Outcome of cardiac arrests attended by emergency medical services staff at community outpatient dialysis centers.

Cardiac arrest is the leading cause of death among dialysis patients in the United States. We measured the outcome of cardiac arrests attended by Emergency Medical Services (EMS) staff at hemodialysis facilities in a 14-year population-based retrospective study to identify cardiac arrest cases at a dialysis unit. Associated factors were determined using unconditional logistic regression. Of the 102 cardiac arrests identified around the time of dialysis, 10 occurred before, 72 during, and 20 after hemodialysis. The initial measured abnormality was ventricular fibrillation or tachycardia in 72 cases. Of those who survived transportation to a hospital, survival to discharge was 24 with 15% survival at 1 year. Compared to arrests that occurred prior to dialysis, the odds of ventricular fibrillation were 5-fold greater in patients on dialysis but 14-fold greater in those arresting after dialysis. One-third of cases occurred after the introduction of automated external defibrillators, and in half of the cases these devices were attached prior to EMS arrival. Once these devices were attached, most were used for defibrillation. We conclude that ventricular arrhythmias are the predominant features among arrested in-center dialysis patients with most occurrences during dialysis. The role of these devices in dialysis units will need a larger study to evaluate their efficacy.

Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.

BACKGROUND: Early cardiopulmonary resuscitation (CPR) improves survival in out-of-hospital cardiac arrest, and dispatcher-delivered instruction in CPR can increase the proportion of arrest victims who receive bystander CPR before emergency medical service (EMS) arrival. However, little is known about the survival effectiveness of dispatcher-delivered telephone CPR instruction. METHODS AND RESULTS: We evaluated a population-based cohort of EMS-attended adult cardiac arrests (n=7265) from 1983 through 2000 in King County, Washington, to assess the association between survival to hospital discharge and 3 distinct CPR groups: no bystander CPR before EMS arrival (no bystander CPR), bystander CPR before EMS arrival requiring dispatcher instruction (dispatcher-assisted bystander CPR), and bystander CPR before EMS arrival not requiring dispatcher instruction (bystander CPR without dispatcher assistance). In this cohort, 44.1% received no bystander CPR before EMS arrival, 25.7% received dispatcher-assisted bystander CPR, and 30.2% received bystander CPR without dispatcher assistance. Overall survival was 15.3%. Using no bystander CPR as the reference group, the multivariate adjusted odds ratio of survival was 1.45 (95% confidence interval [CI], 1.21, 1.73) for dispatcher-assisted bystander CPR and 1.69 (95% CI, 1.42, 2.01) for bystander CPR without dispatcher assistance. CONCLUSION: Dispatcher-assisted bystander CPR seems to increase survival in cardiac arrest.

Out-of-hospital cardiac arrest in men and women.

BACKGROUND: The incidence of sudden cardiac death is roughly 3 times greater in men than in women. However, in patients treated for out-of-hospital cardiac arrest, the relationships between sex and survival after adjustment for age and cardiac rhythm are unclear. METHODS AND RESULTS: In this retrospective cohort study, we examined 7069 men and 2582 women who were treated for out-of-hospital cardiac arrest in Seattle and suburban King County between 1990 and 1998. We compared successful prehospital resuscitation (hospital admission) and survival from event to discharge in men and women. Women had markedly reduced rates of ventricular fibrillation (VF), slightly older age, fewer witnessed arrests, and fewer arrests in public locations than men. Although their unadjusted resuscitation rate was lower (29% versus 32%, P<0.0001), women had a greater likelihood of resuscitation than men after adjustment for VF (odds ratio [OR] 1.13; 95% confidence interval [CI], 1.03 to 1.25) and after adjustment for VF plus additional factors (OR, 1.27; 95% CI, 1.14 to 1.41). The difference in resuscitation rates between men and women decreased as they aged (test for trend, P<0.0001). Unadjusted survival rates were also lower in women than in men (11% versus 15%, P<0.0001). Women had similar survival after adjustment for VF (OR, 0.97; 95% CI, 0.85 to 1.11) and after adjustment for VF plus additional factors (OR, 1.09; 95% CI, 0.93 to 1.27). CONCLUSIONS: The lower unadjusted resuscitation and survival rates observed in women were primarily due to women's lower incidence of VF, a relatively favorable cardiac rhythm. After adjustment for VF and other factors, women had higher resuscitation rates than men, but similar rates of survival from event to discharge.

Elevated levels of plasma C-reactive protein are associated with decreased graft survival in cardiac transplant recipients.

BACKGROUND: Inflammation may be involved in the origin of transplant coronary artery disease. We hypothesized that plasma levels of C-reactive protein (CRP) and interleukin-6 (IL-6), markers for systemic inflammation, would correlate with cardiac transplant graft survival. METHODS AND RESULTS: We studied 99 consecutive cardiac transplant recipients who were referred for routine endomyocardial biopsy and/or surveillance coronary angiography. Plasma levels of CRP and IL-6 were measured by their respective ELISAs. Patients were divided into 2 groups: those who died or required retransplantation and those who survived without the need for retransplantation. During the follow-up period of 5.0+/-2.7 years (range, 0.2 to 15.1 years) after transplant, 20 patients died and 9 required retransplantation. There was no significant difference in age, race, sex, cause of native myopathy, presence of diabetes, or use of aspirin, statins, or calcium channel blockers between the 2 groups. Although IL-6 did not relate to graft failure, CRP level was predictive of allograft failure (P:=0.003). The risk of allograft failure increased 36% for every 2-fold increase in CRP level. Moreover, CRP levels also correlated significantly with the frequency of grade 3 rejection (P:=0.02). In multivariate analysis, when combined with other significant predictors such as donor age and sex mismatching of the graft, CRP still significantly predicted graft failure (P:=0.025) with a 32% increase in the risk of graft failure for every 2-fold increase in CRP level. CONCLUSIONS: These findings suggest that elevated plasma levels of CRP are associated with subsequent allograft failure in cardiac transplant recipients.

Accuracy of computer-interpreted electrocardiography in selecting patients for thrombolytic therapy. MITI Project Investigators.

A prehospital computer-interpreted electrocardiogram (ECG) was obtained in 1,189 patients with chest pain of suspected cardiac origin during an ongoing trial of prehospital thrombolytic therapy in acute myocardial infarction. Electrocardiograms were performed by paramedics 1.5 +/- 1.2 h after the onset of symptoms. Of 391 patients with evidence of acute myocardial infarction, 202 (52%) were identified as having ST segment elevation (acute injury) by the computer-interpreted ECG compared with 259 (66%) by an electrocardiographer (p less than 0.001). Of 798 patients with chest pain but no infarction, 785 (98%) were appropriately excluded by computer compared with 757 (95%) by an electrocardiographer (p less than 0.001). The positive predictive value of the computer- and physician-interpreted ECG was, respectively, 94% and 86% and the negative predictive value was 81% and 85%. Prehospital screening of possible candidates for thrombolytic therapy with the aid of a computerized ECG is feasible, highly specific and with further enhancement can speed the care of all patients with acute myocardial infarction.

Myocardial Infarction Triage and Intervention Project--phase I: patient characteristics and feasibility of prehospital initiation of thrombolytic therapy.

Prehospital initiation of thrombolytic therapy by paramedics, if both feasible and safe, could considerably reduce the time to treatment and possibly decrease the extent of myocardial necrosis in patients with acute coronary thrombosis. Preliminary to a trial of such a treatment strategy, paramedics evaluated the characteristics of 2,472 patients with chest pain of presumed cardiac origin; 677 (27%) had suitable clinical findings consistent with possible acute myocardial infarction and no apparent risk of complication for potential thrombolytic drug treatment. Electrocardiograms (ECGs) of 522 of the 677 patients were transmitted by cellular telephone to a base station physician; 107 (21%) of the tracings showed evidence of ST segment elevation. Of the total 2,472 patients, 453 developed evidence of acute myocardial infarction in the hospital; 163 (36%) of the 453 had met the strict prehospital screening history and examination criteria and 105 (23.9%) showed ST elevation on the ECG and, thus, would have been suitable candidates for prehospital thrombolytic treatment if it had been available. The average time from the onset of chest pain to prehospital diagnosis was 72 +/- 52 min (median 52); this was 73 +/- 44 min (median 62) earlier than the time when thrombolytic treatment was later started in the hospital. Paramedic selection of appropriate patients for potential prehospital initiation of thrombolytic treatment is feasible with use of a directed checklist and cellular-transmitted ECG and saves time. This strategy may reduce the extent and complications of infarction compared with results that can be achieved in a hospital setting.

Effect of age on use of thrombolytic therapy and mortality in acute myocardial infarction. The MITI Project Group.

The findings in 3,256 consecutive patients hospitalized for acute myocardial infarction were tabulated to assess the history, treatments and outcome in the elderly; 1,848 patients (56%) were greater than 65 years of age, including 28% who were aged greater than or equal to 75 years. The incidence of prior angina, hypertension and heart failure (only 3% of patients less than 55 years of age had a history of heart failure compared with 24% greater than or equal to 75 years old) was found to increase with age. Twenty-nine percent of patients less than 75 years of age were treated with a systemic thrombolytic drug compared with only 5% of patients older than 75 years. Mortality rates increased strikingly with advanced age (less than 2% in patients less than or equal to 55, 4.6% in those 55 to 64, 12.3% in those 65 to 74 and 17.8% in those greater than or equal to 75 years). Both the incidence of complicating illness and a nondiagnostic electrocardiogram (ECG) increased with age. In a multivariate analysis of outcome in older patients (greater than or equal to 65 years), adverse events were related to both prior history of heart failure (odds ratio 3.9) and increasing age (odds ratio 1.4 per each decade of age). Outcome was not improved by treatment with thrombolytic drugs, but these agents were prescribed to only 12% of patients greater than 65 years of age, thereby reducing the power for detecting such an effect.(ABSTRACT TRUNCATED AT 250 WORDS)

Out-of-hospital cardiac arrest in octogenarians and nonagenarians.

BACKGROUND: Studies of elderly patients who have out-of-hospital cardiac arrest have contradictory results. The studies usually define elderly patients as those older than 70 years, and include relatively few octogenarians and nonagenarians. OBJECTIVES: To compare the survival after out-of-hospital cardiac arrest of octogenarians, nonagenarians, and younger patients and to determine the influence of age on survival after adjusting for factors known to influence out-of-hospital cardiac arrest outcome. METHODS: We conducted a retrospective cohort study in suburban King County, Washington, on 5882 patients who had out-of-hospital cardiac arrest from presumed cardiovascular disease between January 1, 1987, and December 31, 1998, and who received cardiopulmonary resuscitation from bystanders, emergency medical technicians, or both. The main outcome measure was survival to hospital discharge. RESULTS: In patients who had out-of-hospital cardiac arrest due to a cardiac cause, younger patients had higher hospital discharge rates than octogenarians, who in turn had higher hospital discharge rates than nonagenarians (19.4% vs 9.4% vs 4.4%; P<.001). However, survival to hospital discharge improved significantly for younger patients, octogenarians, and nonagenarians who had ventricular fibrillation or pulseless ventricular tachycardia (36% vs 24% vs 17%; P<.001). After multiple logistic regression analysis controlling for other factors, increased age was weakly associated with decreased survival to hospital discharge (odds ratio, 0.92; 95% confidence interval, 0. 85-0.99). CONCLUSIONS: Octogenarians and nonagenarians have lower survival to hospital discharge than younger patients, but age is a much weaker predictor of survival than other factors such as initial cardiac rhythm. Decisions regarding resuscitation should not be based on age alone. Arch Intern Med. 2000;160:3439-3443.

The revolution and evolution of prehospital cardiac care.

Prehospital cardiac care, first established in Belfast, Northern Ireland, in 1966, may be called revolutionary in that it was a radical break from existing practices. The Belfast program "moved" the coronary care unit into the community by treating the early complications of acute myocardial infarcation. The program staffed a mobile coronary care unit with a physician and nurse and demonstrated that patients with out-of-hospital sudden cardiac arrest could be resuscitated. The idea of prehospital cardiac care spread to other countries after publication of the Belfast experience in the Lancet. The first program in the United States, stationed at St Vincent's Hospital in New York, NY, began in 1968 and was modeled after the Belfast program. The physician-staffed model, however, was not widely imitated in the United States. Rather, beginning in 1969, programs using specially trained personnel, know as paramedics, began in Miami, Fla, Seattle, Wash, Columbus, Ohio, Los Angeles, Calif, Portland, Ore, and Nassau County, New York. Paramedic-staffed programs were designed not only to treat early complications of acute myocardial infarction, but also to attempt resuscitation for primary cardiac arrest. Most of the early paramedic programs were based in fire departments. Other programs used private ambulance or police personnel. Prehospital cardiac care has evolved significantly in the past 3 decades. Some notable developments include the tiered response system, training of the general public in cardiopulmonary resuscitation, low-energy defibrillators, automatic external defibrillators, and 12-lead electrocardiographic telemetry. The basic lesson of prehospital cardiac care is that the timely provision of cardiopulmonary resuscitation and defibrillation saves lives.

Hospital mortality in acute myocardial infarction in the era of reperfusion therapy (the Myocardial Infarction Triage and Intervention Project).

This study was conducted in 19 hospitals in the metropolitan Seattle area and included 6,270 unselected patients who had acute myocardial infarction (AMI) between January 1988 and April 1991. Hospital mortality was determined and related to patient demographic and clinical characteristics, the use of reperfusion therapies, and to complications after AMI. Thrombolytic therapy or direct coronary angioplasty < 6 hours from symptom onset was used to treat 1,185 (19%) and 524 (9%) patients, respectively. There were 629 (10%) hospital deaths; most occurred during the first 3 days of hospitalization. Factors affecting mortality after admission included: recurrent chest pain, recurrent AMI, development of heart failure, and the occurrence of stroke. After adjustment for age, treatment with thrombolytic therapy or direct angioplasty had no independent effect on reducing the overall mortality rate. Hospital mortality rates for AMI have improved considerably since 1970, although recurrent myocardial ischemic events continue to have an adverse effect on outcome. The current use of reperfusion treatments has had minimal causal impact on overall mortality rates, principally because less than one third of patients, who are relatively "low risk," are eligible and receive these treatments.

Use of the automatic external defibrillator in homes of survivors of out-of-hospital ventricular fibrillation.

This 57-month study evaluated the use of automatic external defibrillators (AEDs) in the homes of high risk cardiac patients (survivors of out-of-hospital ventricular fibrillation [VF]). The goal was to determine the utility of these devices by trained lay persons in actual cardiac arrest episodes. Ninety-seven survivors of out-of-hospital VF were enrolled in the study; 59 patients received AEDs, and 38 patients served as a control group. During the study period, 7 deaths occurred in the hospital without preceding out-of-hospital cardiac arrest or from noncardiac causes. There were 14 out-of-hospital cardiac arrests, 10 in the AED group and 4 in the control group. There was 1 long-term survivor in the control group. In the AED group, among the 10 cardiac arrests for which the device was available, it was used in 6. Only 2 patients were in VF; 1 was resuscitated with residual neurologic deficits and survived several months. This study observed a small potential for AEDs to save high risk patients.

Elevated plasma tissue plasminogen activator and anti-THP-1 antibodies are independently associated with decreased graft survival in cardiac transplant recipients.

Hemostatic and immunologic factors have been implicated in future cardiac events in patients with coronary artery disease. The role of these factors and their interaction is less established in cardiac transplant recipients. We sought to characterize the role of these factors in these patients. Cardiac transplant patients who presented for surveillance coronary angiography and/or endomyocardial biopsy were eligible for enrollment. Ninety-nine consecutive patients were enrolled. Plasma levels of tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor-1, von Willebrand factor, fibrin D-dimer, and anti-t-PA antibody were determined by enzyme-linked immunosorbent assays. Anti-THP-1 cell antibodies directed against a monocytic leukemia cell line were detected by incubating patient plasma with THP-1 cells. Bound antibody was detected using goat peroxidase-labeled immunoglobulin G directed against human immunoglobulins. Lipids were measured by enzymatic methods. Multivariate analysis identified the presence of anti-THP-1 cell antibodies (risk ratio 4.41, p = 0.002), t-PA antigen (risk ratio 1.10, p = 0.033), donor age 20 to 26 years (risk ratio 8.83, p = 0.042), and donor age >36 years (risk ratio 15.53, p = 0.009) as predictors of allograft failure. Altered hemostatic function, as demonstrated by elevated plasma t-PA antigen levels, is predictive of subsequent allograft failure in cardiac transplant recipients. In addition, the presence of anti-THP-1 cell antibodies in these patients is predictive of allograft failure.

Diffuse disseminated atheroembolism. Three cases with neuro-ophthalmic manifestation.

Neuro-ophthalmic manifestations led to the diagnosis of diffuse disseminated atheroembolism (DDA) in three men whose systemic symptoms had remained unexplained for years. The cholesterol emboli that cause DDA originate from friable plaques in the aorta and great vessels. Ophthalmologists should be alert to the diagnosis of DDA in patients with elevated ESRs, stroke, transient amaurosis, or cholesterol emboli in the fundi. Early diagnosis is important because arteriography, endarterectomy, and anticoagulation seem to increase the risk of serious, even fatal, embolization in these patients.

Synthesis and biological activity of guanylhydrazones of 2- and 4-pyridine and 4-quinoline carboxaldehydes.

A series of guanylhydrazones derived from 2- and 4-pyridine and 4-quinoline carboxyaldehydes was synthesized from S-methylisothio-semicarbazide hydroiodide using known procedures. The compounds are analogous to anticancer and antiviral thiosemicarbazones, but several of the guanylhydrazones derived from 4-quinoline carboxaldehyde showed no activity against P388 lymphocytic leukemia in mice. Guanylhydrazones derived from all three heterocyclic aldehydes revealed significant blood pressure lowering effects in the rat, however.

Prevalence of aspirin use among patients calling 9-1-1 for chest pain.

OBJECTIVE: Early aspirin administration during an acute myocardial infarction (AMI) decreases morbidity and mortality. This investigation examined the extent to which patients with a complaint of chest pain, the symptom most identified with AMI by the general population, self-administer aspirin before the arrival of emergency medical services (EMS) personnel. METHODS: In this prospective, cross-sectional prevalence study, data were derived through the analysis of EMS incident reports for patients with a complaint of chest pain from June 1, 1997, to August 31, 1997. RESULTS: The study included 694 subjects. One hundred two (15%) took aspirin for their chest pain before the arrival of EMS personnel. Of the 322 subjects who reported taking aspirin on a regular basis, 82 (26%) took additional aspirin for their acute chest pain. Only 20 (5%) of the 370 patients who were not using regular aspirin therapy self-administered aspirin acutely (p<0.001). In addition, patients with lower intensity of chest pain (p = 0.03) were more likely to take aspirin for their chest pain. CONCLUSION: Only a relatively small fraction of individuals calling 9-1-1 with acute chest pain take aspirin prior to the arrival of EMS personnel. These individuals are more likely to self-administer aspirin if they are already taking it on a regular basis. It is also possible that they are less likely to take aspirin if their chest pain is more severe.

Dispatcher assistance and automated external defibrillator performance among elders.

OBJECTIVES: Automated external defibrillators (AEDs) provide an opportunity to improve survival in out-of-hospital, ventricular fibrillation (VF) cardiac arrest by enabling laypersons not trained in rhythm recognition to deliver lifesaving therapy. The potential role of emergency dispatchers in the layperson use of AEDs is uncertain. This study was performed to examine whether dispatcher telephone assistance affected AED skill performance during a simulated VF cardiac arrest among a cohort of older adults. The hypothesis was that dispatcher assistance would increase the proportion who were able to correctly deliver a shock, but might require additional time. METHODS: One hundred fifty community-dwelling persons aged 58-84 years were recruited from eight senior centers in King County, Washington. All participants had received AED training approximately six months previously. For this study, the participants were randomized to AED operation with or without dispatcher assistance during a simulated VF cardiac arrest. The proportions who successfully delivered a shock and the time intervals from collapse to shock were compared between the two groups. RESULTS: The participants who received dispatcher assistance were more likely to correctly deliver a shock with the AED during the simulated VF cardiac arrest (91% vs 68%, p = 0.001). Among those who were able to deliver a shock, the participants who received dispatcher assistance required a longer time interval from collapse to shock [median (25th, 75th percentile) = 193 seconds (165, 225) for dispatcher assistance, and 148 seconds (138, 166) for no dispatcher assistance, p = 0.001]. CONCLUSIONS: Among older laypersons previously trained in AED operation, dispatcher assistance may increase the proportion who can successfully deliver a shock during a VF cardiac arrest.

Impact of community intervention to reduce patient delay time on use of reperfusion therapy for acute myocardial infarction: rapid early action for coronary treatment (REACT) trial. REACT Study Group.

BACKGROUND: Reperfusion therapy for acute myocardial infarction (AMI) is a time-dependent intervention that can reduce infarct-related morbidity and mortality. Out-of-hospital patient delay from symptom onset until emergency department (ED) presentation may reduce the expected benefit of reperfusion therapy. OBJECTIVE: To determine the impact of a community educational intervention to reduce patient delay time on the use of reperfusion therapy for AMI. METHODS: This was a randomized, controlled community-based trial to enhance patient recognition of AMI symptoms and encourage early ED presentation with resultant increased reperfusion therapy rates for AMI. The study took place in 44 hospitals in 20 pair-matched communities in five U.S. geographic regions. Eligible study subjects were non-institutionalized patients without chest injury (aged > or =30 years) who were admitted to participating hospitals and who received a hospital discharge diagnosis of AMI (ICD 410); n = 4,885. For outcome assessment, patients were excluded if they were without survival data (n = 402), enrolled in thrombolytic trials (n = 61), receiving reperfusion therapy >12 hours after ED arrival (n = 628), or missing symptom onset or reperfusion times (n = 781). The applied intervention was an educational program targeting community organizations and the general public, high-risk patients, and health professionals in target communities. The primary outcome was a change in the proportion of AMI patients receiving early reperfusion therapy (i.e., within one hour of ED arrival or within six hours of symptom onset). Trends in reperfusion therapy rates were determined after adjustment for patient demographics, presenting blood pressure, cardiac history, and insurance status. Four-month baseline was compared with the 18-month intervention period. RESULTS: Of 3,013 selected AMI patients, 40% received reperfusion therapy. Eighteen percent received therapy within one hour of ED arrival (46% of treated patients), and 32% within six hours of symptom onset (80% of treated patients). No significant difference in the trends in reperfusion therapy rates was attributable to the intervention, although increases in early reperfusion therapy rates were noted during the first six months of the intervention. A significant association of early reperfusion therapy use with ambulance use was identified. CONCLUSIONS: Community-wide educational efforts to enhance patient response to AMI symptoms may not translate into sustained changes in reperfusion practices. However, an increased odds for early reperfusion therapy use during the initiation of the intervention and the association of early therapy with ambulance use suggest that reperfusion therapy rates can be enhanced.

Rapid early action for coronary treatment: rationale, design, and baseline characteristics. REACT Research Group.

OBJECTIVE: Early reperfusion for acute myocardial infarction (AMI) can reduce morbidity and mortality, yet there is often delay in accessing medical care after symptom onset. This report describes the design and baseline characteristics of the Rapid Early Action for Coronary Treatment (REACT) community trial, which is testing community intervention to reduce delay. METHODS: Twenty U.S. communities were pair-matched and randomly assigned within pairs to intervention or comparison. Four months of baseline data collection was followed by an 18-month intervention of community organization and public, patient, and health professional education. Primary cases were community residents seen in the ED with chest pain, admitted with suspected acute cardiac ischemia, and discharged with a diagnosis related to coronary heart disease. The primary outcome was delay time from symptom onset to ED arrival. Secondary outcomes included delay time in patients with MI/unstable angina, hospital case-fatality rate and length of stay, receipt of reperfusion, and ED/emergency medical services utilization. Impact on public and patient knowledge, attitudes, and intentions was measured by telephone interviews. Characteristics of communities and cases and comparability of paired communities at baseline were assessed. RESULTS: Baseline cases are 46% female, 14% minorities, and 73% aged > or =55 years, and paired communities have similar demographics characteristics. Median delay time (available for 72% of cases) is 2.3 hours and does not vary between treatment conditions (p > 0.86). CONCLUSIONS: REACT communities approximate the demographic distribution of the United States and there is baseline comparability between the intervention and comparison groups. The REACT trial will provide valuable information for community educational programs to reduce patient delay for AMI symptoms.

Enantiomers of phenylpropanolamine suppress food intake in hyperphagic rats.

Phenylpropanolamine (PPA, d,l-norephedrine), available in many over-the-counter nasal decongestants and appetite suppressants, is a racemic mixture of the enantiomers d- and l-norephedrine. The present study evaluates the effects of the individual PPA enantiomers on a variety of nondrug (food deprivation) and drug-induced hyperphagias (2-deoxyglucose and insulin). Racemic PPA has been shown to significantly suppress food intake in these hyperphagic models. Both l-norephedrine (5-50 mg/kg) and d-norephedrine (5-150 mg/kg), administered intraperitoneally, significantly suppressed feeding after a 4-hr fast during the dark cycle. During the light period, l-norephedrine (7.5, 10, 15 mg/kg) and d-norephedrine (75, 100, 150 mg/kg) significantly reduced food intake at the 1-hr and 3-hr time intervals in the 24-hr food deprivation-, insulin- and 2-deoxyglucose-induced hyperphagic models. Only 7.5 mg/kg l-norephedrine in the insulin-induced hyperphagia at 3 hr failed to significantly suppress feeding. These results indicate that each individual PPA enantiomer possesses the ability to suppress food intake in rats made hyperphagic by various stimuli.

Barriers and facilitators to the prescription of automated external defibrillators for home use in patients with heart disease: a survey of cardiologists.

OBJECTIVE: Because the majority of cardiac arrests occur at home, the use of automated external defibrillators (AEDs) in the home could potentially improve survival of out-of-hospital cardiac arrest. Currently, physicians must prescribe AEDs for home use by patients. The purpose of this study was to investigate the barriers and facilitators to prescription of home use of AEDs. DESIGN: Telephone interviews were conducted with 85 cardiologists and paper and pencil surveys (via fax) with 59 additional cardiologists in Washington State. OUTCOME MEASURES: Cardiologists were asked about their current practices and their perceived barriers and facilitators to prescription of AEDs for home use. RESULTS: Eighty-five percent of the sample believed that AEDs could be effective in preventing death, although only 7% of the cardiologists had ever prescribed an AED. Reasons for nonprescription included the use of implantable cardioverter defibrillators, perceived lack of a clear patient niche, and lack of knowledge about the device. The majority of respondents reported that they would be more likely to prescribe AEDs if they were the standard of care (71%), were covered by insurance (67%), and came with comprehensive training (58%). CONCLUSION: The results showed that cardiologists believe that home use of AEDs can be effective but that many issues regarding the prescription of AEDs remain.