Evaluation of an Online Sexual Health Program among Adolescent Girls with Emotional and Behavioral Difficulties.

OBJECTIVES: Adolescent girls with emotional and behavioral difficulties (EBDs) have a heightened risk of negative sexual health, including HIV, other sexually transmitted infections (STIs), and unplanned pregnancy. Few evidence-based sexual health interventions are available for adolescent girls with EBDs. This study tested the feasibility, acceptability, and efficacy of a brief, online sexual health program called HEART (Health Education and Relationship Training). METHODS: Forty-seven participants (M-age = 15.79; SD = 1.71; 62% Black, 23% Hispanic) recruited from community-based organizations in the southeastern U.S. were compared to a non-equivalent comparison group who received an attention-matched intervention. RESULTS: Findings support the feasibility of participant recruitment and program administration in community-based settings. Participants completed HEART in 44 minutes and experienced few technological difficulties. HEART was highly acceptable: most participants liked, learned from, and were engaged with the program. Further, 92% would recommend HEART to a friend and 98% would use what they learned in the future. At posttest, intervention participants had significantly higher communication intentions, communication skills, STI/HIV knowledge, sexual self-efficacy, condom attitudes, and condom norms than the comparison group (ps < .003; effect size ds = .38-1.65). Significant improvement in condom intentions was observed when comparing pretest to posttest scores among intervention participants only, t(46) = -3.21, d = 0.47. CONCLUSIONS: Findings support the feasibility, acceptability, and efficacy of HEART among adolescent girls with EBDs in community-based settings. This study also addresses the growing need for research into the transferability of sexual health interventions to facilitate evidence-based decision-making about program dissemination and implementation.

Feasibility and acceptability of a web-based HIV/STD prevention program for adolescent girls targeting sexual communication skills.

Adolescent girls are at substantial risk of sexually transmitted diseases including HIV. To reduce these risks, we developed Health Education And Relationship Training (HEART), a web-based intervention focused on developing sexual assertiveness skills and enhancing sexual decision-making. This study assessed the feasibility and acceptability of this new program and examined if perceived acceptability varied according to participant ethnicity, sexual orientation or sexual activity status. Participants were part of a randomized controlled trial of 222 10th-grade girls (Mage = 15.26). The current analyses included those in the intervention condition (n = 107; 36% white, 27% black and 29% Hispanic). HEART took approximately 45 min to complete and was feasible to administer in a school-based setting. Participants found the program highly acceptable: 95% liked the program and learned from the program, 88% would recommend the program to a friend and 94% plan to use what they learned in the future. The primary acceptability results did not vary by the ethnicity, sexual orientation or sexual activity status of participants, suggesting broad appeal. Results indicate that this new online program is a promising method to reach and engage adolescents in sexual health education.

Maternal polycystic ovary syndrome and the risk of autism spectrum disorders in the offspring: a population-based nationwide study in Sweden.

Although many studies indicate the interplay of genetic and environmental factors in the etiology of autism spectrum disorder (ASD), our limited understanding of the underlying mechanisms hampers the development of effective ways of detecting and preventing the disorder. Recent studies support the hypothesis that prenatal androgen exposure contributes to the development of ASD. This would suggest that maternal polycystic ovary syndrome (PCOS), a condition associated with excess androgens, would increase the risk of ASD in the offspring. We conducted a matched case-control study nested within the total population of Sweden (children aged 4-17 who were born in Sweden from 1984 to 2007). The sample consisted of 23 748 ASD cases and 208 796 controls, matched by birth month and year, sex and region of birth. PCOS and ASD were defined from ICD codes through linkage to health-care registers. Maternal PCOS increased the odds of ASD in the offspring by 59%, after adjustment for confounders (odds ratio (OR) 1.59, 95% confidence interval (CI) 1.34-1.88). The odds of offspring ASD were further increased among mothers with both PCOS and obesity, a condition common to PCOS that is related to more severe hyperandrogenemia (OR 2.13, 95% CI 1.46-3.10). Risk estimates did not differ between sexes. In conclusion, children of women with PCOS appear to have a higher risk of developing ASD. This finding awaits confirmation, and exploration of potentially underlying mechanisms, including the role of sex steroids in the etiology of ASD.

Regression of oral lichenoid lesions after replacement of dental restorations.

The aim of the study was to determine the prognosis and to evaluate the regression of lichenoid contact reactions (LCR) and oral lichen planus (OLP) after replacement of dental restorative materials suspected as causing the lesions. Forty-four referred patients with oral lesions participated in a follow-up study that was initiated an average of 6 years after the first examination at the Department of Odontology, i.e. the baseline examination. The patients underwent odontological clinical examination and answered a questionnaire with questions regarding dental health, medical and psychological health, and treatments undertaken from baseline to follow-up. After exchange of dental materials, regression of oral lesions was significantly higher among patients with LCR than with OLP. As no cases with OLP regressed after an exchange of materials, a proper diagnosis has to be made to avoid unnecessary exchanges of intact restorations on patients with OLP.

Medical and social prognoses of non-specific building-related symptoms (Sick Building Syndrome): a follow-up study of patients previously referred to hospital.

OBJECTIVES: The aim of this study was to describe and analyse the medical and social prognoses of patients with non-specific building-related symptoms. METHODS: A follow-up questionnaire focusing on current medical and social status, care, treatment, other actions taken and personality traits was sent to 239 patients with non-specific building-related symptoms assessed during the period between 1986 and 1998 at University Hospital in Umeå, Sweden. The response rate was 79%. RESULTS: Fatigue, irritation of the eyes, and facial erythema were the most common weekly symptoms reported at follow-up. As females constituted 92% of the respondents, statistical analyses were restricted to women. The level and severity of symptoms decreased over time, although nearly half of the patients claimed that symptoms were more or less unchanged after 7 years or more, despite actions taken. Twenty-five percent of the patients were on the sick-list, and 20% drew disability pension due to persistent symptoms at follow-up. The risk of having no work capabilities at follow-up was significantly increased if the time from onset to first visit at the hospital clinic was more than 1 year. This risk was also significantly higher if the patient at the first visit had five or more symptoms. All risk assessments were adjusted for length of follow-up. Symptoms were often aggravated by different situations in everyday life. CONCLUSIONS: Long-lasting symptoms aggravated by environmental factors exist within this group of patients. The results support that early and comprehensive measures for rehabilitation are essential for the patients.

Changes in health over time in patients with symptoms allegedly caused by their dental restorative materials.

OBJECTIVES: In Sweden, many patients with symptoms allegedly caused by their dental materials have exchanged their restorations, but the effects of the exchange have been insufficiently investigated. Therefore, the aim of the study was to describe the change in health over time for these patients and the hypothesis was that the patients could be divided based on their symptoms and that the ability to recover differs between these groups. Furthermore, we also examined if other factors such as replacement of dental restorative materials and follow-up time had any impact on the perceived health status. METHODS: A questionnaire was sent to 614 patients who had been referred to the School of Dentistry, Umeå, Sweden, with symptoms allegedly caused by dental restorative materials. The response rate was 55%. RESULTS: The risk of having any further complaints was higher for patients with complex symptoms (P = 0.03) and these patients had exchanged their restorations to a significantly larger extent than the others (P = 0.03). The remaining complaints was more frequent among men (P = 0.02). Exchange of dental restorative materials had no significant impact on the ability to recover completely. However, the patients who had exchanged their restorations completely perceived a significantly larger alleviation of their symptoms than the others (P < 0.01), although the frequency of most of the symptoms had increased. CONCLUSIONS: Patients with complex symptoms had a more unfavorable long-term prognosis concerning persistent complaints than those with localized symptoms only. Furthermore, the results indicate that the patients might experience health improvements after removal of their dental restorative materials. The reason for this improvement, however, is unclear. Further analyses regarding other possible explanations than the 'odontological/medical' are needed.

Coping and self-image in patients with visual display terminal-related skin symptoms and perceived hypersensitivity to electricity.

OBJECTIVES: The aim of the present study was to measure coping resources and self-image in patients with visual display terminal (VDT)-related skin symptoms and hypersensitivity to electricity (HE). METHODS: From 1980 to 1998, 350 patients with electrical sensitivity were registered. The patients were subdivided into two groups: patients with skin symptoms evoked by VDTs, television screens, and fluorescent-light tubes and patients with so-called hypersensitivity to electricity with multiple symptoms evoked by exposure to different electrical environments. A questionnaire was sent to all patients and contained the coping resources inventory (CRI) and the structural analysis of social behaviour (SASB) in order for us to measure coping resources and self-image, respectively. The CRI and SASB scores were compared with those of control groups. Two hundred and fifty respondents (73%) returned the questionnaire, 200 (78.5% women) in the VDT group and 50 (62% women) in the HE group. RESULTS: The patient group rated high on the CRI spiritual/philosophical scale and high on the SASB spontaneous, positive and negative clusters but low on the controlled cluster. The female patients scored high on the CRI emotional scale. The VDT group rated lower than the controls on the SASB controlled cluster and higher on both the positive and negative cluster. The HE group scored higher than the control group on the SASB spontaneous and positive clusters. The women in the HE group scored higher on the CRI cognitive and CRI total scale than the VDT group and control group and higher on the CRI emotional scale than the controls. The women in the HE group rated higher than both the women in the VDT and control groups on the SASB spontaneous and positive clusters. CONCLUSIONS: The deviant self-image found in these patients, especially the female HE patients, support the view that VDT and HE symptoms can be stress related. In the clinic, a trustful alliance should be established with the patient in order for a more realistic view to be achieved of the capacity.

Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-White syndrome.

INTRODUCTION: Delta wave morphology correlates with the site of ventricular insertion of accessory AV pathways. Because lesions due to radiofrequency (RF) current are small and well defined, it may allow precise localization of accessory pathways. The purpose of this study was to use RF catheter ablation to develop an ECG algorithm to predict accessory pathway location. METHODS AND RESULTS: An algorithm was developed by correlating a resting 12-lead ECG with the successful RF ablation site in 135 consecutive patients with a single, anterogradely conducting accessory pathway (Retrospective phase). This algorithm was subsequently tested prospectively in 121 consecutive patients (Prospective phase). The ECG findings included the initial 20 msec of the delta wave in leads I, II, aVF, and V1 [classified as positive (+), negative (-), or isoelectric (+/-)] and the ratio of R and S wave amplitudes in leads III and V1 (classified as R > or = S or R < S). When tested prospectively, the ECG algorithm accurately localized the accessory pathway to 1 of 10 sites around the tricuspid and mitral annuli or at subepicardial locations within the venous system of the heart. Overall sensitivity was 90% and specificity was 99%. The algorithm was particularly useful in correctly localizing anteroseptal (sensitivity 75%, specificity 99%), and mid-septal (sensitivity 100%, specificity 98%) accessory pathways as well as pathways requiring ablation from within ventricular venous branches or anomalies of the coronary sinus (sensitivity 100%, specificity 100%). CONCLUSION: A simple ECG algorithm identifies accessory pathway ablation site in Wolff-Parkinson-White syndrome. A truly negative delta wave in lead II predicts ablation within the coronary venous system.

Use of clozapine to treat levodopa-induced psychosis in Parkinson's disease: retrospective review.

Levodopa-induced psychosis can complicate the treatment of Parkinson's disease (PD). In this retrospective, uncontrolled report, we describe our experience treating PD-related psychosis with clozapine, emphasizing those patients treated for longer than 1 year. Twenty-seven patients were treated, 14 for longer than 1 year. Most patients showed a rapid improvement from baseline within 1 month using the Clinical Global Impression and Global Psychosis Rating Scores. Five patients discontinued the drug due to side effects, but only two patients reported side effects after 6 months of treatment. Clozapine appears to be effective in treating PD related psychotic symptoms while not interfering with motor function.

Requests for medical advice from patients and families to health care providers who publish on the World Wide Web.

BACKGROUND: The Internet is a novel, rapidly growing means of worldwide public communication. METHODS: We reviewed all unsolicited electronic mail and other communications from nonmedical individuals requesting medical information over a 12-month period from the physician at 1 established site on the World Wide Web. This site was the only Internet site with a primary focus on cardiac arrhythmias. RESULTS: Seventy unsolicited inquiries were received from 39 patients and 20 family members (the sources of 11 inquiries are unknown) from 20 states, Washington, DC, and 9 foreign countries (locations of 15 inquiries are unknown). Follow-up was obtained in 22 cases. The inquiries concerned cardiological conditions in 67 cases (96%) and cardiac electrophysiologic conditions and procedures in 52 cases (74%). The goals of the inquiries were diagnosis (15), therapy (48), prognosis (1), and patient education (6). On follow-up of 22 cases, the people initiating the inquiries stated that they were reassured (16), consulted a general cardiologist (1), consulted a cardiac electrophysiologist (4), or visited a tertiary care electrophysiology center (1). CONCLUSIONS: The increasing use of the Internet by the general public seeking specific medical information for themselves and for their families suggests a widespread, unmet need for objective medical advice. This study demonstrates that the public can choose accurately whom to ask for subspecialty advice in the area of cardiovascular diseases. Professional societies and regulatory agencies should develop physician guidelines for providing medical advice over the Internet.

Validation of the EINTHOVEN model-based computerized electrocardiogram rhythm analysis system with three classes of clinical arrhythmias.

Rhythm analysis by commercial systems does not meet clinical needs well, because (1) differential diagnosis of complex rhythms is not performed, (2) common rhythms are often misdiagnosed, and (3) transitions between rhythms are not described. We have developed a model-based diagnostic software system named EINTHOVEN that is designed to address the above limitations. A demonstration is available on the World Wide Web at http:@einthoven.uokhsc.edu. The system has been validated using simple rhythms from introductory electrocardiogram (ECG) textbooks. We present here the results of evaluation with more complex rhythm strips taken from clinical records and intermediate-level ECG textbooks. Rhythm strips were described by the onset and offset of each electrical event (P wave, QRS complex, and T wave) and by a morphology classification for each event. The rhythms included a variety of supraventricular and ventricular rhythms. The analysis was considered correct if it named all correct diagnoses in a rhythm strip, incorrect if it completed the analysis and failed to name the correct diagnoses, and indeterminate if it failed to complete the analysis. The system was designed not to complete an analysis if it could not explain an entire rhythm by at least 1 pathophysiological model. The test rhythms were not used to develop the system. Forty-six of 56 test rhythms were diagnosed correctly, and 8 were not analyzed completely. The 2 incorrect diagnoses were atrial tachycardia with variable conduction (diagnosed as intermittent complete heart block) and atrial fibrillation (diagnosed as irregular junctional tachycardia). All 56 rhythms were diagnosed correctly after minor technical improvements to the system. The processing time of the system was 7.6-fold (range 1.5-to 16.9-fold) faster than the elapsed time of the individual records. These preliminary results suggest (1) that computer-based interpretation of complex rhythms is possible, (2) that further software development is necessary to reach a clinical level of accuracy, and (3) that there are no theoretical obstacles to achieving this goal.

Para-Hisian pacing. A new method for differentiating retrograde conduction over an accessory AV pathway from conduction over the AV node.

BACKGROUND: Differentiation between ventriculoatrial (VA) conduction over an accessory AV pathway (AP) and the AV node (AVN) may be difficult, especially in patients with a septal AP. METHODS AND RESULTS: A new pacing method, para-Hisian pacing, was tested in 149 patients with AP and 53 patients without AP who had AV nodal reentrant tachycardia (AVNRT). Ventricular pacing was performed adjacent to the His bundle and proximal right bundle branch (HB-RB), initially at high output to capture both RV and HB-RB. The output was then decreased to lose HB-RB capture. The change in timing and sequence of retrograde atrial activation between HB-RB capture and noncapture was examined. Loss of HB-RB capture without change in stimulus-atrial (S-A) interval or atrial activation sequence indicated exclusive retrograde AP conduction. An increase in S-A interval without change in His bundle-atrial interval or atrial activation sequence indicated exclusive retrograde AVN conduction. A change in atrial activation sequence indicated the presence of both retrograde AP and AVN conduction. Para-Hisian pacing correctly identified retrograde AP conduction in 132 of 147 AP patients, including all septal and right free wall APs. Retrograde AVN conduction masked AP conduction in 9 of 34 patients with a left free wall AP and 6 of 9 patients with the permanent form of junctional reciprocating tachycardia. Para-Hisian pacing correctly excluded AP conduction in all 53 patients with AVNRT. CONCLUSIONS: Para-Hisian pacing reliably identifies retrograde conduction over septal and right free wall APs, but AVN conduction may mask APs located far from the pacing site or with a long retrograde conduction time.

Role of the tricuspid annulus and the eustachian valve/ridge on atrial flutter. Relevance to catheter ablation of the septal isthmus and a new technique for rapid identification of ablation success.

BACKGROUND: Typical atrial flutter (AFL) results from right atrial reentry by propagation through an isthmus between the inferior vena cava (IVC) and tricuspid annulus (TA). We postulated that the eustachian valve and ridge (EVR) forms a line of conduction block between the IVC and coronary sinus (CS) ostium and forms a second isthmus (septal isthmus) between the TA and CS ostium. METHODS AND RESULTS: Endocardial mapping in 30 patients with AFL demonstrated atrial activation around the TA in the counter-clockwise direction (left anterior oblique projection). Double atrial potentials were recorded along the EVR in all patients during AFL. Pacing either side of the EVR during sinus rhythm also produced double potentials, which indicated fixed anatomic block across EVR. Entrainment pacing at the septal isthmus and multiple sites around the TA produced a delta return interval < or = 8 ms in 14 of 15 patients tested. Catheter ablation eliminated AFL in all patients by ablation of the septal isthmus in 26 patients and the posterior isthmus in 4. AFL recurred in 2 of 12 patients (mean follow-up, 33.9 +/- 16.3 months) in whom ablation success was defined by the inability to reinduce AFL, compared with none of 18 patients (mean follow-up, 10.3 +/- 8.3 months) in whom success required formation of a complete line of conduction block between the TA and the EVR, identified by CS pacing that produced atrial activation around the TA only in the counterclockwise direction and by pacing the posterior TA with only clockwise atrial activation. CONCLUSIONS: (1) The EVR forms a line of fixed conduction block between the IVC and the CS; (2) the EVR and the TA provide boundaries for the AFL reentrant circuit; and (3) verification of a complete line of block between the TA and the EVR is a more reliable criterion for long-term ablation success.

EINTHOVEN and tolerance for human error: design issues in a decision support system for cardiac arrhythmia interpretation.

Decision support systems are becoming increasingly accepted in medical practice in the United States. Clinicians recognize the need for aid in interpretation of complex cardiac rhythms. The EINTHOVEN system is being developed to meet that need. In this paper, we address the need to deal with errors in the input due to inaccuracies in hand annotations by the inexperienced user and to interact with the user to correct them. Four specific types of input errors are described: missing waves, mispositioned waves, mislabeled waves, and extra waves. General and specific mechanisms by which these errors can be recognized and remedied are described. These results may be interesting as an example of the practical problems that arise in the design of real-world expert systems.

Automated analysis of intracardiac electrograms obtained during extrastimulus tests using a three-dimensional electrophysiology model.

Catheter ablation procedures are performed by highly trained and experienced cardiology subspecialists. Yet the massive amount of data produced during these procedures creates a data overload problem that can impede the performance of even the best practitioners. This may be evidenced by (1) overlooking important signal features, (2) misinterpreting the signals, and (3) misinterpreting catheter locations in the heart, all of which can lead to increased procedure duration, applications of radiofrequency energy to the wrong part of the heart, or both. This article presents the first results from a project aimed at developing a model-based system for interpreting intracardiac electrograms in near real time. The system is intended to assist physicians in interpreting the enormous amounts of data recorded during catheter ablation studies. It is an extension of the Einthoven system that has been extended to account for the three-dimensional relationships in the cardiac conduction system as recorded in the various intracardiac electrograms. The new three-dimensional cardiac conduction model and the enhancements to Einthoven's reasoning algorithms are presented. The locus of this study is on interpreting the results of ventricular extrastimulus tests. Data collected for this study and the output generated by the system are presented.

An algorithm for complete enumeration of the mechanisms of supraventricular tachycardias that use multiple atrioventricular, AV nodal, and/or Mahaim pathways.

The EINTHOVEN system is a model-based expert system that interprets the cardiac rhythm from the electrocardiogram. It simulates the expected behavior of realistic semi-quantitative cardiac models constructed by heuristic rules to generate interpretations that include both text descriptions and event-by-event causal explanations in the form of ladder diagrams. The simulation has been limited by an inability to predict all possible behaviors of hearts with more than one reentrant circuit. We now describe an algorithm that overcomes this limitation. Its output has been validated by an independent possibility-tree analysis. Timing and storage measurements are presented for models with up to three slow atrioventricular nodal pathways, four atrioventricular pathways, and a single atriofascicular (Mahaim) pathway. This is the first report in the literature of an algorithm that enumerates all possible mechanisms for reentrant supraventricular tachycardias that use atrioventricular, atrioventricular nodal, and/or atriofascicular pathways in humans.

A client/server system for remote diagnosis of cardiac arrhythmias.

Health care practitioners are often faced with the task of interpreting complex heart rhythms from electrocardiograms (ECGs) produced by 12-lead ECG machines, ambulatory (Holter) monitoring systems, and intensive-care unit monitors. Usually, the practitioner caring for the patient does not have specialized training in cardiology or in ECG interpretation; and commercial programs that interpret 12-lead ECGs have been well-documented in the medical literature to perform poorly at analyzing cardiac rhythm. We believe that a system capable of providing comprehensive ECG interpretation as well as access to online consultations will be beneficial to the health care system. We hypothesized that we could develop a client-server based telemedicine system capable of providing access to (1) an on-line knowledge-based system for remote diagnosis of cardiac arrhythmias and (2) an on-line cardiologist for real-time interactive consultation using readily available resources on the Internet. Furthermore, we hypothesized that Macintosh and Microsoft Windows-based personal computers running an X server could function as the delivery platform for the developed system. Although we were successful in developing such a system that will run efficiently on a UNIX-based work-station, current personal computer X server software are not capable of running the system efficiently.

Comorbidity of other chronic age-dependent diseases in dementia.

This study compares the prevalence rates of 5 common age-dependent diseases in non-demented and demented subjects. Control and dementia populations were approximately age-matched and their numbers also approximated. Prevalence rates for hypertension, myocardial infarction (MI), stroke, cancer and diabetes were determined. The rates of two or more coexisting diseases in the same patient were also compared. Two populations were studied: one was designated the autopsy series, and the other the hospital series. In the autopsy series, the rate of cardiomegaly/hypertension was 1.3 times higher in the control than in the dementia population, and for MI it was 1.7 times higher in the former than in the latter. The rate for stroke was higher in the control group by only a factor of 1.1, for cancer by only a factor of 1.2, and for diabetes the rates were almost identical in the two populations. The rate differences were statistically significant only with respect to cardiomegaly and MI. When the non-vascular and vascular dementias were compared, the rates in the latter were higher by only a factor of 1.3 for cardiomegaly, stroke, cancer and diabetes; for MIs, the rates were about the same in the two dementia categories. The data for two or more coexisting diseases were almost identical in control and dementia autopsy populations. In the hospital series, the hypertension rate was 1.6 times higher in the control than in the Alzheimer's disease (AD) group; for MI, the control group was higher by a factor of 1.5.(ABSTRACT TRUNCATED AT 250 WORDS)

Model-based interpretation of the ECG: a methodology for temporal and spatial reasoning.

A new software architecture for automatic interpretation of the electrocardiographic rhythm is presented. Using the hypothesize-and-test paradigm, a semiquantitative physiological model and production rule-based knowledge are combined to reason about time- and space-varying characteristics of complex heart rhythms. A prototype system implementing the methodology accepts a semiquantitative description of the onset and morphology of the P waves and QRS complexes that are observed in the body-surface electrocardiogram. A beat-by-beat explanation of the origin and consequences of each wave is produced. The output is in the standard cardiology laddergram format. The current prototype generates the full differential diagnosis of narrow-complex tachycardia and correctly diagnoses complex rhythms, such as atrioventricular (AV) nodal reentrant tachycardia with either hidden or visible P waves and varying degrees of AV block.