ISPD Cardiovascular and Metabolic Guidelines in Adult Peritoneal Dialysis Patients Part I – Assessment and Management of Various Cardiovascular Risk Factors

Cardiovascular disease contributes significantly to the adverse clinical outcomes of peritoneal dialysis (PD) patients. Numerous cardiovascular risk factors play important roles in the development of various cardiovascular complications. Of these, loss of residual renal function is regarded as one of the key cardiovascular risk factors and is associated with an increased mortality and cardiovascular death. It is also recognized that PD solutions may incur significant adverse metabolic effects in PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendations regarding lifestyle modification, assessment and management of various cardiovascular risk factors, as well as management of the various cardiovascular complications including coronary artery disease, heart failure, arrhythmia (specifically atrial fibrillation), cerebrovascular disease, peripheral arterial disease and sudden cardiac death, to be published in 2 guideline documents. This publication forms the first part of the guideline documents and includes recommendations on assessment and management of various cardiovascular risk factors. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. The ISPD workgroup also identifies areas where evidence is lacking and further research is needed.     

Airbag-induced thumb avulsion: two case reports

Although airbags are designed to save lives and protect victims from serious injuries, airbag deployment can cause unwanted lesions. In this case report, two cases are presented of young women who sustained an important fracture dislocation of the first carpometacarpal joint (CMC I joint) caused by airbag deployment during a car collision.     

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.     

Effect of left ventricular remodeling after cardiac resynchronization therapy on frequency of ventricular arrhythmias

We evaluated whether cardiac resynchronization therapy affects the prevalence of ventricular tachycardia in relation to reverse remodeling in patients with end-stage heart failure. Clinical, echocardiographic, and implantable cardioverter-defibrillator (ICD) data of 17 patients with ICDs were obtained before and after they had received an upgrade to an ICD-cardiac resynchronization therapy device.     

Response to desmopressin is influenced by the genotype and phenotype in type 1 von Willebrand disease (VWD): results from the European Study MCMDM-1VWD

We have prospectively evaluated the biologic response to desmopressin in 77 patients with type 1 von Willebrand disease (VWD) enrolled within the Molecular and Clinical Markers for the Diagnosis and Management of type 1 VWD project. Complete response to desmopressin was defined as an increase of both ristocetin cofactor activity (VWF:RCo) and factor VIII coagulant activity (FVIII:C) to 50 IU/dL or higher and partial response as VWF:RCo or FVIII:C lower than 50 IU/dL after infusion, but at least 3-fold the basal level. Complete response was observed in 83% of patients; partial in 13%; and no response in 4%. Patients with some abnormality of VWF multimeric pattern had significantly lower basal FVIII:C and VWF, lower VWF:RCo/Ag ratio, and less complete responses to desmopressin than patients with a normal multimeric pattern (P=.002). Patients with mutations at codons 1130 and 1205 in the D'-D3 domain had the greatest relative increase, but shortest FVIII and VWF half-lives after infusion. Most partial and nonresponsive patients had mutations in the A1-A3 domains. Response to desmopressin in these VWD patients seemed to be associated with the location of the causative mutation. The presence of subtle multimeric abnormalities did not hamper potential clinically useful responses, as in typical type 1 VWD.     

Anatomic correlates of a normal perfusion scan using 64-slice computed tomographic coronary angiography

Both myocardial perfusion imaging (MPI) and multislice computed tomography (MSCT) are currently used to detect coronary artery disease (CAD). However, MSCT permits early detection of atherosclerosis while myocardial perfusion is still normal. In addition, MPI results can be normal despite the presence of high-risk CAD (left main and balanced 3-vessel CAD). In this study, the range of anatomic findings using MSCT in patients with normal MPI results was evaluated. In 180 patients presenting with chest pain, MPI (with gated single-photon emission computed tomography) and 64-slice MSCT were performed. In patients with normal MPI results, prevalences of completely normal coronary arteries, nonobstructive CAD, and obstructive CAD were determined using MSCT. The occurrence of high-risk CAD, including left main and 3-vessel disease, was also evaluated. Normal MPI and adequate MSCT findings were obtained in 97 patients (54%; 50% women; average age 58 +/- 12 years; 5% with known CAD). A total of 38 patients (39%) showed normal coronary anatomy, whereas nonsignificant and significant CAD were observed in 37 (38%) and 18 patients (19%), respectively. Importantly, only 4 patients (4%) presented with high-risk CAD using 64-slice MSCT, 2 with left main and 2 with 3-vessel disease. In conclusion, a normal MPI result can be associated with a wide range of anatomic observations and cannot exclude the presence of both nonobstructive and obstructive CAD. However, importantly, the prevalence of high-risk CAD was rare.     

Radiography in acute ankle injuries: the Ottawa Ankle Rules versus local diagnostic decision rules

STUDY OBJECTIVE: We validate the Ottawa Ankle Rules and 2 Dutch ankle rules in distinguishing clinically significant fractures from insignificant fractures and other injuries in patients with a painful ankle presenting to the emergency department. METHODS: This prospective comparison of 3 ankle rules was conducted in the ED of a 580-bed community teaching hospital in Amsterdam from January 1998 to April 1999. Participants included 647 consecutive patients aged 18 years or older presenting with a painful ankle after trauma. All physicians received extensive and pictorial training on how to correctly score the respective items of the rules. The physician on call recorded these items derived from history and physical examination on a standardized data sheet. All patients subsequently underwent standard radiographic assessment. A radiologist and a trauma surgeon evaluated the radiographs blinded from the results of the data sheet form and the treatment given. The diagnostic performance of the 3 rules was measured in terms of sensitivity, specificity, and the reduction of radiographs. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves was calculated and compared. RESULTS: Seventy-four fractures were seen, of which 41 were clinically significant. The Ottawa Ankle Rules had a sensitivity of 98% for identifying clinically significant fractures; the local rules scored 88% and 59%, respectively. The potential savings in radiographs for the 3 decision rules were 24%, 54%, and 82%, respectively. The area under the ROC curve was better for both the local rules (0.84 and 0.83) compared with the Ottawa Ankle Rules (0.76). CONCLUSION: Because the identification of all relevant fractures is more important than a reduction in radiographs, the higher sensitivity of the Ottawa Ankle Rules makes these most suitable for implementation in The Netherlands.