bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of Payment Changes on Trends in Post‐Acute Care
Authors: Buntin Melinda Beeuwkes , Colla Carrie Hoverman , Escarce José J.
Published: April 2009

Objective.To test how the implementation of new Medicare post‐acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies.

Data Sources.Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data.

Study Design.We used multinomial logit models to measure realized access to post‐acute care and to predict how access to alternative sites of care changed in response to prospective payment systems.

Data Extraction Methods.A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement.

Principal Findings.Although the effects of the payment systems on the use of post‐acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill.

Conclusions.Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post‐acute care. Changing these incentives results in shifting of patients between post‐acute sites.
Lifestyles, Demographics, Dietary Behavior, and Obesity: A Switching Regression Analysis
Authors: Yen Steven T. , Chen Zhuo , Eastwood David B.
Published: April 2009

Objectives. To investigate the effects of lifestyles, demographics, and dietary behavior on overweight and obesity.

Data Source. Continuing Survey of Food Intakes by Individuals 1994–1996, U.S. Department of Agriculture.

Study Design. We developed a three‐regime switching regression model to examine the effects of lifestyle, dietary behavior, and sociodemographic factors on body mass index (BMI) by weight category and accommodating endogeneity of exercise and food intake to avoid simultaneous equation bias. Marginal effects are calculated to assess the impacts of explanatory variables on the probabilities of weight categories and BMI levels.

Principal Findings. Weight categories and exercise are found to be endogenous. Lifestyle, dietary behavior, social status, and other sociodemographic factors affect BMI differently across weight categories. Education, employment, and income have strong impacts on the likelihood of overweight and obesity. Exercise reduces the probabilities of being overweight and obese and the level of BMI among overweight individuals.

Conclusion. Health education programs can be targeted at individuals susceptible to overweight and obesity. Social status variables, along with genetic and geographic factors, such as region, urbanization, age, and race, can be used to pinpoint these individuals.
Late Pleistocene giant short‐faced bears, mammoths, and large carcass scavenging in the Saltville Valley of Virginia, USA
Authors: SCHUBERT BLAINE W. , WALLACE STEVEN C.
Published: April 2009

The Saltville Valley of southwestern Virginia contains an abundance of extinct Late Pleistocene megafauna. Recent excavations in the valley produced two particularly notable discoveries, the remains of a scavenged mammoth (Mammuthussp.) and a giant short‐faced bear (Arctodus simus). The bear is the first carnivoran record from Saltville, and its large dental dimensions, dentary proportions, and exceptionally short‐face, evince an exceedingly powerful bite for this individual. Mammoth remains are relatively abundant from Saltville, but the material described here preserves extreme examples of scavenging by carnivores. Based on comparisons with the feeding behavior and bone alteration patterns of extant hyenas, cats, wolves, and bears, we conclude that at least two types of large carnivorans scavenged this mammoth carcass. AMS radiocarbon dates of 14 510 ± 5514C yr BP on theMammuthusand 14 853 ± 5514C yr BP on theA. simusdemonstrate that they are nearly the same age. Very few direct radiocarbon dates onA. simushave been reported from the contiguous United States. The SaltvilleA. simusrepresents the most eastern date for the species, as well as the only date from the Appalachian Highlands.
Edge‐Related Variation in Medicinal and Other “Useful” Wild Plants of Bwindi Impenetrable National Park, Uganda
Authors: OLUPOT WILLIAM , BARIGYIRA ROBERT , MCNEILAGE ALASTAIR J.
Published: April 2009

Abstract:  Harvesting of wild plants for nontimber uses is widespread in the tropics, but its impact is usually quantified only for one or a few species at a time. Thus, forest managers are never clear about how well their efforts are protecting such plants. We quantified abundance and edge‐related variation in 91 species of useful wild plants commonly harvested by communities around Bwindi Impenetrable National Park (BINP), Uganda, to evaluate the effect of their harvest. Forty percent of these species were harvested exclusively for medicines, 22% for weaving, and 24% for other uses. Fourteen percent were harvested for combinations of uses. Plants were surveyed around the entire periphery of the park transects that extended out 1 km into the forest interior from the edge. Analyses of edge and interior distribution were controlled for effects of topography. Individually, nine (10%) species were very rare, occurring in <0.5% of the plots searched. Of the remaining 82 species, most (50%) decreased significantly away from the park boundary, whereas 4.9% increased and 45.1% showed no pronounced edge‐related distributions. Rarer species were no more likely to be less abundant near the edge than commoner species. These results suggest that most plants used for nontimber purposes in BINP are not currently being harvested unsustainably. In this respect many of the species of useful wild plants we examined resembled animals commonly hunted in tropical forests for bushmeat because they increased in abundance in disturbed habitat. Conservation action should initially aim to understand what influences distributions of very rare species. Edge‐based assessments of distributions may be valuable for revealing harvest impact on species of useful wild plants commonly harvested by people living around forest islands in the tropics.
Conservation of Deep Pelagic Biodiversity
Authors: ROBISON BRUCE H.
Published: April 2009

Abstract:  The deep ocean is home to the largest ecosystems on our planet. This vast realm contains what may be the greatest number of animal species, the greatest biomass, and the greatest number of individual organisms in the living world. Humans have explored the deep ocean for about 150 years, and most of what is known is based on studies of the deep seafloor. In contrast, the water column above the deep seabed comprises more than 90% of the living space, yet less than 1% of this biome has been explored. The deep pelagic biota is the largest and least‐known major faunal group on Earth despite its obvious importance at the global scale. Pelagic species represent an incomparable reservoir of biodiversity. Although we have yet to discover and describe the majority of these species, the threats to their continued existence are numerous and growing. Conserving deep pelagic biodiversity is a problem of global proportions that has never been addressed comprehensively. The potential effects of these threats include the extensive restructuring of entire ecosystems, changes in the geographical ranges of many species, large‐scale elimination of taxa, and a decline in biodiversity at all scales. This review provides an initial framework of threat assessment for confronting the challenge of conserving deep pelagic biodiversity; and it outlines the need for baseline surveys and protected areas as preliminary policy goals.
Metamorphic phase relations in orthopyroxene‐bearing granitoids: implication for high‐pressure metamorphism and prograde melting in the continental crust
Authors: BHOWMIK S. K. , SAHA L. , DASGUPTA S. , FUKUOKA M.
Published: April 2009

In this work, the factors controlling the formation and preservation of high‐pressure mineral assemblages in the metamorphosed orthopyroxene‐bearing metagranitoids of the Sandmata Complex, Aravalli‐Delhi Mobile Belt (ADMB), northwestern India have been modelled. The rocks range in composition from farsundite through quartz mangerite to opdalite, and with varying K2O, Ca/(Ca + Na)rock and FeOtot + MgO contents. A two stage metamorphic evolution has been recorded in these rocks.

An early hydration event stabilized biotite with or without epidote at the expense of magmatic orthopyroxene and plagioclase. Subsequent high‐pressure granulite facies metamorphism (∼15 kbar, ∼800 °C) of these hydrated rocks produced two rock types with contrasting mineralogy and textures. In the non‐migmatitic metagranitoids, spectacular garnet ± K‐feldspar ± quartz corona was formed around reacting biotite, plagioclase, quartz and/or pyroxene. In contrast, biotite ± epidote melting produced migmatites, containing porphyroblastic garnet incongruent solids and leucosomes.

Applying NCKFMASHTO T–M(H2O) and P–T pseudosection modelling techniques, it is demonstrated that the differential response of these magmatic rocks to high‐pressure metamorphism is primarily controlled by the scale of initial hydration. Rocks, which were pervasively hydrated, produced garnetiferous migmatites, while for limited hydration, the same metamorphism formed sub‐solidus garnet‐bearing coronae. Based on the sequence of mineral assemblage evolution and the mineral compositional zoning features in the two metagranitoids, a clockwise metamorphic P–T path is constrained for the high‐pressure metamorphic event. The finding has major implications in formulating geodynamic model of crustal amalgamation in the ADMB.
Correlates of Community Health Service Utilization for Menopausal Symptoms among Urban Japanese Women
Authors: Matsui Noriko , Sakane Ayako , Omori Yukiko , Kimoto Satoko , Kadota Naoko , Moriya Michiko
Published: April 2009

ABSTRACT
Objectives: This study aims to identify the factors associated with community health service utilization for menopausal symptoms among Japanese women in urban areas by using Andersen's behavioral model of health service use.

Design: A cross‐sectional study was conducted.

Sample: The sample comprised 350 women aged 40–60 years living in a community in Japan.

Measurements: The independent variables were predisposing (demographics, social status, and health beliefs), enabling (family and community resources), and need factors (perceived health status and the need for community health services). The dependent variable was community health service utilization. A logistic regression model was used.

Results: 8 of the women were categorized in “treatment required” by simplified menopausal index score, and 103 women said that they would use the services. Knowledge regarding the services, OR: 1.814 (1.084–3.036); the absence of a negative attitude toward menopausal syndromes, OR: 0.605 (0.367–0.998); and the presence of a positive attitude, OR: 2.203 (1.070–4.536); influenced community health service utilization.

Conclusions: An appropriate attitude toward menopausal symptoms was observed to be more relevant to community health service utilization than the experience or acuity of the menopausal symptoms themselves. Therefore, community‐dwelling, middle‐aged women should be provided with sufficient education regarding menopausal symptoms to encourage their utilization of community health services.
The Effects of a Walking Program on Older Chinese American Immigrants With Hypertension: A Pretest and Posttest Quasi‐Experimental Design
Authors: Chiang Chun‐Ying , Sun Fan‐Ko
Published: April 2009

ABSTRACT
Objective: Hypertension is known to have high rates among Chinese Americans. Identifying culturally specific interventions to reduce sedentary behavior may be effective in reducing hypertension. This study examines the effects of an 8‐week walking program with and without cultural modification.

Design: The study used a 2‐group, pretest and posttest, quasi‐experimental design.

Sample: A total sample of 128 Chinese American immigrants with hypertension were assigned to walking groups.

Results: The results showed that the walking program had no significant effects upon participant blood pressure or walking endurance. The results also revealed that individuals in the maintenance stage walked longer than those in the preparation stage. A comparison of demographic data showed that subjects with a lower level of education walked more minutes per week, which contributed to lower systolic blood pressures among this group as compared with those with a higher level of education.

Conclusions: These results suggest that this walking protocol, when translated into Chinese and when accompanied by a weekly telephone reminder and other interactions with a Chinese‐speaking nurse, is appropriate to use without additional cultural modification. Future research should examine other components of Chinese culture or should apply this protocol for a longer period of time.
Assessment of Depressive Symptoms and Cognitive Impairment in Elders From Rural Areas of the Brazilian State of Rio Grande do Sul
Authors: Morais Eliane P. , Rodrigues Rosalina A. P. , Sousa Valmi D.
Published: April 2009

ABSTRACT
Objective: The main objective of this study was to examine the relationships among demographic characteristics, depressive symptoms, and cognitive impairment in oldest‐old elders from rural areas of the Brazilian State of Rio Grande do Sul.

Design: A cross‐sectional, descriptive correlational design was used to conduct the study.

Sample: 137 Brazilian elders age 80 years or over.

Measurements: A target population data form, a county data form, a demographic questionnaire, the Mini‐Mental State Examination, and the Depressive Cognition Scale were used to collect the data.

Results: A significant difference was found between males and females in regard to cognitive impairment. In addition, educational level and depressive symptoms were correlated with cognitive impairment. Depressive symptoms were a weak but significant predictor of cognitive impairment after controlling for the effect of age, gender, and educational level of the oldest‐old elders.

Conclusions: The findings need to be interpreted cautiously since the sample scored above the cutoff points for cognitive impairment, and had low scores on depressive symptoms. Despite several limitations, findings from this study can be a foundation for further studies, and well‐designed correlational or experimental approaches, are warranted.
Lymphoma Arising From a Calcinotic Lesion in a Patient with Juvenile Dermatomyositis
Authors: Morris Paula , Herrera‐Guerra Angel , Parham David
Published: April 2009

Abstract:  Approximately one‐third of adult patients with dermatomyositis develop malignancy, usually within 1 year of diagnosis of dermatomyositis. This phenomenon is not seen in patients with juvenile dermatomyositis. We are reporting a case of B‐cell lymphoma arising from a calcinotic lesion in a 14‐year‐old girl who had been diagnosed with juvenile dermatomyositis 3 years prior. Our review of the literature revealed only one other case of malignancy arising from an area of calcinosis.
Dyskeratosis Congenita – Report of a Case with Emphasis on Gingival Aspects
Authors: Lourenço Silvia V. , Boggio Paula A. , Fezzi Fernando A. , Sebastião Alexandre L. , Nico Marcello Menta S.
Published: April 2009

Abstract:  A case of dyskeratosis congenita (DC) of an 11‐year‐old male is reported. He presented with the characteristic clinical triad of reticular pigmentation of the skin, dystrophic nails and oral lesions, and up to the present he had not developed hematological compromise. Oral lesions consisted of extensive tongue erosions and keratosis, and exuberant gingivitis associated. Appropriate periodontal treatment was performed with discrete improvement only. We emphasize that severe gingival inflammation, although infrequent, may represent an alteration specific to DC and therefore should be considered as an additional sign of this syndrome.
Penile Linear Porokeratosis in a Child: A Case Report
Authors: KIENAST ANTONIA K. , HOEGER PETER H.
Published: April 2009

Abstract:  We report a 15‐year‐old boy with a 2 year history of erythematous, linear atrophic lesions on the dorsum penis and the inner part of the praeputium. A biopsy revealed changes typical of linear porokeratosis. Potential implications for subsequent development of penile carcinoma are discussed.
Subcutaneous Fat Necrosis in a Newborn Associated with Asymptomatic and Uncomplicated Hypercalcemia
Authors: LADOYANNI E. , MOSS C. , BROWN R. M. , OGBOLI M.
Published: April 2009

Abstract:  Subcutaneous fat necrosis in a newborn is a rare, benign and self‐limiting panniculitis. Hypercalcemia may develop and has been implicated as the cause of serious complications including seizures, nephrocalcinosis, and death. We report a case of subcutaneous fat necrosis in a newborn associated with asymptomatic and uncomplicated hypercalcemia, which resolved spontaneously.
An Audit of the Activities of the Pediatric Dermatology Nurse Specialist (PDNS)
Authors: USMANI NAILA , TEASDALE JOANNE , CLARK SHEILA M.
Published: April 2009

Abstract:  In the current financial climate where resources in the National Health Service are becoming increasingly limited, it is essential that the role of the pediatric dermatology nurse specialist remains appreciated and supported. Our pediatric dermatology nurse specialist was first employed in September 2002 having had 6 years experience nursing children with a wide variety of dermatologic conditions prior to her employment. She achieved her pediatric community nursing degree in 2003 undertaking the nurse prescribing extended formulary course in 2006, her training history representative of many nurse specialists. We present the results of an audit highlighting how the employment of our pediatric dermatology nurse specialist has led to a decrease in hospital admissions as well as providing a significant positive impact on waiting lists.
Phacomatosis Pigmentopigmentalis: Aberrant Mongolian Spots and Segmental Café Au Lait Macules
Authors: WOLF RONNI , WOLF DANNY , DAVIDOVICI BATYA
Published: April 2009

Abstract:  We report a case of an otherwise healthy male newborn, with segmental café au lait spots on his left buttocks and left thigh down to the medial knee, in a nevoid pattern, and an aberrant Mongolian spot on the ipsilateral cheek of the buttocks in a checkerboard pattern. We propose the name phacomatosis pigmentopigmentalis in analogy to phacomatosis pigmentovascularis, and phacomatosis pigmentokeratotica.
Pseudoatrophic Macules Associated with Neurofibromatosis‐1
Authors: CHIU CHIEN‐SHAN , WANG JIAAN‐DER , YEN CHUNG‐YANG , CHEN YI‐JU , SHEN JUI‐LUNG
Published: April 2009

Abstract:  A 14‐year‐old boy with neurofibromatosis type 1 presented with two ill‐demarcated, grayish‐white, and atrophic patches on his left back, which were confirmed as neurofibroma by histopathologic examinations. This clinical presentation of neurofibroma has rarely been reported in patients with neurofibromatosis.
Social Aspects of Epilepsy in Childhood
Authors: HAAS A. M. LORENTZ DE
Published: April 2009

There is a generally known interaction between epilepsy and social environment. The influence of this interaction on the epileptic child can become manifest in behaviour and adjustment, and in the frequency of seizures.

In this connection, family and school are discussed as the main constituents of the background of childhood epilepsy.

A few remarks are made on the organization of management and treatment.

Il y a une action réciproque bien connue entre l'épilepsie et le milieu social. L'influence de cette action réciproque sur l'enfant épileptique peut devenir manifeste dans le comportement et l'adaptation, et dans la fréquence des crises.

La discussion porte sur la famille et l'école, principaux constituants de l'arrièreplan de l'épilepsie chez l'enfant. On émet quelques considérations sur l'organisation du maniement de ces enfants et sur leur traitement.
The Effect of Chlordiazepoxide on the Electroencephalogram
Authors: Jeavons P. M.
Published: April 2009

Chlordiazepoxide was given to 41 patients suffering from epilepsy of various types and electroencephalograms were taken before and after treatment. Paroxysmal discharges in the EEG were reduced in 17 cases, and in 18 there was an increase in normal alpha activity. The most unusual finding was a reduction in abnormal background slow activity. Fast activity was induced in more than half the cases. The clinical effects were unpredictable, but there was reduction in infantile spasms and petit mal attacks. The effect on other forms of epilepsy was equivocal. Behaviour improved in some cases and worsened in others.

Il a été administré du chlordiazépoxide à 41 malades atteints d'épilepsie de types variés; des électroencéphalogrammes avaient été enregistrés avant et après le traitement. Des décharges paroxysmales dans l'EEG ont diminué en 17caset l'on a constaté en 18 cas une augmentation de l'activité alpha normale. La découverte la plus rare a été celle d'une réduction de l'activité lente anormale de l'arrière plan. Il y a eu induction d'une activité rapide dans plus de la moitié des cas. Les effets cliniques ont été imprévisibles mais il y a eu diminution des spasmes infantiles et des crises de petit mal. L'effet obtenu sur d'autres formes d'épilepsie a été douteux. Le com‐portement a été amélioré en certains cas et aggravé en d'autres.
When States Discriminate: The Non‐uniform Tax Treatment of Municipal Bond Interest
Authors: Denison Dwight V. , Hackbart Merl , Moody Michael J.
Published: April 2009

There is a long history of states using tax systems to encourage residents to invest in bonds issued by jurisdictions within their state. This preferential or discriminatory tax treatment was ruled unconstitutional in 2006 by the Kentucky Court of Appeals. The Kentucky court decision, which sets the stage for this essay, was overturned by the U.S. Supreme Court in 2008. This essay addresses the possible implications of this and similar discriminatory tax policies. Such discriminatory policies are the foundation of the municipal bond market, and altering the practice would have significant implications for revenue collections and borrowing costs in most states and localities. While the Supreme Court's position has been rendered, the case has caused policy makers and administrators to scrutinize discriminatory tax policies and their impact on budgets and borrowing costs.
Nancy Alfaro as an Exemplary Collaborative Public Manager: How Customer Service Was Aligned with Customer Needs
Authors: Naff Katherine C.
Published: April 2009

Nancy Alfaro is the quintessential practitioner of collaborative public management. More than that, she is a collaborative public manager focused on delivering customer service. Finding herself in the midst of a flurry of activity when San Francisco mayor Gavin Newsom suddenly ordered her to allow same‐sex marriages in 2004, she pulled together the resources to perform more than 1,000 weddings in three days. Now, as director of San Francisco's 311 Customer Service Center, Alfaro oversees an operation that has reduced the number of telephone numbers residents may need to call for information and nonemergency services from 2,300 to just one. How Ms. Alfaro accomplished these remarkable tasks can be the source of fruitful lessons for other public officials.
Looking for Meaning in the Alabama Lectures' Book Series: An Epitaph for an Old Friend of Public Administration after 57 Years
Authors: Lee Mordecai
Published: April 2009

This essay analyzes and reviews the significance of the Alabama Public Administration Lecture Series, one of the most distinguished and long‐lasting platforms in public administration. Based on guest lectures that were delivered annually to University of Alabama graduate students in public administration, the series began in 1944 and concluded in 2000. During those 57 years, most of the lectures were published as books, usually by the University of Alabama Press. The last book of the series will be published in 2009. This article examines the series as a whole and asks, what does the series tell us about public administration? What does it tell us about how our field got to where it is now? These questions are important because the books present a running conversation on the important subjects of public administration. The article shows that the lecture series offers a history of the field, reflecting the topics that were considered important by leading thinkers in their times.
Entrepreneurial Spirals: Deviation–Amplifying Loops of an Entrepreneurial Mindset and Organizational Culture
Authors: Shepherd Dean A. , Patzelt Holger , Haynie J. Michael
Published: April 2009

As environments become more dynamic and increasingly competitive, organizations must become more entrepreneurial. To explain how and why an organization becomes more (or less) entrepreneurial over time, we investigate the interrelationship between the psychology of individuals and the culture of organizations. To that end, we develop the notion of entrepreneurial spirals—enduring, deviation–amplifying loops—that serve to link the manager's mindset to his or her organization's culture and vice versa. We investigate how entrepreneurial spirals start, perpetuate, and stop, and detail the implications and insights suggested by entrepreneurial spirals for the relationship between managerial mindset and organizational culture.
Pacing and Defibrillation Lead Exchange Without Vein Puncture
Authors: ANTONELLI DANTE , FREEDBERG NAHUM A. , TURGEMAN YOAV
Published: April 2009

Background: During lead implantation, venous access is generally achieved by puncturing the subclavian or axillary vein. Sometimes, although rarely, after lead positioning, the lead must be changed because of its inadequate mechanical stability or poor pacing parameters. This report concerns a technique of lead exchange that avoids an additional vein puncture.

Method: The tip of the lead, that has to be replaced, is retracted from the right atrium or ventricle into the superior vena cava; the lead insulation is lanced along a few millimeters; the straight flexible tip of the guide wire is inserted between the insulation layer and the conductor of the lead. Then the lead is advanced, while the guide wire is driven in, until the tip of the guide wire is in the superior vena cava. At this point, the tip of the guide wire, gently retracted from its position, is released in the vein lumen. Subsequently, the lead is completely extracted from the vein but the guide wire is maintained inside it. A dilator with a mounted peel‐away sheath is advanced over the guide wire. The lead positioning follows in the usual manner.

Results: Three (2.2%) of the 139 implanted defibrillator leads and 13 (3.3%) of the 391 pacing leads were replaced. All the procedures were successful; their mean time was 2 ± 1 minutes.

Conclusion: This technique is successful and safe in providing vein access using the previously implanted lead, thus avoiding the need to repeat the puncturing of a vein.
Pacemaker‐Based Analysis of Atrioventricular Conduction and Atrial Tachyarrhythmias in Patients with Primary Sinus Node Dysfunction
Authors: STOCKBURGER MARTIN , TRAUTMANN FREDERIKE , NITARDY AISCHA , MARTIN‐JUST‐TEETZMANN   M.D.  , SCHADE STEFAN , CELEBI OEZLEM , KREBS ALICE , DIETZ RAINER
Published: April 2009

Background: Most patients with symptomatic sinus node disease (SND) receive DDDR pacemakers (PM) in order to cover SND and atrioventricular (AV) block from the outset. But the concern about adverse effects of right ventricular pacing (RVP) is increasing. So far, data on the incidence of AV block in SND are based on clinical events. The study undertakes to assess and appraise AV block and atrial tachyarrhythmias (AT) from memory and electrograms of a dual‐chamber PM set to an AAIR‐DDDR switch mode (AAISafeR).

Methods: A dual‐chamber PM incorporating the AAISafeR mode was implanted in 58 patients (70 ± 10 years, 28 males) with SND, but without AV block >I. AV block and AT episodes were retrieved from the PM memory and validated from electrograms. AV block episodes were classified potentially relevant while comprising AV block III or AV block I/II during exercise.

Results: The patients experienced a median of 90 (interquartile range 7–1,084) commutations. Possibly relevant AV block occurred in 32 patients (55%). Validation revealed high‐quality PM‐based categorization. The RVP prevalence was 0% (0–16%). The median AT prevalence was 0.03 (0–26) min/day. RVP was the only multivariate predictor of AT (P = 0.001).

Conclusions: Potentially relevant AV block occurs frequently in patients with SND. Nonetheless, the RVP prevalence is kept low through the AAISafeR mode. The protection of SND patients with demand‐actuated ventricular pacing appears reasonable. The AT prevalence is low in SND patients treated by the AAISafeR mode. Even low RVP proportions appear to favor AT. Prospective evaluation is needed.
Effect of Noise on T‐Wave Alternans Measurement in Ambulatory ECGs Using Modified Moving Average versus Spectral Method
Authors: SELVARAJ RAJA J. , CHAUHAN VIJAY S.
Published: April 2009

Background: The modified moving average (MMA) and spectral method (SM) are commonly used to measure T‐wave alternans (TWA), but their accuracy has not been compared in ambulatory electrocardiograms (ECGs) where TWA signal‐to‐noise ratio is low. Our objective was to compare the effect of noise and signal nonstationarity on the accuracy of TWA measurement using MMA versus SM when applied to synthetic and ambulatory ECGs.

Methods: Periodic and nonperiodic noise were added to noiseless synthetic ECGs. Simulated TWA (0–20 μV) was added to synthetic ECGs and ambulatory ECG recordings. TWA was measured using SM and MMA, and the measurement error relative to added TWA was compared. An MMA ratio was used to discriminate TWA signal from noise. Signal nonstationarity was simulated by changing heart rate, TWA magnitude, and TWA phase.

Results: With no added TWA, MMA falsely measured TWA in synthetic and ambulatory ECGs, while false measurement was not seen with SM. An MMA ratio > 1.2 eliminated false TWA detection. In the presence of low TWA magnitude (<10 μV), TWA was overestimated by MMA and underestimated by SM in proportion to the noise level. In synthetic ECGs with periodic noise and 10‐μV added TWA, MMA was less accurate than SM. The effects of simulated signal nonstationarity on the TWA magnitude measured with MMA versus SM were similar using a 64‐beat analysis window.

Conclusions: In the presence of noise, MMA falsely detects or overestimates simulated TWA in ambulatory ECG recordings. In this setting, the proposed MMA ratio improves the specificity of MMA.
Atrial Fibrillation and CHADS2 Risk Factors are Associated with Highly Sensitive C‐Reactive Protein Incrementally and Independently
Authors: CRANDALL MARK A. , HORNE BENJAMIN D. , DAY JOHN D. , ANDERSON JEFFREY L. , MUHLESTEIN JOSEPH B. , CRANDALL BRIAN G. , WEISS J. PETER , LAPPÉ DONALD L. , BUNCH T. JARED
Published: April 2009

Background: Inflammation has been shown to have a direct role in the initiation, maintenance, and recurrence of atrial fibrillation (AF) although the underlying mechanisms are unknown. Similarly, it is unclear if inflammatory markers are elevated due to the AF alone or the coexisting cardiovascular diseases that increase the risk of AF.

Methods: Consecutive patients who underwent angiography for suspicion of coronary artery disease, but without a myocardial infarction, were studied. Serum was analyzed to determine high‐sensitivity C‐reactive protein (hs‐CRP) level. Patients’ AF status was determined through ICD‐9 codes, review of hospital discharge summaries, clinical evaluations, and electrocardiograms.

Results: A total of 2,340 patients were studied (64±12 years). Comorbid diseases included 1,438 (61%) coronary artery disease, 1,309 (56%) hypertension, 433 (19%) diabetes, 345 (15%) congestive heart failure, and 43 (2%) a prior stroke. The hs‐CRP level was significantly higher in patients with AF (n = 238) compared to those without (14.0 mg/L vs 9.1 mg/L, P < 0.001). Greater CHADS2 score was also significantly associated with higher hs‐CRP in a linear fashion (medians [mg/L], 0: 1.99, 1: 2.91, 2: 3.49, 3: 3.89, 4–5: 4.82, P <0.001). The presence of AF was associated with higher hs‐CRP level across all scores (medians [mg/L], 0: 2.22 vs 1.98, P = 0.83, 1: 3.85 vs 2.86, P = 0.057, 2: 4.96 vs 3.29, P = 0.021, 3: 6.29 vs 3.17, P = 0.09, 4–5: 4.82 vs 4.50, P = 0.87).

Conclusion: Risks factors associated with AF were associated with higher hs‐CRP in an incremental manner. The presence of AF increased hs‐CRP across the CHADS2 score strata is supportive of the concept that AF is an inflammatory process and may convey independent risk.
Use of Triple‐Site Ventricular Pacing in a Patient with Severe Congestive Heart Failure and Atrial Fibrillation
Authors: OSMAN FAIZEL , JEILAN MOHAMED , NG G. ANDRE
Published: April 2009

Cardiac resynchronization therapy (CRT) has become an accepted treatment for selected patients with drug‐resistant heart failure. Data for patients in atrial fibrillation (AF) remains limited but suggests benefit in these patients too. We report the case of an 82‐year‐old patient with heart failure, VVIR permanent pacemaker, and permanent AF who had an upgrade to triple‐site CRT implantation with good clinical response. Triple‐site ventricular pacing may enhance the chance of response and LV reverse remodeling and should be considered in AF patients undergoing CRT implantation.
Late Sensing Due to Extremely Delayed Right Ventricular Activation in Arrhythmogenic Right Ventricular Cardiomyopathy
Authors: BRAMANTI ORESTE , MELLUSO CONCETTA , LUCÀ FABIANA , ORETO LILIA , ORETO GIUSEPPE
Published: April 2009

A patient with arrhythmogenic right ventricular cardiomyopathy/dysplasia, implanted with a dual‐chamber implantable cardioverter‐defibrillator programmed in DDD mode, showed an unexpected ventricular sensing dysfunction: despite a very long (320 ms) programmed atrioventricular (AV) interval, ventricular stimuli were delivered in the ST segment after each spontaneous conducted QRS complex. This suggested the presence of ventricular undersensing. When, however, the system was programmed in VVI mode, spontaneous QRS complexes were normally sensed, although electrogram (ECM) analysis revealed that ventricular sensing occurred 160 ms after the beginning of QRS complex. A new ventricular lead was then implanted in the outflow tract of the right ventricle, resulting in normal ventricular sensing function. At the time of intervention, the amplitude of the spontaneous ventricular signal recorded from the old ventricular lead was 2.8 mV.
In this patient, no true undersensing occurred although ventricular stimuli were delivered 140 ms after the beginning of spontaneous QRS complexes when the system was in DDD mode: the cause of the apparent pacemaker malfunction was the extremely prolonged ventricular depolarization. Due to fibrofatty muscle replacement, the depolarization wavefront reached the ventricular muscle surrounding the pacemaker lead with such a delay that at the end of the programmed sensed AV interval (320 ms) the ventricular EGM had not yet attained the sensing threshold. This apparent undersensing should, thus, be defined as “late sensing.”
Cardiac Resynchronization in a Child with Dilated Cardiomyopathy and Borderline QRS Duration: Speckle Tracking Guided Lead Placement
Authors: GONZALEZ MARIA B. GONZALEZ Y , SCHWEIGEL JOANA , KOSTELKA MARTIN , JANOUŠEK JAN
Published: April 2009

Cardiac resynchronization therapy (CRT) is proved to prevent heart transplantation in some patients with dilated cardiomyopathy and mechanical dyssynchrony. We report of the benefit of CRT accomplished by atrial synchronized single‐site left ventricular pacing in an 8‐year‐old boy with idiopathic dilated cardiomyopathy, normal atrioventricular conduction, borderline QRS complex duration (120 ms), and marked mechanical left ventricular dyssynchrony proved by echocardiographic speckle tracking.
Angiographic Markers of Restenosis after Drug‐Eluting Stent Implantation: Surrogates for Late Clinical Outcomes?
Authors: POPMA JEFFREY J. , ALMONACID ALEXANDRA
Published: April 2009

Introduction:

Although angiographic measures of restenosis, including late lumen loss, binary angiographic restenosis, and follow‐up percent diameter stenosis have value in determining the efficacy of new drug‐eluting stents (DES) designs, their ability to predict clinical events, including death, myocardial infarction, and target lesion revascularization (TLR) has been questioned.

Methods:

We reviewed the available literature and recent DES clinical trials to determine the relationship between clinical and angiographic markers of restenosis and late clinical outcomes after stent use.

Results:

Angiographic markers are useful surrogates for predicting differences in TLR between bare metal and DES. Due to the curvilinear relationship between late lumen loss and TLR and the skewedness of the late lumen loss distribution, late lumen loss as a single index has been less effective at predicting clinical differences between different DES when the absolute values of late lumen loss are low. Beyond predicting clinical restenosis, follow‐up angiographic indices have been less predictive of other late clinical events, such as very late stent thrombosis or aneurysm formation.

Conclusions:

Angiographic markers of restenosis may be a useful surrogate for TLR in pilot studies of patients treated with DES, but their use as a surrogate marker for all clinical events after stent placement, including death, myocardial infarction, and stent thrombosis, may be confounded by the progression of atherosclerosis at remote sites and vagaries of the distribution of late lumen loss in patients treated with DES.
XIENCE V™ Stent Design and Rationale
Authors: DING NI (NADINE) , PACETTI STEPHEN D. , TANG FUH‐WEI , GADA MANISH , ROORDA WOUTER
Published: April 2009

Drug‐eluting stents (DES) are a preferred treatment modality for occlusive coronary artery disease. First‐generation DES have demonstrated high levels of efficacy. However, concerns have been raised over late thrombotic events. XIENCE V™ everolimus‐eluting coronary stent is a second‐generation DES designed to be more deliverable and safe, while maintaining efficacy in a broad patient population compared with first‐generation DES.

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As a drug/device combination product, the overall performance of a DES is determined by its components and how well they are integrated. XIENCE V utilizes the MULTI‐LINK VISION® stent, the antiproliferative drug everolimus, a fluorinated polymer drug carrier, poly(vinylidene fluoride‐co‐hexafluoropropylene) (PVDF‐HFP), and a stent‐specific delivery system. A DES coating must fulfill the multiple goals of biocompatibility, controlled drug release and maintenance of the coating durability through stent crimping, and expansion in vivo. The XIENCE V coating utilizes a two‐layer coating system composed of an acrylate primer and a fluorinated copolymer drug reservoir. Fluorinated polymers have a long history of use in permanent vascular implant applications. The XIENCE V fluorinated copolymer offers in vivo biocompatibility combined with excellent chemical stability and high purity. Described in this article are the design rationale and polymer selection criteria. The hemocompatibility and biocompatibility of the fluorinated polymer coating are discussed. Characterization results on drug release control, possible drug release mechanism, coating integrity, coating uniformity, and fatigue resistance are also presented.
Choice of DES: A European Clinician's Perspective
Authors: SASTRY SANJAY , MORICE MARIE‐CLAUDE
Published: April 2009

The introduction of the first generation of drug‐eluting stents (DES) in 2002 revolutionized interventional cardiology by minimizing restenosis. Reports of increased late stent thrombosis with these stents compared with bare metal stents, probably due to delayed endothelialization, emerged late in 2006. These studies contained serious methodological flaws, however. Subsequent meta‐analyses clearly showed only a small incremental risk of late stent thrombosis across all patient groups. Importantly, a significant and sustained benefit of DES due to reduced restenosis and thus repeat revascularization was also shown. Several “real‐world” registries have confirmed these results, as well as suggesting that use in more complex situations is not associated with adverse outcomes. Stent thrombosis is a multifactorial problem, in which the stent is only one element. Further research is required to determine optimal procedural technique and antiplatelet regimes.

Second‐generation DES, with different antiproliferative drugs and more biocompatible polymers, have shown promising results in comparative studies with the first generation. Current follow‐up data for these stents is only up to 3 years, however.

DES are safe and effective in the long term, though intensive research continues into ways to reduce the risk of stent thrombosis in the next generation.
Future Directions of Drug‐Eluting Stents
Authors: KUKREJA NEVILLE , ONUMA YOSHINOBU , SERRUYS PATRICK W.
Published: April 2009

Coronary artery stents have changed the face of interventional cardiology since their introduction in 1986. The commercial release of drug‐eluting stents in 2002 promised to abolish in‐stent restenosis as the predominant clinical limitation following stent implantation. Concerns raised about increased risks of adverse events with drug‐eluting stents now appear unfounded but have heralded a new era of research, where only hard clinical end‐points in sufficiently large numbers of patients are considered adequate. In this review, we highlight some of the potential future directions of drug‐eluting stents including specialized stent platforms (including dedicated bifurcation stents), fully degradable stents, and the potential use of stents to prevent cardiac events.
Sequence of Electrocardiographic and Acoustic Cardiographic Changes and Angina during Coronary Occlusion and Reperfusion in Patients Undergoing Percutaneous Coronary Intervention
Authors: Lee Eunyoung , Drew Barbara J. , Selvester Ronald H. , Michaels Andrew D.
Published: April 2009

Background: Previous studies have suggested that ventricular function may be impaired without or prior to electrocardiographic changes or angina during ischemia. Understanding of temporal sequence of electrical and functional ischemic events may improve the detection of myocardial ischemia.

Methods: A prospective study was performed in 21 subjects undergoing percutaneous coronary intervention (PCI) who had both ST amplitude changes >2 standard deviations above baseline on 12‐lead electrocardiography (ECG), and new or increased third or fourth heart sound (S3 or S4) intensity measured by computerized acoustic cardiography. The sequence of the onset and resolution of these signs of ischemia were examined following coronary balloon inflation and deflation.

Results: Electrocardiographic ST amplitude and diastolic heart sound changes occurred contemporaneously, shortly after coronary occlusion (mean onset from balloon inflation; ST changes, 21 ± 17 seconds; S4, 25 ± 26 seconds; S3, 45 ± 43 seconds). In 40% of patients, a new or increased S3 or S4 developed earlier than ST changes. Anginal symptoms occurred in only 2 of the 21 subjects during ischemia with a mean onset time of 68 seconds. ST‐segment changes resolved earliest (33 seconds after balloon deflation) while diastolic heart sounds (89 ± 146 seconds) and angina (586 ± 653 seconds) resolved later.

Conclusion: A new or intensified S3 and/or S4 occurred contemporaneously with electrocardiographic changes during ischemia. These diastolic heart sounds persisted longer than ST changes following coronary reperfusion. Acoustic cardiographic assessment of diastolic heart sounds may aid in the early detection of myocardial ischemia, particularly in those patients with an uninterpretable ECG.
The Measurement of the QT and QTc on the Neonatal and Infant Electrocardiogram: A Comprehensive Reliability Assessment
Authors: Gow Robert M. , Ewald Benjamin , Lai Lillian , Gardin Letizia , Lougheed Jane
Published: April 2009

Background: An electrocardiogram has been proposed to screen for prolonged QT interval that may predispose infants to sudden death in the first year of life. Understanding the reliability of QT interval measurement will inform the design of a screening program.

Methods: Three pediatric cardiologists measured the QT/RR intervals on 60 infant electrocardiograms (median age 46 days), from leads II, V5 and V6 on three separate occasions, 7 days apart, according to a standard protocol. The QTc was corrected by Bazett's (QTcB), Fridericia's (QTCFrid), and Hodges' (QTcH) formulae. Intraobserver and interobserver reliability were assessed by intraclass correlation coefficients (ICC), limits of agreement and repeatability coefficients for single, average of two and average of three measures. Agreement for QTc prolongation (> 440 msec) was assessed by kappa coefficients.

Results: QT interval intraobserver ICC was 0.86 and repeatability coefficient was 25.9 msec; interobserver ICC increased from 0.88 for single observations to 0.94 for the average of 3 measurements and repeatability coefficients decreased from 22.5 to 16.7 msec. For QTcB, intraobserver ICC was 0.67, and repeatability was 39.6 msec. Best interobserver reliability for QTcB was for the average of three measurements (ICC 0.83, reproducibility coefficient 25.8 msec), with further improvement for QTcH (ICC 0.92, reproducibility coefficient 16.69 msec). Maximum interobserver kappa for prolonged QTc was 0.77. Misclassification around specific cut points occurs because of the repeatability coefficients.

Conclusions: Uncorrected QT measures are more reliable than QTcB and QTCFrid. An average of three independent measures provides the most reliable QT and QTc measurements, with QTcH better than QTcB.
Happiness and Stress Alter Susceptibility to Cardiac Events in Long QT Syndrome
Authors: Lane Richard D. , Reis Harry T. , Peterson Derick R. , Zareba Wojciech , Moss Arthur J.
Published: April 2009

Objective: We sought to determine whether the circumstances preceding an arrhythmic event differed from those preceding a prior control occasion in patients with Long QT Syndrome (LQTS), a well‐characterized genetic disorder that puts affected individuals at risk for sudden cardiac death.

Methods: Thirty‐eight patients (89% female) with LQTS completed a “case‐crossover interview” in which each patient served as his/her own control by reporting on circumstances preceding an arrhythmic event (syncope, aborted cardiac arrest, or defibrillator discharge) and preceding a control occasion (the next‐to‐last birthday). On average the interview was conducted 17 months after the cardiac event and control occasion.

Results: During the 24‐hour period preceding the cardiac event compared to the day before the control occasion, psychological stress was elevated, peak happiness was reduced, and peak exertion was not significantly different. Rated for the 6‐month intervals preceding the event and control occasions, none of these three variables was significantly associated with events.

Conclusions: Happiness is associated with a reduction in the 24‐hour risk of cardiac events in patients with LQTS, with stress having an opposite effect. To our knowledge, this is the first report indicating that positive emotion may have a protective effect on life‐threatening ventricular arrhythmias. This study lends further support to the role of emotions in influencing cardiac events in arrhythmia‐prone patients.