Expert consensus on acute management of ventricular arrhythmias - VT network Austria.

The Arrhythmia Working Group of the Austrian Society of Cardiology (ÖKG) has set the goal of systematically structuring and organizing the acute care of patients with ventricular arrhythmias (VA), i.e. ventricular tachycardia (VT) or ventricular fibrillation (VF) in Austria. Within a consensus paper, national recommendations on the basic diagnostic work-up of VA (12-lead ECG, medical history, family history, laboratory analyses, echocardiography, search for reversible causes, ICD interrogation), as well as further medical treatment and therapeutic measures (indication of coronary angiography, ablation therapy) are established. Since acute ablation of VT is indicated in the current ESC guidelines as a class IB indication for scar-associated incessant VT or electrical storm (ES; ≥ 3 ICD therapies in 24 h) as well as for ischemic cardiomyopathy (iCMP) with recurrent ICD shocks, organizational measures must be taken to ensure that these guidelines can be implemented. Therefore, a VT network will be established covering all areas in Austria, consisting of primary and secondary VT centers. Organizational aspects of an acute VT network are defined and should subsequently be implemented by the participating hospitals. All electrophysiologic centers in Austria that deal with VT ablation are to be integrated into the network in the medium-term. Centers that co-operate in the network are divided into primary and secondary VT centers according to predefined criteria.

State of the art: leadless ventricular pacing : A national expert consensus of the Austrian Society of Cardiology.

BACKGROUND: Cardiac pacing has been shown to improve quality of life and prognosis of patients with bradycardia for almost 60 years. The latest innovation in pacemaker therapy was miniaturization of generators to allow leadless pacing directly in the right ventricle. There is a long history and extensive experience of leadless ventricular pacing in Austria. However, no recommendations of national or international societies for indications and implantation of leadless opposed to transvenous pacing systems have been published so far. RESULTS: A national expert panel of skilled implanters gives an overview on the two utilized leadless cardiac pacing systems and highlights clinical advantages as well as current knowledge of performance and complication rates of leadless pacing. Furthermore, a national consensus for Austria is presented, based on recent studies and current know-how, specifically including indications for leadless pacing, management of infection, suggestions for qualification, and training of the operators and technical standards. CONCLUSIONS: Leadless pacing systems can be implanted successfully with a low complication rate, if suggestions for indications and technical requirements are followed. An overview of the two utilized leadless cardiac pacing systems is given, specifically highlighting clinical advantages as well as current knowledge of performance and complication rates. Furthermore, a national consensus for Austria is presented, specifically including indications for leadless pacing, management of infection, and suggestions for qualification and technical standards.

Reduction of fluoroscopy dose for cardiac electrophysiology procedures: A feasibility and safety study.

BACKGROUND: Exposure to high doses of radiation during cardiac interventional procedures is associated with increased rates of cataract and cancer in patients and staff members. Thus, reduction of radiation is recommended by international medical societies. The aim of this study was to evaluate, if the lowest reasonable fluoroscopic acquisition setting for electrophysiological procedures using a novel X-ray detector operated at a minimum detector entrance dose per fluoroscopy pulse is feasible and safe. METHODS: 641 consecutive patients (407 m/234f) underwent ablation procedures at our institution between August 2015 and December 2017. All ablations were performed using an Artis Q.zen X-ray system (Siemens, Germany). The first 308 patients were treated using the conventional dose program ("fluoroscopy zen standard"), from October 2016 until December 2017 another 333 patients underwent ablations using the optimized X-ray dosing program "fluoroscopy zen ULD". For the standard program fluoroscopy dose was set to 18nGy/f, for the minimized dosing program the dose was set to 6nGy/pulse and could be increased to 10 or 15 nGy/pulse manually. RESULTS: A total of 213 AV-node reentry tachycardia (AVNRT), 73 accessory pathways (AP), 71 atrial flutter and 284 atrial fibrillation (AF) ablation procedures were performed. Pulmonary vein isolation was performed using an electroanatomic mapping system (CARTO, Biosense Webster, USA) in 117 or a cryoballoon (Cryocath Medtronic, USA) in 167 patients. Total area dose could be reduced in all groups by a mean of 74.7% (4201.4µGym² vs. 1063.7µGym²), with a relative reduction of 73.1% for left atrial and 78.0% for right sided ablations. Total fluoroscopy time, procedure duration, acute ablation success, recurrence rate and complications remained unchanged. CONCLUSION: Fluoroscopy dose could be significantly reduced using an optimized X-ray dosing program in a novel X-ray detector without increasing total fluoroscopy time and without alterations of the incidence of recurrences or complications.

[Architectural modernization of psychiatric hospitals influences the use of coercive measures]. / Bauliche Modernisierungen in psychiatrischen Kliniken beeinflussen Zwangsmaßnahmen.

BACKGROUND: Coercive measures are widely applied in psychiatric hospitals as a last resort to prevent patients seriously harming themselves or others, with negative psychological and somatic consequences for those affected. OBJECTIVE: In a naturalistic observational study it was investigated whether relocation of the structural milieu of a psychiatric hospital to an architectonically improved new building influenced the application of coercive measures. MATERIAL AND METHODS: The frequency and duration of coercive measures (e.g. fixation, coercive medication and preventive restraints) were routinely documented and compared in the periods before and after the relocation. RESULTS: After the relocation the utilization of coercive measures was significantly reduced by 48-84 %. CONCLUSION: Despite the limitations of the study design the results suggest that the architectural improvements reduced the application of coercive measures. It is speculated that the positive structural milieu enhanced the well-being of patients and staff and their social relations, which in turn prevented coercive measures.

Bonding of acrylic denture teeth to resin denture bases.

Anterior teeth debonding from dentures is a common problem. This study tested the bond strength of denture teeth to two types of denture resin, with and without grooving the ridge-lap surface. Bond strength and fracture type of three different groups were compared: 1. Teeth bonded to heat-cured polymethyl methacrylate (PMMA); 2. Teeth bonded to pour-type PMMA; 3. Grooved teeth bonded to pour-type PMMA. Specimens were manufactured following ISO standard 22112. Force values at failure were analysed using one-way analysis of variance, using the mixed procedure with confidence interval of 95%. Types of failure were identified as adhesive, cohesive or combination. In descending order, mean failure forces were 418.55N (Group One), 367.55N (Group Two) and 290.05N (Group Three). There was no significant difference between the means of groups 1 and 2 (p = 0.0627). Group Three differed from both other groups (p < 0.001). Groups One and Two showed predominantly cohesive fractures wthin denture teeth (83% and 72% respectively); group Three showed predominantly cohesive fractures within the denture PMMA (75%). Without ridge-lap modification, the bond strengths of denture teeth to pour-type and heat-cured denture resin were similar. Failures were predominantly of cohesive nature within the teeth themselves. Grooving the ridge-lap reduced fracture resistance and led to breakages predominantly in denture PMMA.

Localizing the accessory pathway in ventricular preexcitation patients using a score based algorithm.

OBJECTIVES: Clinical data was analyzed to find an efficient way to localize the accessory pathway in patients with ventricular preexcitation. METHODS: The delta wave morphologies and ablation sites of 186 patients who underwent catheter ablation were analyzed and an algorithm ("locAP") to localize the accessory pathway was developed from the 84 data sets with a PQ interval ≤0.12s and a QRS width ≥0.12s. Fifty additional patients were included for a prospective validation. The locAP algorithm ranks 13 locations according to the likelihood that the accessory pathway is localized there. The algorithm is based on the locAP score which uses the standardized residuals of the available data sets. RESULTS: The locAP algorithm's accuracy is 0.54 for 13 locations, with a sensitivity of 0.84, a specificity of 0.97, and a positive likelihood ratio of 24.94. If the two most likely locations are regarded, the accuracy rises to 0.79, for the three most likely locations combined the accuracy is 0.82. This new algorithm performs better than Milstein's, Fitzpatrick's, and Arruda's algorithm both in the original study population as well as in a prospective study. CONCLUSIONS: The locAP algorithm is a valid and valuable tool for clinical practice in a cardiac electrophysiology laboratory. It could be shown that use of the locAP algorithm is favorable over the localizing algorithms that are in clinical use today.

The discrimination potential of amalgam restorations for identification: part 1.

The dental identification of human remains utilizes the matching of dental restorations. The radiographic images of amalgam restorations are paramount in this process. The compound amalgam restoration has a unique radiographic morphology and can be readily identified in both antemortem and postmortem data. To test the radiographic morphology of compound amalgam restorations, 10 out of 40 Typodont teeth, restored by students, were tested for their discriminatory potential by 12 examiners. The results showed that the radiographic morphology of compound amalgam restorations can be accurately matched by dentally trained personnel. This suggests that in cases where accurate radiographic material is used for dental comparison, less than 12 concordant features are necessary for positive dental identification. If the antemortem and postmortem radiographic images of a compound amalgam restoration are exactly the same then this feature is unique and identification can be achieved by a single concordant feature.

The discrimination potential of amalgam restorations for identification: part 2.

The standard dental bitewing radiograph is used to detect interproximal caries but it also provides a specific view of the dental restorations that can be duplicated for identification purposes. The antemortem and postmortem bitewing radiographs are often not at the same angle and result in distorted images of the restorations. The aim of this study was to investigate the progressive increase in angulations of a bitewing radiograph of the same restoration and to determine at what angle the image is distorted sufficiently as not to be recognized. Bitewing radiographs were taken of the same two restorations at 5 ̊, 10 ̊, 15 ̊ and 20 ̊ superior, inferior, mesial and distal to the original 0 ̊bitewing radiograph. Twenty examiners were required to determine at what angle the distortion prevented matching of the image with the original bitewing radiograph. The results showed that the image distortion at 15 ̊became suspect but at 20 ̊none of the images could be matched to the original bitewing radiograph.

Effect of an antifungal denture liner on the saliva yeast count in patients with denture stomatitis: a pilot study.

Although in vitro studies on the release of antifungal agents from tissue conditioners have been done, no in vivo research on the topic could be found. The purpose of this study was to determine the in vivo effect of an antifungal agent released from a tissue conditioner on the salivary yeast count. Forty edentulous patients with denture stomatitis caused by Candida albicans were divided in two groups. Group 1 (control) was treated with a tissue conditioner only. Group 2 was treated with a tissue conditioner incorporating 500,000 U nystatin. Oral rinses were performed by both groups before treatment and every second day during treatment for a period of 14 days. Total yeast counts of the oral rinses were performed and the averages and standard deviations for both groups calculated and logarithm-transformed data of the counts over time were statistically analysed using the Wilcoxon signed-rank test. The average oral rinse yeast count of the control group decreased up to day 4. Thereafter, the count increased till the end of the test period. At day 14, the oral rinse yeast level was higher than the pre-treatment level. The average yeast count of the test group decreased up to day 7. Thereafter, the count increased but remained significantly lower (P=0.01) than the control group and did not return to its pre-treatment level. A nystatin-containing short-term denture liner significantly decreases the salivary yeast count of patients with denture stomatitis compared with a liner without nystatin.

Detection of phase singularities in triangular meshes.

OBJECTIVES: Phase singularities have become a key marker in animal and computer models of atrial and ventricular fibrillation. However, existing algorithms for the automatic detection of phase singularities are limited to regular, quadratic mesh grids. We present an algorithm to automatically and exactly detect phase singularities in triangular meshes. METHODS: For each node an oriented path inscribing the node with one unit of spatial discretization is identified. At each time step the phase information is calculated for all nodes. The so-called topological charge is also computed for each node. A non-zero (+/- 2pi) charge is obtained for all nodes with a path enclosing a phase singularity. Thus all charged nodes belonging to the same phase singularity have to be clustered. RESULTS: With the use of the developed algorithm, phase singularities can be detected in triangular meshes with an accuracy of below 0.2 mm - independent of the type of membrane kinetics used. CONCLUSIONS: With the possibility to detect phase singularities automatically and exactly, important quantitative data on cardiac fibrillation can be gained.

A comparison of the accuracy of two methods used by pre-doctoral students to measure vertical dimension.

STATEMENT OF PROBLEM: Measuring vertical dimension is a soft-tissue measurement. Therefore, inaccuracy may occur. PURPOSE: The purpose of this study is to compare the accuracy of the Willis gauge method with the caliper method. MATERIALS AND METHODS: The Willis gauge measures the distance between the septum of the nose and the chin. The caliper method measures the distance between reference points on the tip of the nose and the chin. Twenty predoctoral students applied both methods 10 times in measuring the rest vertical dimension (RVD) and the occlusal vertical dimension (OVD) of a single edentulous patient. The measurements obtained from one experienced clinician were selected as controls for the interocclusal distances (IOD) for the Willis and the caliper methods, respectively. One-sided t tests and a 1-sided nonparametric test were used to determine significant differences between the 2 methods (alpha=.05). RESULTS: The variances in the RVD values for the Willis gauge method were higher than for the caliper method for most students. A Wilcoxon signed rank test showed that the accuracy of the OVD measurements for the caliper method was significantly better than for the Willis gauge method (P=.001). This was not the case for the RVD measurements (P=.073). The average IOD for the Willis method was significantly higher than the control IOD (P=.026). The average IOD for the caliper method was not significantly larger than the control (P=.1303). CONCLUSION: This study showed that the use of the caliper method by predoctoral students was a significantly more reliable method of measuring the OVD for the patient evaluated.

Psychiatric commitment: patients' perspectives.

OBJECTIVE: The literature pertaining to patients' perceptions of commitment and its consequences is limited. The object of this study was to learn more about these experiences from the patient's perspective. MATERIAL AND METHODS: 108 court-committed patients (78% of whom were schizophrenic) were identified for inclusion in a retrospective follow-up study. After an interval varying from one to 4.5 years from time of commitment to follow-up, 76 patients could be contacted, of whom 47 were included in the follow-up. RESULTS: The majority of patients felt that their court commitment had not been justified and could have been avoided. Events and circumstances identified as particularly stressful about commitment were confinement in a locked ward, side effects of medication, feelings of helplessness, and certain staffbehaviors. Adverse psychological, somatic, and social consequences were common. Coercive measures during hospitalization were strongly associated with negative feelings about the effect of commitment on mental health and about subsequent treatment. The majority, however, also remained in treatment after commitment was terminated, said they would return to hospital in event of future crisis, and had pertinent comments about how commitment could have been avoided. CONCLUSIONS: Many patients who had been court-committed reported negative feelings about their experiences, but the great majority had continued in treatment, both at the termination of commitment and later. They also had ideas about how to reduce the negative impact of commitment that are worth including in future contingency plans.

Homocysteine impairs the nitric oxide synthase pathway: role of asymmetric dimethylarginine.

BACKGROUND: Hyperhomocysteinemia is a putative risk factor for cardiovascular disease, which also impairs endothelium-dependent vasodilatation. A number of other risk factors for cardiovascular disease may exert their adverse vascular effects in part by elevating plasma levels of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase. Accordingly, we determined if homocysteine could increase ADMA levels. METHODS AND RESULTS: When endothelial or nonvascular cells were exposed to DL-homocysteine or to its precursor L-methionine, ADMA concentration in the cell culture medium increased in a dose- and time-dependent fashion. This effect was associated with the reduced activity of dimethylarginine dimethylaminohydrolase (DDAH), the enzyme that degrades ADMA. Furthermore, homocysteine-induced accumulation of ADMA was associated with reduced nitric oxide synthesis by endothelial cells and segments of pig aorta. The antioxidant pyrrollidine dithiocarbamate preserved DDAH activity and reduced ADMA accumulation. Moreover, homocysteine dose-dependently reduced the activity of recombinant human DDAH in a cell free system, an effect that was due to a direct interaction between homocysteine and DDAH. CONCLUSION: Homocysteine post-translationally inhibits DDAH enzyme activity, causing ADMA to accumulate and inhibit nitric oxide synthesis. This may explain the known effect of homocysteine to impair endothelium-mediated nitric oxide-dependent vasodilatation.

Mild-to-moderate hypertriglyceridemia in young men is associated with endothelial dysfunction and increased plasma concentrations of asymmetric dimethylarginine.

OBJECTIVES: The aim of this study was to investigate endothelial function and common carotid intima-media thickness (IMT) in healthy young men with mild-to-moderate hypertriglyceridemia. Plasma asymmetric dimethylarginine (ADMA), an endogenous nitric oxide synthase inhibitor, was measured to further elucidate the mechanisms involved. BACKGROUND: Hypertriglyceridemia is a risk factor for coronary heart disease although the mechanisms behind the increased risk remain to be defined. Acute elevation of plasma triglycerides induced by an intravenous fat load is associated with impaired endothelial function. The results of studies examining acute effects induced by a high-fat meal or effects of chronic hypertriglyceridemia on endothelial function are more inconsistent. METHODS: Flow-mediated vasodilation and nitroglycerin-induced vasodilation of the brachial artery and common carotid IMT were measured noninvasively by ultrasound technique in 15 hypertriglyceridemic (HTG) subjects and 15 matched controls, mean age 34 years. Plasma concentrations of ADMA were measured by high-performance liquid chromatography. RESULTS: Flow-mediated vasodilation was decreased in the HTG group (p < 0.0001), whereas nitroglycerin-induced vasodilation and carotid IMT did not differ significantly. Asymmetric dimethylarginine concentrations were higher in the HTG group (p < 0.05). CONCLUSIONS: Hypertriglyceridemia in young men is associated with endothelial dysfunction and increased plasma concentration of ADMA but not with increased IMT of the common carotid artery. The corollary is that chronic hypertriglyceridemia results in endothelial dysfunction, possibly due to increased ADMA concentration, and that endothelial dysfunction might precede increased IMT among the early manifestations of atherosclerosis.

Appetitve effects of drug cues modelled by pictures of the intake ritual: generality of cue-modulated startle examined with inpatient alcoholics.

RATIONALE: A cue-modulated startle test recently confirmed that smoking cues in smokers may not be withdrawal-like and aversive as traditionally believed. OBJECTIVE: Analogous tests were applied to alcohol cues in inpatient alcoholics. METHODS: Twenty-six withdrawn alcoholics (18 men) were examined. Alcohol-related pictures were compared to standardised pleasant, neutral or unpleasant control scenes using an acoustic startle test and measures of pleasure, arousal and desire for alcohol. RESULTS: Pictures depicting preparation for drinking (cues) were different from unpleasant control pictures and similar to pleasant pictures but only on the startle test; no differential effects were found for alcohol craving and mixed motivational effects were reported subjectively. The effects were not due to arousal and control pictures depicting post-drinking events showed less effect than the alcohol cues. CONCLUSIONS: New techniques of measuring drug cue motivation indicate that drug cues may have incentive properties in individuals in treatment for alcoholism.

Low apolipoprotein A-IV plasma concentrations in men with coronary artery disease.

OBJECTIVES: The objective of this study was to evaluate the relation between apolipoprotein A-IV (apoA-IV) plasma concentrations and coronary artery disease (CAD). BACKGROUND: Experimental in vitro and in vivo studies favor apoA-IV to be protective against the development of atherosclerosis. Mice that overexpress either human or mouse apoA-IV demonstrated a significant reduction of aortic atherosclerotic lesions compared with control mice. Data on apoA-IV plasma concentrations and CAD in humans are lacking. METHODS: We determined in two independent case-control studies of a Caucasian and an Asian Indian population whether apoA-IV plasma concentrations are related to the presence of angiographically assessed CAD. RESULTS: Plasma apoA-IV levels were significantly lower in 114 male Caucasian subjects with angiographically defined CAD when compared with 114 age-adjusted male controls (10.2 +/-3.8 mg/dL vs. 15.1 +/- 4.0 mg/dL, p < 0.001). Logistic regression analysis indicated that the association between apoA-IV levels and CAD was independent of the high-density lipoprotein cholesterol and triglyceride concentrations. The inverse relationship between plasma levels of apoA-IV and the presence of CAD was confirmed in an independent sample of 68 male Asian Indians with angiographically documented CAD and 68 age-matched controls. CONCLUSIONS: The results of this cross-sectional study demonstrate for the first time an association between low apoA-IV concentrations and CAD in humans and suggest that apoA-IV may play an antiatherogenic role in humans.

HER-2 oncogene is not amplified in primary carcinoma of the fallopian tube. Austrian Cooperative Study Group for Fallopian Tube Carcinoma.

73 women suffering from primary carcinoma of the fallopian tube underwent surgical excision of their tubes. The tissue was embedded in paraffin and investigated for HER-2 oncogene amplification with a quantitative polymerase chain reaction method. DNA could be extracted and successfully prepared in 65/73 samples. None of the tissue samples exhibited amplified the HER-2 oncogene. Data suggest that the HER-2 oncogene does not play a role in tumor transformation and progression in fallopian tube carcinomas. This contrasts with observations in ovarian carcinomas, with which fallopian tube carcinomas share many clinical, histological and biochemical similarities.

Clinical therapy and HER-2 oncogene amplification in breast cancer: chemo- vs radiotherapy.

One hundred and five breast cancer patients with stage T3/4, N+/-, Mo were treated at random either with a pre- and postoperative chemotherapy (A) (5-drug-combination + tamoxifen) or with a pre- and postoperative radiotherapy (B). Paraffin embedded tissue samples were prepared from tumor material taken by biopsy prior to therapy as well as at surgery from patients of both groups to estimate the HER-2 oncogene copy numbers before and after treatment. In 53 and 50% of the pretherapeutic samples the HER-2 gene was amplified in groups A and B, respectively. In the post-therapeutic group 60% of the chemotherapy and 48% of the radiotherapy patients, respectively, had low or high HER-2 oncogene copy numbers. In addition, HER-2 amplification before and after therapy was estimated in 28 patients. An increase of oncogene copy numbers could be detected in 21% of the chemotherapy patients, and a decrease was noted in 11%. No radiotherapy patient showed a rise, but 11% a loss of copy numbers. Although amplification of HER-2 oncogene was not found to be associated with overall survival as it was in many studies before, it could still be a predictor of clinical outcome and the cause of mammary carcinomas developing into stage T3/4.