Bleeding complications in patients with atrial fibrillation undergoing cardioversion randomized to transesophageal echocardiographically guided and conventional anticoagulation therapies

In a multicenter randomized trial, we studied a transesophageal echocardiography (TEE) guided strategy with short-term anticoagulation compared with a conventional strategy for patients with atrial fibrillation >2 days' duration and undergoing cardioversion. Composite major and minor bleeding was a predetermined secondary end point of the study. The objective of the study was to assess the incidence, location, and predictors of bleeding in the 2 treatment groups. A total of 1,222 patients were assigned to a TEE guided or conventional strategy and followed over 8 weeks. We present data on major and minor adjudicated bleeding complications for the 2 study groups during the 8-week study period. Composite major and minor bleeding complications occurred in 51 of 1,222 patients (4.2%) and were significantly lower in the TEE guided group compared with the conventional group (2.9 vs 5.5%, p = 0.025). The TEE group had fewer cancellations of cardioversion as a result of bleeding (0% vs 0.7%, p = 0.003). Major (n = 14) and minor (n = 38) bleeding complications were predominantly gastrointestinal (71.4% and 31.6%, respectively) and were associated with warfarin use. Predictors of bleeding included patient age, conventional group assignment, inpatient status, and functional status. Thus, composite major and minor bleeding complications occurred in 4.2% of the 1,222 patients and were significantly lower in the TEE guided group compared with the conventional group. Treatment variables affecting length of anticoagulant therapy in the conventional arm combined with advancing age and functional status are important concerns in patients who undergo cardioversion of atrial fibrillation.     

Indirect fluorescent antibody testing of nasopharyngeal swabs for influenza diagnosis in lung transplant recipients.

BACKGROUND: Rapid and reliable diagnosis of respiratory viral infections (RVI) in lung transplant recipients is essential to direct therapy of acute graft dysfunction and identify epidemic trends. Traditional techniques of serology and viral culture are limited by the lack of antibody response and delay in diagnosis. METHODS: We examined the clinical utility of indirect fluorescent antibody (IFA) testing in adult lung transplant patients with suspected RVI, compared with serology and culture. Nasopharyngeal and throat swabs (NT) were obtained to sample epithelial cells, followed by application of monoclonal antibody to respiratory syncytial virus, adenovirus, parainfluenza 1-3 and influenza A and B. The Bartels Respiratory Viral Detection kit was used with IFA results available within 24 hours. RESULTS: Nine of 18 patients tested positive for RVI with influenza A (n = 8) and influenza B (n = 1) detected. The sensitivity of IFA (67%) was higher than that of cell culture (45%). With intensive supportive therapy, infection was self-limiting in bronchiolitis obliterans syndrome (BOS) Grade 0-2 patients. However, patients with BOS Grade 3 manifested an acute exacerbation of airflow obstruction, which proved to be irreversible. CONCLUSIONS: Lung transplant patients with "flu-like" symptoms should proceed to IFA testing of NT swab specimens for early diagnosis. Samples collected within 7 days of symptom onset have high sensitivity as compared with serology and viral culture techniques.     

A cohort study of systemic and local complications of toe prostheses

We investigated the role of toe implants in systemic disease and evaluated local complications after foot surgery. Information was obtained from the medical records of Kaiser Permanente (northern California) patients who had undergone toe surgery between 1979 and 1988. Computerized hospitalization records were used to identify patients with toe implants (N=814) and matched controls with foot surgery not involving implants (N=837). Brain cancer and alopecia areata occurred more among implant patients, whereas dysphagia occurred more among nonimplant patients. A larger proportion of implant patients were diagnosed with pain and swelling, tendonitis, and osteomyelitis or periostitis. Nonimplant patients were more often diagnosed with derangement of foot or ankle and delayed postoperative healing. We did not find a general association between implants and connective tissue diseases.     

Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial

Context  Depression and low perceived social support (LPSS) after myocardial infarction (MI) are associated with higher morbidity and mortality, but little is known about whether this excess risk can be reduced through treatment. Objective  To determine whether mortality and recurrent infarction are reduced by treatment of depression and LPSS with cognitive behavior therapy (CBT), supplemented with a selective serotonin reuptake inhibitor (SSRI) antidepressant when indicated, in patients enrolled within 28 days after MI. Design, Setting, and Patients  Randomized clinical trial conducted from October 1996 to April 2001 in 2481 MI patients (1084 women, 1397 men) enrolled from 8 clinical centers. Major or minor depression was diagnosed by modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and severity by the 17-item Hamilton Rating Scale for Depression (HRSD); LPSS was determined by the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI). Random allocation was to usual medical care or CBT-based psychosocial intervention. Intervention  Cognitive behavior therapy was initiated at a median of 17 days after the index MI for a median of 11 individual sessions throughout 6 months, plus group therapy when feasible, with SSRIs for patients scoring higher than 24 on the HRSD or having a less than 50% reduction in Beck Depression Inventory scores after 5 weeks. Main Outcome Measures  Composite primary end point of death or recurrent MI; secondary outcomes included change in HRSD (for depression) or ESSI scores (for LPSS) at 6 months. Results  Improvement in psychosocial outcomes at 6 months favored treatment: mean (SD) change in HRSD score, -10.1 (7.8) in the depression and psychosocial intervention group vs -8.4 (7.7) in the depression and usual care group (P<.001); mean (SD) change in ESSI score, 5.1 (5.9) in the LPSS and psychosocial intervention group vs 3.4 (6.0) in the LPSS and usual care group (P<.001). After an average follow-up of 29 months, there was no significant difference in event-free survival between usual care (75.9%) and psychosocial intervention (75.8%). There were also no differences in survival between the psychosocial intervention and usual care arms in any of the 3 psychosocial risk groups (depression, LPSS, and depression and LPSS patients). Conclusions  The intervention did not increase event-free survival. The intervention improved depression and social isolation, although the relative improvement in the psychosocial intervention group compared with the usual care group was less than expected due to substantial improvement in usual care patients.      

Somatization, dissociation and general psychopathology in patients with psychogenic non-epileptic seizures

The etiology of psychogenic non-epileptic seizures (PNES) remains uncertain. Previous studies have shown that PNES patients are characterized by high levels of somatization, dissociation and general psychopathology but a correlation of measures of these features and PNES severity or outcome has never been demonstrated, although this would strengthen a possible etiological link. This study measured somatization (Screening Test for Somatoform Symptoms-2), dissociation (Dissociative Experience Scale, DES), and general psychopathology (Symptom Checklist-90-Revised, SCL-90) in 98 patients with PNES and 63 patients with epilepsy. All mean scores were raised in the PNES compared to the epilepsy group. However, only measures of somatization and general psychopathology discriminated between patients with PNES and epilepsy in a logistic regression model (even when patient gender was controlled for). In PNES patients, high somatization scores correlated with poor outcome and greater seizure severity even after correction was made for dissociation and psychopathology. Dissociation and psychopathology scores were not independently associated with outcome or severity. The results suggest that, as a group, patients with PNES are best characterized by their tendency to express psychosocial distress by producing unexplained somatic symptoms which are brought to medical attention. Although dissociation may be relevant in some individuals it does not appear to be an independent factor across the whole PNES patient group.