Association of apelin and AF in patients with implanted loop recorders undergoing catheter ablation.

BACKGROUND: Previous studies showed an association between apelin and atrial fibrillation (AF). The aim of this study was to analyse the effect of pulmonary vein isolation (PVI) in patients with paroxysmal AF on plasmatic apelin concentrations. METHODS: Nine consecutive patients (aged from 43 to 69 years, 3 females and 6 males) with documented paroxysmal atrial fibrillation and implanted loop recorders (ILR) for continuous ECG monitoring were included in this study. All the patients underwent a radiofrequency catheter ablation with PVI. RESULTS: The plasmatic concentration of apelin increased after PVI. The average plasmatic concentration of apelin before PVI was 0.299 ng/ml (±0.16), 3 months after PVI 0.462 ng/ml (±0.10) and 9 months after PVI 0.565 ng/ml (±0.146). There was an increase in the concentration of apelin 3 months and 9 months after the PVI by 0.163 ng/ml (p=0.07) and by 0.266 ng/ml (p=0.01), respectively. The concentration of apelin inversely correlated with the AF burden (r=-0.44, p=0.03). CONCLUSIONS: Our study showed a significant increase in apelin levels after the reduction of AF burden via PVI and an inverse correlation with AF burden. Apelin might be a promising marker of AF (Tab. 2, Fig. 2, Ref. 28).

Eisenmenger syndrome - an electrocardiographic and echocardiographic assessment of the right ventricle.

BACKGROUND: Eisenmenger syndrome represents severe, irreversible, and end-stage pulmonary arterial hypertension (PAH) associated with congenital heart defects. For long-term outcome optimal right ventricular (RV) adaptation is crucial with precise assessment of its hypertrophy, dilatation and function. OBJECTIVES: Associations of electrocardiographic (ECG) and echocardiographic (ECHO) RV characteristics were analyzed. METHODS: Included were 52 patients (39F/13M), median age 45 years (24-78). Following ECG parameters were analyzed: Butler-Leggett formula (B-L), Sokolow-Lyon criterion (S-L), QRS duration (QRS), maximum spatial QRS vector magnitude (QRS max); and ECHO parameters: RV diameter (RVd), RV wall thickness (RVAW), RV/LV function. RESULTS: Following significant ECG-ECHO associations were demonstrated: S-L criterion and B-L formula with RVAW (p 120 ms only with severely dilated RV (RVd > 45 mm), while QRS max 33 mm); A new combined scoring system was introduced. CONCLUSIONS: In Eisenmenger syndrome RV hypertrophy is compensatory; diagnosis of prognostically unfavorable RV dilatation is therefore important. Combined ECG-ECHO analysis enables more accurate risk stratification. QRS duration > 120 ms seems to be a late marker; QRS max together with ECHO parameters may help to distinguish patients at higher risk for clinical deterioration (Tab. 3, Fig. 8, Ref. 53).

Gender equity imbalance in electrocardiology: A call to action.

Despite the increasing number of women entering the medical profession, senior positions and academic productivity in many fields of medicine remain to be men dominated. We explored gender equity in electrocardiology as perceived by recent academic productivity and also active participation (presidencies and board constituents) in both the International Society of Electrocardiology (ISE) and the International Society for Holter and Noninvasive Electrocardiology (ISHNE). Academic productivity was measured by authorship (first and senior) in the Journal of Electrocardiology (JECG) and the Annals of Noninvasive Electrocardiology (ANE) in 2015. The percentage of women ISE and ISHNE Presidents was 5.6% and 0%, respectively. Current women board constituents for each society was 12.1% for ISE, and 9.4% for ISHNE. JECG articles published in 2015 had considerably less women compared to men for both senior (16.3%) and first (25.3%) authorship. ANE articles published in 2015 followed the same trends in gender, having less women compared to men for both senior (9.4%) and first (19.3%) authorship. There is a gender equity imbalance in the field of Electrocardiology. Identifying a gender imbalance is important for understanding reasons behind these trends, and may also help improve gender equity in Electrocardiology.

The relation between oxidative stress biomarkers and atrial fibrillation after pulmonary veins isolation.

INTRODUCTION: The current paradigm claims a link between oxidative stress and atrial fibrillation. The aim of our research was to study a relation between the percentage of time spent in atrial fibrillation (AF burden) and concentrations of oxidative stress biomarkers, before and after pulmonary veins isolation (PVI). METHODOLOGY: We included 19 patients (mean age 55±10years, 4 females and 15 males) with implanted loop recorders undergoing PVI. Plasmatic concentrations of advanced glycation end-products (AGEs), fructosamine, advanced oxidation protein products and thiobarbituric-acid reacting substances (TBARS) were measured and AF burden was recorded immediately before and 3months after the PVI. AF burden was also recorded 9months after the PVI. RESULTS: Post procedural AGEs concentration significantly negatively correlated with AF burden after 3months (ρ=-0.63; p<0.01) and 9months (ρ=-0.5; p=0.04), respectively as well as TBARS concentration significantly negatively correlated with AF burden after 9months (ρ=-0.61; p=0.01). CONCLUSION: Our study showed AGEs and TBARS to be potential predictors for AF burden after the PVI. We suppose that the more oxidative stress after the PVI is provoked, the more fibrotic tissue is produced. That means a better electrical isolation of pulmonary veins and consequently a lower AF burden.

Integration of the e-Learning into the medical university curricula.

OBJECTIVES: The aim of this contribution was to present the e-Learning introduction in the Slovak Medical University (SMU) with a focus on the implementation phase of the two blended courses - Healthcare Quality and Healthcare Professionals' Ethics. BACKGROUND: The introduction of the e-Learning was realized during the period 2008-2009 in the partnership of SMU and IBM Company, following strictly the project management approach. METHODS: The development of the e-module beta-versions was evaluated by the modules' authors using a structured interview. In a consequent pilot testing, the blended courses were evaluated by 23 students of the bachelor program in Rescue health care, and by 61 public health students at the master level program, respectively, using the standardized questionnaires. RESULTS: The tangible results included the documented SMU strategy for the e-Learning integration, six e-Learning modules and evaluation results. The authors' evaluation showed high scores for the experience in collaboration with IBM, as well as for the experience with the LMS environment. The students' evaluation showed a high acceptance of the e-Learning by both part-time and full-time students. The access to Internet was not recognized as a serious barrier. CONCLUSION: The first experience with the integration of the e-Learning into the curricula of the Slovak Medical University showed the advantage of the systematic approach. The experience with developing the strategy in an interdisciplinary/ intercultural team, the knowledge about specific characteristics of distance learning by the involved SMU staff, and the know-how and skills represented the important benefits. It was demonstrated that the blended learning is recommended as optimal for the education in medical environment (Tab. 4, Fig. 1, Ref. 22).

[The contribution of 24-hour ambulatory blood pressure monitoring to the treatment of hypertensive patients in teaching hospital in Nitra]. / Prínos 24-hodinového ambulantného monitoringu krvného tlaku k liecbe pacientov s hypertenziou vo Fakultnej nemocnici v Nitre.

BACKGROUND: Twenty-four hours ambulatory blood pressure monitoring (ABPM) in patients with arterial hypertension is a recognized method for diagnostic of hypertension and for monitoring of the effects of antihypertensive treatment. The aim of our study was to evaluate the contribution of ABPM in clinical practise. METHODS AND RESULTS: Records of ABPM in hypertensive patients were evaluated retrospectively. Total of 37 patients aged 27-69 years with the newly diagnosed hypertension in the period of 1996-2001 were included in the study. The indications to ABPM, percent of dippers and no dippers diagnosed on the basis of diurnal index and the modification in antihypertensive treatment in no dippers were analysed. 1) ABPM was used for monitoring of the effect of antihypertensive therapy in 78%, for diagnosing borderline hypertension in 19% and of white coat hypertension in 3% cases; 2) 22 patients (59%) were diagnosed as no dippers; 3) Antihypertensive therapy was modified in 7 patients no dippers (20%). CONCLUSIONS: The contribution of ABPM is obvious, however at current conditions its broader application could increase the diagnostic and therapeutical quality of clinical decision making in hypertensive patients.

[Contribution of the evidence-based medicine to the solution of some problems in electrocardiography]. / Prispevok medicíny zalozenej na dôkazoch k rieseniu niektorých problémov elektrokardiografie.

The paper summarizes the author's view on the possibilities to use the principles of evidence-based medicine for the re-evaluation of classical hypotheses and formulation of new hypotheses in electrocardiology. Electrocardiographic diagnostics of the left ventricular hypertrophy based on the voltage criteria, which is known to suffer by high number of so-called false negative results and low sensitivity, is shown as an example. An alternative approach is presented, based on the acceptation of these so-called false negative results as true results, reflecting changes in electrical properties of myocardium due to electrophysiological remodeling in left ventricular hypertrophy. In this context a new parameter is introduced for the quantification of the relative voltage deficit--the specific potential of myocardium. Results of experimental and clinical studies supporting the new paradigm are presented.

[Three-dimensional presentation of the electrocardiogram: new possibilities in comparative studies using cardiologic imaging methods]. / Trojrozmerná prezentácia elektrokardiogramu: nové moznosti pre komparatívne stúdie so zobrazovacími kardiologickými metódami.

The aim of the study was to demonstrate a biomathematical model for the topographic presentation of orthogonal electrocardiogram DECARTO, to present the possibilities for visualisation and processing of ECG in relation to others cardiological imaging methods. In DECARTO (Dipolar ElectroCARdioTOpography), the orthogonal ECG is used as an input signal, the signal is processed by the means of a biomathematical model and presented as areas of activated points on a spherical surface closely surrounding the heart, so-called decartograms. Decartograms can be visualised using the projection of the spherical image surface onto geometrically defined planar or 3D surfaces. The selection of the surface depends on the purpose of ECG imaging, on the evaluation of advantages and limitation of the particular possibilities, such as the degree of deformation, and their comparability with other imaging methods. Another possibility of 3D visualisation of decartograms is the utilisation of time as a 3rd dimension of the space. Additionally to analytically defined geometrical surfaces, it is possible to project decartograms onto a real surface of the heart, constructed from data of other image techniques. In this paper we present a superposition of decartogram and SPECT imaging, which combines graphic presentation of two diagnostic methods providing different but complementary information on the heart. The combination of comparable information allows to study the relationship between electrogenesis and perfusion of myocardium and its metabolism, to study diagnostic and prognostic importance of both agreements and disagreements of used methods. The fusion of information on the structure and function of the heart could potentially increase the diagnostic power of both methods.

Change climate in the University Hospital Bratislava.

Organizational change can generate skepticism and resistance in employees, making it sometimes difficult or impossible to implement organizational improvements. To enable the University Hospital Bratislava to manage these realities in a most effective way, the assessment of attitudes to change was conducted among 304 full-time hospital employees in the summer of 1999. The assessment was based on the Change Climate Survey allowing for investigation of attitudes in four main areas: orientation towards change in general, understanding and acceptance of change, management of change, and change outcomes. In spite of some limitations due to the fact that the survey did not use a true random sample, in general, the results seem to be able to illustrate the University Hospital employees' attitudes to change. The findings indicate that, in general, the attitudes of the hospital employees towards change are rather positive. However, the mixed feelings prevail among the employees from the point of understanding and acceptance of the current changes. Similarly, the mixed feelings persist among the employees with respect to the way the change is managed, though with slightly positive attitudes towards the level of communication. From the practical point of view, the results imply that emphasizing the involvement of organization members in learning about their organization and how to change it might prove to be more effective in managing change in the University Hospital Bratislava, than the traditional approaches to planned change, where consultants carry out most of the change activities, with the agreement and collaboration of management. (Tab. 8, Ref. 28.)

[Basic assessment of needs for training in evidence-based medicine in Slovakia]. / Zakladny odhad potrieb vzdelavania v oblasti mediciny zalozenej na dokazoch na Slovensku.

BACKGROUND: The health care reform in Slovakia produces a desire for greater responsibility for and control of strategic decisions and to be better able to evaluate international knowledge and experience in the specific national social and professional contexts. Evidence based medicine (EBM) provides an increasingly organised and accessible database of international knowledge in health and health care, capable of informing decisions at the macro and micro levels. AIM: The aim of this pilot study was to assess education, training and other capacity building needs in EBM and evidence based health care. METHODS: This study was primarily qualitative and based on a triangular approach, which included: (1) The analysis of the situation in pre- and postgraduate education in Slovakia aiming to the estimation of needs in EBM and critical appraisal skills training; (2) The analysis of questionnaires distributed in a sample of 50 medical doctors and university educated public health workers undergoing a postgraduate training; (3) The discussion in focused groups. RESULTS: The findings and analysis uncovered a gap in knowledge and experience of EBM approaches, particularly of searching for evidence, utilising information technology, of undertaking critical appraisals of the validity and quality of external evidence and of knowledge of English. On the other hand the findings revealed a high access to information including the Internet access at the workplace, an increasing awareness of the need for up-date information, a demand for training and potential opportunities for action. CONCLUSIONS AND RECOMMENDATIONS: The effective implementation introduction of EBM approach would require changes in broader political, cultural and behavioural contexts, including changes in pre- and postgraduate systems of professional and managerial education, changes in professional and managerial attitudes and changes in emphasis in skills and capacity building and improvements in knowledge management systems at the national level.

Electrocardiographic diagnosis of left ventricular hypertrophy: is the method obsolete or should the hypothesis be reconsidered?

The current ECG diagnosis of LVH is based on QRS voltage criteria and aims to estimate left ventricular mass. Its underlying hypothesis includes unstated assumptions about the non-spatial determinants of QRS voltage;that the electrical properties of hypertrophied myocardium do not differ from those healthy myocardium, and that they are not changed in the course of developing LVH. Since these two assumptions are not true, the performance of the voltage criteria is limited and is reflected in the high number of so-called false negative ECG results, as well as their low sensitivity. The reconsidered hypothesis is based on a more complex understanding of LVH and on the analysis of information provided by electrocardiography. It considers false negative results for LVH diagnosis as a relative voltage deficit, and introduces a new parameter for its quantification: the specific potential (the relative QRS voltage).The relative voltage deficit is related to changes of active and passive electrical properties (electrophysiological remodelling) of the hypertrophied myocardium. This new hypothesis also takes into account changes of the relative QRS voltage in different stages of LVH. The potential of this concept is its usefulness as a parameter in the frame of diagnostics of LVH, of diffuse changes of myocardium, in cardiovascular risk assessment, and well as for evaluation of the effects of therapy.

[Role of orthogonal electrocardiography and vectorcardiography in a paradigm shift in diagnosis of left ventricular hypertrophy]. / Moznosti ortogonálnej elektrokardiografie a vektorkardiografie prispiet' k zmene paradigmy v diagnostike hypertrofie lavej komory.

A new contingency approach to the ECG diagnostics of left ventricular hypertrophy, its theoretical background, and first results of experimental and clinical studies are presented. This approach considers false negative ECG results as a consequence of the relative voltage deficit and introduces a new parameter: the specific potential of myocardium. As well it considers nonlinear changes of non-spatial determinants with respect to the stage and progression of left ventricular hypertrophy. The potential advantages of the concept of the specific potential of myocardium can be summarized as follows: (1) It utilizes equally both electrocardiographic and echocardiographic information, without stressing the priority or neglecting any of particular methods and creates a broader basis for the clinical diagnosis of left ventricular hypertrophy, (2) It utilizes also the false negative ECG results for diagnostics and quantifies the relative voltage deficit.

Contribution to systematic education of quality management in Slovak health care.

THE AIM: Of the study was to contribute to quality improvement initiatives in Slovak health services through systematic approach to the education and training in quality management (QM). Consequently, the main objectives were to analyse the content of the education in QM abroad, to conduct an audit of perceived training needs in Slovakia, and to propose the design of QM training programme to be applied within CME scheme based on the study results. Triangular method in the design of the study was implemented. Review of relevant information, data from the questionnaire and semi-structured interview in the sample of 67 Slovak trainees from Health Management School and School of Public Health--were adopted in complementary fashion. BETWEEN FINDINGS: Highlighted in the survey are positive attitudes to training in quality management documented by the median score higher than 6 in all tested areas, on scale 0-10. No significant differences in profession groups as physicians, nurses, HC managers or among training institutions involved were displayed. However, potential obstacles were identified in deeper study using interviews. The absence of knowledge and skills in management in general and in quality management approaches especially are observed. Typically, the role of strategic planning is undermined. The large scale of quality management approaches is converted to problems of accreditation. Barriers to participative culture, innovation, devolution of accountability, resistance to change and to team based management are authentic findings as well. CONCLUSIONS: Drawn from the study were related to: fostering managers--"transformational leaders" for locally driven decision making in health care policy and practice; need of training activities for the continuing education in quality with respect to specific target groups interests and their level of knowledge in management; content of training oriented towards combination of rational utilization of information, critical analytical skills and planning for quality with human resource development-interpersonal skills, team building (soft skills), not just reduction of quality management tools to hard techniques (statistics, ISO norms); methods of education, where the usage of experiential learning methods, participative training inclusive action learning is highlighted; team training complemented with individual professional development support inclusive a coaching and mentoring scheme. AS IMPLICATIONS: Four types of CME training: Basic Module QM, Training for QM teams, Training Trainers Scheme and Guiding through Accreditation and Quality Award were proposed. (Tab. 9, Ref. 38.)

[Performance of Slovak hospitals as related to Porter's generic strategies]. / Výkon nemocníc na Slovensku vo vzt'ahu k uplatnovaným generickým stratégiám podla Portera.

Porter's generic strategies characterize organizations in terms of their competitiveness, and are related to the performance of the organization. The aim of this study was to analyze the Porter's generic strategies and their effect on performance in the context of the Slovak hospital industry. Acute care hospitals with more than 30 beds were included into the study. National institutes providing specialized service were excluded from the study. Strategy and performance were evaluated on the basis of self-reported questionnaires, completed by chief administrators of hospitals (total 76 completed questionnaires were obtained, out of 81 distributed, i.e. 94% response rate). The cluster analysis was used for the identification of strategic orientation. Performance differences across strategic groups were tested using multivariate analysis of covariance (MANCOVA). The hierarchical cluster analysis uncovered a four-group taxonomy of hospitals: the group "Focused Cost Leadership" included 33% of hospitals, the group "Stuck-in-the middle" 49%, the group "Wait and See" 13% and the group "Cost leadership" 5%. Significant differences in performance were related to the Porter's pure, or hybrid strategies, respectively. In terms of industry evolution, the Slovak hospital industry could be characterized as fragmented, having a large number of small and medium size mainly state owned hospitals, with absence of market leaders, and with high exit barriers (mainly social and political) that hold back consolidation. (Tab. 1, Ref. 35.).

Performance implications of Porter's generic strategies in Slovak hospitals.

The aim of the study was to examine the use of Porter's generic strategies and their effect on performance in the context of the Slovak hospital industry. Using mail survey the study first identified the natural taxonomy of four strategic types of Slovak hospitals, based on their use of Porter's generic strategies in pure form and in combination. Next the study examined whether different strategic types were associated with different levels of organisational performance, while controlling for such variables as size and location, which have been argued to influence the hospital performance. The findings indicate that hospitals which follow a "stuck-in-the-middle" strategy, in general, have superior performance on all used performance measures, while hospitals that place only low emphasis on cost leadership, differentiation and focus, labelled "wait and see" in this study, perform the poorest. The study concludes that the research provided body of knowledge relevant for the Slovak hospital industry, that may be used by hospital managers in the strategy formulation process as well as by the researches in exploring the influence of different contingencies on hospitals' strategic orientation.

Investigating regional differences in short-term effects of air pollution on daily mortality in the APHEA project: a sensitivity analysis for controlling long-term trends and seasonality.

Short-term effects of air pollution on daily mortality in eight western and five central-eastern European countries have been reported previously, as part of the APHEA project. One intriguing finding was that the effects were lower in central-eastern European cities. The analysis used sinusoidal terms for seasonal control and polynomial terms for meteorologic variables, but this is a more rigid approach than the currently accepted method, which uses generalized additive models (GAM). We therefore reanalyzed the original data to examine the sensitivity of the results to the statistical model. The data were identical to those used in the earlier analyses. The outcome was the daily total number of deaths, and the pollutants analyzed were black smoke (BS) and sulfur dioxide (SO(2)). The analyses were restricted to days with pollutant concentration < 200 microg/m(3) and < 150 microg/m(3) alternately. We used Poisson regression in a GAM model, and combined individual city regression coefficients using fixed and random-effect models. An increase in BS by 50 microg/m(3) was associated with a 2.2% and 3.1% increase in mortality when analysis was restricted to days < 200 microg/m(3) and < 150 microg/m(3), respectively. The corresponding figures were 5.0% and 5.6% for a similar increase in SO(2). These estimates are larger than the ones published previously: by 69% for BS and 55% for SO(2). The increase occurred only in central-eastern European cities. The ratio of western to central-eastern cities for estimates was reduced to 1.3 for BS (previously 4.8) and 2.6 for SO(2) (previously 4.4). We conclude that part of the heterogeneity in the estimates of air pollution effects between western and central-eastern cities reported in previous publications was caused by the statistical approach used and the inclusion of days with pollutant levels above 150 microg/m(3). However, these results must be investigated further.

Standards for the function of an academic 12-lead electrocardiographic core laboratory.

An academic 12-lead electrocardiogram (ECG) core laboratory aims to provide the highest possible quality ECG recording, measurement, and storage to aid clinicians in research into important cardiovascular outcomes and to maximize the credibility of scientific results based solely, or in part, on ECG data. This position paper presents a guide for the structure and function of an academic ECG core laboratory. The key functional aspects are: 1) Data collection, 2) Staff composition, 3) Diagnostic measurement and definition standards, 4) Data management, 5) Academic considerations, 6) Economic consideration, and 7) Accreditation. An ECG Core Laboratory has the responsibility for rapid and accurate analysis and responsible management of the electrocardiographic data in multicenter clinical trials. Academic Laboratories, in addition, provide leadership in research protocol generation and production of research manuscripts for submission to the appropriate peer-review journals.

Basic estimate of needs for training in evidence-based medicine in Slovakia.

This study reports the findings of the first survey of the knowledge and needs for training in evidence based medicine (EBM) of health-care workers in Slovakia. This study was primarily qualitative and based on a triangular approach, which included: analysis of the situation in pre- and postgraduate education in Slovakia aimed at estimating needs in EBM and critical appraisal skills (CAS) training; analysis of questionnaires distributed in a sample of medical doctors and university educated public health workers undergoing postgraduate training; and focus group discussions. The findings revealed a real gap in knowledge in EBM and CAS in Slovakia and identified several areas as the focus for intervention. The results showed also some important behavioural and cultural aspects, including low individual responsibility for education; tendency to delegate responsibility to authorities (experts, top management, Ministry of Health); and persistence of the state paternalistic type of education. Concludes that managers planning to implement EBM in Slovakia should therefore consider a broader behavioural and cultural context for change, not just introduction of a training EBM module.

Hospital human resource planning in Slovakia.

The study is an attempt to provide empirical evidence, in the context of acute hospital care, of the current human resource practices in the health sector of the Slovak Republic. Using a sample of 72 acute care hospitals the research explored the perceived functions, typical customers and priorities of hospital human resource departments, ownership of a workforce plan, and the relationships between ownership of a workforce plan and type of hospital, as well as the degree to which different human resource activities are given priority. Cross-tabulation procedure revealed statistically significant relationships between ownership of a workforce plan and the degree of priority given to having a quick, efficient and cost-effective recruitment and selection system and, not surprisingly, the degree of priority given to ensuring that the human resource department has a workforce plan. The study evidence also indicates that, although the human resource staff in hospitals seem to be aware of their role in assisting hospital management in decision making, the human resource function in the Slovak hospitals still rather resembles that of a personnel administration than that of an important strategic human resource activity.