Electrocardiogram abnormalities in older individuals by race and ethnicity.

BACKGROUND: Aging is associated with many ECG changes. ECG abnormalities are known to be more prevalent with age and differ across race and ethnicity, yet there are limited studies categorizing the ECG changes in the older population and the differences seen among racial groups. We sought to determine ECG differences associated with race and ethnicity in this ethnically diverse, elderly population. METHODS: The ECG parameters of subjects between the ages of 75 and 99 years from a large and diverse inner-city patient population were analyzed. Subjects were grouped into one of four categories: Hispanic, Black, Non-Hispanic White, or Other for analysis. Rhythm, axis, voltage, and conduction parameters were determined according to the 12 SL algorithm and interpretation statements (GE Healthcare, Wauwatosa, Wisconsin) that were confirmed by an overreading cardiologist. RESULTS: 38,238 subjects were included. Of all groups, Non-Hispanic Whites exhibited more conduction abnormalities such as bundle branch block compared to the other groups, as well as the highest incidence of atrial fibrillation (AF) (12.6%, p < 0.05). Hispanics had the highest proportion of normal sinus rhythm. Blacks exhibited the least amount of AF (6.3%), as well as the highest incidence of LVH (25.5%), RAD (13.5%), and the largest percentage of abnormal ECGs (72.8%). CONCLUSION: Significant differences among the elderly of different race and ethnicity were noted with most parameters.

Systematic review of the current status of cadaveric simulation for surgical training.

BACKGROUND: There is growing interest in and provision of cadaveric simulation courses for surgical trainees. This is being driven by the need to modernize and improve the efficiency of surgical training within the current challenging training climate. The objective of this systematic review is to describe and evaluate the evidence for cadaveric simulation in postgraduate surgical training. METHODS: A PRISMA-compliant systematic literature review of studies that prospectively evaluated a cadaveric simulation training intervention for surgical trainees was undertaken. All relevant databases and trial registries were searched to January 2019. Methodological rigour was assessed using the widely validated Medical Education Research Quality Index (MERSQI) tool. RESULTS: A total of 51 studies were included, involving 2002 surgical trainees across 69 cadaveric training interventions. Of these, 22 assessed the impact of the cadaveric training intervention using only subjective measures, five measured impact by change in learner knowledge, and 23 used objective tools to assess change in learner behaviour after training. Only one study assessed patient outcome and demonstrated transfer of skill from the simulated environment to the workplace. Of the included studies, 67 per cent had weak methodology (MERSQI score less than 10·7). CONCLUSION: There is an abundance of relatively low-quality evidence showing that cadaveric simulation induces short-term skill acquisition as measured by objective means. There is currently a lack of evidence of skill retention, and of transfer of skills following training into the live operating theatre.

ANTECEDENTES: Existe un interés creciente en los cursos de simulación con cadáveres para la formación de residentes en cirugía, así como en aumentar la disponibilidad de dichos cursos. Ello es debido a la necesidad de modernizar y mejorar la eficiencia del entrenamiento en el marco actual del reto que supone la formación quirúrgica. El objetivo de esta revisión sistemática era describir y evaluar la evidencia del uso de la simulación con cadáveres en la formación quirúrgica de posgrado. MÉTODOS: Siguiendo la normativa PRISMA, se realizó una revisión sistemática de la literatura de estudios que evaluaban prospectivamente el entrenamiento quirúrgico mediante la simulación con cadáveres. Se realizaron búsquedas en todas las bases de datos relevantes y en registros de ensayos clínicos hasta enero de 2019. Se evaluó el rigor metodológico utilizando la herramienta MERSQI (Medical Education Research Quality Index), ampliamente validada. RESULTADOS: Se incluyeron 51 estudios, con un total de 2.002 residentes de cirugía y 69 intervenciones de formación con simulación con cadáveres. Del total de dichos estudios, 22 evaluaron el impacto de la cirugía con cadáver utilizando solo medidas subjetivas, 5 midieron el impacto por el cambio en el conocimiento del alumno y 23 utilizaron herramientas objetivas para evaluar el cambio en el comportamiento del alumno después de la formación. Solo un estudio evaluó el resultado en pacientes, demostrando la transferencia de habilidades del entorno simulado al lugar de trabajo. De los estudios incluidos, el 55% tenía una metodología débil (puntuación MERSQI < 10,7). CONCLUSIÓN: Existe amplia evidencia, pero de baja calidad, referente a la simulación con cadáveres en la formación quirúrgica, demostrando que esta popular herramienta puede ser útil para adquirir habilidades a corto plazo, tal como indican los resultados derivados de medidas objetivas. Actualmente hay una falta de evidencia basada en estudios longitudinales respecto a la retención de habilidades y de cómo estas se transfieren al quirófano real una vez finalizada la formación. Se requieren futuros ensayos aleatorizados de alta calidad para abordar este punto.

Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings. DESIGN: Systematic review of randomised and quasi-randomised controlled trials, and meta-analysis. DATA SOURCES: Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews. REVIEW METHODS: Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors. DATA EXTRACTION: Outcomes were number of fallers, fall related injuries, fall rate, death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement. RESULTS: 19 studies, of variable methodological quality, were included. The combined risk ratio for the number of fallers during follow-up among 18 trials was 0.91 (95% confidence interval 0.82 to 1.02) and for fall related injuries (eight trials) was 0.90 (0.68 to 1.20). No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral. CONCLUSIONS: Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates.

Reasons for ART non-adherence in the Deep South: adherence needs of a sample of HIV-positive patients in Mississippi.

HIV prevalence in the American Deep South has reached crisis proportions and greater numbers of patients are enrolling in clinical care and beginning antiretroviral therapy (ART). In order to gain maximum benefit from ART, patients must sustain high levels of adherence to demanding regimens over extended periods of time. Many patients are unable to maintain high rates of adherence and may need assistance to do so, which may be based upon an understanding of barriers to adherence for a given population. The current study sought to gain understanding of barriers to adherence for a mixed urban/rural HIV-positive patient population in Mississippi and to determine whether barriers to adherence may be specific to gender, employment, depressive symptoms or educational attainment status. Seventy-two patients who missed a dose of ART medication over the last three days endorsed the top five reasons for missing a dose as: (1) not having the medication with them, (2) sleeping through the dose time, (3) running out of the medication, (4) being busy with other things and (5) other. Reported barriers were fairly consistent across different groups, although women and those classified as having moderate to severe depressive symptoms reported different patterns of adherence barriers. Results suggest that adherence interventions implemented in the Deep South must take into account specific barriers faced by individuals within this region, where stigma, gender disparities and limited resources are prevalent.

An empirical test of the information, motivation and behavioral skills model of antiretroviral therapy adherence.

Nearly perfect adherence to demanding antiretroviral therapy (ART) is now recognized as essential for HIV-positive patients to realize its life sustaining benefits. Despite the dire consequences of non-adherence, a large number of patients do not follow their ART regimen. While many factors influence adherence, the literature is dominated by studies on only one or a small set of them. Multivariate, theory-based models of adherence behavior are of great interest. The current study tested one such model, the Information, Motivation and Behavioral Skills (IMB) model of ART adherence (Fisher et al., under review). A sample of HIV-positive patients on ART in clinical care in Puerto Rico (N=200) provided data on adherence-related information, motivation and behavioral skills as well as adherence behavior per se. Structural equation model tests used to assess the propositions of the IMB model of ART adherence provided support for the interrelations between the elements proposed by the model and extended previous work. Implications for future research and intervention development are discussed.

Determinants of HIV risk among Indian truck drivers.

Although there are very high levels of HIV risk sexual behavior in India, there has been little research on the determinants of this behavior, the psychosocial correlates of condom use, or the potential for effective behavior change interventions. The present research used the information-motivation-behavioral skills model of HIV risk behavior to explore these issues in a sample of Indian truck drivers, a population that comprises an important vector of HIV transmission. This paper presents correlational data on the predictors of HIV risk and preventive behavior in a sample of truck drivers in Chennai, India. The data were collected via detailed individual structured interviews with 300 Indian truck drivers. Results indicated that Indian truck drivers had substantial deficits with respect to HIV prevention information, motivation, and behavioral skills. Consistent with the IMB model, these deficits were often found to be predictive of HIV risk and preventive behavior. The implications of these findings for future intervention are discussed.

Linear lesion radiofrequency ablation in canine vagal atrial fibrillation: effects of special catheters designed for efficiency, and the critical role of lesions from the crista terminalis to the superior vena cava.

OBJECTIVE: To determine whether specially devised catheters could be used to place radiofrequency (RF) linear lesions quickly and efficiently for termination and/or prevention of atrial fibrillation (AF). METHODS: Two versions of 2 different types of ablating catheters were used in 12 canines with AF induced by rapid pacing during vagal stimulation. 1) Modified basket catheters in two versions, one designed to produce caudo-cranial linear lesions through extended bare electrode-splines in contact with the atrial wall; and the other designed to produce horizontal linear lesions by revolving within the atrium. Together these would form "longitude and latitude" grids in the atrium. 2) The second catheter type was 2 versions of coil electrodes with thermocouples centered under each of the large-area coil electrodes. One version of these deflectable coil electrodes was intended to produce lesions in the tricuspid valve annulus-inferior vena cava (IVC) isthmus; and along the crista terminalis from the superior vena cava (SVC) to the IVC. A different type of deflection angulation on the second version was intended to produce more horizontal lesions from the crista to the tricuspid annulus. Guidance was fluoroscopic, and by electrograms and transesophageal echo. Gross pathologic examinations followed each experiment. Prior to use in canines, all electrode configurations were tested in vitro on fresh bovine preparations suspended in saline at 37 degrees C. RESULTS: The bare spline and coil electrode catheter configurations produced discrete non-perforating non-charring lesions in the in vitro preparations. One dog died of exsanginating hemorrhage. Post mortem examination revealed the lesions to be extremely variable, ranging from no evidence of effective RF delivery to deep lesions with perforation. Seven clinical successes were achieved (6 complete), with the coil electrode catheters accounting for 5 of the 7, although the procedure times were shorter with the baskets. Critical lesions were those from the crista to the SVC. Planned trans-isthmus lesions were not done, but may be needed to prevent atrial flutter not seen prior to effective AF ablation. CONCLUSIONS: Special basket and coil-electrode catheters may be useful but require refinement. The finding that lesions between the crista terminalis and the SVC were critical to success may be applicable to some cases of AF in humans.

Sinus node recovery after 25 years of atrial flutter.

This case report demonstrates that the sinus node can recover relatively quickly even after being suppressed by atrial flutter for 25 years, and that a permanent pacemaker may not always be necessary in all patients with sinus arrest after a successful atrial flutter ablation.

Case report: is this SVT or VT? An exception to the rule.

This case illustrates the difficulties sometimes encountered by clinicians when using algorithms in diagnosing a wide-complex tachycardia based on a 12-lead EKG.

Histopathological correlation of ablation lesions guided by noncontact mapping in a patient with peripartum cardiomyopathy and ventricular tachycardia.

A patient with peripartum cardiomyopathy developed a nearly incessant nonsustained VT. Guided by a noncontact mapping system, the tachycardia was mapped to the mid-septum of the right ventricle and ablated. Despite transient success, the tachycardia recurred and the patient subsequently died of multiorgan failure. Histopathological correlation of the ablation site revealed a nontransmural lesion that may have contributed to the failure of the ablation.

Internal transcardiac pericardiocentesis for acute tamponade.

If the catheter is still in the pericardium when tamponade is recognized during catheterization or electrophysiologic procedures, it can be used for definitive aspiration and relief of tamponade. This is physiologically beneficial to the patient, and psychologically beneficial to both patient and medical staff.

Ethyl 5-methyl-4-(2,5,5-trimethyl-1, 3-dioxan-2-yl)isoxazole-3-carboxylate.

The title compound, C(14)H(21)NO(5), possesses an isoxazolyl group in the axial position of the 1,3-dioxanyl ring. The two rings are rotated about the bond joining them such that the two C(methyl)-C(dioxanyl)-C-C torsion angles are 92.1 (2) and -84.1 (2) degrees. In this conformation, neither the methyl nor ethoxycarbonyl substituents on the isoxazole are presented towards the dioxanyl chair.

Death and readmission in the year after hospital admission with cardiovascular disease: the Hunter Area Heart and Stroke Register.

OBJECTIVES: To compare outcomes one year after hospital admission for patients initially discharged with a diagnosis of acute myocardial infarction (AMI), other ischaemic heart disease (other IHD), congestive heart failure (CHF) or stroke. DESIGN: Cohort study. SETTING: Hunter Area Heart and Stroke Register, which registers all patients admitted with heart disease or stroke to any of the 22 hospitals in the Hunter Area Health Service in New South Wales. PATIENTS: 4981 patients with AMI, other IHD, CHF or stroke admitted to hospital as an emergency between 1 July 1995 and 30 June 1997 and followed for at least one year. MAIN OUTCOME MEASURES: Death from any cause or emergency hospital readmission for cardiovascular disease. RESULTS: In-hospital mortality varied from 1% of those with other IHD to 22% of those with stroke. Almost a third of all patients discharged alive (and 38% of those aged 70 or more) had died or been readmitted within one year. This varied from 22% of those with stroke to 49% of those with CHF. The causes of death and readmission were from a spectrum of cardiovascular disease, regardless of the cause of the original hospital admission. CONCLUSIONS: Data from this population register show the poor outcome, especially with increasing age, among patients admitted to hospital with cardiovascular disease. This should alert us to determine whether optimal secondary prevention strategies are being adopted among such patients.

Psychosocial experiences of cardiac patients in early recovery: a community-based study.

OBJECTIVE: To report on the nature, incidence and severity of problems commonly experienced by cardiac patients in the early months of recovery, and to test the hypotheses that there exist differences in the incidences of these problems depending on age and sex. METHODS: 1124 emergency cardiac patients discharged from hospital with acute myocardial infarction, unstable angina, stable angina pectoris, chronic ischaemic heart disease or heart failure were surveyed 4 months after discharge. They were asked to indicate how often during the previous 2 weeks they had experienced each of a range of feelings and problems common to cardiac patients. RESULTS: A large proportion of patients reported experiencing problems in the areas of emotional reactions (70%), physical condition (79%), convalescence (67%) and relating to family and friends (63%). Severe problems were experienced especially in the physical and convalescence areas (43% and 44%, respectively). A greater proportion of patients diagnosed with heart failure experienced problems than those with other diagnoses, and these problems were more severe. Amongst myocardial infarction patients, a greater proportion of females than males reported severe problems in the emotional and physical areas, and patients 65 years and over were more likely than younger patients to report experiencing severe problems with physical condition. CONCLUSIONS: Many cardiac patients are experiencing psychosocial problems 4 months after hospital discharge, especially with physical activities and convalescence. A knowledge of the incidence and nature of these problems may help nurses to assist patients to validate their experiences.

Electrophysiologic testing to identify patients with coronary artery disease who are at risk for sudden death. Multicenter Unsustained Tachycardia Trial Investigators.

BACKGROUND: The mortality rate among patients with coronary artery disease, abnormal ventricular function, and unsustained ventricular tachycardia is high. The usefulness of electrophysiologic testing for risk stratification in these patients is unclear. METHODS: We performed electrophysiologic testing in patients who had coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias could be induced were randomly assigned to receive either antiarrhythmic therapy guided by electrophysiologic testing or no antiarrhythmic therapy. The primary end point was cardiac arrest or death from arrhythmia. Patients without inducible tachyarrhythmias were followed in a registry. We compared the outcomes of 1397 patients in the registry with those of 353 patients with inducible tachyarrhythmias who were randomly assigned to receive no antiarrhythmic therapy in order to assess the prognostic value of electrophysiologic testing. RESULTS: Patients were followed for a median of 39 months. In a Kaplan-Meier analysis, two-year and five-year rates of cardiac arrest or death due to arrhythmia were 12 and 24 percent, respectively, among the patients in the registry, as compared with 18 and 32 percent among the patients with inducible tachyarrhythmias who were assigned to no antiarrhythmic therapy (adjusted P<0.001). Overall mortality after five years was 48 percent among the patients with inducible tachyarrhythmias, as compared with 44 percent among the patients in the registry (adjusted P=0.005). Deaths among patients without inducible tachyarrhythmias were less likely to be classified as due to arrhythmia than those among patients with inducible tachyarrhythmias (45 and 54 percent, respectively; P=0.06). CONCLUSIONS: Patients with coronary artery disease, left ventricular dysfunction, and asymptomatic, unsustained ventricular tachycardia in whom sustained ventricular tachyarrhythmias cannot be induced have a significantly lower risk of sudden death or cardiac arrest and lower overall mortality than similar patients with inducible sustained tachyarrhythmias.