Prophylactic implantable cardioverter-defibrillator therapy in patients with left ventricular systolic dysfunction: a pooled analysis of 10 primary prevention trials

Strategies to decrease sudden cardiac death in patients with left ventricular systolic dysfunction are evolving. Recent clinical trials have evaluated the role of prophylactic implantable cardioverter-defibrillators (ICDs) in patients with and without additional risk stratifiers. We pooled studies comparing treatment with and without ICDs from published data and presented abstracts, irrespective of QRS duration and etiology of systolic dysfunction. On the basis of the available clinical trials, implantation of an ICD for primary prevention of death provides a 7.9% absolute mortality reduction (p = 0.003) in patients with left ventricular (LV) systolic dysfunction who were receiving optimized medical therapy. This finding was not sensitive to the exclusion of any individual trial. The ICD is an effective primary preventative measure in patients who are at risk for death; however, the application of this therapy needs to be individualized for the patient, similar to drug therapies in LV systolic dysfunction. In health care settings without unlimited resources, optimal use of this therapy will require better risk stratification methods or lowering of the initial device cost.     

“Many miles to go …”: a systematic review of the implementation of patient decision support interventions into routine clinical practice

Background

Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings.

Methods

An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment.

Results

After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption.

Conclusions

It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a ‘referral model’ consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the ‘barriers’ and ‘facilitators’ approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.

     

Assessment of dental anxiety and its correlation with denture satisfaction in edentulous patients

Objective: The objectives of this study were to measure the level of dental anxiety and its correlation with dental history, denture satisfaction and other variables. Materials and methods: A cross-sectional study was conducted on 150 completely edentulous patients reporting to the Department of Prosthodontics, KLES's Institute of Dental Sciences, Belgaum, over a period of 17 months (August 2005 to March 2007). The anxiety level of the patients was assessed with the help of a questionnaire, after obtaining an informed consent. Reliability of the dental anxiety scale was assessed by means of coefficient alpha. Results: The results of this study concluded that dental anxiety scale for edentulous patients was a reliable scale for measuring dental anxiety. The anxiety score was higher for female than male patients. A significant correlation was found between denture satisfaction score and anxiety. Discussion: Anxiety plays a major role in denture satisfaction. The variables included: Previous denture experience, occupation, medical history, age, gender, dental anxiety scale, period of edentulousness, age of previous dentures, number of complete dentures, denture satisfaction score, and the score on the Hamilton anxiety scale Conclusion: The study indicated that gender correlates significantly with dental anxiety. Patients with medical history were found to be more anxious than normal patients. Patients with higher anxiety values were less satisfied with the treatment. Lastly, subjects with higher general anxiety showed greater values on the dental anxiety scale. Clinical significance: The assessment of dental anxiety will help the prosthodontist in the management of anxious patients and secondly to provide evidence-based research into this psychological construct which has been shown to predict dental avoidance. Keywords: Dental anxiety, Denture satisfaction, Completely edentulous patients. How to cite this article: Shrivastava R, Srivastava R, Shigli K, Prashanth MB, Kumaraswamy BN, Nethravathi TD. Assessment of Dental Anxiety and its Correlation with Denture Satisfaction in Edentulous Patients. J Contemp Dent Pract 2012;13(3):257-260. Source of support: Nil Conflict of interest: None declared.     

Basic research: Issues with animal experimentations

In vivo studies using the animals are helpful in developing the treatment strategies as they are important link between the successful in vitro testing and safe human use. Various research projects in the field of fixation of fractures, development of newer biomaterials, chemotherapeutic drugs, use of stem cells in nonunion of fractures and cartilage defects etc., have hugely depended on animal experimentation. The employment of animals in experiments is both scientific and ethical issue. There must be reasonable reasons to show that it will significantly advance the present knowledge and lead to improvement in care. The regulatory bodies exist for humane use and care of animals used for experiments e.g., International Council for Laboratory Animal Science, Council for International Organizations of Medical Sciences, International Union of Biological Sciences, International Committee on Laboratory Animals. In India, Indian National Science Academy, Indian Council of Medical Research, National Centre for Laboratory Animal Sciences promote high standards of laboratory animal quality, care and health. The Committee for the Purpose of Control and Supervision on Experiments on Animals guidelines are well defined and is a must read document for any one interested to carry out research with animal facilities.     

Evolving electroanatomic substrate and intra-atrial reentrant tachycardia late after Fontan surgery

Atrial Remodeling After the Fontan Operation. Introduction: The prevalence of intra‐atrial reentrant tachycardia (IART) increases with age in Fontan patients. This study aimed to characterize the atrial electroanatomic substrate for IART late after Fontan surgery. Methods and Results: Detailed electroanatomic mapping of the right atrium (RA) was performed in 11 consecutive patients (33 ± 9 years) with older style Fontan circulation (atriopulmonary and atrioventricular connection) who underwent their first radiofrequency catheter ablation (RFCA) for IART. A comparative group of 30 non‐Fontan congenital heart disease (CHD) patients were also studied. Fontan patients had larger RA (P = 0.004), larger low‐voltage area ≤0.5 mV (P = 0.01), and more fractionated potentials (P < 0.001) than non‐Fontan CHD patients. RA enlargement correlated significantly with both low‐voltage zones (Spearman ρ= 0.68, P < 0.001) and fractionated potentials (Spearman ρ= 0.48, P = 0.001). Among Fontan patients, both age and time since Fontan surgery were significantly correlated to the amount of low‐voltage areas (Spearman ρ= 0.87, P < 0.001; Spearman ρ= 0.63, P = 0.04, respectively). Successful RFCA was accomplished in 30 (73%) patients and was less likely in Fontan patients (54% vs 83%, P = 0.04). Larger RA was significantly associated with a lower success rate (P = 0.04). During a follow‐up duration of 2.3 ± 1.6 years, IART recurred in 47% of patients. Larger RA size and larger low‐voltage areas predicted IART recurrence after RFCA. Conclusion: Fontan patients demonstrate progressive adverse atrial electrical remodeling with increasing age and time since surgery. Newer strategies beyond surgical incisions, such as pharmacotherapies that retard the progression of atrial fibrosis, may be required to reduce the long‐term risk of atrial arrhythmias.     

Is Inappropriate Implantable Defibrillator Shock Therapy Predictable?

Objective: To identify implantable cardioverter defibrillator (ICD) patients who are at risk of receiving inappropriate shock. Background: Inappropriate ICD shock, usually from atrial fibrillation (AF) or sinus tachycardia (ST), is a common problem. We hypothesized that clinical variables would predict which patients with single chamber ICDs would be more likely to receive inappropriate therapy and be candidates for more accurate discriminators such as those available in dual chamber ICDs. Methods: The ICD registry at St. Michael's Hospital has it's clinical information and demographic data updated after each clinic visit. Inappropriate shock was considered as the outcome variable. Possible predictors considered were age, gender, ejection fraction, NYHA class, prior CABG and prior history of AF. Univariate predictors were identified using t-test for continuous variables and Chi-square test for categorical variables. Multivariate predictors were identified using stepwise logistic regression analyses. Results: Of 299 patients, 261 had complete data for analysis. In this population 78% were male, mean age was 60 ± 13 years, mean ejection fraction was 37 ± 15% and mean follow up was 53 ± 36 months. One hundred and sixteen of the 261 patients (44%) received one or more inappropriate therapies (73% within 2 years of receiving their device), and 140 (51%) received one or more appropriate therapies. Significant predictors of inappropriate therapy by multivariate model were prior AF (OR 2.6, 95% CI 1.5–4.5) and NYHA class 1 vs. classes 2–4 (OR 2.2, 95% CI 1.2–3.7). Conclusion: Clinical characteristics of ICD patients can predict those at risk for inappropriate shock and should be considered for interventions to decrease such shocks.     

Docking Based Screening of Potent Flavonoids as CHK2 Inhibitors from Genus Miliusa

Proceedings of the National Academy of Sciences, India Section B: Biological Sciences - Annonaceae plants play significant role in ethanopharmacology due to their medicinal properties and...