Research at the Auction Block

The “fair benefits” approach to international research is designed to produce results that all can agree are fair without taking a stand on divisive questions of justice. But its appealing veneer of collaboration masks ambiguities at both a conceptual and an operational level. An attempt to put it into practice would look a lot like an auction, leaving little reason to think the outcomes will satisfy even minimal conditions of fairness.     

Value of Pre-Hospital Discharge Defibrillation Testing in Recipients of Implanted Cardioverter Defibrillators

Opinions vary regarding the need to perform defibrillation testing prior to hospital discharge in recipients of state-of-the-art cardioverter defibrillators (ICDs). Our protocol is to perform predischarge ICD testing 1 day after implant. This report includes 682 consecutive implants. Adverse observations at testing were grouped into (1) risk of defibrillation failure, (2) surgical complications, (3) sensing/pacing issues or narrow defibrillation margin warranting closer follow-up, or (4) findings correctable by device reprogramming. Among the 682 patients, 63% had single-chamber and 37% dual-chamber or biventricular ICDs. In 48 patients (7%) there were 69 concerns and/or interventions, with overlaps among the four categories, including one failure to defibrillate (0.15%), and six other patients at risk. Surgical complications included 11 hematomas (1.6%), and six lead dysfunctions. Closer follow-up was indicated in 19 patients (2.7%), for high pacing thresholds in seven, sensing issues in seven, and <10 J defibrillation margin in five. Device reprogramming was needed in 31 patients (4.5%), for tachycardia detection and therapy settings in 12, and for pacing/sensing functions in 22 patients. In eight patients ventricular fibrillation could not be induced. There was no morbidity or mortality due to testing. The state-of-the-art ICDs delivering biphasic shocks are remarkably reliable. The routine pre-hospital discharge defibrillation testing of such ICDs may be optional and left to the physicians' discretion.     

The effect of calcium channel blockade with nifedipine on splanchnic and systemic haemodynamics in cirrhosis

The splanchnic and systemic haemodynamic effects of a single sublingual dose of nifedipine (slow calcium channel blocker) in nine patients with cirrhosis of the liver and portal hypertension were studied. Nifedipine produced a significant reduction in the mean arterial blood pressure (98 +/- 5.3 vs. 86 +/- 5 mmHg, P less than 0.05) but did not alter the mean heart rate, portal venous pressure or total liver blood flow. The systemic antihypertensive effect of nifedipine can be achieved without altering liver blood-flow in patients with chronic liver disease and portal hypertension.     

Outcomes in Adolescents with Postural Orthostatic Tachycardia Syndrome Treated with Midodrine and β-Blockers

Background: Postural orthostatic tachycardia syndrome (POTS) is associated with debilitating fatigue, dizziness, and discomfort in previously healthy adolescents. The effects of medical therapy have not been well studied in this patient population. This study assessed the relative efficacy and impact of drug therapy on the functioning and quality of life in adolescents with POTS.
Methods: A retrospective, single center, chart review analysis with a follow-up written survey was conducted on a group of 121 adolescents who had undergone autonomic reflex screening at the Mayo Clinic from 2002 to 2005 as part of an evaluation for possible POTS.
Results: Of 121 surveys sent, 47 adolescents returned a completed survey. In this cohort of patients, the two most commonly prescribed drug therapies were midodrine (n = 13) and β-blockers (n = 14). Patients in the midodrine group were comparable to patients in the β-blocker group in gender, age, pretreatment postural heart rate changes, and months from initial evaluation to survey completion. More patients treated with a β-blocker reported improvement after visiting Mayo Clinic (100% vs 62%, P = 0.016) and more attributed their progress to medication (63.6% vs 36.4%, P = 0.011) than did those treated with midodrine.
Conclusion: Treatment with both midodrine and β-blockers was associated with overall improvement in POTS patients' general health; however, adolescents taking β-blockers were more likely than those taking midodrine to credit the role of medications in their improvement.     

Sudden Death Mortality in Implantable Cardioverter Defibrillator Patients

Implanfable Cardioverter defibrillator (ICD) prevention of sudden cardiac death (SCD) is not absolute and our experience was reviewed to determine the frequency and nature of SCO in this population. The incidence and cause of mortality in 56 consecutive patients, who underwent ICD implantation beginning May 1982 with follow-up through May 19, 1990 were analyzed. Twenty-one patients died, 33% of the mortality was due to SCD, and 52% of deaths may be considered arrhythmic. The cumulative 1, 3, and 5 year SCD survivals were 93%, 89%, and 75%. All seven patients dying of SCD presented initially with SCD, all received previous shocks prior to SCD, and two of the seven patients had devices that were probably inactive at the time of death. We conclude that ICDs reduce but by no means eliminate arrhythmic death, particularly in those at highest risk for SCD. Arrhythmic death remained the most common cause of death in this population.     

Diabetes and Multiple Stents Independently Double the Risk of Short-term Revascularization

Several studies show worse outcome for diabetic patients after percutaneous transluminal coronary angioplasty (PTCA). There are relatively few studies evaluating outcome in the modern era of coronary stenting. We compared the incidence of death, myocardial infarction (MI), and repeat target lesion revascularization (RTLR) by PTCA or coronary artery bypass grafting (CABG) over a 6-month follow-up in 110 diabetic and 400 nondiabetic patients receiving Palmaz-Schatz stents. All patients received aspirin/ticlopidine and stents were deployed using high-pressure inflations. Seventy-five (68.2%) diabetic patients and 272 (68%) nondiabetic patients had single stents, while 35 (31.8%) diabetic and 128 (32%) nondiabetic patients had multiple stents (≥ 2stents in the same vessel). The success rate and acute major complications were not significantly different between diabetic and nondiabetic patients. There was also no significant difference in death, MI, and repeat PTCA between these two groups. Diabetic patients underwent CABG more frequently than nondiabetic patients (12.7% vs 3.2%, respectively, P =0.001) and diabetic patients also had RTLR more frequently than nondiabetic patients (25.5% vs 12.8%, respectively, P = 0.002) during 6-month follow-up. Multivariate analysis showed that diabetes and multiple stents independently contributed to the 6-month RTLR rate. Coronary stenting in diabetic patients can be carried out with a high success rate and low incidence of acute major complications. The presence of diabetes mellitus and multiple stent placement significantly increase the incidence of repeat target lesion revascularization.