Is the Degree of Arrhythmia Suppression a Predictor of Survival?

The effectiveness of an antiarrhythmic drug is judged by the degree of ventricular arrhythmia (VA) suppression. We evaluated the relationship between the degree of VA suppression and survival in a dose-adjusted trial of 110 symptomatic patients treated with amiodarone. Cohorts had left-ventricular ejection fraction (LVEF) of 41 plus minus 18%, ventricular premature contractions (VPCs) of 445 plus minus 571 h, couplets (C) of 733 plus minus 1498 24 h and nonsustained (N) ventricular tachycardia (VT) of 65 plus minus 217 24 h; these conditions were followed for 15 plus minus 11.5 months. Amiodarone was initiated with an oral loading of 670 plus minus 111.7 mg per day for 10 days and continued on maintenance of 274.9 plus minus 102 mg per day. Survival rates of responders and nonresponders with VPCs <70%, 70--89%, greater-than-or-equal90%; C greater-than-or-equal 90%; NVT (100%); and the response to all 3 criteria (suppresion of VPCs greater-than-or-equal70%, C greater-than-or-equal 90% and complete abolition of NVT) were not statistically significant. Survival rates as a function of LVEF <40% (51 patients) or greater-than-or-equal40% (59 patients), as well as responders or nonresponders to all three criteria, were not significant (p = NS). We conclude that, in patients treated with low-dose amiodarone, the degree of VA suppression of PVCs, C and NVT does not predict survival; the survival of patients with LVEF <40% improved irrespective of VA suppression; and criteria for VA suppression should be reassessed at lower levels of suppression for the improvement of the drug risk:benefit ratio. More improvement is not necessarily better.     

Prolonged radionuclide transit in “nutcracker esophagus”

Symptomatic patients with abnormal esophageal manometry characterized by esophageal peristaltic waves of increased amplitude (the nutcracker esophagus, NE) have been recognized with increasing frequency. Whether or not this represents a true functional abnormality is unresolved at this time. We have utilized radionuclide transit (RT), a true esophageal function test, to evaluate patients with NE. Eighteen consecutive symptomatic patients with the NE and ten clinically and manometrically normal subjects constituted this study group. RT in normals were 6.8±0.2 sec ( ±Se) and 27.6±3.8 in patients with NE. RT was abnormal in 17/18 patients with NE. Chaotic bolus transit was seen in 11/18 patients with NE but not in normals. The defect was localized to the distal esophagus since transit through the proximal esophagus was not significantly different between the two groups. This defect in RT may be related to spontaneous simultaneous contractions seen in 50% of these patients. Further work will be necessary to determine if NE is a true functional abnormality or a marker for other motility abnormalities such as diffuse esophageal spasm.This study is supported by Navy Clinical Investigation Protocol No. 0-06-1398.The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense.     

Emergency department medication and drug interaction evaluation

The emergency department evaluation had two primary objectives: 1) to determine the accuracy of the oral medication history given at arrival at the emergency department and 2) to determine how often the emergency department physician may prescribe medications which when taken with current medications, may cause a potential drug interaction. Data were collected from 228 emergency department visits of clinic patients 65 years old and older. The average number of medications reported by the patients' medication history was 3.0 +/- 2.3 (range 0-13). The number of medications the patient "forgot" was 1.3 +/- 1.8 (range 0-9). A complete medication history was given by 50.4% of patients. There was an upward trend that correlated with an increased chance for an incomplete medication history as the total number of current medications increased. The rate of a potentially significant drug interaction between a newly prescribed medication in the emergency department and current medications was 3.4% for patients receiving a new medication.     

Effect of a cognitive behavioral intervention on reducing symptom severity during chemotherapy.

PURPOSE: To describe a randomized trial of a cognitive behavioral intervention on reducing symptom severity among patients diagnosed with solid tumors and undergoing a first course of chemotherapy and to determine whether the intervention had an additive or interactive effect on symptom severity in the presence of supportive care medications. PATIENTS AND METHODS: Patients (N = 237) were accrued from comprehensive and community cancer centers, interviewed, and randomly assigned to either the experimental intervention (n = 118) or conventional care (n = 119). A symptom severity index, based on summed severity scores across 15 symptoms, was the primary outcome. Each patient's site of cancer, stage at diagnosis, chemotherapy protocols, and use of supportive medications were learned from medical records. RESULTS: Groups were equivalent at baseline, and attrition by characteristics by group was not different. The proportion of patients not receiving chemotherapy at 10 and 20 weeks did not differ by group. At the 10- and 20-week observations, there was a significant interaction between the experimental group and baseline symptom severity. Patients in the experimental group who entered the trial with higher symptom severity reported significantly lower severity at 10 and 20 weeks. Controlling for chemotherapy treatment status at follow-up and supportive care medications did not alter the effect of the experimental intervention. CONCLUSION: Compared with conventional care alone, the experimental intervention was effective among patients who entered the trial with higher levels of symptom severity. Age, sex, site or stage of cancer, and supportive medications did not modify the effect of this cognitive behavioral intervention on symptom severity.     

Serum antibodies to JC virus, BK virus, simian virus 40, and the risk of incident adult astrocytic brain tumors.

Genomic sequences of the human polyomaviruses, JC virus (JCV) and BK virus (BKV), and simian virus 40 (SV40) have been reported from several types of human brain tumors, but there have been no population-based seroepidemiologic studies to evaluate the association between polyomavirus infection and brain tumors. We conducted a case-control study, nested within a prospective cohort, to investigate the association between antibodies to JCV, BKV, and SV40, as measured in serum collected 1-22 years before diagnosis and incident primary malignant brain tumors. Brain tumor cases (n = 44) and age-, gender-, and race-matched controls (n = 88) were identified from participants of two specimen banks in Washington County, Maryland. IgG antibodies to the capsid proteins of JCV and BKV were assessed using ELISAs. SV40-neutralizing antibodies were measured using plaque neutralization assays. Similar to the general population, the prevalence of JCV and BKV infection was high in our study population (77 and 85%, respectively). Antibodies to SV40 were less prevalent (11%). The odds ratio for subsequent brain tumor development was 1.46 [95% confidence interval (CI), 0.61-3.5] for JCV, 0.66 for BKV (95% CI, 0.22-1.95), and 1.00 for SV40 (95% CI, 0.30-3.32). Given the high prevalence of JCV and BKV infections and the millions who were potentially exposed to SV40 through contaminated polio vaccines, future studies should attempt to replicate these findings.