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Results for “protocol optimization”

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PubMed1995

Prospective randomized study on the cryopreservation of human embryos with dimethylsulfoxide or 1,2-propanediol protocols.

OBJECTIVE: To investigate the optimal protocol for cryopreservation of human embryos obtained from IVF. DESIGN: Prospective randomized study. SETTING: Consenting patients in an academic research environment. PATIENTS: Couples undergoing IVF. INTERVENTIONS: A cohort of 2,220 supernumerary multicellular embryos were obtained from 488 patients who were randomized over slow freezing protocols with dimethylsulfoxide (DMSO, 819 embryos), 1,2-propanediol (699 embryos) or a mixture of DMSO and 1,2-propanediol (702 embryos). A total of 725 embryos have been thawed (DMSO, 232 embryos; 1,2-propanediol, 250 embryos and DMSO and 1,2-propanediol, 243 embryos) for transfer in natural ovarian cycles. MAIN OUTCOME MEASURES: Embryo survival rate, embryo implantation rate, clinical pregnancy rate (PR), delivery rate, live-birth rate. RESULTS: The embryo survival rate was significantly higher with the DMSO protocol (52.6%) than with the 1,2-propanediol (32.0%) or the DMSO and 1,2-propanediol protocols (34.9%). The clinical PR per thawing cycle was significantly higher in the DMSO protocol (17.2%) than in the 1,2-propanediol protocol (3.9%). The clinical implantation rate per embryo thawed was significantly different between a DMSO-frozen embryo (4.7%) and a 1,2-propanediol-frozen embryo (1.2%). A DMSO and 1,2-propanediol-frozen embryo had a 3.7% chance of of implantation. The delivery rate per thawing cycle was significantly higher in the DMSO protocol (12.5%) than in the 1,2-propanediol protocol (2.6%). The live-birth rates per embryo thawed were 3.5%, 0.8%, and 2.9% in the DMSO, 1,2-propanediol, and DMSO and 1,2-propanediol groups, respectively. CONCLUSION: Supernumerary multicellular embryos as presented in daily clinical IVF practice have the highest chance of survival and of implantation after cryopreservation when DMSO has been used.

Birth Rate↗

PubMed1991

Asthma in the emergency department: impact of a protocol on optimizing therapy.

The objective of this study was to evaluate the impact of a simple educational intervention on the prescribing habits of internal medicine residents in the treatment of acute asthma in a busy emergency department (ED). Prescribing habits for 16 residents were documented for 4 months. The first 2 months served as a control period during which eight residents managed asthma patients without the benefit of any specific educational intervention beyond standard department protocols. A total of 129 patients treated by the residents during this initial phase were assessed. During the second 2-month period, a 10-minute verbal presentation and explicit written treatment protocol were provided to another eight residents, and their treatment of 83 patients was covertly evaluated. Increased prescribing of desired therapy was significantly improved in every area except that of prescribing an inhaled steroid metered dose inhaler for use as a discharge medication. The 10-minute verbal presentation given in conjunction with a three-page handout was found to be highly effective for eliciting improvement in treatment practices during short clinical rotations. The duration of this effect beyond each rotation is unknown. This educational intervention should be presented by the ED medical director, clinical pharmacist, or other appropriate clinician in virtually any ED as quality of patient care can be dramatically improved.

Acute Disease↗

PubMedDate not supplied

[Recommendation for studies of optimizing therapy protocols].

Guidelines to establish the principles for the standard of Good Clinical Practice (GCP) for trials on medicinal products in human beings were coming into operation in the European Community in 1991. These recommendations are more extensive than those of the German drug regulatory act (AMG). Included are outlines for the protection of the patient, the responsibilities of the investigator, for biometrics and the quality assurance. Although most of the studies in pediatric oncology optimizing treatment schedules do not belong to the studies as defined by the AMG, certain rules and regulations are strictly adhered to, e.g. the Declaration of Helsinki for the protection of human rights, medical justification of involved risks, adequate and freely obtained informed consent of the patient and the parents. Furthermore, the approval of Ethics Committees must be requested.

Child↗

PubMed1995

Paraformaldehyde fixation of neutrophils for immunolabeling of granule antigens in cryoultrasections.

Paraformaldehyde (PFA) fixation was optimized to facilitate the immobilization and labeling of multiple granule antigens, using short fixation regimens and cryoultramicrotomy of unembedded neutrophils (PMNs). In the optimal protocol, extraction of azurophil granule antigens (especially of the abundant elastase) was obviated by manipulating the polymeric state of PFA, and hence its rate of cross-linking, by altering its concentration and pH in a multistep process. Primary fixation conditions used (4% PFA, pH 8.0, 5 min) favor fixative penetration and rapid cross-linking. Stable cross-linking of the antigen was achieved in a secondary fixation step using conditions that favor larger, more cross-linking polymeric forms of PFA (8% PFA, pH 7.2, 15 min). Immobilization of granule antigens was enhanced by flotation of cut sections on fixative (8% PFA, pH 8.0) before labeling and by using post-labeling fixation with 1% glutaraldehyde. The optimized protocol facilitated immobilization and immunolabeling of elastase, myeloperoxidase, lactoferrin, and cathepsin D in highly hydrated, unembedded PMNs.

Antibodies↗

PubMed2026

Comparative evaluation of three high-molecular-weight DNA extraction kits for Oxford Nanopore sequencing of Clostridioides difficile and Clostridium perfringens.

UNLABELLED: Clostridioides difficile and Clostridium perfringens are Gram-positive, spore-forming anaerobic pathogens affecting humans and animals, for which genomic data have been mainly generated using short-read or hybrid sequencing approaches. In this study, we evaluated three commercial non-bead-beating DNA extraction kits designed for high-molecular-weight DNA recovery for Oxford Nanopore long-read whole-genome sequencing of two C. difficile and two C. perfringens strains, including one reference strain and one clinical or environmental isolate per species. Based on sequencing performance and kit ease of use, one kit was selected for additional sequencing of plasmid-carrying strains of both species. All three kits allowed correct identification of sequence types, toxin-encoding genes, and antimicrobial resistance determinants, confirming their suitability for clinical and epidemiological applications. However, the BT MasterPure Kit provided the highest DNA concentrations, longest fragment sizes, and superior read lengths and N50 values, particularly for C. difficile, achieving >100× coverage and enabling reliable circularization of chromosomes and plasmids, including a C. difficile metronidazole resistance plasmid and C. perfringens plasmids carrying toxin and antibiotic resistance genes. The other kits produced slightly lower DNA yields, resulting in shorter reads and reduced genome coverage for C. difficile, highlighting the challenge of extracting high-quality DNA from Gram-positive, spore-forming bacteria. Overall, this study provides practical guidance for selecting DNA extraction protocols optimized for Oxford Nanopore sequencing of C. difficile and C. perfringens, supporting high-quality genome assemblies and plasmid characterization and facilitating the routine genomic surveillance of clinically relevant spore-forming pathogens. IMPORTANCE: High-quality genomic data are essential for accurate characterization of Clostridioides difficile and Clostridium perfringens, two clinically and epidemiologically important Gram-positive, spore-forming pathogens. However, long-read sequencing performance can be strongly influenced by the choice of DNA extraction method, particularly for organisms with robust cell walls, where commonly used methods can lead to fragmented DNA. In this work, DNA of four strains was extracted using three commercial high-molecular-weight DNA extraction kits and sequenced using Oxford Nanopore Technologies. The best-performing kit was also evaluated using three additional strains known to harbor plasmids in order to assess its plasmid recovery efficiency. The results demonstrated successful plasmid recovery, circularization, and characterization. DNA extraction protocols optimized for Oxford Nanopore sequencing enable the rapid and cost-effective characterization of C. difficile and C. perfringens for genomic surveillance or outbreak investigations.

Clostridioides difficile↗

PubMed1991

Routine programmed electrical stimulation in survivors of acute myocardial infarction for prediction of spontaneous ventricular tachyarrhythmias during follow-up: results, optimal stimulation protocol and cost-effective screening.

Of 3,286 consecutive patients treated for acute myocardial infarction, electrophysiologic testing was performed in 1,209 survivors (37%) free of significant complications at the time of hospital discharge to determine their risk of spontaneous ventricular tachyarrhythmias during follow-up. Sustained monomorphic ventricular tachycardia was inducible by programmed electrical stimulation in 75 (6.2%). Antiarrhythmic therapy was not routinely prescribed regardless of the test results. During the 1st year of follow-up, 14 infarct survivors (19%) with inducible ventricular tachycardia experienced spontaneous ventricular tachycardia or fibrillation in the absence of new ischemia compared with 34 (2.9%) of those without inducible ventricular tachycardia (p less than 0.0005). During the extended follow-up period (median 28 months) of those with inducible ventricular tachycardia, 19 (25%) had a spontaneous electrical event; 37% of these first events were fatal. These results suggest that the most cost-effective strategy for predicting arrhythmia will be obtained by restricting electrophysiologic testing to infarct survivors whose left ventricular ejection fraction is less than 40% and using a stimulation protocol containing four extrastimuli. Electrophysiologic testing is the single best predictor of spontaneous ventricular tachyarrhythmias during follow-up in infarct survivors. The majority (94%) with a negative test benefit from the more reliable reassurance that all is well, whereas the 25% risk of electrical events in those with inducible ventricular tachycardia justifies a prospective trial of effective prophylactic antiarrhythmic interventions.

Anti-Arrhythmia Agents↗

PubMed1990

The suppressive effect of an antibody to the alpha beta cell receptor in rat adjuvant arthritis: studies on optimal treatment protocols.

An antibody (R73) to the alpha beta T cell receptor (TCR) was able to dramatically suppress adjuvant arthritis (AA) in rats. The efficacy of R73 treatment was investigated with regard to antibody dosage, injection route and timing of injections. R73 was equally effective in reducing joint swelling throughout a wide dose range (80 to 2000 microgram/dose) when given on day 15, 18, and 21 after arthritis induction. Both i.p. and i.v. injection were able to suppress the pre-existing joint swelling to the same extent. However, R73 was only effective when given before or at the peak of joint swelling which occurred between day 18 to 24. Synovial membrane hyperplasia, mononuclear cell infiltration as well as cartilage and bone destruction were markedly reduced after therapy. The effect of R73 was associated with depletion of alpha beta+ T cells from the circulation even at low antibody doses. Only few alpha beta+ T cells were found in the pannus tissue. Late treatment on day 27, 30 and 33 after arthritis induction did not influence clinical scoring of the disease and histological examination thereafter did not show any difference between treated animals and controls. We conclude that antibody therapy directed at the TCR seems to be very effective even in pre-existing autoimmune diseases if the relevant T cell population is affected. However, inflammation and joint destruction may reach a state at which anti-TCR treatment is no longer effective.

Animals↗

PubMed1988

Optimization of MR protocols: a statistical decision analysis approach.

A new method of optimizing MRI data acquisition protocols is presented. Tissues are modeled with probability density functions (PDFs) of tissue parameter values (such as T1, T2). The imaging data acquisition process is modeled as a mapping from a tissue parameter space to a signal strength space. Tissue parameter PDFs are mapped to signal strength PDFs for each tissue in a clinical problem. The efficacy of an MRI protocol is evaluated using the methods of statistical decision analysis applied to the signal strength PDFs, including the propagation of noise. This procedure evaluates the ability to discriminate different tissues based on the signal strengths produced with the protocol. The model can incorporate an arbitrary number of tissues, parameters, and pulse sequences in the protocol. The multivariate nature of MRI and the observed broad distribution of tissue parameter values makes this model more appropriate for optimizing data acquisition protocols than methods which maximize the signal-difference-to-noise ratio between discrete values of the tissue parameters. It is shown that these two methods may calculate different optimal protocols. The method can be used to optimize data acquisition for quantitative computer-based tissue classification, as well as imaging. Data acquisition and image processing philosophies are discussed in light of the method.

Computer Simulation↗

PubMed1991

Is nuclear medicine cost-effective?

Clearly, there is currently no consensus on the cost-effectiveness of nuclear medicine--or in fact any other aspect of medicine. It is hoped that common sense prevails in clinical medicine today. An appropriate case history and physical examination may negate the need for any additional investigation. From the perspective of the capital cost of equipment and supply costs, ultrasound is clearly the most cost-effective diagnostic imaging modality. But while it is useful, it does not always provide definitive answers, and other modalities must be used to arrive at a diagnosis. In comparison, the capital cost of general radiology equipment and nuclear medicine equipment is relatively equal. Radiology has more operating costs per case than nuclear medicine and requires a lower staffing component per given volume of examinations. In any given diagnostic imaging procedure, the practitioner and imagist must maintain a dialogue to ascertain the appropriateness of the study and to use the available resources in the most effective manner. This is even more imperative when CT scanning and MRI are included in the equation. The development of an investigative protocol that makes the most efficient use of the various imaging modalities without compromising the quality of care makes sense for the patient, the physician and the insurance provider. It is unreasonable to expect the physician to be aware of the optimal protocol for the diagnostic workup of every patient. The guidance of the imaging department is required to maximize the efficient use of the available facilities. A critical and exhaustive appraisal of the medical literature may be required to determine the optimal diagnostic protocol.(ABSTRACT TRUNCATED AT 250 WORDS)

Capital Expenditures↗

PubMed1981

Optimized blood sampling protocols and sequential design of kinetic experiments.

Design of optimal blood sampling protocols for kinetic experiments is discussed and evaluated, with the aid of several examples--including an endocrine system case study. The criterion of optimality is maximum accuracy of kinetic model parameter estimates. A simple example illustrates why a sequential experiment approach is required; optimal designs depend on the true model parameter values, knowledge of which is usually a primary objective of the experiment, as well as the structure of the model and the measurement error (e.g., assay) variance. The methodology is evaluated from the results of a series of experiments designed to quantify the dynamics of distribution and metabolism of three iodothyronines, T3, T4, and reverse-T3. This analysis indicates that 1) the sequential optimal experiment approach can be effective and efficient in the laboratory, 2) it works in the presence of reasonably controlled biological variation, producing sufficiently robust sampling protocols, and 3) optimal designs can be highly efficient designs in practice, requiring for maximum accuracy a number of blood samples equal to the number of independently adjustable model parameters, no more or less.

Animals↗

PubMed2025

ATAC-seq in Emerging Model Organisms: Challenges and Strategies.

The Assay for Transposase-Accessible Chromatin with sequencing (ATAC-seq) is a versatile and widely utilized method for identifying potential regulatory regions, such as promoters and enhancers, within a genome. ATAC-seq has been successfully applied to a wide range of established and emerging model organisms. However, implementing this method in emerging model systems, such as arthropods, can be challenging due to several factors that influence data quality. These factors include the availability of a sufficient amount and quality of tissue or cells, the need for species- and tissue-specific protocol optimization, the completeness and accuracy of the reference genome, and the quality of the genome annotation. In this article, we emphasize the key steps in the ATAC-seq protocol that, based on our experience, have the greatest impact on data quality when adapting this method for emerging model organisms. Specifically, we discuss the importance of nuclei isolation, the incubation conditions of the Tn5 transposase, and PCR amplification of the library. Furthermore, we outline essential quality checkpoints during the bioinformatic analysis of ATAC-seq data to assist in assessing data integrity and consistency. Given that many emerging model organisms may not be readily available in laboratory cultures, we also emphasize the importance of evaluating how different preservation methods affect ATAC-seq data quality. Based on examples in one spider and one ant species, we demonstrate that replication and thorough quality controls at all steps of the protocol and data analysis are essential to assess the usability of ATAC-seq data. Our data highlights the importance of isolating the right number of intact nuclei, as well as ensuring optimal amplification conditions during library preparation to obtain good-quality sequence data for downstream analyses. We recommend using fresh tissue samples if possible because we show that direct cryopreservation of the tissue may affect chromatin integrity. This effect could be avoided or reduced by preserving the homogenate in cell culture medium. Overall, we explain the ATAC-seq protocol and downstream analyses in detail and give step-by-step advice to researchers who are new to the field and want to implement this method. With careful planning and validation, ATAC-seq can reveal the regulatory landscape of a genome and aid in identifying elements that govern gene expression.

Animals↗

PubMed1995

Comparison of ambulance dispatch protocols for nontraumatic abdominal pain.

STUDY OBJECTIVE: To compare rates of undertriage and overtriage of six ambulance dispatch protocols for the presenting complaint of nontraumatic abdominal pain, and to identify the optimal protocol. DESIGN: Retrospective prehospital and emergency department chart review to classify patients' conditions as "emergency" or "nonemergency." Utility analysis was used to identify the preferred protocol and monetary cost-effectiveness analysis to identify the least expensive protocol. SETTING: County emergency medical services (EMS) system with five receiving hospitals serving a mainly urban population of approximately 350,000. PARTICIPANTS: Records of 902 patients who called 911 for nontraumatic abdominal pain were reviewed; patients not transported were excluded. Twenty-seven county EMS medical directors completed questionnaires. RESULTS: Six ambulance dispatch protocols for nontraumatic abdominal pain were developed: indiscriminate-dispatch, four selective protocols, and no-dispatch. A dichotomous classification system was derived prospectively from the prehospital and medical records of patients who had activated the EMS system before the study period to define "emergency" and "nonemergency" conditions associated with nontraumatic abdominal pain. Emergency criteria identified patients with conditions requiring medical treatment within 1 hour. Reviewers determined, for each patient, whether an ambulance would have been dispatched by each of the protocols. Undertriage and overtriage rates were calculated for each protocol. County EMS medical directors assigned utility values to four potential outcomes of ambulance dispatch by the direct scaling method. The outcomes comprised correct and incorrect decisions to dispatch ambulances to patients with and without emergencies. The protocols were compared by decision analysis. A cost analysis was also performed, using an estimated marginal cost per transport of $302. Sensitivity analysis demonstrated the effect of varying the cost of an undertriage error and the cost per response. Of the 788 patients included in the study, 7.8% had conditions defined as emergencies. The four selective ambulance dispatch protocols had overtriage rates ranging from 10% to 51% and undertriage rates of 4% to 7%. None of the protocols was proven superior on the basis of the medical directors' assignment of utility values. The marginal cost of dispatching advanced life support ambulances to all patients with this complaint was $3,838 per emergency. CONCLUSION: The majority of patients with nontraumatic abdominal pain who requested ambulance transport during the study period did not have conditions that were classified as emergencies. In the study model, if an undertriage error costs more than $3,674, indiscriminate ambulance dispatch is the least expensive protocol, and if an undertriage error costs less than $3,674, no ambulance dispatch is the least expensive strategy.

Abdominal Pain↗

PubMed1994

Comparison of sensitizing protocols for ultraviolet B-induced immunosuppression in C3H mice.

To compare previously used protocols for ultraviolet (UV)-induced suppression of contact hypersensitivity in mice, and to develop an optimized protocol for C3H mice, the effect of 3 different allergens, varying allergen concentrations in the induction or challenge phase, local and distant sites of allergen application in respect to irradiation site, 2 mouse substrains and 2 different light sources was studied. A concentration of 0.5% of oxazolone (OXA) gave a slightly better contact sensitization than a 1% concentration of trinitrochlorobenzene (TNCB). Titration experiments revealed that for both OXA and TNCB, a 1% sensitization concentration was optimal, while the optimal challenge concentration was 0.5% for OXA and 1% for TNCB. The magnitude of the resulting contact sensitization was not influenced by either the mouse substrain (C3H/HeJ or C3H/HeN) or the site of allergen application (back or belly), but application of fluorescein isothiocyanate to the ears only produced weak sensitization. A standard UVB dose of 1.3 kJ/m2 suppressed TNCB contact sensitivity to a greater extent than that of OXA. A similar degree of UV-induced suppression was obtained with a given UVB dose, irrespective of a 50-fold difference in the concomitant UVA dose. Based on our results, a proper protocol of contact sensitization for UV-induced immunosuppression in C3H mice includes sensitization with 0.5% OXA on either the mouse back or belly, ear challenge with 0.5% OXA and ear swelling reading 24 h after challenge.

Allergens↗

PubMed1994

A comparison of techniques for localizing actin and tubulin in hyphae of Saprolegnia ferax.

We have evaluated protocols for immunofluorescence (IF) staining of the potentially interacting actin filaments (F-actin) and microtubules in hyphae of Saprolegnia ferax, using rhodamine-phalloidin (RP) and freeze-substitution electron microscopy (FSEM), respectively, as standards for their distribution. Saprolegnia has four distinguishable cortical F-actin populations with characteristic organizations and RP- and actin-IF-staining affinities, all of which could be labeled with both probes after some protocols. Other protocols stained only some of the populations. Cortical F-actin was always more reproducibly and sharply stained with RP than IF, indicating that the former is the probe of choice for F-actin in these cells. Although no single IF protocol revealed all of the F-actin and microtubule populations, showing the potential need to optimize protocols for specific antibodies, simultaneous localization was readily achieved by dual labeling with RP and tubulin IF. Tubulin IF patterns differed from FSEM: mitotic spindles were revealed but not the more abundant prophase microtubule arrays, and the cytoplasmic microtubules were subapically displaced and bundled into long cables. These cables, which apparently linked nuclei, indicate a previously undetected involvement in nuclear spacing. The tubulin antibody successfully used for IF failed to recognize any proteins in immunoblots, indicating that immunoblots may not always be a useful indicator of success with IF.

Actins↗

PubMed1987

Critical features of bacterial mutation assays.

This review discusses features of the standard protocols currently used in bacterial mutation assays which can have a critical effect upon the test outcome. Such features if not strictly controlled may affect the results qualitatively as well as quantitatively. These include the dose-intervals of the test compound used; the number of bacterial cells exposed to the test compound; the phase of growth such cells are in during exposure; and the length of time that the cells are exposed prior to the addition of soft agar (in the Salmonella/plate incorporation assay). The following possible modulating effects will also be discussed: the nature of the solvent used; the nature and quantity of the exogenous metabolizing system (usually liver S9-fraction) and the quantity of amino-acid (e.g. histidine) within the test system being that either deliberately added or present unavoidably within the test sample (e.g. biological fluids). If bacterial mutagenicity assays are to realize their full potential for the detection of genotoxic carcinogens, the use of rigid protocols should be discouraged. Where possible, consideration of the compound's structure should lead to the employment of the optimal protocol for the detection of genotoxic carcinogens within that chemical class. The relative speed and low cost of bacterial assays should be exploited in this way to avoid the generation of false negative results during the primary screening of novel compounds.

Animals↗

PubMed1990

Technical aspects of myocardial SPECT imaging with technetium-99m sestamibi.

Most reports to date using single photon emission computed tomography (SPECT) with technetium-99m (Tc-99m) sestamibi have used acquisition parameters that were optimized for thallium-201. To fully utilize the superior imaging characteristics of Tc-99m sestamibi, there is a need to optimize the technical aspects of SPECT imaging for this agent. Performance can be enhanced through the careful selection of optimal radiopharmaceutical doses, imaging sequences, acquisition parameters, reconstruction filters, perfusion quantification methods and multidimensional methods for visualizing perfusion distribution. The current report describes theoretical considerations, phantom studies and preliminary patient results that have led to optimized protocols, developed at Emory University and Cedars-Sinai Medical Center, for same-day rest-stress studies, given existing instrumentation and recommended dose limits. The optimizations were designed to fit a low-dose-high-dose rest-stress same-day imaging protocol. A principal change in the acquisition parameters compared with previous Tc-99m sestamibi protocols is the use of a high-resolution collimator. The approach is being developed in both prone and supine positions. A new method for extracting a 3-dimensional myocardial count distribution has been developed that uses spherical coordinates to sample the apical region and cylindrical coordinates to sample the rest of the myocardium. New methods for visualizing the myocardial distribution in multiple dimensions are also described, with improved 2-dimensional, as well as 3- and 4-dimensional (3 dimensions plus time) displays. In the improved 2-dimensional display, distance-weighted and volume-weighted polar maps are used that appear to significantly improve the representation of defect location and defect extent, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer Graphics↗

PubMed1991

A review of cardiac imaging with sestamibi and teboroxime.

Overall, it is clear that the two new technetium-labeled compounds can provide diagnostic myocardial perfusion imaging both at stress (exercise and pharmacologic) and rest, but they have very different mechanisms of transport in comparison to each other and to thallium. Therefore, new imaging protocols will need to be developed and refined by practical experience as the use of these agents expands. Further investigative work needs to be done to optimize protocols and computer processing of images. In addition, special clinical situations will become associated with the use of these new compounds. Nuclear cardiology will continue to advance during this time of great changes and challenges if informational exchange on these topics continues to flourish and critical clinical trials are completed.

Coronary Disease↗

PubMed1994

Exercise assessment of arthritic and elderly individuals.

Exercise testing is now widely used as both a diagnostic tool in the elderly and as a means of generating the information necessary to provide them with a valid exercise training prescription. An appropriate medical history and physical examination prior to exercise testing will allow for the adequate assessment of an individual's risk of undergoing an exercise test. Appropriate screening of the individual, assessment of risk prior to exercise, and appropriate monitoring during and following the exercise test have contributed to the relative safety of maximal exercise testing, with statistics indicating roughly one death occurs in every 10,000 clinical maximal exercise tests. When designing an exercise test protocol for use in the elderly, their reduced exercise capacities, increased prevalence of CV disease, and the reason for doing the test must be taken into consideration. The Bruce treadmill protocol is the most widely used exercise test in populations of all ages; however, because of its relatively high VO2 demands in the initial minutes of exercise, it may not be the optimal protocol for the elderly. Other alternative protocols including the Naughton and Balke tests may be more appropriate, especially when attempting to generate a valid exercise prescription. However, the modified Balke protocol, with a constant speed of 2 miles/h and starting on the level, is probably the best protocol for exercise testing in the elderly for the purposes of generating an exercise prescription. If individuals are unable to undergo exercise tests on a treadmill, cycle and arm ergometer tests provide alternative test modalities, but these have a number of inherent problems that must be considered prior to exercise testing. The interpretation of an elderly individual's ECG responses during a maximal exercise test is intimately related to their risk of having CV disease prior to the exercise test, though fewer false-positive tests will be evident because of the increased prevalence of CV disease in the elderly.

Aged↗