Indications for predismissal testing with arrhythmia-induction in patients receiving an implantable cardioverter defibrillator

Arrhythmia induction during implantation of cardioverter defibrillators (ICD) is a standard procedure. However, controversy exists regarding the need for routine arrhythmia induction before discharge from hospital (pre-hospital discharge (PHD) test). In order to reduce the number of tests we identified risk factors that predict relevant ICD malfunction. METHODS AND RESULTS: 965 patients receiving a first device implantation (n=724) or device/system replacement (n=241) between 1998 and 2004 were analysed. During implantation 176 (18%) complications (intraoperative undersensing of induced arrhythmias, unsuccessful arrhythmia-therapy or low DFT safety margin) occurred. Frequent (>4 times) intraoperative lead repositioning due to low sensing values was present in 44 patients (5%). 9% of the patients with first ICD implantation, 21% with device replacement and 27% with system replacement developed complications during PHD testing with arrhythmia induction. Intraoperative complications, although corrected during implantation, were independent risk factors for malfunction during PHD testing (p<0.05). Additional predictors for malfunction were intraoperative lead repositioning (>4 times) and a history of both VF and VT (p<0.05). Patients without intraoperative complications rarely developed malfunction during PHD testing (3.7% first device, 6.25% system replacement). Only in patients undergoing device replacement was a higher risk for failure (13%) evident. No risk factors could be identified for these subgroups. CONCLUSION: Routine arrhythmia induction during PHD is recommended in ICD patients with intraoperative complications, although corrected during implantation, as well as frequent intraoperatives lead repositioning. Patients undergoing device/system replacement uncomplicated implantation are not generally at low risk for device failure.     

Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia

OBJECTIVE: To assess the predictive capacity for the diagnosis of ventilator-associated pneumonia (VAP) of serum procalcitonin levels before and on the day it is suspected. DESIGN AND SETTING: Single-center observational study in the intensive care unit of a teaching hospital. PATIENTS AND PARTICIPANTS: Consecutive patients whose serum procalcitonin levels were available on the day that VAP was clinically suspected (day 1) and at some time within the preceding 5 days ("before"). MEASUREMENTS AND RESULTS: Serum procalcitonin levels were determined on day 1 and "before". Among the 73 suspected episodes VAP was confirmed by quantitative bronchoalveolar lavage cultures in 32 and refuted in 41. Respective median "before" procalcitonin levels were 1.89 ng/ml (interquartile range 0.18-6.01) and 2.14 (0.76-5.75) in patients with and without VAP, but their respective median day-1 procalcitonin levels did not differ: 1.07[Symbol: see text]ng/ml (0.39-6.57) vs. 1.40 (0.67-3.39). On day 1 a 0.5[Symbol: see text]ng/ml procalcitonin threshold had 72% sensitivity but only 24% specificity for diagnosing VAP. Between "before" and day 1, procalcitonin increased in 41% and 15% of patients with and without VAP, respectively. Thus a procalcitonin rise on day 1, compared to its "before" level, had 41% sensitivity and 85% specificity for diagnosing VAP, with respective positive and negative predictive values of 68% and 65%. CONCLUSIONS: Crude values and procalcitonin rise had poor diagnostic value for VAP in this particular setting and thus should not be used to initiate antibiotics when VAP is clinically suspected.     

Nomograms for estimating coronary artery disease prognosis with gated stress myocardial perfusion SPECT

Background  

Nomograms can be useful tools for estimating coronary artery disease (CAD) risk. We sought to devise risk-based nomograms for stress myocardial perfusion SPECT to include measures of % ischemic myocardium and left ventricular function.     

Suicidal ideation in patients undergoing brain tumor surgery: prevalence and risk factors

Purpose

Suicidal ideation (SI) is an important complication in cancer patients that should be promptly recognized and adequately managed. We investigated the prevalence rate and correlates of pre-operative SI in brain tumor (BT) patients admitted for elective BT surgery.

Methods

Two hundred and eleven consecutive patients (70 % women; mean age 55.9 ± 15.4 years) scheduled for BT surgery were evaluated for SI (“suicidal thought” item from the Beck Depression Inventory-II), depressive/anxiety symptom severity (Hospital Anxiety and Depression scale (HADS)), health-related quality of life (SF-36 scale), functional status (Barthel Index), and psychiatric histories and treatments. The majority of patients were diagnosed with meningioma (39 %) and high-grade glioma (17 %).

Results

SI was self-reported by 12 (6 %) patients. Patients expressing SI were most commonly diagnosed with meningioma (50 %). Patients with SI were more likely to have a past history of psychiatric disorders, scored higher on the HADS anxiety subscale, and reported worse health-related quality of life across physical and mental health domains. In multivariate regression analyses, worse perceived mental health was associated with increased risk for SI independently from clinical, sociodemographic, and other patient-oriented variables considered in the study.

Conclusions

SI was self-reported by 6 % of BT patients before surgical intervention and was associated with a past history of psychiatric disorders and worse perceived health status. Poor mental health was an independent correlate of SI. The perception of health status by a patient should be considered as an important determinant of poor mental health in BT patients.

     

Evaluation of knowledge-based reconstruction for magnetic resonance volumetry of the right ventricle after arterial switch operation for dextro-transposition of the great arteries

Right ventricular (RV) volume and function evaluation is essential in the follow-up of patients after arterial switch operation (ASO) for dextro-transposition of the great arteries (d-TGA). Cardiac magnetic resonance (CMR) imaging using the Simpson’s method is the gold-standard for measuring these parameters. However, this method can be challenging and time-consuming, especially in congenital heart disease. Knowledge-based reconstruction (KBR) is an alternative method to derive volumes from CMR datasets. It is based on the identification of a finite number of anatomical RV landmarks in various planes, followed by computer-based reconstruction of the endocardial contours by matching these landmarks with a reference library of representative RV shapes. The purpose of this study was to evaluate the feasibility, accuracy, reproducibility and labor intensity of KBR for RV volumetry in patients after ASO for d-TGA. The CMR datasets of 17 children and adolescents (males 11, median age 15) were studied for RV volumetry using both KBR and Simpson’s method. The intraobserver, interobserver and intermethod variabilities were assessed using Bland–Altman analyses. Good correlation between KBR and Simpson’s method was noted. Intraobserver and interobserver variability for KBR showed excellent agreement. Volume and function assessment using KBR was faster when compared with the Simpson’s method (5.1?±?0.6 vs. 6.7?±?0.9 min, p?<?0.001). KBR is a feasible, accurate, reproducible and fast method for measuring RV volumes and function derived from CMR in patients after ASO for d-TGA.     

Influences of different vasopressors on stroke volume variation and pulse pressure variation

Pulse pressure variation (PPV) and stroke volume variation (SVV) during mechanical ventilation have been shown to be effective parameters to predict preload responsiveness. Although induced hypertension decreases PPV and SVV, the influences of different vasopressors on PPV and SVV are unknown. 94 patients undergoing elective otologic surgery were randomly divided into three groups: Group P (patients were given phenylephrine), Group D (patients were given dopamine), Group E (patients were given ephedrine). When surgery was ongoing and the circulation state was stable, patients were given the vasopressor to increase the systolic arterial pressure (SAP) to the pre-calculated levels: low level, 10 % < ΔSAP ≤ 20 %; medium level, 20 % < ΔSAP ≤ 30 %; high level, 30 % < ΔSAP ≤ 40 %. When invasive arterial pressure reached the target value, PPV, SVV and other parameters were recorded. Dopamine decreased the PPV and SVV more significantly than ephedrine, but less significantly than phenylephrine. The influences of phenylephrine, dopamine and ephedrine on SVV and PPV are different due to their different pharmacological mechanisms.     

Comorbidity of Asperger's syndrome and Bipolar disorder

Background and objective

Asperger's Syndrome (AS) is a pervasive developmental disorder that is sometimes unrecognized, especially in the adult psychiatric setting. On the other hand, in patients with an AS diagnosis, comorbid psychiatric disorders may be unrecognized in the juvenile setting. The aim of the paper is to show and discuss some troublesome and complex problems of the management of patients with AS and comorbid Bipolar Disorder (BD).

Methods

The paper describes three patients affected by AS and bipolar spectrum disorders.

Results and conclusion

Mood stabilizers and 2^nd generation antipsychotics were effective in the treatment of these AS patients with comorbid BD, while the use of antidepressants was associated with worsening of the mood disorder.It is of importance to recognize both the psychiatric diagnoses in order to arrange an exhaustive therapeutic program and to define specific and realistic goals of treatment.

     

A Daily Life Comparison of Sociotropy-Autonomy and Hopelessness Theories of Depression

The hopelessness theory and Beck’s cognitive theory of depression were compared, controlling for other factors associated with mood change and stress reactivity. Using a high-risk design, 179 individuals were selected based on cognitive vulnerabilities and substance use frequency. Assessments of mood, daily events, and specific attributions were acquired using the Experience Sampling Method. Strong support was found for attributional style and sociotropy as indirect determinants of depressed mood, as well as for the notions of causal mediation and vulnerability specificity. Hopelessness theory explained a slightly larger portion of variance in depressed mood overall. The personality diatheses described by either theory were largely independent of each other and their mechanisms of action were not influenced by depression history or substance use.     

Impact estimates of nosocomial bloodstream infection: looking from a different angle

Mortality associated with nosocomial bloodstream infection is multifactorial. Source of infection, etiology, age, underlying disease, acute illness, and appropriateness of antimicrobial therapy all contribute to the final outcome. As such, estimates of mortality attributable to bloodstream infection may differ largely according to the presence or absence of risk factors in distinct patient populations. The adverse effect of nosocomial bloodstream infection for the individual patient is substantial, with about a doubling of the risk of death. Yet, in settings with a high standard of care in terms of infection prevention and control, the occurrence rate of bloodstream infection is relatively low and therefore its impact on overall ICU mortality rather limited. As a consequence, untargeted interventional studies focused on infection prevention should use occurrence rate of infection rather than mortality as outcome variable.