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Biomedical subjects

C S Simpson

Publications and source records attributed to C S Simpson.

At least 19 recordsLinked to original sources
PubMed2006

Treating the right patient at the right time: access to heart failure care.

Heart failure affects over 500,000 Canadians, and 50,000 new patients are diagnosed each year. The mortality remains staggering, with a five-year age-adjusted rate of 45%. Disease management programs for heart failure patients have been associated with improved outcomes, the use of evidence-based therapies, improved quality of care, and reduced costs, mortality and hospitalizations. Currently, national benchmarks and targets for access to care for cardiovascular procedures or office consultations do not exist. The present paper summarizes the currently available data, particularly focusing on the risk of adverse events as a function of waiting time, as well as on the identification of gaps in existing data on heart failure. Using best evidence and expert consensus, the present article also focuses on timely access to care for acute and chronic heart failure, including timely access to heart failure disease management programs and physician care (heart failure specialists, cardiologists, internists and general practitioners).

Follow-Up Studies↗
PubMed2005

Canadian Cardiovascular Society commentary on implantable cardioverter defibrillators in Canada: waiting times and access to care issues.

The Canadian Cardiovascular Society is the national professional society for cardiovascular specialists and researchers in Canada. In the spring of 2004, the Canadian Cardiovascular Society Council formed an Access to Care Working Group in an effort to use the best science and information to establish reasonable triage categories and safe wait times for access to common cardiovascular services and procedures. The Working Group has elected to publish a series of commentaries to initiate a structured national discussion on this very important issue. Access to treatment with implantable cardioverter defibrillators is the subject of the present commentary. The prevalence pool of potentially eligible patients is discussed, along with access barriers, regional disparities and waiting times. A maximum recommended waiting time is proposed and the framework for a solution-oriented approach is presented.

Canada↗
PubMed2005

Treating the right patient at the right time: access to care in non-ST segment elevation acute coronary syndromes.

In 2004, the Canadian Cardiovascular Society formed an Access to Care Working Group with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary discusses the rationale for access benchmarks for urgent cardiac catheterization and revascularization, including hospital transfer in the setting of non-ST elevation acute coronary syndromes. The literature on standards of care, wait times, wait list management and clinical trials was reviewed. A survey of all cardiac catheterization directors in Canada was performed to develop an inventory of current practices in identifying and triaging patients. The Working Group recommended the following medically acceptable wait times for access to diagnostic catheterization and revascularization in patients presenting with acute coronary syndromes: for diagnostic catheterization and percutaneous coronary intervention, the target should be 24 h to 48 h for high-risk, three to five days for intermediate-risk and five to seven days for low-risk patients; for coronary artery bypass graft surgery, the target should be three to five days for high-risk, two to three weeks for intermediate-risk and six weeks for low-risk patients. All stakeholders must affirm the appropriateness of these standards and work continuously to achieve them. However, some questions remain around what are the best clinical risk markers to delineate the triage categories and the utility of clinical risk scores to assist clinicians in triaging patients for invasive therapies.

Angina, Unstable↗
PubMed2005

General commentary on access to cardiovascular care in Canada: universal access, but when? Treating the right patient at the right time.

In 2004, the Canadian Cardiovascular Society formed an Access to Care Working Group with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary is the first in the series and lays out issues regarding timely access to care that are common to all cardiovascular services and procedures. The commentary briefly describes the 'right' to timely access, wait lists as a health care system management tool, and the role of the physician as patient advocate and gatekeeper. It also provides advice to funders, administrators and providers who must monitor and manage wait times to improve access to cardiovascular care in Canada and restore the confidence of Canadians in their publicly funded health care system.

Canada↗
PubMed2001

Clinical assessment of clonidine in the treatment of new-onset rapid atrial fibrillation: a prospective, randomized clinical trial.

PURPOSE: The role of digoxin and verapamil in the control of ventricular response in rapid atrial fibrillation is well established. This study investigates how clonidine compares with these standard therapies in rate control for new-onset rapid atrial fibrillation. We set out to test the hypothesis that clonidine effectively reduces heart rate in patients with new-onset rapid atrial fibrillation. SUBJECTS AND METHODS: Forty patients were seen in the emergency department with new-onset (< or =24 hours' duration), stable, rapid atrial fibrillation. Eligible patients were randomized to receive either clonidine, digoxin, or verapamil. Changes in heart rate and blood pressure over 6 hours, as well as frequency of conversion to sinus rhythm were recorded and analyzed. RESULTS: The mean reduction in heart rate over 6 hours was 44.4 beats/min (95% confidence interval [CI] 28.4-60.4 beats/min) in the clonidine group, 52.1 beats/min (95% CI 40.8-63.4 beats/min) in the digoxin group, and 41.8 beats/min (95% CI 22.5-61.0 beats/min) in the verapamil group. Analysis of variance of the heart rate changes in the 3 groups after 6 hours was not significant (P =.55). At 6 hours, 7 of 12 clonidine patients, 8 of 15 digoxin patients, and 7 of 13 verapamil patients remained in atrial fibrillation (P =.962 on chi(2)). CONCLUSION: Clonidine controls ventricular rate in new-onset atrial fibrillation with an efficacy comparable to that of standard agents.

Acute Disease↗
PubMed2001

Safety and feasibility of a novel rate-smoothed ventricular pacing algorithm for atrial fibrillation.

OBJECTIVES: This study was conducted to establish the safety and performance of a new rate-smoothing pacing algorithm for patients with atrial fibrillation (AF). BACKGROUND: Irregularity of the ventricular response is a hallmark of AF. This irregularity may contribute to symptoms and hemodynamic compromise in patients with AF. Interventions designed to reduce irregularity have not previously been evaluated in a long-term, clinical setting. METHODS: We designed a prospective, double-blind study with randomized crossover. Patients with either paroxysmal or chronic AF whose conditions were medically refractory and who were referred for an atrioventricular node ablation procedure all underwent pacemaker implantation. Subjects were then randomly assigned to either DDD mode with the rate-smoothing algorithm (RSA) on, or to OOO mode. After 2 months they were crossed over to the other arm. RESULTS: Fourteen patients (9 with paroxysmal AF and 5 with chronic AF) were enrolled. There were no significant differences between the group randomly assigned to RSA first versus the group assigned to OOO first. The mean left ventricular ejection fraction with the RSA was not significantly different than it was in OOO mode (45.1 +/- 18.6 vs 51.9 +/- 12.3; P =.11), although some individuals with uncontrolled ventricular rates did have a large decrease in ejection fraction with rate smoothing. One developed overt heart failure. One quality-of-life instrument detected a significant improvement in the "physical limitations" domain with the rate-smoothing mode. Eleven of 14 patients preferred the RSA ON arm, and 6 of those 11 elected to defer the ablation procedure. CONCLUSIONS: Long-term rate-smoothed pacing is feasible. Because of concerns about pacing-induced heart failure in some patients with rapid ventricular rates, rate-smoothed pacing should be reserved for those who remain symptomatic despite adequate control of the ventricular rate. The RSA may help to reduce symptoms in patients with medically refractory AF; more study is required to define its efficacy in reducing symptoms and morbidity in this population.

Aged↗
PubMed2000

Regulation of neuronal cell adhesion molecule expression by NF-kappa B.

The neuronal cell adhesion molecule (NCAM) is a key mediator of structural plasticity in the central nervous system, but the mechanisms that control its expression are unknown. Equally, although the transcription factor NF-kappaB is present in the brain, few NF-kappaB-regulated genes relevant for central nervous system function have been identified. We have previously demonstrated that NF-kappaB is activated in neuronal cultures treated with kainic acid or nitric oxide. We show here that kainic acid or nitric oxide also increase the levels of NCAM mRNA and protein in neurons and that this induction of NCAM expression is sensitive to dexamethasone and to antisense, but not missense, oligonucleotides designed to suppress NF-kappaB synthesis. Nitric oxide also stimulates protein binding to an NF-kappaB site in the promoter of the NCAM gene. This indicates that NF-kappaB, which has recently been implicated in synaptic plasticity and also in the etiology of neurodegenerative disease, plays a crucial role in the activity-dependent regulation of NCAM gene expression. In addition, since both NCAM and NF-kappaB are present in the post-synaptic density, this represents a route allowing direct communication between the synapse and the nucleus.

Animals↗
PubMed2000

Activation of dopamine D(3) receptors induces c-fos expression in primary cultures of rat striatal neurons.

A modulation of the expression of immediate-early genes (IEGs) such as c-fos is likely involved in the long-term influence of dopaminergic ligands on the activity of basal ganglia neurons. The roles of individual dopamine receptor types in this regard remain unclear, and the present study employed primary cultures of rat striatal neurons to examine the potential modulation of c-fos expression by D(3) receptors. Neurons were treated with the preferential D(3) receptor agonists, (+/-)-7-OH-DPAT and PD 128,907, which showed, respectively, 16-fold and 56-fold selectivity for recombinant rat D(3) vs. D(2) receptors (K(i) values, rD(2)/rD(3) = 59.5/3.7 nM and 251/4.5 nM, respectively). At concentrations of 3 and 30 nM, respectively, (+/-)-7-OH-DPAT and PD 128,907 significantly increased the expression of c-fos mRNA. The action of (+/-)-7-OH-DPAT was expressed stereospecifically; its (+)-isomer (K(i) values, D(3)/D(2) = 1.6/56.7 elicited a 26% +/- 7.6% increase in c-fos expression whereas its (-)-isomer (K(i) values, D(3)/D(2) = 59/1,060 nM) was ineffective. Further, stimulation of c-fos mRNA expression by PD 128,907 (20 nM) was markedly and significantly (P < 0.05) attenuated (-91.8% +/- 5.3%) by 30 nM of the selective D(3) receptor antagonist, (+)-S 14297 (K(i) values, D(3)/D(2) = 11/401 nM). In contrast, the action of PD 128,907 was significantly less affected (-24.5% +/- 7.8%) by 30 nM of its less active distomer, (-)-S 17777 (K(i) values, D(3)/D(2) = 294/3,191 nM). An examination of the concentration-response relationship revealed that (+/-)-7-OH-DPAT and PD 128,907 both produced bell-shaped dose-response curves for c-fos induction. The sequential activation of D(2) receptors-which inhibit striatal c-fos expression (Simpson and Morris [1995] Neuroscience 68:97-106)-by higher concentrations of (+/-)-7-OH-DPAT and PD 128,907 is presumably involved in the inflexion at higher doses. In conclusion, the present data demonstrate that activation of D(3) receptors results in a selective induction of c-fos mRNA expression in cultured striatal neurons. These data show that neuronal D(3) receptors control the expression of IEGs and suggest that D(3) receptors may mediate long-term adapative changes in the activity of neurons in the basal ganglia.

2-Naphthylamine↗
PubMed2000

Recurrent seizure diagnosed by the insertable loop recorder.

INTRODUCTION: The Insertable Loop Recorder (ILR) has emerged as an important new tool in the diagnostic armamentarium for patients with syncope. METHODS AND RESULTS: A case report illustrates how the ILR unexpectedly led to the diagnosis of seizure as the explanation for a man's recurrent, but infrequent episodes of sudden loss of consciousness. CONCLUSIONS: This case raises the possibility that the development of implantable recording devices which monitor physiologic parameters other than cardiac rhythm (eg. brain, nerve or muscle activity) may provide the long-term monitoring capability needed to improve the diagnostic yield for conditions, such as seizures, which occur infrequently.

Aged↗
PubMed2000

Unipolar electrogram characteristics predictive of successful radiofrequency catheter ablation of accessory pathways.

INTRODUCTION: The purpose of this study was to determine the characteristics of the unipolar electrogram that are most helpful in predicting successful radiofrequency ablation of accessory pathways. METHODS AND RESULTS: The unipolar electrogram was analyzed at 185 ablation sites in 53 patients; 94 attempts were directed at the site of earliest atrial activation ("atrial group") and 91 at the site of earliest ventricular activation ("ventricular group"). The electrogram was analyzed for several features, including pattern ("QS" or "initial R"). Unipolar pattern: Overall, a "QS" pattern was seen at 55% of unsuccessful, 75% of temporarily successful, and 90% of permanently successful sites. For the atrial group, the respective frequencies were 53%, 77%, and 92%, and for the ventricular group, 57%, 73%, and 86%. The difference in pattern distribution between unsuccessful and permanently successful sites was significant for all groups: overall, P < 0.0001; atrial group, P = 0.0005; ventricular group, P = 0.02. Absence of a "QS" pattern (i.e., "initial R") predicted a 92% chance of unsuccessful ablation. Additional features: Activation times were significantly shorter at permanently successful than at unsuccessful (P < 0.0001) or temporarily successful sites (P = 0.0002). No significant differences were found in atrial or ventricular amplitudes or in A/V ratios. Intrinsic deflection slew was lower at temporarily successful sites (P = 0.03 vs all other sites). CONCLUSION: Ablation at sites revealing an "initial R" pattern (i.e., absent "QS") is very unlikely to be successful. Activation time is shorter at successful sites. These features are equally applicable when mapping the atrial potential as when mapping the ventricular potential.

Adolescent↗
PubMed2000

Impact of a mandatory physician reporting system for cardiac patients potentially unfit to drive.

CONTEXT: Sudden cardiac incapacitation of a driver may lead to the death or serious injury of passengers or bystanders. This has raised public safety concerns and has led to the creation of legislation to protect the public. Some jurisdictions in Canada and the United States have introduced mandatory physician reporting of patients who may be unfit to drive for medical reasons. The impact on motor vehicle accident (MVA)-related morbidity and mortality of mandatory physician reporting for at-risk cardiac patients is unknown. OBJECTIVE: To determine the impact of mandatory physician reporting legislation (for cardiac patients) in Ontario (population 10.3 million) on MVA-related morbidity and mortality. DATA SOURCES: Reporting data were obtained from the Ontario Ministry of Transportation. Incidence and prevalence data were taken from Ontario Ministry of Health sources and from the literature (MEDLINE). Data for modelling were taken from the literature (MEDLINE) and from the Canadian Cardiovascular Society's Consensus Conference document on cardiac illness and fitness to drive. DATA EXTRACTION: Licence suspension data (correlated with medical illness) were taken directly from government documents. These were then applied to a 'risk of harm' formula used to calculate the risk posed to bystanders and passengers by the suspended patients if they had continued to drive. Canadian licence suspension guidelines were then reviewed in conjunction with cardiac disease incidence and prevalence data to arrive at the number of patients who should have been suspended. Physician compliance with the legislation was then calculated, along with the potential impact on MVA-related morbidity and mortality in the scenario of 100% physician compliance. STUDY SELECTION: All Ontario drivers who had licence suspensions in 1996 for reasons of cardiac disease were included in the analysis. DATA SYNTHESIS: Nine hundred and ninety-four licences were suspended for cardiac reasons in 1996, compared with an estimated 72,407 that should have been suspended if Canadian guidelines had been followed (1.4%). Less than one death or serious injury was avoided as a result of the legislation (from the 'risk of harm' formula). If all drivers with cardiac illness had been suspended from driving, up to 29.2 such events could potentially have been avoided. However, only 13 of 929 (1.4%) road fatalities in Ontario in 1996 were attributed to a driver with a medical illness. CONCLUSIONS: Mandatory physician reporting of patients with cardiac illness has a negligible impact on MVA-related morbidity and mortality.

Accidents, Traffic↗
PubMed2000

Dysautonomia among patients with fibromyalgia: a noninvasive assessment.

OBJECTIVE: Fibromyalgia (FM) is a prevalent and poorly understood disorder associated with a significant amount of disability. Some clinical characteristics are common to both FM and vasovagal syncope (which is caused by dysautonomia). We assessed the response of patients with FM to a head up tilt table test (HUT). We also examined sympathovagal balance by assessing heart rate variability (HRV). METHODS: We studied 17 women with FM and 14 female control subjects. After baseline functional assessments, they underwent a 3 stage HUT (with isoproterenol). HRV was assessed over a 24 h period and also before and during HUT. Quality of life was assessed using the Medical Outcomes Study SF-36 Short Form Health Survey. RESULTS: HUT was positive in 64.7% of the patients with FM compared with 21.3% of controls (p = 0.016). FM patients had less HRV, as measured by either time domain or frequency domain analysis. The FM group had a different response to HUT than controls. Quality of life was significantly lower in patients with FM compared to controls (p < or = 0.001 in all domains). CONCLUSION: Patients with FM have abnormal responses to 2 tests of autonomic nervous system function. Further research is needed to determine if dysautonomia plays a role in the pathogenesis of FM or is a result of FM.

Adult↗
PubMed1999

Activation of nuclear factor kappaB by nitric oxide in rat striatal neurones: differential inhibition of the p50 and p65 subunits by dexamethasone.

Nitric oxide (NO), an intercellular messenger in the brain, has been implicated in both neuronal plasticity and neurotoxicity. It has been suggested that NO can activate the DNA binding activity of nuclear factor kappaB (NF-kappaB) family proteins in some cell types while having an inhibitory effect in others. In this study we have investigated the effect of acute NO in primary neuronal cultures of rat striatum using immunohistochemistry. Exposure of neurones to the NO-mimetic S-nitroso-n-acetylpenicillamine (SNAP; 200 microM) and to bacterial lipopolysaccharide (LPS; 10 microg/ml) for 30 min increased nuclear protein expression of the p50 subunit of NF-kappaB. SNAP also enhanced nuclear protein expression of the p65 subunit of NF-kappaB. Simultaneously, the cytoplasmic expression of phosphorylated inhibitory protein IkappaB alpha was dramatically increased by SNAP (200 microM), LPS (10 microg/ml), and kainate (50 microM) treatment. In the adult rat, stimulation with NOR-3 (2 mg/kg), a NO donor, increased NF-kappaB DNA binding activity in the striatum after 45 min. Because glucocorticoids inhibit NF-kappaB activity, primary cultures were pretreated with dexamethasone (50 microM) before SNAP, LPS, and kainate treatment, and the effect on the protein expression level of the individual subunits p50 and p65 present in the classical form of the transcription factor NF-kappaB was assessed. Dexamethasone pretreatment resulted in a marked reduction of p65 protein in striatal neurones after SNAP, LPS, and kainate, whereas p50 expression was reduced by dexamethasone pretreatment only after an LPS stimulus. This study indicates that NO-releasing compounds can directly induce nuclear NF-kappaB subunit expression in rat striatum and that glucocorticoids selectively inhibit p65 subunit expression following exposure to NO.

Animals↗
PubMed1999

A cost effective approach to the investigation of syncope: relative merit of different diagnostic strategies.

OBJECTIVE: To compare the cost effectiveness of a conventional diagnostic work-up with that of several different diagnostic cascades for the investigation of undifferentiated syncope. DESIGN: A MEDLINE search established a weighted estimate of diagnostic yield for several diagnostic investigations. 'High-end' and 'low-end' cost estimates were calculated for these investigations based on figures from four representative Canadian tertiary care centres in four different provinces. Several diagnostic models were applied to a hypothetical cohort of 100 patients with undifferentiated syncope. RESULTS: The conventional diagnostic cascade resulted in a diagnosis in 85% of patients, at a cost per diagnosis of $467 to $959. The optimal model increased the diagnostic yield to 98.9%, at a cost of $460 to $1043 per diagnosed patient. CONCLUSION: A combination of new technology and selective use of investigations has the potential to raise diagnostic yield without appreciably increasing cost per diagnosis.

Algorithms↗