Abstract PO-246: Supporting community health center patients in completing follow-up colonoscopy: A qualitative summary of patient navigation activities

Background Fecal immunochemical tests (FITs) are an acceptable and cost-effective way to identify patients at risk for colorectal cancer (CRC). However, patients who receive an abnormal FIT result must obtain a follow-up colonoscopy. Rates of follow- up colonoscopy are low in most healthcare settings, particularly in federally qualified health centers (FQHCs). Half of patients with an abnormal FIT result fail to complete this essential colonoscopy screening component. Patient navigation can provide much needed support for patients to complete the follow-up colonoscopy. Methods PRECISE is a patient-randomized trial of patient navigation vs usual care for follow-up colonoscopy that will enroll 1,200 patients across 28 community health center clinics in Washington State (anticipated 37% Latinx). For the study, we trained a bilingual (native Spanish speaker) patient navigator (PN) using an intensive 8-week program, based on the New Hampshire Colorectal Cancer Screening Program. As part of the recruitment and data tracking tool used by the PN, open text fields are available for documenting interactions with navigated patients. We present a qualitative content analysis of the open text fields of navigated patients. These findings identify a broad range of supportive interactions engaged in by the PN to assist patients in overcoming barriers to follow-up colonoscopy completion. Results To-date, 124 patients have been randomized to navigation, and 44 of these had open text field documentation. Our content analysis found slightly more than half (N=23) required more intensive navigation assistance for overcoming a variety of barriers such as fear of or misinformation about the colonoscopy; help with scheduling, transportation, and interpreter services; and assistance with obtaining and completing the bowel preparation. Those that needed less navigation (N=21) mostly required assistance with scheduling the colonoscopy and often had protective factors such as prior colonoscopy experience or support from family/friends for completing the procedure. Overall, the top three areas the PN tended to provide support for overcoming barriers included: contacting the gastroenterologist office to problem- solve issues like lack of referral, scheduling delays, or to obtain appointment information (40 instances); assisting the patient with obtaining, understanding, and completing the bowel preparation including diet restrictions, medication interaction, and preparing/consuming the mixture (25 instances); and verifying, coordinating, and offering transportation/escort support before and after the colonoscopy procedure (22 instances). Conclusion The PRECISE trial highlights the importance of targeted patient navigation to improve CRC screening completion. Our open text field findings demonstrate the necessary role of patient navigation for overcoming the multitude of educational and structural challenges facing FQHC patients when attempting to complete a follow-up colonoscopy.

Citation Format: Jennifer L. Schneider, Jennifer S. Rivelli, Jamie Thompson, Amanda Petrik, Neha Yadav, Hanna Dinh, Cindy Pulido, Shirley Mendez, DeeDee Torres, Gloria Coronado. Supporting community health center patients in completing follow-up colonoscopy: A qualitative summary of patient navigation activities [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-246.

Abstract PO-272: COVID-19 adaptations to patient navigation services for follow-up colonoscopy after an abnormal fecal test result in a community health center setting

The PRECISE study tests the effectiveness of a targeted patient navigation program for follow-up colonoscopy after an abnormal fecal test result in a community health center setting. We present adaptations and mid-study learnings related to the COVID-19 pandemic. Colorectal cancer (CRC) screening by annual fecal immunochemical test (FIT) is an accessible and cost-effective strategy to lower CRC incidence and mortality. However, this mode of screening depends on follow-up colonoscopy after an abnormal FIT result to prevent CRC or find it in early, treatable forms. Unfortunately, almost half of patients with an abnormal FIT result fail to complete this essential screening component, negating any benefit of FIT screening. Patient navigation can provide much needed support for patients to complete a follow-up colonoscopy. PRECISE is a patient-randomized trial of patient navigation vs usual care for follow-up colonoscopy that will enroll 1,200 patients across 28 community health center clinics in Washington state (anticipated 37% Latinx). As part of the study, we trained a bilingual (English and Spanish) patient navigator using an intensive 8-week program, based on the New Hampshire Colorectal Cancer Screening Program. The program included multiday trainings on CRC health

information, colonoscopy steps, patient navigator skills, the navigation protocol, data reporting; a full-day motivational interviewing training delivered by a professional trainer; and in-person meetings with schedulers at local gastroenterology (GI) offices. On March 13, 2020, study enrollment for PRECISE was suspended due to the COVID-19 pandemic during which time all non-urgent medical procedures, including colonoscopies, were canceled or delayed. We trained our patient navigator to outreach to all randomized patients for whom navigation was in process at the time of study suspension. We developed COVID-19-specific talking points, and the outreach protocol was modified to address colonoscopy scheduling delays. To-date, 252 patients have been randomized (124 to navigation and 128 to usual care).

Navigator conversations with local GI offices revealed several COVID-related GI practice changes: the pre-procedure consultation is generally delivered as a telehealth (phone-based) visit and COVID-19 testing is required prior to the colonoscopy. Furthermore, many practices mandate the use of face masks by patients and their escorts, and prohibit escorts from accompanying the patient in the pre-procedure area. We adapted navigator messages to address fear and anxiety about getting medical care during the peak COVID-19 pandemic. This innovative clinical trial highlights the importance of patient navigation to improve CRC screening in community health centers and examines COVID-19 adaptions to the navigation intervention.

Citation Format: Jamie Thompson, Jennifer Rivelli, Amanda Petrik, Jennifer Schneider, Neha Yadav, Hanna Dinh, Cindy Pulido, Shirley Mendez, DeeDee Torres, Lakshmi Penimarthi, Gloria Coronado. COVID-19 adaptations to patient navigation services for follow-up colonoscopy after an abnormal fecal test result in a community health center setting [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-272.

Growing up in Australia: paradox of overweight/obesity in children of immigrants from low-and-middle -income countries

Objective

Children of immigrants from low-and-middle-income countries show excess overweight/obesity risk relative to host populations, possibly due to socioeconomic disadvantage. The present study was conducted to estimate overweight/obesity prevalence and its association with the family socioeconomic-position in 2-11-year-old Australian-born children of immigrants and Australian-mothers.

Methods

A cross-sectional analysis of 10-year data from the Longitudinal Study of Australian Children was undertaken. Overweight/obesity was defined according to the International Obesity Taskforce, age-and sex-specific BMI cut-off-points.

Results

Approximately 24% children aged 2-3 years (22% sons, and 25% daughters), were overweight/obese with no significant difference between children of immigrants and Australian-mothers. Overweight/obesity prevalence consistently increased with age for sons of mothers from low-and-middle-income countries but not daughters. Adjusting for the family socioeconomic-position did not explain excess overweight/obesity in children of mothers from low-and-middle-income countries. The odds of overweight/obesity in sons were significantly higher at 8-9 years (OR 1.5; p = 0.03) and 10-11 years (OR 1.5; p = 0.03) and in daughters at 4-5 years (OR 1.7; p = 0.002) when the mothers were from low-and-middle-income countries.

Conclusion

Excess weight in children of immigrants is not due to socioeconomic disadvantage alone. Other social processes and interactions between immigrants and host cultures may be involved.

Human genome meeting 2016 : Houston, TX, USA. 28 February - 2 March 2016

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Gibbs P42 FANTOM5 web resource for the large-scale genome-wide transcription start site activity profiles of wide-range of mammalian cells T. Kasukawa, M. Lizio, J. Harshbarger, S. Hisashi, J. Severin, A. Imad, S. Sahin, T. C. Freeman, K. Baillie, A. Sandelin, P. Carninci, A. R. R. Forrest, H. Kawaji, The FANTOM Consortium P43 Rapid and scalable typing of structural variants for disease cohorts W. Salerno, A. English, S. N. Shekar, A. Mangubat, J. Bruestle, E. Boerwinkle, R. A. Gibbs P44 Polymorphism of glutathione S-transferases and sulphotransferases genes in an Arab population A. H. Salem, M. Ali, A. Ibrahim, M. Ibrahim P46 Genetic divergence of CYP3A5*3 pharmacogenomic marker for native and admixed Mexican populations J. C. Fernandez-Lopez, V. Bonifaz-Peña, C. Rangel-Escareño, A. Hidalgo-Miranda, A. V. Contreras P47 Whole exome sequence meta-analysis of 13 white blood cell, red blood cell, and platelet traits L. Polfus, CHARGE and NHLBI Exome Sequence Project Working Groups P48 Association of adipoq gene with type 2 diabetes and related phenotypes in african american men and women: The jackson heart study S. Davis, R. Xu, S. Gebeab, P Riestra, A Gaye, R. Khan, J. Wilson, A. Bidulescu P49 Common variants in casr gene are associated with serum calcium levels in koreans S. H. Jung, N. Vinayagamoorthy, S. H. Yim, Y. J. Chung P50 Inference of multiple-wave population admixture by modeling decay of linkage disequilibrium with multiple exponential functions Y. Zhou, S. Xu P51 A Bayesian framework for generalized linear mixed models in genome-wide association studies X. Wang, V. Philip, G. Carter P52 Targeted sequencing approach for the identification of the genetic causes of hereditary hearing impairment A. A. Abuzenadah, M. Gari, R. Turki, A. Dallol P53 Identification of enhancer sequences by ATAC-seq open chromatin profiling A. Uyar, A. Kaygun, S. Zaman, E. Marquez, J. George, D. Ucar P54 Direct enrichment for the rapid preparation of targeted NGS libraries C. L. Hendrickson, A. Emerman, D. Kraushaar, S. Bowman, N. Henig, T. Davis, S. Russello, K. Patel P56 Performance of the Agilent D5000 and High Sensitivity D5000 ScreenTape assays for the Agilent 4200 Tapestation System R. Nitsche, L. Prieto-Lafuente P57 ClinVar: a multi-source archive for variant interpretation M. Landrum, J. Lee, W. Rubinstein, D. Maglott P59 Association of functional variants and protein physical interactions of human MUTY homolog linked with familial adenomatous polyposis and colorectal cancer syndrome Z. Abduljaleel, W. Khan, F. A. Al-Allaf, M. Athar , M. M. Taher, N. Shahzad P60 Modification of the microbiom constitution in the gut using chicken IgY antibodies resulted in a reduction of acute graft-versus-host disease after experimental bone marrow transplantation A. Bouazzaoui, E. Huber, A. Dan, F. A. Al-Allaf, W. Herr, G. Sprotte, J. Köstler, A. Hiergeist, A. Gessner, R. Andreesen, E. Holler P61 Compound heterozygous mutation in the LDLR gene in Saudi patients suffering severe hypercholesterolemia F. Al-Allaf, A. Alashwal, Z. Abduljaleel, M. Taher, A. Bouazzaoui, H. Abalkhail, A. Al-Allaf, R. Bamardadh, M. Athar

Change and stability in work-family conflict and mothers' and fathers' mental health: Longitudinal evidence from an Australian cohort

Work-family conflict (WFC) occurs when work or family demands are 'mutually incompatible', with detrimental effects on mental health. This study contributes to the sparse longitudinal research, addressing the following questions: Is WFC a stable or transient feature of family life for mothers and fathers? What happens to mental health if WFC increases, reduces or persists? What work and family characteristics predict WFC transitions and to what extent are they gendered? Secondary analyses of 5 waves of data (child ages 4-5 to 12-13 years) from employed mothers (n = 2693) and fathers (n = 3460) participating in the Longitudinal Study of Australian Children were conducted. WFC transitions, across four two-year intervals (Waves 1-2, 2-3, 3-4, and 4-5) were classified as never, conscript, exit or chronic. Significant proportions of parents experienced change in WFC, between 12 and 16% of mothers and fathers for each transition 'type'. Parents who remained in chronic WFC reported the poorest mental health (adjusted multiple regression analyses), followed by those who conscripted into WFC. When WFC was relieved (exit), both mothers' and fathers' mental health improved significantly. Predictors of conscript and chronic WFC were somewhat distinct for mothers and fathers (adjusted logit regressions). Poor job quality, a skilled occupation and having more children differentiated chronic fathers' from those who exited WFC. For mothers, work factors only (skilled occupation; work hours; job insecurity) predicted chronic WFC. Findings reflect the persistent, gendered nature of work and care shaped by workplaces, but also offer tailored opportunities to redress WFC for mothers and fathers. We contribute novel evidence that mental health is directly influenced by the WFC interface, both positively and negatively, highlighting WFC as a key social determinant of health.

Adsorption of four perfluorinated acids on non ion exchange polymer sorbents

Perfluorinated compounds (PFCs) have attracted global concern due to their ubiquitous distribution and properties of persistence, bio accumulation and toxicity. The process of adsorption has been identified as an effective technique to remove PFCs in water. Different non ion-exchange polymeric adsorbents were tested with regard to their sorption kinetics and isotherms at low PFCs concentrations. Selected PFCs were perfluorobutanoic acid (PFBA), perfluoroheptanoic acid (PFHpA), perfluorooctanoic acid (PFOA) and perfluorodecanoic acid (PFDA) and the tested polymers were three types of Dowex optopores (V-493, V503, and L493), Amberlite XAD-4, and Filtrasorb 400 (Granular Activated Carbon-GAC). We observed the selective adsorption of PFCs on synthetic polymers. For PFDA, Amberlite XAD-4 gave the Freundlich adsorption constant of 2,965 (microg PFCs/g sorbent)(microg PFCs/L)(-n), which was higher than that of GAC (121.89 (microg PFCs/g sorbent) (microg PFCS/L)(-n)). In the case of PFBA, GAC showed better performance (13.36) (microg PFCs/g sorbent) microg PFCS/L)(-n) than synthetic polymers (0.62-5.23) (microg PFCs/g sorbent) (microg PFCS/L)(-n). Adsorption kinetics of all adsorbents were well described (R2 = 0.85-1) by pseudo-second order kinetic model. Sorption capacity was influenced by initial PFCs concentration for all adsorbents. GAC reached the equilibrium concentration within 4 hours, Amberlite XAD 4 reached it within 10 hours and other polymers took more than 70 hours.

Testosterone inhibits early atherogenesis by conversion to estradiol: critical role of aromatase

The effects of testosterone on early atherogenesis and the role of aromatase, an enzyme that converts testosterone to estrogens, were assessed in low density lipoprotein receptor-deficient male mice fed a Western diet. Castration of male mice increased the extent of fatty streak lesion formation in the aortic origin compared with testes-intact animals. Administration of anastrazole, a selective aromatase inhibitor, to testes-intact males increased lesion formation to the same extent as that observed with orchidectomized animals. Testosterone supplementation of orchidectomized animals reduced lesion formation when compared with orchidectomized animals receiving the placebo. This attenuating effect of testosterone was not observed when the animals were treated simultaneously with the aromatase inhibitor. The beneficial effects of testosterone on early atherogenesis were not explained by changes in lipid levels. Estradiol administration to orchidectomized males attenuated lesion formation to the same extent as testosterone administration. Aromatase was expressed in the aorta of these animals as assessed by reverse transcription-PCR and immunohistochemistry. These results indicate that testosterone attenuates early atherogenesis most likely by being converted to estrogens by the enzyme aromatase expressed in the vessel wall.

Tumour-growth inhibition by induced hyperglycaemia/hyperlactacidaemia and localized hyperthermia

The present study was undertaken to exploit pathophysiological properties of solid tumours for a tumour-specific therapy. Experiments were carried out on DS-sarcomas implanted s.c. in the hind foot dorsum of Sprague Dawley rats. Treatment strategies included tumour acidification, lactate accumulation and disturbance of the microcirculation by induced systemic hyperglycaemia/hyperlact-acidaemia (15-25/10 mmol/L; for 60 min) as well as localized hyperthermia (water-bath; 43 degrees C, 30 min.). A special infusion solution was developed for the systemic treatment containing glucose, lactic acid and organic buffer without inorganic ions. Growth kinetics of tumour volume and animal survival were taken as endpoints in order to quantify therapeutic efficiency. After a single treatment with combined modalities, i.e., with hyperglycaemia/hyperlactacidaemia and hyperthermia, approximately 50% of the tumours showed complete remission in three independent series of experiments; around 40% of the animals survived more than two months. In the untreated control group, all animals died from the disease within 10-15 days after tumour implantation. The overall effect on tumour volume changes of the combined therapy was supra-additive compared to that of treatment with hyperthermia or hyperglycaemia/hyperlactacidaemia alone. However, treated animals either showed a dramatic response to the combination of treatments with complete tumour remission or hardly responded at all, justifying a subdivision into responders and non-responders. Pathophysiological mechanisms responsible for this behaviour have to be elucidated in future studies. Nevertheless, the present study represents an approach to an efficient tumour therapy with a potential application in clinical oncology in the not too distant future.

Uniformity of captopril benefit in the SAVE Study: subgroup analysis. Survival and Ventricular Enlargement Study

The Survival and Ventricular Enlargement (SAVE) Study demonstrated that long-term administration of the angiotensin-converting enzyme inhibitor captopril to recent survivors of myocardial infarction with left ventricular dysfunction resulted in a reduction in cardiovascular mortality and morbidity. Analysis of multiple subgroups demonstrated that baseline demographics (older age) and clinical characteristics (such as prior MI, history of diabetes or hypertension), that have previously been associated with a higher risk of cardiovascular events, were associated with greater end point event rates in SAVE regardless of therapy assignment at the time of randomization. The effectiveness of captopril therapy in reducing cardiovascular mortality and morbidity was examined in multiple subgroups. Although not all subgroups provided adequate statistical power, the benefits of captopril therapy were relatively uniform in the SAVE study. This indicates that the benefits were not confined to one particular subgroup and conversely that targeting of captopril therapy should be to the broadest group, as defined by SAVE entry criteria, to result in a reduction in cardiovascular mortality and morbidity.

Exercise increases the circulating concentration of the N-terminus of the atrial natriuretic factor prohormone in normal individuals

Recently two peptides consisting of amino acids (aa) 1 to 30 and 31 to 67 of the N-terminus of the 126 aa prohormone of atrial natriuretic factor (proANF), as well as atrial natriuretic factor (ANF, aa 99 to 126; C-terminus), were found to have vasodilatory and natriuretic properties. These peptides, as well as ANF, circulate in humans as part of the N-terminus of the prohormone. To determine the effect of graded exercise on the circulating concentrations of the N-terminus and C-terminus of the ANF prohormone in normal persons, 12 healthy individuals (mean age 45 +/- 2 years) were evaluated before, for 2 hours after, and during bicycle exercise at a work loads of 25, 50, 75, 100, 125, 150, and 175 W. Both the N- and C-terminus of the ANF prohormone were released simultaneously with graded exercise in direct proportion to the intensity of the work load, measured objectively via maximal oxygen consumption (VO2max), respiratory quotient, and heart rate. Both the N-terminus and C-terminus of the ANF prohormone had strong positive correlations (p less than 0.001) with blood pressure, heart rate, VO2max, and respiratory quotient. Following exercise, the C-terminus returned to preexercise levels within 30 minutes, while the N-terminus remained significantly elevated at 30 and 60 minutes postexercise, reflecting the longer half-life of the N-terminus in the circulation.

Acute and sustained release of the atrial natriuretic factor prohormone N-terminus with acute myocardial infarction

This investigation was designed to determine if acute ischemic cardiac injury causes the release of the 98 amino acid (aa) N-terminus of the 126 aa atrial natriuretic factor prohormone (pro ANF). Seventeen patients with acute myocardial infarction, but without clinical evidence of congestive heart failure, had their circulating concentrations of the whole N-terminus (ie, pro ANF 1-98), the midportion of the N-terminus of the ANF prohormone (consisting of aa 31-67; pro ANF 31-67) and creatine phosphokinase (CPK) monitored daily for 14 days. All seventeen patients had elevated plasma pro ANF 1-98 and pro ANF 31-67 concentrations at the time of presentation. Maximal increase on day three post-infarction correlated with the size of infarction estimated by the maximal CPK (r = 0.675; p less than 0.05) but did not correlate with the amount of left ventricular dysfunction. Another three patients with acute myocardial infarction were treated with tissue plasminogen activator (tPA). The measured pro ANF 1-98 and pro ANF 31-67 levels in these patients were within our normal range and significantly lower (p less than 0.001) than seen in patients with acute myocardial infarction not given thrombolytic therapy. Six patients with unstable angina, likewise, had normal circulating pro ANFs 1-98 and 31-67 concentrations during prolonged episodes of chest pain. These data suggest that myocardial necrosis but not ischemia triggers the release of the entire 126 aa prohormone.

Prohormone atrial natriuretic peptides 1-98 and 31-67 increase with exercise in congestive heart failure patients

Recently two peptides consisting of amino acids (a.a.) 1-30 and 31-67 of the N-terminus of the 126 a.a. prohormone of atrial natriuretic factor (pro ANF), as well as atrial natriuretic factor (ANF, a.a. 99-126; C-terminus) were found to have vasodilatory and natriuretic properties. These peptides, as well as ANF, circulate in man as part of the N-terminus of the prohormone. To determine the effect of graded exercise on the circulating concentration of the N-terminus and C-terminus of the ANF prohormone in persons with abnormal salt and water metabolism, 12 individuals with stable congestive heart failure (CHF) were evaluated before and after bicycle exercise testing and the results were subdivided based on the maximal exercise they could achieve. In all of the CHF patients, the circulating concentration of the whole N-terminus (ie, a.a. 1-98), the midportion of the N-terminus (pro ANF 31-67), which circulates as a distinct 3900 molecular weight (m.w.) peptide after being proteolytically cleaved from the N-terminus, and the C-terminus (ANF) increased with exercise. The patients who were able to achieve 100 and 125 watts of workload had a greater maximal oxygen consumption and, in general, a greater percent increase in the circulating concentration of both the N-terminus and the C-terminus of the ANF prohormone than those who had less exercise capacity. Evaluation of the echocardiographic, radionucleotide, and the exercise parameters revealed that the circulating concentrations of these atrial peptides correlated best with left atrial dimension, but that left ventricular systolic and diastolic dimensions also correlated positively with their concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute and sustained release of atrial natriuretic factor with acute myocardial infarction

The present investigation was designed to determine if acute ischemic cardiac injury causes the release of atrial natriuretic factor (ANF). Seventeen patients with acute myocardial infarction but without clinical evidence of congestive heart failure had their circulating concentration of ANF and creatine phosphokinase monitored daily for 14 days. All 17 patients had an elevated plasma ANF concentration at time of presentation. Maximal increase in ANF was on day 2 and 3 post-infarction. This maximal increase correlated with the size of infarction estimated by the maximal creatine phosphokinase concentration (r = 0.475; p less than 0.05), but did not correlate with the amount of left ventricular dysfunction. ANF began to decrease by day 4 post-infarction and was normal at 10 days post-infarction in 14 of the 17 (82%) patients. At 12 days post-infarction, all 17 patients had normal ANF levels. Another three patients with acute myocardial infarction were treated with tissue plasminogen activator (tPA). The measured ANF levels in these patients were within our normal range and were significantly lower (p less than 0.001) than those seen in patients with acute myocardial infarction not given thrombolytic therapy. Six patients with unstable angina likewise had normal circulating ANF concentrations during prolonged episodes of chest pain. These levels were also significantly lower (p less than 0.001) than the 17 patients with acute infarcts not given tPA. The distinct pattern of release of ANF may be useful as an adjunct to serum cardiac enzymes in determining if a myocardial infarction has occurred.

Increased plasma concentration of atrial natriuretic factor with squamous cell carcinoma invasion of the right and left atria of the heart

Atrial natriuretic factor is a new peptide hormone synthesized in the heart which has potent natriuretic, diuretic, and vasodilatory properties. A 47-year-old man with squamous cell carcinoma of the lung resected 6 months previously presented with syncope secondary to hypotension and a low serum sodium. He was evaluated to determine if atrial natriuretic factor (ANF) might be the etiology of this clinical picture. His plasma concentration of atrial natriuretic factor was increased three-fold over that of 70 normotensive person. Further evaluation revealed metastatic lesions in the right and left cardiac atria with the mass on the left occluding 75% of the left atrial chamber. The mass effect in the atria increasing atrial stretch and atrial pressure one would expect was the main contributor to the increased ANF level. The contribution of direct tumor invasion into the atria and/or production of atrial natriuretic factor by the tumor itself to produce this elevated plasma level of atrial natriuretic factor could not be determined, but this markedly elevated level of atrial natriuretic factor does appear to be the etiology of this patient's clinical picture.

Chronic cor pulmonale

Chronic cor pulmonale is defined as right heart hypertrophy and/or chronic right heart failure. There are many etiologies, but the common cause is increased right heart work from pulmonary hypertension. Etiology can be conveniently discussed by assuming two prototypes, the asphyxial or hypoxic type and the vascular obliterative type. A common cause of the asphyxial type is chronic obstructive pulmonary disease, and the obliterative type is represented by chronic pulmonary thromboembolic disease or primary pulmonary hypertension. Pathology is discussed, emphasizing the cardiac manifestations of chronic cor pulmonale including data of specific cardiac chamber size. An overview of hemodynamics is given, and the use and limitation of electrocardiography and chest x-rays are discussed. The exciting potential use of echocardiography for the serial non-invasive measurement of anatomical and pathophysiological features is outlined, along with the value of a careful physical examination and the proper utilization of laboratory tests in the diagnosis of chronic cor pulmonale. In the patient with the asphyxial type, the treatment of pulmonary infectious exacerbations, the role of corticosteroids, digoxin, diuretics, phlebotomy, bronchodilators (theophylline, beta adrenergic agonists, and anticholinergics), and long-term oxygen therapy is noted. The controversy surrounding the use of vasodilators and calcium blockers in these patients is discussed. Treatment aspects of the vascular obliterative type, including the role of vasodilators, calcium blockers, prostacyclin, anticoagulants, and overall strategy are discussed. A brief note is mentioned of the promising role of surgical therapy in chronic thromboembolic disease causing chronic cor pulmonale.

Sustained therapeutic efficacy and safety of oral propafenone for treatment of chronic ventricular arrhythmias: a 2-year experience

Thirty-two men with chronic ventricular arrhythmias responded to propafenone, a new potent antiarrhythmic agent, in short-term trials with 85% or greater reduction of total ventricular premature complexes (VPCs) per hour, 95% or greater reduction of ventricular couplets (VCs) per hour, and 100% abolition of ventricular tachycardia (VT) beats per 24 hours. These patients were continued on long-term propafenone therapy to assess sustained therapeutic efficacy and safety. Thirty patients completed 1 year and 26 patients completed 2 years of testing with this agent; one patient died of sudden death and another died of a noncardiac cause. Although there were significantly fewer patient responders at 1 and 2 years, the majority of patients (greater than 79%) continued to respond optimally to propafenone. Side effects were minor and included bitter taste, dizziness, congestive heart failure, fatigue, and significant prolongation of the PR and QRS intervals. Propafenone has sustained antiarrhythmic efficacy after 2 years without serious toxicity.

Recent progress in the electrocardiographic diagnosis of ventricular hypertrophy

The surface electrocardiogram remains an insensitive method for detection of ventricular hypertrophy. Technical problems related to body size and habitus and distance from the heart cannot be overcome. Coronary arterty disease and amyloidosis, although frequently associated with hypertrophy, tend to obscure the electrocardiographic changes because of the attendant loss of voltage. The progress made in the last 20 years is due primarily to re-evaluation of traditional criteria in terms of careful anatomic correlation. The studies cited have the advantage of using specific clinical diagnoses in a defined population, specific chamber weights, and a 97.5 percentile confidence level for distinguishing normal pathologic and electrocardiographic data from abnormal. They are limited because the results may not apply to females or patients with mitral stenosis and congenital heart disease. In general, the electrocardiogram can be expected to detect left ventricular hypertrophy in six out of ten patients with the disease, and will misdiagnose the problem in about one out of every ten without the disease. Methodology using multiple criteria will achieve the best sensitivity and specificity. Several methods are available and of comparable accuracy. Simplicity of these methods varies widely and will be a factor in the choice of the method selected. The electrocardiogram will perform best in the population of patients with hypertension and aortic stenosis or regurgitation and have its greatest limitation in patients with coronary artery disease and myocardial infarctions. Echocardiography is proven to be more sensitive than the electrocardiogram for detection of left ventricular hypertrophy. Sensitivity is around 90 per cent with 95 per cent specificity. Its major limitations lie in the expense as compared to the electrocardiogram and in inadequate image resolution in a small proportion of patients. In order to achieve the results reported by centers proficient in this technique, careful attention must be paid to precise standardization of measurements and selection of images to be measured. When this is done the echocardiogram certainly offers a distinct advantage over the electrocardiogram in detecting left ventricular hypertrophy. We recommend the use of left atrial abnormality as a criterion to diagnose left ventricular hypertrophy when there is right bundle branch block. When left bundle branch block is present on the electrocardiogram, traditional criteria are probably no more accurate than the bundle branch block itself.(ABSTRACT TRUNCATED AT 400 WORDS)

QRS voltage measurements in autopsied men free of cardiopulmonary disease: a basis for evaluating total QRS voltage as an index of left ventricular hypertrophy

Use of total 12-lead QRS electrocardiographic voltage as a criterion for left ventricular (LV) hypertrophy has been of recent interest. Although upper and lower limits of QRS voltage for individual electrocardiographic leads have been reported in clinically healthy men and women, the upper limit of total 12-lead QRS voltage has not been established in adults free of cardiopulmonary disease by clinical and necropsy criteria. Therefore, the total QRS voltage from all 12 electrocardiographic leads was determined in 30 autopsied men known to be free of cardiopulmonary disease by clinical assessment and by a special cardiac examination using postmortem coronary angiography and chamber partition determination of LV weight. Gross heart weight, LV weight and total QRS voltage are reported. Comparisons were made between disease-free patients and previously reported patients with aortic valve stenosis, aortic regurgitation and cardiac amyloidosis with respect to total QRS voltage and gross heart weight. Total QRS voltage and gross heart weight were significantly greater in patients with severe aortic stenosis (mean 245 mm) and severe aortic regurgitation (mean 274 mm) than in our patients (mean 127 mm). Total QRS voltage was significantly less, whereas gross heart weight was significantly greater in patients with cardiac amyloidosis (mean 101 mm) than in our normal subjects (mean 127 mm). These data provide a basis for evaluating the total 12-lead QRS voltage as a criterion for LV hypertrophy.

Effect of propafenone on left ventricular ejection fraction

The effects of orally administered propafenone on ejection fraction (EF) determined by radionuclide angiography were studied in 2 groups of patients receiving different dosing regimens. Fourteen group A patients had no clinical evidence of left ventricular (LV) dysfunction and were not receiving digoxin therapy. In this group a mean daily dosage of 879 mg resulted in a decrease in resting LVEF from 52 +/- 9% to 48 +/- 11% (p less than 0.05). Eight group B patients had clinical radionuclide evidence of LV dysfunction and were receiving digoxin therapy. In this group, a daily dosage of propafenone of 600 mg/day resulted in no significant change in LVEF. No clinically significant effects on cardiac compensation were evident in either group. These data suggest a negative inotropic effect that is either related to propafenone dosage or at least partially attenuated by digoxin therapy. Further studies are necessary to define precisely the effects of propafenone on LV function.

Relation of right ventricular ejection fraction to exercise capacity in chronic left ventricular failure

Although the left ventricle is traditionally viewed as the heart's main pumping chamber, no correlation has been shown between left ventricular (LV) ejection fraction (EF) at rest and exercise capacity in patients with chronic LV failure. Because vasodilators with venodilating activity increase exercise capacity more than predominant arterial dilators in patients with LV failure, right ventricular (RV) function may relate to exercise capacity in these patients. In 25 patients with chronic LV failure, caused by coronary artery disease in 12 patients and idiopathic dilated cardiomyopathy in 13 patients, RVEF and LVEF at rest were measured by radionuclide angiography. Maximal upright bicycle exercise testing was also performed to determine maximal oxygen consumption, which averaged only 13 +/- 4 ml/min/kg. The LVEF at rest was 26 +/- 10% and did not correlate with maximal oxygen consumption (r = 0.08). However, the RVEF was 41 +/- 12% and correlated with maximal oxygen consumption (r = 0.70, p less than 0.001) in the same patients. The correlation was stronger (r = 0.88) in patients with coronary artery disease than in those with idiopathic dilated cardiomyopathy (r = 0.60). Thus, RVEF at rest is more predictive of exercise capacity than LVEF in the same patients with chronic LV failure. These results are consistent with the clinical observation that only venodilating agents increase exercise capacity of patients with chronic LV failure.

Effect of propafenone in patients with stable ventricular arrhythmias

Thirty patients with clinically significant ventricular ectopy were treated with propafenone, a new potent antiarrhythmic agent with membrane stabilizing action. Patients had a minimum mean of greater than 30 ventricular premature beats per hour documented by continuous 48-hour ambulatory ECG recording. Twenty-five patients qualified as responders, defined as greater than 85% reduction of ventricular ectopy compared to baseline, and completed a double-blind placebo-crossover phase. Significant reduction in single ventricular ectopy per hour, paired ventricular ectopy per hour, and ventricular tachycardia beats per hour were observed. Almost total abolition of ventricular tachycardia and paired ventricular ectopy was achieved. Side effects were minimal and well tolerated. A significant prolongation of the PR interval occurred. QRS prolongation and prolongation of the corrected QT interval was observed in some patients, with new left bundle branch block developing in two patients. Long-term efficacy and safety studies will be necessary to determine the ultimate role of this new agent in the selection of antiarrhythmic therapy, but these initial results are encouraging.