Evaluation of left ventricular mechanical dyssynchrony as determined by phase analysis of ECG-gated SPECT myocardial perfusion imaging in patients with left ventricular dysfunction and conduction disturbances

Background  Cardiac resynchronization therapy (CRT) is approved for the treatment of patients with advanced systolic heart failure and evidence of dyssynchrony on electrocardiograms. However, a significant percentage of patients do not demonstrate improvement with CRT. Echocardiographic techniques have been used for more accurate determination of dyssynchrony. Single photon emission computed tomography (SPECT) myocardial perfusion imaging has not previously been used to evaluate cardiac dyssynchrony. The objective of this study is to evaluate mechanical dyssynchrony as described by phase analysis of gated SPECT images in patients with left ventricular dysfunction, conduction delays, and ventricular paced rhythms. Methods and Results  A novel count-based method is used to extract regional systolic wall thickening amplitude and phase from gated SPECT images. Five indices describing the phase dispersion of the onset of mechanical contraction are determined: peak phase, phase SD, bandwidth, skewness, and kurtosis. These indices were determined in consecutive patients with left ventricular dysfunction (n=120), left bundle branch block (n=33), right bundle branch block (n=19), and ventricular paced rhythms (n=23) and were compared with normal control subjects (n=157). Phase SD, bandwidth, skewness, and kurtosis were significantly different between patients with left ventricular dysfunction, left bundle branch block, right bundle branch block, and ventricular paced rhythms and normal control subjects (all P<.001) Peak phase was significantly different between patients with right ventricular paced rhythms and normal control subjects (P=.001). Conclusions  A novel SPECT technique for describing left ventricular mechanical dyssyn-chrony has been developed and may prove useful in the evaluation of patients for CRT. This study was funded in part by a research grant from the Medtronic-Duke Strategic Alliance, of which Dr Borges-Neto is the primary investigator.     

Poverty, health services, and health status in rural America

Access to health services for everyone has been a major policy goal in the United States: inequitable access is assumed to lead to inequitable health status, particularly for low-income groups. A sophisticated model of the relation between poverty, health care needs, service use, and health outcomes is used to analyze cross-sectional data on 7,823 adults from 36 rural communities. Improved access and use are helpful, but evidence clearly indicates that combined health and social initiatives will be necessary to reduce inequalities in health status.     

Impact of a Pharmacist-Based Consult Service on Nutritional Rehabilitation of Nonambulatory Patients with Severe Developmental Disabilities

A pharmacist consult service was developed to evaluate the appropriateness of enteral feeding through a permanent ostomy in 24 nonambulatory patients with severe developmental disabilities. Several problems with enteral nutrition were identified. Policies to improve them were instituted, and several educational presentations were made. Pharmacists' actions were implemented, including assessment of energy needs by indirect calorimetry and rearrangement of enteral feeding schedules to achieve optimal nutrition support and pharmacotherapy administration. By the fourth month of the consult service, body weight in these patients increased from 101 ± 6% of baseline to 109 ± 7% (p<0.05). Weight continued to increase through the seventh month of the consult service to 116 ± 12% of baseline (p<0.0001). Measured resting energy expenditure for the group was 889 ± 170 kcal/day compared with the predicted 1055 ± 163 kcal/day.     

Using stories to battle unintentional injuries: Narratives in safety and health communication

After 14 years of rising death rates due to unintentional injuries in the U.S., it is time to ask how safety messages can be redesigned to have a greater impact on risky behavior. To this end, many researchers have called for a new, narrative approach to prevention messages—based on persuasive stories about people who have suffered injuries and illnesses in the past. Still, there is scant evidence that story-based communications are more effective than equivalent non-narrative messages at changing actual (rather than self-reported) safety and health behavior. Our research examined the impact of injury stories on actual safety behavior in a controlled experimental setting at a US university. Teams of participants assembled a product (a child's swing) using written instructions. The instructions contained safety messages targeting assembly mistakes that have been linked to serious injuries in children who play on swings. Participant teams were randomly assigned to three conditions: assembly instructions containing story-based safety messages, instructions with concrete (but non-anecdotal) safety messages, and instructions with traditional abstract safety messages. After adjustment for covariates, story-based messages resulted in a 19 percent improvement in safety behavior, compared with non-narrative communications. Importantly, injury stories did not create undue fear of the message object, demonstrating that brief anecdotes about accident victims can convince people to take reasonable precautions without creating unwarranted alarm about risks.     

Performance measures for evaluating services for people with a first episode of psychosis

Aim: The purpose of this project was to operationalize and apply a previously identified set of performance measures designed to evaluate services for those experiencing a first episode of a schizophrenia spectrum disorder. Methods: Operational definitions were developed for previously identified measures through an iterative process of discussions between clinical experts and health‐care evaluators. Data were collected from existing sources including corporate databases, clinical databases and chart review. Results: Definitions were developed for 44 measures covering seven of eight domains recommended for service level evaluation by the Canadian Institute for Health Information domains. Forty measures could be calculated. Conclusions: The measures represent a comprehensive set of performance measures suitable for the evaluation of services for people with a first‐episode psychosis. The measures could be used by other services in order to establish standards and norms for routine clinical practice.     

Auditory steady-state evoked potentials (ASSEPs): a study of optimal stimulation parameters for frequency-specific threshold measurement in dogs.

OBJECTIVE: To define the optimal stimulation parameters (AM/FM vs AM alone and modulation rate) for frequency-specific threshold measurements using ASSEPs in dogs. Dependent variables were thresholds and recording times needed to obtain a response at threshold. To compare the ASSEP threshold results obtained with the optimal stimulation parameters to those obtained with the Tone-Burst/Auditory Brainstem Response (TB/ABR) combination. METHODS: Thirty-two sedated Beagle puppies were tested at 5 audiometric frequencies (0.5-8 kHz) and 6 ASSEP modulation rates (21-199 Hz). RESULTS: The ASSEP threshold-modulation rate functions had a high-pass profile with corner frequencies of 101 Hz for 0.5, 1 and 2 kHz carriers and of 151 Hz for 4 and 8 kHz carriers. AM stimuli did not yield higher thresholds than the AM/FM ones except at 1 kHz. Modulation type had no effect on testing duration. Audiometric profiles were obtained much more rapidly with ASSEPs than with TB/ABRs (mean: 50 vs 135 min). Both ASSEP and TB/ABR provided thresholds estimates characterized by low intersubject variability. CONCLUSIONS: ASSEPs are a valid and rapid method for audiometric assessment in sedated dogs. SIGNIFICANCE: ASSEPs offer a new, competitive tool for frequency-specific assessment of hearing in the canine species.     

Psychiatric morbidity among people aged 85+ in 1987. A follow-up study at two and a half years: Associations with changes in psychiatric morbidity

This article reports findings from a longitudinal survey of very elderly people living at home in London. The research aimed to identify social, psychological and physical characteristics associated with positive ageing and successful survival in the community in later life and its converse—negative ageing—as well as the associated policy implications. Associations with psychiatric morbidity, measured using the General Health Questionnaire, among sample members without cognitive impairment between the baseline interviews in 1987 and at follow-up, two and a half years later in 1990, are reported. Twenty-five per cent of survivors scored over the threshold of the GHQ in 1987 and 30% scored over the threshold in 1990. Half of those with a score over the threshold in 1990 also scored over the threshold in 1987. Hierarchical regression (using residualized change analysis) was used to estimate the effects of the independent variables on changes in psychiatric morbidity. The most significant predictor of psychiatric morbidity (GHQ score) in 1990 was baseline GHQ score, followed by health and functional status scores. Health and functional status were also the strongest predictors of baseline (1987) GHQ scores. The uniqueness of the study lies in the collection of follow-up data on a sample of very elderly people, given that most surveys are corss-sectional and contain too few people aged 85+ to merit separate analysis. It contributes to the small body of literature on outcome of depression. The lack of consistent associations with recovery from psychiatric morbidity in the literature enhances the importance of studies aiming to identify factors associated with different outcomes.     

The association of cancer survival with four socioeconomic indicators: a longitudinal study of the older population of England and Wales 1981–2000

Background  

Many studies have found socioeconomic differentials in cancer survival. Previous studies have generally demonstrated poorer cancer survival with decreasing socioeconomic status but mostly used only ecological measures of status and analytical methods estimating simple survival. This study investigate socio-economic differentials in cancer survival using four indicators of socioeconomic status; three individual and one ecological. It uses a relative survival method which gives a measure of excess mortality due to cancer.