Prognosis of CRT-treated and CRT-untreated unselected population with LBBB in Stockholm County.

AIMS: Left bundle branch block (LBBB) might be the first finding of cardiovascular diseases but also the prerequisite for cardiac resynchronization therapy (CRT) in heart failure (HF) with reduced ejection fraction (HFrEF). The prognosis for patients with LBBB and the implications of CRT in an unselected real-world setting are the focus of our study. METHODS AND RESULTS: A central electrocardiogram (ECG) database and national registers have been screened to identify patients with LBBB. Predictors of HF and the use of CRT were identified with Cox models. The hazard ratios (HRs) of death, cardiovascular death (CVD), and HF hospitalization (HFH) were estimated according to CRT use. Of 5359 patients with LBBB and QRS > 150 ms, median age 76 years, 36% were female. At the time of index ECG, 41% had a previous history of HF and 27% developed HF. Among 1053 patients with a class I indication for CRT, only 60% received CRT with a median delay of 137 days, and it was associated with a lower risk of death [HR: 0.45, 95% confidence interval (CI): 0.36-0.57], CVD (HR: 0.47, 95% CI: 0.35-0.63), and HFH (HR: 0.56, 95% CI: 0.48-0.66). The age of over 75 years and the diagnosis of dementia and chronic obstructive pulmonary disease were predictors of CRT non-use, while having a pacing/defibrillator device independently predicted CRT use. CONCLUSION: In an unselected LBBB population, CRT is underused but of great value for HF patients. Therefore, it is crucial to find ways of better implementing and understanding CRT utilization and characteristics that influence the management of our patients.

Congestion and Diuretic Resistance in Acute or Worsening Heart Failure.

Hospitalisation for acute heart failure (AHF) is associated with high mortality and high rehospitalisation rates. In the absence of evidence-based therapy, treatment is aimed at stabilisation and symptom relief. The majority of AHF patients have signs and symptoms of fluid overload, and, therefore, decongestion is the number one treatment goal. Diuretics are the cornerstone of therapy in AHF, but the treatment effect is challenged by diuretic resistance and poor diuretic response throughout the spectrum of chronic to worsening to acute to post-worsening HF. Adequate dosing and monitoring and evaluation of diuretic effect are important for treatment success. Residual congestion at discharge is a strong predictor of worse outcomes. Therefore, achieving euvolaemia is crucial despite transient worsening renal function.

The antibacterial structure-activity relationship for common chitosan derivatives.

The relationship between the degree of substitution and antibacterial activity was studied for six common chitosan derivatives N, N,N-trimethyl chitosan (TMCNH2/TM and TMCTM/DM) N-(2-(N,N,N-trimethylammoniumyl)acetyl)-chitin (TACin), N-(2-hydroxyl) propyl-3-trimethyl ammonium chitosan (HTC), hydroxypropyl chitosan (HPC), thioglycolic chitosan (TGC) and carboxymethyl chitosan (CMC). The degree of substitution (DS) in the 36 studied samples ranged from 0.02 to 1.1 as determined by 1H NMR. The activity was determined as the minimum inhibitory concentration (MIC) against S. aureus and E. coli at pH 7.2 and 5.5. The antibacterial effect of TMC and TACin increased with DS. Samples of these derivatives with high DS were more active than chitosan at pH 7.2. HTC was more active than chitosan against S. aureus, but this activity was not affected by DS. In other cases, the activity of HTC decreased with an increase in DS. The DS for the TGC was very low and the activity was similar to unmodified chitosan. The activity of HPC decreased with DS. CMC was not active in this study.

Computerized algorithms compared with a nephrologist's diagnosis of acute kidney injury in the emergency department.

BACKGROUND: The aim of this study was to examine acute kidney injury (AKI) diagnosis based on different computerized algorithms compared with a nephrologist's diagnosis in patients visiting an emergency department (ED) of a university hospital. METHODS: In this retrospective study, we used electronic medical records at the University Hospital in Reykjavik to identify all patients aged ≥18 years, who presented to the ED in the year 2010 with an elevated serum creatinine (SCr) level. All SCr values were reviewed and a nephrologist determined whether AKI was present using the KDIGO SCr criteria and clinical data. Computerized algorithms based on the KDIGO SCr criteria, accounting for various time intervals for baseline SCr and changes in follow-up SCr, were constructed using the statiscal software R. RESULTS: At 53,816 ED visits, SCr was measured in 15,588 patients for a total of 21,559 measurements. Elevated SCr was observed in 2878 (18.4%) patients. Strict adherence to the KDIGO SCr criteria yielded a 79% sensitivity, 94% specificity, 68% positive predictive value (PPV) and 96% negative predictive value (NPV) for the diagnosis of AKI. Allowing for a longer time frame (>365 days) for baseline SCr, resulted in 93% sensitivity, 96% specificity, 80% PPV and 99% NPV. The algorithms which included a decrease in SCr from the index ED value yielded a sensitivity of 97% but lower specificity, 74% and 80%. CONCLUSIONS: The algorithms that perform best yield excellent sensitivity and specificity and could be used to identify patients with AKI in the ED to enhance early diagnosis and treatment.

[The usefullness of implantable loop recorders for evaluation of unexplained syncope and palpitations]. / Notagildi ígraeddra taktnema vid mat á óútskýrdu yfirlidi og hjartsláttaróþaegindum.

OBJECTIVE: Syncope is a common complaint and determining the underlying cause can be difficult despite extensive evaluation. The purpose of this study was to evaluate the usefulness of an implantable loop recorder for patients with unexplained syncope and palpitations. MATERIAL AND METHODS: This was a retrospective analysis of 18 patients, five of whom still have the device implanted. All patients had undergone extensive evaluation for their symptoms before getting the loop recorder implanted and this was therefore a highly select group. RESULTS: Of the thirteen patients where use of the device was completed, the mean age was 65±20 years. The loop recorder was in use for a mean time of 20±13 months. Unexplained syncope, eleven of thirteen, was the most common indication. The other two received the loop recorder for unexplained palpitations. Four patients had sick sinus syndrome during monitoring, three had supraventricular tachycardia and one had ventricular tachycardia. Further three had typical symptoms but no arrhythmia was recorded and excluding that as a cause. Two patients had no symptoms the entire time they had the loop recorder. Of the five patients still with the device three had syncope as the indication for monitoring and two have the device as a means of evaluating the results of treatment for arrhythmia. CONCLUSION: This study on our initial experience with implantable loop recorders shows that these devices can be useful in the investigation of the causes of syncope and palpitations.