Diminished left ventricular dyssynchrony and impact of resynchronization in failing hearts with right versus left bundle branch block.

OBJECTIVES: We compared mechanical dyssynchrony and the impact of cardiac resynchronization therapy (CRT) in failing hearts with a pure right (RBBB) versus left bundle branch block (LBBB). BACKGROUND: Cardiac resynchronization therapy is effective for treating failing hearts with conduction delay and discoordinate contraction. Most data pertain to LBBB delays. With RBBB, the lateral wall contracts early so that biventricular (BiV) pre-excitation may not be needed. Furthermore, the magnitude of dyssynchrony and impact of CRT in pure RBBB versus LBBB remains largely unknown. METHODS: Dogs with tachypacing-induced heart failure combined with right or left bundle branch radiofrequency ablation were studied. Basal dyssynchrony and effects of single and BiV CRT on left ventricular (LV) function were assessed by pressure-volume catheter and tagged magnetic resonance imaging, respectively. RESULTS: Left bundle branch block and RBBB induced similar QRS widening, and LV function (ejection fraction, maximum time derivative of LV pressure [dP/dt(max)]) was similarly depressed in failing hearts with both conduction delays. Despite this, mechanical dyssynchrony was less in RBBB (circumferential uniformity ratio estimate [CURE] index: 0.80 +/- 0.03 vs. 0.58 +/- 0.09 for LBBB, p < 0.04; CURE 0-->1 is dyssynchronous-->synchronous). Cardiac resynchronization therapy had correspondingly less effect on hearts with RBBB than those with LBBB (i.e., 5.5 +/- 1.1% vs. 29.5 +/- 5.0% increase in dP/dt(max), p < 0.005), despite similar baselines. Furthermore, right ventricular-only pacing enhanced function and synchrony in RBBB as well or better than did BiV, whereas LV-only pacing worsened function. CONCLUSIONS: Less mechanical dyssynchrony is induced by RBBB than LBBB in failing hearts, and the corresponding impact of CRT on the former is reduced. Right ventricular-only pacing may be equally efficacious as BiV CRT in hearts with pure right bundle branch conduction delay.     

Contrast echocardiography accurately predicts myocardial perfusion before angiography during acute myocardial infarction

OBJECTIVES: To determine whether myocardial contrast echocardiography (MCE) can quickly and accurately assess myocardial perfusion and infarct-related artery (IRA) patency before emergency angiography during acute myocardial infarction (AMI). BACKGROUND: Despite encouraging experimental and clinical studies, the reliability and practicality of MCE in predicting IRA patency during AMI before angiography has not been proven. METHODS: Two-dimensional echocardiography and MCE were performed in 51 patients with AMI just before emergency angiography. With knowledge of the electrocardiogram findings and regional wall motion, myocardial perfusion was assessed to predict IRA patency. RESULTS: Myocardial perfusion studies were adequate for interpretation in 40 patients. An occluded IRA was predicted in 28 patients; the artery was occluded in 22 patients, and six patients had Thrombolysis In Myocardial Infarction (TIMI) grade 2 flow or less. A patent IRA was predicted in 12 patients; eight patients had TIMI grade 3 flow, one patient had TIMI grade 2 flow and the IRA was occluded in three patients. In one of the three patients, the appropriate view was not obtained. In another patient, collateral flow was adequate for near-normal regional wall motion, and in the last, the findings suggested reperfusion of the proximal artery with distal embolic occlusion. Taken together, MCE accurately predicted either TIMI grade 2 flow or less, or TIMI grade 3 flow in 36 of 40 patients. Sensitivity was 87.5%, specificity and positive predictive value were 100% and negative predictive power was 66.7% (P<0.001). CONCLUSIONS: MCE, together with the electrocardiogram and regional wall motion, can be used to quickly and reliably predict IRA patency early during AMI and may be useful to facilitate a management strategy.     

Integrating Systematic Chronic Care for Diabetes into an Academic General Internal Medicine Resident-Faculty Practice

Background  The quality of care for diabetes continues to fall short of recommended guidelines and results. Models for improving the care of chronic illnesses advocate a multidisciplinary team approach. Yet little is known about the effectiveness of such models in an academic setting with a diverse patient population and resident physicians participating in clinical care. Objective  To implement a chronic illness management (CIM) practice within an academic setting with part-time providers, and evaluate its impact on the completion of diabetes-specific care processes and on the achievement of recommended outcomes for patients with diabetes mellitus. Design  Retrospective cohort study Subjects  Patients with the diagnosis of diabetes mellitus who receive their primary care in an academic general internal medicine resident-faculty practice. Measurements  Process and outcomes measures in patients exposed to the CIM practice were compared with non-exposed patients receiving usual care. Main Results  Five hundred and sixty-five patients met inclusion criteria. Patients in the CIM practice experienced a significant increase in completion of care processes compared to control patients for measurement of annual low-density lipoprotein (LDL) cholesterol (OR 3.1, 95% CI 1.7–5.7), urine microalbumin (OR 3.3, 95% CI 2.1–5.5), blood pressure (OR 1.8, 95% CI 1.1–2.8), retinal examination (OR 1.9, 95% CI 1.3–2.7), foot monofilament examination (OR 4.2, 95% CI 3.0–6.1) and administration of pneumococcal vaccination (OR 5.2, 95% CI 3.0–9.3). CIM-exposed patients were also more likely to achieve improvements in clinical outcomes of glycemic and blood pressure control reflected by hemoglobin A1c less than 7.0% (OR 1.7, 95% CI 1.02–3) and blood pressure less than 130/80 (OR 2.8, 95% CI 2.1–4.5) compared to controls. Conclusions  A systematic chronic care model can be successfully integrated into an academic general internal medicine practice and may result in improved processes of care and some clinical outcomes for diabetic patients. This study provides a model for further hypothesis generation and more rigorous testing of the quality benefits of structured chronic illness care in diverse outpatient practices.     

A polymorphism in the IGF-I gene influences the age-related decline in circulating total IGF-I levels

OBJECTIVE: Recent studies have demonstrated an association between a 192 bp polymorphism of the IGF-I gene and total IGF-I serum levels, birth weight, body height and the risk of developing diabetes and cardiovascular diseases later on in life. This IGF-I gene polymorphism in the promoter region of the IGF-I gene may directly influence the expression of IGF-I. In the present study we evaluated the role of this polymorphism in the age-related decline in serum IGF-I levels. SUBJECTS AND METHODS: All subjects were participants of the Rotterdam Study, a population-based cohort study of diseases in the elderly. We studied a total group of 346 subjects, who comprised two subgroups: a randomly selected population-based sample of 196 subjects, and a group of 150 subjects selected on IGF-I genotype. In the total group of 346 individuals the relationship between this 192 bp polymorphism and the age-related decline in circulating total IGF-I levels was studied. RESULTS: Homozygous carriers of the 192 bp allele demonstrated significant decline in serum IGF-I with age (r=-0.29, P=0.002). This decline is similar to that seen in the general population. An age-related decline in serum total IGF-I was not observed in heterozygotes (r=-0.06, P=0.48) and non-carriers (r = -0.12, P=0.32). Interestingly, the relationship between age and serum IGF-binding protein-3 levels showed the same pattern. CONCLUSION: We observed only in homozygous carriers of the 192 bp alleles of the IGF-I gene an age-related decline in circulating total IGF-I levels, but not in heterozygotes and non-carriers of the 192 bp allele. We hypothesize that this IGF-I gene polymorphism directly or indirectly influences GH-mediated regulation of IGF-I secretion.     

The Significance of Posture in Communication Systems†

Abstract

We examined psychodynamic interview tasks and techniques to identify clinical actions that improve or impede exploration of subjects' emotional responses, conflicts, defenses, and central relationship themes. This article extends previous quantitative studies (Perry, Fowler, &; Greif, unpublished; Perry, Fowler, &; Semeniuk, 2005) by examining interview vignettes in 50—minute psychodynamic research interviews. We conducted qualitative analyses on 72 dynamic research interviews given by 26 subjects to delineate categories of tasks and interventions. Results indicated five broad tasks of the dynamic interview: 1) Frame Setting; 2) Offering Support; 3) Exploring Affect; 4) Offering Trial Interpretations; and 5) Providing a Formulation and Feedback of relationship themes and conflicts. We further selected two interviews each from 10 subjects, in which there was a difference of one standard deviation or greater on the Overall Dynamic Interview Adequacy scale (Perry, 1999), and interviewer errors from the Therapeutic Alliance Analogue scale (Perry, Brysk, &; Cooper, 1989). We utilized excerpts from these interviews to highlight the importance of these tasks and techniques in deepening discussion of dynamically meaningful material.