President's Message - Bob Lowe
1999 has been a challenging year for the ACVPRA as well as Cardiac and Pulmonary Rehab nationwide.

First, the loss of HCFA (Medicare) support caused many Pulmonary Rehab programs in the state to close their doors or place pulmonary patients into exercise maintenance programs.  Although the future of Pulmonary Rehab hangs in the balance, it looks as if HCFA may provide billing codes soon (see Legislative Updates below).

Second, the Balanced Budget Act (BBA) which will drastically reduce Medicare reimbursement will have a profound effect on all of our programs which involve Medicare patients.  Please go to the BBA website to send an automated letter (yes you can add your own comments too) of concern to your local congressman/woman. It's simple to do!

The issues above make it more important than ever for our state association to take an active role in promoting Cardiac and Pulmonary Rehab. We can do this in a variety of ways.

1)  We can and should get involved at the national level. We should participate in letter writing campaigns whenever possible.

2) We should be involved in local chapters of the American Heart Association, the American Lung Association, Better Breathers, and the Arkansas Organ Recipient Association.

3) We should encourage the growth of our profession by providing training grounds for students and other professionals.  Nursing, Physical, Occupational, and Respiratory Therapy, Kinesiology, and Medical students need to be exposed to what we do.  Inservices, seminars, and internships provide opportunities for these students to see what it is we do.

4)  We should encourage physician involvement.  Your medical director is a first step in promoting your programs.  He or she can solicit the support of other physicians.  Of course, providing excellent care of physicians' patients is always a good way to get their support!

5)  We should collect and examine outcomes.  They can be used as benchmarks of your program's effectiveness or can lead to research projects.

6)  We should collaborate with colleges and universities:  internships, research projects, seminars, guest lectures, etc.

7)  We should partner with the many companies that provide equipment, medicine, or other supplies to us and our patients.  They can help provide some relief in times of tight budgets.

8)  We should strive to cooperate with insurers by providing the highest quality care at the same time we keep costs to a minimum.  Although it may seem that insurance companies are our enemies they really are our allies.  Since many policies are the product of local agencies it pays to stay on good terms with those insurers.

These are some of the few ways we can help promote our profession; there many others.  We have many talented individuals in the state of Arkansas:  don't be afraid to ask someone for advice or help.  Let's help our profession grow and prosper.

Alert!!!!

Please go to the following link to learn more about the Balanced Budget Act  (BBA) and send a personalized (automated) letter to your congressman/woman, http://www4.capweb.net/aha/

Next Meeting :
Tuesday April 25, 2000 at Conway Regional Health and Fitness Center conference room from 10:30 a.m. to 12:00 p.m.  Tentative speakers will be Dr. Glenn Irion from the University of Central Arkansas who will discuss collaborative opportunities between universities and cardiopulmonary programs and Mr. Leslie Warren, regional sales manager from Cholestech, who will speak about measuring lipids with a desktop analyzer.  Refreshments will be served!  Please click here for a detailed map on how to get to CRHFC or call Bob Lowe at 501-202-1824 for directions or for additional information.

Meeting Agenda
1) Presentations
    a.  Cholestech cholesterol analyzer - Mr. Leslie Warren, Regional
         Sales Manager.
    b.  Collaborating with universities - Dr. Glen Irion, UCA

2) Old Business
     a. Minutes from January 27, 2000 meeting held in Ft. Smith
     b. Continued discussion of meeting locations

3) New Business:
     a. Treasurer's Report - Sue Manning, BHMMC
     b. Annual workshop update - Jon Davis, SVIMC
     c. Pulmonary update - Bob Lowe, BHMC
     d. Cardiac rehab and peripheral vascular disease update - Bob Lowe, BHMC
     e. Medicare forms update - Bob Lowe, BHMC
     f. Volunteers for annual workshop, newsletter, and webpage
     g. other items of interest

4) Sharing ideas.  This is an opportunity to share ideas with other programs.  Do you have something to share?  This is the time to help others!  Bring your ideas.

Membership
Membership is still only $10.00!  What a bargain.  Why become a member?  Receive the ACVPRA newsletter four times a year, attend informative and interactive ACVPRA  quarterly meetings, attend the annual workshop, and work with other professionals across the state to help the shape the future of cardiac and pulmonary rehab in Arkansas!  There isn’t another organization which offers so much for so little!   If you are already a member pass this information on to someone else so they can take advantage of this great deal!   Go to membership application

Important Resources at the AACVPR website:
Outcomes of Pulmonary Rehabilitation - Update by Michael J. Berry, Ph.D.
July 1998 is available at the American Association of Cardiovascular and
Pulmonary Rehabilitation (AACVPR) website www.aacvpr.org.

AACVPR Cardiac Rehabilitation Bibliography compiled by Scott O. Roberts, Ph.D., FAACVPR and Maria L.G. Encarnacion, B.S. is available at the AACVPR website www.aacvpr.org.

MEDLINE Journals With Links to Publisher Web Sites:

www.ncbi.nlm.nih.gov/PubMed/fulltext.html.  This is a list of the journals in
MEDLINE for which publishers have provided links to their journal Web sites. Web-based journals usually contain the full-text of the original article, but this is
not always the case. It varies by publisher and journal. Publishers are responsible for providing NLM with the links for each article. This list of journals shown here is produced automatically from the database, and includes all journals for which at least one link exists. As of 08-Nov-99 , there are 499 journals on this list. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals. In these cases, follow accessinstructions provided on the journal's Web page. Policies vary by publisher and by journal.

The Canadian Lung Association maintains a website with numerous resources at www.lung.ca/resource.html.

The Vascular Biology Working Group (www.vbwg.org).  The mission of the Vascular Biology Working Group: Review and exchange of scientific research and clinical data from the field of vascular biology.

Next Wave's Career Development Center for Postdocs and Junior Faculty http://nextwave.sciencemag.org/feature/careercenter.shtml

American Heart Association.  American Heart Association Scientific Advisories and Statements can be found at www.americanheart.org/Scientific/statements.  Most AHA Scientific Statements and Advisories are published in Circulation. Joint AHA and American College of Cardiology (ACC) statements also appear in the Journal of the American College of Cardiology (JACC).

American Heart Association Advocacy at www.americanheart.org/Support/Advocacy/paprior.htm is your advocate for
Research Funding, Tobacco Control, Access to Emergency Care, Public Access
to Defibrillation, Physical Activity, and Other Important Policy Issues.

Take Action Now! Tell your legislators how they can help the AHA fight heart disease and stroke at http://congress.nw.dc.us/aha/issues.html.

The AHA encourages you to take action and support the AHA's health initiatives by becoming a member of the AHA's grassroots network

The AHA Monograph Series covering a wide range of topics such as obesity and cardiovascular disease, the vulnerable atherosclerotic plaque, MR in
cardiovascular disease, pulmonary edema, and other important titles to
healthcare professionals can be ordered online at www.futuraco.com.

The AHA sponsors several professional development seminars and meetings
throughout the year.  Visit the AHA website at www.americanheart.org/Scientificfor more information.

Calendar

May 5-7, 2000.  Frontiers in Lipoprotein & Vascular Disease Research:  Basic
Science, Analytical, Clinical, and Public Health Applications.  Hyatt Regency
Hotel at Union Station, St. Louis, Missouri.  Contact: 800-323-2996 (x405) for
more information.

September 21-23, 2000. The Integrative Biology of Exercise.  The American
Physiological Society.  Portland, Maine.  For more information go to
www.faseb.org/aps.

June 6-8, 2001.  Second Symposium on Cardiac Rehabilitation Integrated to theTreatment of the Disease will be held at the Hotel Quebec Hilton.  For more
information and to view a preliminary program go to www.ulaval.ca/symp-rehab/prog_preli_bilingue.htm. Abstract deadline December 8, 2000.

The AACVPR Legislative and Regulatory Agenda by Phill Porte, Legislative Analyst.

AACVPR has a fairly aggressive legislative and regulatory agenda in place, but it is apparent there has been an understandable amount of misunderstanding withinthe Association's membership regarding AACVPR's efforts with the Health Care Financing Administration (HCFA) and the Congress. This column will hopefully clarify the Association's positions on some potentially confusing but criticallyimportant issues.

HCFA, the Federal agency that administers the Medicare and Medicaid programs, must strictly adhere to the authority granted to it by Congress. HCFA's primaryauthority, to administer the Medicare program, is found in Title XVIII of the Social Security Act. While HCFA has some discretionary authority granted to it, HCFA relies heavily on the specific statutory authority of Title XVIII as its means for providing Medicare benefits to beneficiaries.

Several important examples will illustrate the specificity that HCFA generally
follows. Section 1834 (c) of the statute authorizes payment and establishes
standards for mammography screening. No one would argue the importance of mammography screening as an effective tool in the early detection/prevention of
breast cancer. Yet if that specific authorizing language did not exist, HCFA would argue that it has no authority to pay for mammography screening. Title XVIII is quite explicit in that HCFA can pay only for "reasonable and necessary" services for the diagnosis and/or treatment of a specific illness; preventive services have not been deemed to be "necessary." After all, mammography screening is a tooloften used with asymptomatic patients. Because preventive services generally are not covered by Medicare, in the absence of the specific Section 1834 authorization, HCFA could not pay for mammography screening.

Much of Title XVIII spells out specific limits on coverage, addressing
hospitalization, physician visits, certain therapy services, etc. Unfortunately, the matter of coverage of benefits not specifically mentioned becomes a more
complicated matter, and that is where both cardiac and pulmonary rehabilitation fall. There is no specific legislative authorization for cardiac rehabilitation, yet it
has been a covered service for years. Pulmonary rehabilitation, which does not have specific legislative authorization for coverage, does not enjoy the same
national coverage yet, dependent upon simple geography, Medicare beneficiaries in most of the country do receive some level of coverage for pulmonary
rehabilitation.

How does this happen without the specific mention of either? Section 1861(s)(2) of Title XVIII provides a fairly broad definition of medical and other health
services. This section includes the following two phrases:

" services and supplies furnished as an incident to a physician's professional
service, of kinds which are commonly furnished in physicians' offices .

"  hospital services incident to physicians' services rendered to outpatients ."

These two phrases are not only the source for authorization of payment for
outpatient rehabilitation services, it is also the source of headaches for both
cardiac and pulmonary rehabilitation.

Very few would argue the benefits of this legislative language, stating it has
appropriately authorized payment for important health care services. However, in recent months HCFA has latched on to the phraseology "incident to physicians'services," arguing that it is this phrase that truly requires HCFA to mandatesubstantial physician involvement in cardiac rehabilitation. Specifically, HCFA argues that without direct physician involvement in reviewing rhythm strips,without physician review of patient status on a regular basis, without physician contribution to the regular review of the plan of treatment, HCFA has no authority to pay for cardiac rehabilitation.

This interpretation clearly puts AACVPR in a box, recognizing that to maintain payment for cardiac rehabilitation services, some level of accommodation with
HCFA thinking must be made. Unless, however, AACVPR seeks legislative relief and changes the actual Medicare statute to clarify this matter both for HCFA andits contractors (carriers and intermediaries). For that reason, with the tacit support of HCFA, AACVPR is working with various Capitol Hill offices to change the Medicare statute to eliminate the current level of ambiguity that authorizescoverage. Such a change requires specific legislative action that amends Title XVIII, giving HCFA new directives in coverage of these services. Ideally, thelegislative language adopted by Congress would not only define both cardiac andpulmonary rehabilitation services but also address the important issue of the extent of physician involvement. That is what AACVPR's legislative initiative is all about.

Politically, AACVPR is emphasizing that we are not adding new benefits to the Medicare program. Rather, we are simply shifting authorization for coverage andpayment from one ambiguous section of the statute to a new, more defined
section. When Congress takes up Medicare legislation this Fall, we hope to have
it include our legislative initiative.

AACVPR Update

Fellow AACVPR Members.
Please encourage all of your staff to sign on and send this prepared email
from the AHA Website.  All they need to do is add their name and address.
Encourage them to also ask their spouses, relatives, etc. to send messages.
The more messages received, the more folks will understand the negative
impact of the BBA and consider further reform.  The future of healthcare as
we know it depends on it!
Thanks. http://www.aha.org/emailcongress.html

FROM NATIONAL:
Dues notices for AACVPR membership renewal will be mailed on March 10.
Please watch your mail!  Included on the 2000-2001 dues notice is an
opportunity to contribute to the Heart & Lung Foundation.

1,175 rehab programs have applied for inclusion in the 2000-2001
Membership Directory.  This is 75 programs over the number included in
the 1999-2000 directory.

The Call for Nominations has been sent to the Board, Executive
Committee, Fellows, Affiliate Society Presidents and Past Presidents.
Nomination forms are due in to National by March 17, 2000.

FROM GRQ:
Pulmonary Rehab:  The PR Task Force held a 2 1/2 hour conference call
last Friday and made major progress in its editing of the pulmonary rehab
template.  We are very much on schedule, albeit a tight one, to complete
work within the next two weeks.

Major issues raised include:

Appropriate role of physician as part of pulmonary rehab. Staffing ratios for pulmonary rehab services. Definitions of the various components of pulmonary rehab. Scope (time period of services)

While these issues are far reaching, we are still confident that
consensus on all points will be reached.  The next meeting of the group,
via conference call, will be either tomorrow or early next week, decision
pending.

On cardiac rehab, it is our understanding the Hash letter is ready to go,
pending a sign off by the American Heart Association.

Grant Opportunities

Visit GrantsNet at http://www.grantsnet.org to find information on Grants and
Grant Writing:  How not to kill your grant application;  Professional Development: The second article in the Career Development Center's series on mentoring; and The GrantDoctor: The GrantDoctor's pick of the best grant writing & funding sites 1999.  GrantsNet now has 602 profiles of funding programs in the GrantsNet database.

Certification Update
Applications are currently under review for the year 2000.  For more information contact Jan Wood, Program Certification Coordinator, AACVPR, 7611 Elmwood Ave., Suite 201, Middleton, WI 53562.  Tel: (608) 831-6989.  FAX: (608) 831-5122.  E- mail: jwood@tmaha.com.

Medicare News

The AACVPR has begun a new internet Legislative Update via e-mail.  The following is the first update from Susan Rees srees@tmahq.com.

Dr. Hirsch et al have requested a CPT code for periperhal vascular rehab.
After some negotiations with the CPT Editorial Panel, it is our
understanding that the code that will be approved has two key components
that will affect AACVPR members.  First, the code, we believe, will
require a one-on-one staffing ratio.  Secondly, the code does not have
any physician component involved.

One-on-one staffing ratio:  If this code is approved with such a
requirement, it is hard to imagine that the payment would be substantial
enough to warrant broad adaptation of the benefit.  And remember, just
because the AMA's CPT Editorial Panel creates a new code, that alone does
not obligate HCFA to embrace it.

More importantly is the presumption, correctly so as we have been told,
that there is no physician involvement in providing PVD.  With no
physician involvement, the CPT code will likely not be referred to the
RUC Committee to determine a payment level because there will be no
payment for physician services.  If HCFA decides to embrace the concept
and establish a payment level for it, we do not anticipate a payment high
enough to make it attractive to everyone.  In fact, that is generally
part of HCFA's thinking.  Bringing a new benefit on line, whatever it is,
cannot be a budget buster, especially if it revolves around a quality of
life concept.

The statutory authorization for cardiac rehab coverage and payment hinges
on the concept that the service is incident to physician services.  It is
not a huge, impossible stretch for HCFA to follow this thought process:
The American College of Cardiology has gone on record saying that PVD has
no physician component.  IF PVD is more similar to cardiac rehab than it
is different, might we (HCFA) assume that there is no physician component
in cardiac rehab.  If there is no physician component in cardiac rehab,
we should reduce payment for cardiac rehab because a portion of what we
have been paying for cardiac rehab has acknowledged the role of a
physician providing overall direction to the cardiac rehab program.

While we are not saying this WILL happen, we believe it is part of our
job to alert AACVPR to the possibilities, positive and negative, that go
along with a policy change by HCFA.

In the Journals:

Effects of an Angiotensin-Converting-Enzyme Inhibitor, Ramipril, on
Cardiovascular Events in High-Risk Patients.  *The Heart Outcomes Prevention Evaluation Study Investigators. (N Engl J Med 2000;342:145-53.)

Abstract
Background:  Angiotensin-converting-enzyme inhibitors improve the outcome
among  patients with left ventricular dysfunction, whether or not they have heart
failure. We assessed the role of an angiotensin-converting-enzyme inhibitor,
ramipril, in patients who were at high risk for cardiovascular events but who did
not have left ventricular dysfunction or  heart failure.

Methods:  A total of 9297 high-risk patients (55 years of age or older) who had
evidence of vascular disease or diabetes plus one other cardiovascular risk factor
and who were not known to have a low ejection fraction or heart failure were
randomly assigned to receive ramipril (10 mg once per day orally) or matching
placebo for a mean of five years. The primary outcome was a composite of
myocardial infarction, stroke, or death from cardiovascular causes. The trial was a two-by-two factorial study evaluating both ramipril and vitamin E. The effects of vitamin E are reported in a companion paper.

Results. A total of 651 patients who were assigned to receive ramipril (14.0
percent) reached the primary end point, as compared with 826 patients who were
assigned to receive placebo (17.8 percent) (relative risk, 0.78; 95 percent
confidence interval, 0.70 to 0.86; P<0.001). Treatment with ramipril reduced the
rates of death from cardiovascular causes (6.1 percent, as compared with 8.1
percent in the placebo group; relative risk, 0.74; P<0.001), myocardial infarction
(9.9 percent vs. 12.3 percent; relative risk, 0.80; P<0.001), stroke (3.4 percent vs.
4.9 percent; relative risk, 0.68; P<0.001), death from any cause (10.4 percent vs.
12.2 percent; relative risk, 0.84; P=0.005), revascularization procedures (16.0
percent vs. 18.3 percent; relative risk, 0.85; P=0.002), cardiac arrest (0.8 percent
vs. 1.3 percent; relative risk, 0.63; P=0.03), heart failure (9.0 percent vs. 11.5
percent; relative risk, 0.77; P<0.001), and complications related to diabetes (6.4
percent vs. 7.6 percent; relative risk, 0.84; P=0.03).

Conclusions: Ramipril significantly reduces the rates of death, myocardial
infarction, and stroke in a broad range of high-risk patients who are not
known to have a low ejection fraction or heart failure.

*The investigators are listed in the Appendix of the Heart Outcomes Prevention
Evaluation Study Investigators. Effects of an Angiotensin-Converting-Enzyme
Inhibitor, Ramipril, on Cardiovascular Events in High-Risk Patients. N Engl J Med 2000;342:145-53.

Address reprint requests to Dr. Salim Yusuf at the Canadian Cardiovascular
Collaboration Project Office, Hamilton General Hospital, 237 Barton St. E.,
Hamilton, ON L8L 2X2, Canada, or at yusufs@fhs.mcmaster.ca.

Vitamin E Supplementation and Cardiovascular Events in High-Risk Patients. The Heart Outcomes Prevention Evaluation Study Investigators.* (N Engl J Med 2000;342:154-60.)

Abstract
Background: Observational and experimental studies suggest that the  amount of
vitamin E ingested in food and in supplements is associated with a lower risk of
coronary heart disease and atherosclerosis.

Methods: We enrolled a total of 2545 women and 6996 men 55 years of age or
older who were at high risk for cardiovascular events because they had
cardiovascular disease or diabetes in addition to one other risk factor. These
patients were randomly assigned according to a two-by-two factorial design to
receive either 400 IU of vitamin E daily from natural sources or matching placebo
and either an angiotensin-converting-enzyme inhibitor (ramipril) or matching
placebo for a mean of 4.5 years (the results of the comparison of ramipril and
placebo are reported in a companion article). The primary outcome was a
composite of myocardial infarction, stroke, and death from cardiovascular causes.  The secondary outcomes included unstable angina, congestive heart failure, revascularization or amputation, death from any cause, complications of diabetes, and cancer.

Results:  A total of 772 of the 4761 patients assigned to vitamin E (16.2 percent)
and 739 of the 4780 assigned to placebo (15.5 percent) had a primary outcome
event (relative risk, 1.05; 95 percent confidence interval, 0.95 to 1.16; P=0.33).
There were no significant differences in the numbers of deaths from
cardiovascular causes (342 of those assigned to vitamin E vs. 328 of those
assigned to placebo; relative risk, 1.05; 95 percent confidence interval, 0.90 to
1.22), myocardial infarction (532 vs. 524; relative risk, 1.02; 95 percent
confidence interval, 0.90 to 1.15), or stroke (209 vs. 180; relative risk, 1.17; 95
percent confidence interval, 0.95 to 1.42). There were also no significant
differences in the incidence of secondary cardiovascular outcomes or in death
from any cause. There were no significant adverse effects of vitamin E.

Conclusions:  In patients at high risk for cardiovascular events, treatment with
vitamin E for a mean of 4.5 years has no apparent effect on cardiovascular
outcomes.

*The investigators are listed in the Appendix of the Heart Outcomes Prevention
Evaluation Study Investigators. Effects of an Angiotensin-Converting-Enzyme
Inhibitor, Ramipril, on Cardiovascular Events in High-Risk Patients. N Engl J Med 2000;342:145-53.

Address reprint requests to Dr. Salim Yusuf at the Canadian Cardiovascular
Collaboration Project Office, Hamilton General Hospital, 237 Barton St. E.,
Hamilton, ON L8L 2X2, Canada, or at yusufs@fhs.mcmaster.ca.
 

The multicenter study of enhanced external counterpulsation (MUST-EECP):
effect of EECP on exercise-induced myocardial ischemia and anginal episodes
Rohit R. Arora, et al.  JACC.  Volume 33(7) June 1999 pp 1833-1840.

Abstract
OBJECTIVES:  The purpose of this study was to assess safety and efficacy of
enhanced external counterpulsation (EECP).

BACKGROUND:  Case series have shown that EECP can improve exercise
tolerance, symptoms and myocardial perfusion in stable angina pectoris.

METHODS:  A multicenter, prospective, randomized, blinded, controlled trial was conducted in seven university hospitals in 139 outpatients with angina,
documented coronary artery disease (CAD) and positive exercise treadmill test.
Patients were given 35 h of active counterpulsation (active CP) or inactive
counterpulsation (inactive CP) over a four- to seven-week period. Outcome
measures were exercise duration and time to 1-mm ST-segment depression,
average daily anginal attack count and nitroglycerin usage.

RESULTS:  Exercise duration increased in both groups, but the between-group
difference was not significant (p > 0.3). Time to 1-mm ST-segment depression
increased significantly from baseline in active CP compared with inactive CP (p =
0.01). More active-CP patients saw a decrease and fewer experienced an
increase in angina episodes as compared with inactive-CP patients (p < 0.05).
Nitroglycerin usage decreased in active CP but did not change in the inactive-CP
group. The between-group difference was not significant (p > 0.7).

CONCLUSIONS:  Enhanced external counterpulsation reduces angina and
extends time to exercise-induced ischemia in patients with symptomatic CAD.
Treatment was relatively well tolerated and free of limiting side effects in most
patients.

The relation between systolic blood pressure and mortality: Framingham data re-analyzed.  Port S, et al. Lancet 2000;355(9199):175-180.

A re-analysis of data from the first 18 years of the Framingham Heart Study
challenges the view that there is a continuous and graded relation between
systolic blood pressure and mortality. Investigators conducting the re-analysis
applied a new model that included age-specific and sex-specific rates.

Findings:
  1)         Neither all-cause nor cardiovascular deaths relied on systolic blood
               pressure in a strictly linear manner.
  2)         The risk of death was unrelated to systolic pressure up to approximately
               the 70th percentile of systolic blood pressure for persons of a given age
               and gender.
  3)         Risk increased sharply with pressures higher than the 80th percentile.

Conclusion and comment: The findings contradict the idea that 140 mm Hg is a
useful cut-off for hypertension for all adults. Rather, there is an age- and sex-
dependent threshold for hypertension. Based on this finding, the authors suggest
a reclassification of hypertension cut points, which would be based on these
percentiles and factor in a person's age and sex.

In a related editorial, Michael H. Alderman, MD, concluded that despite the
controversy introduced by the new study  the current consensus that
pharmacologic treatment be initiated in people with systolic pressures greater
than 140 mm Hg, especially when they are at increased absolute risk of a stroke
or heart attack, need not be altered.  It is well supported by  a solid mix of clinical, epidemiological, and mechanistic information.

Weight Gain After Lung Volume Reduction Surgery Is Not Correlated With
Improvement in Pulmonary Mechanics.  Paul J. Christensen, et al. Chest.
1999;116:1601-1607.

Study objectives: Malnutrition and low body weight are common in patients with
emphysema. Previous work has demonstrated correlation between severity of
airflow obstruction and body weight. Lung volume reduction surgery (LVRS) is a
recent advance in the treatment of patients with severe emphysema that results in
improved pulmonary function. We formed the hypothesis that improved lung
mechanics after LVRS would result in body weight gain.

Design: Retrospective chart review.

Patients: All patients who underwent bilateral LVRS for severe emphysema at the
University of Michigan between January 1995 and April 1996 were eligible for the
study.

Measurements and results: Pulmonary function and body weight were measured
preoperatively and at 3, 6, and 12 months postoperatively for patients who
underwent bilateral LVRS between January 1995 and April 1996. The average
weight gain in 38 patients returning for 12 months of follow-up was 3.8 ± 0.9 kg, or 6.2% of the preoperative weight. Women gained significantly more weight than men (9.2 vs 2.2%, respectively) at 1 year. Interestingly, there was no correlation between change in weight and postoperative change in FEV1, FVC, residual volume (RV), total lung capacity (TLC), or RV/TLC at 12 months. However, there was a statistically significant correlation between weight gained and improvement in diffusion of carbon monoxide measured 12 months postoperatively.

Conclusions: This study shows that patients with severe emphysema gain weight
after LVRS. These changes were independent of changes in pulmonary
mechanics but may be a result of improved gas exchange. These findings provide
further information about benefits of LVRS in patients with advance emphysema
that are beyond simple changes in pulmonary function.

Correspondence to: Paul Christensen, MD, VA Medical Center (111G), 2215
Fuller Rd, Ann Arbor, MI 48105; e-mail: pchriste@umich.edu.

The Importance of Physical Fitness In the Performance of Adequate
Cardiopulmonary Resuscitation. Alejandro Lucía, et al.  Chest. 1999;115:158-164.

The aim of the present investigation was to evaluate the influence of the physical
fitness of a cardiopulmonary resuscitation (CPR) provider on the performance of
and physiologic response to CPR. To this end, comparisons were made of
sedentary and physically active subjects in terms of CPR performance and
physiologic variables. Two study groups were established: group P (n = 14),
composed of sedentary, professional CPR rescuers (mean [± SD]; age, 34 ± 6
years; VO2max, 32.5 ± 5.5 mL/kg/min), and group Ex (n = 14), composed of
physically active, nonexperienced subjects (age, 34 ± 6 years;  VO2max, 44.5 ±
8.5 mL/kg/min). Each subject was required to perform an 18-min CPR session,
which involved manual external cardiac compressions (ECCs) on an electronic
teaching mannequin following accepted standard CPR guidelines. Subjects' gas
exchange parameters and heart rates (HRs) were monitored throughout the trial.
Variables indicating the adequacy of the ECCs (ECC depth and the percentage of
incorrect compressions and hand placements) also were determined. Overall CPR
performance was similar in both groups. The indicators of ECC adequacy fell
within accepted limits (i.e., an ECC depth between 38 and 51 mm). However,
fatigue prevented four subjects from group P from completing the trial. In contrast, the physiologic responses to CPR differed between groups. The indicators of the intensity of effort during the trial, such as HR or percentage of maximum oxygen uptake ( VO2max) were higher in group P subjects than group Ex subjects, respectively (HRs at the end of the trial, 139 ± 22 vs 115 ± 17 beats/min, p < 0.01; percentage of VO2max after 12 min of CPR, 46.7 ± 9.7% vs 37.2 ± 10.4%, p < 0.05). These results suggest that a certain level of physical fitness may be beneficial to CPR providers to ensure the adequacy of chest compressions performed during relatively long periods of cardiac arrest.

The Efficacy of Exercise as an Aid for Smoking Cessation in Women A
Randomized Controlled Trial.  Bess H. Marcus, et al. Arch Intern Med.
1999;159:1229-1234.

Background Smoking prevalence rates among women are declining at a slower
rate than among men.

Objective To determine if exercise, a healthful alternative to smoking, enhances
the achievement and maintenance of smoking cessation.

Methods Two hundred eighty-one healthy, sedentary female smokers were
randomly assigned to either a cognitive-behavioral smoking cessation program
with vigorous exercise (exercise) or to the same program with equal staff contact
time (control). Subjects participated in a 12-session, group-based smoking
cessation program. Additionally, exercise subjects were required to attend 3
supervised exercise sessions per week and control subjects were required to
participate in 3 supervised health education lectures per week. Abstinence from
smoking was based on self-report, was verified by saliva cotinine level, and was
measured at 1 week after quit day (week 5), end of treatment (week 12), and 3
and 12 months later (20 and 60 weeks after quit day, respectively).

Results Compared with control subjects (n=147), exercise subjects (n=134)
achieved significantly higher levels of continuous abstinence at the end of
treatment (19.4% vs 10.2%, P=.03) and 3 months (16.4% vs 8.2%, P=.03) and 12
months (11.9% vs 5.4%, P=.05) following treatment. Exercise subjects had
significantly increased functional capacity (estimated VO2 peak, 25 ± 6 to 28 ± 6,
P<.01) and had gained less weight by the end of treatment (3.05 vs 5.40 kg,
P=.03).

Conclusions Vigorous exercise facilitates short- and longer-term smoking
cessation in women when combined with a cognitive-behavioral smoking
cessation program. Vigorous exercise improves exercise capacity and delays
weight gain following smoking cessation.

Guidelines
NHLBI: Clinical Guidelines for Cholesterol: Recommendations Regarding Public Screening for Measuring Blood Cholesterol, Expert Panel on High Blood Cholesterol in Adults, Hypertension: High Blood Pressure Guidelines (JNC VI) JNC VI Quick Reference Card, and  Obesity:  Clinical Guidelines on Overweight and Obesity (Updated June 1999) can be found at http://www.nhlbi.nih.gov/guidelines/index.htm.

Grant Opportunities
Grants For Health Services Dissertation Research can be found at http://www.ahcpr.gov/fund/dissrt98.htm.  The purpose of this program, found in the Ongoing Program Announcement, Release Date: September 15, 1998, PA: PAR-98-111, Application Receipt Dates: May 5 and November 15 (Annually), is to support research undertaken as part of an academic program to qualify for a doctorate. AHCPR supports and conducts research to improve the outcomes, quality, access to, and cost and utilization of  health care services. AHCPR achieves this mission through health services research designed to (1) improve clinical practice, (2) improve the health system's ability to provide access to and deliver high quality, high-value health care, and (3) provide policy makers with the ability to assess the impact of system changes on outcomes, quality, access, cost and use of health care services.  AHCPR will accept applications from students seeking a doctorate in areas relevant to health services research. Total direct costs, under this announcement, must not exceed $30,000 for the entire project period.

Application kits are available at most institutional offices of sponsored research. They may also be obtained from the Division of Extramural Outreach and Information Resources, National Institutes of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone (301) 435-0714, E-mail: asknih@od.nih.gov

AHCPR applicants can also obtain application materials from the AHCPR contractor:
Equals Three Communications, Inc.,
7910 Woodmont Avenue, Suite 200,
Bethesda, MD 20814-3015
Telephone (301) 656-3100
FAX (301) 652-5264
 

ACSM's Research Development Department can be reached at: Phone: (317) 637-9200, fax (317) 634-7817, Email rdacsm@acsm.org, Jane E. Gleason - Manager, Research Development  Ext. 125.

Through the ACSM Foundation and the Office of Research Development, the College offers research grants to ACSM student members, as well as new and senior investigators. Several specific funding areas include: injury prevention, weightlessness and space physiology, exercise and aging, exercise and cardiovascular disease risk factors, and exercise and heart rate response. The Research Development department serves as a scientific information source to other ACSM National Center departments. In addition, a reference list of research funding opportunities in exercise science and sports medicine outside ACSM is available.

The following research grants are available:
Reebok Research Grants on Injury Prevention and Human Performance; ACSM Foundation Research Grant; NASA Space Physiology Research Grants; Polar Research Grant on Controlled Heart Rate Zone Exercise. CybexResearch Grants on Exercise and Human Aging. Fellowship Fund for Epidemiological Research on Physical Activity Research Endowment Grants. Others to be announced in 1999.

American Diabetes Association Scientific and Medical Division
Diabetes and cardiovascular disease.
American Diabetes Association Scientific and Medical Division
1660 Duke Street
Alexandria, VA 22314
(703) 549-1715
Research@diabetes.org

Dairy Management Inc.
Product and Nutrition Competitive Research Program
Dairy Management Inc.
Research Department
10255 W. Higgins Road, Suite 900
Rosemont, IL 6001-85616
(847) 803-2000
FAX (847) 803-2077

Juvenile Diabetes Foundation International
Diabetes Research
JDF International
The Diabetes Research Foundation
Grant Administrator
432 Park Avenue South
New York, NY 1001-68013
(212) 889-7575
Fax (212) 532-7891

Recent Cardiac Rehabilitation Clinical Care Guideline Developed
Coronary heart disease, heart failure, and cardiac transplantation are common cardiac problems of patients throughout the United States. The impact of these debilitating conditions on the patients, their families, and their communities represents both a major challenge and opportunity for providing optimal comprehensive management. According to the World Health Organization (WHO) cardiac rehabilitation is "the sum of activities required to ensure patients the best possible physical, mental and social conditions so that they may resume and maintain as normal a place as possible in the community." The recent guidelines were developed by a panel of experts, many who are ACSM members, under the sponsorship of the Agency for Health Care Policy and Research (AHCPR).  These new guidelines use the U.S. Public Health Service definition of cardiac rehabilitation, as "cardiac rehabilitation services are comprehensive, longterm programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk sudden death or reinfarction, control cardiac symptoms, stabilized or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients."  The guideline is available in versions designed for the health care professional and for the consumer, and is intended to optimize the quality, safety, effectiveness, and access to cardiac rehabilitation services. The document has important implications for physicians and allied health professionals involved in secondary prevention. The guideline comments on special populations including the elderly, heart failure patients and cardiac transplantations. The four major recommendations for health care providers are:

1.  Cardiac rehabilitation is an essential part of the discharge plan for patients who have had myocardial infarction or revascularization with CABGS or PTCA.

2.  Cardiac rehabilitation is safe for patients who have been appropriately screened and evaluated.

3.  Cardiac rehabilitation is presently underutilized.

4.  Cardiac rehabilitation can be delivered in a number of settings.

The panel further defines cardiac rehabilitation as a multifactorial intervention process following a well designed program structure including; evaluation of patients status (medical, nutritional, psychological, educational, and vocational), and implementation of a program based on this evaluation. The implementation of cardiac rehabilitation is individualized based on patient needs.  The guideline provides broad recommendations based on evaluation of the scientific evidence pertaining to the various components of cardiac rehabilitation. The key components of cardiac rehabilitation are each addressed, including, exercise, education, counseling (about cardiac risk factor modification, development of psychosocial and motivational skills), and behavioral interventions.  In the complete Clinical Practice Guideline the scientific evidence underlying each of the recommendations is given and the conclusions are discussed. In addition, extensive tables and references are given for each of the areas.

Information on How to Obtain the Clinical Practice Guideline To order single copies of the guideline products or to obtain further information on their availability, call the AHCPR clearinghouse tollfree at (800) 358-9295 or write to:
AHCPR Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907

The full text of guideline documents for online retrieval may be accessed through a free, electronic service from the National Library of Medicine called HSTAT (Health Services/Technology Assessment Text). A fact sheet describing Online Access for Clinical Practice Guidelines (AHCPR Publication No. 940075) and copies of the Quick Reference Guide for Clinicians and the Consumer Version of each guideline are available through AHCPR's InstantFAX, a fax on demand service that operates 24 hours a day, 7 days a week, AHCPR is available to anyone using a facsimile machine equipped with a touchtone telephone handset: Dial (301) 594-2800, push "1", and then press the facsimile machine's start button for instructions and a list of currently available publications.

Program Listings
If you have any changes to your program information (phone, fax, e-mail, etc.) Please send them to Bob Lowe (501-202-1209 fax or bclowe@baptist-health.org).

Wide World Web
The ACVPRA has a mirror website at the national AACVPR website.  Click  here to visit our homepage.  If you have any interesting web sites please submit them to Bob Lowe.

Cardiology.org  An excellent site for information maintained by Victor Froelicher MD and Jonathan Myers, Ph.D. can be found at http://www.cardiology.org/toc.htm.  This site includes Powerpoint slides, ACC/AHA exercise testing guidelines, 1994 ACC/ACSM Task Force Guidelines, books, latest papers, services,  internships, exercise test collection products page, links, interactive pages at Cardiology.org including: ECG abnormalities, human body mass index,  Duke score, Framingham prognosis, and more.  In addition, the following *.zip files may be downloaded from http://204.161.114.88/slides.htm: The Standard Exercise ECG is the Preferred Initial Stress Test for Women,  Advances in Clinical Exercise Physiology, Cardiac Aspects of Exercise, Exercise Test As Gatekeeper,  Exercise Testing for Diagnosis of CAD,  Applications of Exercise Testing, Risk Stratification of CAD With Exercise Test, and Exercise ECG Interpretation.

The National Heart, Lung, and Blood Institute (NHLBI) maintains a website at http://www.nhlbi.nih.gov/index.htm.  Items available include:  Cholesterol Education Month Kit, Clinical Guidelines on Overweight and Obesity, Interactive Site: Lowering Cholesterol for People with Heart Disease, and Achieving Your Healthy Weight.  Links are available to Health Information | Scientific Resources | Research Funding| News and Press Releases | Committees, Meetings, Events | Clinical Guidelines| Studies Seeking Patients | Labs at the NHLBI | Technology Transfer| What's New | Search | Site Index | About NHLBI| NIH Home Page | Links to Other Sites | Contact the NHLBI

Medicine and Science in Sports and Exercise site with on-line articles and position stands including the Recommended Quantity and Quality of Physical Activity, Exercise for Patents with Coronary Artery Disease, and others can be found at  http://www.ms-se.com/.

Physician and Sports Medicine site includes online articles such as

Strength Training: Rationale for Current Guidelines for Adult Fitness Programs. Matthew S. Feigenbaum, Med; Michael L. Pollock, PhD http://www.physsportsmed.com/issues/1997/02feb/
pollock2.htm
and
Congestive Heart Failure: Training for a Better Life. James R. Clark, MD, with Carl Sherman. http://www.physsportsmed.com/issues/1998/08aug/clark.htm.  To search back issues go to: http://www.physsportsmed.com/issues.

ACVPRA Officers
Click here to go to the ACVPRA Officers page.

Membership Form
Click here to go to the ACVPRA membership application.

Suggestion Box
Please send comments, suggestions, corrections, and articles of interest to Bob Lowe.

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