Mar 16, · 33 Variations is a play by Moisés Kaufman, inspired by Ludwig van Beethoven's Diabelli sioprovcabradeperfscormarcodenmenssol.co débuted on Broadway on March 9, , starring Jane Fonda. Originally written in , its world première was held at Arena Stage in Washington, D.C. Feb 05, · "Variations in resting heart rate may allow for the identification of early unexpected changes in an individuals' health," Quer's team concluded. WebMD News from HealthDay Sources. Mar 14, · Bach Goldberg Variations “Variation 19” with Score - P. Barton FEURICH piano - Duration: Paul Barton 5, views.
Values during exercise and recovery were computed as absolute value, and as percent changes vs baseline. Physiological backgrounds and the sensor. Upper panels, physiological backgrounds.
Left, the systolic force-frequency relation: an increased heart rate progressively increases the contractile force of the heart. Middle, the diastolic force-frequency relation: cardiac cycle abnormalities of patients with heart failure are characterized by a prolonged left ventricular systole and an abnormal shortening of left ventricular diastole. The systolic-diastolic mismatch is accentuated during exercise and may impair cardiac reserve in these patients by restricting ventricular filling and coronary perfusion.
Right, the second heart sound S2 amplitude recording simultaneously with diastolic blood pressure during stress: similar S2-frequency trend during stress blue symbols and recovery red symbols in a patient with exercise-induced diastolic hypertension and post-exercise hypotension.
The S2 amplitude depends on the force with which the valves close, which in turn depends on the pressure gradient across the valve at the time of closure.
Lower panels, the sensor and the device. A precordial non-invasive, operator-independent sensor and system for monitoring the systolic and diastolic force-frequency relation, and the pressure-frequency relation. The data can be read remotely by a wireless sensor network right.
Computing force variation as a function of heart rate. Left panel, the systolic force-frequency relation. The amplitude of the vibration due to isovolumic myocardium contraction was obtained to record systolic force for each cardiac beat red points.
The curve of the systolic force variation as a function of heart rate was then computed; mobile mean blue curve was utilized to assess baseline, exercise, and recovery values.
Middle, the curve of the systolic pink line and diastolic black lines time variation as a function of heart rate. Right panel, computing the second heart sound amplitude variation as a function of heart rate. Software algorithms. The Variations 19 - 33 provides a system comprising a microprocessor which receives informative signals from the heart regarding the patient's systolic and diastolic force-frequency relationship. The system records the points of the force-frequency relationship by successive beats, from which it then derives a diagram of the force-frequency relationship over predetermined time periods.
If the point on the force-frequency relationship is within an abnormal region of the force-frequency relationship, specific provisions are adopted or an appropriate therapeutic regime is initiated. Monitoring the patient's condition can reveal an abnormal situation which although not critical in itself may predict a future worsening of chronic heart failure.
In particular, it can help verify the effectiveness of therapies and their influence on the patient's condition in daily life. Positive or negative decompensation changes as a result of certain events can be determined, as well as variations in the force-frequency curve over 24 h.
Thus a three-dimensional diagram is determined which for each heart rate not only indicates the instantaneous force value but also permits monitoring any variation of said value over time.
The systolic force-frequency relation, the diastolic time-frequency relation and the second heart sound derived systemic pressure were recorded at both stress and recovery in the recruited subjects to exploit sensor-based dichotomy patterns in the leap to non-invasive intelligent remote heart monitoring.
SPSS 11 for Windows was used for statistical analysis. The statistical analyses included descriptive statistics frequency and percentage of categorical variables and mean and standard deviation of continuous variables. Changes in continuous variables during recovery were compared by analysis of variance for repeated measures.
Since all the sensor-based parameters are physiologically heart-rate dependent, comparisons of recovery minutes 1, 3 and 5 values were made with sensor-recorded values at the same heart rates during exercise.
The first 52 consecutive enrolled subjects 7 controls underwent both echocardiographic Table 2 and sensor hemodynamic assessment Fig.
At recovery minute 1 we observed a decrease in LV end-systolic volume, increased stroke volume index, and a decreased systemic diastolic and systolic pressure. Since systemic pressure changes are measured by protocol and derivable by the sensor S2 vibrations amplitudecomparisons were made Fig.
Diastolic time length was easily measured only by the sensor: at each recovery heart rate diastole was longer than during exercise Fig. Validation of sensor-based contractility, diastolic function and pressure assessment in the post-exercise period. Upper panels, ecocardiographic quantitative hemodynamic changes during exercise in 52 subjects at rest Watt 0progressive graded bicycle exercise workload blue symbols and three stages of recovery red symbols, R1, 3, 5 min.
There was a significant increase overshoot in the ejection fraction and ventricular-arterial coupling during the first minute of recovery, compared with the end-exercise value. Minimal value of systemic vascular resistance is recognized at peak Variations 19 - 33, and during early recovery. Systemic pressure measures were blunted in the post-exercise phase, due to nitric oxide spillover and adenosine accumulation.
A transient, favourable mismatch between cardiac contractility and afterload reduction occurs at recovery in normal subjects, and to an even greater degree in diseased hearts. Lower panels, sensor-based data in the same 52 subjects. An effective, significant comparison with echocardiography is feasible for contractility left, force-frequency relation and blunted sensor-derived arterial pressure in the post-exercise phase middle, S2 recording.
Diastolic time during stress and diastolic time recovery overshoot monitoring is simple with the sensor, its difficulty comparable with echo measurement operator-dependent and time-consuming. However, integration of sensor-times and echo-volume allows simple measurement of diastolic filling rate. Contractility comparisons between different groups of patients based on the incoming disease are reported in Fig. Cumulative sensor data in the enrolled subjects.
Progressive graded exercise workload blue symbols and three stages of recovery red symbols, R1, 3, 5 min. Left panel, contractility at different heart rates force-frequency relation : higher mean force data are observed at each recovery step with respect to exercise values. Middle panel, sensor-derived systemic pressure changes: lower mean pressure values are observed at each recovery step in comparison with exercise values.
Right panel, diastolic empty symbols and systolic full symbols times at increasing heart rates during exercise blue and at decreasing heart rates during recovery red : diastolic times overshoot is observed at each recovery heart rate, with improved ventricular filling and coronary perfusion time. Cumulative sensor data in the controls and different patient groups.
Patients with stress-induced ischemia upper middle panel showed a flat contractile reserve at ischemia and a clear recovery contractile overshoot. During exercise the force frequency relation was upsloping in controls and blunted in patients.
Post-exercise contractility overshoot. Left, the exercise force-frequency relation is blunted in a CHF patient.
Right, the exercise force-frequency relation is upsloping in a control subject. Post-exercise contractility curve mirrored the stress values. The diastolic time increased abruptly during the first minute of recovery, with an overshoot phenomenon. Sensor-based diastolic time-frequency relation in the post-exercise phase. Diastolic empty symbols and systolic full symbols times at increasing heart rates during exercise blue and at decreasing heart rates during recovery red.
At peak stress subjects showed a normal diastolic time still longer than systole left panel. The systolic-diastolic mismatch, with relative systolic dominance, was promptly resolved during recovery, Variations 19 - 33. At each recovery heart rate the diastolic time increased with respect to the exercise period in both groups, with a recovery diastolic time overshoot. Diastolic time overshoot is observed at each recovery heart rate, with improved ventricular filling and coronary perfusion time.
Sensor-derived systemic pressure and post-exercise hypotension. Cumulative sensor data in subjects without left panel and with right panel post-exercise hypotension. Progressive graded exercise workload, blue symbols; three stages of recovery, red symbols, R1, 3, 5 min. A significant correlation was found between post-exercise hypotension and recovery S2 undershoot.
Standard systemic pressure measures obtained by sphygmomanometer were blunted in the post-exercise phase, and a general decrease in the sensor-based derived systemic pressure were found [ 6 ]. Furthermore, during recovery as during stress, the cutaneous operator-independent force sensor described systolic and diastolic duration in real time. Simultaneous calculation of stroke volume with echo and diastolic time with force sensor allowed us to monitor the diastolic filling rate [ 5 ].
During exercise the normal force-frequency relation is upsloping, while a flat-biphasic force-frequency relation is abnormal [ 20 — 24 ]. A post-exercise sensor-based contractility overshoot was more frequent in patients vs controls, and frequently associated with an abnormal blunted force-frequency relation during exercise. Several investigators using different methods [ 1225 — 27 ] have reported an overshoot of cardiac function during recovery from maximal exercise in patients with cardiac disease.
Koike et al. Tanabe at al. They found that not only O 2 uptake but also cardiac output fell much more slowly after maximal exercise as CHF worsened. Although insufficient afterload reduction during exercise in CHF contributes to the impaired stroke volume response to exercise, systemic vascular resistance at 1 min of recovery significantly decreased from that at peak exercise in patients with CHF who showed overshoot of cardiac output during recovery [ 28 — 31 ].
The marked increase in stroke volume during early recovery in patients with overshoot appears to result from both an immediate afterload reduction and a relatively slow decrease in cardiac sympathetic stimulation during recovery [ 3233 ]. Knowledge of the post-exercise overshoot also had prognostic value since patients with a moderate exercise intolerance and a normal recovery period had a better prognosis than a patient with a post-exercise overshoot [ 34 ].
We found that at each recovery heart beat frequency, the diastolic time was higher than the diastolic time recorded during exercise, in both controls and patients. Why does diastolic time increase in the post- exercise phase? However at each heartbeat frequency the fixed total cardiac cycle time can be differently divided between systole and diastole [ 5 ].
The diastolic time fraction is determined by factors that modulate systolic duration through modulation of myocyte contraction [ 36 — 40 ]. At recovery, improved myocardial contractility and reduction in systemic vascular resistance significantly shortened left ventricular ejection time, with a proportionate increase in diastolic time fraction. Stress-induced "systolic-diastolic mismatch" can be easily quantified by a disproportionate decrease in diastolic time fraction, and is associated with several cardiac diseases, possibly expanding the spectrum of information obtainable during stress [ 5 ].
The post-exercise diastolic time fraction indicates the duration of absence of compression of intramural vessels during a heartbeat and has a dominant role in the subendocardial layer — whose perfusion is mainly diastolic, whereas the perfusion in the subepicardial layer is also systolic [ 3638 ].
The lengthening of cardiological diastole is much more pronounced than lengthening of cardiological systole, and the former is much more effective for subendocardial perfusion, even in the absence of coronary artery disease. This indicates the relevance of monitoring both exercise and recovery diastolic time in the critically diseased heart [ 3739 ]. A significant correlation was found between post-exercise hypotension and recovery S2 undershoot Fig. In this investigation, blood pressure systolic, diastolic and mean correlated closely with S2 amplitude during both stress and recovery [ 6 ].
This could be explained by the fact that amplitude is primarily determined by one factor, the force of valve closure [ 4142 ]. In the selected patients of our study, a significant correlation was found between post-exercise hypotension and recovery second heart sound lower amplitude, to confirm the sensor's ability to mirror the diastolic pressure trend.
Acute exercise may serve as a non-pharmacological aid in the treatment of hypertension. S2 amplitude monitoring could be a method for assessing the efficacy of acute post-exercise blood pressure reduction. Congestive heart failure HF is a serious public health problem due to its prevalence, high mortality, high morbidity, and the expense of ongoing therapy [ 2 ]. Several strategies to control fluid volume status are used in the practice. Clinic visits for assessment of filling pressure by physical examination, multiple types of non-invasive measurements, and repeated cardiac catheterization may be employed.
There is considerable cost and inconvenience for the patient associated with these strategies and, more importantly, these methods represent pressure and volume status only as one discrete point in time without the perturbance of daily activities or stress. A system of frequent monitoring could alert clinicians to early signs and symptoms of decompensation, providing the opportunity for intervention before patients become severely ill and require hospitalization [ 1 ].
Implantable hemodynamic monitors that are capable of measuring chronic right ventricular oxygen saturation and pulmonary artery pressure are currently being developed Chronicle, Medtronic Inc. Minneapolis, Minnesota, USA [ 48 ]. Minneapolis, Minnesota, USA have recently been introduced and may provide an early warning of thoracic fluid retention [ 49 ]. However the predictive values of these implantable devices is still unknown [ 4849 ].
Furthermore, such strategies will have to be evaluated for cost effectiveness, scalability, safety, and acceptability to patients. As technologies such as micro-technologies, telecommunication, low-power design, new textiles, and flexible sensors become available, new user-friendly devices can be developed to enhance the comfort and security of the patient.
All these systems can provide a safe and comfortable environment for home healthcare, preventive medicine, and public health. Expert monitoring of the heart — via a chest wall sensor — can reliably and non-invasively sense the contractile force and the diastolic function of the heart. Positive or negative decompensation changes as a result of certain events can be determined, as well as variations in the force-frequency curve over a h period.
When abnormal patterns are recognized, specific provisions are adopted or an appropriate therapeutic regime is initiated [ 51 ]. This novel method and device for the diagnosis and therapy of chronic heart failure can be integrated with other standard physiological sensors and biomarkers. Our research will continue to optimize features of both the sensor and algorithm, and will develop an engineering model for industrialization, aiming at the device's eventual use in long-term home monitoring for tailoring drug treatment and preventing re-hospitalization.
Contractility can be continuously measured by a cutaneous accelerometer during the post-exercise phase. Knowledge of the recovery overshoot phenomenon could be helpful for recognizing advanced failing patients in home monitoring systems. Diastolic duration time can be monitored during the post-exercise phase and a recovery diastolic time overshoot phenomenon can be easily assessed by the sensor.
S2 amplitude monitoring is Variations 19 - 33 method for assessing acute post-exercise blood pressure reduction. The daily life of both healthy subjects and patients involves periods of rest alternating with physical activity; and activity consists of mild to severe exercise with obviously subsequent recovery periods.
Heart disease affects not only peak exercise systolic performance, but also post-exercise recovery, diastolic time intervals and blood pressure changes — all of which can be monitored by a non-invasive wearable sensor. J Am Coll Cardiol. Eur Heart J. Seto E: Variations 19 - 33 comparison between telemonitoring and usual care of heart failure: a systematic review.
Telemed J E Health. Force-frequency relation recording system in the stress echo lab. Cardiovasc Ultrasound. Filling timing and flow at different heart rates. Opie LH: Mechanisms of cardiac contraction and relaxation. Heart Disease. Google Scholar. Hasenfuss G, Holubarsch C, Hermann HP, Astheimer K, Pieske B, Just H: Influence of the force- frequency relationship on haemodynamics and left ventricular function in patients with non- failing hearts and in patients with dilated cardiomyopathy. Heart disease.
WB Saunders Company, 7. Picano E: Stress Echocardiography. J Appl Physiol. J Am Soc Echocardiogr. Eur J Echocardiogr. The result also indicates that households dependent on unimproved water sources were more likely to use either of the treatment options in the survey of Our finding complies with a study finding in Zambia that shows that households obtaining water from unimproved sources rivers and streams were more likely to chlorinate their water [ 25 ].
Another study finding shows that households that considered public water was unsafe for drinking preferred to boil Variations 19 - 33 drinking water prior to consumption [ 26 ]. Moreover, the survey analysis on households with an intermittent water supply had higher odds of treating their water at the household level is corroborated by a study finding in Egypt that shows households with an intermittent supply were more likely to let the water stand and settle [ 24 ].
Household head with at least primary education level had higher odds of treating their water prior to drinking than households heads who had no formal education in each of the three surveys. Our finding is similar to a study finding in Zambia that indicates that chlorine use was more likely among those with post-secondary education [ 25 ]. The number of households treating water at point-of-use in was significantly lower than the two latter surveys.
There was an increasing trend from to in the number of households using appropriate water treatment methods. The rise in the number of households reportedly using the treatment methods from to might be from the emphasis given to demand creation service during this survey time and its persuasiveness. There was a decreasing trend from to in the number of households reportedly treating their water decreased. The number of households dependent on improved water sources increased from to Therefore, decreasing in the number of households using point-of-use water treatment from to might be from the perception of the households to treat improved water sources, less emphasis might be given to promotion services and shortage in the supply of the treatment methods.
The declining number of users from to also shows limitations in the government effort to scale-up of different treatment methods and disagree with the prior reports [ 1028 ]. Moreover, it is suspicious that the report on the cooperation of concerned government offices with different organizations that pledge support in facilitating partnerships and effective implementation of HWTS [ 10 ].
In the country, sincehealth extension workers have been deployed and implementing water safety measures including the household water treatment and safe storage practices [ 29 ].
The EDHS data we analyzed were collected cross-sectionally and, therefore, have the following limitations: 1 The responses were liable to biases social desirability bias ; 2 The analysis fails to show the cause and effect relationship between independent variables and dependent variable [ 30 ]. The data did not indicate whether households claimed using the treatment methods were confirmed users and how consistent is the water treatment.
In addition, the data did not explicitly indicate different types of filtration methods used by households. Psychosocial factors, one of the factors associated with WASH technology adoption and use, were not included in the data for analysis.
Therefore, the representativeness of the data is one of the strengths when compared with area-specific studies being conducted in the country. Household and individual level characteristics mainly education status of household head, owning a radio and television, and wealth quintiles had an association with the household use of the treatment methods. Community-level factors mainly being in urban or rural had also a significant association with treatment use in the survey.
There were within-region and between-region variations in the use of treatment methods in each survey. The finding in general suggests the need for designing intervention and implementation strategies at the national level for wide-scale use of the treatment methods which ultimately ensure the health gains. A study on the consistency in the use of the treatment methods among reported users and its effectiveness against diarrheal disease needs to be conducted in the country.
Moreover, further study about household behavioral factors related to the safe water system is needed to design appropriate behavior changing intervention strategies. Global, regional, and national causes of child mortality in a systematic analysis. Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study Lancet Infect Dis.
Burden of disease from inadequate water, sanitation and hygiene in low and middle income settings: a retrospective analysis of data from countries. Trop Med Int Health. Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Water, sanitation and hygiene interventions to combat childhood diarrhoea in developing countries, vol.
What factors affect sustained adoption of clean water and sanitation technologies? Google Scholar. Federal Minsitry of Health: national workshop on evaluating household water treatment performance and scaling up safe-drinking water solutions.
Demographic and Health Survey Demographic and Health Survey sampling and household listing manual. Mickey J, Greenland S. A study of the impact of confounder-selection criteria on effect estimation. Amer J Epidemiol. Clarke E. What is preventive medicine? Can Fam Phys. Household water chlorination reduces incidence of diarrhea among under-five children in rural Ethiopia: a cluster randomized controlled trial.
PLoS One. Randomized controlled trial in rural Ethiopia to assess a portable water treatment device. Environ Sci Technol. Prevalence and determinants of acute diarrhea among children younger than five years old in Jabithennan District, Northwest Ethiopia, BMC Public Health. Prevalence of diarrhoea and associated factors among under-five children in Jigjiga District, Somali Region, eastern Ethiopia. Open J Prev Med. Prevalence of diarrhea and associated risk factors among children under-five years of age in eastern Ethiopia: a cross-sectional study.
Brown J, Clasen T. High adherence is necessary to realize health gains from water quality interventions. The joint effects of efficacy and compliance: a study of household water treatment effectiveness against childhood diarrhea.
Water Res. Can information alone change behavior? Response to arsenic contamination of groundwater in Bangladesh. J Develop Econ. Wright J, Gundry SW. Household characteristics associated with home water treatment: an analysis of the Egyptian Demographic and Health Survey.
J Water Health. Zambia: Environmental Health Project; Perception of drinking water safety and factors influencing acceptance and sustainability of a water quality intervention in rural southern India. Rapid assessment of drinking water quality in the Federal Democratic Republic of Ethiopia. Geneva: World Health Organization; In: Directorate WSS, editor. Ministry of Health: Addis Ababa, Ethiopia; Carlson M, Morrison R.
Study design, precision, and validity in observational studies. J Palliat Med. Download references. The data that support the findings of this study are available from MEASURE DHS but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. AG conceived and designed the study, analyzed the data, and interpreted and drafted the manuscript.
All authors have read and approved the final manuscript. Correspondence to Abraham Geremew. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions. Geremew, A. Appropriate household water treatment methods in Ethiopia: household use and associated factors based on, and EDHS data. Environ Health Prev Med 23, 46 Download citation.
Received : 08 May Accepted : 17 September Published : 27 September Skip to main content. Search all BMC articles Search. Download PDF. Abstract Background Diarrheal disease attributable to water and sanitation can be prevented using point-of-use water treatment. Methods The data of, and Ethiopian demographic and health surveys were used for analysis. Results The number of households that reported treating water with appropriate water treatment methods was 3.
Background Diarrhea is among the leading cause of mortality and morbidity in developing countries [ 1 ]. Sample size and sampling technique The sample in each EDHS was designed to provide population and health indicators at the national and regional levels.
Study variables Households reported using appropriate water treatment methods were considered for analysis as an outcome of an interest. Results Household characteristics and drinking water sources Data about appropriate water treatment and characteristics attributable to it were analyzed using 13, 16, and 16, households respectively for, and EDHS.
Table 3 Bivariate regression result on factors associated with the household use of appropriate water treatment methods in DHS of, andEthiopia Full size table. Table 4 Multivariable regression result on factors associated with the household use of appropriate water treatment methods in DHS of, andEthiopia Full size table. Table 5 Multivariable regression result of a pooled data of three DHS on factors associated with the household use of appropriate water treatment, Ethiopia Full size table.
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