Randomized Controlled Trial Protocol on the Effects of a Sensory Motor Intervention Associated with Kangaroo Skin-to-Skin Contact in Preterm Newborns.

There is still very limited evidence on the effects of neonatal interventions on infant neurodevelopmental outcomes, including general movements (GMs). This research will primarily assess the effects of a sensory motor physical therapy intervention combined with kangaroo skin-to-skin contact on the GMs of hospitalized preterm newborns. Secondary outcomes include body weight, posture and muscle tone, behavioral state, length of hospital stay, and breastfeeding. This study protocol details a two-arm parallel clinical trial methodology, involving participants with a postmenstrual age of 34-35 weeks admitted to a Neonatal Intermediate Care Unit (NInCU) with poor repertoire GMs. Thirty-four participants will be randomly assigned to either the experimental group, receiving a 10-day sensory motor physical therapy associated with kangaroo skin-to-skin contact, or the control group, which will only receive kangaroo skin-to-skin contact. The study will measure GMs (primary outcome), and body weight, posture and muscle tone, behavioral state, length of hospital stay, and breastfeeding (secondary outcomes). Data collection occurs in the NInCU before and after the intervention, with follow-up measurements post discharge at 2-4 weeks and 12-15 weeks post-term. SPSS will be used for data analyses. The results will provide novel information on how sensory motor experiences may affect early neurodevelopment and clinical variables in preterm newborns.

Late preterm and very preterm infants differ in the acquisition time and quantity of reaches with grasping at reaching onset: an exploratory study.

Introduction: The onset of manual reaching allows the expansion of the infant's interaction with the environment. When born preterm, infants become vulnerable to problems in the development of reaching. However, it is still unknown whether there are differences in reaching according to the degree of prematurity. Objective: This study aimed to explore the differences in reaching acquisition and behavior between late preterm and very preterm infants, as well as whether age and clinical variables influence the results. Method: This is an exploratory, comparative, observational study. In total, 24 infants were included soon after reaching onset; 12 infants were born late preterm (35.55 ± 0.67 gestational weeks) and 12 very preterm (30.60 ± 0.05 gestational weeks). Infants were placed in a baby seat, and a toy was placed at a reachable distance for 2 min. Reaching behavior was the primary variable; birth weight and length of hospital stay were secondary variables. Results: The age of reaching onset was higher in the very preterm group. The proportion of reaches with grasping was higher in the late preterm group. These differences were affected by the lower birth weight and longer length of hospital stay in the very preterm group. The proportions of proximal and distal adjustments did not differ between groups. Conclusion: Very preterm infants presented disadvantages in the acquisition time and the number of reaches with grasping, but not in the proportions of proximal and distal adjustments of reaching, relative to late preterm infants. Group differences were influenced by clinical variables.

Motor repertoire in 3- to 5- month-old infants with prenatal exposure to syphilis and toxoplasmosis.

AIM: To characterize the motor repertoire of 3- to 5-month-old infants who were prenatally exposed to the infectious agents of syphilis and toxoplasmosis. METHODS: Exploratory observational study that evaluated 15 exposed infants (34.4 ± 3.5 weeks gestation) recruited from a referral center. Age assessment ranged 12-20 (median 12) weeks post-term. General Movement Assessment, including the Motor Optimality Score-Revised (MOS-R), was used to assess the global quality of fidgety movements (FMs) and to quantify and detail coexisting motor patterns. Clinical variables were also collected. Later motor outcomes were obtained from medical reports when possible. RESULTS: MOS-R ranged 10-26 (median 24). There was a higher proportion of infants with normal (80.0 %) than aberrant FMs, but the proportion of infants with reduced MOS-R (80.0 %) was higher compared to optimal MOS-R. One infant with aberrant FMs was later diagnosed with cerebral palsy. Only 13.3 % of the infants showed smooth and fluent movement character. All observed tongue movements were abnormal. CONCLUSION: Infants had predominantly normal FMs, but with reduced MOS-R and abnormalities in the coexisting motor repertoire.

Electrified methane steam reforming on a washcoated SiSiC foam for low-carbon hydrogen production.

In view of largely available renewable electricity as a green future resource, here we report the electrification of a Rh/Al2O3 washcoated SiSiC foam for methane steam reforming (MSR). We show that, thanks to the suitable bulk resistivity of the SiSiC foam, its direct Joule heating up to relevant temperatures is feasible; the interconnected geometry greatly reduces heat and mass transfer limitations, which results in a highly active and energy efficient system for low-carbon H2 production. The foam-based electrified MSR (eMSR) system showed almost full methane conversion above 700°C and methane conversions approaching equilibrium were obtained in a range of conditions. Energy efficiency as high as 61% and specific power consumption as low as 2.0 kWh/ N m H 2 3 were measured at 650°C, at gas hourly space velocity (GHSV) of 150,000 cm3/h/gcat. When driven by renewable electricity, the proposed reactor configuration promises a high potential to address the decarbonization challenge in the near-term future.

Association between the General Movement Optimality Score and clinical features in newborns during hospitalization: A cross-sectional study.

AIMS: To describe the General Movements (GMs) of hospitalized newborns to verify if their global and detailed GMA are related and if their GMs are associated with clinical features. METHODS: Cross-sectional study. Thirty-eight preterm and full-term newborns, who were hospitalized in the neonatal intermediate care unit of a reference hospital, were included. Prechtl's General Movement Assessment (GMA), including the General Movement Optimality Score (GMOS) list, was used as an assessment tool. Clinical variables, such as preterm birth, birthweight, length of hospitalization, Apgar scores, pregnancy problems, admission at neonatal intensive care unit, use of invasive mechanical ventilation, and brain imaging findings were also collected. Newborns were videoed at a single time for 3 min before discharge. RESULTS: Most newborns presented GMs with normal or poor repertoire quality. GMOS ranged from 17 to 42 points. Scores were lower in abnormal GMs. Abnormal GMs were associated with preterm birth, length of hospital stay >30 days and birthweight <2500 g. Accordingly, lower GMOSs were also associated with preterm birth, a birthweight <2500 g and a hospital stay >30 days but also with the invasive mechanical ventilation application. CONCLUSION: Preterm and full-term newborns presented normal or abnormal GMs during hospitalization. Preterm birth, low birthweight, longer hospital stay and a time period of invasive ventilation were associated with worse GM behaviors.

Bucket hydrokinesiotherapy in hospitalized preterm newborns: a randomized controlled trial.

OBJECTIVE: To examine the effects of hydrokinesiotherapy in a bucket on physiological parameters and clinical outcomes of hospitalized preterm newborns. METHODS: In this randomized controlled trial, 34 preterm newborns with low birth weight were randomly allocated into experimental (EG) or control (CG) groups and were assessed four times on two alternate days: pre-intervention, post-intervention, 15 min after the intervention, 30 min after post-intervention. On both days, between pre-and post-intervention, the EG underwent hydrokinesiotherapy in a bucket for 10 min and the CG only had the diaper changed. Physiological parameters and body weight gain were considered primary outcomes. Behavioral state and degree of respiratory distress were secondary outcomes. RESULTS: Newborns in the EG presented transitory changes in heart and respiratory rates after the intervention. Oxygen saturation was higher in the EG compared to the CG at post-intervention and up to at least 15 min after post-intervention on both days. The EG was in a more active state than the CG at post-intervention on both days. These changes occurred within normal ranges. Body temperature, degree of respiratory distress, and body weight gain did not differ between groups. CONCLUSION: The hydrokinesiotherapy caused isolated changes in the physiological parameters and led to a more active behavioral state in hospitalized preterm newborns with low birth weight. These changes did not affect the newborns' clinical conditions. The technique was safe, but clinical outcomes, including body weight gain, were not improved.

Habilidades funcionais e qualidade de vida em crianças com Leucemia Linfoblástica Aguda / Functional abilities and quality of life in children withacute lymphoblastic leukemia

Objetivo: Comparar as capacidades funcionais e a qualidade de vida entre crianças com leucemia linfoblástica aguda em tratamento com quimioterapia e/ou radioterapia e crianças sem o tratamento, de 4 a 7 anos de idade. Método: Participaram do estudo 50 crianças, sendo 25 em tratamento (grupo experimental) e 25 que já terminaram o tratamento (grupo controle), avaliados por meio do Inventário de Avaliação Pediátrica de Incapacidade (PEDI) e da Escala de Qualidade de Vida da Criança (AUQEI). Resultados: Não houve diferença entre os grupos nos escores brutos do PEDI e na pontuação do AUQEI. Os escores normativos do PEDI apresentaram-se predominantemente abaixo do esperado para a idade em ambos os grupos. A pontuação do AUQEI demonstrou uma qualidade de vida prejudicada no grupo experimental e no controle. Conclusão: Sugere-se que a leucemia linfoblástica aguda e seus tratamentos (quimio e radioterápicos) geram prejuízos funcionais e psicossociais, tanto no momento do tratamento oncológico como após sua conclusão e remissão da doença. É relevante que haja promoção de um acompanhamento longitudinal e multiprofissional da criança com câncer, a fim de minimizar os danos e reinseri-la na comunidade efetivamente.

Health demands and care of children with congenital Zika syndrome and their mothers in a Brazilian state.

BACKGROUND: A Zika virus (ZIKV) infection outbreak occurred in Brazil in 2015, accompanied by a marked increase in the number of newborns presenting with microcephaly and other neurological disorders. This characteristic set of birth defects was later termed congenital Zika syndrome (CZS). The therapeutic itinerary of mothers and children infected by ZIKV can be determined by several factors, including the relationship established with existing healthcare services. Here, we aimed to describe and analyze the extent to which children with CZS, born from 2015 to 2018 in the state of Mato Grosso do Sul, Brazil, and their mothers were treated according to the guidelines established by the Brazilian Ministry of Health. METHODS: This was a descriptive cross-sectional study that considered all children (and respective mothers) with confirmed or suspected CZS born in Mato Grosso do Sul. Children and their mothers were identified based on all suspected or confirmed cases of congenital anomalies in Mato Grosso do Sul that were reported to the Registry of Public Health Events. We analyzed data on the epidemiological profile of mother-child pairs and the care received by them. Data were summarized using statistical descriptive analysis. RESULTS: We showed that most mothers were white women (57%) with low income. Among pregnant women, 73% had a diagnosis of fever caused by ZIKV infection at a primary health care institution (PHCI), but only 36% received the necessary information regarding the risk of CZS. Over a third (36%) of the mothers did not receive guidance about childcare follow-up and 73% did not receive guidance regarding the availability of social support after childbirth. Gaps in medical care were observed mainly in pregnant women treated at a PHCI. Specialized assistance for children was adequate in most cases. Psychosocial support was not made available to women throughout their therapeutic itineraries. CONCLUSIONS: Here, we identified gaps in the care of families and children with disabilities, which can have an important impact on their quality of life. Beyond protocols, practical interventions must cover all the needs that arise throughout the therapeutic itineraries not only of children but also of pregnant women and mothers.

Evidence of training influence on infant manual behavior: a systematic review

INTRODUCTION: Researchers have widely investigated how interventions by means of training can improve manual behaviors in infants. However, no systematic review has been found on this topic. OBJECTIVE: To analyze the quality of scientific evidence considering the methodological quality and level of evidence by type of study in research on training of object-directed manual behaviors in infants in the first 18 months of life. METHODS: National Library of Medicine (PubMed/MEDLINE), Latin American and Caribbean Health Sciences (LILACS), Virtual Health Library (BIREME/BVS), Science Direct, SciELO, and Physiotherapy Evidence Database (PEDro) databases were used. Only clinical trials that assessed the benefits of manual object-directed training in infants and were published up to February 2018, in English, were included. The Cochrane Collaboration Model was adapted to extract bibliographical data from the articles and their methodological quality was assessed using the PEDro scale and the Oxford Centre for Evidence-Based Medicine's Levels of Evidence. RESULTS: Twenty one clinical trials were included. Studies investigated typically developing full-term infants, preterm infants, and infants at risk for autism spectrum disorders. Trainings were administered to infants by means of "sticky mittens" paradigm, task-specific practice, or contingency reinforcement. Most of the studies presented fair or poor methodological quality. Only studies that used task-specific active practice presented high methodological quality. CONCLUSIONS: The results indicate there is high quality evidence that task-specific training improves object-directed manual behaviors in typically developing infants and preterm infants in the first 2-4 months of life. Studies addressing infants with established diagnoses of developmental dysfunction are lacking.

INTRODUÇÃO: Pesquisadores tem amplamente investigado como o treino pode melhorar comportamentos manuais em lactentes. No entanto, nenhuma revisão sistemática foi encontrada sobre este tópico. OBJETIVO: Analisar a qualidade da evidência científica considerando a qualidade metodológica e o nível de evidência por tipo de estudo em pesquisas sobre treino de comportamentos manuais direcionados a objetos em lactentes nos primeiros 18 meses de vida MÉTODO: Foram utilizadas as bases de dados da Biblioteca Nacional de Medicina (PubMed / MEDLINE), Literatura Latino-Americana e do Caribe (LILACS), Biblioteca Virtual em Saúde (BIREME / BVS), Science Direct, SciELO e Physiotherapy Evidence Database (PEDro). Apenas ensaios clínicos que avaliaram os benefícios do treino manual orientado a objetos em lactentes e que foram publicados até fevereiro de 2018, em inglês, foram incluídos. O Modelo de Colaboração Cochrane foi adaptado para extrair dados bibliográficos dos artigos e sua qualidade metodológica foi avaliada pela escala PEDro e pelo Nível de Evidência Científica por Tipo de Estudo de Oxford. RESULTADOS: Vinte e um ensaios clínicos foram incluídos. Os estudos investigaram lactentes nascidos a termo, prematuros e lactentes de risco para distúrbios do espectro autista. Os treinos foram administrados aos lactentes por meio das abordagens do paradigma de "luvas aderentes", prática específica da tarefa ou reforço de contingência. A maioria dos estudos apresentou qualidade metodológica razoável ou fraca. Apenas os estudos que utilizaram a prática ativa específica da tarefa apresentaram qualidade metodológica alta. CONCLUSÃO: Há evidência de alta qualidade de que o treino específico da tarefa aprimora comportamentos manuais orientados a objetos em lactentes com desenvolvimento típico e lactentes prematuros nos primeiros 2-4 meses de vida. Estudos abordando lactentes com diagnósticos estabelecidos de disfunção do desenvolvimento não foram encontrados.

General movements and motor outcomes in two infants exposed to Zika virus: brief report.

OBJECTIVE: We described the general movements (GMs) in the fidgety period and the motor performance of two infants who were exposed to Zika virus (ZIKV) during distinct trimesters of gestation. METHODS: Infants were assessed at 4 and 12 months of age. Prechtl's GM assessment and the Alberta Infant Motor Scale were used. RESULTS: In Case 1, the mother presented confirmed ZIKV infection in the 10th week of gestation and the infant was born full-term with brain abnormalities and microcephaly. Fidgety movements were absent at 16 weeks after term and motor development was severely impaired at 12 months of age. In Case 2, the mother presented confirmed ZIKV infection in the 34th week of gestation and the infant was born full-term with no signs of brain changes or microcephaly. Fidgety movements at 13 weeks were normal in presentation and motor outcome was typical at 12 months. CONCLUSION: GM assessment can be useful for ZIKV-exposed infants. These findings represent the first information on GMs and long-term motor outcomes in ZIKV-exposed infants.

Brief reaching training with "sticky mittens" in preterm infants: Randomized controlled trial.

OBJECTIVE: To examine whether a brief reaching training with sticky mittens was effective to improve reaching behavior in newly reaching preterm infants. METHODS: In this randomized controlled trial, twenty four 5-month-old (±16-week-old corrected age) preterm infants were randomly allocated into experimental or control groups. Infants were assessed three times in a single session: pretraining (immediately before training), posttraining (immediately after training), and retention (4 min after the posttraining). During training, infants in the experimental group wore open fingers Velcro covered mittens. Training consisted of one 4-minute session of stimulated reaching using Velcro covered toys. Controls did not receive the training. During assessments, infants were placed in a baby chair and toys without Velcro were offered at their midline for 2 min. Number of total reaches, proximal adjustments and distal adjustments of reaching were primary outcomes. Grasping was a secondary outcome. RESULTS: Groups were similar in the pretraining. In the posttraining, trained infants performed greater amount of total reaches and bimanual reaches than untrained infants. Greater amount of bimanual reaches in trained infants was maintained in the retention test. Distal adjustments and grasping outcome were not influenced by the training. CONCLUSIONS: A brief-term training with open fingers sticky mittens benefited reaching behavior and favored retention of increased bimanual reaches in newly reaching late preterm infants. However, it was not sufficient to influence hand openness and early grasping.

Influência da intervenção sensório-motora no sistema respiratório de recém-nascidos prematuros / Influence of sensorimotor intervention on the respiratory system of preterm infants

Introdução: A intervenção sensório-motora é utilizada para prevenir ou minimizar alterações no desenvolvimento de recém-nascido pré-termo (RNPT). Entretanto, mais estudos sobre sua influência em RNPT hospitalizados são necessários. Objetivos: Verificar a influência da intervenção sensório-motora sobre parâmetros fisiológicos e peso corporal em RNPT hospitalizados. Métodos: Avaliaram-se 30 RNPT estáveis, submetidos a uma intervenção sensório-motora durante 10 minutos diários por 3 dias consecutivos. Análises comparativas foram realizadas considerando as variáveis frequência respiratória (FR), frequência cardíaca (FC), saturação de oxigênio (SaO2), Boletim Silverman-Andersen (BSA) e peso corporal, mensuradas imediatamente antes da intervenção, imediatamente após, e no 15º minuto após término da intervenção. Resultados: A FR foi maior no 15º minuto após a intervenção do que antes (p<0,05). A SaO2 aumentou logo após a intervenção (p<0,05). O peso corporal aumentou ao longo dos três dias (p<0,001). A FC e o BSA permaneceram constantes. Conclusão: A intervenção sensório-motora pode ter contribuído para melhor frequência respiratória e saturação de oxigênio e demonstrou-se segura aos RNPT.

Introduction: Sensorimotor intervention is frequently used to prevent or minimize dysfunction in the development of preterm newborns (PTNB). However, further studies on its influence in hospitalized PTNB are needed. Objective: To verify the influence of a sensorimotor intervention on physiological parameters and body weight in hospitalized PTNB. Methods: Thirty stable PTNB underwent a sensorimotor intervention during 10 minutes daily for 3 consecutive days. Comparative analyzes were performed considering the variables respiratory rate (RF), cardiac frequency (CF), oxygen saturation (SaO2), Silverman-Andersen Score (SAS), and body weight, measured immediately before the intervention, immediately after, and at 15 minutes after the intervention. Results: RF was higher in the 15th minute after the intervention than before (p<0.05). SaO2 increased immediately after the intervention (p<0.05). Body weight increased over the three days (p<0.001). CF and SAS remained constant. Conclusion: The sensorimotor intervention may have contributed to better respiratory rate and oxygen saturation and was shown to be safe for PTNB.

Prospective Use of Microvolt T-Wave Alternans Testing to Guide Primary Prevention Implantable Cardioverter Defibrillator Therapy.

BACKGROUND: We hypothesized that a negative microvolt T-wave alternans (MTWA) test would identify patients unlikely to benefit from primary prevention implantable cardioverter defibrillator (ICD) therapy in a prospective cohort. METHODS AND RESULTS: Data were pooled from 8 centers where MTWA testing was performed specifically for the purpose of guiding primary prevention ICD implantation. Cohorts were included if the ratio of ICDs implanted in patients who were MTWA "non-negative" to patients who were MTWA negative was >2:1, indicating that MTWA testing had a significant impact on the decision to implant an ICD. The pooled cohort included 651 patients: 371 MTWA non-negative and 280 MTWA negative. Among non-negative patients, 62% underwent ICD implantation whereas only 13% of MTWA-negative patients received an ICD (P<0.01). Despite a substantially lower prevalence of ICDs, long-term survival (6.9 years) was significantly better among MTWA-negative patients (68.2% non-negative vs. 87.1% negative, P=0.026). CONCLUSIONS: MTWA-negative patients had significantly better survival than MTWA non-negative patients, the majority of whom had ICDs. Despite a very low prevalence of ICDs, long-term survival among patients with left ventricular ejection fraction ≤40% and a negative MTWA test was better than in the ICD arm of any study to date that has demonstrated a benefit of ICDs. This provides further evidence that MTWA-negative patients are unlikely to benefit from primary prevention ICD therapy.

Microvolt T-wave alternans in short QT syndrome.

BACKGROUND: T-wave alternans (TWA) is an accepted marker of risk for malignant ventricular arrhythmias, for which prognosis value has been established in different populations. Short QT syndrome (SQTS) is a very rare primary electrical disease carrying the risk of ventricular fibrillation. TWA in SQTS has not been evaluated yet. METHODS: Thirteen patients with SQTS (QT = 308 ± 16 ms, QTc = 329 ± 10 ms, heart rate = 69 ± 8 beats/min) underwent microvolt TWA measurement using spectral analysis. TWA testing was performed using Heartwave II (Cambridge Heart™, Inc., Bedford, MA, USA) during bicycle exercice and classified as negative, positive, or indeterminate according to the published standards for clinical interpretation. RESULTS: Twelve patients were male (mean age 23 ± 5 years). Five were asymptomatic, three presented with aborted sudden cardiac death, and five with unexplained syncope. Six patients belonged to two unrelated families, while familial cases of SQTS were present for two other patients. A familial history of sudden death (SD) was present for seven patients. Ventricular fibrillation was inducible in three patients. Four patients were implanted with an implantable cardioverter-defibrillator and one presented with polymorphic ventricular tachycardia during follow-up. TWA was negative in each but one patient (indeterminate). Maximal negative heart rate was 118 ± 12 beats/min. Patients with previous SD displayed significant shorter QT and higher resting heart rate compared to the remaining cases. CONCLUSIONS: TWA testing is negative in 12 of 13 SQTS patients, even in the symptomatic or inducible ones. Measurement of TWA using conventional protocol and criteria for risk stratification in SQTS seems therefore useless.

Microvolt T-wave alternans as predictor of electrophysiological testing results in professional competitive athletes.

BACKGROUND: Several studies have confirmed the equivalence of the microvolt T-wave alternans (mTWA) and the electrophysiology (EPS) tests in cardiac disease. No data are available in populations of competitive athletes with arrhythmias that might jeopardize the pursuit of their professional career. METHODS: We prospectively studied 100 trained competitive athletes, including elite types (72/100), (mean age +/- standard deviation: 26.1 +/- 4.5 years). Forty-eight of them were wholly normal (Group A, mean age: 24.5 +/- 8.5 years) and 52 of them had severe arrhythmias (Group B, mean age: 28.2 +/- 11.5 years) and were symptomatic in 85% of cases for prolonged palpitations and syncope, but lacked any overt structural heart disease at standardized cardiological screening. All athletes were evaluated with the microvolt T-wave alternans exercise-stress test, using the Heart Wave System with Microvolt Sensors. Group B underwent EPS to evaluate inducibility to sustained ventricular tachycardia (VT) during programmed electrical stimulation. RESULTS: In Group A, the mTWA outcome was determinate in 45 subjects (94%) and indeterminate in 3 (6%). No symptomatic event was reported in a follow-up of 36.1 months. In Group B, the mTWA test was positive in 7 symptomatic subjects (15%), indeterminate in 3 (7%), and negative for the remaining 42 subjects (76%). Forty-one of 42 negative mTWA subjects were also negative in the EPS test, without any syncope or sustained VT during 25.3 months of follow-up. In the positive mTWA test subjects, 5 (72%) were positive for inducibility of rapid sustained monomorphic VT in EPS, 1 was positive for severe sustained atrial tachyarrhythmias, and 1 refused EPS. We were able to pronounce a correct diagnosis of lymphocytic myocarditis for only 1 mTWA and EPS-positive subject. For the other 4 positive patients with arrhythmogenic micropathology, severe arrhythmic events were revealed in the follow-up and aggressive hybrid treatment was necessary. CONCLUSION: Microvolt-TWA study seems to be a useful, noninvasive, and feasible tool for evaluating arrhythmic risk in the athletic population. The mTWA test showed a high negative predictive value, using both EPS and the follow-up observation for severe arrhythmic cardiac events as an endpoint. The positive predictive value was present in a limited number of cases that were, however, subjects with a high risk of sudden arrhythmic death.

[T-wave alternation: a new method for identifying patients at risk of malignant ventricular tachyarrhythmia]. / L'alternanza dell'onda T: un nuovo metodo per individuare i pazienti a rischio di tachiaritmie ventricolari maligne.

T wave alternans (TWA) is a change, in the microvolt range, of T wave amplitude on ABABAB sequence. TWA depends on heart rate, being optimally analyzed at a target frequency of 110 b/min. Initial studies used atrial pacing to reach the target frequency and reported a sensitivity and specificity of 89% for TWA in predicting tachyarrhythmic events. Subsequently, similar results were obtained using ergometric test to reach the target frequency, a less invasive and more "physiologic" approach to increase heart rate. This method became therefore the elective system to increase heart rate in order to evaluate the presence of TWA by means of spectral analysis. At present, various groups of high arrhythmic risk patients have been evaluated, including those with a recent myocardial infarction, congestive heart failure, implantable cardiac defibrillator and clinical indication to programmed ventricular stimulation. In all clinical conditions analyzed, TWA analysis demonstrated a good diagnostic accuracy, suggesting a possible clinical use of the test in these settings.