The potential impact of acute coronary syndromes on automatic sensing system in Subcutaneous-ICDs.

BACKGROUND: The Subcutaneous-ICD (S-ICD) is emerging as a suitable option for most ICD candidates, however some open issues regarding the sensing algorithm still remain. OBJECTIVES: We aimed to examine the performance of the S-ICD sensing algorithm in patients hospitalized for ST elevation myocardial infarction (STEMI), non ST elevation acute coronary syndrome (NSTE-ACS) or chronic coronary syndrome (CCS), before and after revascularization. METHODS: We performed a S-ICD automated screening on 75 patients, 21 hospitalized for STEMI, 23 for NSTE-ACS and 31 for CCS, before and after percutaneous revascularization, regardless their eligibility to ICD implantation. RESULTS: Patients did not differ in clinical, electrocardiographic and echocardiographic parameters. Rates of screening pass were significantly lower in STEMI patients compared to NSTE-ACS and CCS (5% vs 56.7% vs 81% respectively, p < .0001). The viability of the primary vector was lower in STEMI patients compared to NSTE-ACS and CCS (33% vs 56% vs 71%, p .027 respectively). After revascularization, there were no more significant differences between groups. Pairing subjects at baseline and after revascularization, STEMI subjects percentages of screening success were respectively 5% and 81% (p < .001) and the rates of primary vector viability were 33% and 81% (p .002). STEMI was the only independent predictor of screening failure at multivariate logistic regression analysis (odds ratio 10.68 confidence interval 2.77-41.38, p = .001). CONCLUSION: The performance of the S-ICD and possible malfunction detections in the context of an acute ischemic event deserve further evaluation. Adequate patient selection and the development of dynamic device programming are warranted.

Preserved cardiorespiratory function and NT-proBNP levels before and during exercise in patients with recent onset of rheumatoid arthritis: the clinical challenge of stratifying the patient cardiovascular risks.

Rheumatoid arthritis (RA) is associated with an increased risk of myocardial infarction and congestive heart failure. In RA patients, elevated NT-proBNP levels have been reported to be a prognostic marker of left ventricular dysfunction. In this study, we evaluated cardiorespiratory functional capacity and NT-proBNP levels before and during cardiopulmonary exercise test in early RA (ERA) patients. Twenty ERA patients and 10 healthy controls were studied by color Doppler echocardiography to evaluate ventricular systolic and diastolic function. Arterial stiffness and wave reflections were quantified non-invasively using applanation tonometry of the radial artery. Cardiopulmonary treadmill test was performed to measure peak VO2 and VE/VCO2 parameters. NT-proBNP plasma levels were measured before and at the exercise peak during cardiopulmonary exercise. The peak oxygen uptake [VO2 (ml/min/kg)], the ventilatory equivalents for carbon dioxide (EqCO2), respiratory exchange ratio and arterial stiffness were similar between patients and controls during cardiopulmonary exercise test. Basal and peak cardiopulmonary exercise NT-proBNP plasma levels were comparable in ERA patients with respect to healthy controls. When we analyzed patients according to disease characteristics and cardiovascular risk factors, ERA patients with high disease activity, BMI > 25 kg/m2 and ACPA positivity presented significantly higher baseline and exercise peak NT-proBNP levels. Cardiorespiratory function is preserved in patients with recent onset of rheumatoid arthritis. The increased basal and exercise peak NT-proBNP plasma levels in patients with negative disease prognostic factors represent a possible marker to stratify the cardiovascular risk in patients with early rheumatoid arthritis.

Prediction of functional capacity by low-dose dobutamine stress echocardiography in chronic heart failure.

AIM: The aim of this study was to determine if low-dose dobutamine stress echocardiography (LD-DSE) is associated with functional capacity in unselected elderly patients with chronic heart failure. METHODS: This was a prospective trial. Thirty five consecutive patients were included, with age >65 years and left ventricular dysfunction (12 ischemic), by blindly assessed LD-DSE and cardiopulmonary exercise testing (CPT). Contractile reserve was defined as a change (D) in wall motion score index (WMSI) = or <0.2 at peak dose dobutamine. At CPT treadmill exercise time, peak VO2, %Vo2 and VE/VCO2 slope were determined. Preserved functional capacity was defined as percent of maximal predicted O2 consumption (%VO2) >80%. Baseline NT-proBNP plasma levels were assessed. RESULTS: CPT variables were not related to clinical and baseline echocardiography characteristics but were related to DWMSI (exercise time, P=0.004; peak VO2, P=0.008; %VO2, P<0.001; VE/Vco2, P<0.001). Contractile reserve was present in 16 of 17 patients with preserved functional capacity (sensitivity=94%) and in 2 of 13 patients without (specificity=85%). Baseline NT-proBNP levels were lower in patients with contractile reserve (476+/-365 pg/mL) than in those without (1 345+/-1 219 pg/mL) (P=0.019), but were mildly related to CPT variables (P=0.049 and 0.027 with exercise time and %VO2, respectively). CONCLUSION: Contractile reserve elicited at LD-DSE is associated with functional capacity in unselected elderly patients with chronic heart failure.

Assessment of left ventricular systolic dysfunction by tissue Doppler imaging to detect subclinical cardiomyopathy early after anthracycline therapy.

AIM: Anthracycline (ANT) chemotherapy for breast cancer, while associated with high response rates, is fraught by risks of irreversible cardiotoxicity. Unfortunately means to detect such cardiotoxicity early on and at a sublinical stage are lacking. We evaluated the role of systolic tissue Doppler imaging (TDI) in appraising postchemotherapy left ventricular (LV) remodelling. METHODS: Patients undergoing ANT-chemotherapy for breast cancer were enrolled, and underwent baseline and >6-months echocardiography (standard and TDI). According to the pattern of LV-TDI systolic remodelling from baseline to follow-up, patients were stratified in: group 1 (no LV-TDI worsening), group 2 (minor LV-TDI worsening), and group 3 (major LV-TDI worsening). Fifty-six patients were included (follow-up 9+/-6 months). RESULTS: At baseline, no patient had abnormal LV ejection fraction (LVEF), LV-TDI systolic dysfunction or New York Heart Association (NYHA) >1. Follow-up overall analysis showed significant deterioration in LVEF, end-diastolic diameter (EDD) end-systolic diameter (ESD), and TDI-systolic parameters (all P<0.05). Specifically, 29 (51.8%) patients showed no adverse LV-TDI systolic remodelling, while 17 (30.4%) were in group 2, and 10 (17.9%) in group 3. All groups shared similar conditions at baseline. Patients with adverse LV-TDI remodelling had significant increases in EDD and ESD, as well as a significantly decreased LVEF (all P<0.05). No patient in group 1 had abnormal LVEF at follow-up, while 1 patient in group 2 and 2 patients in group 3 had abnormal LVEF (P<0.05). CONCLUSION: Subclinical systolic dysfunction occurs in almost 50% of patients early after chemotherapy for breast cancer, with a more adverse by LV-TDI remodelling implying a more pronounced deterioration of standard echocardiographic parameters.

Computerized nuclear morphometry for the prediction of inguinal lymph nodes metastases in squamous cell carcinoma of the vulva.

This study evaluated the sensitivity and specificity of computerized morphometry in predicting lymph nodes metastases (LNM) in patients with squamous cell carcinoma (SCC) of the vulva. Histologic samples obtained from 20 consecutive cases of SCC of the vulva with positive inguinal LNM were morphometrically assessed and compared with samples from 20 consecutive cases of vulvar SCC negative for LNM. Computerized morphometry was performed on tumor cells and on adjacent nonneoplastic epithelial cells located 2-4 mm from the tumor margins. Computerized morphometric variables of tumor cell nuclei in patients with negative LNM significantly differed from those in patients with positive LNM. Morphometric differences in nuclear size and contour regularity were detected when comparing the nonneoplastic nuclei adjacent to the tumor of both groups. Multivariate analysis showed that the only independent predictors of LNM were the depth of the invasion (P= 0.005) and the mean nuclear roundness of the nonneoplastic nuclei adjacent to the tumors (P= 0.008). Using these variables, a discriminant score revealed a sensitivity of 90% and a specificity of 86.4% for predicting LNM in SCC of the vulva. Our data suggest that cells from the primary tumors with LNM differ morphometrically from primary tumors with no LNM. In addition, normal epithelial cells adjacent to the tumor express morphometric changes between the two groups. The results of our study justify the need for a prospective study of a larger number of patients to evaluate the reproducibility and the clinical use of the data.

Substance abuse: an overview.

Substance abuse continues to be a major adolescent health risk. Despite encouraging trends toward decreased drug use in the late 1980s, an increase in use occurred in the early 1990s and only now is beginning to level off. A brief update on the status of the most commonly abused substances is provided. A discussion of current research is given in support of viewing drug addiction as a medical condition, i.e., a "brain disease." Reasons are suggested to explain why adolescents use and abuse drugs and why trends occur in their use. Two aspects of diagnosis are reviewed: psychiatric and medical comorbidity and drug screening and laboratory assessment of the adolescent. Prevention and early intervention are presented with an emphasis on drug education, behavioral wellness, family communication, doctor-patient discussion and assessment, and referral. Commentary is made on the ethics of care; issues of confidentiality and the right to privacy with regard to drug testing and sharing of information are explored. A review of various policy statements of the American Academy of Pediatrics and other medical organizations is presented.

In vitro hyperreactivity to lipopolysaccharide in patients with history of unstable angina is not associated with seropositivity for Cytomegalovirus, Helicobacter pylori and Chlamydia pneumoniae.

BACKGROUND: Inflammation and possibly chronic infections are associated with acute coronary syndromes; however, the mechanisms responsible for this association are not yet fully elucidated. The aim of this study was to assess whether the hyperreactivity of the inflammatory system, that we have shown in unstable patients with persistently elevated C-reactive protein and with recurrence of symptoms, was associated with chronic infection. METHODS: In 20 unstable angina patients seropositivity and antibody levels vs Cytomegalovirus, Helicobacter pylori and Chlamydia pneumoniae were measured and correlated with the interleukin-6 production in vivo in 1 ml of whole blood stimulated with 0.1 microgram lipopolysaccharide for 4 hours. RESULTS: No positive correlation was found between antibody titer and interleukin-6 levels. No correlation was also found between seropositivity to Cytomegalovirus, Helicobacter pylori or Chlamydia pneumoniae and interleukin-6 levels. CONCLUSIONS: Our study suggests that seropositivity for infective agents, including Chlamydia pneumoniae, does not affect the monocyte response to lipopolysaccharide and thus cannot account for the enhanced interleukin-6 production observed in unstable angina patients with raised levels of C-reactive protein and worse prognosis, and suggests the predominant role of the individual response to different stimuli.

Thrombocytosis in women with vulvar carcinoma.

Thrombocytosis (platelet count >400 x 10(9)/L) is frequently found in association with malignant disease. Although the pathogenesis of thrombocytosis in malignancy is currently unclear, it appears to be a poor prognostic factor in patients with lung, colon, breast, and cervical carcinoma. The current study was initiated to assess the incidence of thrombocytosis in vulvar carcinoma and to evaluate its prognostic significance for patients with vulvar carcinoma. The pretreatment platelet counts of 201 women treated for vulvar cancer were reviewed and correlated to the patient's age, stage of disease, node status, histologic type, and outcome. Differences between categories were analyzed by means of the ANOVA test, and survival was compared using the log-rank test on the Kaplan-Meier life table. Thrombocytosis was presented in 14.92% of patients with vulvar malignancies and in 15.46% of patients with squamous cell carcinoma of the vulva. No correlation was found between thrombocytosis and tumor size, incidence of lymph node metastases, or stage of the disease. The 5-year survival rate for patients with thrombocytosis was 89.29%, which was not significantly different from the 76.47% 5-year survival of patients with normal platelet counts (P = 0.586). When adjusted for age, histological differentiation, number of tumors, staging, incidence of nodal metastases, platelet count, hemoglobin, and white blood count, only the staging, number of tumors, and histological differentiation were associated with an unfavorable prognosis (P = 0.0001, P = 0.003, P = 0.03, respectively). Thrombocytosis was not found to be a prognostic factor in patients with carcinoma of the vulva in this series of 201 patients.

Prognostic factors in surgically treated stage IB-IIB carcinoma of the cervix with negative lymph nodes.

Comerci G, Bolger BS, Flannelly G, Maini M, de Barros Lopes A, Monaghan JM. Prognostic factors in surgically treated stage IB-IIB carcinoma of the cervix with negative lymph nodes. Int J Gynecol Cancer 1998; 8: 23-26. Two hundred and seventy-five females with stage IB-IIB negative lymph node cervical cancer, treated between January 1988 and December 1994 by radical hysterectomy and pelvic lymph node dissection, form the basis of this analysis. The clinical records were reviewed for all patients including histopathology, clinical features at presentation, and follow-up. Tumors were re-staged according to the 1995 FIGO classification. Median follow-up was 55 months and 85.8% were followed for longer than two years. There were 21 recurrences, 12 of which were true central recurrence (disease-free survival at 5 years: 91.66%). Fifteen of 25 deaths were due to cervical cancer (crude survival at 5 years: 93.27%). In univariate log-rank analysis, stage (P = 0.005), tumor size (P = 0.0002), and lymph-vascular space involvement (LVSI) (P = 0.01) appeared to be statistically significant factors for tumor recurrence. Other factors including age, histology type, differentiation, adjacent cervical intraepithelial neoplasia or cervical glandular intraepithelial neoplasia, and presence of intraepithelial disease at resection margin were not found to be statistically significant. In multivariate analysis (Cox regression) tumor size (P = 0.02) and LVSI (P = 0.03) were the only independent variables. In the presence of negative lymph nodes and complete surgical excision, tumor size and LVSI are important predictors of local recurrence.

Threats to chronically ill adolescents. Challenges for physicians as we approach the next millennium.

The frequency of all forms of juvenile arthritis, including juvenile rheumatoid arthritis, other major connective tissue diseases, and other rheumatic diagnoses, is estimated to be approximately 160,000-190,000 U.S. children under 15 years of age. The author suggests that the legitimization of alternative medicine and the corporatization of U.S. health care are undermining the quality of care that chronically ill adolescents receive.

Efforts by the American Academy of Pediatrics to prevent and reduce violence and its effects on children and adolescents.

The American Academy of Pediatrics (AAP) is an organization of 53,000 pediatricians committed to the attainment of optimal physical, mental, and social health for all infants, children, adolescents, and young adults. Recognizing the major impact that violence has on children and youth, the AAP has been working to prevent and reduce violence and its effects on the pediatric population. This article will describe AAP efforts intended to help pediatricians, other professionals, and the public to combat the problem.

Presurgical assessment and therapy of microinvasive carcinoma of the cervix.

Retrievable pathological specimens and clinical data on 70 patients with microinvasive carcinoma diagnosed on surgical specimens from cone biopsy or hysterectomy (Stage IA) were reviewed and compared to pertinent findings in the literature with the intent of evaluating diagnostic criteria and defining pathological features that may influence the outcome by therapy. Emphasis was given to the preoperative assessment emphasizing that both an accurate colposcopic evaluation and a detailed pathological analysis may reliably point to a conservative therapeutic approach. Increasing depth of stromal invasion was associated with lesion width as well as with endocervical extension, as measured on colposcopy, microcolpohisteroscopy, and histology. Lymph-vascular space involvement was significantly related to depth of invasion. Two patients of 28 with dissected nodes had node metastases as well as lymph-vascular space involvement. Both developed a pelvic recurrence. One had a > 1- to < or = 3-mm invasion depth, the other a > 3- to < or = 5-mm lesion invasion. While advocating a conservative procedure for Stage IA1, we suggest discrimination with regard to Stage IA2 because we believe that lymph-vascular involvement should be meticulously evaluated. In fact, > 1- to < or = 3-mm lesions without lymph-vascular space involvement can be conservatively treated, while for any other lesion falling within the Stage IA2 category a modified radical histerectomy plus pelvic lymphadenectomy should be recommended.

Mucormycosis: emerging prominence of cutaneous infections.

Twenty-five patients with mucormycosis were seen at two university-affiliated hospitals from 1979 to 1993. These cases included 10 cutaneous, 9 rhinocerebral, and 3 disseminated infections, as well as one case each of pulmonary, renal, and peritoneal dialysis catheter-related infection. Eleven of the patients were diabetic and seven had ketoacidosis, including four who became acidotic after admission to the hospital. The mortality rates associated with rhinocerebral, disseminated, and pulmonary infections were 78%-100%, while those associated with cutaneous and miscellaneous forms were zero. In view of the prominence of cutaneous infections, the 10 cases of cutaneous mucormycosis (in addition to a case from a community hospital) are reported in detail. Systemic diseases were present in four of the 11 patients. Local factors leading to infection were identified in nine of the cases and included motor vehicle accident-related and other trauma, surgery, a spider bite, and an intravenous infusion catheter. The cases of cutaneous mucormycosis reported in the literature have been analyzed for identification of predisposing factors, treatment, and outcome. Aggressive surgical debridement is the most important component of therapy, and administration of amphotericin B is a useful adjunct. Skin grafting is useful as a method of repairing defects left by extensive debridement.

Medical complications of anorexia nervosa and bulimia nervosa.

The internist plays a critical role in the care of eating disorder patients, especially in the management of the life-threatening medical complications of these conditions. In anorexia nervosa, the immediate danger is related to the effects of voluntary starvation, including hypophosphatemia, bone marrow failure, cardiac decompensation, and shock. Patients with bulimia nervosa more often experience severe fluid and electrolyte abnormalities resulting in hypovolemia, secondary hyperaldosteronism, depletion of total body potassium, and cardiac arrhythmias. Immediate management of medical complication and correction of nutritional deficits are necessary before patients can benefit from psychotherapy. The need for continued involvement of the internist in the ongoing care of the eating disorder patient is stressed. The high mortality and the likelihood of chronicity without early intervention underscore the need for early recognition and skilled management of eating disorders.

Bromocriptine-unresponsive prolactin macroadenoma in a prepubertal female.

Macroprolactinomas occur rarely in prepubertal children. A prepubertal 11 10/12-year-old female with a macroprolactinoma presented with a diagnosis of anorexia nervosa. Findings included severe headaches, anorexia, weight loss, and growth failure. The initial serum prolactin level was 2,916 ng/ml. This value fell after beginning treatment with bromocriptine, but later rose despite a doubling of the dose. Transsphenoidal surgical resection was performed and postoperative radiation given. The use of bromocriptine, surgical resection, and radiation therapy in the treatment of macroprolactinomas are discussed.