Relationship between the Duration of the Basal QRS Complex and Electrical Therapies for Ventricular Tachycardias among ICD Patients

Background: In implantable cardioverter‐defibrillators (ICD) patients, the duration of the basal QRS complex (QRSd) is not associated with a greater risk of developing ventricular tachyarrhythmias. QRSd could be inversely related to the effectiveness of antitachycardia pacing (ATP) because it may be associated with longer conduction times of the paced‐impulses and hence, with a greater propensity to require shocks to terminate ventricular tachycardias (VTs). Methods: We followed 216 ICD patients (pacing site: right ventricular apex; QRSd ≤ 100: 34%) for 21 ± 12 months. ICD programming was standardized. QRSd was determined on the electrocardiogram (50 mm/s) at device implantation. Results: Five hundred and fifty‐one VTs (cycle length: 329 ± 35 ms) occurred in 67 patients (36% had a QRSd ≤ 100 ms). ATP terminated 86% of VTs and 11% needed shocks. Mean ATP efficiency per patient was 83%. QRSd was significantly correlated with the probability of successful ATP (C‐coefficient: 0.66), the best cut‐off point being 100 (sensitivity and specificity of 91% and 49%). Patients with QRSd ≤ 100 had a higher ATP effectiveness (98% vs 75%; P = 0.003) and fewer VTs terminated by shocks (1% vs 23%; P = 0.003). By logistic regression, QRSd > 100 remained as an independent predictor of receiving shocks to terminate VTs (P = 0.01). According to Kaplan‐Meier analysis, the occurrence of VTs was similar regardless of the QRSd (30% vs 38%; P = 0.2), but the incidence of shock due to VTs was higher in patients with a QRSd > 100 (19% vs 7%; P = 0.01). Conclusion: Since QRSd is a negative and independent predictor of effective ATP, ICD patients with QRSd > 100 ms require shocks more frequently to terminate VTs. (PACE 2010; 596–604)     

Stress Echocardiography in Aortic Stenosis

Stress interventions have been classically combined with cardiac catheterization recordings to understand the hemodynamic principles of valvular stenosis. Indices of aortic stenosis such as pressure gradient and valve area were based on simple hydraulic principles and have proved to be clinically useful for patient management during a number of decades. With the advent of Doppler echocardiography, these hemodynamic indices can be readily obtained noninvasively. Abundant evidence obtained using exercise and pharmacological stress echocardiography has demonstrated that the assumptions of classic hemodynamic models of aortic stenosis were wrong. Consequently, it is recognized that conventional indices may be misleading indicators of aortic stenosis significance in particular clinical situations. To improve diagnostic accuracy, several alternative hemodynamic models have been developed in the past-few years, including valve resistance and left ventricular stroke work loss, among others. Nevertheless, these more-accurate indices should be obtainable noninvasively and need to demonstrate greater diagnostic and prognostic power than conventional indices; preliminary data suggest such superiority. Stress echocardiography is well established as the tool of choice for testing hypothesis and physical models of cardiac valve function. Although the final role of alternative indices is not yet well established, the new insights into valvular hemodynamics provided by this technique may change the clinical assessment of aortic stenosis.     

Heparin promotes soluble vascular enothelial growth factor receptor expression in human placental villi: a rebuttal

See also Drewlo S, Levytska K, Sobel M, Baczyk D, Lye SJ, Kingdom JCP. Heparin promotes soluble VEGF receptor expression in human placental villi to impair endothelial VEGF signalling. J Thromb Haemost 2011; 9: 2486–97.     

ANGEBOHRT

Der Freie Zahnarzt -     

RECURRENT NONMELANOMA SKIN CANCER IN SOUTHERN AUSTRALIA

Background and Objective. In retrospective studies of nonmelanoma skin cancers, the recurrence rates were relatively high. This study had as its aim to determine the recurrence rate of nonmelanoma skin cancer (NMSC) and prospectively, risk factors for recurrence in southern Australia. Study Design. This is a prospective study of outpatients with histologically confirmed NMSC. All patients seen by a dermatologist between November 1988 and November 1989 were entered into the study and followed for at least 3 years. Any recurrent NMSCS were removed and recorded. Results. Four hundred and eighty-one patients were entered and 420 followed for at least 3 years. A recurrent NMSC developed in 8% (adjusted for losses). A multivariate analysis determined that the main risk factor for recurrence within the first 3 years of follow-up was the number of NMSC a patient had when entering into the study. Those with 3 to nine NMSC were five times more likely to develop a recurrence than those with less than three NMSC. Those with 10 or more NMSC were 25 times more likely to develop a recurrence. Age, sex, and types of skin cancers removed were not risk factors within the first 3 years of follow-up. Conclusions. Patients who have had multiple skin cancers require careful follow-up because of the risk of developing recurrences.     

Left Coronary to Pulmonary Artery Fistula

Two patients with left coronary artery to pulmonary artery fistula are described and the literature is briefly reviewed.     

Identification of factors associated with deficient immunization coverage: An instrument to manage preventive health services

One of the most important challenges in the management of childhoodimmunization programmes is the persistence of some populationgroups with deficient immunization coverage. In the presentstudy we identify some factors associated with deficient immunizationcoverage in pre-school populations living in Murcia (Spain).The main purpose is to develop some instruments to help managersof immunization programmes in developing strategies directedat high risk groups. Case-control study was designed on thebasis of pre-school population (8579 children) living in thecity during 1989 and 1990. All of the 380 cases and a similarnumber of randomly chosen controls were studied. Multivariatelogistic regression method was used for statistical analysis.Secondly, two nominal group techniques were conducted with healthand social professionals, and, lastly, one group interview wasconducted with some mothers of deficiently immunized children.Variables associated with a deficient immunization coverageincluded: a large number of children in the family, being bornat public hospitals, a greater age of the child, and livingin certain city zones. The most important problems detectedby professionals are lack of social and health services coordination,poor functioning of administrative registers, lack of strategiesto catch marginal groups, and missed opportunities for the immunizationof high-risk children. Mothers identified some problems in servicesaccessibility, inadequate information from health professionals,and special characteristics of marginal groups. Informationfrom registers (case-control study), professionals, and consumersproves some useful in the management of preventive services.Early identification of high-risk children with deficient immunizationcoverage would make it possible to assign more resources togroups with greater needs.     

Mortality by cause of death and marital status in Spain

A number of studies have shown an association between maritalstatus and mortality, with most of them finding a lower mortalityin married as compared to unmarried persons. The purpose ofthis study is to show the differences in mortality from theleading causes of death by marital status among men and womenin Spain. An analysis was made of persons aged 25 years andolder who died in Spain during 1991. The mortality differencesby marital status and sex were analysed for all the deaths andfor the most frequent causes of death, using the ratios of age-adjusteddeath rates calculated from Poisson log—linear models.For both men and women, mortality was always higher in singleand widowed persons than in married persons, except for a non-statisticallysignificant mortality from diabetes mellitus and cirrhosis ofthe liver in single women. Divorced and separated men had ahigher mortality than married men for all the causes of deathtaken together; the mortality among divorced and separated women,on the other hand, was lower than in married women. Divorcedand separated men and women generally had a lower mortalitythan married persons for the different causes of death, exceptfor traffic accidents, suicide, cirrhosis of the liver and HIVinfection, where it was higher. The results obtained are similarto the findings of most studies in other countries, in whicha lower mortality has been observed in married persons as comparedto those who are widowed or single. However, the data showingthat divorced and separated persons have a lower mortality fromsome causes of death than married persons stand in contrastto most published studies. This work has shown that unmarriedpersons are not a homogeneous group, in that divorced and separatedpersons are very different from those who are single or widowed.