Relationship between Intrathoracic Impedance, BNP and Six-Minute Hall Walk Sanjeev K. Gulati, John McKenzie, George H. Crossley, Mary Anne Papp, Jason Sims, John Andriulli; Sanger Heart & Vascular Institute, Charlotte, NC; Glendale Memorial Hospital & Medical Center, Glendale, CA; Mid-State Cardiology of St. Thomas Heart, Nashville, TN; Medical College of Wisconsin, Milwaukee, WI; Medtronic, Mounds View, MN; Southern New Jersey Cardiac Specialists, Vorhees, NJ

Background: Acute increases in weight are an important sign of worsening heart failure (HF). Recent data indicates that intrathoracic impedance (Z), a measure of thoracic fluid, predicts worsening HF with 70–80% sensitivity. However, the relationship between weight and Z is unknown. We compared Z changes with weight changes in HF patients. We expect that acute weight changes will associate with Z, but only if due to fluid accumulation. Methods: Subjects (n = 102, 68 ± 13 yr, 70% male) were enrolled at ICD or CRT-D implant. Inclusion criteria included baseline: BNP > 80pg/ml; QRS>130ms; LVEF<35%; and 6-MHW<450 m. Daily weights were recorded in a diary, while daily Z was stored by the device for 1 year of follow up. We compared daily weights and daily Z as patients progressed towards an OptiVol fluid index crossing (FIX), which is proven to predict future HF events. Patients with less than 75% of weight data within 30 days before a FIX were excluded from analysis. Results: The graph below represents trends in daily weight and Z thirty days before a FIX (n = 18). As expected, approximately 18 days before a FIX the Z begins to decrease. In contrast, weight begins to change about 11 days before a FIX. Compared to 30 days before, on the day of FIX patient weight increased 3.2 ± 2.2 lbs, while Z had dropped 5.6 ± 0.6 ohms. Importantly, the second graph details that only 70% of patients had greater than 50% compliance with daily weight data. Conclusion: Intrathoracic impedance and daily weight exhibit similar trends during volume accumulation. However, Z begins to change approximately 7 days before weight. It may be that combining weight and Z may increase the specificity of either measure. However, daily weights are impeded by patient compliance. Device diagnostics, including intrathoracic impedance, may improve remote management of heart failure patients, irrespective of patient compliance.

On the Fast Track was a project initiated, developed and delivered by the members of the Cooperative Venture for Capacity Building (CVCB). The project aimed to improve the use of CVCB research outputs by rural R&D corporation project managers and practitioners. It involved a trial of practical capacity building approaches that applied the CVCB research findings. The design involved consolidating CVCB research outputs into meaningful learning tools and supporting capacity-building practitioners in applying their learning in their day-to-day work or projects through mentoring. Sixty-three people from all over Australia participated in the project. Participants included farm/rural advisers and consultants, project officers and managers/investors, project designers and extension staff as well as people involved in community development. They came from rural industries (Dairy, Cotton, Sugar, Meat & Livestock, Horticulture, Wool, Grains), NRM/property planning, community and farmer representative organisations and research organisations. Each participant attended a 2-day workshop, applied what was learned on an issue in their own work with mentoring support over a 9-month period, and participated in a final reflective workshop. This paper provides an overview of the project's tools and processes, the key learnings from applying the approach, and evaluation of the approach. The paper concludes with insights relevant to people seeking to enhance the practice of the professionals engaged in capacity building, and to better implement capacity-building research.

Background: The 6-MHW and B-natiuretic peptide (BNP) have prognostic significance in the heart failure population. This study aims to define the relationship between the 6-MHW and BNP. Methods: Inclusion criteria: baseline BNP>80pg/ml; LVEF<35%; initial 6-MHW<450 m. The 6-MHW distance, BHF and BNP were measured monthly. Paired Student's-t tests were used. Results: The mean 6-MHW, BNP, and BHF scores were equal from baseline to 3 months (p values: 0.15, 0.48, 0.17: N=60). BNP and BHF scores were equal from baseline to 5 months (p values 0.13, 0.16: N=50) with significant change in 6-MHW (p = 0.004: N=50). Significant changes in distance walked are noted when comparing those subjects with the greatest positive and negative changes in 6-MHW (top and bottom halves). Those in the bottom half had lower BHF scores with no change as compared to those in the top half with higher BHF scores and significant change.Tabled 1Top Half6-MHW (M) ± SDBNP (pg/dl) ± SDBHF score ± SDBaseline (N=30)294.7 ± 98.5465.4 ± 450.83.3 ± 3.5Month 3 (N=30)374.5 ± 100.1401.6 ± 418.82.0 ± 2.4P value<0.00010.180.02Baseline (N=25)247.1 ± 103.6453.3 ± 448.43.7 ± 4.4Month 5 (N=25)348.1 ± 99.9373.2 ± 371.81.8 ± 1.6P value<0.00010.070.02Bottom HalfBaseline (N=30)301.5 ± 119.9425.8 ± 501.52.5 ± 3.7Month 3 (N=30)245.96 ± 112.3482.2 ± 871.82.97 ± 3.6P value0.00030.300.20Baseline (N=25)303.6 ± 105.5339.1 ± 413.72.6 ± 3.5Month 5 (N=25)276.3 ± 120.8306.1 ± 316.13.3 ± 4.7P value0.0080.351.71 Open table in a new tab Conclusions: Patients with increased clinical heart failure scores (as defined by the BHF) are more likely to have improved functional status as defined by the 6-MHW as opposed to BNP values. This study confirms the reproducibility of the 6-MHW and that it correlates better with clinical symptoms (BHF) as compared to biomarkers (BNP).

The ergogenic effects of caffeine ingestion (240–840 mg) on exercise performance is well established, albeit in some cases with negative side effects. However, recent evidence shows that much smaller doses can have beneficial effect on endurance performance as well as on mental function. Less is known about the possible synergistic effects of low dose of caffeine (CAF) and carbohydrate (CHO) feedings, especially as related to team sports performance. PURPOSE: To determine the effects of low dose (100 mg) CAF ingestion along with typically recommended CHO on physical and mental function during intermittent high intensity exercise that mimics the demands of competitive team sports. METHODS: Physically active male (N=6) and female (N=4) low to moderate caffeine users participated in this study. Experimental trials consisted of four ∼22-minute quarters (QTR) of shuttle running. Physical and mental function tests were administered throughout the experimental trial including (20-m sprint, vertical jump, gross motor skill test, force sensation, rating of perceived exertion, profile of mood states and psychomotor vigilance test).On four separate occasions, subjects received 20-oz of flavored water placebo (PLA), CHO, PLA+CAF and CHO+CAF prior to exercise. During exercise, subjects ingest PLA, CHO, PLA and CHO respectively (3.5 ml·kg-1). RESULTS: No difference was found in 20-m sprint time, vertical jump and gross motor skills performance between any treatments. However, both caffeine treatments (PLA+CAF and CHO+CAF) significantly improved psychomotor vigilance and reduced force sensation at HALFTIME (p<0.05). CHO+CAF also improved self-reported perception of fatigue, vigor and overall mood compared to PLA+CAF (p<0.05). Systolic blood pressure was increased with CHO+CAF compare to other three treatments. However, no difference was found in heart rate, core body temperature, plasma volume change, or hydration status between any treatments. CONCLUSION: The data suggest that ingestion of a low dose of caffeine prior to exercise did not add to the expected benefits of CHO feedings alone on physical tasks. However, all of the mental function tasks were significantly enhanced with the combination of CHO plus CAF, with little or no adverse side effects. Funded by Gatorade Sports Science Institute.

Adults often express concern about the increasing production of books with scatological humour despite the evidence of the popularity of such literature with children. This article explores a range of recently published picture books where the anthropomorphic dog is subject to children's laughter. Bakhtin's theory of the carnivalesque is identified as a useful construct to use in order to understand the nature of this humour and indeed, the theory can provide a rationale for the possible use of scatology in early childhood settings. The dialogic nature of the picture book (image versus narrative) provides a useful structure to exploit carnivalesque humour. However, the paper recognises that providing a carnivalesque space in the classroom is a problematic business that challenges how adults perceive both the nature of children's literature and the adult as the agent of control within the early childhood centre.

OBJECTIVES:We sought to test the hypothesis that complex fractionated electrograms (CFAEs) recorded during atrial fibrillation (AF) could be used as target sites for catheter ablation of AF. BACKGROUND:Mapping of AF in humans has shown that areas of CFAEs correlate with areas of slowed conduction and pivot points of reentrant wavelets. We hypothesized that such areas of CFAEs could be identified in patients with AF and might serve as target sites for catheter ablation to maintain sinus rhythm. METHODS:The study population included 121 patients (29 females; mean age, 63 years) with refractory AF (57 paroxysmal, 64 chronic). All patients underwent nonfluoroscopic electroanatomic mapping (CARTO) during AF. Using CARTO, the biatrial replica, displayed in a three-dimensional color-coded voltage map, was created during AF, and areas associated with CFAEs were identified. Radiofrequency ablation of the area with CFAEs was performed, aiming to eliminate CFAE and/or convert to sinus rhythm. RESULTS:Complex fractionated atrial electrograms were found in seven of nine regions of both atria, but were mainly confined to the interatrial septum, pulmonary veins, roof of left atrium, and left posteroseptal mitral annulus and coronary sinus ostium. Ablations of the areas associated with CFAEs resulted in termination of AF without external cardioversion in 115 of the 121 patients (95%); 32 (28%) required concomitant ibutilide treatment. At the one-year follow-up, 110 (91%) patients were free of arrhythmia and symptoms, 92 after one ablation and 18 after two. CONCLUSIONS:Areas with CFAEs represent a defined electrophysiologic substrate and are ideal target sites for ablations to eliminate AF and maintain normal sinus rhythm.

We examined risk of ocular melanoma with exposure to artificial sources of exposure to ultraviolet radiation (UVR) in a population‐based epidemiologic study of 290 cases of ocular melanoma and 893 controls aged 18–79 years in Australia in 1996–1998. Cases were identified through a prospective survey of all ophthalmologists and cancer registries in Australia; 91.8% participated. Controls were sourced from electoral rolls; 67.4% of those who were eligible and contactable participated, while 27.3% could not be contacted. Exposure to welding and use of sunlamps, including sunbeds and tanning booths, was measured by telephone interview. Analyses used unconditional logistic regression and included age, sex, region of birth, eye color, ocular and cutaneous sun sensitivity and personal sun exposure as covariates. Risk of choroid and ciliary body melanoma in 246 cases increased significantly with longer duration of use of sunlamps, first use before 21 years of age and first use after 1980. These effects were independent of personal sun exposure. Risk of these melanomas also increased with increasing duration of welding exposure, although the trend was not significant overall. There was no evidence that these exposures increased the risk of iris (n = 25) or conjunctival (n = 19) melanomas. Personal exposure to sunlamps and welding predicts risk of choroid and ciliary body melanoma in Australia. © 2004 Wiley‐Liss, Inc.

Uveal melanoma is the most frequent primary malignant intraocular tumor of adults. Among various non-modifiable risk factors, Caucasian race seems to be the most significant with light skin color, blond hair, and blue eyes being specific risk factors. The racial predisposition to uveal melanoma have been explained on the basis of susceptibility of Caucasian race to oncogenic effects of sunlight. Although there is ample evidence in support of this hypothesis in regard to skin melanoma, the evidence in regard to uveal melanoma is insufficient and contradictory. In the following review, we examine physiologic, epidemiological, and genetic data in order to determine the role of sunlight exposure in the pathogenesis of uveal melanoma.

Routinely collected incidence data have often lacked specific identification of ocular melanoma in the past and with increasing diagnosis and management of this disease by noninvasive techniques may now underestimate the true incidence. We attempted to accurately measure the incidence of ocular melanoma in Australia from 1990 to 1998 using 2 population‐based sources, cancer registries and ophthalmologists. We examined the distribution across the continent, by latitude and in subpopulations, and evaluated the extent of nonnotification to cancer registries. One‐half (51%) of the incident cases from 1996 to 1998 were diagnosed clinically and had no tissue diagnosis. An estimated 20% of melanomas, mainly those lacking a tissue diagnosis, were not notified to Australian cancer registries, but only 1.3% were not notified by ophthalmologists. Expert reviewers agreed that a high proportion (95%) of clinically diagnosed lesions were probable or possible melanomas. Incidence was significantly higher in men than in women, especially at older ages, relatively uniform across the Australian states with only weak evidence of a latitude gradient, and higher in rural than in urban areas. The incidence of ocular melanoma in people born in Southern Europe was half and in those born in Asia only 20% of the rate in people born in Australia and New Zealand. We concluded that it was possible to identify a high proportion of cases by surveying relevant sources additional to cancer registries and to be reasonably confident of the accuracy of the clinical diagnoses. The higher incidence in older men, who probably have higher sun exposure, than in older women and in residents of rural areas, where outdoor work is more prevalent, than in urban areas; the low incidence in dark‐eyed populations, who may have a lower sensitivity to or less transmission of solar radiation to the choroid; and the preferential location of ocular melanomas in ocular sites known to receive the highest exposure to solar radiation all support a role for solar radiation in the aetiology of ocular melanoma. The absence of a strong latitude gradient in incidence does not argue against such a role because exposure of the eye to solar UV is probably determined most by the horizon sky, where ambient solar UV is less affected by latitude. © 2003 Wiley‐Liss, Inc.

Previous studies examining sun exposure and ocular melanoma have produced inconsistent results. We investigated this association in a population‐based case‐control study in Australia. Cases (n = 290) aged 18–79 years were diagnosed between January 1996 and July 1998. Controls (n = 893) were randomly selected from the electoral rolls and frequency‐matched to cases by age, sex and state. A self‐administered questionnaire and a telephone interview measured sun exposure on weekdays and weekends at 10, 20, 30 and 40 years of age and over the whole of life for specific jobs and recreations. Multivariate logistic regression models of ocular melanoma and sun exposure contained age, sex, region of birth, eye color and measures of ocular and cutaneous sun sensitivity as covariates. Choroid and ciliary body melanoma (n = 246) was positively associated with time outdoors on weekdays and, less persuasively, total time outdoors but not ambient solar irradiance. Odds ratios increased with increasing exposure to OR 1.8 (95% confidence interval 1.1–2.8) for the highest quarter of sun exposure on weekdays up to 40 years of age for men and women together. The strongest positive associations were for total exposure up to 40 years of age, lifetime occupational exposure and total exposure at about 20 years of age in men; all had odds ratios between 2 and 3 in the highest exposure categories. There was inconclusive evidence for an association between sun exposure and iris (n = 25) or conjunctival (n = 19) melanomas. Sun exposure is an independent risk factor for choroidal and ciliary body melanoma in Australia. © 2002 Wiley‐Liss, Inc.

Ethnicity, cutaneous nevi and eye color are generally accepted risk factors for melanoma of the eye. although case-control studies have produced conflicting results. We sought to determine the constitutional risk factors for melanomas of the choroid, ciliary body, iris and conjunctiva in Australia. A population-based case-control study was conducted, with case ascertainment from a prospective national incidence survey and randomly selected community controls. Two hundred and ninety cases aged 18-79 years and diagnosed between I st January 1996 and 31st July 1998 were enrolled with 916 controls frequency matched by age, sex and State or Territory of residence, Risk of choroidal and ciliary body melanoma (n = 246) was increased in people with grey (OR 2.9, 95% CI 1.5-5.5), hazel (OR 2.2, 95% CI 1.4-3.7) and blue eyes (OR 1.7, 95% CI 1.0-2.7) compared with brown eyes, Risk was also increased in those with 4 or more nevi on their back, those unable to tan, and those who squinted when outdoors as a child. Risk was reduced in people born other than in Australia and New Zealand (OR 0.7, 95% CI 0.5-1.0), Non-brown eye color was a risk factor for iris melanoma (n = 25), No risk factors were identified for conjunctival melanoma (n = 19), Eye color is the strongest constitutional predictor of choroidal and ciliary body melanoma, and may indicate a protective effect of melanin density at these sites. An independent association with cutaneous nevi suggests a role for other genetic factors. (C) 2001 Wiley-Liss. Inc.

This article investigates the importance of treatment requests made by patients with kidney failure and other life-threatening conditions on nephrologists' treatment decisions. A total of 535 nephrologists from the U.S., Canada, and Britain returned mailed surveys in which they read 5 scenarios and then indicated how the patient described in the scenario should be treated. Results revealed that when patients communicated their preferences, nephrologists were significantly more likely to provide dialysis. Although there were no differences among the 3 countries when treatment preferences were not expressed, Americans were much more likely to provide dialysis when requested by the patient Whereas most nephrologists agreed to change treatment decisions at the request of the patient, American doctors were less likely to comply with requests to terminate dialysis and were more likely to agree to provide dialysis for incompetent patients they initially refused to dialyze if asked to do so by the family. In the 3 scenarios in which the patients' treatment preferences were unstated, approximately 45% of the doctors who recommended dialysis still cited the patient's request for dialysis as the most important factor in their decision. This tendency was more pronounced for American nephrologists. Results suggest the need to further investigate the interactions of doctors and chronically ill patients and to account for the cultural and institutional contexts in which these interactions occur.Finally, physicians need to teach themselves to recognize better the shadow line between prolonging life and prolonging dying and to understand that death should be a human act of dignity and not a prolonged mechanical failure that can be fixed with even more technology.

The purpose of this article is to report on the safety and effectiveness of brain arteriovenous malformation (AVM) embolization for two series of patients, of which one was treated with particulate embolization and the other with acrylic embolization. Sixty-five consecutive patients from embolization logs and patient records from 1988 to 1993 were reviewed. AVMs were routinely treated with particulate embolization early in the review (1988-1991), and after a transition period, the technique was changed to acrylic embolization for the remainder of the study period (1992-1993). All patients were treated with the ultimate goal of complete AVM obliteration. AVMs were embolized and resected, if possible, and if unresectable, they were reduced in size with embolization and radiated. The course of treatment for each patient was reviewed. The effectiveness at the end of treatment was analyzed for the ability to resect the AVM and, if unresectable, the ability to reduce the AVM to radiation size. Additionally, the safety of each embolization technique was evaluated in the context of comprehensive care, in terms of the safety of the procedure itself, the surgical resection after embolization, and the outcome at the end of comprehensive treatment. This article outlines the safety and effectiveness of acrylic and particulate embolization at a single institution. The ability to surgically resect an AVM after embolization and to reduce nidus size with acrylic was at least comparable with that with particulate embolization. Comprehensive complication rates were lower after acrylic embolization and were heavily influenced by a decreased number of surgical complications in the acrylic series. These data support the need to conduct a randomized prospective clinical trial to compare the relative safety and effectiveness of the two methods of embolization.