Does resting two-dimensional echocardiography identify patients with ischemic cardiomyopathy and low likelihood of functional recovery after coronary revascularization?

OBJECTIVE: To evaluate the potential of a simple and widely available technique as two-dimensional (2D) echocardiography to identify patients with ischemic cardiomyopathy and low likelihood of functional recovery after coronary revascularization. METHODS: Two-dimensional echocardiography and radionuclide ventriculography (RNV) were performed before coronary revascularization in 94 patients with ischemic cardiomyopathy. Left ventricular ejection fraction (LVEF) was measured by RNV. Regional wall motion abnormalities, wall motion score index, end-diastolic wall thickness (EDWT), left ventricular (LV) volumes and LV sphericity index were assessed in the echocardiographic images. RNV was repeated 9-12 months after revascularization to assess LVEF change; an improvement >or=5% was considered clinically significant. RESULTS: Nine hundred and ninety-nine segments were severely dysfunctional; 149 out of 999 (15%) had an EDWT or=100 ml/ml) and of the end-systolic volume index (>or=80 ml) was present in 32 (34%) and 21 (22%) patients, respectively. A spherical shape of the LV was observed in 35 (37%) patients. LVEF after revascularization increased in 30 out of 94 patients (32%) from 30+/-8% to 39+/-9% (P<0.0001). On multivariate analysis, the EDVI was the only predictor of no recovery in LVEF [odds ratio, 1.06, confidence interval (CI), 1.04-1.1, P<0.0001]. The cut-off value of EDVI >or=90 ml/ml accurately identified patients that virtually never recover. Post-operatively, LVEF increased in three out of 42 (7%, 95% CI 0-15%) patients with EDVI >or=90 ml/ml as compared to 27 out of 52 (52%) patients with EDVI<90 ml/ml (P<0.0001). CONCLUSIONS: In patients with ischemic cardiomyopathy and severe LV enlargement, improvement of LVEF after revascularization is unlikely to occur. Conversely, in patients with relatively preserved LV size, a higher likelihood of functional recovery may be anticipated.     

Safety of dobutamine stress echocardiography in patients with aortic stenosis

BACKGROUND AND AIM OF THE STUDY: Aortic valve disease is becoming one of the most important cardiac diseases in western society. Low-dose dobutamine stress echocardiography (DSE) is recommended in patients with low-gradient aortic stenosis (AS) and severe left ventricular (LV) dysfunction. DSE is also used in patients with AS and moderately reduced or normal LV function for diagnostic purposes. The study aim was to assess the safety of DSE in the setting of AS and various degrees of LV dysfunction. METHODS: A total of 75 patients with AS who underwent DSE at the authors' center between 1997 and 2001 was reviewed. Group A patients (n = 20) had severely reduced mean LV ejection fraction (LVEF) of 25 +/- 6% and underwent low-dose DSE; group B patients (n = 55) had moderate to normal LV function (LVEF 51 +/- 8%) and underwent high-dose DSE. The mean pressure gradient, valve area and side effects after DSE were evaluated. RESULTS: Serious cardiac arrhythmias occurred in 10 patients. In group A, four patients (20%) developed non-sustained ventricular tachycardia. In group B, two patients (4%) had non-sustained ventricular tachycardia (VT), four (7%) had paroxysmal supraventricular tachycardias, and two (4%) severe symptomatic hypotension. Among the 20 patients with evidence of ischemia on DSE, three developed adverse side effects (no difference compared with patients without ischemia; p = 0.922). Fourteen patients received atropine during DSE, and 1 of these developed non-sustained VT after atropine administration. CONCLUSION: Serious cardiac arrhythmias occur frequently during both low-dose and high-dose DSE in patients with AS. Adverse side effects do not relate to stress-induced ischemia or atropine addition.     

The risk of tuberculosis in transplant candidates and recipients: a TBNET consensus statement

Tuberculosis (TB) is a possible complication of solid organ and hematopoietic stem cell transplantation. The identification of candidates for preventive chemotherapy is an effective intervention to protect transplant recipients with latent infection with Mycobacterium tuberculosis from progressing to active disease. The best available proxy for diagnosing latent infection with M. tuberculosis is the identification of an adaptive immune response by the tuberculin skin test or an interferon-γ based ex vivo assay. Risk assessment in transplant recipients for the development of TB depends on, among other factors, the locally expected underlying prevalence of infection with M. tuberculosis in the target population. In areas of high prevalence, preventive chemotherapy for all transplant recipients may be justified without immunodiagnostic testing while in areas of medium and low prevalence, preventive chemotherapy should only be offered to candidates with positive M. tuberculosis-specific immune responses. The diagnosis of TB in transplant recipients can be challenging. Treatment of TB is often difficult due to substantial interactions between anti-TB drugs and immunosuppressive medications. This management guideline summarises current knowledge on the prevention, diagnosis and treatment of TB related to solid organ and hematopoietic stem cell transplantation and provides an expert consensus on questions where scientific evidence is still lacking.     

Cytoreduction and HIPEC in The Netherlands: Nationwide Long-term Outcome Following the Dutch Protocol

Purpose

This nationwide study evaluated results of cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal metastasis of colorectal origin in the Netherlands following a national protocol.

Methods

In a multi-institutional study prospective databases of patients with peritoneal carcinomatosis (PC) from colorectal cancer and pseudomyxoma peritonei (PMP) treated according to the Dutch HIPEC protocol, a uniform approach for the CRS and HIPEC treatment, were reviewed. Primary end point was overall survival and secondary end points were surgical outcome and progression-free survival.

Results

Nine-hundred sixty patients were included; 660 patients (69 %) were affected by PC of colorectal carcinoma and the remaining suffered from PMP (31 %). In 767 procedures (80 %), macroscopic complete cytoreduction was achieved. Three-hundred and thirty one patients had grade III–V complications (34 %). Thirty-two patients died perioperatively (3 %). Median length of hospital stay was 16 days (range 0–166 days). Median follow-up period was 41 months (95 % confidence interval (CI), 36–46 months). Median progression-free survival was 15 months (95 % CI 13–17 months) for CRC patients and 53 months (95 % CI 40–66 months) for PMP patients. Overall median survival was 33 (95 % CI 28–38 months) months for CRC patients and 130 months (95 % CI 98–162 months) for PMP patients. Three- and five-year survival rates were 46 and 31 % respectively in case of CRC patients and 77 and 65 % respectively in case of PMP patients.

Conclusions

The results underline the safety and efficacy of cytoreduction and HIPEC for PC from CRC and PMP. It is assumed the uniform Dutch HIPEC protocol was beneficial.     

Mortality and quality of life after proximal femur fracture—effect of time until surgery and reasons for delay

Introduction

Studies yield conflicting results from the effect of early surgery on mortality. Some observed a positive, others a negative and some did not find any effect of early operation. In this study, mortality and quality of life in relation to time until surgery as well as reasons for delay were observed prospectively.

Material and methods

Data of 138 patients (>65 years) with proximal femoral fractures and consecutive surgery were observed. Demographic data as well as mortality rate, survival time and Barthel Index up to 1 year in relation to different time frames were observed. Reasons for operative delay were divided into being administrative or patient-related.

Results

Three-month mortality was 10.1% and 1-years was 23.9%. Neither time from injury until hospital admission nor from injury until surgery or from hospital admission until surgery up to 48 hours had any effect on mortality and survival time. The age of patients dying in the follow-up period was significantly higher than the age of patients surviving (86.8 vs. 84.4 years). No influence of any delay in time until surgery on the Barthel Index was observed.

Conclusion

In proximal femoral fractures, a delay of surgery up to 48 hours did not influence mortality and Barthel Index negatively, nor did other associating factors. Only the patients age at the time of injury influences mortality rate, survival time, and Barthel Index significantly. The older the patient at the time of injury; the higher the mortality rate, the shorter the survival time and the lower the Barthel Index.     

Reliability and concurrent validity of the Infant Motor Profile

Aim

The Infant Motor Profile (IMP) is a qualitative assessment of motor behaviour in infancy. It consists of five domains: movement variation, variability, fluency, symmetry, and performance. The aim of this study was to assess interobserver reliability and concurrent validity of the IMP with the Alberta Infant Motor Scale (AIMS) and an age‐specific neurological examination.

Method

Fifty‐nine preterm infants (25 females, 34 males; median gestational age 29.7wks, median birthweight 1285g) and 146 term infants (74 females, 72 males; median gestational age 40.1wks, birthweight 3500g) were included. Assessments were performed at corrected ages of 4, 6, 10, 12, and 18 months and consisted of the IMP, AIMS, and an age‐specific neurological examination. Interobserver reliability was investigated on a sample of 25 video recordings. Non‐parametric statistics were used to analyse the data.

Results

Interobserver reliability was high (intraclass correlation coefficient 0.95). At all ages, AIMS scores correlated weakly to fairly with total IMP scores (Spearman's ρ 0.36–0.55), but moderately to strongly with scores on the performance domain of the IMP (Spearman's ρ 0.47–0.84). A clear relation was found between total IMP score and outcome of the neurological examination (Kruskal–Wallis p<0.001 at all ages).

Interpretation

Interobserver reliability of the IMP is good. Concurrent validity with the AIMS is best for the IMP performance domain. Concurrent validity with age‐specific neurological examination is very good.