Complications in the clinical course of tako-tsubo cardiomyopathy

Objective

This study evaluated the frequency, severity and outcome of complications in the clinical course of tako-tsubo cardiomyopathy (TTC).

Background

TTC is regarded as a benign disease since left ventricular (LV) function returns to normal within a short time. However, severe complications have been reported in selected patients.

Methods

From 37 hospitals, 209 patients (189 female, age 69 ± 12 years) were prospectively included in a TTC registry.

Results

Complications developed in 108/209 patients (52%); 23 (11%) had > 2 complications. Complications occurred median 1 day after symptom onset, and 77% were seen within 3 days. Arrhythmias were documented in 45/209 patients (22%) including atrial fibrillation in 32 (15%) and ventricular tachycardia in 17 (8%). Of 8 patients resuscitated (4%), 6 survived. Additional complications were right ventricular involvement (24%), pulmonary edema (13%), cardiogenic shock (7%), transient intraventricular pressure gradients (5%), LV thrombi (3%) and stroke (1%). During hospitalization, 5/209 patients (2.5%) died. Patients with complications were older (70 ± 13 vs 67 ± 10 years, p = 0.012), had a higher heart rate (91 ± 26 vs 83 ± 19/min, p = 0.025), more frequently Q\ waves on the admission ECG (36% vs 21%, p = 0.019) and a lower LV ejection fraction (47 ± 15 vs 54 ± 14%, p = 0.002). Multivariate regression analysis identified Q-waves on admission (OR 2.49, 95% CI 1.23–5.05, p = 0.021) and ejection fraction ≤ 30% (OR 4.03, 95% CI 1.04–15.67, p = 0.022) as independent predictors for complications.

Conclusions

TTC may be associated with severe complications in half of the patients. Since the majority of complications occur up to day 3, monitoring is advisable for this time period.     

Psoas:lumbar vertebra index: central sarcopenia independently predicts morbidity in elderly trauma patients

Introduction

Central sarcopenia as a surrogate for frailty has recently been studied as a predictor of outcome in elderly medical patients, but less is known about how this metric relates to outcomes after trauma. We hypothesized that psoas:lumbar vertebral index (PLVI), a measure of central sarcopenia, is associated with increased morbidity and mortality in elderly trauma patients.

Methods

A query of our institutional trauma registry from 2005 to 2010 was performed. Data was collected prospectively for the Pennsylvania Trauma Outcomes Study (PTOS). Inclusion criteria: age >55 years, ISS >15, and ICU LOS >48 h. Using admission CT scans, psoas:vertebral index was computed as the ratio between the mean cross-sectional areas of the psoas muscles and the L4 vertebral body at the level of the L4 pedicles. The 50th percentile of the psoas:L4 vertebral index value was determined, and patients were grouped into high (>0.84) and low (≤0.83) categories based on their relation to the cohort median. Primary endpoints were mortality and morbidity (as a combined endpoint for PTOS-defined complications). Univariate logistic regression was used to test the association between patient factors and mortality. Factors found to be associated with mortality at p < 0.1 were entered into a multivariable model.

Results

A total of 180 patients met the study criteria. Median age was 74 years (IQR 63–82), median ISS was 24 (IQR 18–29). Patients were 58 % male and 66 % Caucasian. Mean PLVI was 0.86 (SD 0.25) and was higher in male patients than female patients (0.91 ± 0.26 vs. 0.77 ± 0.21, p < 0.001). PLVI was not associated with mortality in univariate or multivariable modeling. After controlling for comorbidities, ISS, and admission SBP, low PLVI was found to be strongly associated with morbidity (OR 4.91, 95 % CI 2.28–10.60).

Conclusions

Psoas:lumbar vertebral index is independently and negatively associated with posttraumatic morbidity but not mortality in elderly, severely injured trauma patients. PLVI can be calculated quickly and easily and may help identify patients at increased risk of complications.     

Teleneurology in stroke management: costs of service in different organizational models

Telemedicine is in increasing use in clinical neuroscience such as acute stroke care, especially by applying remote audiovisual communication for patient evaluation. However, telephone consultation was also used linking stroke centres to smaller hospitals. We compared costs of telestroke services using audiovisual and telephone communication in different organizational models. Within a small network in Northern Bavaria video-based teleconsultation (VTC) and telephone advice (TA) was provided for evaluation of acute stroke patients on a weekly rotation. The costs of the admissions process with or without one of both methods of telemedicine were calculated and compared from the perspective of the spoke hospital. Different levels of service and network size were modelled and costs of transfers as well as loss of revenues were calculated. Yearly total labour costs were 415,000 € for an on-site service VTC-service compared to 61,000 € in an on-call service. Additional costs for one teleconsultation were 109.55 € in VTC and 49.82 € in TA (VTC/TA ratio 2.2). The ratio decreased to 0.8 when accounting for costs of transfer and loss of reimbursement for all patients transferred as transfer of patients to the stroke centre was more frequent after TA (9.1 vs. 14.9 %full-time on-site ser). Costs of one QALY gained by using VTC instead of TA ranged from 115.00 € to 515.86 € depending on the different models. In the first view TA looks like the less expensive method as it is easy to access and works without additional costs. When accounting for all disadvantages TA becomes slightly more expensive. In telestroke care VTC should be recommended as the method of choice also from an economic perspective.