“Heart Rate‐Dependent” Electrocardiographic Diagnosis of Left Ventricular Hypertrophy

A case is presented revealing the common phenomenon of heart rate‐dependent diagnosis of electrocardiographic (ECG) diagnosis of left ventricular hypertrophy (LVH), which consists of satisfaction of LVH criteria only at faster rates whereas ECGs with a slow heart rate do not satisfy such criteria. The mechanism of the phenomenon has been attributed to the tachycardia‐mediated underfilling of the left ventricle bringing the electrical “centroid” of the heart closer to the recording electrodes, which results in augmentation of the amplitude of QRS complexes, particularly in leads V2–V4. (PACE 2013; 36:e136–e137)     

Recording of high V1-V3 precordial leads may be essential to the diagnosis of Brugada syndrome during the ajmaline test

Sodium channel-blocking agents are routinely used to unveil the Brugada syndrome in patients in whom the typical electrocardiographic pattern is absent or doubtful. In this article, the authors report a patient with syncopal episodes of unknown origin in whom the conventional electrocardiographic result was normal and a negligibly small "saddle back" type repolarization was present in lead V2 recorded 2 intercostal spaces above the conventional site. Intravenous ajmaline (50 mg) did not elicit the type 1 pattern of the Brugada syndrome in the precordial leads obtained at their usual level, but a clear-cut coved-type repolarization was apparent in high right precordial leads. These findings indicate that high precordial leads should be routinely recorded while assessing the ajmaline test in patients suspected of having the Brugada syndrome.     

When the Body and Appendage of the Left Atrium Disagree: “Focal” Atrial Fibrillation—Implications for Atrial Thrombus Formation and Risk of Thromboembolism

A case is presented of a man who had 5 hours of atrial fibrillation followed by spontaneous conversion and maintained sinus rhythm that persisted as shown by surface electrocardiography. Transesophageal echocardiography performed 24 hours after electrocardiographic conversion documented an atrial fibrillation pattern within the left atrial appendage, with a normal sinus Doppler pattern in the body of the left atrium. This apparent regional discrepancy in atrial function may partially explain the increased risk for “late” thromboembolism among patients with atrial fibrillation who appear to be successfully converted with sustained sinus rhythm. (J Am Soc Echocardiogr 1999;12:1097-1100.)     

Is Consent “Informed” When Patients Receive Care from Medical Trainees?

Objectives: Medical care requires consent and consent requires information. Prior studies have shown that patients are poorly informed about the medical training hierarchy. The authors assessed the impact of “informed” on “consent,” by assessing willingness to be seen by trainees before and after information about trainee’s credentials. Methods: A convenience sample of patients in an urban emergency department (ED) waiting room was surveyed, ascertaining willingness to be seen before and after information about trainees credentials, using Likert scales. McNemar’s test, linear regression, and mixed models were used to assess statistical significance of information in changing preferences and patient characteristics predicting knowledge, willingness, and change in willingness to be seen with more information. Results: The authors approached 397 patients, and 199 (50%) English speakers participated. Initially, 45% of subjects knew the meaning of “medical student,” and 35%“intern” and “resident.” In a controlled multivariate linear regression, educational attainment (p < 0.0001) predicted more knowledge, Hispanic ethnicity predicted less (p = 0.03). Subjects were less willing to be seen by lower‐ranking trainees (p < 0.001). Information about trainees caused a significant increase in unwillingness to be seen by medical students (17% to 28%, p = 0.004) and interns (8% to 13%, p = 0.029). Conclusions: Substantial numbers of ED patients would prefer not to be seen by trainees. When patients are informed about trainees’ credentials, they become less willing to be seen by more junior trainees. Further research should clarify informed consent for care among non–English speakers and should address these issues in other medical settings.     

The electrocardiogram in preterm infants with intraventricular hemorrhage and apnea

To determine the relationship of electrocardiographic changes to both intraventricular hemorrhage (IVH) and neonatal apnea, continuous electrocardiographic monitoring, serial electrocardiograms, and cranial echoencephalograms were obtained on 41 consecutive preterm neonates with birth weight below 1,250 g. Nineteen patients (46%) were diagnosed as having an IVH within the first postnatal week. Six patients died while still requiring mechanical ventilation. Of the 35 surviving infants, 21 experienced apnea. Though the QRS axis was significantly different in the two groups, in both groups it was within the normal range. Of note, 69% of those surviving neonates with IVH experienced apnea, while 53% of those surviving without IVH had apnea. Unlike adult patients with subarachnoid hemorrhage, there are no characteristic electrocardiographic changes in preterm neonates with IVH. Therefore, the neonatal electrocardiogram could not be used to predict neonatal apnea. Continuous electrocardiographic monitoring was useful in detecting transient arrhythmias and episodes of bradycardia in apneic infants. Infants with IVH appeared to be at higher risk for neonatal apnea than their non-IVH peers. The authors stress the importance of continuous electrocardiographic monitoring in all preterm neonates at risk for IVH.     

On “the lateralization of pain”

The hypothesis out forth by Merskey and Watson [16] that pain, when lateralized, occurs more often on the left was tested in a sample of 264 patients seen at the University of Washington Pain Service. Contrary to the hypothesis, pain occurred with equal frequency on the left and the right. No differences were observed between patients with left and right lateralized pain on the MMPI, IBQ or Zung depression scales. The discrepancy between these findings and those of Merskey and Watson probably reflects differences in the populations studied, differences in the conventions used to define pain laterality, and the fact that the multiple statistical tests on a single sample used by Merskey and his colleagues lead to a large probability of obtaining spuriously significant results.     

“Voxel-Based Morphometry” Should Not Be Used with Imperfectly Registered Images

John Ashburner and Karl Friston (2000) introduced a standardized method of “voxel-based morphometry” (VBM) for comparisons of local concentrations of gray matter between two groups of subjects. Segmented images of gray matter from grossly normalized high-resolution images are smoothed and their group differences analyzed by the now-conventional voxelwise Worsley approach to Gaussian random fields of differences. This comment concerns an unfortunate interaction between the algorithm's spatial normalization and voxelwise comparison steps, whereby several obvious quantitative confounds are injected at the core of the inference engine the authors put forward. Specifically, the statistics of the resulting voxelwise comparisons are uninformative about group differences wherever the spatial normalization algorithm has failed to register on any robustly appearing image gradient. The method of Ashburner and Friston is defensible only far from all image gradients.     

Myocardial perfusion imaging with thallium-201 to assess left ventricular hypertrophy and regional ischaemia in hypertensive patients

The increase in mortality from cardiovascular disease in the presence of electrocardiographic signs of left ventricular hypertrophy (LVH) has been ascribed to ischaemic changes in the hypertrophied left ventricle even in the absence of overt coronary artery disease. To test this hypothesis and to investigate the usefulness in the detection of LVH myocardial perfusion scintigraphy with thallium-201 and echocardiography was performed in thirty-three hypertensive patients. Sixteen had had electrocardiographic signs of left ventricular hypertrophy. Twelve patients had symptoms of cardiovascular disease. In twenty-six subjects the scintigraphic procedure consisted of a combined rest--exercise study, in the other seven only resting images were obtained. Measurement of septal wall thickness on the scintiscans correlated fairly well with echographic dimensions and allowed separation of a group of patients with LVH from a group without. In individual patients, however, the perfusion scan was not a reliable tool to affirm the presence of LVH. A total of eight patients, six with LVH on the echocardiogram, had an abnormal rest--exercise perfusion scan, either with a new perfusion defect after exercise and/or with a resting defect alone. In nine other patients with echocardiographic LVH, on the other hand, no abnormal perfusion was found. Thus, perfusion abnormalities did not correlate with the presence of LVH. The presence of such abnormalities in relation to increasing age and symptomatic cardiovascular disease could well be the expression of anatomic coronary artery disease and cannot be differentiated from the possible ischaemia of the hypertrophied left ventricle.     

Terminology Matters: Patient Understanding of “Opioids” and “Narcotics”

Background: The terms “opioid” and “narcotic” are often used interchangeably by healthcare providers. The purpose of this study was to compare understanding “narcotics” vs. “opioids.” Methods: A convenience sample of English‐speaking women (n = 188), aged 21–45 years, seeking care at a primary care clinic were asked (1) “What is an opioid/narcotic?” (2) “Give an example of an opioid/narcotic?” (3) “Why does someone take an opioid/narcotic?” and (4) “What happens when someone takes an opioid/narcotic for a long time?” Responses were recorded verbatim by a research assistant and then coded independently by two investigators. Results: More than half of respondents (55.9%) responded “don’t know” to all 4 opioid questions, while just 3.2% responded “don’t know” to all 4 narcotic questions (P < 0.01). Most women were unfamiliar with the term opioid (76.3%) and did not know why someone would take an opioid (68.8%). About two‐thirds of respondents were able to give an example of a narcotic (64.2%) and knew the consequences of long‐term narcotic use (63.2%). Conclusions: While more women were more familiar with narcotic, many identified negative connotations with this term. Future research should explore how to improve patient understanding and attitudes regarding both the terms opioids and narcotics.     

Elderly‐onset degenerative “lumbar spondylotic myelopathy” in a patient with a low‐placed spinal cord successfully treated by laminotomy: a case report

The authors report a rare case of elderly‐onset “lumbar spondylotic myelopathy” occurred on a low‐placed spinal cord compressed at multiple levels with thickened ligamenta flava. A posterior decompression surgery could alleviate neurological symptoms successfully instead of untethering of the spinal cord, a widely accepted surgery for tethered cord.     

Snapshot quiz – “Tattoo of Scheepers”

An ink marker at the descending part of the gastrojejunostomy or duodenojejunostomy after a pancreaticoduodenectomy or pylorus‐preserving pancreaticoduodenectomy prevents a misplacing of a postoperative endoscopic intervention.     

Experience with introduction of an instrumental-diagnostic complex in outpatient clinics

The paper is concerned with introduction under outpatient conditions of an instrumental diagnostic complex including, apart from routine electrocardiographic and x-ray examinations, more specialized techniques, namely phonocardiography and echocardiography. Based on examination of 273 patients with different heart diseases the authors worded indications for echocardiography with emphasis on the necessity of rejecting or confirming the diagnosis, of specifying the diagnosis upon the deciding on the surgical treatment, and so forth. The authors conclude that it is necessary to use the instrumental diagnostic complex under outpatient conditions. They stress, however, that its successful use completely depends on the number of outpatients. The present paper is of interest for physicians specialized in functional diagnosis made in- and outpatiently.     

心律失常患者起搏器置换术的护理

介绍了25例心室VVI起搏器置换病人的护理，包括术前准备、术后心电监护、并发症的观察与护理、出院指导等。主要包括专科护士掌握起搏器置换适应症，术前配合医生对患行X线检查，测试原起搏电极参数以确定置换方案；术后严密心电监护，观察起搏器起搏、感知功能；适当限制新安置起搏器侧肢体的活动，防止电极导线脱位；观察伤口渗情况以及囊袋有无感染或血肿；出院前行健康宣教和生活指导，嘱患定期随访等。25例病人置换术后，起搏与感知功能均良好。     

“Used parts”: The rational approach to understanding organizational systems and structures

Nurses, especially advanced practice nurses, involved in different levels of the health care system will be exposed often to managerial and business issues. This sociological analogy can provide a concise explanation and exposure to the interdisciplinary world of organizational systems. The rational systems perspective, over all, adequately fits these two different organizations. Whether not-for-profit or for-profit, distinct goals and maximum efficiency are necessary for the success of each organization. The parallels are easily made and nicely fit. Who would have thought that “used parts” could be so very similar whether for-profit or nonprofit is involved? However, the rational system works whether it is for-profit or nonprofit. Thus, the overall importance of understanding different organizational systems is paramount.Some nurses are flexible enough to work in any organizational structure. Depending on beliefs and needs, a nurse will find an organizational structure that fits her long-range goals. There are many different kinds of organizational designs in health care, and the organizational model will depend on the services provided and the philosophy of the institution. Learning about organizational perspectives will provide a better understanding of relationships, patterns of communication, priorities, and how people work within organizations.It is likely that when a nurse understands these differences in organizational structure and systems, the choice of where to work will fit the individuals' value systems and work ethics, thus enhancing retention and individual satisfaction in the workplace.     

The significance of transient left ventricular dilation during SPECT dipyridamole thallium-201 scintigraphy

We assessed the significance of transient left ventricular dilation (TLVD) during single photon emission computed tomography (SPECT) dipyridamole thallium-201 scintigraphy (DTS) in 49 patients who underwent both DTS and diagnostic coronary arteriography. Quantitative analysis of DTS images and independent review by 3 experienced observers determined that 17 patients had TLVD and 32 patients had no TLVD. Patients with TLVD were similar to patients without TLVD with respect to age, history of myocardial infarction, coronary risk factors and occurrence of chest pain or electrocardiographic changes during DTS. The frequency of three-vessel coronary artery disease (3VD) was greater in patients with TLVD than in patients without TLVD (94% vs. 16%, p<0.01). The sensitivity of TLVD was 76% and the specificity 96% for the detection of 3VD. Of the 16 patients with 3 VD who manifested TLVD, standard SPECT DTS analysis demonstrated defect or perfusion abnormalities in 14 patients and no abnormalities in 2 patients. In conclusion, the finding of TLVD during SPECT DTS is a specific marker for severe coronary disease and can provide additive information to standard SPECT thallium-201 analysis.     

“Aloha”: An In-House Nursing Home Vacation

This article describes a weeklong in-house “vacation” that was held at a Department of Veterans Affairs nursing home. The author provides the guidelines used to plan, implement, and evaluate the project. The in-house nursing home vacation was successful, as measured by the number of residents in attendance, their positive evaluations, and their desire to repeat the experience. The primary reason for the success of this program was the number and strength of the interactive partnerships.     

From “first” to “last” steps in life – Pressure patterns of three generations

Background

The human foot has to bear loads during all kinds of bipedal locomotion throughout the whole life. Rapid developmental changes of foot morphology and foot function occur during the first years of walking. Furthermore, disease dependent modifications can also have an influence on plantar loading. Therefore, it is reasonable to assume that foot function will undergo changes in life. However, the main differences between the pressure patterns in young and elderly have not been well described. The aim of the study was to evaluate age-dependent pressure patterns in different age-related stages.

Methods

Hundred and four healthy humans of four different age groups were retrospectively analysed by means of plantar pressure measurements (toddlers: mean age 1.0 (SD 0.2) year; 7-year olds: 7.0 (SD 0.4) years; adults: 31.9 (SD 2.1) years; seniors: 68.7 (SD 3.2) years). The emed^® pressure platform was used to evaluate peak pressure, maximum force, contact time, contact area and arch index.

Findings

Significant differences were found for each parameter between almost every age group. The highest peak pressure values were observed for the seniors’ (P < 0.001). Peak pressures are low in toddlers (145 kPa), high in 7-year olds and adults (400–600 kPa) and even higher in elderly (?800 kPa).

Interpretation

Elderly adults can still be functionally mobile even if pressures are high. The results for the investigated age groups can be used as normative foot loading data to compare to pathological foot function.     

Radioiodination of human growth hormone with characterization and minimization of the commonly defined “damaged products”

The radioiodination and Chromatographie purification of human growth hormone (hGH) has been studied in order to better define and control the so-called “preparation damage”, which is often a cause of interferences, loss in specific activity and sensitivity, misclassification errors in radioligand assays, and a source of misinterpretation when the tracer is used in receptors or in vivo studies.

A series of labelings and false labelings, with and without protein carrier in the buffer used for Sephadex purification, indicate that the “preparation damage” peak is made up of two components: aggregated ¹²⁵I-hGH and BSA-carried radioactivity. The former can be minimized by the use of recently extracted non-lyophilized hGH, and the latter by enzymatic labeling. Both components can be better resolved, and thus eliminated, when Sephadex G-100 is employed rather than G-75.     

The “Filarial Dance” Is Not Characteristic of Filariasis

The objective of this series was to show that the sonographic appearance described as the “filarial dance” is not characteristic of filariasis but occurs in nonendemic areas as a manifestation of epididymal obstruction. An experienced observer documented cases after initial observation of the filarial dance in routine clinical practice using high‐frequency linear array transducers. The filarial dance was described as excessive to‐and‐fro movement of echogenic particles within a prominent epididymis and graded 1 to 4 according to the extent and distribution of the abnormality. The country of birth, exposure to filarial infection or travel to a filarial‐endemic area, previous scrotal surgery including vasectomy, any previous or current scrotal inflammatory disease, and any congenital testicular abnormalities were recorded. Over a 10‐year period, sonographic appearances consistent with the filarial dance were observed in 18 patients (bilateral in 6). The mean patient age was 47.7 (range, 28–91) years. The abnormality was graded in the 24 affected testes as follows: grade 1, n = 3; grade 2, n = 8; grade 3, n = 8; and grade 4, n = 5. No patient had a history of filariasis or travel to an endemic area. Six of 18 patients (33.3%) had bilateral vasectomies; 5 (27.8%) had a history of epididymo‐orchitis in the ipsilateral testis; 3 (16.7%) had previous scrotal surgery; and 4 (22.2%) had no relevant urologic history. We have described a sonographic appearance identical to the filarial dance in men with no history of filarial infection. Most had previous scrotal surgery or infection, suggesting that the filarial dance may not always be due to movement of filarial worms. The unifying condition in patients with filariasis and our patients is lymphatic obstruction, likely the underlying cause of the appearance in both groups.     

The outcome of patients after “collapse”

Objective: There have been few studies examining patients with a triage diagnosis of collapse and none which has determined the outcome of these patients as a group. This study was undertaken to determine the frequency of the triage diagnosis of collapse, the differential diagnosis in these patients, and if any errors in diagnosis occurred. Design: Case notes over a six month period from the 1 October 1991 to the 31 March 1992 were retrospectively studied. Outcome was assessed at six months. Setting: The Emergency Department of the Geelong Hospital, a 450 bed teaching hospital serving a population of 250,000 in a large provincial centre in Victoria. Results: There were 17,588 attendances to the ED during the study period. One hundred and seventy four patients (1%) had a triage diagnosis of collapse, of whom 173 were included in the study. One hundred and seventy patients were followed up at six months. Faint was the commonest diagnosis (28%), and was usually benign. In particular, faint was the commonest diagnosis in patients over 75 years of age. For patients in whom the diagnosis of faint was made, it was correct in 98% of cases. There was a high overall mortality (9%), and a very high mortality in patients over 75 (24%). No patient less than 60 years of age died. Early deaths were generally due to major cerebrovascular accidents. Later deaths were mostly due to either untreated cardiac disease in very elderly or demented patients or metastatic cancer. The high death rate did not reflect misdiagnosis. It reflected the high morbidity and mortality of conditions which present with collapse, particularly in patients over 75 years of age. Misdiagnosis in these patients was uncommon (3%) and was generally related to three diagnostic areas, epilepsy, arrhythmias and gastrointestinal haemorrhage. Conclusion: Patients presenting with a triage diagnosis of collapse form a significant part of the emergency department workload. Faint is the commonest diagnosis and is usually benign. However, many conditions which present with collapse are associated with a high morbidity and mortality, particularly in patients over 75 years of age. Therefore care must be taken to exclude these more serious conditions, particularly epilepsy, arrhythmia and gastrointestinal haemorrhage, before a diagnosis of simple faint is made.