Stimulation Hierarchy: Optimal Sequence for Double and Triple Extrastimuli During Electrophysiological Studies

To determine the optimal ventricular stimulation sequence, an 11-step programmed electrical stimulation (PES) protocol was completed, even if a ventricular arrhythmia (VA) was induced with earlier steps. The protocol consisted of one, two, and three extrastimuli during sinus rhythm (SR), and at two drive pacing rates (VP1 and VP2) plus rapid burst and ramp pacing. By analyzing the 79 completed protocols that induced the clinical arrhythmia, the following were determined: (1) the frequency of induced clinical and nonclinical VA with each stimulation step; (2) the yield ratio (YR) of each step, defined as the probability of inducing clinical versus nonclinical arrhythmia; (3) the cumulative yield of induced clinical and nonclinical arrhythmia with two widely used stimulation sequences, i.e., triple extrastimuli delivered early in the stimulation protocol (MMC sequence) and triple extrastimuli delayed until after double extrastimuli failed to induce the clinical arrhythmia (B sequence); (4) the relative efficiency of these sequences were determined. The percentage of induced clinical and nonclinical arrhythmia with SR + 3 extrastimuli, VP1 + 2 extrastimuli, and VP2 + 2 extrastimuli were (53%, 5%), (36%, 5%), and (41%, 9%), respectively. The cumulative yield of induced clinical VA with the MMC-type sequence reached 55% by the third step of the protocol, whereas 50% was attained only at the eighth step of the B-type sequence. The cumulative percentage of induced nonclinical VA with either sequence was similar during the early steps of the protocol. The MMC sequence was more efficient, requiring overall 36% of potential steps for clinical arrhythmia induction, compared with 48% for the B sequence (P less than 0.001). For questionable arrhythmia states, e.g., syncope of unknown origin and nonsustained VT, a modified sequence is proposed that may further reduce the induction of uninterpretable arrhythmias.     

Clinical, biochemical and pathological features of initial and repeat transrectal ultrasonography prostate biopsy positive patients

BACKGROUND: Using sextant biopsy, 16-41% of prostate cancers were diagnosed on repeat biopsy. The objective of the present study was to compare the differences in the clinical, biochemical and pathological features between patients with positive results on initial and repeat biopsies, with an aim to identify factors that can be used to improve the detection rate of transrectal ultrasound (TRUS) biopsy of the prostate. METHODS: Between February 2000 and April 2001, 222 patients with a mean age of 64 years (range 38-85) underwent TRUS-guided 10-core prostate biopsy for either abnormal prostate specific antigen (PSA) levels (>4 ng/mL) and/or abnormal digital rectal examination (DRE). Of this number, 165 patients underwent their first biopsy, whereas 45 and 12 patients had had one or two previous biopsies, respectively. RESULTS: Prostate cancer detection rates for the initial biopsy group (n = 165), second biopsy group (n = 45) and third biopsy group (n = 12) were 29.7, 23.0 and 41.7%, respectively. Six patients who had a negative first 10-core biopsy underwent a second 10-core biopsy and one patient (16%) was found to have cancer. Apart from total prostate volume, there were no significant statistical differences between the patient age, mean total PSA, PSA density, PSA-transition zone density, DRE and TRUS findings between the initial and repeat biopsy groups of subjects who had cancer. Those who had cancer detected only on repeat biopsies had larger prostate glands (P = 0.041). CONCLUSION: Patients who had cancer detected only on repeat biopsies had bigger prostate glands, supporting the hypothesis that TRUS sextant biopsy as a technique suffers the error of under-sampling in a bigger prostate.     

Self-mutilation in female remanded prisoners II: A cluster analytic approach towards identification of a behavioural syndrome

Cluster analysis of phenomenological variables and the associated symptom profile of self-mutilation in 74 female prisoners identified a subgroup with a disorder of mood who injured themselves as a symptom-relieving mechanism and received a diagnosis of borderline personality disorder (BPD). Marked differences were found between the women in this cluster in the form of their behaviour and on a range of different variables compared with a second, more heterogeneous, cluster who had injured themselves as a reaction to life-events, psychotic illness, or in a suicide attempt. The relevance of a symptom-relieving mechanism to research into self-mutilation and BPD is discussed. It is proposed that future research should concentrate on the ‘affective instability’ component of BPD and the affective symptoms reported by subjects with this diagnosis prior to impulsive behaviours such as self-mutilation.     

Managing difficult behaviour in a long-term prison

Use of the term psychopathic disorder, or some related diagnostic concept, is avoided in this paper, as it is written from the perspective of a prison governor who has to manage difficult behaviour in a long-term prison. The context in which difficult behaviour is handled is vital, and this paper addresses some of the management aspects of the issues raised in the previous paper. It determines the nature of the behaviour and the options for responding to it: difficult behaviours rather than difficult individuals are the chief focus. The formal options for managers in the Prison Service are not always as effective as the informal controls exercised by staff and prisoners: indeed, the formal sanctions tend to be punitive in practice if not in theory. The special units in prisons have tried to develop a response which is therapeutic, not punitive. Access to these units is not easy and they have not been used by the Prison Service as much as was expected when they were set up. The special hospitals provide another opportunity to break the cycle of punishment and I believe there is a case for close cooperation between at least one special hospital and at least one unit as a half-way house facilitating the change of role from prisoner to patient and back to prisoner in a way that is helpful to the individual.     

ICD Data Storage: Value in Arrhythmia Management

Sophisticated diagnos tic information is provided by the latest generation of implantable defibriliators. The success of therapy and the type of therapy successful in terminating ventricular arrhythmias is provided by interrogating the ICD device. In addition, R to R interval information can be retrieved. In selected devices, either locai bipolar electrograms from the rate sensing leads or wide bipolar electrograms from the energy delivering leads provide visual confirmation of the presence of ventricular tachyarrhythmic events loading to ther apy. The value and limilations of this sophisticated diagnostic information in providing insight into the electrical events triggering therapy and the events triggering ventricular arrhythmias are discussed.     

NASPE POLICY STATEMENT The NASPE* BPEG** Defibrillator Code

BERNSTEIN, A.D., et al .: The NASPE/BPEG Defibrillator Code. A new generic code, patterned after and compatible with the NASPE/BPEG Generic Pacemaker Code (NBG Code) was adopted by the NASPE Board of Trustees on January 23, 1993. It was developed by the NASPE Mode Code Committee, including members of the North American Society of Pacing and Electrophysiology (NASPE) and the British Pacing and Electrophysiology Group (BPEG). It is abbreviated as the NBD (for NASPE/BPEG Defibrillator) Code. It is intended for describing the capabilities and operation of implanted cardioverter defibrillators (ICDs) in conversation, record keeping, and device labeling, and incorporates four positions designating: (1) shock location; (2) antitachycardia pacing location; (3) means of tachycardia detection; and (4) antibradycardia pacing location. An additional Short Form, intended only for use in conversation, was defined as a concise means of distinguishing devices capable of shock alone, shock plus antibradycardia pacing, and shock plus antitachycardia and antibradycardia pacing. (PACE, Vol. 16, September 1993)     

A comparison of positive and negative alcohol expectancy and value and their multiplicative composite as predictors of post-treatment abstinence survivorship

Within social learning theory, positive alcohol expectancies represent motivation to drink and negative expectancies, motivation to restrain. It is also recognized that a subjective evaluation of expectancies ought to moderate their impact, although the evidence for this in social drinkers is problematic. This paper addresses the speculation that the moderating effect will be more evident in clinical populations. This study shows that (i) both expectancy and value reliably, independently and equally predict clients’abstinence survivorship following discharge from a treatment programme (and that this is almost entirely confined to the negative rather than positive terms). When (ii) expectancy evaluations are processed against expectancy through multiplicative composites (i.e. expectancy X value), their predictive power is only equivalent to either expectancy or value on its own. However (Hi) when the multiplicative composite is assessed following the statistical guidelines advocated by Evans (1991) (i.e. within the same model as its constituents, expectancy and value) the increase in outcome variance explained by its inclusion is negligible and casts doubt upon its use in alcohol research. This does not appear to apply to value, however, and its possible role in treatment is discussed.