Assessment of Alcohol Withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar)

A shortened 10-item scale for clinical quantitation of the severity of the alcohol withdrawal syndrome has been developed. This scale offers an increase in efficiency while at the same time retaining clinical usefulness, validity and reliability. It can be incorporated into the usual clinical care of patients undergoing alcohol withdrawal and into clinical drug trials of alcohol withdrawal.     

BMT: Fractionation of Gene Modified Hematopoietic Autografts into Multiple Weekly Infusions Does Not Improve Engraftment in Unconditioned Canine Recipients

Hematopoietic stem cell (HSC) gene therapy will require efficient transfer of genes to HSCs and long term engraftment and proliferation of genetically modified HSCs following adoptive transfer. We evaluated whether fractionation of grafts into 4-5 weekly infusions to non-myeloablated, autologous canine recipients would improve engraftment of genetically modified HSCs. Experimental animals and controls receiving a single infusion had similar levels of engraftment with approximately 3-10% of marrow derived progenitors carrying transgene sequences for up to 29 months. There appears to be no improvement of engraftment of genetically modified HSCs in non-myeloablated large animal recipients by dose fractionation.     

Reversible Impairment of Left and Right Ventricular Systolic and Diastolic Function During Short-Lasting Atrial Fibrillation in Patients with an Implantable Atrial Defibrillator: A Tissue Doppler Imaging Study

AF with a fast ventricular response may cause ventricular mechanical impairment, though whether short-lasting AF with satisfactory rate control may affect ventricular function is unknown. This study investigated if prompt cardioversion by an implantable atrial defibrillator (IAD) may prevent left (LV) and right ventricular (RV) systolic and diastolic dysfunction. Ten patients (mean age 61 +/- 9 years, 8 men) with paroxysmal AF without structural heart disease who received an IAD were studied by echocardiography and tissue Doppler imaging (TDI) for both ventricles. Measurements were made during baseline sinus rhythm and at 1-minute, 20-minute, 4-hour, and 1-week postcardioversion of an episode of spontaneous AF. The occurrence of AF and the ventricular rate were monitored at 2-hour intervals by the device. There were 50 episodes of AF with a mean duration of 8.8 +/- 8.9 days (2 hours to 37 days). There was no difference in M-mode measured LV fractional shortening and ejection fraction between baseline sinus rhythm and after cardioversion. However, the TDI derived myocardial systolic velocity (TDI-S) was significantly lower at 1-minute postcardioversion and was normalized at 1 week in both LVs (baseline: 5.7 +/- 1.8, 1 minute: 4.2 +/- 1.0, 20 minutes: 4.3 +/- 0.9, 4 hours: 4.8 +/- 1.0, 1 week: 5.5 +/- 1.8 cm/s; P < 0.005 when comparing 1 minute and 20 minutes to baseline; P < 0.05 when comparing 4 hour to baseline) and RV (baseline: 10.4 +/- 2.1, 1 minute: 7.8 +/- 1.4, 20 minutes: 8.1 +/- 1.2, 4 hours: 9.2 +/- 1.5, 1 week: 10.0 +/- 2.0 cm/s; P < 0.005 when comparing 1 minute, 20 minutes, and 4 hours to baseline). For diastolic function, transmitral Doppler study showed a decrease in early filling velocity at 1 minute (P < 0.05) and 20 minutes (P < 0.005), which was normalized at 4 hours. There was no change in transtricuspid Doppler flow. However, TDI derived myocardial early filling velocity was decreased in the LV (baseline: 6.0 +/- 2.8, 1 minute: 5.4 +/- 2.3, 20 minutes: 5.4 +/- 2.1, 4 hours: 6.1 +/- 2.2, 1 week: 5.8 +/- 1.7 cm/s; P < 0.05 when comparing 1 minute and 20 minutes to baseline) and RV (baseline: 8.9 +/- 3.5, 1 minute: 7.9 +/- 3.3, 20 minutes: 8.1 +/- 3.3, 4 hours: 8.5 +/- 2.9, 1 week: 8.4 +/- 3.5 cm/s; P < 0.05 when comparing 1 minute to baseline). AF of a longer duration (> 48 hours) resulted in a more depressed TDI-S in LV (> 48 hours: 4.2 +/- 1.0, < or = 48 hours: 5.3 +/- 1.3 cm/s; P < 0.01). Shocks in sinus rhythm did not affect any of the above echocardiographic parameters. Therefore, despite adequate rate control, short-lasting AF impairs systolic and diastolic function in both ventricles, which improves gradually after cardioversion. Early restoration of sinus rhythm by an IAD minimizes ventricular dysfunction. TDI is a sensitive tool to assess early systolic and diastolic dysfunction.     

Myopotential Sensing by a Dual Chamber Implantable Cardioverter Defibrillator:

Myopotential Oversensing by a Dual Chamber ICD. Introduction : Inappropriate discharges and/or improper inhibition of bradycardia pacing due to oversensing of extraneous signals in implantable cardioverter defibrillators (ICDs) have been described. With one exception, no previous report involving an intact lead system bas cited myopotential oversensing as the cause.
Methods and Results : Two case reports of myopotential oversensing by a dual chamber ICD system are reported. In the first patient suffering from chronic pulmonary obstructive disease, intermittent myopotential seasing during labored respiration resulted in episodic inhibition of bradycardia pacing. In the second patient, oversensing of sustained myopotentials generated during strenuous isometric activity resulted in an inappropriate ICD discharge. For both, the ICD system consisted of a CPI model 1810 Ventak AV used in conjunction with a model 0125 Endotak lead, incorporating integrated bipolar sensing.
Conclusion : Although modern ICDs have proven to be highly effective in detecting and terminating malignant tachyarrhythmias, the opportunity for improving their detection specificity remains.     

Calcium Carbimide in Alcoholism Treatment. Part 1: a placebo-controlled,double-blind clinical trial of short-term efficacy⋆

A randomized, double-blind, placebo-controlled single cross-over study of the alcohol sensitizing drug, calcium carbimide (CC), was conducted in 128 patients with alcohol dependence. Seventy-one (55%) completed the 4-month study. Patients reported drinking and pill-taking behaviour, and submitted urines (for analysis of alcohol and the tablet marker riboflavin) on 97%, and 91% of treatment days, respectively. All of the 69 analyzable computers were abstinent on at least 85% of days, and 58% (40) were alcohol-free during the study. Medications were taken on at least 85% of days. Symptoms and adverse clinical findings were not increased in frequency during CC, compared to placebo. Seventy-eight per cent of the patients believed they had received CC throughout the study, suggesting that CC exerts a strong psychological deterrent effect. Alcohol consumption was significantly reduced to the same extent with CC and placebo, compared to pre-treatment levels.     

Long-Term Memory Monitoring in Infant Tachycardias

Evaluation and detection of pathological tachycardias in infants sometimes is difficult. Noninvasive recording of the infant's ECG at the time of symptoms forms the mainstay of diagnosis, although invasive electrophysiological testing may be required. Accurate rhythm diagnosis is central to successful treatment. The advent of high capacity ambulatory memory monitoring makes it possible to record ECG signals, as well as apnea data. We present two cases of infant tachycardia studied by memory monitor. These devices yield good quality ECG signals and may provide information regarding a particular rhythm disturbance.     

Treatment choices in advanced cancer: issues and perspectives

Treatment choices are difficult in advanced cancer, a disease in which there is little chance of a cure and in which the aim of treatment is usually to achieve palliation. With the clinical evidence and quality-of-life instruments currently available, it may be difficult to decide whether the burdens of cytotoxic chemotherapy are outweighed by its benefits. However, in some cancers, such as advanced colorectal cancer, there is evidence to demonstrate that chemotherapy is justified, with overall benefit to the patient. There are, nevertheless, many factors to be considered in the selection of the best possible care for each patient. These include the availability of new treatments with improved tolerability profiles, resource implications, quality of life and survival benefits (and how to assess them), the willingness or otherwise of patients to undergo chemotherapy, and information and participation preferences among patients. The differing attitudes of health care professionals and groups of patients add to the complexity of this issue. Guidelines offer one way of promoting the consistent and optimal management of patients with advanced cancer; however, individual patient choice will always take precedence over guidelines which, by definition, are devised with common needs in mind.     

When Is it Safe not to Replace an Implantable Cardioverter Defibrillator Generator?

In most reports on patients receiving implantable cardioverter defibrillators. shocks were received mainly during the first 2 to 3 years. Thus, the question had been raised as to the need for device replacement after 3 or 4 years if no shocks had been received. In order to answer this question, shock experience in 184 putients receiving the implantable cardioverter defibrillator was analyzed. Patients were followed for a mean of 24 ± 18.7 months. A patient's shock was judged to be appropriate if there was electrocardio-graphic documentation of sustained ventricular tachyarrhythmia at the time of shock or if it was preceded by sudden onset of presyncopal or syncopal symptoms. The majority of patients had coronary artery disease. In approximately two-thirds of patients, left ventricular ejection fraction was below 40%. One hundred fourteen patients had inducible sustained monomorphic ventricular tachycardia. On follow-up, there were 29 deaths, five of which were sudden. Sixty-eight patients received an appropriate shock during follow-up (37%). Over 90% of these 68 received their first shock within the 2 years after implant. The actuarial risk of receiving an appropriate shock by the fifth year after implant was 69%. Conversely, 31% of patients who survived 5 years had not received an appropriate shock. Hazard analysis indicates that there is a high incidence of first appropriate shock during the year following implant. Subsequently, the incidence dropped to a relatively steady rate with a rise in this rate during the fifth year. This analysis suggested a bimodal distribution of appropriate shocks. The results indicate that implantable cardioverter defibrillator generators should be replaced even up to the fifth year despite the fact that a patient had not received an appropriate shock.