on behalf of the CIBIS III InvestigatorsBackground-In patients with chronic heart failure (CHF), a ␤-blocker is generally added to a regimen containing an angiotensin-converting-enzyme (ACE) inhibitor. It is unknown whether ␤-blockade as initial therapy may be as useful. Methods and Results-We randomized 1010 patients with mild to moderate CHF and left ventricular ejection fraction Յ35%, who were not receiving ACE inhibitor, ␤-blocker, or angiotensin receptor blocker therapy, to open-label monotherapy with either bisoprolol (target dose 10 mg QD; nϭ505) or enalapril (target dose 10 mg BID; nϭ505) for 6 months, followed by their combination for 6 to 24 months. The 2 strategies were blindly compared with regard to the combined primary end point of all-cause mortality or hospitalization and with regard to each of these end point components individually. Bisoprolol-first treatment was noninferior to enalapril-first treatment if the upper limit of the 95% confidence interval (CI) for the absolute between-group difference was Ͻ5%, corresponding to a hazard ratio (HR) of 1.17. In the intention-to-treat sample, the primary end point occurred in 178 patients allocated to bisoprolol-first treatment versus 186 allocated to enalapril-first treatment (absolute difference Ϫ1.6%, 95% CI Ϫ7.6 to 4.4%, HR 0.94; 95% CI 0.77 to 1.16). In the per-protocol sample, 163 patients allocated to bisoprolol-first treatment had a primary end point, versus 165 allocated to enalapril-first treatment (absolute difference Ϫ0.7%, 95% CI Ϫ6.6 to 5.1%, HR 0.

RABBIA, FRANCO, BERNARD SILKE, ANDREA CONTERNO, TIZIANA GROSSO, BARBARA DE VITO, IVANA RABBONE, LIVIO CHIANDUSSI, AND FRANCO VEGLIO. Assessment of cardiac autonomic modulation during adolescent obesity. Obes Res. 2003; 11:541-548. Objective: To investigate the cardiovascular autonomic function in pediatric obesity of different duration by using standard time domain, spectral heart rate variability (HRV), and nonlinear methods. Research Methods and Procedures: Fifty obese children (13.9 Ϯ 1.7 years) were compared with 12 lean subjects (12.9 Ϯ 1.6 years). Obese children were classified as recent obese (ROB) (Ͻ4 years), intermediate obese (IOB) (4 to 7 years), and long-term obese (OB) (Ͼ7 years). In all participants, we performed blood pressure (BP) measurements, laboratory tests, and 24-hour electrocardiogram/ambulatory BP monitoring. The spectral power was quantified in total power, very low-frequency (LF) power, high-frequency (HF) power, and LF to HF ratio. Total, long-term, and short-term time domain HRV were calculated. Poincaré plot and quadrant methods were used as nonlinear techniques. Results: All obese groups had higher casual and ambulatory BP and higher glucose, homeostasis model assessment, and triglyceride levels. All parameters reflecting parasympathetic tone (HF band, root mean square successive difference, proportion of successive normal-to-normal intervals, and scatterplot width) were significantly and persistently reduced in all obese groups in comparison with lean controls. LF normalized units, LF/HF, and cardiac acceleration (reflecting sympathetic activation) were significantly increased in the ROB group. In IOB and OB groups, LF, but not nonlinear, measures were similar to lean controls, suggesting biphasic behavior of sympathetic tone, whereas nonlinear analysis showed a decreasing trend with the duration of obesity. Long-term HRV measures were significantly reduced in ROB and IOB. Discussion: Autonomic nervous system changes in adolescent obesity seem to be related to its duration. Nonlinear methods of scatterplot and quadrant analysis permit assessment of autonomic balance, despite measuring different aspects of HRV.

Objective To assess the impact of a set of interventions in reducing the interruption/distraction rate during medication administration. Design and participants Pre-and postintervention observational study of nurses undertaking medication rounds. Setting Acute Medical Admissions Unit (AMAU) of a 1000-bed teaching hospital. Intervention A set of measures previously proven successful in reducing interruptions (behaviour modification and staff education; checklists; visible symbols in the form of a red vest; and signage) were adapted and introduced onto the AMAU. Main outcome measures Rate of interruptions and distractions pre-and postintervention overall and for each individual source of interruption. Results There was a highly significant association (p<0.0001) between the overall interruption/distraction rate and the pre-/postintervention studies, with the rate of interruptions postintervention being 0.43 times that of the preintervention level. When individual sources of interruptions and distractions were compared pre-and postintervention, a significant difference (p<0.05) in the interruption/distraction rate was found for five of the 11 categories assessed. Conclusions The data support a multifactorial approach to reducing the interruption/distraction rate on medication rounds. Suggestions for future research include: directly quantifying the impact of the interventions described in this study on the volume of medication administration errors; assessing the time lost as a result of interruptions and distractions during the medication round; and developing a standardised means of recording and analysing interruptions and distractions to allow meaningful comparison of the benefits of interventions across studies.

In-hospital mortality estimation using only routinely collected emergency department admission data is possible in unselected acute medical patients using the MARS system. Such a score applied to acute medical patients at the time of admission, could assist senior clinical decision makers in promptly and accurately focusing limited clinical resources. Further studies validating the impact of this model on clinical outcomes are warranted.