Class of 2013 Abstract / Specific Aims: To examine the relationship between hospital readmission rates and responses to a medication adherence questionnaire (Morisky) in patients with congestive heart failure (CHF). Methods: The Morisky questionnaire, assessing medication adherence, was administered to all CHF patients admitted from September 15, 2012 to March 7, 2013. Information collected from the electronic medical record (EMR) for all patients with complete Morisky questionnaires included: age, sex, ethnicity, insurance, height, weight, marital status, tobacco use, alcohol use, number of home medications, all-cause and CHF admission in the previous 365 days from when the questionnaire was administered as well as the following events/disease states: myocardial infarction, hypertension, atrial fibrillation, stroke, diabetes mellitus, peripheral vascular disease, chronic obstructive pulmonary disease, congestive heart disease and chronic kidney disease. Main Results: Of the 120 patients enrolled, 52% scored 1-5 on the Morisky questionnaire indicating some problem with medication adherence while 48% scored 0 (no problems). There was no correlation between the Morisky score and age (95% CI: -3.3-5.7), number of medications (95% CI: -0.26, 2.85), or number of comorbidities (95% CI: -1.02,0.03). The Morisky questionnaire was not predictive of all cause readmissions (95% CI: 0.35, 2.01) p = 0.691). For CHF readmissions the Morisky score was not significant (95% CI: 0.6, 4.11, p=0.358) but the confidence interval suggests a trend. Conclusion: There is no correlation between Morisky scores, age, comorbidities, and medication number. Readmission rates were not predicted by Morisky scores; with more participants a trend may be detected for CHF readmissions.

Rate of readmission among hospitalized heart failure (HF) patients is used as an indicator of quality and efficiency of healthcare. A low sodium diet is a component of the accepted treatment for HF. Instruction by dietitians may help reduce dietary sodium without negatively affecting quality of life. The effect of low sodium diet education on hospital readmission within 30 and 45 days of discharge for HF patients (N=52) was conducted. Chi-square analysis determined education did not significantly affect remittance within 30 (P=.143) or 45 days (P=.474). Patients readmitted within 30 days were older (P=.005). Men were more likely to be readmitted than women within 30 (P=.021) and 45 days (P=.019). Higher NT-proBNP levels were observed in individuals readmitted within 30 (P=.011) and 45 days (P=.010). Low sodium diet education did not affect readmission but older age, male sex, and higher NT-proBNP values increased the rate of readmission.

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Recent work has found that a frequency domain and time domain analysis of the heart rate variability signals can provide significant insights into function of the heart in healthy subjects and in patients with heart disease. Patients with congestive heart failure are an important clinical health issue and it is hoped that this work will contribute towards gaining knowledge of this debilitating pathological condition. Our laboratory has recently acquired more than three thousand 24-hour ECG tapes recorded during called Study of Left Ventricular Dysfunction (SOLVD). The SOL VD trial was conducted between 1987-1990 to test the efficacy of a medication called, Enalapril, to treat patients with heart failure. There were an equal number of patients with (group A) and without overt heart failure (group B). The work reported in this thesis describes the development of a hardware and software framework used to analyze the ECG signals recorded on these tapes. Primary objective of this work was to develop and test a system which would assist in analyzing the above tapes so as to examine if there are differences between two groups using the HRV parameters from both frequency and time domain. The research was conducted in three steps: Hardware design, software and algorithm development and finally the validation phase of the design, to test the usefulness of the overall system. The tapes were replayed on a tape recorder and the ECG was digitized at a rate corresponding to 500 samples/second. Labview software was invoked for this task. Secondly a set of algorithms were developed to perform QRS-detection and QT-interval identification. The detection algorithms involved placing critical ECG fiducials onto the ECG waveform through the use of a trained model. The model construction used patient specific pre-annotated data coupled with statistical and genetic algorithm techniques. The beat-to-beat HRV signal was thus generated using the annotation data from the ECG. Frequency domain indices were obtained using power spectral computation algorithms while time domain statistical indices were computed using standard methods. QT-interval algorithms were tested using a set of manually and automatically tagged set of beats from a sample of subjects. For the third part of this research, i.e. validation phase, we set up a test pool of 200 tapes each from patients with overt heart failure and with no heart failure, recorded at the baseline before the subjects entered the study. This phase of the study was conducted with the help of a statistician in a blinded fashion. Our results suggest that there is significant difference between frequency domain and time domain parameters computed from the HRV signals recorded from subjects belonging to group A and group B. The group A patients had a lot of ectopic beats and were challenging to analyze. These results provide a confirmation of our analytical procedures using real clinical data. The QT-analysis of the ECG signals suggest that automatic analysis of this interval is feasible using algorithms developed in this study. / Thesis / Master of Applied Science (MASc)

The purpose of this investigation was to examine the potential differences in autonomic nervous system adaptations, as assessed by heart rate variability techniques, between a group of stabilized CHF patients randomized to either a training group (aerobic+resistance) or a control group (usual care). In a single-blind, randomized controlled trial of 3-months of supervised exercise training and a further 3-months of home-based exercise, 28 stabilized CHF patients (NYHA 1-111) were randomized to either a training (AERWT) (n=16;11M,5F; age, 64.9±2.3; LVEF, 29.4±1.7%) or usual care (UC) (n=12; 10M,2F; age, 58.0±2.8; LVEF, 24.4±2.0%) group. Upon completion of the supervised exercise program, the AERWT group increased peak oxygen uptake (V02) (13.2±0.5 to 15.5±0.84 ml/kg/min, p<0.05), and single-arm curl scores (16.2±2.8 to 19.2±3.3 kg, p<0.05) significantly compared to the UC group, without any deleterious effect upon clinical status or left-ventricular function (LVEF: 31.3±1.7 to 33.2±1.9%, p=0.99). Physical training reduced expired ventilation and carbon dioxide based on successive workloads during symptom-limited incremental cycle ergometry in the AERWT group; however, this was found to be non-significant, in addition to changes in resting heart rate, anaerobic threshold, maximal exercise duration, maximal power output, and double product following training. Supine, resting power spectral indices remained unchanged from baseline to 6-months in both groups, as did the recovery of power spectral indices during supine rest following a symptom-limited incremental cycle ergometry test. A qualitative comparison of the power spectral changes from supine to standing revealed no significant differences between groups with respect to improvements in the baroreceptor response to orthostatic stress. Time domain parameters, derived from 24-hour ambulatory bolter monitoring, were also obtained at baseline, 3-months, and 6-months. The indices believed to be largely representative of vagal modulation, SDNN-Index, r-MSSD, and pNN50, tended to increase in the AERWT group with increased participation in the training program; however, the results did not obtain statistical significance (p=0.07). In addition, there were no significant changes in mean 24-hour heart rate or NN-interval, SDNN, or SDANN in the AERWT group (p=0.21). The present investigation revealed some evidence to suggest that exercise training in selected populations of CHF patients results in favourable changes in vagal modulation and baroreceptor sensitivity; however, unlike Coats et al. (1992), the present investigation failed to note any significant alterations in HRV frequency domain indices as a result of exercise training despite identical improvements in peak V02. The lack of significant findings in both the frequency and time domain HRV data could indicate that the autonomic dysfunction is so widespread and rampant in CHF that we cannot induce alterations through training as would be demonstrated in normal, healthy controls. In effect, these findings reinforce the hypothesis that in CHF the heart is the 'slave' of the periphery, and that due to the progressive lack of neural control of both the heart and circulation, in addition to an impairment in pump function, that the only effective means of improving physiological variables is through changes at the peripheral level. / Thesis / Master of Science (MS)

Appendum consists of last two leaves. / Copies of author's previously published articles inserted. / Bibliography: leaves 241-283. / xviii, 284 leaves : ill. ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / The studies described were designed to identify and address (through the application of relatively novel and potentially useful adjunctive therapeutic strategies) some of the determinants of sub-optimal therapeutic response in intermediate coronary syndrome and chronic congestive heart failure; especially when targeted towards those patients who fail to gain the maximal benefit from pre-existing modalities of pharmacological treatment. / Thesis (Ph.D.)--University of Adelaide, Dept. of Medicine, 1999

A descriptive design was used in this study to describe the feeding behaviors (as defined by changes in body position) in infants with congestive heart failure secondary to congenital heart disease. In addition, short term physiologic changes associated with the behaviors were measured through the use of pulse oximetry and cardiorespiratory monitors. Nine infants were observed in this study as they were being fed by their nurses. The method chosen was naturalistic observation. Descriptive statistics were used to analyze the demographic data and the measured physiologic variables. A point by serial correlation was conducted to describe any relationships between the position changes and the measured physiologic variables. Statistically significant relationships were found between certain positions and oxygen saturation, heart rate and respiratory rate. The results indicate that infants do experience position changes that are accompanied by changes in physiologic variables during feeding. These position changes can be categorized as infant-mediated or nurse-mediated.

The physiological and clinical considerations of centrifugal and axial pumps as ven- tricular assist devices (VADs) demands limitations on the power, size and geometry of the impellers. A typical pump design method is to rely on the characteristics of previously designed pumps with known performance using empirical equations and nondimensional parameters based on uid dynamics similarity law. Such data are widely available for industrial pumps operating in Reynolds number region of 108. VADs operate in Re < 106 and therefore the similarity concept does not apply between the industrial diagrams and the medical application of small pumps. The present dissertation employs a parametric approached analytical model to in- vestigate more than 150 axial and centrifugal pumps. The design parameters are optimised using the response surface methodology. The effect of different design parameters on the performance, force analysis and hemocompatibility of the pumps is thoroughly investigated by modelling the haemolysis through a power-law equation. The results show an explicit and consistent relationship between the number of blades, outlet width, outlet angle and the hemocompatibility of the device. Centrifu- gal pumps showed signi cantly lower probability of blood complications compared to axial pumps. The evaluation of the design characteristics helps pump designers to select their parameters accordingly for a low probability of blood complications. Furthermore, experimental techniques are employed to test more than 70 pumps in different conditions of flow, pressure and rotational speed. The experimental results validate the numerical simulations and create a database of empirical equations and data points for small axial and centrifugal pumps. The specifi c speed and speci fic diameters of the pumps are plotted on an ns − ds diagram to enable preliminary design of small pumps for VADs suitable for different stages of congestive heart failure (CHF).

Orientador: Aparecido Antônio Camacho / Banca: Evandro Zacché Pereira / Banca: Maria Lucia Gomes Lourenço / Banca: Antonio Sergio Ferraudo / Banca: Aureo Evangelista Santana / Resumo: Cães com degeneração mixomatosa da válvula mitral (DMVM) estadiados na classe II-ISACHC da insuficiência cardíaca congestiva apresentam diversas alterações dentro do estágio clínico. Evidenciando-se um ou mais sinais clínicos, aumento de câmaras cardíacas, alterações no ritmo e frequência cardíaca, bem como variabilidade da frequência cardíaca, relacionando-se ao maior ou menor predomínio do sistema nervoso autonômico parassimpático. O objetivo deste estudo foi determinar a possível existência de subclasses dentro da classe II e conhecer as variáveis que diferenciariam estas subclasses. Foram utilizadas vinte e duas variáveis na análise multivariada de 15 cães pertencentes à classe II-ISACHC da ICC. Por meio da análise de agrupamento pelo método hierárquico e não hierárquico, foram determinadas três subclasses excludentes (subclasse S1, subclasse S2 e subclasse S3). Foi possível relacionar a subclasse S1 com as variáveis de variabilidade da frequência cardíaca (e.g. NNm, PNN>50%), a subclasse S3 com as variáveis de remodelamento cardíaco (e. g. AE/Ao, DIVEd/Ao, FE%) e a subclasse S2 com câmara ventricular direita (e.g. DIVDd/Ao). Posterior à análise exploratória de fatores foram determinados três fatores (PSNA, RCFS e VDST) que relacionam as variáveis inclusas em cada fator com as subclasses. O PSNA incluiu as variáveis de variabilidade da frequência cardíaca e frequência cardíaca, o RCFS incluiu as variáveis de remodelamento cardíaco e função sistólica e o VDST integra a câm... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The dogs with myxomatous mitral valve degeneration (MMVD) staged in class II-ISACHC of congestive heart failure (CHF) have several changes within the clinical stage. Evidencing one more clinical signs, increased heart chambers, changes in heart rate and rhythm, changes in heart rate variability relating to the greater or lesser prevalence of the parasympathetic autonomic nervous system. The objective of this study was to determine the possible existence of subclasses within class II and to know the variables that would differentiate these subclasses. Twenty-two variables were used in the multivariate analysis of 15 dogs, class II of CH. Using hierarchical and non-hierarchical clustering, three exclusive subclasses (S1, S2 and S3) were determined. It was possible to relate subclass S1 to heart rate variability variables (e.g. NNm, PNN>50%), subclass S3 with cardiac remodeling variables (e.g. LA/Ao, LVDd/Ao, EF%) and subclass S2 with right ventricular chamber (e.g. RVDd/Ao). After analysis of factors were determined three factors (PSNA, RCFS and VDST) that relate the variables with the subclasses. The PSNA included variables of heart rate and heart rate variability, the RCFS contained the variables of cardiac remodeling and systolic function and the VDST enclosed the right ventricular chamber. The analysis of variance of the factors compared by subclasses determined that subclass S1 has higher values of PSNA when compared to subclasses S2 and S3. The subclass S3 had higher val... (Complete abstract click electronic access below) / Doutor