may reverse the crypt surface hyperproliferation induced by the secondary bile acid and tumor promoter, deoxycholate. We hypothesized that butyrate may reverse deoxycholate-induced crypt surface proliferation in vivo. METHODS: Thirty-one Sprague-Dawley rats (250-300 g) underwent surgical isolation of the colon and 24-hour luminal instillation of either sodium chloride, butyrate, deoxycholate, or butyrate plus deoxycholate (all solutions, 2 ml; pH 7; total sodium = 20 mM). Study variables included colon weight, mucosal DNA, mucosal protein, and proliferating cell nuclear antigen immunohistochemistry, labeling of which was determined in five crypt compartments from base to surface (12 crypts per rat). Labeling indexes were calculated as proliferating cell nuclear antigen immunohistochemistry-labeled cells divided by total counted cells in the whole colonic crypt and each of five crypt compartments. The phi(h) value (an index of premalignant risk) was calculated as the ratio of labeled cells in the two surface compartments divided by the total labeled cells. RESULTS: Deoxycholate significantly increased colon wet weight, mucosal protein, total crypt labeling indexes, crypt surface labeling indexes, and the phi(h) value and raised the mucosal DNA content. Butyrate alone slightly reduced total mucosal DNA and protein content. The combination of butyrate plus deoxycholate significantly decreased mucosal DNA and tended to reduce mucosal protein compared with deoxycholate alone. In contrast to prior in vitro findings, butyrate plus deoxycholate did not reverse the deoxycholate-induced surface hyperproliferative changes as measured by proliferating cell nuclear antigen labeling. CONCLUSIONS: Because co-treatment with butyrate plus deoxycholate inhibits deoxycholate-induced increases in total mucosal DNA and protein content, we conclude that butyrate may play a role in maintaining the proliferative balance of the colonic mucosa, in vivo. However, co-treatment with butyrate plus deoxycholate does not reverse the deoxycholate-induced increases in colon weight and proliferating cell nuclear antigen labeling indexes under the studied experimental conditions.

    Title Radiofrequency Catheter Ablation for Av Nodal Reentrant Tachycardia Associated with Persistent Left Superior Vena Cava.
    Date November 1997
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Slow AV nodal pathway ablation using RF is highly effective for patients with refractory AV nodal reentrant tachycardia (AVNRT). We report three catheter ablation cases using RF current in patients associated with persistent left superior vena cava (PLSVC). Three patients with drug refractory AVNRT of common variety were involved in this study. An electrode catheter introduced through the left subclavian vein inserted directly into the coronary sinus, a typical anatomical finding of PLSVC. The ablation procedure was initially performed at the posteroinferior region of Koch's triangle. A slow pathway potential could not be found from that area; nonsustained junctional tachycardia (NSJT) did not occur during the delivery of RF current; there was failure to eliminate slow AV nodal pathway conduction. The catheter then was moved into the bed of the proximal portion of the markedly enlarged coronary sinus. A slow AV nodal pathway potential was recorded through the ablation catheter, and the delivery of RF current caused NSJT in two patients. Complete elimination of slow AV nodal pathway conduction was accomplished in these two patients by this method. No adverse effects were provoked by this procedure. Catheter ablation of the slow AV nodal pathway guided by a slow pathway potential and the appearance of NSJT was feasible and safe in the area of the coronary sinus ostium in patients associated with PLSVC.

    Title Interpersonal Perception of the Aids Risk Potential of Persons of the Opposite Sex.
    Date October 1997
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    Individuals engage in high rates of AIDS risk behavior, despite awareness that infection is preventable, and use biased decision rules for determining the AIDS risk potential of their own and others' behavior. In this laboratory study, 32 male and 32 female university students made judgments of the AIDS risk potential of persons of the opposite sex following exposure to explicit information regarding AIDS-related attitudes and behavior in a discussion group. A social relations analysis showed that judgments of AIDS risk potential were determined by perceiver-based assimilation that was stronger than target-based consensus for both men and women. Further, perceptions of others were related to self-perception. However, the consensus that was observed showed moderate accuracy. Implications for AIDS prevention are discussed.

    Title Efficacy and Safety of Sotalol in Patients with Refractory Atrial Fibrillation or Flutter.
    Date October 1997
    Journal American Heart Journal
    Excerpt

    Sotalol's usefulness in treatment of atrial fibrillation and atrial flutter is unproven. This study evaluated (1) the efficacy of sotalol in preventing recurrences of paroxysmal atrial fibrillation or atrial flutter and controlling ventricular rate (in chronic atrial fibrillation or relapse of paroxysmal atrial arrhythmias), (2) the safety of sotalol, and (3) predictors of sotalol efficacy. Thirty-three patients, 28 with paroxysmal and five with chronic atrial fibrillation or atrial flutter, received an average dose of 265 +/- 119 mg of oral sotalol per day. During a 10 +/- 12 month follow-up, recurrence rate for paroxysmal arrhythmia was 64%, with a 50% recurrence at 4.6 months. For patients with chronic atrial fibrillation, ventricular rates were well controlled with sotalol administration (136 +/- 33 beats/min versus 88 +/- 23 beats/min; p = 0.04). No patient with chronic atrial fibrillation converted to sinus rhythm during the study. Side effects necessitated sotalol discontinuation in three patients. By multivariate analysis, younger age, higher ejection fraction, and absence of hypertension independently predicted sotalol efficacy.

    Title Can Ecg Changes Predict the Long-term Outcome in Patients Admitted to Hospital for Suspected Acute Myocardial Infarction?
    Date October 1997
    Journal Cardiology
    Excerpt

    7,028 patients with suspected acute myocardial infarction and discharged alive from hospital were followed in a 10-year community-based study. The long-term prognosis was relatively good if the electrocardiograms (ECGs) were normal (5-year all-cause death rate 5%), poor with uncodable ECGs showing rhythm or conduction disturbances (37%), and intermediate with new Q wave, new ST elevation, new T wave inversion or ischemic ECG (17-21%), and with new ST depression (27%). Similar patterns were found for ischemic cardiac death and reinfarction. The long-term prognosis of patients with suspected acute myocardial infarction is relatively good if the ECGs are normal and poor if ECGs are uncodable. ST depression may be a marker for a worse long-term outcome.

    Title Preirradiation Paclitaxel in Glioblastoma Multiforme: Efficacy, Pharmacology, and Drug Interactions. New Approaches to Brain Tumor Therapy Central Nervous System Consortium.
    Date October 1997
    Journal Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology
    Excerpt

    The purpose of this study was to determine the response rate of paclitaxel administered at maximal tolerated doses (MTD) in patients with newly diagnosed glioblastoma multiform.

    Title Symptomatic Blunt Head Injury in Children--a Prospective, Single-investigator Study.
    Date September 1997
    Journal Clinical Pediatrics
    Excerpt

    The goal of this study was to describe a single emergency physician's experience with symptomatic blunt head injury in children and prospectively assess the sensitivity and predictive value of the neurologic examination. The author utilized a prospective patient series comparing neurologic examination with computed tomography (CT) of the head. Nine of 42 patients had intracranial injury for a prevalence of 21%; two patients (5%) had intracranial injury with only subtle neurologic examination findings. Twenty-six patients had a negative neurologic examination, and all had normal-appearing CT scans. Sixteen patients had a positive neurologic examination, of whom nine had a positive CT scan. The properties of the neurologic examination as a diagnostic test, with CT as the gold standard, were as follows: sensitivity = 100%, specificity = 78%, positive predictive value = 56%, negative predictive value = 100%. Normal findings from neurologic examination can be used in some children with symptomatic blunt head injury to delay or eliminate the need for CT of the head.

    Title Comparison of Long-term Outcomes of Patients Treated with Nonthoracotomy and Thoracotomy Implantable Defibrillators.
    Date January 1997
    Journal The American Journal of Cardiology
    Excerpt

    In 193 consecutive patients treated with implantable defibrillators at our institution, thoracotomy approaches were used in 87 patients and nonthoracotomy approaches in 106 patients. Long-term outcomes of the 2 groups were compared by the intention-to-treat analysis. Surgical mortality (30-day mortality) rates were 5.7% in the thoracotomy group and 0% in the nonthoracotomy group. Six of 106 patients who underwent nonthoracotomy implantation had a high defibrillation threshold and did not receive nonthoracotomy defibrillators. The duration of follow-up was 52 +/- 31 months in the thoracotomy group, and 23 +/- 15 months in nonthoracotomy group. Actuarial survival rates at 6 and 24 months were, respectively, 90% and 81% in nonthoracotomy patients and 89% and 80% in thoracotomy patients (p = NS). In patients with left ventricular ejection fraction <30%, surgical mortality was 0% by the nonthoracotomy and 10% by the thoracotomy approach. Despite the 10% difference in 30-day mortality, survival rates at 6 months were 85% in nonthoracotomy patients and 81% in thoracotomy patients. At 24 months they were 73% in nonthoracotomy patients and 74% in thoracotomy patients. Thus, this nonrandomized study suggests that while short-term survival is better in nonthoracotomy patients than thoracotomy patients, the difference in survival diminishes quickly during the first few months and disappears by 6 months. The results were similar in patients with severe ventricular dysfunction. Several important implantable-cardioverter defibrillator (ICD) trials initially utilized thoracotomy ICDs. Although questions may be raised with regard to applicability of such a trial in the era of nonthoracotomy ICDs, this study suggests that the results of such ICD trials will be largely applicable to patients treated with nonthoracotomy ICDs.

    Title Comparison of Burst Pacing, Autodecremental (ramp) Pacing, and Universal Pacing for Termination of Ventricular Tachycardia.
    Date October 1996
    Journal Archives Des Maladies Du Coeur Et Des Vaisseaux
    Excerpt

    This study was designed to test the comparative efficacy of burst pacing, autodecremental (ramp) pacing, and universal (steep ramp) pacing for termination of ventricular tachycardia. A prospective, randomized sequence cross-over design was used to achieve comparisons of the pacing modalities that were matched for patient, day, and ventricular tachycardia characteristics. Thirty eight patients were enrolled, whose ventricular tachycardia was well-enough tolerated to be reinduced, and tested with 3 pacing modalities. There were 27 series 1 patients in which the pacing modalities were nonsynchronized burst pacing, synchronized burst pacing, and ramp pacing. The 11 patients in series 2 were tested with synchronized burst pacing, ramp pacing, and universal pacing. All pacing methods proved to be comparable in their ability to terminate ventricular tachycardia (p = NS). The 2 burst methods required the fewest number of attempts (significant vs ramp pacing). Universal pacing required the fewest number of stimuli. The mean paced cycle length was similar will all methods. The shortest paced cycle lengths were found with the autodecremental and universal methods because of their ramp patterns. It is concluded that burst, ramp, and universal pacing are of similar efficacy, although ramps were least efficient. Choice of a modality depends on operator preference, and individual patient response.

    Title Changing Aids Risk Behavior: Effects of an Intervention Emphasizing Aids Risk Reduction Information, Motivation, and Behavioral Skills in a College Student Population.
    Date August 1996
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    This research used the Information-Motivation-Behavioral Skills (IMB) model of AIDS risk behavior change (J. D. Fisher & Fisher, 1992a) to reduce AIDS risk behavior in a college student population. College students received an IMB model-based intervention that addressed AIDS risk reduction information, motivation, and behavioral skills deficits that had been empirically identified in this population, or were assigned to a no-treatment control condition. At a 1-month follow-up, results confirmed that the intervention resulted in increases in AIDS risk reduction information, motivation, and behavioral skills, as well as significant increases in condom accessibility, safer sex negotiations, and condom use during sexual intercourse. At a long-term follow-up, the intervention again resulted in significant increases in AIDS preventive behaviors.

    Title Nonsustained Ventricular Tachycardia in Coronary Artery Disease: Relation to Inducible Sustained Ventricular Tachycardia. Mustt Investigators.
    Date July 1996
    Journal Annals of Internal Medicine
    Excerpt

    BACKGROUND: Many physicians believe that electrocardiographic characteristics of nonsustained ventricular tachycardia correlate with the risk for sudden death in survivors of myocardial infarction. Sustained ventricular tachycardia induced by programmed electrical stimulation has also been shown to predict sudden death. OBJECTIVE: To determine whether electrocardiographic characteristics of spontaneous nonsustained ventricular tachycardia can predict the inducibility of sustained ventricular tachycardia by programmed electrical stimulation in patients with coronary artery disease having abnormal ventricular function. DESIGN: Observational cohort study. SETTING: 70 clinical electrophysiology laboratories in the United States and Canada. PATIENTS: 1480 consecutive patients with coronary artery disease, left ventricular ejection fraction of 0.40 or less, and asymptomatic nonsustained ventricular tachycardia. INTERVENTION: Electrophysiologic study attempting to induce sustained monomorphic ventricular tachycardia. MEASUREMENTS: Daily frequency, duration, and cycle length of spontaneous episodes of nonsustained ventricular tachycardia, measured by standard electrocardiographic recordings. RESULTS: No statistically significant difference in the frequency or duration of spontaneous nonsustained ventricular tachycardia was seen between patients with and those without inducible sustained ventricular tachycardia. Rates of spontaneous tachycardia were slightly slower in patients with inducible ventricular tachycardia than in patients without inducible ventricular tachycardia (P = 0.047), but the difference was not clinically significant. CONCLUSION: Electrocardiographic characteristics of spontaneous nonsustained ventricular tachycardia do not predict which patients with coronary artery disease will have inducible sustained ventricular tachycardia.

    Title Prehospital Management of Pediatric Asthma Requiring Hospitalization.
    Date January 1996
    Journal Pediatric Emergency Care
    Excerpt

    Our objective was to evaluate the quality of prehospital assessment and management in pediatric asthma requiring hospitalization via a retrospective chart review. Charts were obtained from a pediatric emergency department (ED) with 24,000 annual visits. Included in the study were 27 patients less than 18 years of age with asthma requiring hospitalization, transported to the Boston City Hospital Pediatric ED by Boston Emergency Medicine Services (EMS). We found that 12 patients admitted to the pediatric intensive care unit over an 18-month period, and 15 patients admitted to the ward over a six-month period, received prehospital care from Boston EMS. Only 63% of cases (17/27) had a physical examination marker of asthma severity noted on the EMS record. Twenty-six percent of cases (7/27) did not receive O2 in the field. Thirty percent of cases (8/27) were hypoxic at ED presentation. None of the hypoxic patients had received albuterol in the field, and one did not receive O2. We conclude that further study of the prehospital assessment and management of pediatric asthma is warranted.

    Title Success of Cardiopulmonary Resuscitation After Heart Attack in Hospital and Outside Hospital.
    Date January 1996
    Journal Bmj (clinical Research Ed.)
    Excerpt

    To determine factors associated with cardiopulmonary resuscitation being attempted after cardiac arrest from myocardial infarction, in or outside hospital, and estimate short term and long term survival rates.

    Title Evaluation of End Points of Serial Drug Testing in Patients with Sustained Ventricular Tachycardia After Healing of Acute Myocardial Infarction.
    Date January 1996
    Journal The American Journal of Cardiology
    Excerpt

    Serial electrophysiologic drug testing was used to guide antiarrhythmic therapy in a consecutive series of 150 patients with clinical sustained ventricular tachycardia (VT) or cardiac arrest and inducible monomorphic VT. All patients had coronary artery disease and a history of myocardial infarction. For patients with clinical sustained VT, drug responders and partial drug responders (VT slowed by drug to rate < 150 beats/min, with systolic blood pressure > or = 90 mm Hg) had similar total mortality rates (2-year actuarial survival 100% and 94%, p = NS), which were statistically different from that of patients with drug inefficacy (2-year survival 67%). Partial drug responders had high arrhythmia recurrence rates, similar to those of patients with drug inefficacy. For cardiac arrest survivors, the results of electrophysiologically guided drug testing did not predict prognosis. Patients with a change in mode of VT induction during antiarrhythmic therapy had a favorable prognosis (no deaths during follow-up).

    Title Reproducibility of Electrophysiological Testing During Antiarrhythmic Therapy for Ventricular Arrhythmias Unrelated to Coronary Artery Disease.
    Date November 1995
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Although electrophysiological studies are commonly used in the management of patients with ventricular tachycardia (VT), the reproducibility of these studies during therapy has not been established in patients in whom VT is associated with conditions other than coronary artery disease. Therefore, we performed confirmation studies during drug therapy in 60 patients (mean age 48 +/- 18 years; 41 male) with sustained ventricular arrhythmias induced during initial study to assess the reproducibility of drug effect. The stimulation protocol used included the serial introduction of up to three premature ventricular stimuli during sinus rhythm and with ventricular pacing at two pacing rates. Rapid ventricular pacing techniques were also used. Antiarrhythmic drug efficacy was confirmed in 78% of patients. Sustained VT was induced at repeat electrophysiological study in 18% of patients during antiarrhythmic therapy that had been felt to be effective on the basis of a single drug study. We conclude that electrophysiological study results during antiarrhythmic therapy exhibit significant day-to-day variability. Sustained VT can be induced during antiarrhythmic therapy previously determined to be effective by electrophysiological techniques in many patients.

    Title Clinical Investigation of Antiarrhythmic Devices. A Statement for Healthcare Professionals from a Joint Task Force of the North American Society of Pacing and Electrophysiology, the American College of Cardiology, the American Heart Association, and the Working Groups on Arrhythmias and Cardiac Pacing of the European Society of Cardiology.
    Date October 1995
    Journal European Heart Journal
    Title Understanding and Promoting Aids-preventive Behavior: Insights from the Theory of Reasoned Action.
    Date September 1995
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    Psychological determinants of AIDS-preventive behaviors were examined from the perspective of the theory of reasoned action in prospective studies of gay men, heterosexual university students, and heterosexual high school students. Across samples, preventive behaviors, and prospective intervals of 1 and 2 months' duration. AIDS-preventive behaviors were predicted by behavioral intentions; behavioral intentions were a function of attitudes and norms; and attitudes and norms were a function of their theorized basic underpinnings. Discussion focuses on the development of AIDS-prevention interventions that modify intentions, attitudes, and norms concerning performance of AIDS-preventive behaviors by targeting the empirically identified underpinnings of attitudes and norms related to specific preventive behaviors in specific populations of interest.

    Title Naspe/acc/aha/esc Medical/scientific Statement Special Report--clinical Investigation of Antiarrhythmic Devices: a Statement for Healthcare Professionals from a Joint Task Force of the North American Society of Pacing and Electrophysiology, the American College of Cardiology, the American Heart Association, and the Working Groups on Arrhythmias and Cardiac Pacing of the European Society of Cardiology.
    Date July 1995
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    The goal of radiofrequency catheter ablation and the criterion for efficacy is the elimination of arrhythmogenic myocardium. The application of radiofrequency current in the heart clearly results in lower morbidity and mortality rates than thoracic and cardiac surgical procedures in general, and comparisons of therapy with radiofrequency catheter ablation and therapy with thoracic and cardiac surgical procedures in randomized clinical trials are unwarranted. Trials of radiofrequency catheter ablation versus medical or implantable cardioverter defibrillator therapy may be indicated in certain conditions, such as ventricular tachycardia associated with coronary artery disease. Randomized trials are recommended for new and radical departures in technology that aim to accomplish the same goals as radiofrequency catheter ablation. Surveillance using registries and/or databases is necessary in the assessment of long-term safety and efficacy.

    Title Long-term Outcomes and Modes of Death of Patients Treated with Nonthoracotomy Implantable Defibrillators.
    Date July 1995
    Journal The American Journal of Cardiology
    Excerpt

    Long-term outcomes of all patients who underwent nonthoracotomy implantable cardioverter-defibrillator (ICD) implantation at our institution from April 1991 to October 1994 were studied using the intention-to-treat analysis. Of 94 consecutive patients, 81 underwent nonthoracotomy ICD implantation and 13 underwent thoracotomy (for concomitant surgery in 11 and unavailability of nonthoracotomy leads in 2). Six of 81 patients had a high defibrillation threshold, 4 subsequently underwent thoracotomy, and 2 were treated with amiodarone. Surgical mortality was 0%. The duration of follow-up was 20 +/- 13 months, and was > 12 months in 74% of 67 living patients. Actuarial survival rates at 1 and 2 years were, respectively, 98% and 94% for sudden death and 91% and 83% for total mortality. Deaths during long-term follow-up were mostly due to nonsudden cardiac or noncardiac deaths. Two-year mortality rates were 12% and 25% in patients with ejection fraction > or = 30% and < 30%, respectively. Thus, instances of sudden death and surgical mortality are very few in patients with nonthoracotomy ICDs. Deaths during long-term follow-up are mostly due to nonsudden cardiac and noncardiac deaths. Therefore, ICD therapy may have greater impact on survival in patients with lower risks of nonsudden cardiac and cardiac death (e.g., younger patients with minimal heart disease) than in patients with severe cardiac or noncardiac disease. Prospective studies are needed to address this question.

    Title Clinical Investigation of Antiarrhythmic Devices. A Statement for Healthcare Professionals from a Joint Task Force of the American Heart Association, the North American Society of Pacing and Electrophysiology, the American College of Cardiology, and the Working Groups on Arrhythmias and Cardiac Pacing of the European Society of Cardiology.
    Date April 1995
    Journal Circulation
    Title Clinical Investigation of Antiarrhythmic Devices. A Statement for Healthcare Professionals from a Joint Task Force of the North American Society of Pacing and Electrophysiology, the American College of Cardiology, the American Heart Association, and the Working Groups on Arrhythmias and Cardiac Pacing of the European Society of Cardiology.
    Date April 1995
    Journal Journal of the American College of Cardiology
    Excerpt

    The goal of radiofrequency catheter ablation and the criterion for efficacy is the elimination of arrhythmogenic myocardium. The application of radiofrequency current in the heart clearly results in lower morbidity and mortality rates than thoracic and cardiac surgical procedures in general, and comparisons of therapy with radiofrequency catheter ablation and therapy with thoracic and cardiac surgical procedures in randomized clinical trials is unwarranted. Trials of radiofrequency catheter ablation versus medical or implantable cardioverter-defibrillator therapy may be indicated in certain conditions, such as ventricular tachycardia associated with coronary artery disease. Randomized trials are recommended for new and radical departures in technology that aim to accomplish the same goals as radiofrequency catheter ablation. Surveillance using registries and/or databases is necessary in the assessment of long-term safety and efficacy.

    Title Prediction of Electrophysiologic Study Results in Patients Treated with Amiodarone.
    Date March 1995
    Journal American Heart Journal
    Excerpt

    To identify whether electrophysiologic study results during early-phase amiodarone therapy can be predicted by previous electrophysiologic study, we reviewed the electrophysiologic data of 50 patients with inducible sustained ventricular arrhythmias who underwent 4.3 +/- 1.3 drug trials before being given amiodarone. Study results during testing with agents of the modified Vaughan Williams Ia classification were compared with data obtained after 2 weeks of amiodarone therapy. Partial response by electrophysiologic study was defined as well-tolerated ventricular tachycardia < 150 beats/min associated with a blood pressure > or = 90 mm Hg. Significant slowing in the rate of induced ventricular tachycardia was seen during therapy with both Ia agents and amiodarone, although there was a trend toward greater slowing during amiodarone treatment (180 +/- 45 beats/min vs 164 +/- 65 beats/min; p = 0.09). Two of three patients with noninducible ventricular tachycardia during amiodarone showed profound ventricular tachycardia slowing during Ia therapy. Thirty-eight of 50 patients demonstrated concordance of electrophysiologic study results with regard to achieving partial response criteria. Twenty patients died during a mean follow-up period of 37 +/- 29 months; 7 of the 10 sudden deaths occurred in patients who did not meet partial response criteria. We conclude that patients with inducible sustained ventricular arrhythmias failing serial drug testing with Ia agents only rarely have their ventricular tachycardia suppressed during amiodarone therapy. Partial response criteria are often concordant between testing on agents of the Ia classification and amiodarone, and there was no significant difference in survival in patients based on their partial response status.

    Title Serial Electrophysiologic-pharmacologic Studies for the Control of Ventricular Arrhythmias.
    Date January 1995
    Journal Coronary Artery Disease
    Title Comparison and Frequency of Ventricular Arrhythmias After Defibrillator Implantation by Thoracotomy Versus Nonthoracotomy Approaches.
    Date December 1994
    Journal The American Journal of Cardiology
    Excerpt

    Postoperative exacerbation of ventricular arrhythmias has been reported in some patients treated with thoracotomy implantable cardioverter-defibrillators (ICDs). This phenomenon, which may be related to epicardial patch electrodes, may be less frequent after nonthoracotomy ICD implantation. In this nonrandomized study, postoperative arrhythmias in thoracotomy approaches (n = 52) were compared with those in nonthoracotomy approaches (n = 59). Preoperatively, all patients were clinically stable receiving an antiarrhythmic regimen chosen by serial drug testing. Nine of 52 patients in the thoracotomy group developed sustained ventricular tachycardia postoperatively while receiving the same antiarrhythmic regimen chosen preoperatively, and 1 patient eventually died. Two additional patients developed frequent and prolonged episodes of nonsustained ventricular tachycardia requiring changes in the antiarrhythmic regimen. In the nonthoracotomy group, only 3 of 59 patients developed sustained ventricular tachycardia and 1 developed frequent nonsustained ventricular tachycardia. Thus, only 4 of 59 patients in the nonthoracotomy group developed clinically significant ventricular arrhythmia during the postoperative period compared with 11 of 52 patients in the thoracotomy group (p < 0.05). Surgical mortality was 6% in the thoracotomy group, and 0% in the nonthoracotomy group. In the remaining clinically stable patients, a marked (sevenfold) increase in asymptomatic ventricular arrhythmias was noted in 15 of 39 patients in the thoracotomy group, and in 3 of 55 patients in the nonthoracotomy group (p < 0.05). Thus, postoperative exacerbation of ventricular arrhythmia, sometimes noted with thoracotomy approaches, is very rare with nonthoracotomy approaches.

    Title Mutually Independent Atrial, Junctional, and Ventricular Rhythms Following Radiofrequency Ablation in a Patient with Postoperative Junctional Ectopic Tachycardia.
    Date November 1994
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Overwhelming Escherichia Coli Sepsis in Ureterovesical Junction Obstruction Without Reflux.
    Date October 1994
    Journal Archives of Pediatrics & Adolescent Medicine
    Title Empirical Tests of an Information-motivation-behavioral Skills Model of Aids-preventive Behavior with Gay Men and Heterosexual University Students.
    Date September 1994
    Journal Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association
    Excerpt

    This article contains empirical tests of the information-motivation-behavioral skills (IMB) model of AIDS-preventive behavior (J.D. Fisher & Fisher, 1992; W.A. Fisher & Fisher, 1993a), which has been designed to understand and predict the practice of AIDS-preventive acts. The IMB model holds that AIDS-preventive behavior is a function of individuals' information about AIDS prevention, motivation to engage in AIDS prevention, and behavioral skills for performing the specific acts involved in prevention. The model further assumes that AIDS-prevention information and motivation generally work through AIDS-prevention behavioral skills to influence the initiation and maintenance of AIDS-preventive behavior. Supportive tests of the model, using structural equation modeling techniques, are reported with populations of gay male affinity group members (n = 91) and heterosexual university students (n = 174).

    Title Comparison of Defibrillator Therapy and Other Therapeutic Modalities for Sustained Ventricular Tachycardia or Ventricular Fibrillation Associated with Coronary Artery Disease.
    Date June 1994
    Journal The American Journal of Cardiology
    Excerpt

    Outcomes of 282 patients referred to the arrhythmia service at Montefiore Medical Center for sustained ventricular tachycardia (n = 214) or ventricular fibrillation (n = 68) associated with coronary artery disease were analyzed retrospectively. All patients underwent serial drug trials by electrophysiologic testing and Holter monitoring. Sixty-eight patients who did not respond to drug therapy were treated with implantable cardioverter-defibrillators (ICD group), and 214 patients were treated with other methods guided by electrophysiologic testing and Holter monitoring (non-ICD group). The non-ICD group included 49 patients who responded to drug therapy as judged by electrophysiologic testing, as well as patients who did not respond and were not treated with defibrillator therapy for various reasons. Ten patients died in the hospital (2 patients in the ICD group, 8 in the non-ICD group). Actuarial survival rates free of total cardiac death at 1, 2, and 3 years were, respectively, 94%, 87%, and 85% in the ICD group, and 82%, 78%, and 73% in the non-ICD group (p = NS). Survival rates free of total death at 1, 2, and 3 years were 90%, 82%, and 76% in the ICD group, and 82%, 76%, and 70% in the non-ICD group, respectively (p = NS). Survival rates free of total cardiac and total deaths of 49 patients treated with an effective regimen determined by electrophysiologic testing were not significantly different from those of the ICD group. This retrospective study suggests that outcomes of patients treated with ICDs may not be dramatically different from those of patients treated with other methods guided primarily by electrophysiologic testing.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Programmed Ventricular Stimulation Using Tandem Versus Simple Sequential Protocols.
    Date June 1994
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    The objective was to determine whether two commonly used ventricular stimulation protocols, one more complex than the other, produced concordant results. If such were the case, the simpler protocol would streamline activities in clinical electrophysiology laboratories.

    Title Icd Implantation Via Thoracoscopy, "mailslot" Thoracotomy, and Subxiphoid Incision.
    Date March 1994
    Journal The Annals of Thoracic Surgery
    Excerpt

    An improved method of thoracoscopic implantable cardioverter defibrillators implantation is described. "Mailslot" thoracotomy is more expeditious than thoracoscopic implantation via multiple ports. If required for adequate defibrillation thresholds, subxiphoid, subdiaphragmatic implantation of a defibrillator patch may be performed.

    Title Combined Treatment of Mitral Stenosis and Atrial Fibrillation with Valvuloplasty and a Left Atrial Maze Procedure.
    Date March 1994
    Journal The Journal of Thoracic and Cardiovascular Surgery
    Title Hypothetical Death Rates of Patients with Implantable Defibrillators Remain Very Hypothetical.
    Date January 1994
    Journal The American Journal of Cardiology
    Title Influence of Left Ventricular Function on Survival and Mode of Death After Implantable Defibrillator Therapy (cleveland Clinic Foundation and Montefiore Medical Center Experience).
    Date January 1994
    Journal The American Journal of Cardiology
    Excerpt

    To determine the influence of left ventricular (LV) function on survival and mode of death in patients with an implantable cardioverter-defibrillator (ICD), sudden death, surgical mortality, total arrhythmia-related death, total cardiac death and total death were retrospectively evaluated in 377 consecutive patients. The outcomes were also compared between patients with an LV ejection fraction > or = 30% (214 patients, group 1) and < 30% (148 patients, group 2). Surgical mortality was 3.9% (1.8% in group 1, 7% in group 2). During the follow-up of 25 +/- 20 months, actuarial survival rates of all patients at 3 years were 96% for sudden deaths, 81% for total cardiac deaths and 74% for total mortality. When the 2 groups were compared, survival rates of groups 1 and 2 at 3 years, respectively, were 99 and 90% for sudden death (p < 0.05), 97 and 84% for sudden death and surgical mortality (p < 0.01), 94 and 80% for the total arrhythmia-related death (p < 0.001), 88 and 68% for total cardiac death (p < 0.0001), and 81 and 62% for total mortality (p < 0.002). In group 2, 73% of total cardiac deaths within 1 year were causally related to the arrhythmia. Thus, in patients with an ICD, sudden death rates were very low. However, total cardiac death and total death rates were relatively higher. The outcomes of patients with an ICD were strongly influenced by the degree of LV dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Prevention of Sudden Death in Patients with Coronary Artery Disease: the Multicenter Unsustained Tachycardia Trial (mustt).
    Date December 1993
    Journal Progress in Cardiovascular Diseases
    Excerpt

    This trial will significantly advance our understanding of the prognostic and therapeutic usefulness of electrophysiologic studies in patients with coronary artery disease. Several features of this trial are worth emphasizing. First, the protocol for performing programmed stimulation and serial drug testing is designed to mirror those currently in use by many practicing electrophysiologists. While practice patterns vary, the procedures used in the trial reflect what is considered "usual and standard" practice. Second, because half of the patients with inducible sustained ventricular tachycardia will be given no antiarrhythmic therapy, we will be able to ascertain the true risk of sudden death in this patient population without the influence of these agents. Third, this trial will assess the usefulness of a method of guiding antiarrhythmic therapy (electrophysiologic testing) to reduce mortality in this high-risk population. It will not evaluate the efficacy of a specific type of antiarrhythmic therapy.

    Title North American Society of Pacing and Electrophysiology Policy Statement. The Naspe/bpeg Defibrillator Code.
    Date November 1993
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    A new generic code, patterned after and compatible with the NASPE/BPEG Generic Pacemaker Code (NBG Code) was adopted by the NASPE Board of Trustees on January 23, 1993. It was developed by the NASPE Mode Code Committee, including members of the North American Society of Pacing and Electrophysiology (NASPE) and the British Pacing and Electrophysiology Group (BPEG). It is abbreviated as the NBD (for NASPE/BPEG Defibrillator) Code. It is intended for describing the capabilities and operation of implanted cardioverter defibrillators (ICDs) in conversation, record keeping, and device labeling, and incorporates four positions designating: (1) shock location; (2) antitachycardia pacing location; (3) means of tachycardia detection; and (4) antibradycardia pacing location. An additional Short Form, intended only for use in conversation, was defined as a concise means of distinguishing devices capable of shock alone, shock plus antibradycardia pacing, and shock plus antitachycardia and antibradycardia pacing.

    Title Is Implantable Defibrillator Therapy the Therapy of Choice for All Patients with Malignant Ventricular Tachyarrhythmias?
    Date September 1993
    Journal Circulation
    Title Initial Experience with Transvenous Implantable Cardioverter Defibrillator Lead Systems: Operative Morbidity and Mortality.
    Date April 1993
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Introduction of non-thoracotomy lead systems (Medtronic, Inc.) for the implantable cardioverter defibrillator (ICD) has expanded the indications for use of this mode of therapy. Patients previously considered "too ill" to undergo a thoracotomy as well as patients who are at a high risk for developing sudden death but without previous cardiac arrest, are now considered candidates. The initial experience with the non-thoracotomy lead system at our institution was analyzed for morbidity and mortality. Thirty-four patients underwent attempted intravascular lead implantation, with 30 having initial successful implantation (88.2%). There were 23 males; average ejection fraction (EF) was 38.6%. Three patients developed pulmonary edema and low output immediately after the procedure. Three patients developed electromechanical dissociation during defibrillation threshold testing. A prolonged testing time for the non-thoracotomy lead system was noted when compared to the thoracotomy system (57.39 vs 32.30 min; P < 0.0000). There were more intraoperative morbidities with the non-thoracotomy leads than with the thoracotomy system. There were no perioperative deaths. The potential consequences of prolonged anesthesia time and extensive defibrillation threshold testing should be considered when choosing the route of ICD implant, the type of anesthesia, and the intraoperative testing protocol for each patient.

    Title Long-term Stability of Defibrillation Thresholds with Intrapericardial Defibrillator Patches.
    Date April 1993
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    From March 1982 to May 1, 1992, 105 consecutive patients underwent initial implant of cardioverter defibrillators (ICD) at our institution. Twenty-nine patients (23 male and 6 female, average ejection fraction 32.24%) with ICD systems implanted via thoracotomy and either intra- or extrapericardial patches, had one or more revisions including 56 generator changes or staged implant procedures, three patch revisions, one patch lead fracture without revision, and one sensing lead revision. The time between pulse generator revisions averaged 19.5 months. Initial defibrillation threshold mean was 12.8 joules (n = 25); at first revision, 14.46 joules (n = 29), (P = NS); by fifth revision, 15.0 joules (n = 2), (P = NS). One patch was noted to be crinkled at 70 months; one patch had migrated by 39 months, and two patch leads had fractured at the costal margin by 69 and 90 months. One patient with marginal defibrillation thresholds had an additional patch placed at revision to an upgraded ICD unit. Once acceptable defibrillation threshold (DFT) is obtained, the long-term intrapericardial DFT remains stable unless a specific problem occurs. As a small, nonstatistically significant increase in DFT may occur, caution must be exercised in patients with marginal DFTs.

    Title Direct Current and Radiofrequency Catheter Ablation: So Far and Yet So Near.
    Date March 1993
    Journal Journal of the American College of Cardiology
    Title Electrophysiological Effect of the Maze Procedure on Canine Sinoatrial Node Function.
    Date December 1992
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    The maze procedure is an operation that has had great initial success in curing atrial fibrillation. This procedure includes several right atrial incisions that may interrupt the integrity of the sinoatrial node or its arterial supply. To assess the effect of the maze procedure on sinus node function (SNF), the following studies were performed: sinus node recovery times (SNRT), corrected SNRT (CSNRT), CSNRT under autonomic blockade maximal heart rate and intrinsic heart rates. Thirty-four dogs underwent a right thoracotomy with cardiopulmonary bypass (CPB). The dogs were divided into three groups. Group 1 (n = 9), the sham group, underwent CPB without any incisions. Group 2 (n = 8) underwent CPB and one of the right atrial incisions. Group 3 (n = 18) underwent CPB and all three of the right atrial incisions. SNF was determined before and after the procedure. Groups 1 and 2 had no significant difference in measured SNF acutely after the procedure. In Group 3 the mean SNRT increased from 552 msec to 1,984 msec (P = 0.005). Sinus node dysfunction was corroborated by all studies. In the chronic studies, a trend toward recovery of SNF was observed. The maze procedure results in significant acute sinus node dysfunction. This dysfunction may resolve spontaneously over the ensuing months. Modifications of the maze procedure that avoid the sinus node or its blood supply area may reduce procedure related sinus node dysfunction.

    Title Programmed Electrical Stimulation Protocols: Variations on a Theme.
    Date December 1992
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    A series of prospective protocols were designed to determine the yield ratio (true positives vs. false positives = nonclinical) in various patient groups using a variety of programmed electrical stimulation (PES) variables. First, a PES protocol was used in 772 patients. Single, double, and triple extrastimuli were delivered in sequence (leaving each successive extrastimulus just beyond its refractory period before moving to the next extrastimulus) during sinus rhythm and two ventricular paced rates at the RV apex, before moving to the outflow tract and repeating the sequence and then moving on to isoproterenol infusion with the PES sequence repeated at the apex. This protocol met NASPE standards for induction of VT in patients with coronary artery disease and a history of VT, while failing to induce monomorphic VT in any control patient. The best yield ratios combined with the greatest likelihood of inducing clinical tachycardia were achieved with sinus rhythm and three extrastimuli, and pacing at the lower rate and three extrastimuli. Pacing at the faster rate and triple extrastimuli was highly inductive of clinical arrhythmias, but had a low yield ratio due to induction of more nonclinical arrhythmias than other steps. The next protocol was performed in 61 patients with inducible ventricular tachycardia. In each case, the protocol described above was completed at the RV apex, even if tachycardia was also induced at an earlier point in the protocol. This allowed for more accurate yield ratios to be established for each step in the protocol, since each patient was exposed to each of these steps.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Comparison of Left Ventricular Cryolesions Created by Liquid Nitrogen and Nitrous Oxide.
    Date December 1992
    Journal Journal of the American College of Cardiology
    Excerpt

    This study was designed to compare the cryosurgical lesions produced by liquid nitrogen (-196 degrees C) and nitrous oxide (-76 degrees C).

    Title Stimulation Hierarchy: Optimal Sequence for Double and Triple Extrastimuli During Electrophysiological Studies.
    Date October 1992
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    To determine the optimal ventricular stimulation sequence, an 11-step programmed electrical stimulation (PES) protocol was completed, even if a ventricular arrhythmia (VA) was induced with earlier steps. The protocol consisted of one, two, and three extrastimuli during sinus rhythm (SR), and at two drive pacing rates (VP1 and VP2) plus rapid burst and ramp pacing. By analyzing the 79 completed protocols that induced the clinical arrhythmia, the following were determined: (1) the frequency of induced clinical and nonclinical VA with each stimulation step; (2) the yield ratio (YR) of each step, defined as the probability of inducing clinical versus nonclinical arrhythmia; (3) the cumulative yield of induced clinical and nonclinical arrhythmia with two widely used stimulation sequences, i.e., triple extrastimuli delivered early in the stimulation protocol (MMC sequence) and triple extrastimuli delayed until after double extrastimuli failed to induce the clinical arrhythmia (B sequence); (4) the relative efficiency of these sequences were determined. The percentage of induced clinical and nonclinical arrhythmia with SR + 3 extrastimuli, VP1 + 2 extrastimuli, and VP2 + 2 extrastimuli were (53%, 5%), (36%, 5%), and (41%, 9%), respectively. The cumulative yield of induced clinical VA with the MMC-type sequence reached 55% by the third step of the protocol, whereas 50% was attained only at the eighth step of the B-type sequence. The cumulative percentage of induced nonclinical VA with either sequence was similar during the early steps of the protocol. The MMC sequence was more efficient, requiring overall 36% of potential steps for clinical arrhythmia induction, compared with 48% for the B sequence (P less than 0.001). For questionable arrhythmia states, e.g., syncope of unknown origin and nonsustained VT, a modified sequence is proposed that may further reduce the induction of uninterpretable arrhythmias.

    Title Combined Maze Procedure and Septal Myectomy in a Septuagenarian.
    Date August 1992
    Journal The Annals of Thoracic Surgery
    Excerpt

    A 75-year-old woman with refractory paroxysmal atrial fibrillation and hypertrophic obstructive cardiomyopathy underwent a successful combined maze procedure and septal myectomy. Postoperative episodes of atrial fibrillation and flutter occurred only during periods of bradyarrhythmia and did not recur with atrial inhibited pacing.

    Title Rapid Suppression of Spontaneous Ventricular Arrhythmias During Oral Amiodarone Loading.
    Date July 1992
    Journal Annals of Internal Medicine
    Excerpt

    OBJECTIVE: To determine the time course of effects of amiodarone during an oral loading period. DESIGN: A prospective, nonrandomized study. SETTING: Arrhythmia referral center at a university hospital. PATIENTS: Fifty patients with refractory sustained ventricular tachycardia (n = 44) or ventricular fibrillation (n = 6) and frequent (greater than or equal to 30/h) ventricular premature complexes. INTERVENTION: Oral amiodarone, 1200 mg/d for 14 days and 400 mg/d thereafter. MEASUREMENTS: Ambulatory electrocardiographic monitorings, 12-lead electrocardiograms, and amiodarone blood levels on days 3, 5, 7, 9, 11, 13, and 28. RESULTS: Dramatic reductions of ventricular arrhythmias were noted during the first 72 hours of the therapy. Average ventricular premature complexes/h, couplets/h, and nonsustained ventricular tachycardias/24 h were 524 +/- 1224/h, 16 +/- 61/h, and 167 +/- 611/24 h, respectively, at baseline, and reduced to 140 +/- 243/h, 11 +/- 50/h, and 33 +/- 117/24 h, respectively, on day 3 (P less than 0.05 for all). Subsequent reductions of ventricular arrhythmias from day 3 to day 13 were more gradual but were still significant (P less than 0.05). A significant reduction of ventricular arrhythmias (greater than or equal to 70% reduction of ventricular premature complexes and greater than or equal to 90% reduction of nonsustained ventricular tachycardias) was noted in 50% of patients on day 3, in 65% on day 7, and in 83% on day 13. Prolongation of the QT interval exhibited a similar time course. There were no further differences in reduction of ventricular premature complexes or QT intervals between day 13 and day 28. CONCLUSIONS: Oral amiodarone given in loading doses produces rapid and dramatic reductions in spontaneous ventricular arrhythmias within 72 hours. Subsequent reductions of spontaneous arrhythmia were gradual and less dramatic.

    Title Clinical Evaluation of the Safety of Repetitive Intraoperative Defibrillation Threshold Testing.
    Date July 1992
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    One goal of the initial implantation procedure for a cardioverter defibrillator is determination of the configuration and patch location with the lowest defibrillation threshold (DFT). To determine the safety of multiple defibrillation tests, an analysis of the intraoperative defibrillation threshold tests (DFTT) in our patients was performed. In 84 patients, the mean number of DFT trials was 5.27; the mean number of joules received was 275.0. The maximum number of shocks in one implant procedure was 50 for a total of 4,895 joules without complications. Four patients received 30 or more DFT shocks without complication. There were two complications related directly to the DFTT: one patient with severe noninflammatory cardiomyopathy developed electromechanical dissociation and was subsequently resuscitated and survived; the second patient with severe triple vessel coronary artery disease suffered an intraoperative myocardial infarction during testing and eventually died 22 days postoperatively. All patients received an ICD unit; six patients had DFTs of greater than 20 joules. Based on our experience, we followed the clinical status (heart rate, blood pressure, ECG changes, fluid status, total anesthesia time) during the DFTT to determine the extent and duration of our testing protocol. Multiple shocks due to repositioning of the leads in a stable patient should not prohibit extensive testing as adverse consequences do not appear to be cumulative.

    Title Changing Aids-risk Behavior.
    Date June 1992
    Journal Psychological Bulletin
    Excerpt

    This article contains a comprehensive, critical review of the acquired immunodeficiency syndrome (AIDS)-risk-reduction literature on interventions that have targeted risky sexual behavior and intravenous drug use practices. A conceptually based, highly generalizable model for promoting and evaluating AIDS-risk behavior change in any population of interest is then proposed. The model holds that AIDS-risk reduction is a function of people's information about AIDS transmission and prevention, their motivation to reduce AIDS risk, and their behavioral skills for performing the specific acts involved in risk reduction. Supportive tests of this model, using structural equation modeling techniques, are then reported for populations of university students and gay male affinity group members.

    Title Reproducibility of Electrophysiologic Testing During Antiarrhythmic Therapy for Ventricular Arrhythmias Secondary to Coronary Artery Disease.
    Date June 1992
    Journal The American Journal of Cardiology
    Excerpt

    Although electrophysiologic studies are often used to assess antiarrhythmic drug efficacy in patients with ventricular tachycardia (VT), the reproducibility of these studies during therapy has not been definitively established. Confirmation studies were performed during drug therapy in 64 patients (51 men, mean age 63 years) with sustained ventricular arrhythmias induced during initial study to assess the reproducibility of drug effect. All patients had coronary artery disease. The stimulation protocol used included the serial introduction of up to 3 premature ventricular stimuli during sinus rhythm and with ventricular pacing at 2 pacing rates. Rapid ventricular pacing techniques were also used. Antiarrhythmic drug efficacy was confirmed in 77% of patients. Sustained VT was induced at repeat electrophysiologic study in 19% of patients during antiarrhythmic therapy that was previously thought to be effective. In summary, electrophysiologic study results during antiarrhythmic therapy exhibit significant day-to-day variability. Sustained VT can be induced during antiarrhythmic therapy that was previously defined as effective by programmed stimulation in a substantial number of patients.

    Title Programmed Electrical Stimulation of the Ventricle: an Efficient, Sensitive, and Specific Protocol.
    Date June 1992
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    A relatively simple and efficient ventricular programmed electrical stimulation (PES) protocol was developed, capable of achieving high degrees of sensitivity and specificity. In a series of 481 subjects, 1, 2, and 3 extrastimuli (ES) were used successively during sinus rhythm and ventricular pacing at two drive cycle lengths, at one or more ventricular sites, together with rapid ventricular pacing, and other maneuvers such as isoproterenol infusion. Three ES were used immediately after two ES at each drive rate, rather than returning after completion of the protocol with two ES. Using the protocol, appropriate arrhythmias could be induced in 88% of all patients with ventricular fibrillation, 84% of all patients with sustained ventricular tachycardia (91% with underlying coronary disease), and 58% of patients with severe nonsustained ventricular tachycardia. There were significant differences in inducibility between patients whose ventricular arrhythmias were due to coronary artery disease and other causes. In contrast, sustained ventricular arrhythmias (all ventricular fibrillation) could be induced in only 5% of a control group of control patients, for a specificity of 95%. The protocol described is simpler and more efficient than those that use exhaustive testing of two ES before going to three ES. Three ES during sinus rhythm proved to be the most productive step, with a higher yield ratio (true: false-positives) than two ES or three ES during pacing, especially at faster rates. Greater efficiency is also achieved by leaving the timing of an extrastimulus just beyond its effective refractory period when an additional extrastimulus is to be added, compared to protocols in which the extrastimulus is moved later in the cycle and then decremented in tandem with the additional extrastimulus. Coupling intervals less than 200 msec produced some false-positives, but fewer overall than intervals greater than or equal to 200 msec, and with yield ratios comparable to other protocol steps. The protocol described meets NASPE standards for ventricular programmed stimulation protocols, and with its demonstrated specificity and relative simplicity and efficiency may be useful as a model for groups not yet committed to an alternative protocol.

    Title Influence of Left Ventricular Function on Outcome of Patients Treated with Implantable Defibrillators.
    Date May 1992
    Journal Circulation
    Excerpt

    The outcomes of patients treated with implantable defibrillators were compared between patients with left ventricular ejection fraction greater than or equal to 30% and less than 30%.

    Title Implementation of a New Dddr Algorithm for Tachycardia Prevention and Treatment Utilizing an Implantable Ram-based Software-controlled Pacemaker.
    Date April 1992
    Journal Journal of Electrocardiology
    Excerpt

    Reentry within the atrioventricular node or over accessory pathways are common causes of symptomatic tachycardia. These arrhythmias are frequently initiated by a spontaneous atrial or ventricular premature beat. Appropriately timed atrial or ventricular extrastimuli can, in some patients, render one limb of the reentrant circuit refractory and prevent induction of tachycardia. Currently available implantable devices are not suitable for this application. The authors have implemented a new implantable pacing algorithm capable of extremely short atrial and ventricular refractory periods, rapid triggered ventricular pacing rates, protection against encroachment on the ventricular vulnerable period, protection against tachycardia induction by ventricular premature beats, automated antitachycardia pacing in either atrium and ventricle, as well as an extensive event storage capability. This application has been made possible by a new, RAM-based microprocessor controlled dual chamber pacemaker (Medtronic Prometheus Model 6100). Its use in intraatrial tachycardia with atrioventricular block as well as Wolff-Parkinson-White syndrome is demonstrated. This device is capable of prevention of tachycardia induction in some patients. Where prevention is not feasible or fails, it is backed up by automated or manually activated antitachycardia pacing. The great flexibility of a completely reprogrammable software based pacemaker has enabled the implementation of a very complex experimental pacemaker that will permit evaluation in the implanted setting of this new pacing strategy.

    Title Direct Current Shock Ablation: Quantitative Assessment of Proarrhythmic Effects.
    Date March 1992
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Catheter ablation using direct current (DC) shock has proved invaluable in the management of a variety of tachycardias. However, sporadic reports of fatal arrhythmias following ablation have raised the question of the proarrhythmic potential of DC shock ablation. The present study was undertaken in 45 patients to assess prospectively any proarrhythmia related to DC shock ablation, using matched pre- and postablation Holter monitors and programmed electrical stimulation (PES). Nineteen of these patients had Holter monitors for three successive postablation days to observe trends. There was unmatched data in 11 additional patients. All 56 patients provided prospective follow-up for clinical events. There was no immediate sustained VT/VF at the time of the ablation. Four patients had sustained VT in the first 72 hours after ablation; three episodes were similar to the preablation clinical arrhythmias; one patient had torsades de pointes interrupting bradycardia. Twelve patients met Holter, PES, or clinical criteria for proarrhythmia; none were treated on the basis of these findings. On Holter monitoring, there were significant increases in VPCs/hour and couplets/hour in patients undergoing atrial or atrioventricular junctional ablations; and an increase in couplets after accessory pathway ablations. Increases in these categories were not significant for VT patients; nor were increases in episodes of VT/hour or atrial arrhythmias significant in any group. Patients were followed for 44 +/- 33 months, with an actuarial survival of 95% at 1 year, 88% at 3 years, and 85% at 4 years. There were six deaths during follow-up. Two patients had sudden death: one at 2 months had early evidence of proarrhythmia; the other at 32 months may have represented later myocardia deterioration. One patient died of heart failure at 77 months; and there were three noncardiac deaths. DC shock ablation in humans is much less proarrhythmic than in dogs. The low incidence of clinical proarrhythmic events during prolonged follow-up after discharge resulted in low sensitivity, specificity, and positive predictive values for Holter and PES, although the negative predictive values of these tests were greater than 90%. Only one of 12 patients who met criteria for proarrhythmia in the days immediately following ablation had subsequent clinical events consistent with proarrhythmia. These results may be useful as standards for comparison with results of radiofrequency or other ablation modalities.

    Title Exacerbation of Ventricular Arrhythmias During the Postoperative Period After Implantation of an Automatic Defibrillator.
    Date November 1991
    Journal Journal of the American College of Cardiology
    Excerpt

    The postoperative course of 68 consecutive patients treated with an implantable defibrillator during the period from 1982 through 1990 was studied. In 46 patients (group 1), no concomitant surgery was performed during the implantation. In 22 patients (group 2), concomitant surgery (coronary artery bypass [n = 12], valve replacement [n = 3] or arrhythmia surgery [n = 7]) was performed. All patients in group 1 were clinically stable before surgery, receiving an antiarrhythmic regimen chosen by serial drug testings. The same regimen was continued postoperatively. Eight of the 46 patients in group 1 whose condition had been stable in the hospital for 19 +/- 25 days preoperatively developed multiple episodes of sustained ventricular tachycardia 4 +/- 9 days after implantation while receiving the same antiarrhythmic regimen. Although the exacerbation was transient in some patients, six required different antiarrhythmic therapy and one eventually died. Two additional patients had frequent and prolonged episodes of nonsustained ventricular tachycardia that could trigger the defibrillator, requiring changes in the antiarrhythmic regimen. Another patient had progressive cardiac failure and died on day 5. A marked (sevenfold) increase in asymptomatic ventricular arrhythmias was noted in 42% of the remaining 35 patients. In group 2 (combined surgery), one patient developed refractory ventricular tachycardia 3 days postoperatively and died on that day. Three patients developed frequent nonsustained ventricular tachycardia postoperatively, requiring changes in the antiarrhythmic regimen. The overall surgical mortality rate was 4.4% (4.3% in group 1 and 4.5% in group 2) and was due to refractory ventricular tachycardia in two patients and cardiac failure in one.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Benefits of Implantable Defibrillators Are Overestimated by Sudden Death Rates and Better Represented by the Total Arrhythmic Death Rate.
    Date June 1991
    Journal Journal of the American College of Cardiology
    Excerpt

    Benefits of the implantable defibrillator on survival were studied in 56 consecutive patients (concomitant coronary bypass or arrythmia surgery in 15) during an 8 year period between 1982 and 1990. During a follow-up period of 29 +/- 25 months, six patients had a sudden death and eight patients had a nonsudden cardiac death. Nonsudden cardiac deaths included three surgical deaths (death within 30 days after the surgery; two in patients without and one in a patient with concomitant cardiac surgery), one arrhythmia-related nonsudden death (death within 24 h after an arrhythmic event despite initial termination of the arrhythmia by the implantable defibrillators) and four nonarrhythmic cardiac deaths. The actuarial survival rate free of events at 1, 2 and 3 years was 96%, 96% and 92%, respectively, for sudden death, 91%, 91% and 87% for sudden death and surgical mortality and 89%, 89% and 85% for total arrhythmic death (sudden death, surgical mortality and arrhythmia-related nonsudden death). Thus, in patients treated with an implantable defibrillator, 1) the rate of sudden death is low (8% at 3 years); 2) 50% of nonsudden cardiac deaths are causally related to arrhythmia (surgical mortality or arrhythmia-related nonsudden death); 3) the total arrhythmic death rate is substantially higher than the sudden death rate; and 4) benefits of an implantable defibrillator are overestimated by reported sudden death and nonsudden cardiac death rates. The benefits may be better represented by the total arrhythmic death and nonarrhythmic cardiac death rates.

    Title Use of Disopyramide by Arrhythmia Specialists After Cardiac Arrhythmia Suppression Trial: Patient Selection and Initial Outcome.
    Date May 1991
    Journal American Heart Journal
    Title Sudden Death Mortality in Implantable Cardioverter Defibrillator Patients.
    Date April 1991
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Implantable cardioverter defibrillator (ICD) prevention of sudden cardiac death (SCD) is not absolute and our experience was reviewed to determine the frequency and nature of SCD in this population. The incidence and cause of mortality in 56 consecutive patients, who underwent ICD implantation beginning May 1982 with follow-up through May 19, 1990 were analyzed. Twenty-one patients died, 33% of the mortality was due to SCD, and 52% of deaths may be considered arrhythmic. The cumulative 1, 3, and 5 year SCD survivals were 93%, 89%, and 75%. All seven patients dying of SCD presented initially with SCD, all received previous shocks prior to SCD, and two of the seven patients had devices that were probably inactive at the time of death. We conclude that ICDs reduce but by no means eliminate arrhythmic death, particularly in those at highest risk for SCD. Arrhythmic death remained the most common cause of death in this population.

    Title Occurrence of Icd Shocks and Patient Survival.
    Date April 1991
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Fifty-six consecutive patients who underwent initial implantation of an implantable cardioverter defibrillator (AICD) between May 1982 and January 1990 were analyzed. During a mean follow-up of 31.5 +/- 25 months, 32 (60%) patients experienced a spontaneous shock from their device. Their clinical characteristics and survival were compared to those of 21 patients without shocks. No statistically significant difference was found in the distribution between the two groups in age, sex, cardiac diagnosis, New York Heart Association Class, presenting arrhythmia, or mean follow-up (F/U). The group with shocks had a higher incidence of previous MI (P = 0.021) a lower mean ejection fraction (P = 0.023) and had been tried on a greater number of medical regimens (P = 0.003). The 1-, 3-, and 5-year cumulative survivals were 84%, 69%, and 37% in the group with shocks and 93%, 93%, and 93% for the group without shocks. Our data suggests that the occurrence of a shock is a negative prognostic indicator and that the excellent prognosis of patients without shocks contributes in large part to the favorable outcome of AICD patients.

    Title Fate of Explanted Icd Patients.
    Date April 1991
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Of 56 consecutive patients who underwent an initial AICD implantation at our center, we analyzed eight patients who subsequently had their units explanted and not replaced by other antitachycardia devices. The mean age was 57.8 years, mean ejection fraction was 28.4%; six patients had coronary disease and two had cardiomyopathy. The presenting arrhythmia was sudden death in four patients and sustained ventricular tachycardia in four others. Mean follow-up from implant to explant was 25 +/- 22 months, and 22 +/- 10 months from explant to end of follow-up. Reasons for explantation were: infection in five patients, lead fracture in one patient, battery depletion in one patient, and one patient underwent cardiac transplantation. Devices were not reimplanted because of: patient refusal in three patients, physician discretion in two patients (one recurrent infection, one received no shocks over 24 months), cardiac transplantation in one patient, ablation of VT focus in one patient, and one patient died while being treated for infection. Three patients died 2, 21, and 26 months after device explantation of nonsudden cardiac, sudden cardiac and noncardiac causes, respectively. Conclusions: Preoperative clinical parameters were not indicative of a lower risk of arrhythmic events in these patients as compared to the general population of AICD implantees. Of eight patients, two received alternate nonmedical therapy, one died while receiving treatment for a device-related infection; of the five remaining patients none died of cardiac causes. Termination of AICD therapy for malignant ventricular arrhythmias does not imply imminent sudden cardiac death for most patients treated by alternate modes of therapy.

    Title Ventricular Tachycardia/fibrillation: Therapeutic Alternatives.
    Date April 1991
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    It is now clear that no single therapy is appropriate for a consecutive series of patients with ventricular tachycardia or ventricular fibrillation (VT/VF). Drug responders by electrophysiological studies, patients who are not inducible following surgery, and patients treated with an implantable cardioverter defibrillator (ICD) all can have similarly low sudden death rates and virtually identical long-term mortality. However, many patients fail to respond to drugs, and surgical risks are excessive in others, and always higher than for an ICD implant. Nevertheless, overall survival in each of these groups (and probably for patients treated with antitachycardia pacers and ablation) is about 60% at 60 months. Major challenges now are: (1) choosing therapy to maximize risk-benefit ratio; and (2) treatment of the pump failure and progressive disease that now accounts for most cardiac mortality.

    Title Inadvertent Aicd Inactivation While Playing Bingo.
    Date January 1991
    Journal American Heart Journal
    Title Prognosis of Patients with Ventricular Tachycardia or Fibrillation and a Normal Electrophysiologic Study.
    Date January 1991
    Journal American Heart Journal
    Excerpt

    The outcome of 26 patients with sustained ventricular tachycardia (n = 16) or ventricular fibrillation (n = 10) and no inducible ventricular tachycardia (less than or equal to 10 beats) by baseline programmed stimulation was studied. Coronary artery disease was present in 14 patients, dilated cardiomyopathy was seen in seven, valvular heart disease was present in two, and no apparent cardiac abnormalities were found in three. The mean left ventricular ejection fraction was 53 +/- 14%. During the follow-up period of 24 +/- 16 months, actuarial survival rates at 1 and 2 years were 95% and 89% for sudden death and 95% and 83% for total cardiac death, respectively. No patients with a known ejection fraction greater than 30% died suddenly during the follow-up. Noninducibility by programmed stimulation in patients with sustained ventricular tachycardia or fibrillation is associated with a relatively preserved ventricular function. It may predict a low risk of sudden death in patients with preserved ventricular function.

    Title Rate-dependent Bundle Branch Block: Occurrence, Causes and Clinical Correlations.
    Date July 1990
    Journal Journal of the American College of Cardiology
    Title Daily Bedside Electrophysiological Testing Following Surgery for the Wpw Syndrome.
    Date April 1990
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    A simple technique is described that allows daily bedside evaluation of the results of surgery for the Wolff-Parkinson-White (WPW) syndrome, using standard postoperative myocardial wires, a single-channel ECG machine, and a temporary pacer capable of rapid stimulation. Rate incremental atrial and ventricular ramp pacing was performed daily in 40 postoperative WPW patients. This technique, together with underdrive pacing in some individuals permits quick assessment of anterograde and retrograde conduction. Two surgical failures were identified in early postoperative days, and promptly returned to the operating room for successful reoperation. No additional failures were identified at formal predischarge electrophysiological testing or following discharge. The technique permits reassurance on a daily basis to apparent successes and early identification in the event of failure, permitting prompt intervention.

    Title Time Dependence of Ventricular Refractory Periods: Implications for Electrophysiologic Protocols.
    Date March 1990
    Journal Journal of the American College of Cardiology
    Excerpt

    Cardiac refractory periods are routinely measured during electrophysiologic testing. Informal observations suggested that the effective refractory period lengthened with a prolongation of the time in sinus rhythm (basic cycle length time) between successive runs of drive stimuli (S1S1s). If this were true, failure to control the basic cycle length time could affect the results and interpretation of electrophysiologic testing. To study this phenomenon, the effective refractory period was studied in 20 patients during sinus rhythm and two ventricular paced rates with up to three extrastimuli, while varying the basic cycle length time from 2 to 3, to 10 to 20 s. With each of the stimulation sequences used, the effective refractory period lengthened as the basic cycle length time increased ("basic cycle length time-effective refractory period effect"). The effect was most pronounced when extrastimuli were used during the two ventricular paced rates. As the basic cycle length time increased from 2 to 3 to 20 s, the mean effective refractory period determined during sinus rhythm increased from 296 to 300 ms; with the first ventricular paced rate, the effective refractory period increased from 259 to 272 ms (p less than 0.0003) and with the second ventricular paced rate, the effective refractory period increased from 250 to 263 ms (p less than 0.01). The basic cycle length time-effective refractory period effect became more pronounced as the number of extrastimuli increased. With the second ventricular paced rate, as basic cycle length was increased from 2 to 3 to 20 s, the mean prolongation in the cumulative effective refractory period (S1 to final extrastimulus) as the number of extrastimuli increased from 1 to 2 to 3, was 13 (p less than 0.01), 42 (p less than 0.0003) and 82 ms (p less than 0.001), respectively. Results were confirmed in 17 instances by redetermining the effective refractory period at the 2 to 3 s basic cycle length time after the final 20 s basic cycle length time determination, and demonstrating that it was similar to the effective refractory period after the initial 2 to 3 s basic cycle length time. No further prolongation of the effective refractory period could be demonstrated by increasing basic cycle length time from 20 to 60 s, and no significant effect of medications on the basic cycle length time-effective refractory period effect could be demonstrated.

    Title Combination of Disopyramide and Mexiletine for Better Tolerance and Additive Effects for Treatment of Ventricular Arrhythmias.
    Date April 1989
    Journal Journal of the American College of Cardiology
    Excerpt

    The efficacy and tolerance of disopyramide and mexiletine used alone and in combination were studied in 21 patients with frequent (greater than or equal to 30/h) ventricular premature complexes. Ambulatory electrocardiographic monitoring was performed at baseline and during therapy with disopyramide alone, mexiletine alone and a combination of disopyramide and mexiletine. During single drug therapy, the dose of disopyramide was 602 +/- 152 mg/day and that of mexiletine was 738 +/- 144 mg/day. During combination therapy with smaller doses of disopyramide (524 +/- 134 mg/day) and mexiletine (652 +/- 146 mg/day), no patient had side effects. At baseline before therapy, the mean number of ventricular premature complexes per hour, was 608 +/- 757, of couplets per hour was 22.4 +/- 45.8 and of episodes of nonsustained ventricular tachycardia/24 h was 219.7 +/- 758.2. The mean number of ventricular premature complexes per hour was reduced to 156 +/- 217 with disopyramide alone, 188 +/- 298 with mexiletine alone and 76 +/- 144 with combination therapy (p less than 0.05 for combination therapy versus disopyramide or mexiletine alone; p = NS for disopyramide versus mexiletine). Individually, an effective regimen (greater than 83% reduction in ventricular premature complexes and abolition of nonsustained ventricular tachycardia) was found in 5 (24%) of 21 patients during therapy with disopyramide alone, in 3 (14%) receiving mexiletine alone and in 13 (62%) receiving combination therapy (p less than 0.05 for combination therapy versus disopyramide or mexiletine; p = NS for disopyramide versus mexiletine). Thus, the antiarrhythmic effects of disopyramide and mexiletine are additive.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Survival of Patients with the Automatic Implantable Cardioverter Defibrillator.
    Date February 1989
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Between May 1982 and May 1988, 37 patients (28 males and 9 females, mean age 57.6, range 16-76 years) of approximately 600 evaluated for sustained ventricular tachycardia and/or fibrillation (VT/VF) were treated with an automatic implantable cardioverter defibrillator (AICD). Twenty-eight of the patients had coronary artery disease, 7 had nonischemic cardiomyopathy, 1 had amyloid heart disease, and 1 had rheumatic heart disease. The mean ejection fraction was 32.2 +/- 12.9% (range, 9-64%). Eleven patients have died at a mean of 16.7 months after implantation. The cumulative survival rate was 81% at 1 year, 77% at 2 years, 68% at 3 years, and 53% at 4, 5, and 6 years. Considering only sudden deaths, the survival was 97% at 1 and 2 years, 90% at 3 years, and 80% at 4, 5, and 6 years. Twenty-one of the 37 patients received spontaneous shocks. If the first shock marks the time to death in the absence of an AICD, the cumulative survival rate would have been 56% at 1 year, 42% at 2 years, 29% at 3 years, and 14% at 4, 5, and 6 years. The maximum amount of time to a first appropriate shock was 39.7 months. Thirty-nine devices have been explanted: 28 for battery depletion; 5 for infections; 3 for improper sensing; 2 for electronic failure; and 1 at the time of cardiac transplantation. The average time to failure of the 28 units removed for battery depletion was 19.8 +/- 6.9 months.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Automatic Methods for Detection of Tachyarrhythmias by Antitachycardia Devices.
    Date March 1988
    Journal Journal of the American College of Cardiology
    Excerpt

    Electrical devices play an increasingly important role in the control of tachyarrhythmias. Antitachycardia pacing and automatic defibrillation have been severely limited by the poor specificity of tachycardia discrimination in commercially available devices. Although absolute heart rate has been the principal means of automatic diagnosis, several new detection algorithms and methods are being investigated. Multiple electrode timing comparison, signal processing and pattern recognition are employed in these newer techniques. Although each offers some improvement over present technology, none is capable of identifying all arrhythmias. The methods employing comparison of atrial and ventricular rates, without additional criteria, are unable to detect ventricular tachycardia in the presence of 1:1 retrograde conduction. Electrographic analysis techniques require very stable electrodes and may not tolerate normal morphologic variations. A combination of two or more approaches may ultimately be required. All techniques will require that certain critical variables be programmable to allow for individualization in each clinical situation. Soft-ware-controllable devices and those capable of sensing from both the atria and the ventricles will provide the sophistication necessary for the implementation of complex tachycardia detection algorithms. This report reviews automatic tachycardia detection techniques in current use and under investigation.

    Title Electrical Devices for Treatment of Arrhythmias.
    Date February 1988
    Journal The American Journal of Cardiology
    Excerpt

    Electrical devices can be used for preventing and terminating tachycardia and for achieving hemodynamic improvement during a continuing tachycardia. Conventional approaches to tachycardia prevention include pacing at physiologic rates to prevent brady-cardia-related tachycardia or tachycardias associated with prolonged QT-interval syndromes. More exotic techniques, such as those involving stimulation during the refractory period, are undergoing investigation. Some tachycardias cannot be easily terminated or recur incessantly. Hemodynamics can be improved by pacing methods that result in a narrower QRS complex by coupled pacing and, in supraventricular tachycardias, by pacing rapidly enough to create atrioventricular block. Most clinical tachycardias are caused by reentry. Careful analysis of the timing of individual stimuli that successfully terminate tachycardias indicate that critical relations exist in the conduction velocity, refractoriness and physical properties and dimensions of the reentry circuit and the remaining myocardium. Elucidating these relations has permitted inferences into the mechanisms by which pacing terminates or accelerates tachycardias. A vast number of pacing patterns have evolved for use in tachycardia termination. None of these appear to be foolproof. There is widespread and justified concern about the risk of acceleration of tachycardia when antitachycardia pacing is used in the ventricle. Experience indicates that only a few patients are suitable for termination of ventricular tachycardia by pacing, but these carefully selected patients may do well. Both the results and the potential for widespread use may be better with pacing for termination of supraventricular tachycardia. Life-threatening tachycardias or fibrillation can be terminated by direct-current countershock. Although many technical problems remain, implantable cardioverter-defibrillators, possibly combined with antitachycardia pacemakers, will play an increasing role in the management or serious arrhythmias.

    Title Long-term Efficacy of Antitachycardia Pacing for Supraventricular and Ventricular Tachycardias.
    Date January 1988
    Journal The American Journal of Cardiology
    Excerpt

    Over a 14-year period, 53 patients received implanted pacemakers to assist in the control of recurrent tachycardias. Indications were: prevention of tachycardia in 2 patients with supraventricular tachycardia (SVT), and 4 with ventricular tachycardia (VT); termination of tachycardia (15 SVT, 20 VT); and long-term periodic programmed electrical stimulation with potential for tachycardia termination (12 VT). Pacemakers for prevention of VT were implanted in 3 patients with prolonged QT interval syndromes and 1 in whom Holter monitoring showed a significant reduction in ectopic activity during pacing. Pacers were implanted for tachycardia termination only after patients underwent a rigorous protocol aimed at achieving 100 trials of the proposed modality. Patients with tachycardia also requiring antibradycardia pacemakers received pacemakers capable of noninvasive programmed stimulation for use during follow-up. There were no tachycardia recurrences among those patients in whom pacemakers were implanted for prevention. Pacers capable of outpatient programmed stimulation were useful, and it may be desirable to expand their use. The 15 patients with pacers designed for termination of SVT were followed for a mean of 68 months. Among these, actuarial continuation of pacing efficacy was 93% at 1 year, and 78% at 5 years. The 20 patients with pacers for termination of VT were followed for a mean of 37 months. Actuarial efficacy was 78% at 1 year, and 55% at 5 years. Sudden death occurred in 4 of these patients, none clearly pacer related. Pacemakers can play a major therapeutic role in some patients with recurrent tachycardias. The role of such pacemakers in patients with VT may be expanded with the advent of combined pacer-defibrillators.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title The Prognostic Value of the Changes in the Mode of Ventricular Tachycardia Induction Noted During Therapy with a Marked Reduction of Ventricular Ectopic Activity.
    Date November 1987
    Journal American Heart Journal
    Excerpt

    The prognostic significance of changes in the mode of induction of ventricular tachycardia (VT) noted during therapy was studied in 49 patients with sustained VT or ventricular fibrillation. Before treatment, all patients had inducible sustained VT by programmed stimulation (one to three extrastimuli) and frequent (greater than or equal to 30/hr) ventricular premature complexes (VPCs). On the discharge regimen, VT was no longer inducible by programmed stimulation in 22 patients (group 1). Twenty-seven patients (group 2) with persistent induction of VT despite extensive serial drug testings were discharged on a regimen that resulted in a marked reduction of VPCs on Holter monitoring (greater than or equal to 50% reduction of VPCs, greater than or equal to 90% reduction of couplets, and abolition of nonsustained VT). The modes of induction at baseline and on the discharge regimen were compared in each patient in group 2. Induction of VT was more difficult, requiring more aggressive stimulation protocol in 5 of 27 patients, unchanged in 14 patients, and easier in 8 patients. The duration of follow-up was 20 +/- 13 months (mean +/- SD). Arrhythmia-free survival rates at 6, 12, 18, and 24 months were 95%, 89%, 82%, and 73% in group 1, 92%, 84%, 75%, and 75% in group 2, 93%, 83%, 77%, and 69% in 27 patients with noninducibility or harder induction, and 95%, 90%, 79%, and 79% in 22 patients with the same or easier induction, respectively. The differences were not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Disopyramide-pyridostigmine Interaction: Selective Reversal of Anticholinergic Symptoms with Preservation of Antiarrhythmic Effect.
    Date October 1987
    Journal Journal of the American College of Cardiology
    Excerpt

    This double-blind, randomized, placebo crossover study was used to evaluate the effects of a cholinesterase inhibitor--slow-release pyridostigmine (180 mg orally every 12 hours)--on the anticholinergic and antiarrhythmic properties of disopyramide. Quantitative side effects questionnaire scores were used to guide disopyramide administration in 20 men with ventricular tachycardia. Disopyramide was given to each patient both with placebo and with active pyridostigmine. The maximal administered dose for each regimen was used in conjunction with corresponding questionnaire scores to calculate an index or estimate of the maximal tolerable dose of disopyramide. Additional evaluations performed at baseline and at each maximal administered dose regimen included tear and saliva quantitation, 24 hour electrocardiogram (ECG), exercise testing and programmed ventricular stimulation. Results showed that the maximal administered dose of disopyramide was greater with active pyridostigmine than with placebo: 295 +/- 75 versus 245 +/- 100 mg every 6 hours (p less than 0.05). The calculated maximal tolerable dose was substantially greater in the presence of pyridostigmine: 355 +/- 90 versus 260 +/- 115 mg every 6 hours (p less than 0.001). Maximal side effects questionnaire scores also reflected decreased anticholinergic activity in the presence of pyridostigmine compared with placebo: 101.9 +/- 2.2 versus 104.6 +/- 2.8, respectively (p less than 0.005). Baseline tear and saliva production was significantly reduced during disopyramide therapy, but was restored toward normal by the addition of pyridostigmine.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Antiarrhythmic Effects of Vvi Pacing at Physiologic Rates: a Crossover Controlled Evaluation.
    Date September 1987
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Ventricular pacing can prevent bradycardia-dependent ventricular ectopic activity (VEA) and is helpful in some cases of drug-refractory ventricular tachycardia (VT). This study is a prospective evaluation of VVI pacing for the control of VEA not related to underlying bradycardia, drug side-effects, or prolonged QT interval syndromes. Twenty-nine patients undergoing serial electrophysiologic-pharmacologic testing for VT control were studied. Eighteen of these patients (12 men; mean age = 60.1) both completed the protocol and had sufficient VEA for analysis. Coronary disease was present in 13 patients, cardiomyopathy in two patients, and one patient each had myocarditis, mitral valve prolapse, and no structural heart disease. Ambulatory (Holter) monitor recordings during VVI pacing were compared with control recordings made in the absence of pacing. VVI pacing rates were 10-15 bpm above the mean daily heart rate (mean = 92 bpm; range = 63-110). Hours from paced recordings were paired with hours from control (prior to analysis) according to time of day to reduce the effects of spontaneous variability in VEA frequency. Overall, VVI pacing reduced ventricular premature complexes (VPCs) 26% from 331 to 245/hour (p less than 0.001). During pacing, couplets (pairs, successive VPCs) were reduced from 6.95 to 1.03/hour (p less than 0.000001) and VT (greater than or equal to 3 successive VPCs) from 0.89 to 0.045 episodes/hour (p less than 0.003). Of 13 patients with couplets, 11 had greater than or equal to 50% reduction and five had greater than or equal to 90% reduction. Baseline VT was eliminated in four out of nine patients during pacing. Pacing did not increase VEA significantly in any patient.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Significance of Depression and Cognitive Impairment in Patients Undergoing Programed Stimulation of Cardiac Arrhythmias.
    Date September 1987
    Journal Psychosomatic Medicine
    Excerpt

    Although depression and cognitive impairment have been associated with excess mortality following heart surgery, the relationship of these factors to death following treatment for cardiac arrhythmias is unknown. We prospectively examined the associations between biobehavioral factors, mortality, and arrhythmia manageability in 88 patients undergoing programed electrical stimulation for the diagnosis and treatment of supraventricular and ventricular tachyarrhythmias or syncope of unknown origin. Statistically significant relationships were identified between depression and mortality, and between cognitive impairment and mortality. No relationships were observed between cognitive impairment or psychologic profile and arrhythmia severity or treatment efficacy. Our data suggest that arrhythmia morbidity and mortality may in part be a function of cognitive and emotional impairments that lessen the individual's capacity to comply with lifesaving therapy, maintain a stable physiologic milieu, and continue an adaptive emotional life. Failure to recognize the clinical significance of these impairments in patients at risk for sudden cardiac death will contribute to the current difficulty reducing the death and disability associated with cardiac arrhythmias.

    Title Comparison of the Characteristics of Nonsustained Ventricular Tachycardia on Holter Monitoring and Sustained Ventricular Tachycardia Observed Spontaneously or Induced by Programmed Stimulation.
    Date September 1987
    Journal The American Journal of Cardiology
    Excerpt

    The characteristics of nonsustained ventricular tachycardias (VT) on Holter monitor recordings were compared with the characteristics of sustained VT noted spontaneously or induced by programmed stimulation in 50 patients with a history of spontaneous sustained VT. At baseline before antiarrhythmic therapy, all patients had nonsustained VT (triplets or longer) on Holter recordings and sustained VT inducible by programmed stimulation. The mean rate of the fastest nonsustained VT on Holter monitoring (150 +/- 52 beats/min) was significantly slower that that of induced sustained VT (246 +/- 56 beats/min) (p less than 0.001). Compared with nonsustained VT on Holter monitoring, sustained VT by programmed stimulation were faster in 45 of 50 patients, similar in 2 and slower in 3. There was a poor correlation between the rates of nonsustained VT and sustained VT (r = 0.2195). The duration of the longest nonsustained VT was fewer than 6 beats in 24 patients and 6 beats or more in 26. The mean rates of induced sustained VT were not significantly different between patients with shorter (fewer than 6 beats) and longer (6 or more beats) nonsustained VT. In 12 patients, the rate of spontaneous sustained VT was available. The rate of spontaneous sustained VT (217 +/- 59 beats/min) was similar to that of sustained VT by programmed stimulation (277 +/- 60 beats/min). There was a close correlation (r = 0.8036) between the rates of spontaneous and induced sustained VT. However, the rate of nonsustained VT on Holter monitoring (151 +/- 76 beats/min) was significantly slower than the rate of spontaneous sustained VT (p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Automatic Implantable Cardioverter/defibrillator: Inadvertent Discharges During Permanent Pacemaker Magnet Tests.
    Date August 1987
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    A patient with an automatic implantable cardioverter defibrillator (AICD) received two inadvertent shocks when a magnet was placed over the pacer during a routine permanent pacer check. Analysis of the rhythm strip suggested that both patients' QRS complexes (133 beats/minute) and asynchronous pacer artifacts (70 beats/minute) were counted by the AICD sensing system and exceeded the rate criteria of 153 beats/minute. This resulted in shocks from the AICD during sinus rhythm at 133 beats/minute. To avoid possible inadvertent shocks, an AICD should be deactivated while a magnet is placed over the pacemaker during a permanent pacer check.

    Title Prognostic Value of the Changes in the Mode of Ventricular Tachycardia Induction During Therapy with Amiodarone or Amiodarone and a Class 1a Antiarrhythmic Agent.
    Date July 1987
    Journal The American Journal of Cardiology
    Excerpt

    The prognostic value of 3 previously reported programmed stimulation efficacy criteria was studied in 70 patients taking amiodarone for sustained ventricular tachycardia (VT). At baseline all patients had VT inducible by programmed stimulation. After amiodarone loading (935 +/- 271 mg/day for 16 +/- 7 days), efficacy of amiodarone was determined by 3 programmed stimulation criteria (criterion I = VT not inducible or 15 beats or less; criterion II = VT not inducible or harder to induce; criterion III = VT not easier to induce). Amiodarone was effective in 12, 25 and 49 of 70 patients by criteria I, II and III, respectively. There were 16 recurrences or cardiac arrest during the follow-up period (19 +/- 19 months). Actuarial arrhythmia-free survival rates at 1 and 2 years were: 90% and 90% in patients with efficacy by criterion I and 78% and 78% in patients with inefficacy, respectively; 84% and 84% in patients with efficacy by criterion II and 78% and 78% in patients with inefficacy, respectively; and 80% and 80% in patients with efficacy by criterion III and 79% and 79% in patients with inefficacy, respectively (difference not significant for all). From the results of follow-up at 2 years, sensitivities of criteria I, II and III were 92%, 75% and 33%, respectively. Specificities were 17%, 26% and 70%, respectively, and predictive accuracies were 43%, 43% and 67%, respectively. Thus, patients with efficacy by criterion I appear to have a better prognosis when compared with patients with inefficacy. However, many patients with inefficacy by criterion I had a good outcome (nonspecificity).(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Combination of Tocainide and Quinidine for Better Tolerance and Additive Effects in Patients with Coronary Artery Disease.
    Date July 1987
    Journal Journal of the American College of Cardiology
    Excerpt

    The efficacy and tolerance of tocainide used alone and in combination with quinidine were studied in 20 patients with coronary artery disease and frequent (greater than 30/h) ventricular premature complexes. Holter electrocardiographic monitoring was performed at baseline and during therapy with tocainide alone, quinidine alone and a combination of tocainide and quinidine. During single drug therapy, the dose of tocainide was 1,680 +/- 437 mg/day and that of quinidine was 1,340 +/- 235 mg/day. During combination therapy, with smaller doses of tocainide (1,350 +/- 394 mg/day) and quinidine (1,060 +/- 268 mg/day) in many patients, no patient had side effects. At baseline before therapy, the mean ventricular premature complexes/h were 629 +/- 567, couplets/h were 23.9 +/- 29.7 and nonsustained ventricular tachycardias/24 h were 60.5 +/- 152.2. Compared with baseline values (100%), the frequency of ventricular premature complexes was reduced to 33 +/- 44% with quinidine, 39 +/- 30% with tocainide and 10 +/- 16% with combination therapy (p less than 0.01 for combination versus quinidine or tocainide alone; p = NS for quinidine versus tocainide). Individually, an effective regimen (greater than 83% reduction of ventricular premature complexes and abolition of nonsustained ventricular tachycardia) was found in 3 (15%) of 20 patients receiving tocainide alone, in 6 (30%) receiving quinidine alone and in 16 (80%) receiving combination therapy (p less than 0.01 for tocainide versus combination, quinidine versus combination; p = NS for tocainide versus quinidine). Thus, the antiarrhythmic effects of quinidine and tocainide are additive.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Automatic Implantable Cardioverter-defibrillator: Patient Survival, Battery Longevity and Shock Delivery Analysis.
    Date July 1987
    Journal Journal of the American College of Cardiology
    Excerpt

    The automatic implantable cardioverter-defibrillator (AICD) has been shown to reduce the mortality rate of patients with malignant ventricular tachyarrhythmias. This report describes experience with implantation of 36 automatic implantable cardioverter-defibrillators (AID-B and AID-BR models) in 22 persons over a 44 month patient follow-up period (mean 19.6 months). There were five deaths: two patients died suddenly 22 and 29 months, respectively, after their second implant, one died of congestive heart failure, one died of respiratory failure and one died of catheter sepsis. Although 11 (50%) of the 22 patients never received a countershock for a ventricular tachyarrhythmia and are still alive, the other 11 received one or more spontaneous countershocks. Nine patients (41%) experienced spurious shocks during the follow-up period. Assuming that the first shock for presumed ventricular tachyarrhythmia prevented death, the hypothetical cumulative survival of patients at 42 months would have been 34 +/- 14.1% in the absence of an automatic implantable cardioverter defibrillator rather than the actual survival rate of 59 +/- 16.8%. The cumulative device survival of the 36 AID-B units was 92 +/- 5.62% at 15 months but diminished to 37 +/- 14.4% by 20 months. No unit lasted longer than 22 months. There were 12 battery depletions. The number of shocks emitted did not influence unit longevity. The manufacturer's elective replacement indicator is of uncertain validity. Six units remained active 7 to 17 months after surpassing their replacement indicator. The automatic implantable cardioverter-defibrillator prolongs the life of many patients with otherwise intractable arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Aging, Stress, and Sudden Cardiac Death.
    Date June 1987
    Journal The Mount Sinai Journal of Medicine, New York
    Title Nonsurgical Electrical Ablation (fulguration) of Tachycardias.
    Date April 1987
    Journal Circulation
    Title Comparison of Programmed Stimulation and Holter Monitoring for Predicting Long-term Efficacy and Inefficacy of Amiodarone Used Alone or in Combination with a Class 1a Antiarrhythmic Agent in Patients with Ventricular Tachyarrhythmia.
    Date March 1987
    Journal Journal of the American College of Cardiology
    Excerpt

    The values of two Holter ambulatory electrocardiographic monitoring criteria and one programmed stimulation efficacy criterion reported to be predictive of the efficacy of amiodarone were compared in 70 patients taking amiodarone for sustained ventricular tachyarrhythmias. At baseline, all patients had ventricular tachycardia inducible by programmed stimulation. After amiodarone loading (935 +/- 271 mg for 16 +/- 7 days), efficacy was determined by a programmed stimulation criterion (ventricular tachycardia no longer inducible or less than or equal to 15 beats) and two Holter monitoring criteria (Holter I = greater than or equal to 85% reduction of ventricular premature complexes and abolition of couplets and triplets in 64 patients who had greater than or equal to 10 ventricular premature complexes/h or couplets or triplets or both before therapy; Holter II = abolition of triplets in 41 patients who had triplets before therapy). Amiodarone was effective in 12 of 70 patients by the programmed stimulation criterion, in 49 of 64 patients by Holter criterion I and in 37 of 41 patients by Holter criterion II. In assessing efficacy of amiodarone, programmed stimulation and Holter criteria were discordant in 69% of patients or more (p less than 0.001). There were 16 recurrences or sudden deaths during the entire follow-up period (19 +/- 19 months). Arrhythmia-free survival rates at 24 months of patients with efficacy and inefficacy by each criterion, respectively, were 90 and 78% by programmed stimulation, 84 and 62% by Holter criterion I (p less than 0.05) and 73 and 50% by Holter criterion II (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Value of Holter Monitoring in Predicting Long-term Efficacy and Inefficacy of Amiodarone Used Alone and in Combination with Class 1a Antiarrhythmic Agents in Patients with Ventricular Tachycardia.
    Date February 1987
    Journal Journal of the American College of Cardiology
    Excerpt

    The value of two reported and two new ambulatory electrocardiographic (Holter) criteria was studied in 80 patients taking amiodarone for refractory recurrent sustained ventricular tachycardia. In the 80 patients, the four Holter criteria were as follows: I-85% or greater reduction of ventricular premature complexes and abolition of couplets and nonsustained ventricular tachycardia in 74 patients who had 10 or more ventricular premature complexes/h, or any couplets or nonsustained ventricular tachycardia/24 hours at baseline; II-abolition of nonsustained ventricular tachycardia in 51 patients who had nonsustained ventricular tachycardia at baseline; III-85% or greater reduction of ventricular premature complexes and abolition of nonsustained ventricular tachycardia in 64 patients who had 30 or more ventricular premature complexes/h at baseline; and IV-85% or greater reduction of ventricular premature complexes and abolition of nonsustained ventricular tachycardia in 73 patients who had 10 or more ventricular premature complexes/h at baseline. Amiodarone was judged effective in, respectively, 51 of 74, 44 of 51, 51 of 64 and 61 of 73 patients by criterion I, II, III or IV. During the follow-up period (19 +/- 20 months), there were 19 instances of recurrence of ventricular arrhythmia or sudden death. Actuarial arrhythmia-free survival rate at 24 months was 84, 74, 86 and 85%, respectively, in patients with efficacy by criterion I, II, III or IV and 61, 43, 48 and 39%, respectively, in patients with inefficacy (p less than 0.015 for all). Many patients with efficacy by Holter criteria, however, had a recurrence of arrhythmia, suggesting insensitivity of these Holter criteria.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Susceptibility to Atrial Fibrillation and Ventricular Tachyarrhythmia in the Wolff-parkinson-white Syndrome: Role of the Accessory Pathway.
    Date December 1986
    Journal American Heart Journal
    Excerpt

    Clinical and electrophysiologic characteristics associated with spontaneous and inducible atrial fibrillation and ventricular tachyarrhythmia were assessed in 20 consecutive patients with Wolff-Parkinson-White (WPW) syndrome undergoing surgical division (n = 12) or transcatheter electrical ablation (n = 8) of accessory pathways. Patients with spontaneous atrial fibrillation were characterized by the trend (not significant) of a shorter antegrade accessory pathway effective refractory period (256 +/- 26 vs 303 +/- 109 msec). However, patients with and without spontaneous atrial fibrillation did not differ with respect to prevalence of structural heart disease (3 of 11 vs 2 of 9), intra-atrial conduction time (34 +/- 10 vs 32 +/- 10 msec), or interatrial conduction time (86 +/- 21 vs 88 +/- 17 msec). Thus, atrial and accessory pathway electrophysiologic properties (per se) were not clear determinants of susceptibility to atrial fibrillation. Among the 20 patients, 10 to 35 beats of nonsustained ventricular tachycardia (seven patients) or ventricular fibrillation (three patients) were induced at electrophysiologic study with one to three programmed extrastimuli. Clinically, a ventricular arrhythmia (ventricular fibrillation during atrial fibrillation) had occurred in only one of these patients. The discordance of these observations was significant (p less than 0.01). Patients with and without inducible ventricular arrhythmias were not distinguished by clinical factors or by electrophysiologic properties of the accessory pathway or ventricles. Accessory pathway conduction was completely or partially eliminated by ablation procedures in 14 of 20 patients. During a mean follow-up of 27 months, atrial fibrillation recurred in two patients with failed ablation procedures and in one patient with left atrial enlargement (despite accessory pathway division) (p = 0.019 vs pre-ablation). Ventricular arrhythmias remained inducible in two patients in whom accessory pathway ablation failed (p = 0.01 vs initial study). However, spontaneous ventricular tachyarrhythmias did not occur during follow-up. We conclude that susceptibility to spontaneous or inducible atrial fibrillation and ventricular tachyarrhythmia in patients with WPW syndrome and no organic heart disease depends primarily on the existence of a functional accessory pathway. These susceptibilities are eliminated by interruption of accessory pathway conduction. Ventricular tachyarrhythmias remain infrequent spontaneous events in the WPW syndrome. Their more frequent induction at electrophysiologic study is not predictive of clinical occurrence.

    Title Electrophysiologic Effects and Clinical Efficacy of Mexiletine Used Alone or in Combination with Class Ia Agents for Refractory Recurrent Ventricular Tachycardias or Ventricular Fibrillation.
    Date October 1986
    Journal The American Journal of Cardiology
    Excerpt

    The electrophysiologic effects and clinical efficacy of mexiletine used alone or in combination with class IA agents were studied in 35 patients with recurrent sustained ventricular tachycardia (VT) or ventricular fibrillation refractory to nonexperimental antiarrhythmic agents. At baseline before therapy, all patients had inducible VT by programmed stimulation (1 to 3 extrastimuli) and frequent (at least 30/hour) ventricular premature complexes (VPCs) during Holter monitoring. Mexiletine therapy was effective by programmed stimulation (VT no longer inducible or 15 or less beats) in 8 and ineffective in 27 patients. Twenty patients were discharged with mexiletine (14 of whom took an additional class IA agent). The discharge regimen was effective by programmed stimulation in 6 of these 20 patients. In 14 patients the discharge regimen was ineffective by programmed stimulation, but all patients had a marked reduction of ventricular ectopic activity (at least 83% reduction of VPCs and abolition of non sustained VT). During the follow-up period of 18 +/- 13 months (mean +/- standard deviation), 4 patients had recurrences (3 with an ineffective regimen by programmed stimulation and 1 with an effective regimen by programmed stimulation). Arrhythmia-free survival rates at 12 and 24 months were 86% and 77%, as determined by the Kaplan-Meier method, in patients with an ineffective regimen by programmed stimulation, and 80% and 80% in patients with an effective regimen by programmed stimulation (p = 0.979 by log rank test).(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Is Programmed Stimulation of Value in Predicting the Long-term Success of Antiarrhythmic Therapy for Ventricular Tachycardias?
    Date September 1986
    Journal The New England Journal of Medicine
    Excerpt

    We studied the value of programmed stimulation in assessing the efficacy of antiarrhythmic agents in 52 patients with sustained ventricular tachycardia. All patients in this nonrandomized study had ventricular tachycardia inducible by programmed stimulation and also had frequent ventricular premature complexes (greater than or equal to 30 per hour) on Holter-monitor recordings before therapy. The efficacy of antiarrhythmic agents was assessed by both programmed stimulation and Holter recordings during serial drug testing. A regimen was deemed effective according to the programmed-stimulation criteria in 25 patients (Group 1). Twenty-seven patients in whom tachycardia could still be induced during programmed stimulation despite extensive drug trials were discharged on a regimen that caused a marked reduction of ventricular premature complexes according to Holter monitoring (Group 2). In 23 patients no effective drug regimen was identified by either set of efficacy criteria, and these patients were excluded from the present analysis. Follow-up lasted 18.6 +/- 13.9 months. Rates of arrhythmia-free survival at 12 and 24 months were 88 percent and 72 percent, respectively, in Group 1 and 84 percent and 75 percent in Group 2 (P = 0.637). We conclude that demonstration of antiarrhythmic efficacy by programmed stimulation predicts a good clinical outcome, that inefficacy as shown by the programmed-stimulation protocol used in this study may not preclude a good outcome if there is a marked reduction of spontaneous ventricular premature complexes on Holter monitoring, and that randomized trials should be conducted to validate the results of this observational study.

    Title Discordance Between Ambulatory Monitoring and Programmed Stimulation in Assessing Efficacy of Mexiletine in Patients with Ventricular Tachycardia.
    Date August 1986
    Journal American Heart Journal
    Excerpt

    Programmed electrical stimulation (PES) and 24-hour Holter monitoring were compared in 30 patients with ventricular tachycardia (VT) or ventricular fibrillation (VF) before and during treatment with mexiletine. Before treatment, all patients had greater than or equal to 30 ventricular premature complexes (VPCs)/hr and 22 patients had nonsustained VT on Holter. All had inducible sustained VT by PES (one to three extrastimuli). Mexiletine was effective in only 23% by PES criteria (VT no longer inducible or less than or equal to 15 beats in duration and effective in 57%, 57%, and 73% by Holter criteria I, II, and III, respectively (Holter I greater than or equal to 50% reduction of VPCs, greater than or equal to 90% reduction of couplets and abolition of nonsustained VT; Holter II greater than or equal to 83% reduction of VPCs and abolition of VT; Holter III abolition of VT in patients who had VT during baseline Holter). Results of PES and Holter were discordant in 67%, 60%, and 55% (PES vs Holter I, II, and III, respectively). The majority (greater than or equal to 75%) of the discordance occurred due to mexiletine appearing effective by Holter criteria but ineffective by PES criteria (suggesting insensitivity of efficacy by Holter criteria and/or nonspecificity of induced VT during treatment with mexiletine). Conclusions: PES and Holter are discordant in assessing efficacy of mexiletine (p less than 0.05). Efficacy of mexiletine by Holter criteria is easier to achieve than efficacy by PES. The discordance between the two methods, both with very good reported predictive values, calls for randomized clinical follow-up studies to determine sensitivity and specificity of each method in assessing efficacy of mexiletine.

    Title Amiodarone: Value of Programmed Electrical Stimulation and Holter Monitoring.
    Date July 1986
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    The value of programmed electrical stimulation (PES) and Holter monitoring in the assessment of amiodarone efficacy was reviewed. Many physicians have been disturbed by the persistent inducibility of arrhythmias in patients treated with amiodarone, who nevertheless do very well during the follow-up period. Noninducibility was associated with a favorable prognosis among 366 VT patients. Eighty-eight (24%) were noninducible on amiodarone, and 10% of these had recurrences, vs 39% in patients who remained inducible. Further, increased difficulty of induction with PES or induction of a slower or better tolerated VT may indicate a favorable outlook, and add to the value of PES. Few papers rigorously employed Holter monitoring in the assessment of amiodarone. In general, suppression of previously frequent arrhythmias implies excellent protection for patients with benign arrhythmias and moderate protection with malignant arrhythmias. By Holter assessment in 186 VT patients, arrhythmias were suppressed in 114 (61%), and 18% of these had recurrences vs 50% in patients whose arrhythmias were not suppressed. Studies attempting to correlate the results of PES and Holter monitoring in the same patients are lacking and may prove useful.

    Title Unipolar Pacer Artifacts Induced Failure of an Automatic Implantable Cardioverter/defibrillator to Detect Ventricular Fibrillation.
    Date May 1986
    Journal The American Journal of Cardiology
    Title Marked Intra-atrial Conduction Delay with Split Atrial Electrograms: Substrate for Reentrant Supraventricular Tachycardia.
    Date April 1986
    Journal American Heart Journal
    Title Comparison of Ramp and Stepwise Incremental Pacing in Assessment of Antegrade and Retrograde Conduction.
    Date April 1986
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Conventional assessment of antegrade (AV) and retrograde (VA) conduction involves stepwise increments in pacing rates until block in conduction is observed. This study was designed to establish the comparative characteristics of ramp pacing, in which the rate is continuously and smoothly incremented until block occurs. Two hundred and ten patients participated in portions of this study. Stepwise pacing was performed in 10 beat/minute steps, with the rate held for at least 15 seconds at each step; if marked prolongation or variability in conduction was observed, the rate was held constant for up to 60 seconds to allow for accommodation. With ramp pacing, the rate was gradually increased at a steady 2-4 beats/minute/second. Whenever possible, both stepwise and ramp pacing were performed for assessment of both antegrade and retrograde conduction. All patients had conducted sinus rhythm as their baseline mechanism. Antegrade conduction was similar using incremental stepwise and ramp pacing. The AH interval at a cycle length (CL) of 500 ms, the maximum AH increment, the cycle length at AV block were all remarkably similar (p = NS). Assessment of retrograde conduction produced similar results, with insignificant differences between maximum conducted VA intervals, and cycle length at VA block using the two pacing techniques. Ramp pacing provides a useful and rapid alternative to conventional stepwise incremental pacing in the assessment of antegrade and retrograde conduction in patients using both normal and accessory pathways. Ramp pacing was better tolerated, and some correlations between antegrade and retrograde conduction were stronger with the ramp pacing technique.

    Title Catheter Ablation of Tachycardias.
    Date April 1986
    Journal Archives Des Maladies Du Coeur Et Des Vaisseaux
    Excerpt

    Non-surgical electrode catheter ablation appears to be a useful technique for the treatment of selected patients with resistant supraventricular and ventricular tachycardias. Many problems remain, including the need for improved methods of tachycardia localization, the need for permanent pacing with A-V junctional ablation, a variety of potential and demonstrated complications, and the need for specially designed equipment. The relative role of electrical ablation versus other new techniques such as those employing lasers, remains unsettled. The clearly demonstrated benefits of electrical ablation in a growing number of patients ensures that continued development and refinement will occur.

    Title Discordance Between Ambulatory Monitoring and Programmed Stimulation in Assessing Efficacy of Class Ia Antiarrhythmic Agents in Patients with Ventricular Tachycardia.
    Date October 1985
    Journal Journal of the American College of Cardiology
    Excerpt

    Concordance between programmed stimulation and 24 hour ambulatory electrocardiographic (Holter) monitoring was studied in 54 patients with sustained ventricular tachycardia during 84 therapeutic trials with class IA antiarrhythmic agents. During baseline studies before treatment, all patients had frequent (greater than or equal to 30/h) ventricular premature complexes on Holter recordings and sustained ventricular tachycardia inducible by one to three extrastimuli. During treatment, programmed stimulation and Holter monitoring were repeated. Efficacy of treatment determined by programmed stimulation (ventricular tachycardia no longer inducible or nonsustained) was compared with three Holter criteria of efficacy: I = 83% or more reduction of ventricular premature complexes and abolition of ventricular tachycardia; II = 50% or more reduction of ventricular premature complexes and 90% or more reduction of couplets and abolition of ventricular tachycardia; III = abolition of ventricular tachycardia in patients with ventricular tachycardia during a baseline Holter recording. Treatments were judged effective by programmed stimulation criteria in only 25% of cases but in 51, 63 and 75% of cases by Holter criterion I, II and III, respectively. Results of programmed stimulation and Holter monitor were discordant (effective by one criterion but ineffective by the other) in 50% of cases using Holter criterion I, in 54% using Holter criterion II and in 61% using Holter criterion III. In the majority of discordant results, treatments appeared efficacious by Holter criteria but ineffective by programmed stimulation criteria, suggesting insensitivity of efficacy by Holter criteria or nonspecificity of induced ventricular tachycardia during treatment, or both.

    Title Bethanidine Sulfate: Efficacy in Prevention of Ventricular Tachyarrhythmias During Programmed Stimulation. Report of a Multicenter Study of 56 Patients.
    Date October 1985
    Journal Journal of the American College of Cardiology
    Excerpt

    Twelve cardiac electrophysiology centers conducted an open label prospective trial of bethanidine sulfate, an oral bretylium analog, for the prevention of ventricular tachyarrhythmias during programmed electrical stimulation. The study group included 56 patients (44 men, 12 women; mean age 60 years; 55 with structural heart disease). Sixteen patients had both ventricular tachycardia and fibrillation, 30 had ventricular tachycardia alone and 10 had ventricular fibrillation alone. Programmed stimulation on no antiarrhythmic drugs induced sustained ventricular tachycardia in 46 patients, nonsustained ventricular tachycardia in 4 patients and ventricular fibrillation in 6 patients. During programmed ventricular stimulation after 59 trials of 20 to 30 mg/kg body weight of oral bethanidine (acute dosing in 40 patients, and divided dosing over 24 hours in 19 patients), no ventricular tachyarrhythmias were inducible in 6 patients (11%), sustained ventricular tachycardia was converted to nonsustained ventricular tachycardia in 3 patients (5%), ventricular tachyarrhythmias remained inducible in 39 patients (70%) and spontaneous ventricular tachyarrhythmias occurred more frequently in 4 patients (7%). Side effects prevented repeat testing in four patients. The 10 patients presenting with only ventricular fibrillation appeared to have a higher response rate: no ventricular tachyarrhythmias were inducible in 2 patients and sustained ventricular tachycardia was converted to nonsustained ventricular tachycardia in 2 patients. Despite protriptyline administration in 54 of 59 bethanidine trials, symptomatic hypotension occurred in 30 trials (51%). In conclusion, the efficacy of bethanidine for preventing ventricular tachyarrhythmias as assessed by programmed stimulation is low. Patients presenting with only ventricular fibrillation may have a more favorable response to bethanidine sulfate. Symptomatic hypotension occurs frequently despite concomitant use of protriptyline.

    Title Naspe Ad Hoc Committee on Guidelines for Cardiac Electrophysiological Studies.north American Society of Pacing and Electrophysiology.
    Date September 1985
    Journal Pacing and Clinical Electrophysiology : Pace
    Title The Value of Electrophysiologic Studies in Syncope of Undetermined Origin: Report of 150 Cases.
    Date September 1985
    Journal American Heart Journal
    Excerpt

    A prospective study examined the diagnostic yield and therapeutic efficacy of electrophysiologic studies in patients with SUO. We defined SUO as those syncopal or near-syncopal events remaining unexplained after a standardized, noninvasive evaluation that included a history, physical examination, routine laboratory screening, EEG, nuclear brain scan or CAT scan, 12-lead ECG, chest x-ray, orthostatic vital signs, bedside carotid sinus massage, and at least 24 hours of continuous ECG monitoring. The 150 SUO patients included 95 men and 55 women (mean age 62.0 years); 35 had recurrent SUO, 75 (50%) had organic heart disease, and 129 (86%) had abnormal ECGs. There were 162 abnormal electrophysiologic findings that could explain the SUO uncovered in 112 patients, a diagnostic yield of 75%: one finding in 71 patients, two findings in 32, and three findings in nine. These findings were: His-Purkinje disease in 49 patients (30%), inducible ventricular arrhythmias in 36 (22%), AV nodal disease in 20 (12%), sinus node disease in 19 (12%), inducible supraventricular arrhythmias in 18 (11%), carotid sinus hypersensitivity (not elicited by carotid sinus massage prior to electrophysiologic studies) in 15 (9%), and hypervagotonia in five (3%). When electrophysiologic study findings were classified as clearly abnormal or borderline, 54 patients had at least one clearly abnormal finding, a diagnostic yield of 36%. Subgroups of patients presenting with only a single SUO event, no evidence of organic heart disease, or normal baseline ECGs all had substantial diagnostic yields during electrophysiologic studies. Follow-up data in 137 patients (91%) (mean 31 months) showed recurrences in 16 of 34 patients (47%) without and 15 of 103 patients (15%) with electrophysiologic findings despite therapy directed by electrophysiologic testing (p less than 0.0005). This study and a review of the literature indicate that electrophysiologic testing is useful in elucidating the causes of SUO and directing therapy. A significant number of patients benefit from electrophysiologic studies, even when only clearly abnormal findings are considered diagnostic, when only a single syncopal event has occurred, or whether or not organic heart disease or an abnormal ECG is present.

    Title Combination of Procainamide and Quinidine for Better Tolerance and Additive Effects for Ventricular Arrhythmias.
    Date August 1985
    Journal The American Journal of Cardiology
    Excerpt

    The efficacy and tolerance of quinidine and procainamide used individually and in combination were studied in 19 patients with frequent ventricular premature complexes (VPCs). During single-drug treatment, the maximum tolerated dose of quinidine without extracardiac dose-related side effects was 1.6 +/- 0.21 g/day and that of procainamide was 4.1 +/- 1.05 g/day. During combination therapy with smaller doses (p less than 0.05) of quinidine (1.16 +/- 0.26 g/day) and procainamide (2.80 +/- 0.98 g/day), no patient had side effects. Before treatment, all patients had frequent (more than 60 per hour) VPCs and 17 had ventricular tachycardia on Holter monitoring. The frequency of VPCs was reduced to 22 +/- 19% with quinidine, 47 +/- 40% with procainamide and 9 +/- 11% with combination therapy (p less than 0.05, combination vs procainamide or quinidine alone). Individually, an effective regimen (more than 83% reduction of VPCs and abolition of ventricular tachycardia) was found in 5 patients (26%) receiving quinidine alone at maximal tolerated dose, in 4 (21%) receiving procainamide alone at maximal tolerated dose, and in 14 (74%) receiving combination therapy (p less than 0.01 vs quinidine or procainamide). Thus, the antiarrhythmic effects of quinidine and procainamide are additive. When quinidine or procainamide are additive. When quinidine or procainamide is ineffective because dose-related extracardiac side effects limit the maximal tolerated dose, combination therapy in smaller and tolerable doses avoids side effects and is more effective than either drug alone at the maximal tolerated dose.

    Title Prediction of Sudden Death and Spontaneous Ventricular Tachycardia in Survivors of Complicated Myocardial Infarction: Value of the Response to Programmed Stimulation Using a Maximum of Three Ventricular Extrastimuli.
    Date July 1985
    Journal Journal of the American College of Cardiology
    Excerpt

    The prognostic significance of ventricular arrhythmias induced by programmed electrical stimulation was evaluated in 50 survivors of acute myocardial infarction complicated by a major new conduction disturbance (38 patients), congestive heart failure (33 patients) or sustained ventricular tachyarrhythmias (22 patients), alone or in combination. Programmed stimulation was performed in patients in stable condition 7 to 36 days (mean 16) after infarction using one to three extrastimuli at four times diastolic threshold at a maximum of two right ventricular sites. Two groups were identified by the response to programmed stimulation: 17 patients with sustained (greater than 15 seconds) or nonsustained (greater than 7 beats but less than or equal to 15 seconds) ventricular tachycardia (group I), and 33 patients with 0 to 7 intraventricular reentrant complexes in response to maximal stimulation efforts (group II). Group I patients had a higher incidence of anterior infarction than that of patients in group II (71 versus 42%), had lower left ventricular ejection fraction (mean 0.35 versus 0.48) and were more often treated with antiarrhythmic drugs (47 versus 18%, p less than 0.05). There were no significant differences between groups in the occurrence of congestive failure, new conduction disorders or sustained ventricular arrhythmias with infarction, or in the proportions treated with a beta-receptor blocking agent, coronary bypass grafting or a permanent pacemaker. Total cardiac mortality was 24% during a mean follow-up period of 23 months and did not differ between groups; however, the response to programmed stimulation identified a group at high risk of late sudden death or spontaneous ventricular tachycardia: 7 (41%) of 17 group I patients compared with 0 of 33 group II patients (p less than 0.001). The induction of sustained or nonsustained ventricular tachycardia identified all patients who died suddenly or had spontaneous tachycardia (sensitivity 100%), but triple extrastimuli were required to induce prognostically significant arrhythmias in five of these seven patients; the specificity of this protocol was only 57%. When the clinical variables of the group were evaluated individually, the response to programmed stimulation had a stronger association with occurrence of late sudden death than did any other factor (Fisher's exact test, p less than 0.001); however, a type II error could not be excluded.(ABSTRACT TRUNCATED AT 400 WORDS)

    Title Activation Mapping in Patients with Coronary Artery Disease with Multiple Ventricular Tachycardia Configurations: Occurrence and Therapeutic Implications of Widely Separate Apparent Sites of Origin.
    Date May 1985
    Journal Journal of the American College of Cardiology
    Excerpt

    Catheter or intraoperative activation mapping studies, or both, were performed in 17 patients with coronary artery disease with two to four distinct configurations of ventricular tachycardia, resistant to a mean of 12.1 +/- 6.0 antiarrhythmic drug trials per patient. Mapping studies were performed to guide anticipated surgical ablation of arrhythmias. Activation map data were adequate to determine sites of origin of 30 (64%) of 47 observed tachycardia configurations. These 30 ventricular tachycardias (26 observed clinically) were mapped to 22 separate endocardial sites of origin. Sites of origin of distinct tachycardias were identical or closely adjacent (within 3 cm) in six patients and widely separate (greater than or equal to 4 cm) in eight patients (47% of the group). Activation maps were not adequate to determine sites of origin of 17 (36%) of the 47 tachycardias, including all configurations in three patients. Fifteen patients underwent surgery for control of ventricular tachycardia: aggressive, map-guided endocardial resection (mean 26.5 +/- 14.2 cm2) in 12 patients with identified sites of tachycardia origin and extensive resection of visible endocardial scar (2 patients) or encircling endocardial ventriculotomy (1 patient) in those in whom the sites of origin of all clinical tachycardias remained undetermined. Two inoperable patients were treated with amiodarone. During postoperative electrophysiologic tests (11 of 13 surgical survivors), ventricular tachyarrhythmias were initially uninducible in only 4 of 11 patients. However, in two patients only nonclinical arrhythmias (ventricular flutter) were induced. Six (21%) of 29 clinical tachycardias whose sites of origin were either not determined or not resected (right septum or papillary muscle) remained inducible in five patients. Using previously ineffective antiarrhythmic drugs, initially inducible arrhythmias became uninducible (two patients), or harder to induce than preoperatively (five patients). As a result of surgical resections alone or in combination with previously ineffective drugs (and amiodarone in two inoperable patients), there were no recurrences of ventricular tachycardia in 14 (93%) of 15 patients discharged during 19.0 +/- 14.3 months of follow-up study. Thus, activation mapping may commonly reveal separate apparent sites of origin for clinically observed, morphologically distinct, highly drug-refractory ventricular tachycardias in patients with coronary artery disease with multiple tachycardia configurations. Extensive surgical resection of identified sites of origin may be required to ablate arrhythmias in these patients.(ABSTRACT TRUNCATED AT 400 WORDS)

    Title Disopyramide-pyridostigmine: Report of a Beneficial Drug Interaction.
    Date May 1985
    Journal Journal of Cardiovascular Pharmacology
    Excerpt

    A previously unrecognized beneficial drug interaction is described. Without affecting the antiarrhythmic properties of disopyramide, a sustained-release form of pyridostigmine (a cholinesterase inhibitor) was shown to prevent completely anticholinergic side effects in a study population (17 patients), whereas side effects occurred in 26 of 89 patients (29%) in a control group (p less than 0.025). Pyridostigmine also diminished or abolished disopyramide-induced anticholinergic side effects in each of 10 patients in whom they were already present. Pyridostigmine allowed an increase in tolerated disopyramide blood levels (4.53 +/- 1.59 micrograms/ml versus 3.85 +/- 1.78 micrograms/ml) and a significant increase in disopyramide dosages (224 +/- 68 mg versus 188 +/- 68 mg every 6 h) (p less than 0.02). No patients suffered side effects from pyridostigmine. These data suggest that pyridostigmine can be used to prevent as well as to treat the anticholinergic side effects of disopyramide. The usefulness of disopyramide has previously been limited by these anticholinergic side effects. Further investigation is in progress to determine what role pyridostigmine can play in making disopyramide therapy available to patients who otherwise could not benefit from its use.

    Title Pacing for Ventricular Tachycardia.
    Date January 1985
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Many problems remain to be solved before implanted pacers can assume a major role in the treatment of ventricular tachycardia. Case histories are cited to illustrate some of the difficulties to be overcome. Possible mechanisms for the success and failure of antitachycardia pacing are reviewed. Prospects for antitachycardia pacing will increase with the advent of cardioverter/defibrillator back-up.

    Title Implantation of Automatic Cardioverter-defibrillators Via Median Sternotomy.
    Date January 1985
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    15 AICD (automatic implantable cardioverter-defibrillator) Model B units were implanted in 10 patients. The median sternotomy is our preferred surgical approach using a right atrial patch electrode, a left ventricular apex patch electrode, and two closely placed epicardial sensing electrodes. Follow-up is 109 patient months and all patients are alive. AICD units discharged for ventricular tachycardia, ventricular flutter, and ventricular fibrillation. Discharges also occurred for sinus tachycardia and atrial fibrillation above the rate limit in three units. Premature pulse generator depletion has occurred in four AICD-B units 3 to 18 months postimplant and appears due to a defect in original battery design. Discharge of the AICD for supraventricular tachycardia is a problem that will remain until a better means of differentiating supraventricular tachycardia from ventricular tachyarrhythmias is found. The AICD appears to prevent sudden death from ventricular tachyarrhythmias.

    Title Attempted Nonsurgical Electrical Ablation of Accessory Pathways Via the Coronary Sinus in the Wolff-parkinson-white Syndrome.
    Date October 1984
    Journal Journal of the American College of Cardiology
    Excerpt

    Previous canine experiments suggested that transvenous catheters placed in the coronary sinus could be used to deliver limited energy shocks, resulting in fibrosis in the atrial wall and coronary sulcus with sparing of the coronary artery. From the distribution of the fibrosis, it appeared that this approach could be used for attempted ablation of accessory pathways in patients with the Wolff-Parkinson-White syndrome. Eight patients with symptomatic Wolff-Parkinson-White syndrome underwent electrophysiologic testing with attempted ablation of 10 accessory pathways. Shocks were limited to 40 to 80 J, except in one patient who received shocks of 100 and 150 J. From 2 to 26 shocks were given to each accessory pathway. All the accessory pathways were blocked completely immediately after the shocks. Subsequently, evidence of accessory pathway conduction recurred in each patient. Three had early promise of long-term improvement after the procedure, with prolongation of the refractory periods of the accessory pathways during the remainder of the initial hospitalization. Several weeks later, however, there was evidence of return toward original values in two of these. Another patient who appeared not to benefit during her initial hospitalization returned 7 weeks later with very depressed accessory pathway conduction, possibly due to developing fibrosis. The only significant complication occurred in the patient receiving shocks of 100 and 150 J; he had apparent rupture of the coronary sinus requiring pericardial drainage. In two patients in whom nonsurgical ablation was not successful, intraoperative mapping showed that the accessory pathway was located in an area of fibrosis at the site of the attempted ablation. In summary, nonsurgical electrical ablation of accessory pathways via the coronary sinus may be successful using limited energy levels in a few patients. The procedure remains experimental, and widespread application must await more effective means of delivering the shocks.

    Title Ddd/ddt Pacemakers in the Treatment of Ventricular Tachycardia.
    Date May 1984
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    The possibility of adapting multimode dual-chamber pacemakers for programmed and burst stimulation was explored in a group of patients with ventricular tachycardia. The potential usefulness and pitfalls of these pacemakers were exemplified in one patient, presented in detail. The implanted DDD pacemaker was programmed to an all-synchronous mode (DDT), permitting programmed ventricular stimulation through synchronization with chest wall stimulation provided by a standard external programmable stimulator. With the ventricular sensing refractory period shortened to 200 ms, both programmed electrical stimulation and burst pacing for termination of induced tachycardias were possible. When medications failed to offer protection against the patient's tachycardias, the ventricular sensing refractory period (and minimum stimulation interval) was increased to 300 ms, thereby permitting burst pacing at up to 200 beats/minute for termination of spontaneous episodes. After many trials to confirm the efficacy of such stimulation, and the lack of muscle potential triggering, the patient was discharged home with the pacemaker in the DDT mode. He was instructed to go to his local emergency room, and was equipped with a portable device to trigger his implanted unit. Subsequently, the patient had successful termination of several spontaneous episodes of ventricular tachycardia in an emergency room. Later, he began to experience palpitations during certain exercises, and it was found that the implanted unit was being triggered by pectoral myopotentials. The unit was therefore reprogrammed to decrease the sensitivity, and the patient was again discharged. The need for careful evaluation and close follow-up is emphasized to maximize the benefits and to minimize the very serious potential risks of this pacing mode.

    Title Results of Electrophysiologically Guided Operations for Drug-resistant Recurrent Ventricular Tachycardia and Ventricular Fibrillation Due to Coronary Artery Disease.
    Date April 1984
    Journal The Journal of Thoracic and Cardiovascular Surgery
    Excerpt

    Over a 39 month period, 143 patients with coronary artery disease had programmed stimulation (PES) for recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF). Twenty-two patients underwent operations. Ages ranged from 40 to 71 years; 20 of the 22 were men. All patients had coronary artery disease and 11 had left ventricular aneurysms. The mean ejection fraction was 31% (16% to 50%). Eighteen of the 22 patients underwent operations for drug-resistant ventricular arrhythmias (more than six different drugs plus drug combinations tested per patient). Nineteen patients had intraoperative mapping, endocardial resection, and/or an encircling endocardial ventriculotomy. Three patients with ischemia-related VT had coronary artery bypass (CABG) alone. The 30 day operative mortality was 14%. Thirteen of 19 (68%) operative survivors were effectively controlled with operation alone or a combination of operation and previously ineffective drug therapy. Of the six patients whose VT was inducible postoperatively, three have experienced episodes of sustained VT and one patient died suddenly. Three of these patients have the automatic implantable defibrillator. Operation guided by endocardial mapping is effective alone or in combination with drugs in this select group of patients. If the patients' VT was uninducible postoperatively with or without the addition of antiarrhythmic therapy, late deaths (3/19) were due to poor myocardial reserve and coronary artery disease, not the reemergence of sustained ventricular arrhythmias during a mean follow-up of 15 months.

    Title Nonsurgical Electrical Ablation of Tachycardias: Importance of Prior in Vitro Testing of Catheter Leads.
    Date March 1984
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Nonsurgical electrical ablation of tachycardia pathways or foci has been attempted or carried out using a variety of temporary pacing catheter leads. To determine the ability of such leads to withstand the high energies used in such procedures, 34 leads were suspended in saline, and subjected to repeated electrical shocks. Small (4 French) temporary pacing leads made by a variety of manufacturers tolerated multiple shocks up to 100 joules; above this level, failures became increasingly common, although usually the failure mode was benign with respect to patient care implications. Testing of 6, 7, and 8 French leads revealed considerable inter-and intra-manufacturer differences in the ability to withstand higher energy shocks, reflecting differences in materials and fabrication techniques. It is concluded that careful in vitro lead testing is required prior to using identical models in humans for arrhythmia ablation procedures.

    Title Results of Endomyocardial Biopsy in Patients with Spontaneous Ventricular Tachycardia but Without Apparent Structural Heart Disease.
    Date January 1984
    Journal Circulation
    Excerpt

    To evaluate possible occult myocardial disease in 18 patients whose only major manifestation of heart disease was spontaneous ventricular tachycardia or fibrillation, right ventricular endomyocardial biopsies were performed. None of the patients had symptoms of ischemic or congestive heart disease, and at catheterization none had significant lesions of the coronary arteries or regional wall motion abnormalities of the left ventricle. The mean left ventricular ejection fraction (65 +/- 7%), mean right ventricular ejection fraction (55 +/- 9%), mean cardiac index (3.0 +/- 0.5 1/min/m2), mean right atrial pressure, mean pulmonary capillary wedge pressure, and mean pulmonary artery systolic pressure were normal. However, right ventricular endomyocardial biopsy specimens were abnormal in 16 of 18 (89%) patients: nine (50%) had changes of a significant, although nonspecific, cardiomyopathy with myocellular hypertrophy, interstitial and perivascular fibrosis, and vascular sclerosis; three (17%) had subacute inflammatory myocarditis; two (11%) had diffuse abnormalities of the intramyocardial arteries; and two (11%) had pathologic changes consistent with arrhythmogenic right ventricular dysplasia. In the two (11%) patients with normal biopsy specimens, one had Wolff-Parkinson-White syndrome and the other had mitral valve prolapse. Although histologic abnormalities were found in 89% of these patients, performance of right ventricular endomyocardial biopsies in this group of patients should be considered a research procedure. We conclude that the majority of patients who have serious ventricular arrhythmias but no apparent structural cardiac abnormalities have abnormal right ventricular biopsy specimens and that the arrhythmias may be the first manifestation of a variety of primary myocardial abnormalities.

    Title Survey of Clinical Slit Lamps.
    Date January 1984
    Journal Ophthalmology
    Title Mechanisms for the Success and Failure of Pacing for Termination of Ventricular Tachycardia: Clinical and Hypothetical Considerations.
    Date December 1983
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    The effectiveness of pacing techniques for termination of ventricular tachycardia is well established, and of great value in the electrophysiologic laboratory, and, to a more limited degree, for chronic therapy using implanted anti-tachycardia devices. Although it appears that most clinical ventricular tachycardias are due to reentrant mechanisms, responses to antitachycardia pacing have often been difficult to understand. In this paper, clinical observations are correlated with hypothetical constructs and considerations, in an attempt to derive some general principles related to the success and failure of pacing for ventricular tachycardia. In these analyses, it appears that properties of conductivity and refractoriness in the myocardium are as important as the properties of the tachycardia circuit. Programmed extrastimuli or rapid pacing result in shortening of the effective refractory period of the myocardium, together with depressed conduction velocity of the stimulated wavefront. However, the changes in wavefront conductivity do not occur in step with changes in the effective refractory period; as a result, the stimulated wavefront arrives at the tachycardia circuit in a pattern which differs from the stimulation pattern. In general, it appears that termination of the tachycardia is favored when the stimulated wavefront arrives at the tachycardia circuit at a point when it cannot enter the circuit in an antegrade direction. These conditions are favored by a refractory period in the circuit which is moderately long compared to that of the myocardium. Constructions explaining the observation of a tachycardia termination zone are presented, together with explanations for failure to achieve termination, and for various patterns of acceleration.

    Title Role of a Catheter Lead System for Transvenous Countershock and Pacing During Electrophysiologic Tests: an Assessment of the Usefulness of Catheter Shocks for Terminating Ventricular Tachyarrhythmias.
    Date October 1983
    Journal The American Journal of Cardiology
    Title Validation of Regional Myocardial Flow Measurements with Scintillation Camera Detection of Xenon-133.
    Date August 1978
    Journal Investigative Radiology
    Excerpt

    Measurement of disappearance rates of diffusible isotopes with a scintillation camera has been used to estimate myocardial blood flow in man, although there has been no data to assess the accuracy of the technique. We compared regional flow measurements using scintillation camera detection of 133 Xe with essentially simultaneous measurements using gamma-emitter labeled microspheres and differential spectrometry of left ventricular tissue. In 16 dogs, flows through 20--50% of the left ventricle were obtained at rest and with intravenous isoproterenol; the coefficient of correlation of paired measurements with the two techniques was 0.74. In eight dogs, a coronary artery was ligated, and regions approximately 2.2 cm2 at nearby locations in normal, infarcted and marginal tissue studied; the coefficient of correlation was 0.73. In five dogs, flow in three to five precisely identical 1.1 cm2 regions were measured at rest and with isoproterenol by both methods; correlations within each dog ranging from 0.81 to 0.93 were obtained. Although flows with the scintillation camera technique tended to be lower than values with the microsphere technique, it is suggested that the linear correlations of paired values with the two techniques is evidence that scintillation camera detection of 133Xe can be used to quantitate changes in regional myocardial perfusion in the cardiac catheterization laboratory.

    Title Wenckebach Atrioventricular Block (mobitz Type I) in Children and Adolescents.
    Date October 1977
    Journal The American Journal of Cardiology
    Title Cardiac Pacing and Pacemakers Ii. Serial Electrophysiologic-pharmacologic Testing for Control of Recurrent Tachyarrhythmias.
    Date May 1977
    Journal American Heart Journal
    Excerpt

    The place of pacemakers in the treatment of tachyarrhythmias has expanded far beyond the initial role in the brady-tachy syndrome, of providing a "minimum guaranteed rate" while medications suppress the tachycardia. Techniques have been developed for prevention, termination, and duplication of a patient's spontaneous tachycardia under safe catheterization laboratory conditions. Combined with accumulating information about the normal responses to electrophysiologic stresses, these techniques have led to a new dimension in arrhythmia control. Most tachycardias previously felt to be refractory can be controlled after serial electrophysiologic-pharmacologic testing, during which sequential pharmacologic and pacer regimens are tested until a combination is found which prevents induction of tachycardias, and/or a pace mode is found which reliably terminates the tachycardia. Use of such an approach reduces hospital admissions and referral for surgery, and eliminates prolonged hospitalization for assessment of therapy in patients with infrequent but potentially lethal spontaneous tachycardias.

    Title Effects of Dextrothyroxine on Hyperlipidemia and Experimental Atherosclerosis in Beagle Dogs.
    Date January 1976
    Journal Atherosclerosis
    Excerpt

    Beagle dogs, 24 +/- 6 months old, fed a thiouracil-free semi-synthetic diet containing hydrogenated coconut oil and cholesterol (SS diet) for 12 months, developed marked hyperlipidemia and severe atherosclerosis. SS diet produced a marked elevation of serum cholesterol, triglyceride, phospholipid, and beta-lipoprotein and severe atherosclerosis in large and small arteries. Intimal fatty lesions were always present in the abdominal aorta and many of its branches. Large and small coronary arteries showed similar lesions. The degree of atherosclerosis was directly related to circulating lipid levels. Dextrothyroxine, at dose levels of 0.1 (equivalent to normal human dose) and 0.5 mg/kg body weight, produced a significant dose related lowering of serum lipids and was associated with a markedly decreased severity of aortic and coronary artery lesions. Untreated control dogs that were maintained on purina dog meal developed neither hyperlipidemia nor atherosclerosis.

    Title The New Approaches to Brain Tumor Therapy (nabtt) Cns Consortium: Organization, Objectives, and Activities.
    Date
    Journal Cancer Control : Journal of the Moffitt Cancer Center
    Excerpt

    BACKGROUND: Despite advances in neuro-imaging, neurosurgery, radiation therapy, and chemotherapy, limited progress has been made in the treatment of patients with high-grade astrocytomas. The National Cancer Institute has attempted to speed advances in this field by funding CNS consortia to conduct innovative clinical trials in this patient population since 1994. METHODS: The NABTT CNS Consortium is composed of a consortium headquarters and nine member institutions with outstanding multidisciplinary expertise, clinical and laboratory research capabilities, and access to large numbers of patients with brain tumors. RESULTS: The objectives of the NABTT Consortium are to improve the therapeutic outcome for adults with primary brain tumors, to conduct basic science and clinical research, and to improve the care and quality of life of adults with primary brain tumors. NABTT's clinical studies have discovered important drug interactions between anticonvulsant and antineoplastic agents, defined the activity of paclitaxel and 9-aminocamptothecin in glioblastoma multiforme, tested a novel dose escalation strategy for brain tumor trials, and established new protocol "classes" to expedite and standardize clinical research in this field. CONCLUSIONS: Significant progress in the care of patients with primary brain tumors is likely to result from the highly focused and multidisciplinary efforts of the NIH-funded CNS consortia.

    Title [cpaln(2,6-i-pr(2)c(6)h(3))](2): A Dimeric Iminoalane Obtained by Alkane Elimination.
    Date
    Journal Inorganic Chemistry
    Title Heteroatom Derivatives of Cyclopentadienylaluminum: X-ray Crystal Structure of (eta(5)-c(5)h(5))(2,6-t-bu-4-me-c(6)h(2)o)(2)al.
    Date
    Journal Inorganic Chemistry
    Excerpt

    The cyclopentadienylaluminum aryloxide derivatives bis(cyclopentadienyl)(2,6-di-tert-butyl-4-methylphenoxy)aluminum (1) and (eta(5)-cyclopentadienyl)bis(2,6-di-tert-butyl-4-methylphenoxy)aluminum (2) have been prepared via the alcoholysis of tricyclopentadienylaluminum with 2,6-di-tert-butyl-4-methylphenol. The X-ray crystal structure of 2 was determined. The molecule crystallizes in the monoclinic space group C2/c with a = 15.4870(6) Å, b = 11.5404(5) Å, c = 18.3294(7) Å, beta = 103.0990(10) degrees, Z = 4, and V = 3190.7(2) Å(3) (R[I > 2sigma(I)] = 0.0755, R(w) = 0.1489). In the solid state, the cyclopentadienyl ring is bound eta(5) to the aluminum atom. Ab initio calculations on model compounds indicate that the pentahapto geometry of the cyclopentadienyl ring is due to the electron-withdrawing nature of the aryloxide ligands which allows greater pi-interaction between the aluminum center and the cyclopentadienyl ligand.

    Title Synthesis and Characterization of Dimeric, Trimeric, and Tetrameric Gallophosphonates and Gallophosphates.
    Date
    Journal Inorganic Chemistry
    Excerpt

    THF/toluene solutions of phosphonic or phosphoric acids were reacted with (t)Bu(3)Ga at low temperature to yield the cyclic dimers [(t)Bu(2)GaO(2)P(OH)R](2) (R = Ph, Me, (t)Bu, H, OH; 1-5). Poor crystallinity and variable thermal stabilities of 1-5 necessitated derivatization with Me(3)SiNMe(2) to yield [(t)Bu(2)GaO(2)P(OSiMe(3))R](2) (R = Ph, Me, (t)Bu, H, OSiMe(3); 6-10), which were more amenable to purification and characterization. In solution, trans isomers were predominant for 6 and 7 at ambient temperature, whereas the cis isomer of 8 was predominant. NMR spectroscopy demonstrated cis-trans interconversion for 6-8 and crossover experiments showed interconversion to occur by, or be accompanied with, an intermolecular exchange process. Thermolysis of 3 in refluxing toluene yielded the cluster [((t)BuGa)(2)((t)Bu(2)Ga)(O(3)P(t)Bu)(2){O(2)P(OH)(t)Bu}] (11), which was converted to [((t)BuGa)(2)((t)Bu(2)Ga)(O(3)P(t)Bu)(2){O(2)P(OSiMe(3))(t)Bu}] (12) with Me(3)SiNMe(2). Thermolysis of 1-3 in refluxing diglyme, or solid-state pyrolysis at 250 degrees C in vacuo, yielded [(t)BuGaO(3)PR](4) (R = Ph, (t)Bu, Me; 13-15). The gallophosphate [(t)BuGaO(3)P(OSiMe(3))](4) (16) was similarly obtained by reaction of (t)Bu(3)Ga with H(3)PO(4) in refluxing diglyme, followed by trimethylsilylation with Me(3)SiNMe(2). Compounds 13-16 possess cuboidal Ga(4)P(4)O(12) cores analogous to double-four-ring secondary building units in the gallophosphates cloverite, gallophosphate-A, and ULM-5. The thermal, hydrolytic, and oxidative stabilities of 13-16 are discussed, as are observed intermolecular exchange processes. In addition to characterization of 1-16 by multinuclear ((1)H, (13)C, (31)P) NMR spectroscopy, infrared spectroscopy, mass spectrometry, and elemental analysis, molecular structures for compounds 6, 8, 10, 12, 14, 15, and 16 were determined by X-ray crystallography.

    Title The Information-motivation-behavioral Skills Model of Art Adherence in a Deep South Hiv+ Clinic Sample.
    Date
    Journal Aids and Behavior
    Excerpt

    High levels of adherence to antiretroviral therapy (ART) are critical to the management of HIV, yet many people living with HIV do not achieve these levels. There is a substantial body of literature regarding correlates of adherence to ART, and theory-based multivariate models of ART adherence are emerging. The current study assessed the determinants of adherence behavior postulated by the Information-Motivation-Behavioral Skills model of ART adherence in a sample of 149 HIV-positive patients in Mississippi. Structural equation modeling indicated that ART-related information correlated with personal and social motivation, and the two sub-areas of motivation were not intercorrelated. In this Deep South sample, being better informed, socially supported, and perceiving fewer negative consequences of adherence were independently related to stronger behavioral skills for taking medications, which in turn associated with self-reported adherence. The IMB model of ART adherence appeared to well characterize the complexities of adherence for this sample.

    Title Intravenous Sedation for Cardiac Procedures Can Be Administered Safely and Cost-effectively by Non-anesthesia Personnel.
    Date
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    AIMS: Primary: to determine the safety and efficacy of intravenous sedation for cardiac procedures administered by non-anesthesia personnel. Secondary: to assess cost effectiveness of such sedation. METHODS: Anesthesiologists trained non-anesthesia personnel, and established our sedation protocol, which was then used in 9,558 patients who had cardiac procedures with sedation by non-anesthesia personnel, recorded on a computerized database. Most sedation used was midazolam (MID) and morphine (MOR). Complications and problems were derived from the database and quality assurance committee records. Doses were based on desired level of sedation and procedure duration; highest dose used: MID 78 mg, MOR 84 mg. RESULTS: Data included catheterization (n = 3,819) and transesophageal echo procedures (n = 260); and overall electrophysiology (n = 5,479) and selected subsets. There were complications or problems in only 9 patients (0.1%), a strong safety statement. There were 3 deaths in electrophysiology related procedures, 2 deaths in catheterization related procedures, all in very sick patients and not definitely related to sedation; 4 others developed clinical instability (hives, hypotension and heart failure-all with no sequellae), 2 of which needed reversal medications. Three patients (<0.03%) proved difficult to sedate, and their procedures were completed with help from the anesthesia department; by protocol this was not a complication. A total of $5,365,691 was saved during the last decade on cardiac procedures performed with conscious sedation. CONCLUSION: Non-anesthesia personnel can administer intravenous sedation for cardiac procedures in cardiac settings, with safety and cost-effectiveness demonstrated over many years. Anesthesia services are still appropriate for selected cases.

    Title Attitudes Toward Needle-sharing and Hiv Transmission Risk Behavior Among Hiv+ Injection Drug Users in Clinical Care.
    Date
    Journal Aids Care
    Excerpt

    Risky behavior related to injection drug use accounts for a considerable proportion of incident HIV infection in the United States. Large numbers of injection drug users (IDUs) currently receive antiretroviral therapy in clinical settings and are accessible for risk-reduction interventions to reduce transmission of drug-resistant HIV and spread of HIV to uninfected others. The current study examined attitudes toward needle- or equipment-sharing among 123 HIV-positive IDUs in clinical care in an effort to understand the dynamics of such behavior and to create a basis for clinic-based risk-reduction interventions. Results indicate that at baseline, participants who reported extremely negative attitudes toward needle-sharing were less likely to have shared during the past month than those with less-extreme negative attitudes. Demographic, behavioral, and attitudinal variables were entered into a logistic regression model to examine needle-sharing group membership among HIV-positive IDUs. Being female and having less-extreme negative attitudes toward sharing were independent and significant correlates of sharing behavior. Interventions targeting needle-sharing attitudes deployed within the clinical care setting may be well-positioned to reduce HIV transmission among HIV-positive IDUs.

    Title The Information-motivation-behavioral Skills Model of Antiretroviral Adherence and Its Applications.
    Date
    Journal Current Hiv/aids Reports
    Excerpt

    Suboptimal adherence to highly active antiretroviral therapy (HAART) may have serious consequences for HIV patients, and for public health overall. The Information-Motivation-Behavioral Skills (IMB) model of HAART adherence can be used to understand the dynamics of HAART adherence and to intervene with patients to promote more optimal levels of adherence. This article reviews the core hypotheses of the IMB model of HAART adherence and describes available correlational and experimental evaluations of the model, outcomes of adherence intervention trials that applied the model, and IMB model-based interventions that are currently under evaluation. It then explores one potential promising application of the model that uses a protocol originally developed and demonstrated as a structured patient-centered, provider-delivered risk reduction intervention to deliver information, motivation, and behavioral skills-based adherence-promotion strategies. This protocol could be incorporated into clinical practice as a valuable tool in working with patients individually.

    Title Wide Complex Tachycardia with Cycle Length Alternans: What is the Mechanism?
    Date
    Journal Heart Rhythm : the Official Journal of the Heart Rhythm Society
    Title Toward an Information-motivation-behavioral Skills Model of Microbicide Adherence in Clinical Trials.
    Date
    Journal Aids Care
    Excerpt

    Unless optimal adherence in microbicide clinical trials is ensured, an efficacious microbicide may be rejected after trial completion, or development of a promising microbicide may be stopped, because low adherence rates create the illusion of poor efficacy. We provide a framework with which to conceptualize and improve microbicide adherence in clinical trials, supported by a critical review of the empirical literature. The information-motivation-behavioral skills (IMB) model of microbicide adherence conceptualizes microbicide adherence in clinical trials and highlights factors that can be addressed in behavioral interventions to increase adherence in such trials. This model asserts that microbicide adherence-related information, motivation, and behavioral skills are fundamental determinants of adherent microbicide utilization. Specifically, information consists of objective facts about microbicide use (e.g., administration and dosage) as well as heuristics that facilitate use (e.g., microbicides must be used with all partners). Motivation to adhere consists of attitudes toward personal use of microbicides (e.g., evaluating the consequences of using microbicides as good or pleasant) as well as social norms that support their use (e.g., beliefs that a sexual partner approves use of microbicides). Behavioral skills consist of objective skills necessary for microbicide adherence (e.g., the ability to apply the microbicide correctly and consistently). Empirical evidence concerning microbicide acceptability and adherence to spermicides, medication, and condom use regimens support the utility of this model for understanding and promoting microbicide adherence in clinical trials.

    Title Information-motivation-behavioral Skills Barriers Associated with Intentional Versus Unintentional Arv Non-adherence Behavior Among Hiv+ Patients in Clinical Care.
    Date
    Journal Aids Care
    Excerpt

    Since the arrival of antiretroviral (ARV) therapy, HIV has become better characterized as a chronic disease rather than a terminal illness, depending in part on one's ability to maintain relatively high levels of adherence. Despite research concerning barriers and facilitators of ARV adherence behavior, relatively little is known about specific challenges faced by HIV-positive persons who report "taking a break" from their ARV medications. The present study employed the Information-Motivation-Behavioral Skills Model of ARV adherence as a framework for understanding adherence-related barriers that may differentiate between non-adherent patients who report "taking a break" versus those who do not report "taking a break" from their ARV medications. A sample of 327 HIV-positive patients who reported less than 100% adherence at study baseline provided data for this research. Participants who reported "taking a break" from their HIV medications without first talking to their healthcare provider were classified as intentionally non-adherent, while those who did not report "taking a break" without first talking with their healthcare provider were classified as unintentionally non-adherent. Analyses examined differences between intentionally versus unintentionally non-adherent patients with respect to demographic characteristics and responses to the adherence-related information, motivation, and behavioral skills questionnaire items. Few differences were observed among the groups on demographics, adherence-related information, or adherence-related motivation; however, significant differences were observed on about half of the adherence-related behavioral skills items. Implications for future research, as well as the design of specific intervention components to reduce intentionally non-adherent behavior, are discussed.

    Title Avnrt Ablation: Aiming for 100/0, and for Comfort!
    Date
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Identification of a Physiological Role for Leptin in the Regulation of Ambulatory Activity and Wheel Running in Mice.
    Date
    Journal American Journal of Physiology. Endocrinology and Metabolism
    Excerpt

    Mechanisms regulating spontaneous physical activity remain poorly characterized despite evidence of influential genetic and acquired factors. We evaluated ambulatory activity and wheel running in leptin-deficient ob/ob mice and in wild-type mice rendered hypoleptinemic by fasting in both the presence and absence of subcutaneous leptin administration. In ob/ob mice, leptin treatment to plasma levels characteristic of wild-type mice acutely increased both ambulatory activity (by 4,000 ± 200 beam breaks/dark cycle, P < 0.05) and total energy expenditure (TEE; by 0.11 ± 0.01 kcal/h during the dark cycle, P < 0.05) in a dose-dependent manner and acutely increased wheel running (+350%, P < 0.05). Fasting potently increased ambulatory activity and wheel running in wild-type mice (AA: +25%, P < 0.05; wheel running: +80%, P < 0.05), and the effect of fasting was more pronounced in ob/ob mice (AA: +400%, P < 0.05; wheel running: +1,600%, P < 0.05). However, unlike what occurred in ad libitum-fed ob/ob mice, physiological leptin replacement attenuated or prevented fasting-induced increases of ambulatory activity and wheel running in both wild-type and ob/ob mice. Thus, plasma leptin is a physiological regulator of spontaneous physical activity, but the nature of leptin's effect on activity is dependent on food availability.

    Title A Brief Culturally Tailored Intervention for Puerto Ricans with Type 2 Diabetes.
    Date
    Journal Health Education & Behavior : the Official Publication of the Society for Public Health Education
    Excerpt

    The information-motivation-behavioral skills (IMB) model of health behavior change informed the design of a brief, culturally tailored diabetes self-care intervention for Puerto Ricans with type 2 diabetes. Participants (n = 118) were recruited from an outpatient, primary care clinic at an urban hospital in the northeast United States. ANCOVA models evaluated intervention effects on food label reading, diet adherence, physical activity, and glycemic control (HbA1c). At follow-up, the intervention group was reading food labels and adhering to diet recommendations significantly more than the control group. Although the mean HbA1c values decreased in both groups (Intervention: 0.48% vs. Control: 0.27% absolute decrease), only the intervention group showed a significant improvement from baseline to follow-up (p < .008), corroborating improvements in diabetes self-care behaviors. Findings support the use of the IMB model to culturally tailor diabetes interventions and to enhance patients' knowledge, motivation, and behavior skills needed for self-care.

    Title Selective Improvement of Tumor Necrosis Factor Capture in a Cytokine Hemoadsorption Device Using Immobilized Anti-tumor Necrosis Factor.
    Date
    Journal Journal of Biomedical Materials Research. Part B, Applied Biomaterials
    Excerpt

    Sepsis is a harmful hyper-inflammatory state characterized by overproduction of cytokines. Removal of these cytokines using an extracorporeal device is a potential therapy for sepsis. We are developing a cytokine adsorption device (CAD) filled with porous polymer beads which efficiently depletes middle-molecular weight cytokines from a circulating solution. However, removal of one of our targeted cytokines, tumor necrosis factor (TNF), has been significantly lower than other smaller cytokines. We addressed this issue by incorporating anti-TNF antibodies on the outer surface of the beads. We demonstrated that covalent immobilization of anti-TNF increases overall TNF capture from 55% (using unmodified beads) to 69%. Passive adsorption increases TNF capture to over 99%. Beads containing adsorbed anti-TNF showed no significant loss in their ability to remove smaller cytokines, as tested using interleukin-6 (IL-6) and interleukin-10 (IL-10). We also detail a novel method for quantifying surface-bound ligand on a solid substrate. This assay enabled us to rapidly test several methods of antibody immobilization and their appropriate controls using dramatically fewer resources. These new adsorbed anti-TNF beads provide an additional level of control over a device which previously was restricted to nonspecific cytokine adsorption. This combined approach will continue to be optimized as more information becomes available about which cytokines play the most important role in sepsis.

    Title Defibrillation Testing: Philosophy and Science.
    Date
    Journal Pacing and Clinical Electrophysiology : Pace
    Title Tamponade Detection: Did You Look at the Heart Borders (redux)?
    Date
    Journal Pacing and Clinical Electrophysiology : Pace

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