[Measuring change in rehabilitative cardiology: reliability of a short questionnaire to assess an outcome].

The present Italian health planning demands the use of tools, care and treatments useful for the National Health Service, but with empirical effectiveness scientifically sustained. Aim of the present paper is to verify the validity, the reliability and the responsiveness of the factor "Perception of positive change" (named Schedule C) in cardiovascular rehabilitation. Method. The reliability of the Schedule C of the CBA VE has been examined comparing the mean scores obtained from each item at the entry and just before the discharge through the t-Student for paired sample. To assess the concurrent validity we used the AD Short Scale to measure anxiety and depression. 100 patients who underwent cardiac surgery were enrolled during hospitalization for a Cardiac Rehabilitation Programme. Cronbach's alpha was used to assess internal consistency of each item. Results. Each item of the Schedule C demonstrated good internal consistency (Cronbach Alpha >.88) and elevated correlations item-total for each item. The strong correlation of anxiety and depression scores with the Schedule C points out appropriate concurrent validation. Conclusions. We believe that the Schedule C of the CBA VE is endowed with suitable metric validity and then useful as outcome evaluation in cardiovascular rehabilitation settings

Autonomic control of heart rate: pharmacological and nonpharmacological modulation.

The evidence of the predictive value of autonomic markers has generated a growing interest for interventions able to influence autonomic control of heart rate. The hypothesis is that an increase in cardiac vagal activity as detected by an increase in heart rate variability (HRV) or baroreflex sensitivity (BRS) may be beneficial in the ischemic heart. Numerous experimental data support the hypothesis that augmenting vagal activity might be protective against lethal ischemic arrhythmias. Among them is the evidence that ventricular fibrillation during acute myocardial ischemia may be largely prevented by electrical stimulation of the right cervical vagus or by pharmacological stimulation of cholinergic receptors with oxotremorine. There is an inherent danger in the so far unwarranted assumption that modification of HRV or BRS translates directly in cardiac protection. This may or may not be the case. It should be remembered that the true target is the improvement in cardiac electrical stability and that BRS or HRV are just markers of autonomic activity. Low dose scopolamine increases HRV in patients with a prior myocardial infarction. This observation, combined with the evidence that elevated cardiac vagal activity during acute myocardial ischemia is antifibrillatory, has generated the hypothesis that scopolamine might be protective after MI. We tested low dose scopolamine in a clinically relevant experimental preparation for sudden death in which other vagomimetic interventions are effective and found that this intervention does indeed increase cardiac vagal markers but has minimal antifibrillatory effects. This is in contrast to exercise training that in the same experimental model had a marked effect on both BRS and HRV and at the same time provided strong protection from ischemic ventricular fibrillation. Thus, based on the current knowledge it seems appropriate to call for caution before attributing excessive importance to changes in "markers" of vagal activity in the absence of clearcut evidence for a causal relation with an antifibrillatory effect

Autonomic modulation during acute myocardial ischemia by low-dose pirenzepine in conscious dogs with a healed myocardial infarction: a comparison with beta-adrenergic blockade.

Experimental and clinical evidence documents the ben- eficial effects of blocking sympathetic activity and modulating heart rate to reduce risk for lethal events in ischemic heart disease. Beside -adrenergic receptor blockade, vagal activation is a meaningful ap- proach but not yet easily attainable. Promising results were shown with low-dose atropine and scopolamine, but no follow-up was done because of significant adverse side effects. Pirenzepine is an atropine analogue approved to treat peptic ulcer disease in Europe that is de- void of central actions, which are mostly responsible for anti- muscarinic agents side effects. The vagomimetic action of IV low- dose pirenzepine was studied at rest under control conditions, at rest during acute coronary artery occlusion, and during exercise in con- scious dogs with a healed anterior myocardial infarction (MI). The effects of pirenzepine were then compared, by internal control analy- sis, with those of atenolol (1 mg/kg). Increasing doses of pirenzepine (from 0.01 to 1 mg/kg) were tested in 11 dogs at rest by measuring time and frequency domain heart rate variability (HRV). The most effective dose (0.1 mg/kg) was used in the study. At the most effective dose, pirenzepine increased all measures of time domain HRV by 40–50%. However, the vagomimetic action of pirenzepine was lost during exercise and brief ischemia and no anti-arrhythmic action was observed. Conversely, pirenzepine effectively modulated the heart rate increase during acute ischemia at rest with an effect comparable to that of atenolol. The vagomimetic action of pirenzepine in the acutely ischemic heart supports the possibility that this intervention may be helpful for chronic autonomic modulation in post-MI patients

AIDS and tuberculosis control programmes: an integrated approach at educational level.

Abstract In developing countries with a high prevalence of individuals co-infected by human immunodeficiency virus (HIV) and tuberculosis (TB), urgent public health measures should be implemented to prevent the spread of both diseases. This study was performed by a combined acquired immune deficiency syndrome (AIDS)-TB health team with the following aims: 1) to assess knowledge, attitudes and practice towards AIDS; 2) to identify target groups for health education (HE); 3) to evaluate HE impact; 4) to circulate correct information on AIDS and TB through target groups; and 5) to evaluate integration of AIDS and control TB activities. Secondary school students of Arua District, Uganda, participated in a standardized HE session (covering the key-points of AIDS and TB control) preceded by a pretest (multiple choice) questionnaire and followed 3 months later by the same questionnaire (post-test). The impact of HE on AIDS control was evaluated by comparing answers to pre- and post-test questionnaires and its influence on the TB programme by evaluating case-finding performances in the period preceding and following the survey. We analysed 1,478 questionnaires. The results of our study gave information on knowledge about AIDS, identified females and students < 16 yrs of age as good targets for HE, revealed that the impact of HE was significantly associated with improved knowledge, contributed to improved TB case-finding and offered suggestions for the integration of programmes. The survey represented an opportunity to create a stable AIDS/TB health team at district level

The ALPHA study (T-wave alternans in patients with heart failure): rationale, design and endpoints.

Background. Sudden death and pump failure are the main causes of death in patients with heart failure. Patients with ischemic and non-ischemic cardiomyopathy are at similar risk of arrhythmic mortality; however, standard non-invasive and invasive tests are not routinely available for non-ischemic patients. T-wave alternans (TWA) has been proposed as a potential marker of susceptibility to ventricular tachycardia-fibrillation in several groups of patients. Methods. The ALPHA study was designed to evaluate the independent predictive value of the measurement of microvolt TWA on the combined occurrence, after 18 months of follow-up, of cardiac death and life-threatening arrhythmias in a population of patients with non-ischemic dilated cardiomyopathy and NYHA class II and III. This is a multicenter prospective observational study. A total of 370 patients, with measurable TWA, will be enrolled during routine follow-up for heart failure treatment; a logbook will be used to collect basic information on the whole screened population. Patients will be enrolled during a 2-year period and will be followed up for 18 months. The primary endpoint of the study will be the combined incidence of cardiac death and life-threatening ventricular arrhythmias. The study will complete recruitment by mid 2004 and report in 2006