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OBJECTIVE: This study evaluated the impact of daily ECG (electrocardiogram) self-recordings on time to documented recurrent atrial fibrillation (AF) or atrial flutter (AFL) and time to treatment of recurrent arrhythmia in patients undergoing catheter radiofrequency ablation (RFA) or direct current cardioversion (DCCV) for AF/AFL. BACKGROUND: AF recurrence rates after RFA and DCCV are 20% to 45% and 60% to 80%, respectively. Randomized trials comparing mobile ECG devices to standard of care have not been performed in an AF/AFL population after treatment. METHODS: Of 262 patients consented, 238 were randomized to either standard of care (123) or to receive the iHEART intervention (115). Patients in the intervention group were provided with and trained to use an AliveCor KardiaMobile ECG monitor, and were instructed to take and transmit daily ECG recordings. Data were collected from transmitted ECG recordings and patients' electronic health records. RESULTS: In a multivariate Cox model, the likelihood of recurrence detection was greater in the intervention group (hazard ratio = 1.56, 95% confidence interval [CI]: 1.06-2.30, P = .024). Hazard ratios did not differ significantly for RFA and DCCV procedures. Recurrence during the first month after ablation strongly predicted later recurrence (hazard ratio = 4.53, 95% CI: 2.05-10.00, P = .0006). Time from detection to treatment was shorter for the control group (hazard ratio = 0.33, 95% CI: 0.57-2.92, P < .0001). CONCLUSIONS: The use of mobile ECG self-recording devices allows for earlier detection of AF/AFL recurrence and may empower patients to engage in shared health decision-making.
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Potenciais de Ação , Fibrilação Atrial/terapia , Flutter Atrial/terapia , Telefone Celular , Cardioversão Elétrica , Eletrocardiografia Ambulatorial/instrumentação , Frequência Cardíaca , Ablação por Radiofrequência , Tecnologia de Sensoriamento Remoto/instrumentação , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Cardioversão Elétrica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aplicativos Móveis , Cidade de Nova Iorque , Valor Preditivo dos Testes , Estudos Prospectivos , Ablação por Radiofrequência/efeitos adversos , Recidiva , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Autocuidado , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Atrial fibrillation is a major public health problem and is the most common cardiac arrhythmia, affecting an estimated 2.7 million Americans. The true prevalence of atrial fibrillation is likely underestimated because episodes are often sporadic; therefore, it is challenging to detect and record an occurrence in a "real world" setting. To date, mobile health tools that promote earlier detection and treatment of atrial fibrillation and improvement in self-management behaviors and knowledge have not been evaluated. This study will be the first to address the epidemic problem of atrial fibrillation with a novel approach utilizing advancements in mobile health electrocardiogram technology to empower patients to actively engage in their healthcare and to evaluate impact on quality of life and quality-adjusted life years. Furthermore, sending a daily electrocardiogram transmission, coupled with receiving educational and motivational text messages aimed at promoting self-management and a healthy lifestyle may improve the management of chronic cardiovascular conditions (e.g., hypertension, diabetes, heart failure, etc.). Therefore, we are currently conducting a randomized controlled trial to assess the efficacy of a mobile health intervention, iPhone® Helping Evaluate Atrial fibrillation Rhythm through Technology (iHEART) versus usual cardiac care. METHODS: The iHEART study is a single center, prospective, randomized controlled trial. A total of 300 participants with a recent history of atrial fibrillation will be enrolled. Participants will be randomized 1:1 to receive the iHEART intervention, receiving an iPhone® equipped with an AliveCor® Mobile ECG and accompanying Kardia application and behavioral altering motivational text messages or usual cardiac care for 6 months. DISCUSSION: This will be the first study to investigate the utility of a mobile health intervention in a "real world" setting. We will evaluate the ability of the iHEART intervention to improve the detection and treatment of recurrent atrial fibrillation and assess the intervention's impact on improving clinical outcomes, quality of life, quality-adjusted life-years and disease-specific knowledge. TRIAL REGISTRATION: NCT02731326 ; Verified April 2016.
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Fibrilação Atrial/diagnóstico , Eletrocardiografia/instrumentação , Sistema de Condução Cardíaco/fisiopatologia , Frequência Cardíaca , Aplicativos Móveis , Smartphone , Telemedicina/instrumentação , Potenciais de Ação , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/terapia , Protocolos Clínicos , Eletrocardiografia/métodos , Comportamentos Relacionados com a Saúde , Conhecimentos, Atitudes e Prática em Saúde , Estilo de Vida Saudável , Humanos , Motivação , Cidade de Nova Iorque , Educação de Pacientes como Assunto , Valor Preditivo dos Testes , Estudos Prospectivos , Projetos de Pesquisa , Comportamento de Redução do Risco , Autocuidado , Processamento de Sinais Assistido por Computador , Telemedicina/métodos , Envio de Mensagens de TextoRESUMO
BACKGROUND: Perception of body size is a key factor driving health behavior. Mothers directly influence children's nutritional and exercise behaviors. Mothers of ethnic minority groups and lower socioeconomic status are less likely to correctly identify young children as overweight or obese. Little evaluation has been done of the inverse--the child's perception of the mother's weight. OBJECTIVE: To determine awareness of weight status among mother-child dyads (n = 506). DESIGN: Cross-sectional study conducted in an outpatient pediatric dental clinic of Columbia University Medical Center, New York, NY. PARTICIPANTS: Primarily Hispanic (82.2 %) mothers (n = 253), 38.8 ± 7.5 years of age, and children (n = 253), 10.5 ± 1.4 years of age, responding to a questionnaire adapted from the validated Behavioral Risk Factor Surveillance System. MAIN MEASURES: Anthropometric measures-including height, weight, and waist circumference-and awareness of self-size and size of other generation were obtained. KEY RESULTS: 71.4 % of obese adults and 35.1 % of overweight adults underestimated size, vs. 8.6 % of normal-weight (NW) adults (both p < 0.001). Among overweight and obese children, 86.3 % and 62.3 % underestimated their size, vs. 14.9 % NW children (both p < 0.001). Among mothers with overweight children, 80.0 % underestimated their child's weight, vs. 7.1 % of mothers with NW children (p < 0.001); 23.1 % of mothers with obese children also underestimated their child's weight (p < 0.01). Among children with obese mothers, only 13.0 % correctly classified the adult's size, vs. 76.5 % with NW mothers (p < 0.001). Among obese mothers, 20.8 % classified overweight body size as ideal, vs. 1.2 % among NW mothers (p < 0.001). CONCLUSION: Overweight/obese adults and children frequently underestimate their size. Adults misjudge overweight/obese children as being of normal weight, and children of obese mothers often underestimate the adult's size. Failure to recognize overweight/obesity status among adults and children can lead to prolonged exposure to obesity-related comorbidities.
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Imagem Corporal , Tamanho Corporal , Saúde da Família , Sobrepeso/psicologia , Percepção de Peso , Adolescente , Adulto , Antropometria/métodos , Atitude Frente a Saúde , Índice de Massa Corporal , Criança , Estudos Transversais , Humanos , Pessoa de Meia-Idade , Relações Mãe-Filho , Obesidade/psicologia , Fatores de Risco , Autorrelato , Adulto JovemRESUMO
Functional health literacy (FHL) has become an increasingly prevalent topic of discussion in patient health and well-being. Although FHL has been studied in a variety of populations, it has not been investigated in patients with pacemakers and implantable cardioverter defibrillators (ICDs).The purpose of this study was to evaluate FHL in a primarily older, urban-dwelling ICD/pacemaker population. A secondary objective was to compare 2 commonly used instruments for assessing FHL.A convenience sample of 116 patients was recruited from an urban ICD/pacemaker clinic. Participants were asked to complete the Short Test of Functional Health Literacy in Adults (STOFHLA) followed by the Test of Functional Health Literacy in Adults to assess reading comprehension and numeracy. Logistic regression was used to assess the association between FHL and patient descriptors.The population was 68 ± 13 years of age, and 62.7% were men. The sample was ethnically diverse: 37.1% white, 39.7% Hispanic, and 22.4% African American; 77.4% of the population reported finishing high school. Of the 109 completing the Test of Functional Health Literacy in Adults, 60.6% had adequate FHL, 10.1% had marginal FHL, and 29.4% had inadequate FHL. The presence of coexisting chronic conditions such as diabetes mellitus, hyperlipidemia, and hypertension was associated with inadequate/marginal FHL (P = .007, P = .004, and P = .02, respectively). Of the 113 completing STOFHLA, 67.3% had adequate FHL, 7.1% had marginal FHL, and 25.7% had inadequate FHL. The presence of diabetes mellitus, hyperlipidemia, and hypertension was also associated with inadequate/marginal FHL as assessed by STOFHLA (P = .009, P = .02, and P = .004, respectively).In this older, urban, ICD/pacemaker population, approximately 40% had inadequate/marginal FHL. These results warrant further investigation of FHL in other cardiovascular populations.
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Desfibriladores Implantáveis , Conhecimentos, Atitudes e Prática em Saúde , Letramento em Saúde , Cardiopatias/psicologia , Marca-Passo Artificial , População Urbana , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Nível de Saúde , Cardiopatias/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores SocioeconômicosRESUMO
AIMS AND OBJECTIVES: To determine the relationship between quality of life and perceived self-reported symptoms in an older, ambulatory, urban population living with heart failure. BACKGROUND: While arrhythmias in older individuals with heart failure are well documented, the association between perceived arrhythmia symptoms and quality of life is not well-defined. DESIGN: Prospective, cross-sectional single-centre study. METHODS: A single-centre, prospective study was conducted with heart failure patients recruited from an urban outpatient cardiology clinic in the United States. Fifty-seven patients completed a baseline quality of life survey with 42 of these completing the six-month follow-up survey. Quality of life was evaluated with the SF-36v2(™) and frequency of symptoms with the Atrial Fibrillation Severity Scale. Subjects wore an auto triggered cardiac loop monitor (LifeStar AF Express(®) ) for two weeks to document arrhythmias. Data analysis utilised Spearman's rank correlation and logistic regression. RESULTS: Baseline and six-month quality of life measures did not correlate with recorded arrhythmias. However, perceptions of diminished general health correlated significantly with symptoms of exercise intolerance, lightheadedness/dizziness, palpitations and chest pain/pressure. By multivariable logistic regression, more severe perceived episodes, symptoms of exercise intolerance and lightheadedness/dizziness were independently associated with diminished quality of life. CONCLUSION: Quality of life was significantly worse in patients with perceptions of severe arrhythmic episodes and in those with symptoms of dizziness and exercise intolerance. RELEVANCE TO CLINICAL PRACTICE: The findings of this study indicate that symptomatic heart failure patients suffer from poor quality of life and that interventions are needed to improve quality of life and decrease symptom severity. Nurses who care for heart failure patients play an essential role in symptom evaluation and management and could significantly improve overall quality of life in these patients by carefully evaluating symptomatology and testing interventions and educational programmes aimed at improving quality of life.
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Instituições de Assistência Ambulatorial , Arritmias Cardíacas/fisiopatologia , Insuficiência Cardíaca/fisiopatologia , Qualidade de Vida , Serviços Urbanos de Saúde , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Estudos ProspectivosRESUMO
The purpose of this study was to describe the clinical, research, educational, and professional activities that nurses are engaged in following participation in a 2 month intramural genetics training program. An online survey was administered in 2010 to graduates of the program sponsored by the US National Institute of Nursing Research from 2000 to 2009, in Bethesda, Maryland, USA. The electronic, voluntary survey was sent to 189 graduates via email. The survey included demographic characteristics, educational preparation, professional roles and responsibilities, and attitudes about genetic testing and privacy issues. Of the 95 graduates responding to the survey, 74% had doctorates and 70% were advanced practice nurses. All respondents reported incorporating genetics knowledge into daily clinical, academic, or research practices since completing the program, with 72% reporting being involved in genetically-focused research (52% with research funding), 32% incorporating genetics into patient care, and 79% providing genetics education. Respondents working in a hospital setting or academic institution were more likely to desire additional training in genetics. National Institute of Nursing Research graduates have successfully integrated genomics into a variety of nursing practices.
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Academias e Institutos/estatística & dados numéricos , Educação em Enfermagem/estatística & dados numéricos , Genética Médica/educação , Enfermeiros Clínicos/educação , Profissionais de Enfermagem/educação , Adulto , Atitude do Pessoal de Saúde , Estudos de Coortes , Escolaridade , Feminino , Humanos , Descrição de Cargo , Masculino , Pessoa de Meia-Idade , National Institutes of Health (U.S.) , Vigilância da População , Competência Profissional , Fatores Socioeconômicos , Inquéritos e Questionários , Estados UnidosRESUMO
Background: Personalized treatment of atrial fibrillation (AF) risk factors using mHealth and telehealth may improve patient outcomes. Objective: The purpose of this study was to assess the feasibility of the Atrial Fibrillation Helping Address Care with Remote Technology (AF-HEART) intervention on the following patient outcomes: (1) heart rhythm tracking; (2) weight, alcohol, blood pressure (BP), and sleep apnea reduction; (3) AF symptom reduction; and (4) quality-of-life (QOL) improvement. Methods: A total of 20 patients with AF undergoing antiarrhythmic therapy, cardioversion, and/or catheter ablation were enrolled and followed for 6 months. The AF-HEART intervention included remote heart rhythm, weight, and BP tracking; televisits with a dietician focusing on AF risk factors; and referrals for sleep apnea and hypertension treatment. Results: Patients transmitted a median of 181 rhythm recordings during the 6-month follow-up period. Patients lost an average of 3.5 kilograms at 6 months (P = .005). Patients had improved SF-12 scores (P = .01), AFSS score (P = .01), EQ-5D score (P = .006), and AFEQT Global Score (P = .03). There was significant correlation between weight loss and decrease in symptom severity (r = -0.45, P = .05), and between % weight loss and decrease in symptom severity (r = -0.49, P = .03). Conclusion: This study described the feasibility of the AF-HEART intervention for (1) consistent remote tracking of heart rhythm, weight, and BP; (2) achievement of weight loss; (3) reduction of symptoms; and (4) improvement in QOL. Expansion to a larger randomized study is planned.
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BACKGROUND: There are limited studies evaluating whether atrial fibrillation (AF) patients with increased BMI, age, and left atrial (LA) size have altered intracardiac electrogram (EGM) morphology. METHODS: We analyzed left atrial intracardiac EGMs acquired during invasive electrophysiology study in 54 patients with AF. EGM correlations were assessed among AF risk factors including age, left atrial size, and BMI. RESULTS: BMI correlated positively with DF (r2 = 0.17, p = 0.009) and MP (r2 = 0.16, p = 0.01) with dominant frequency (DF) and mean spectral profile (MP) greater among obese individuals. Age was negatively associated with mean amplitude (r2 = 0.42, p < 0.001) and width (r2 = 0.32, p < 0.001); age was positively correlated with MP (r2 = 0.24, p < 0.001). LA size was negatively correlated with mean amplitude (r2 = 0.18, p = 0.03) and width (r2 = 0.23, p = 0.01); LA size was positively correlated with DF (r2 = 0.22, p = 0.01) and MP (r2 = 0.23, p = 0.01). Mean amplitude and width were decreased among subjects with a severely enlarged LA; DF and MP were increased in those with severely enlarged LA. The associations with BMI and LA size remained significant in multiple regression models that included age, male gender, time since AF diagnosis, and LVEF. CONCLUSIONS: EGM morphology of AF patients with increased BMI, older age, and an enlarged LA possessed decreased amplitude and decreased width and increased DF and MP. These findings suggest that atrial remodeling due to increased age, LA size, and BMI is associated with differences in local atrial activation, decreased refractoriness, and more heterogeneous activation. These novel findings point out clinical risk factors for atrial fibrillation that may affect electrogram characteristics.
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Fibrilação Atrial , Remodelamento Atrial , Idoso , Fibrilação Atrial/diagnóstico por imagem , Índice de Massa Corporal , Técnicas Eletrofisiológicas Cardíacas , Átrios do Coração/diagnóstico por imagem , Humanos , MasculinoRESUMO
BACKGROUND: Patients with Tetralogy of Fallot (TOF) are at increased risk for sudden cardiac death, often undergo implantable cardioverter defibrillator (ICD) implantation at younger ages, and are at greater risk of experiencing inappropriate shocks. We investigated occurrences of ICD shocks in TOF patients to identify prevalence, characteristics associated with inappropriate shocks, and therapeutic interventions after inappropriate shocks. METHODS: Records of patients with repaired TOF and ICD implantation who were followed at Columbia University Irving Medical Center between 1/1/2000 and 5/1/2019 were analyzed. RESULTS: 44 patients with repaired TOF and ICD implantation were reviewed. Mean age at implantation was 39 ± 13 years. Eight (18%) patients received both appropriate and inappropriate shocks, 6 (14%) received only appropriate shocks, and 3 (7%) received only inappropriate shocks. Three patients received inappropriate shocks for sinus tachycardia, 7 for atrial arrhythmias, and 1 for noise artifact. Inappropriately shocked patients had lower beat per minute (bpm) cutoff values for ICD therapy (mean = 162 ± 24 bpm vs. 182 ± 16 bpm, p = 0.007). After inappropriate shocks, 1 patient underwent lead replacement, 1 had the VT cutoff increased, and 6 were treated with medications. CONCLUSIONS: One quarter of TOF patients with ICDs experienced inappropriate shock therapy, the timing of which was most often clustered within the first two years after implant or years later. Lower shock therapy zones were associated with increased risk for inappropriate shocks, and the majority of inappropriate shocks resulted from atrial arrhythmias with rapid ventricular response. Treatments for inappropriate shocks included increasing VT therapy bpm and rhythm and/or rate control medications.
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This study examined left-ventricular assist device (LVAD) patients with pre-LVAD ventricular arrhythmias (VAs) to determine the rate of recurrent post-LVAD VAs and the impact of pre-LVAD atrial fibrillation (AF) on recurrent post-LVAD VAs. Medical records of 195 consecutive LVAD patients were reviewed. Descriptive statistics were generated and Cox proportional hazard models were used to assess the association of clinical variables with the time to recurrent VA. Forty-seven percent of 195 CHF patients who received LVAD-manifested significant VAs prior to LVAD implant (82% Heartmate II, 14% HVAD, 4% other; median follow-up = 17 months), 41% of whom manifested recurrent post-LVAD VAs. Pre-LVAD AF was associated with recurrent VAs (hazard ratio = 3.73; 95% CI 1.33, 10.48; p = 0.012). Recurrent VAs were associated with increased mortality (hazard ratio = 3.06; 95% CI 1.17, 7.98; p = 0.023). A history of AF is prevalent in over half of LVAD patients with recurrent VAs and is associated with time to recurrence of VA.
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Fibrilação Atrial/epidemiologia , Insuficiência Cardíaca/terapia , Coração Auxiliar , Implantação de Prótese/instrumentação , Taquicardia Ventricular/epidemiologia , Fibrilação Ventricular/epidemiologia , Função Ventricular Esquerda , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Frequência Cardíaca , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Implantação de Prótese/efeitos adversos , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/fisiopatologiaRESUMO
BACKGROUND AND PURPOSE: Cognitive dysfunction occurs in 9% to 23% of patients during the first month after carotid endarterectomy (CEA). A 4-basepair (AAAT) tandem repeat polymorphism (either 3 or 4 repeats) has been described in the promoter region of inducible nitric oxide synthase (iNOS), a gene with complex roles in ischemic injury and preconditioning against ischemic injury. We investigated whether the 4-repeat variant (iNOS(+)) affects the incidence of cognitive dysfunction after CEA. METHODS: One-hundred eighty-five CEA and 60 spine surgery (control) subjects were included in this nested cohort analysis. Subjects underwent a battery of 7 neuropsychometric tests before and 1 day and 1 month after surgery. Multivariate logistic regression analyses were performed to determine if the iNOS promoter variant was independently associated with the incidence of cognitive dysfunction at 1 day and 1 month. Further, all right-hand-dominant CEA subjects were grouped by operative side and performance on each test was compared between iNOS(+) and iNOS(-) groups. RESULTS: Forty-four of 185 CEA subjects had at least 1 iNOS promoter allele containing 4 copies of the tandem repeat (iNOS(+)). iNOS(+) status was significantly protective against moderate/severe cognitive dysfunction 1 month after CEA. Right-hand-dominant iNOS(+) CEA subjects undergoing left-side CEA performed significantly better than iNOS(-) subjects on a verbal learning test and those undergoing right-side CEA performed significantly better on a test of visuospatial function. CONCLUSIONS: We demonstrate an iNOS promoter polymorphism variant provides protection against moderate/severe cognitive dysfunction 1 month after CEA. Further, this protection appears to involve cognitive domains localized ipsilateral to the operative carotid artery.
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Transtornos Cognitivos/etiologia , Transtornos Cognitivos/genética , Endarterectomia das Carótidas/efeitos adversos , Óxido Nítrico Sintase Tipo II/genética , Complicações Pós-Operatórias/psicologia , Regiões Promotoras Genéticas/genética , Idoso , Alelos , Apolipoproteínas E/genética , Transtornos Cognitivos/psicologia , Feminino , Genótipo , Humanos , Modelos Logísticos , Masculino , Testes Neuropsicológicos , Óxido Nítrico/biossíntese , Óxido Nítrico/fisiologia , Polimorfismo Genético/genéticaRESUMO
BACKGROUND AND PURPOSE: The purpose of this study was to assess the frequency, severity, and predictors of neurological deficits after adjuvant embolization for cerebral arteriovenous malformations. METHODS: From 1997 to 2006, 202 of 275 patients with arteriovenous malformation received embolization before microsurgery (n=176) or radiosurgery (n=26). Patients were examined before and after endovascular embolization and at clinical follow-up (mean, 43.4+/-34.6 months). Outcome was classified according to the modified Rankin Scale. New neurological deficits after embolization were defined as minimal (no change in overall modified Rankin Scale), moderate (modified Rankin Scale < or =2), or significant (modified Rankin Scale >2). RESULTS: Two hundred two patients were treated in 377 embolization procedures. There were a total of 29 new clinical deficits after embolization (8% of procedures; 14% of patients), of which 19 were moderate or significant. Postembolization deficits resolved in a significant number of patients over time (P<0.0001). Five patients had persistent neurological deficits due to embolization (1.3% of procedures; 2.5% of patients). In multivariate analysis, the following variables significantly predicted new neurological deficit after embolization: complex arteriovenous malformation with treatment plan specifying more than one embolization procedure (OR, 2.7; 95% CI, 1.4 to 8.6), diameter <3 cm (OR, 3.2; 95% CI, 1.2 to 9.1), diameter >6 cm (OR, 6.2; 95% CI, 1.0 to 57.0), deep venous drainage (OR, 2.7; 95% CI, 1.1 to 6.9), or eloquent location (OR, 2.4; 95% CI, 1.0 to 5.7). These variables were weighted and used to compute an arteriovenous malformation Embolization Prognostic Risk Score for each patient. A score of 0 predicted no new deficits, a score of 1 predicted a new deficit rate of 6%, a score of 2 predicted a new deficit rate of 15%, a score of 3 predicted a new deficit rate of 21%, and a score of 4 predicted a new deficit rate of 50% (P<0.0001). CONCLUSIONS: Small and large size, eloquent location, deep venous drainage, and complex vascular anatomy requiring multiple embolization procedures are risk factors for the development of immediate postembolization neurological deficits. Nevertheless, a significant number of patients with treatment-related neurological deficits improve over time. The low incidence of permanent neurological deficits underscores the usefulness of this technique in carefully selected patients.
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Embolização Terapêutica/métodos , Embucrilato/administração & dosagem , Malformações Arteriovenosas Intracranianas/tratamento farmacológico , Doenças do Sistema Nervoso/etiologia , Complicações Pós-Operatórias/etiologia , Adolescente , Adulto , Idoso , Quimioterapia Adjuvante , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Malformações Arteriovenosas Intracranianas/cirurgia , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Valor Preditivo dos Testes , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
OBJECT: Chronic hydrocephalus requiring shunt placement is a common complication following aneurysmal subarachnoid hemorrhage (SAH). Controversy exists over whether microsurgical fenestration of the lamina terminalis during aneurysm surgery affords a reduction in the development of shunt-dependent hydrocephalus. To resolve this debate, the authors performed a systematic review and quantitative analysis of the literature to determine the efficacy of lamina terminalis fenestration in reducing aneurysmal SAH-associated shunt-dependent hydrocephalus. METHODS: A MEDLINE (1950-2007) database search was performed using the following keywords, singly and in combination: "ventriculoperitoneal shunt," "hydrocephalus," "subarachnoid hemorrhage," "aneurysm," "fenestration," and "lamina terminalis." Additional studies were manually singled out by scrutinizing references from identified manuscripts, major neurosurgical journals and texts, and personal files. A recent study from the authors' institution was also incorporated into the review. Data from included studies were analyzed using the chi-square analysis and Student t-test. The Cochran-Mantel-Haenszel test was used to compare overall incidence of shunt-dependent hydrocephalus. RESULTS: The literature search revealed 19 studies, but only 11 were included in this review, involving 1973 patients. The fenestrated and nonfenestrated cohorts (combined from the various studies) differed significantly with regard to patient sex, age, and clinical grade as well as aneurysm location (p=0.0065, 0.0028, 0.0003, and 0.017, respectively). The overall incidence of shunt-dependent hydrocephalus in the fenestrated cohort was 10%, as compared with 14% in the nonfenestrated cohort (p=0.089). The relative risk of shunt-dependent hydrocephalus in the fenestrated cohort was 0.88 (95% CI 0.62-1.24). CONCLUSIONS: This systematic review revealed no significant association between lamina terminalis fenestration and a reduced incidence of shunt-dependent hydrocephalus. The interpretation of these results, however, is restricted by unmatched cohort differences as well as other inherent study limitations. Although the overall literature supports lamina terminalis fenestration, a number of authors have questioned the technique's benefits, thus rendering its efficacy in reducing shunt-dependent hydrocephalus unclear. A well-designed, multicenter, randomized controlled trial is needed to definitively address the efficacy of this microsurgical technique.
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Hidrocefalia , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/cirurgia , Derivação Ventriculoperitoneal , Humanos , Hidrocefalia/etiologia , Hidrocefalia/prevenção & controle , Hidrocefalia/cirurgiaRESUMO
OBJECT: Recent data from both experimental and clinical studies have supported the use of intravenous magnesium as a potential therapy in the setting of cerebral ischemia. This study assessed whether intraoperative magnesium therapy improves neuropsychometric testing (NPT) following carotid endarterectomy (CEA). METHODS: One hundred eight patients undergoing CEA were randomly assigned to receive placebo infusion or 1 of 3 magnesium-dosing protocols. Neuropsychometric testing was performed 1 day after surgery and compared with baseline performance. Assessment was also performed on a set of 35 patients concurrently undergoing lumbar laminectomy to serve as a control group for NPT. A forward stepwise logistic regression analysis was performed to evaluate the impact of magnesium therapy on NPT. A subgroup analysis was then performed, analyzing the impact of each intraoperative dose on NPT. RESULTS: Patients treated with intravenous magnesium infusion demonstrated less postoperative neurocognitive impairment than those treated with placebo (OR 0.27, 95% CI 0.10-0.74, p = 0.01). When stratified according to dosing bolus and intraoperative magnesium level, those who were treated with low-dose magnesium had less cognitive decline than those treated with placebo (OR 0.09, 95% CI 0.02-0.50, p < 0.01). Those in the high-dose magnesium group demonstrated no difference from the placebo-treated group. CONCLUSIONS: Low-dose intraoperative magnesium therapy protects against neurocognitive decline following CEA.
Assuntos
Endarterectomia das Carótidas , Idoso , Isquemia Encefálica/terapia , Transtornos Cognitivos/prevenção & controle , Feminino , Humanos , Infusões Intravenosas , Laminectomia , Magnésio/efeitos adversos , Magnésio/sangue , Masculino , Testes Neuropsicológicos , Complicações Pós-Operatórias , Estudos ProspectivosRESUMO
Although many scales attempt to predict outcome following aneurysmal subarachnoid hemorrhage (aSAH), none have achieved universal acceptance, and most scales in common use are not statistically derived. We propose a statistically validated scale for poor grade aSAH patients that combines the Hunt and Hess grades and the Glasgow Coma Scale (GCS) scores; we refer to this as the Poor Grade GCS (PGS). The GCS scores of 160 poor grade aSAH patients (Hunt and Hess Grades 4 and 5) were recorded throughout their hospital stay. Outcomes were assessed by the modified Rankin scale (mRS). Analysis of variance and the Chi-square test were used to guide an analysis of GCS breakpoints according to outcomes. Multivariable logistic regression analysis was used to assess the ability of the Hunt and Hess, GCS, World Federation of Neurological Surgeons Grading Scale, and the PGS to predict long-term outcome. Outcome analysis revealed significant breakpoints in admission GCS scores: PGS-A (GCS 10-12); PGS-B (GCS 8-9); PGS-C (GCS 5-7); PGS-D (GCS 3-4) (p<0.001). In surgical patients, 95.2% of PGS-A, 58.1% of PGS-B, 35.4% of PGS-C, and 28.6% of PGS-D had a favorable one-year outcome. When controlling for age, sex, and operation status, PGS was the only scale predictive of long-term outcome. The odds ratios (OR) for unfavorable outcome according to PGS admission scores (with PGS-A as the reference) were: PGS-B, OR=14.2 (95% CI 1.5-140.5); PGS-C, OR=38.5 (95% CI 4.2-340.0); and PGS-D, OR=63.4 (95% CI 5.6-707.1). In addition to PGS admission scores, an age of 70 or greater was a significant predictor of poor outcome with an OR of 7.5 (95% CI 1.8-30.7). No patients with a PGS-C or PGS-D over the age of 70 had a favorable long-term outcome. Therefore, elements of the Hunt and Hess and GCS can be combined into the PGS to predict long-term outcome in poor grade aSAH patients. However, patients with PGS-C and PGS-D over the age of 70 should be assessed carefully prior to definitive treatment.
Assuntos
Escala de Coma de Glasgow/estatística & dados numéricos , Exame Neurológico/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/métodos , Hemorragia Subaracnóidea/fisiopatologia , Idoso , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapiaRESUMO
Atrial fibrillation (AF) is a major public health problem and the most common cardiac arrhythmia encountered in clinical practice at this time. AF is associated with numerous symptoms such as palpitations, shortness of breath, and fatigue, which can significantly reduce health-related quality of life and result in serious adverse cardiac outcomes. In light of this, the aim of the present pilot study was to test the feasibility of implementing a mobile health (mHealth) lifestyle intervention titled "Atrial Fibrillation and Cardiac Health: Targeting Improving Outcomes via a Nurse-Led Intervention (ACTION)," with the goal of improving cardiac health measures, AF symptom recognition, and self-management. As part of this study, participants self-identified cardiac health goals at enrollment. The nurse used web-based resources from the American Heart Association (Dallas, TX, USA), which included the Life's Simple 7® My Life Check® assessment, to quantify current lifestyle behavior change needs. Furthermore, on the My AFib Experience™ website (American Heart Association, Dallas, TX, USA), the patient used a symptom tracker tool to capture the date, time, frequency, and type of AF symptoms, and these data were subsequently reviewed by the cardiac nurse. Throughout the six-month intervention period, the cardiac nurse used a motivational interviewing approach to support participants' cardiac health goals. Ultimately, the ACTION intervention was tested in 53 individuals with AF (mean age: 59 ± 11 years; 76% male). Participants were predominantly overweight/obese (79%), had a history of hypertension (62%) or hyperlipidemia (61%), and reported being physically inactive/not preforming any type of regular exercise (52%). The majority (88%) of the participants had one or more Life's Simple 7® measures that could be improved. Most of the participants (98%) liked having a dedicated nurse to work with them on a biweekly basis via the mHealth portal. The most commonly self-reported symptoms were palpitations, fatigue/exercise intolerance, and dyspnea. Seventy percent of the participants had an improvement in their weight and blood pressure as documented within the electronic health record as well as a corresponding improvement in their Life's Simple 7® score at six months. On average, there was a three-pound (1.36-kg) decrease in weight and a 5-mmHg decrease in systolic blood pressure between baseline and at six months. In conclusion, this pilot work provides initial evidence regarding the feasibility of implementing the ACTION intervention and supports testing the ACTION intervention in a larger cohort of AF patients to inform existing AF guidelines and build an evidence base for reducing AF burden through lifestyle modification.
RESUMO
OBJECT: Despite efforts to elucidate both the molecular mechanism and the clinical predictors of vasospasm after aneurysmal subarachnoid hemorrhage (ASAH), its pathogenesis remains unclear. Monocyte chemoattractant protein-1 (MCP-1) is a chemokine that has been firmly implicated in the pathophysiology of vasospasm and in neural tissue injury following focal ischemia in both animal models and human studies. The authors hypothesized that MCP-1 would be found in increased concentrations in the blood and cerebrospinal fluid (CSF) of patients with ASAH and would correlate with both outcome and the occurrence of vasospasm. METHODS: Seventy-seven patients who presented with ASAH were prospectively enrolled in this study between July 2001 and May 2002. Using an enzyme-linked immunosorbent assay, MCP-1 levels were measured in serum daily and in CSF when available. The mean serum and CSF MCP-1 concentrations were calculated for each patient throughout the entire hospital stay. Neurological outcome was evaluated at discharge or 14 days posthemorrhage using the modified Rankin Scale. Vasospasm was evaluated on angiography. RESULTS: The serum MCP-1 concentrations correlated with negative outcome such that a 10% increase in concentration predicted a 25% increase in the probability of a poor outcome, whereas the serum MCP-1 levels did not correlate with vasospasm. Concentrations of MCP-1 in the CSF, however, proved to be significantly higher in patients with angiographically demonstrated vasospasm. CONCLUSIONS: These findings suggest a role for MCP-1 in neurological injury and imply that it may act as a biomarker of poor outcome in the serum and of vasospasm in the CSF.
Assuntos
Quimiocina CCL2/sangue , Quimiocina CCL2/líquido cefalorraquidiano , Aneurisma Intracraniano/metabolismo , Hemorragia Subaracnóidea/metabolismo , Vasoespasmo Intracraniano/etiologia , Adulto , Idoso , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/terapia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Índice de Gravidade de Doença , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/terapia , Resultado do Tratamento , Vasoespasmo Intracraniano/sangue , Vasoespasmo Intracraniano/líquido cefalorraquidianoRESUMO
BACKGROUND: In previous studies, we found that approximately 25% of patients having carotid endarterectomy with general anesthesia (CEA general) develop cognitive dysfunction compared with a surgical control Group 1 day and 1 mo after surgery. In this study, we tested the hypothesis that patients having CEA with regional anesthesia (CEA regional) will develop significant cognitive dysfunction 1 day after surgery compared with a control group of patients receiving sedation 1 day after surgery. We did not study persistence of dysfunction. METHODS: To test this hypothesis, we enrolled 60 patients in a prospective study. CEA regional was performed with superficial and deep cervical plexus blocks in 41 patients. The control group consisted of 19 patients having coronary angiography or coronary artery stenting performed with sedation. A control group is necessary to account for the "practice effect" associated with repeated cognitive testing. The patients from the CEA regional group were enrolled at New York Medical Center and the control group at Columbia-Presbyterian Medical Center. The cognitive performance of all patients was evaluated using a previously validated battery of neuropsychometric tests. Differences in performance, 1 day after compared with before surgery, were evaluated by both event-rate and group-rate analyses. RESULTS: On postoperative day 1, 24.4% of patients undergoing CEA regional had significant cognitive dysfunction, where "significant" was defined as a total deficit score > or =2 SD worse than the mean performance in the control group. CONCLUSIONS: Patients undergoing CEA regional had an incidence of cognitive dysfunction which was not different than patients having CEA general as previously published and compared with a contemporaneously enrolled group.
Assuntos
Anestesia por Condução/efeitos adversos , Transtornos Cognitivos/etiologia , Endarterectomia das Carótidas , Idoso , Anestesia Geral/efeitos adversos , Estenose das Carótidas , Transtornos Cognitivos/diagnóstico , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Dor Pós-Operatória/diagnósticoRESUMO
There are limited data on racial and ethnic disparities related to quality of life (QoL) and health literacy in adults with multiple cardiac conditions. This article evaluates the relationship between health literacy and QoL among patients with cardiac conditions in a multiethnic community in New York City.
Assuntos
Letramento em Saúde/estatística & dados numéricos , Cardiopatias/enfermagem , Adulto , Etnicidade/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Cardiopatias/etnologia , Humanos , Cidade de Nova Iorque , Qualidade de VidaRESUMO
BACKGROUND: Acute allograft rejection appears to be associated with increases in QT/QTc intervals. OBJECTIVES: To determine the relationship between acute allograft rejection and electrocardiogram changes in patients undergoing an orthotopic heart transplant. METHODS: The study population comprised 220 adult patients undergoing heart transplant and enrolled in the NEW HEART study. Electrocardiograms obtained within 72 hours of endomyocardial biopsy were analyzed; electrocardiograms obtained fewer than 10 days after transplant surgery were excluded. Repeated-measures analysis was performed with statistical models including effects for rejection severity (mild and moderate/severe) and time trends independent of rejection status. RESULTS: The 151 male and 69 female transplant recipients (mean age [SD], 54 [13] years) had 969 biopsy/electrocardiogram pairs: 677 with no rejection, 280 with mild rejection, and 12 with moderate/severe rejection. Moderate to severe organ rejection was associated with significant increases in QRS duration (P < .001), QT (P = .009), QTc (P = .003), and PR interval (P = .03), as well as increased odds of right bundle block branch (P = .002) and fascicular block (P = .009) occurring. CONCLUSIONS: Moderate to severe acute allograft rejection was associated with electrocardiographic changes after transplant surgery. Studies are needed to assess the value of computerized electrocardiogram measurement algorithms for detecting acute allograft rejection.