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Biomedical subjects

C Maynard

Publications and source records attributed to C Maynard.

At least 91 records · Page 5Linked to original sources
PubMed1995

Appearance of abnormal Q waves early in the course of acute myocardial infarction: implications for efficacy of thrombolytic therapy.

OBJECTIVES: The purpose of this study was to determine the time course of the appearance of abnormal Q waves on the electrocardiogram (ECG) over the first 6 h of symptoms of myocardial infarction and to determine what implications, if any, such Q waves have for the efficacy of thrombolytic therapy. BACKGROUND: Severe myocardial ischemia can produce early QRS changes in the absence of infarction. Abnormal Q waves on the baseline ECG may not be an accurate marker of irreversibly injured myocardium. METHODS: Data from 695 patients who had no past history of myocardial infarction and whose admission ECG allowed prediction of myocardial infarct size in the absence of thrombolytic therapy (Aldrich score) were pooled from four prospective trials of thrombolytic therapy. The presence and number of abnormal Q waves on each patient's initial ECG were recorded. Four hundred thirty-six patients had left ventricular infarct size measured using quantitative thallium-201 tomography a mean (+/- SD) of 52 +/- 43 days after admission. RESULTS: Of patients admitted within 1 h of symptoms, 53% had abnormal Q waves on the initial ECG. Both predicted and final infarct size were larger in patients with abnormal Q waves on the initial ECG independent of the duration of symptoms before therapy (p < 0.001). Despite this finding, the presence of abnormal Q waves on the admission ECG did not eliminate the effect of thrombolytic therapy on reducing final infarct size (p < 0.0001). CONCLUSIONS: Abnormal Q waves are a common finding early in the course of acute myocardial infarction. However, there is no evidence that abnormal Q waves are associated with less benefit in terms of reduction of infarct size after thrombolytic therapy.

Electrocardiography↗
PubMed1995

Resource utilization in treatment of acute myocardial infarction: staff-model health maintenance organization versus fee-for-service hospitals. The MITI Investigators. Myocardial Infarction Triage and Intervention.

OBJECTIVES: This study sought to compare the use of invasive procedures and length of stay for patients admitted with acute myocardial infarction to health maintenance organization (HMO) and fee-for-service hospitals. BACKGROUND: The HMOs have reduced costs compared with fee-for-service systems by reducing discretionary admissions and decreasing hospital length of stay. It has not been established whether staff-model HMO hospitals also reduce the rate of procedure utilization. METHODS: Using data from a retrospective cohort, we performed univariate and multivariate comparisons of the use of cardiac procedures, length of stay and hospital mortality in 998 patients admitted to two staff-model HMO hospitals and 7,036 patients admitted to 13 fee-for-service hospitals between January 1988 and December 1992. RESULTS: The odds of undergoing coronary angiography were 1.5 times as great for patients admitted to fee-for-service hospitals than for those admitted to HMO hospitals (odds ratio 1.5, 95% confidence interval [CI] 1.3 to 1.9). Similarly, the odds of undergoing coronary revascularization were two times greater in fee-for-service hospitals (odds ratio 2.0, 95% CI 1.6 to 2.5). However, higher utilization was strongly associated with the greater availability of on-site cardiac catheterization facilities in fee-for-service hospitals. The length of hospital stay, by contrast, was approximately 1 day shorter in the fee-for-service cohort (7.3 vs. 8.0 days, p < 0.05). CONCLUSIONS: Physicians in staff-model HMO hospitals use fewer invasive procedures and longer lengths of stay to treat patients with acute myocardial infarction than physicians in fee-for-service hospitals. This finding, however, appears to be associated with the lack of on-site catheterization facilities at HMO hospitals.

Aged↗
PubMed1995

T wave amplitudes in normal populations. Variation with ECG lead, sex, and age.

Consideration of increased T wave amplitude (tall T waves), either alone or in association with other electrocardiographic (ECG) parameters, may be beneficial for the early detection of acute transmural ischemia, and quantification of the increase might be used in quantifying the ischemic area. The primary purpose of this study was to quantify normal T wave amplitude limits according to ECG lead, sex, and age. One thousand nine hundred thirty-five subjects in two normal populations were analyzed, and the 98th percentile of the positive T wave amplitude for each ECG lead (including -aVR) was considered the upper limit of normal. Normal T wave amplitude was two times greater in the precordial than in the limb leads, and it was approximately 25% greater in men than in women in all leads. There was approximately a 10% decrease in normal T wave amplitude between 18-39- and 40-59-year-old patients and a 15% decrease between 40-59- and 60-79-year-old patients. The upper limit of normal T wave amplitudes identified in this study confirm those developed by Lepeschkin for use as means for each lead when age and sex are not considered. These limits might be incorporated into both normograms and automated ECG analysis systems to determine the presence or absence of tall T waves in patients presenting with symptoms of acute transmural ischemia.

Adolescent↗
PubMed1995

Streamlining the triage system for acute myocardial infarction.

The full benefits of thrombolytic therapy can be realized if and only if treatment is delivered as quickly as possible. Streamlining the triage system will not only increase the numbers of patients treated with thrombolytic therapy, it will ultimately reduce mortality and morbidity rates from acute myocardial infarction by limiting loss of heart muscle. Reducing the time to treatment, however, is a daunting task given that both patient and hospital delays contribute to the underutilization or inefficient use of thrombolytic therapy. In particular, patient delays can be difficult to attenuate, given that human behavior is complex and that designing interventions to change behavior is not only challenging but expensive. Results from the MITI registry show that the emergency medical system is the linchpin of an efficient triage system in that it is associated with reduced patient delays as well as reduced treatment delays. Clearly, patients with chest pain need to be aware of the need to take prompt action by calling 911. On the other hand, decisions to use these systems to acquire electrocardiograms or deliver thrombolytic treatment will be faced by increasing numbers of administrators and policy makers in the years to come. Without adequate community support to maintain and improve these systems, the full benefits of thrombolytic therapy cannot be attained.

Aged↗
PubMed1995

Outcomes in African-American women with suspected acute myocardial infarction: the Myocardial Infarction Triage and Intervention Project.

Increasing attention has been given to the investigation of cardiovascular disease in women, although African-American women have received little attention. This study compares characteristics and outcomes in women admitted to coronary care units for suspected acute myocardial infarction (MI). Between January 1988 and December 1991, a total of 554 (5%) African-American and 9738 (95%) white women with suspected acute MI were admitted to coronary care units in metropolitan Seattle, Washington. Relevant demographic socioeconomic, clinical, and outcome data were abstracted from the medical record and entered in the Myocardial Infarction Triage and Intervention registry. African-American women were younger, more often single and unemployed, and were less likely to have health insurance than their white counterparts. In addition, a higher proportion of African-American women reported a history of hypertension and diabetes mellitus. After adjustment for age, African-American women were equally as likely to develop acute MI and were more likely to die in the hospital. In addition, a higher proportion of African-American women were readmitted to coronary care units for suspected MI. Compared with their white counterparts, African-American women with suspected acute MI were considerably worse off from both socioeconomic and clinical standpoints, and their relative disadvantage was apparent in poor outcomes.

Black or African American↗
PubMed1994

Characteristics of Myocardial Infarction Episodes in Two Distant Communities: From the REGICOR Registry in Girona, Spain and the MITI Registry in Greater Seattle, USA.

Background: The objective of the study is to compare patient characteristics and outcome after myocardial infarction (MI) between two geographically and socially different communities. Methods/Results: The study was designed as an ecological comparison between a 1-year hospital registry of consecutive MIs in Seattle (1,400,000 inhabitants and a predominantly urban and suburban distribution) and nine hospitals in Giroma (500,000 inhabitants in a predominantly rural distribution). Hospitalization rates for MI are higher in Seattle (standardized rates of 2.5/1000 for men and 0.8/1000 for women) than in Girona (1.5/1000 for men and 0.2/1000 for women). In both registries men under age 60 accounted for 45.5% of cases. Women accounted for 25% of all MI episodes in Seattle and for only 16% in Giromi. Treatment with thrombolytic and beta-blocking drugs was twice as common in Seattle hospitals as in Girona. Hospital mortality in tertiary care hospitals was similar in both registries, but mortality in local hospitals (having no coronary care unit) in Giroma was significantly higher than other hospital mortality rates for MI. Conclusions: The higher in-hospital mortality rate may in large part be explained by the absence of a coronary care unit. However, the dispersion of Girona's population and the lack of specific programs to provide emergent specialized care to possible MI patients may also contribute to the higher in-hospital mortality rate in Girona.

Journal Article↗
PubMed1994

The prognostic value of facial electroneurography in Bell's palsy.

Twenty six patients with Bell's palsy were studied at presentation using electroneurography. Ninety-four per cent of those who recovered completely could have been predicted by ENoG within 10 days of onset. Of the 18 patients who recovered completely, 13 had a total palsy at presentation.

Action Potentials↗
PubMed1994

Completion rates of clients discharged from drug and alcohol treatment programs in Washington State.

OBJECTIVES: The primary goal of this study was to analyze completion rates of clients in drug and alcohol abuse treatment programs in Washington State and to assess the factors associated with treatment completion. A secondary goal was to examine the utility of a state information system as a source of evaluative data. METHODS: Analyses were conducted of 5827 client records contained in the Washington State Substance Abuse Monitoring System, representing a census of public clients discharged during the last quarter of 1990 from all state-funded alcohol and drug treatment programs in four treatment modalities. Logistic regression was performed to determine the independent predictors of treatment completion. RESULTS: Completion rates were highest for intensive inpatient alcohol treatment (75%) and lowest for intensive outpatient drug programs (18%). Factors associated with treatment completion included screening at a referral assessment center, education, age, ethnicity, and existence of a secondary drug problem. CONCLUSIONS: The fit between clients and treatment programs may be an important factor explaining why some clients complete treatment and others drop out. State client information systems are an important source of data for analyzing treatment completion and other outcomes.

Adolescent↗
PubMed1994

The Edinburgh facial palsy clinic: a review of three years' activity.

Patients with facial palsy can present to almost all medical practitioners. From birth to old age the aetiologies of disease affecting the nerve range from congenital to the more common inflammatory, infective, traumatic and neoplastic. This paper reviews the Edinburgh Facial Palsy Clinic, its structure and function over a three year period. The methods of clinical investigation, special investigation and management strategies are discussed. The diversity of pathology seen over a three year period is presented, confirming the need for a team approach to the management of patients with facial palsy.

Facial Paralysis↗
PubMed1993

Rehospitalization in surviving patients of out-of-hospital ventricular fibrillation (the CASCADE Study). Cardiac Arrest in Seattle: Conventional Amiodarone Drug Evaluation.

Surviving patients of out-of-hospital ventricular fibrillation (VF) often need rehospitalization after initial hospital discharge, but little is known regarding the frequency of or reasons for rehospitalization. Rehospitalization was examined in 224 patients enrolled in the Cardiac Arrest in Seattle: Conventional Amiodarone Drug Evaluation (CASCADE) study, a randomized clinical trial comparing amiodarone with other antiarrhythmic drug therapy in survivors of out-of-hospital VF. The annual rate of rehospitalization was 79/100 patients/year; 168 of 224 patients (75%) were hospitalized at least once before censoring or cardiac mortality. Baseline left ventricular ejection fraction was significantly lower in patients who were rehospitalized. Rehospitalization rates were lower in patients randomized to amiodarone therapy and in those with the automatic implantable cardioverter-defibrillator, although neither difference was statistically significant. However, length of stay for the first rehospitalization was shorter for patients with automatic implantable cardioverter-defibrillators (p = 0.005). More than 50% of patients were rehospitalized in the first year after enrollment; 65% with ejection fractions < or = 0.3 were rehospitalized in the first year. Rehospitalization was a frequent occurrence for surviving patients of out-of-hospital VF, particularly in those with low ejection fractions.

Aged↗
PubMed1993

Hospital mortality in acute myocardial infarction in the era of reperfusion therapy (the Myocardial Infarction Triage and Intervention Project).

This study was conducted in 19 hospitals in the metropolitan Seattle area and included 6,270 unselected patients who had acute myocardial infarction (AMI) between January 1988 and April 1991. Hospital mortality was determined and related to patient demographic and clinical characteristics, the use of reperfusion therapies, and to complications after AMI. Thrombolytic therapy or direct coronary angioplasty < 6 hours from symptom onset was used to treat 1,185 (19%) and 524 (9%) patients, respectively. There were 629 (10%) hospital deaths; most occurred during the first 3 days of hospitalization. Factors affecting mortality after admission included: recurrent chest pain, recurrent AMI, development of heart failure, and the occurrence of stroke. After adjustment for age, treatment with thrombolytic therapy or direct angioplasty had no independent effect on reducing the overall mortality rate. Hospital mortality rates for AMI have improved considerably since 1970, although recurrent myocardial ischemic events continue to have an adverse effect on outcome. The current use of reperfusion treatments has had minimal causal impact on overall mortality rates, principally because less than one third of patients, who are relatively "low risk," are eligible and receive these treatments.

Adult↗
PubMed1993

The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. Myocardial Infarction Triage and Intervention Project Investigators.

BACKGROUND: During the past decade the use of coronary angiography after acute myocardial infarction has substantially increased. Among the possible contributing factors, the increasing availability of cardiac catheterization facilities was the focus of our investigation. METHODS: We investigated whether the availability of cardiac catheterization facilities at an admitting hospital was associated with the likelihood that a patient would undergo coronary angiography. After adjusting for age, sex, cardiac history, and cardiac complications during hospitalization, we evaluated this association in 5867 consecutive patients with acute myocardial infarction admitted to 19 Seattle-area hospitals. We also assessed the association between the presence of on-site cardiac catheterization facilities and in-hospital mortality. RESULTS: Patients admitted to hospitals with on-site cardiac catheterization facilities were far more likely to undergo coronary angiography (odds ratio, 3.21; 95 percent confidence interval, 2.81 to 3.67) than patients admitted to hospitals where transfer to another institution would be required to perform cardiac catheterization. Admission to a hospital with on-site facilities was more strongly associated with the use of coronary angiography than any characteristic of the patient. Although our study had limited power to detect differences in mortality, the availability of coronary angiography had no discernible association with in-hospital mortality rates (odds ratio for mortality among patients admitted to hospitals with on-site facilities vs. patients admitted to hospitals without such facilities, 0.88; 95 percent confidence interval, 0.71 to 1.09). CONCLUSIONS: In this community-wide study, the availability of on-site cardiac catheterization facilities was associated with a higher likelihood that a patient would undergo coronary angiography. However, admission to hospitals with these facilities did not appear to be associated with lower short-term mortality.

Aged↗
PubMed1993

A psychoeducational approach to depression in women.

Depression is conceptualized as a multidimensional process in women. Women who are depressed must deal with a myriad of problems. A group psychoeducational approach provides a comprehensive treatment strategy to assist women in developing the knowledge and skills necessary for managing the stresses associated with being a women in our society. The small group format also contributes the peer support necessary to learn new skills and improve self-esteem. Psychiatric nurses, with their background in client education and knowledge of groups, are in an ideal position to provide the holistic approach that may prevent episodes of clinical depression or reduce relapses. The proposed framework for intervention can provide women with the skills necessary to manage the life events and role demands that have long been implicated in the development and maintenance of their depressive symptoms.

Depression↗
PubMed1992

Long-term survival in 618 patients from the Western Washington Streptokinase in Myocardial Infarction trials.

OBJECTIVES: The aim of this study was to determine whether streptokinase treatment improves long-term survival in patients with acute myocardial infarction. BACKGROUND: Thrombolytic treatment for acute myocardial infarction reduces early mortality and improves the 1-year survival rate, but the long-term (3 to 8 years) survival benefits of treatment and the relation between survival and baseline clinical characteristics, infarct size and ventricular function have not been established. METHODS: We assessed survival status at a minimum of 3 and a mean of 4.9 +/- 2.3 years in 618 patients randomized between 1981 and 1986 to receive conventional treatment (n = 293) or thrombolysis with streptokinase (n = 325) in the Western Washington Intracoronary (n = 250) and Intravenous (n = 368) Streptokinase in Myocardial Infarction trials. The relation between long-term survival and thrombolytic treatment, admission baseline clinical characteristics and late radionuclide tomographic thallium-201 infarct size and ejection fraction was assessed in a subset of patients. RESULTS: Survival at 6 weeks was 94% in patients who received streptokinase versus 88% in the control group (p = 0.01). However, survival at 3 years was 84% in the streptokinase group and 82% in the control group and for the total period of follow-up, there was no significant survival benefit (p = 0.16). Analysis by infarct location showed a higher survival rate at 3 years for patients treated with anterior infarction (76% vs. 67% for the control group), but no overall survival benefit (p = 0.14). Survival at 3 years for patients with an inferior infarction was 89% in the streptokinase group and 91% in the control group (p = 0.62). By stepwise Cox regression analysis, admission clinical variables associated with decreased long-term survival were anterior infarction, advanced age, history of prior infarction and the presence of pulmonary edema or hypotension. Although streptokinase therapy was associated with improved survival, it was not an independent determinant of survival (p = 0.069). Ejection fraction and thallium-201 infarct size measured approximately 8 weeks after enrollment had a strong association with long-term survival. Univariate analysis in a subgroup of 289 patients with complete data selected infarct size, ejection fraction, age and history of prior infarction as predictors of survival. In the multivariate model, only ejection fraction (p < 0.0001), age (p = 0.008) and prior myocardial infarction (p = 0.02) remained strong predictors. CONCLUSIONS: In these early trials of thrombolytic therapy for acute myocardial infarction, streptokinase improved early survival, but there was little long-term survival benefit. This failure to show an improvement in the 3- to 8-year survival rate may also reflect the need to study a larger group of patients or to initiate treatment earlier after symptom onset.

Aged↗
PubMed1992

Gender differences in the treatment and outcome of acute myocardial infarction. Results from the Myocardial Infarction Triage and Intervention Registry.

BACKGROUND: The objective of this study was to compare treatment and outcome of acute myocardial infarction in women and men. METHODS: In this survey, patient hospital records were reviewed, and information about patient characteristics, treatments, and hospital events was entered in the Myocardial Infarction Triage and Intervention Registry. Between January 1988 and June 1990, a total of 4891 consecutive patients, including 1659 women, were hospitalized for acute myocardial infarction in 19 hospitals in the Seattle (Wash) metropolitan area. In-hospital thrombolytic therapy, coronary angiography, angioplasty, and bypass surgery were examined, as were in-hospital complications and death. RESULTS: Women were older and more often had histories previous hypertension and previous congestive heart failure. Thrombolytic therapy was used less often in women, although information about eligibility for treatment was not available to determine if this difference was due to treatment bias or differences in eligibility. Both coronary angiography and coronary angioplasty were used less frequently in women. However, of patients who had coronary angiography, equal proportions of women and men received angioplasty and/or coronary bypass surgery. Hospital mortality was 16% for women and 11% for men, although this difference was diminished by age adjustment. Mortality was higher in women undergoing bypass surgery, but this difference, too, was less apparent after age adjustment. CONCLUSIONS: Despite high levels of risk factors and mortality, coronary angiography and angioplasty were used less often in women, although among those who underwent coronary angiography, there were no gender differences in the use of angioplasty or bypass surgery. Clearly, more needs to be known about decision making for coronary angiography, as this process seems to differ for women and men with acute myocardial infarction.

Aged↗