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The purpose of the study was to objectively measure the exercise intensity associated with affective responses of "good" and "fairly good." In Study 1, 8 active females completed 20 min of affect-regulated exercise to feel "good" or "fairly good" (order counterbalanced) followed by an intensity replication session. On-line gas analysis was used during the replication session to measure the physiological cost of exercising. In Study 2, 10 females completed either 3 trials of exercise to feel "good" (n = 5) or 3 trials to feel "fairly good" (n = 5). Each trial consisted of an affect-regulated session followed by a replication session. Across studies, the intensity to feel "fairly good" was significantly higher than to feel "good." Both intensities lay close to ventilatory threshold. The results add to evidence that women can use affect to regulate intensity and exercise at an intensity that would confer fitness and health benefits if maintained., (Copyright © 2011 Society for Psychophysiological Research.)

Objective: Patients with coronary artery disease complicated by moderate ischemic mitral regurgitation have demonstrably poorer outcome than do patients with coronary artery disease but without mitral regurgitation. The optimal treatment of this condition has become increasingly controversial, and a randomized trial evaluating current practices is warranted., Methods: We describe the design and initial execution of the Cardiothoracic Surgical Trials Network Surgical Interventions for Moderate Ischemic Mitral Regurgitation Trial., Results: This is an ongoing prospective, multicenter, randomized, controlled clinical trial designed to test the safety and efficacy of mitral repair in addition to coronary artery bypass grafting in the treatment of moderate ischemic mitral regurgitation., Conclusions: The results of the Cardiothoracic Surgical Trials Network Surgical Interventions for Moderate Ischemic Mitral Regurgitation Trial will provide long-awaited information on controversial therapies for this morbid disease process., (Copyright © 2012 The American Association for Thoracic Surgery. All rights reserved.)

Background: Because parental recognition of overweight in young children is poor, we need to determine how best to inform parents that their child is overweight in a way that enhances their acceptance and supports motivation for positive change. This study will assess 1) whether weight feedback delivered using motivational interviewing increases parental acceptance of their child's weight status and enhances motivation for behaviour change, and 2) whether a family-based individualised lifestyle intervention, delivered primarily by a MInT mentor with limited support from "expert" consultants in psychology, nutrition and physical activity, can improve weight outcomes after 12 and 24 months in young overweight children, compared with usual care., Methods/design: 1500 children aged 4-8 years will be screened for overweight (height, weight, waist, blood pressure, body composition). Parents will complete questionnaires on feeding practices, physical activity, diet, parenting, motivation for healthy lifestyles, and demographics. Parents of children classified as overweight (BMI > or = CDC 85th) will receive feedback about the results using Motivational interviewing or Usual care. Parental responses to feedback will be assessed two weeks later and participants will be invited into the intervention. Additional baseline measurements (accelerometry, diet, quality of life, child behaviour) will be collected and families will be randomised to Tailored package or Usual care. Parents in the Usual care condition will meet once with an advisor who will offer general advice regarding healthy eating and activity. Parents in the Tailored package condition will attend a single session with an "expert team" (MInT mentor, dietitian, physical activity advisor, clinical psychologist) to identify current challenges for the family, develop tailored goals for change, and plan behavioural strategies that best suit each family. The mentor will continue to provide support to the family via telephone and in-person consultations, decreasing in frequency over the two-year intervention. Outcome measures will be obtained at baseline, 12 and 24 months., Discussion: This trial offers a unique opportunity to identify effective ways of providing feedback to parents about their child's weight status and to assess the efficacy of a supportive, individualised early intervention to improve weight outcomes in young children., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12609000749202.

Background: At exercise intensities around ventilatory threshold (VT), the extent to which individuals experience pleasure or displeasure from the exercise varies between individuals. One source of this variability is proposed to be the cognitive appraisal that occurs during the exercise which influences the generation of the affective response. When individuals self-select their own intensity they choose to exercise around VT and experience more positive affective responses, again the explanation being that cognitive appraisal processes influence the choice of intensity and resulting affective response. However, the specific factors that comprise this appraisal process have not been thoroughly explored. In addition, it is not clear if activity status influences this appraisal and different cognitive factors play a role in the generation of affective responses. Therefore, the purpose of this study was to explore the cognitive factors that influence the affective response experienced during prescribed and self-selected intensity exercise in low-active and high-active women., Methods: Seventeen low-active and 15 high-active women (M age = 45 years, SD = 10) completed a graded exercise test and two 30 min bouts of treadmill exercise, one at a self-selected intensity and one prescribed at an intensity around VT. Using 'think aloud' procedures, every five min, the women were asked to provide an affective response and explain the thought processes that caused them to report that affective response. Using inductive content analysis, the verbal reports provided by the women were analysed for key themes and categories that emerged as explaining the factors that underpinned the generation of the affective response. Data from the low-active and high-active women were analysed separately., Results: Concepts relating to pre-exercise affective state, perceptions of ability, immediate and anticipated outcomes, attentional focus and perceptions of control emerged. The physiological demands of the exercise stimulus influenced affective responses through themes related to the interpretation of physiological symptoms and the physiological state of the body. No thematic differences emerged between high-active and low-active women., Conclusion: Results highlight the complex interaction of psychological and physiological influences in producing an affective response to exercise and provide insight into how exercise can be structured to elicit positive affective responses.

Objective: To determine the relationship between body mass index (BMI) at the time of transplant and posttransplant survival and morbidity., Summary Background Data: The recent International Society for Heart and Lung Transplantation listing criteria for heart transplantation stated that candidates should achieve a BMI <30 kg/m-or percent ideal body weight <140%-before listing for cardiac transplantation. However, data to support these recommendations are limited and often conflicting., Methods: United Network of Organ Sharing provided de-identified patient-level data. Analysis included 19,593 orthotopic heart transplant recipients aged >or=18 years and transplanted January 1 1995-December 31 2005. Follow-up data were provided through February 8, 2008. Recipients were stratified by BMI at the time of transplantation: BMI <18.5 (underweight), 18.5 to 24.99 (normal weight), 25 to 29.99 (overweight), 30 to 34.99 (obesity class I), and >or=35 (obesity class II/III). The primary outcome measure was post-transplant survival., Results: Risk-adjusted median survival in the underweight, normal weight, overweight, obesity I, and obesity II/III groups was 8.31, 10.20, 10.03, 9.51, and 9.05 years, respectively. In multivariate Cox proportional hazards regression, BMI in the overweight (HR = 1.08, 0.99-1.17; P = 0.055) and obesity I (HR = 1.05, 0.99-1.12; P = 0.091) ranges were not associated with significantly diminished survival. However, BMI in the underweight (HR = 1.26, 1.11-1.43; P < 0.001) and obesity II/III (HR = 1.18, 1.01-1.38; P = 0.030) ranges were associated with diminished posttransplant survival., Conclusion: Findings from this analysis do not suggest that obesity I (BMI of 30-34.99) is associated with significantly higher morbidity and mortality. However, underweight and obesity II/III recipients have significantly higher morbidity and mortality compared with other groups.

Objective: To examine patterns of resource use and the cost of care for patients with advanced heart failure treated with medical management (MM) during the final 2 years of life., Methods and Results: The study population (n=47, mean age 70.4 years+/-7.06) included patients randomized to the MM arm of the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial. Inpatient and outpatient use data were obtained from the clinical dataset and Centers for Medicare and Medicaid Services (beginning January 1, 1998). Cost and resource use were tracked from the date of death (t(d)) backward in 3-month intervals (eg, t(d-1), t(d-2)). In the primary analysis, costs were summed across intervals. The mean cost of MM in the final 2 years of life was $156,169, with 50.5% ($78,880.39) expended in the final 6 months. The mean quarterly cost increased (P < .01) 4.9-fold from t(d-8) ($8,816 +/- $14,270) to t(d-1) ($42,836 +/- $41,407). The number of inpatient days increased (P < .01) 6.6-fold from 3.8+/-4.7 days to 22.2+/-23.5 days during the same time intervals., Conclusion: This current economic analysis extends on previous findings by demonstrating that medical therapy in advanced and end-stage heart failure is associated with significant costs and resource consumption; these costs and resource consumption increase significantly as death approaches.

The purpose of the four studies described in this article was to develop and test a new measure of competitive sport participants' intrinsic motivation, extrinsic motivation, and amotivation (self-determination theory; Deci & Ryan, 1985). The items for the new measure, named the Behavioral Regulation in Sport Questionnaire (BRSQ), were constructed using interviews, expert review, and pilot testing. Analyses supported the internal consistency, test-retest reliability, and factorial validity of the BRSQ scores. Nomological validity evidence was also supportive, as BRSQ subscale scores were correlated in the expected pattern with scores derived from measures of motivational consequences. When directly compared with scores derived from the Sport Motivation Scale (SMS; Pelletier, Fortier, Vallerand, Tuson, & Blais, 1995) and a revised version of that questionnaire (SMS-6; Mallett, Kawabata, Newcombe, Otero-Forero, & Jackson, 2007), BRSQ scores demonstrated equal or superior reliability and factorial validity as well as better nomological validity.

Objective: Exercise stress, immune status, and mood are interrelated. The stress of adventure racing is unique; exercise is very prolonged and competitive, with severe sleep deprivation and sustained cognitive demands, usually in arduous terrain and environmental conditions. The purpose of this prospective, descriptive study was to identify mood changes along with symptoms of illness and injury during and in the weeks following an international-level adventure race., Methods: Mood, sleep, injury, and illness data were collected using questionnaires before, during, and for 2 weeks following New Zealand's Southern Traverse Adventure Race in November 2003., Results: Mood was variable between athletes, but peaks of altered mood subscores were evident (P < .05) during the first 24 hours of racing, around race completion, and, as was hypothesized, 3 days after racing. Altered mood subscores resolved within 2 weeks. Symptoms of upper respiratory illness were most common immediately before (25/60, 42%) and after (28/49, 57%) racing, and largely resolved over the 2-week follow-up (5/27, 19%). Skin wounds and infections were common (43/49, 88%) immediately after the race but settled quickly. Pain was universal (100%), and musculoskeletal injury was common (38/48, 79%). Gastrointestinal complaints were common at the finish (8/49, 16%) and during the next 5 days but settled more quickly than upper respiratory symptoms., Conclusions: Adventure racing of approximately 100 hours causes significant symptomatic injury and illness and mood state disruption, which generally resolve within a fortnight following racing. Disrupted mood and symptoms of illness and injury indicate athlete susceptibility to overreaching or overtraining without sufficient recovery.

Using a mixed-method approach, the aim of this study was to explore affective responses to exercise at intensities below-lactate threshold (LT), at-LT, and above-LT to test the proposals of the dual-mode model. These intensities were also contrasted with a self-selected intensity. Further, the factors that influenced the generation of those affective responses were explored. Nineteen women completed 20 min of treadmill exercise at each intensity. Affective valence and activation were measured, pre-, during and postexercise. Afterward, participants were asked why they had felt the way they had during each intensity. Results supported hypotheses showing affect to be least positive during the above-LT condition and most positive during the self-selected and below-LT conditions. Individual differences were greatest in the below-LT and at-LT conditions. Qualitative results showed that factors relating to perceptions of ability, interpretation of exercise intensity, exercise outcomes, focus of concentration, and perceptions of control influenced the affective response and contributed to the individual differences shown in the quantitative data.

Pseudoaneurysm of the carotid artery is a rare complication of deep neck space infection. It carries a high mortality rate even when treated appropriately. We report a case of a pseudoaneurysm of the internal carotid artery in a 2-year-old child who had a neck infection without an associated abscess. The diagnosis was not obvious on MRI but was confirmed by ultrasonography. This was successfully managed by angiographic embolization, followed by antibiotic and anticoagulant treatment. The combination of MRI and ultrasonography, without the use of invasive or radiation techniques, was sufficient for the diagnosis of pseudoaneurysm of the internal carotid artery.

New left ventricular assist devices promise fewer adverse events but, currently, only minor improvements in survival. Small (survival) treatment effects, limited patient populations, and the increasing number of left ventricular assist devices in development challenge the efficient conduct of premarketing trials (especially in destination therapy) and, maybe more importantly, hamper innovation. Novel trial designs would facilitate this process. Among a range of trial designs, we opt for small randomized trials, which would preserve the advantages of randomization and also allow for a shorter enrollment period. We also advocate an evidence shift toward postmarketing studies, with the Interagency Registry of Mechanically Assisted Circulatory Support providing a robust infrastructure.

Objectives: Affective valence responses to exercise may influence adherence. According to a newly proposed dual-mode model, affective responses have been proposed to vary depending on whether exercise is undertaken above or below the anaerobic threshold. With the model in mind, the study objectives were to explore the impact of an above-lactate, below-lactate, and self-selected exercise condition on acute affective responses in sedentary individuals., Design: Using a repeated measures design, 12 volunteers participated in two prescribed intensity exercise conditions (above and below-lactate threshold) and one self-selected intensity exercise condition. The three conditions were randomized., Method: An incremental walking protocol was used to identify exercise intensities that would elicit above- and below-lactate threshold work rates for each participant. The exercise conditions were completed on different days and each lasted for 20 minutes. Physiological and affective responses were recorded pre-exercise, during exercise, and post-exercise., Results: Affective responses were more negative in the above-lactate condition during exercise compared with the below-lactate and self-selected conditions. There were no differences between the conditions post-exercise. Participants exercised around the lactate threshold and at a significantly higher intensity in the self-selected compared with the below-lactate condition. Inter-individual variability in responses was greatest below the lactate threshold, with similar levels of variability in the self-selected and above-lactate conditions., Conclusions: Data are consistent with the proposals of the dual-mode model and support the use of self-selected intensity with sedentary individuals to promote positive affective responses.

Objectives: This study was designed to compare in-hospital mortality and complications and three-year mortality and revascularization for off-pump and on-pump coronary artery bypass graft (CABG) surgery after adjusting for patient risk., Background: The use of off-pump CABG surgery has increased tremendously in recent years, but little is known about its long-term outcomes relative to on-pump CABG surgery, and most studies have been very small., Methods: Short- and long-term outcomes (inpatient mortality and complications, three-year risk-adjusted mortality, and mortality/revascularization) were explored for patients who underwent off-pump CABG surgery (9135 patients) and on-pump CABG surgery (59044 patients) with median sternotomy from 1997 to 2000 in the state of New York., Results: Risk-adjusted inpatient mortality was 2.02% for off-pump versus 2.16% for on-pump (p = 0.390). Off-pump patients had lower rates of perioperative stroke (1.6% vs. 2.0%, p = 0.003) and bleeding requiring reoperation (1.6% vs. 2.2%, p < 0.001) and higher rates of gastrointestinal bleeding, perforation, or infarction (1.2% vs. 0.9%, p = 0.003). Off-pump patients had lower postoperative lengths of stay (median 5 days vs. 6 days, p < 0.001). On-pump patients had higher three-year survival (adjusted risk ratio [RR] =1.086, p = 0.045) and higher freedom from death or revascularization (adjusted RR = 1.232, p < 0.001). When analyses were limited to 1999 to 2000, the two-year adjusted hazard ratio for survival was not significant (adjusted RR = 0.99, p = 0.81)., Conclusions: On-pump patients experience better long-term survival and freedom from revascularization than off-pump patients. However, the survival benefit from on-pump procedures was no longer present in the last two years of the study.

Background Data: The REMATCH trial evaluated the efficacy and safety of long-term left ventricular assist device (LVAD) support in stage D chronic end-stage heart failure patients. Compared with optimal medical management, LVAD implantation significantly improved the survival and quality of life of these terminally ill patients. To date, however, there have been no analyses of the cost related to the LVAD survival benefit. This paper addresses the cost of hospital resource use, and its predictors, for long-term LVAD patients., Methods: Detailed cost data were available for 52 of 68 REMATCH patients randomized to LVAD therapy. We combined the clinical dataset with Medicare data, standard billing forms (UB-92), and line item bills provided directly by clinical centers. Charges were converted to costs by using the Ratio-of-Cost-to-Charges for each major resource category., Results: The mean cost for the initial implant-related hospitalization was $210,187 +/- 193,295. When implantation hospitalization costs are compared between hospital survivors and nonsurvivors, the mean costs increase from $159,271 +/- 106,423 to $315,015 +/- 278,713. Sepsis, pump housing infection, and perioperative bleeding are the major drivers of implantation cost, established by regression modeling. In the patients who survived the procedure (n = 35), bypass time, perioperative bleeding, and late bleeding were the drivers of cost. The average annual readmission cost per patient for the overall cohort was $105,326., Conclusions: The cost of long-term LVAD implantation is commensurate with other life-saving organ transplantation procedures like liver transplantation. As an evolving technology, there are a number of opportunities for improvement that will likely reduce costs in the future.

Objective: Left ventricular assist device implantation is associated with an increased risk of development of circulating anti-HLA class I and II antibodies (sensitization). We investigated the impact of sensitization on posttransplantation outcomes in 105 consecutive left ventricular assist device recipients., Methods: Five hundred twenty-one consecutive adult cardiac allograft recipients between 1992 and 1999 were retrospectively studied. Of these, 105 were supported with a left ventricular assist device. Pretransplantation and posttransplantation antibody production, time to transplantation after listing, rejection, freedom from transplant coronary artery disease, and survival were evaluated by Kaplan-Meier analysis. Among sensitized left ventricular assist device recipients, 26 were treated with a pretransplantation immunomodulatory regimen consisting of intravenous immunoglobulin and cyclophosphamide., Results: There were no significant differences between left ventricular assist device recipients and nonbridged recipients with respect to pretransplantation demographic characteristics and ABO and HLA matching. Among left ventricular assist device recipients, 66% (69/105) were sensitized before transplantation; in contrast, only 6% (24/399) of nonbridged recipients were sensitized (P <.001). Sensitized untreated left ventricular assist device recipients had both a prolongation of waiting time to transplantation and an increased risk of acute rejection. Pretransplantation immunomodulatory therapy reduced both the increased waiting time and the increased risk of acute rejection. However, sensitization or the use of immunomodulatory therapy in left ventricular assist device-bridged recipients did not influence posttransplantation survival relative to nonbridged recipients., Conclusions: Left ventricular assist device recipients have survival outcomes similar to those of nonbridged recipients after cardiac transplantation, despite their significantly higher immunologic risk. The reduced rate of transplantation and the increased incidence of rejection observed in sensitized left ventricular assist device recipients are prevented by immunomodulatory therapy. Sensitization will remain an important issue with increased use of left ventricular assist devices, and improved understanding of this is essential to achieve better outcomes in the management of patients with end-stage heart failure.

The use of circulatory support as destination therapy has been a goal for the treatment of endstage heart failure for several decades. Current investigations are evaluating several circulatory pumps with that particular objective. With continued modification of design, the current and future pumps will become more reliable and provide improved quality of life to patients in need of mechanical circulatory assistance. The new pumps on the horizon specifically address reliability, size, and cost, and are based on the centrifugal system. These devices use the Maglev (Magnetic Levitation) concept that allows for frictionless pumping, low thrombogenicity, minimal noise, and increased durability. Further research with this goal in mind and support from the federal government will be the key to the future use of circulatory assistance as destination therapy for heart failure patients. In addition, the cost-effectiveness of these devices will need to be maintained as the technology improves, as in any new technology that confronts a more intuitive option like the native heart.

Background: Our objectives for this exploratory study were (1) to assess the prevalence in a family practice of violent victimization of women and men by partners, friends, families, and strangers, and (2) to compare the physical symptoms, depression, alcohol use problems, and social support of women and men who were or were not victimized in the previous 12 months., Methods: We conducted a cross-sectional, multicenter study of family practice patients (1999-2000). One-thousand twenty-four patients, including 679 women and 345 men from 18 to 64 years of age completed a standard health history and a demographic questionnaire. The health history questionnaire included a question about violent victimization., Results: Violent victimization was reported by 9.9% of the women and 10.9% of the men. Patients who were victimized were grouped into those who were victimized by partners (4.9% of women and 3.0% of men); by friends, or family, or strangers (2.3% of women and 5.0% of men); or by more than one category of persons other than partners (2.6% of women and 3.0% of men). Almost one third of patients victimized by partners were also victimized by another person. Women who were victimized had more physical symptoms than women who were not victimized. Women who were victimized and men who were victimized by their partners had more depressive symptoms than other women and men. Patients who were victimized by more than one category of other victimizers reported more alcohol use problems than other patients. Patients who were victimized reported less social support than patients who were not victimized., Conclusions: Both women and men report violent victimization in response to a screening question. Violence by partners and by others is related to physical and psychiatric symptoms in women and in men.

Background: The development of minimally invasive cardiac surgery has been characterized by the performance of increasingly complex operations through progressively smaller incisions. Computer (robotic) enhancement has emerged as a potential facilitator of these procedures, initially by providing enhanced endoscopic camera control and, more recently, by allowing the manipulation of surgical instruments through limited thoracic incisions. This report describes the next step in this progression, namely the performance of an atrial septal defect (ASD) repair entirely through thoracoscopic port incisions. This represents the first U.S. application of robotic technology for totally endoscopic open-heart surgery., Materials and Methods: A 33-year-old woman with a secundum atrial septal defect underwent totally endoscopic repair through four port incisions by means of the Da Vinci (Intuitive Surgical, Mountain View, CA) robotic surgical system. Cardiopulmonary bypass was achieved peripherally (femoral Estech endoaortic balloon cannula; femoral and right internal jugular venous Bio-medicus cannulae). The myocardium was protected with antegrade cold blood cardioplegia delivered through the distal port of the arterial cannula. After port insertion, the entire operation, including pericardiotomy, bicaval occlusion, atriotomy, atrial septopexy, and atrial closure, was performed by computer-aided control of a camera and two instrument arms manipulated by a surgeon seated 15 feet away. The fourth port was used for suction and suture passage by the patient-side assistant. The aortic cross-clamp time was 43 minutes, and the postoperative transesophageal echocardiogram demonstrated normal ventricular function and the absence of interatrial shunting. The patient was extubated on the night of surgery, was ambulatory within 15 hours, and was discharged on the morning of postoperative day 3, 63 hours after the procedure. At 30-day follow-up, the patient was well and without complaints, and transthoracic echocardiogram confirmed the continued absence of interatrial shunting., Conclusions: Computer-aided robotic surgical technology can be used to perform open-heart procedures with a totally endoscopic approach. The benefits of this approach may include decreased perioperative pain, decreased recovery times, and improved cosmesis and patient acceptance. Clinical trials currently in progress will demonstrate whether this technology will be of reproducible value in the management of patients with intracardiac disease on a larger scale.

Background: Despite advances in heart transplantation and mechanical circulatory support, mortality among transplant candidates remains high. Better ways are needed to ensure the survival of transplant candidates both inside and outside the hospital., Methods: In a prospective, multicenter clinical trial conducted at 24 centers in the United States, 280 transplant candidates (232 men, 48 women; median age, 55 years; range, 11-72 years) unresponsive to inotropic drugs, intra-aortic balloon counterpulsation, or both, were treated with the HeartMate Vented Electric Left Ventricular Assist System (VE LVAS). A cohort of 48 patients (40 men, 8 women; median age, 50 years; range, 21-67 years) not supported with an LVAS served as a historical control group. Outcomes were measured in terms of laboratory data (hemodynamic, hematologic, and biochemical), adverse events, New York Heart Association functional class, and survival., Results: The VE LVAS-treated and non-VE LVAS-treated (control) groups were similar in terms of age, sex, and distribution of patients by diagnosis (ischemic cardiomyopathy, idiopathic cardiomyopathy, and subacute myocardial infarction). VE LVAS support lasted an average of 112 days (range, < 1-691 days), with 54 patients supported for > 180 days. Mean VE LVAS flow (expressed as pump index) throughout support was 2.8 L x min(-1) x m(-2). Median total bilirubin values decreased from 1.2 mg/dL at baseline to 0.7 mg/dL (P =.0001); median creatinine values decreased from 1.5 mg/dL at baseline to 1.1 mg/dL (P =.0001). VE LVAS-related adverse events included bleeding in 31 patients (11%), infection in 113 (40%), neurologic dysfunction in 14 (5%), and thromboembolic events in 17 (6%). A total of 160 (58%) patients were enrolled in a hospital release program. Twenty-nine percent of the VE LVAS-treated patients (82/280) died before receiving a transplant, compared with 67% of controls (32/48) (P <.001). Conversely, 71% of the VE LVAS-treated patients (198/280) survived: 67% (188/280) ultimately received a heart transplant, and 4% (10/280) had the device removed electively. One-year post-transplant survival of VE LVAS-treated patients was significantly better than that of controls (84% [158/188] vs 63% [10/16]; log rank analysis P =.0197)., Conclusion: The HeartMate VE LVAS provides adequate hemodynamic support, has an acceptably low incidence of adverse effects, and improves survival in heart transplant candidates both inside and outside the hospital. The studies of the HeartMate LVAS (both pneumatic and electric) for Food and Drug Administration approval are the only studies with a valid control group to show a survival benefit for cardiac transplantation.

Background: Implantable left ventricular assist devices have benefited patients with end-stage heart failure as a bridge to cardiac transplantation, but their long-term use for the purpose of enhancing survival and the quality of life has not been evaluated., Methods: We randomly assigned 129 patients with end-stage heart failure who were ineligible for cardiac transplantation to receive a left ventricular assist device (68 patients) or optimal medical management (61). All patients had symptoms of New York Heart Association class IV heart failure., Results: Kaplan-Meier survival analysis showed a reduction of 48 percent in the risk of death from any cause in the group that received left ventricular assist devices as compared with the medical-therapy group (relative risk, 0.52; 95 percent confidence interval, 0.34 to 0.78; P=0.001). The rates of survival at one year were 52 percent in the device group and 25 percent in the medical-therapy group (P=0.002), and the rates at two years were 23 percent and 8 percent (P=0.09), respectively. The frequency of serious adverse events in the device group was 2.35 (95 percent confidence interval, 1.86 to 2.95) times that in the medical-therapy group, with a predominance of infection, bleeding, and malfunction of the device. The quality of life was significantly improved at one year in the device group., Conclusions: The use of a left ventricular assist device in patients with advanced heart failure resulted in a clinically meaningful survival benefit and an improved quality of life. A left ventricular assist device is an acceptable alternative therapy in selected patients who are not candidates for cardiac transplantation.

Background: Constantly changing practices in heart transplantation have improved posttransplant survival in patients with end-stage heart disease. The objective of this study was to evaluate long-term outcomes in different eras of immunosuppressive therapy after cardiac transplantation at a single center during a two-decade period., Methods: A retrospective review of 1,086 consecutive cardiac allograft recipients who underwent transplantation between 1977 to 1999 was performed. Patients were divided into four eras based on type of immunosuppressive therapy: era 1 = steroids, azathioprine (n = 26, February 1977 to March 1983), era II = steroids, cyclosporine (n = 43, April 1983 to April 1985), era III = cyclosporine, steroids, azathioprine (n = 752, April 1985 to December 1995), era IV = cyclosporine, steroids, mycophenolate mofetil (n = 315, January 1996 to October 1999)., Results: The actuarial survival of the entire cohort of 1,086 patients undergoing cardiac transplantation was 79%, 66%, and 49% at 1, 5, and 10 years, respectively. There were significant trends in recipient age and gender distribution among the four eras with increasing proportion of older age (> 60 years) and female recipients in eras III and IV (p = 0.001 and 0.02). Early mortality and long-term survival improved significantly over all eras (p < 0.001). Rejection as a cause of death decreased over time (era I, 24%; era II, 21%; era III, 15%; era IV, 9%; p = 0.02), whereas the contribution of transplant coronary artery disease as a cause of death remained unchanged., Conclusions: Cardiac transplantation provides satisfactory long-term survival for patients with end-stage heart failure. The improving outcomes in survival correlate with improved immunosuppressive therapy in each era. Although the reasons for improvement in survival over time are multifactorial, we believe that changes in immunosuppressive therapy have had a major impact on survival as evidenced by the decreasing number of deaths due to rejection.

Background and Objectives: Accurate assignment of evaluation and management (E&M) codes is a challenge for physicians. Having guidelines close at hand during patient visits might improve appropriateness and accuracy of E&M coding. We developed a template based on a clinical prediction rule for group A beta-hemolytic streptococcal (GABHS) pharyngitis to improve documentation and coding decisions., Methods: Fifty office visits for sore throat were documented using templates and were compared with 50 sore throat visits that were documented using progress notes. We counted history and physical examination items and compared the level of service charged to the level of service supported by the note., Results: Significantly more history of present illness and physical examination items were recorded on templates. Decisions related to treatment for patients with a low probability of GABHS were also improved by the templates. Templates had no effect on billing and coding errors., Conclusions: The template resulted in more-thorough documentation but had no effect on coding and billing errors relative to progress notes.

Deci and Ryan's causality orientations theory suggests that there are individual differences in motivational orientation towards initiating and regulating behaviour. They described three causality orientations: autonomy, control and impersonal. The aim of this paper is to describe the development and concurrent validity of the Exercise Causality Orientations Scale (ECOS), which was designed to measure the strength of these three orientations within exercise. Altogether, 592 working adults aged 35.0 +/- 11.4 years (mean +/- s) completed the ECOS and measures of self-determination, self-consciousness and social desirability. The analysis was conducted in two parts. First, the data were subjected to confirmatory factor analysis using a multi-trait, multi-method framework. The original model resulted in a poor fit to the data. On the basis of its modification indices, three scenarios with ambiguous items were removed successively, resulting in a scale with good psychometric properties. Secondly, Pearson's correlations were conducted between the subscales of the ECOS and those of the questionnaires used for validation. Most of the results supported a priori hypotheses. In conclusion, our results show the ECOS to have good psychometric properties and they provide some support for its concurrent validity.

Background: With increasing use of left ventricular assist devices (LVAD) worldwide, the economics of LVAD implantation have become an important focus of concern. Although these devices have high unit costs, they are the only hope for survival for a large group of terminally ill patients and are likely to have an expansion in indications for use., Methods: We calculated the costs associated with long-term LVAD implantation. We used the ratio of cost-to-charges method to calculate hospital costs per resource category, market prices for drugs and device, and payments for physician services., Results: Based on our experience with "bridge-to-transplantation" patients, we estimated average first-year costs to be $222,460 including professional fees and $192,154 excluding professional fees. The latter figure is comparable to average first-year costs for cardiac transplantation, which is $176,605 without professional fees at our institution., Conclusions: The costs of LVAD therapy will change after the first year of implantation, and device reliability and longevity will be important factors in determining these costs. Should the costs of LVAD therapy continue to track those of cardiac transplantation, devices will be cost-effective only if they offer similar efficacy to cardiac transplantation.

Objectives: The aim of this study was to determine long-term survival (>10 years) after cardiac transplantation in the cyclosporine era and identify risk factors influencing long-term survival., Background: Despite the availability of newer modalities for heart failure, cardiac transplantation remains the treatment of choice for end-stage heart disease., Methods: Between 1983 and 1988, 195 patients underwent heart transplantation at a single center for the treatment of end-stage heart disease. Multivariable logistic regression analysis of pretransplant risk factors affecting long-term survival after cardiac transplantation included various recipient and donor demographic, immunologic and peritransplant variables., Results: Among the group of 195 cardiac transplant recipients, actuarial survival was 72%, 58% and 39% at 1, 5 and 10 years respectively. In the 65 patients who survived >10 years, mean cardiac index was 2.91/m2 and mean ejection fraction was 58%. Transplant-related coronary artery disease (TRCAD) was detected in only 14 of the 65 patients (22%). By multivariable analysis, the only risk factor found to adversely affect long-term survival was a pretransplant diagnosis of ischemic cardiomyopathy (p = 0.04)., Conclusions: Long-term survivors maintain normal hemodynamic function of their allografts with a low prevalence of TRCAD. It is possible that similar risk factors that lead to coronary artery disease in native vessels continue to operate in the post-transplant period, thereby contributing to adverse outcomes after cardiac transplantation. Aggressive preventive and therapeutic measures are essential to limit the risk factors for development of coronary atherosclerosis and enable long-term survival after cardiac transplantation.

Objective: To study risk factors for early and late death after heart transplantation in the current era., Summary Background Data: The current cardiac transplant population differs from earlier periods in that an increasing number of sicker patients, such as those with ventricular assist device (LVAD) support, prior cardiac allotransplantation, and pulmonary hypertension, are undergoing transplantation. In addition, sensitized patients constitute a greater proportion of the transplanted population. Emphasis has been placed on therapies to prevent early graft loss, such as the use of nitric oxide and improved immunosuppression, in addition to newer therapies., Methods: Five hundred thirty-six patients undergoing heart transplantation between 1993 and 1999 at a single center were evaluated (464 adults and 72 children; 109 had received prior LVAD support and 24 underwent retransplantation). The mean patient age at transplantation was 44.9 years. Logistic regression and Cox proportional hazard models were used to evaluate the following risk factors on survival: donor and recipient demographics, ischemic time, LVAD, retransplantation, pretransplant pulmonary vascular resistance, and immunologic variables (ABO, HLA matching, and pretransplant anti-HLA antibodies)., Results: The rate of early death (less than 30 days) was 8.5% in adults and 8.8% in children. The actuarial survival rate of the 536 patients was 83%, 77%, and 71% at 1, 3, and 5 years, respectively, by Kaplan Meier analysis. Risk factors adversely affecting survival included the year of transplant, donor age, and donor-recipient gender mismatching. Neither early nor late death was influenced by elevated pulmonary vascular resistance, sensitization, prior LVAD support, or prior cardiac allotransplantation., Conclusions: Previously identified risk factors did not adversely affect short- or long-term survival of heart transplant recipients in the current era. The steady improvement in survival during this period argues that advances in transplantation have offset the increasing acuity of transplant recipients.

Background: Pica is the compulsive eating of nonnutritive substances and can have serious medical implications. Although it has been described since antiquity, there has been no single agreed-upon explanation of the cause of such behavior., Methods: Databases from MEDLINE and PSYCH-Lit were searched from 1964 to the present to find relevant sources of information using the key words "pica," "obsessive-compulsive disorder," "iron-deficiency anemia," and "nutrition.", Results and Conclusions: Pica is observed most commonly in areas of low socioeconomic status and is more common in women (especially pregnant women) and in children. To our knowledge, the prevalence of pica is not known. Numerous complications of the disorder have been described, including iron-deficiency anemia, lead poisoning, and helminthic infestations. Pica is probably a behavior pattern driven by multiple factors. Some recent evidence supports including pica with the obsessive-compulsive spectrum of disorders. Many different treatment regimens have been described, with variable responses. It is important to be aware of this common, but commonly missed, condition.

End-stage heart failure exerts a tremendous impact on individuals and society in terms of personal and economic suffering. The development of mechanical circulatory support devices has been driven by the shortage of donor organs for heart transplantation. Collaborative efforts in the fields of surgery, medicine, and biomedical engineering, sponsored by both government and industry, have led to devices capable of providing reliable circulatory support. Future mechanical cardiac assist devices will likely play an important role in the treatment of an ever-growing population of patients with end-stage heart failure.

The pathogenicity of Vespula vulgaris wasp workers and larvae to a range of fungi was determined. All fungi were isolated in New Zealand and included isolates from Vespula, known generalist insect pathogens, and isolates generally nonpathogenic to insects. Workers and larvae were highly susceptible to pathogenic isolates at high spore concentrations (>1.75 x 10(5) cfu/individual). Eight isolates, two of Metarhizium anisopliae, five of Beauveria bassiana, and one of Aspergillus flavus were pathogenic while a single isolate of M. flavouiride var. novazealandicum, Cladosporium sp., and Paecilomyces sp. were not. The transfer of spores between workers, and between workers and larvae, was also investigated using several different application methods. Transfer of spores occurred between treated and untreated individuals, and for some of the application methods sufficient spores were transferred to cause mortality of the nontreated individuals. These findings are related to the potential of fungi for the control of wasps., (Copyright 2000 Academic Press.)

Background: Despite the decreased incidence of acute rejection episodes and improvements in short and intermediate term graft survival with current immunosuppressive agents, there has been little progress in decreasing the morbidity and mortality from chronic rejection. This phenomenon may, in part, be related to the development of a humoral immune response with increases in anti-HLA antibodies, which presents as accelerated graft arteriopathy with intimal hyperplasia., Methods: Based on prior experimental work, a pilot, prospective, randomized study was performed in 23 primary cardiac transplant recipients to determine whether the addition of prophylactic photopheresis to a cyclosporine, azathioprine and prednisone regimen was safe and resulted in decreased levels of panel reactive antibodies (PRA) and transplant arteriopathy., Results: There was no difference between the two groups in regard to infection or acute rejection incidence. The photopheresis group had a significant reduction in PRA levels at two time points within the first 6 postoperative months. Coronary artery intimal thickness was significantly reduced in the photopheresis group at 1-yr (0.23 vs. 0.49 mm, p < 0.04) and 2-yr (0.28 vs. 0.46 mm, p < 0.02) follow-up compared with the control group., Conclusion: In this small pilot study, photopheresis is a safe, well-tolerated immunomodulatory technique that is capable of decreasing the severity of chronic rejection manifesting as post-transplant graft intimal hyperplasia.

This study compared the effects of 20 minutes of treadmill exercise at a prescribed intensity exercise (65% VO(2)max) and a preferred intensity exercise on psychological affect and exercise enjoyment in aerobically fit individuals. Affect was measured before exercise, at 5-minute intervals during exercise and 5 minutes post-exercise. Heart rate, ratings of perceived exertion (RPE) and enjoyment were also measured during each session. Results indicated that there was no difference in psychological affect or enjoyment between the two exercise sessions, although work rate was higher in the preferred condition. However, pre-exercise values of affect played an influential role in the affective response to exercise. These results suggest that allowing fit individuals to select their own exercise intensity may be more beneficial physiologically and psychologically.

Objectives: Atrial fibrillation remains a significant source of morbidity after coronary artery bypass grafting (CABG). Whether cardiopulmonary bypass (CPB) temperature influences the occurrence of postoperative atrial fibrillation in CABG patients has not been specifically examined. In the present study, we reviewed postoperative data from patients who were prospectively randomized to mild or moderate hypothermic CPB for elective CABG to determine the incidence of postoperative atrial fibrillation., Design: Randomized, single center, observational study., Setting: Tertiary university medical center., Patients: Adults undergoing elective CABG surgery., Interventions: Enrolled patients were prospectively randomized to mild (34 degrees C [93.2 degrees F]) or moderate (28 degrees C [82.4 degrees F]) hypothermic CPB., Measurements and Main Results: The incidence of postoperative atrial fibrillation was determined by review of ICU and hospital records. There was a significantly higher incidence of atrial fibrillation in the moderate compared with the mild hypothermic CPB group. Patients who had postoperative atrial fibrillation were significantly older than those without atrial fibrillation. Furthermore, a significant increase in the relative risk of developing postoperative atrial fibrillation was found for both age and CPB temperature., Conclusions: Our results indicate that the temperature of systemic cooling during CPB is an important factor in the development of atrial fibrillation after CABG surgery. In addition, this study confirms that increasing age is a significant determinant of postoperative atrial fibrillation.

Objective: With increasing numbers of implantations, left ventricular assist device programs can put a financial strain on a hospital unless an efficient and safe outpatient program is developed. However, the left ventricular assist device is not widely recognized in the medical community as being reliable enough to support a patient at home. We reviewed our experience with these patients at home to assess the safety and the benefits of such a program., Methods: Our institutional 6-year experience with 90 consecutive recipients of a wearable left ventricular assist device was analyzed., Results: Forty-four (49%) of the 90 patients who received TCI vented-electric left ventricular assist devices (Thermo Cardiosystems, Inc, Woburn, Mass) were discharged, spending a total of 4546 days (12.5 years) at home with an average of 103 +/- 16 days of outpatient support (range 9-436 days). Of these 44 patients, all were successfully bridged to transplantation (42 patients, 96%) or planned explantation (2 patients, 4%). None of the outpatients died. The cumulative events per outpatient month were 0.020 for bleeding, 0.053 for device infection, 0.0068 for thromboembolus, and 0.020 for major malfunctions. Our estimated average cost to bridge a patient to transplantation or explantation once discharged is $13,200 and as an inpatient over the same length of time, including only room and board, is $165,200. Thirty percent of outpatients were able to return to work or school, 33% to sexual activity, and 44% to driving. All outpatients performed activities of daily living., Conclusion: Current left ventricular assist device technology provides effective and economical outpatient support and is associated with limited morbidity and a satisfactory quality of life.

Background: Stroke complicates the postoperative course in 1% to 6% of patients undergoing coronary revascularization. There has been no large scale mandatory database reporting on the incidence of stroke after coronary revascularization., Methods: A multicenter regional database from the Bureau of Health Care Research Information Services, New York State Department of Health, on 19,224 patients who underwent coronary revascularization in 31 hospitals within New York State during 1995 was analyzed to determine the risk factors for postoperative stroke., Results: The incidence of postoperative stroke was 1.4% (n = 270). Hospital mortality for patients who had a stroke was 24.8%, compared with 2.0% for the rest of the patient population. Postoperative stroke increased the hospital length of stay threefold (27.9+/-1.9 versus 9.1+/-0.9 days, p<0.0001). Multivariable logistic regression identified the following variables to be significantly associated with a postoperative stroke: calcified aorta (p<0.0001; odds ratio [OR], 3.013), prior stroke (p = 0.0003; OR, 1.909), age (p<0.0001; OR, 1.522 per 10 years), carotid arterial disease (p = 0.002; OR, 1.590), duration of cardiopulmonary bypass (p = 0.0004; OR, 1.27 per 60 minutes), renal failure (p = 0.0062; OR, 2.032), peripheral vascular disease (p = 0.0157; OR, 1.62), cigarette smoking (p = 0.0197; OR, 1.621), and diabetes mellitus (p = 0.0158; OR, 1.373)., Conclusions: Postoperative stroke increases mortality and length of stay after coronary revascularization. Several risk factors can be identified, and some of these factors are potentially amenable to intervention, either before or during coronary revascularization, and should also influence patient selection.

Background: Preoperative characteristics may influence morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). The CABG Patch Trial was designed to assess the impact of prophylactic insertion of an implantable cardioverter-defibrillator in patients undergoing high-risk CABG. This database was used to investigate the influence of symptomatic congestive heart failure (CHF) and angina on morbidity and mortality in CABG patients with ventricular dysfunction., Methods and Results: Data were analyzed for 900 randomized patients with an ejection fraction