Fragmented QRS complexes after acute myocardial infarction are independently associated with unfavorable left ventricular remodeling.

BACKGROUND: Recovery of left ventricular ejection fraction (LVEF) after acute myocardial infarction (MI) is not universal and is difficult to predict. Fragmented QRS (fQRS) complexes are thought to be markers of myocardial scar. We hypothesized that fQRS complexes on 12­lead surface ECGs during the initial post-MI period would be associated with adverse LV remodeling over the following year. METHODS: Change in LVEF between the early (0-2 month) and later (2-12 month) post-MI periods was assessed in two independent cohorts of post-MI patients with initial LV dysfunction. A decline or no recovery in LVEF (ΔLVEF ≤0%) was used as a primary outcome. fQRS complexes were measured on 12­lead ECGs within a week of acute MI. A subset of patients underwent cardiac magnetic resonance imaging (CMR) for scar quantification. RESULTS: Of 705 patients in the combined cohort, 27% experienced the primary outcome (average ΔLVEF of -4%). fQRS complexes were associated with a two-fold higher risk of no LVEF recovery, independent of prior MI or CABG, baseline LVEF, MI location and QRS duration or axis. Of 113 patients undergoing CMR, fQRS was associated with increased peri-infarct zone late gadolinium enhancement (13 ±â€¯5% vs 11 ±â€¯4%, p = 0.02), but not core infarct. CONCLUSIONS: Despite contemporary post-MI therapy, >1 in 4 patients will show a decline in LVEF during follow-up. Fragmented QRS complexes on 12­lead surface ECG early post-MI may be a valuable marker of unfavorable LV remodeling and correlate to increased peri-infarct scar on CMR imaging.

A review of primary writing tremor.

A task-specific tremor (TST) is a rare form of movement disorder that appears while performing or attempting to perform a particular task. Primary writing tremor (PWT) is the most common form of TST which only occurs during the act of writing and hinders it. (Bain PG, Findley LJ, Britton TC, Rothwell JC, Gresty MA, Thompson PD, Marsden CD. MRC Human Movement, and Balance Unit, Institute of Neurology, London, UK. Primary writing tremor. Brain. 1995;118(6):1461-72.) Primary writing tremor type B is present not only during the act of writing but also when the hand assumes a writing posture. (Bain PG, Findley LJ, Britton TC, Rothwell JC, Gresty MA, Thompson PD, Marsden CD. MRC Human Movement and Balance Unit, Institute of Neurology, London, UK. Primary writing tremor. Brain. 1995;118(6):1461-72.) We first of all describe a remarkable case study of a 50-year old, right-handed male who started experiencing a primary writing tremor in his right hand about a year ago. This case was found to be of particular interest because the patient had it relatively difficult when attempting to write numbers as opposed to writing letters. This review further discusses the clinical manifestations of PWT. In addition, three main hypotheses have been proposed for the causation of PWT, although the exact pathophysiology of PWT still remains unknown. It has been suggested that PWT is a separate entity, a variant of essential tremor and not a separate entity, or a type of dystonia. The various treatment options for PWT are discussed including botulinum toxin and oral pharmacotherapy.

Multidisciplinary Clinics in Lung Cancer Care: A Systematic Review.

Multidisciplinary cancer clinics (MDCCs) are recognized in cancer care as an alternate model of care for lung cancer patients. However, the precise MDCC characteristics that could potentially improve the quality of care in lung cancer care have not been clearly defined. We performed a systematic review of the data regarding MDCCs in the treatment of patients with lung cancer to summarize and evaluate the available evidence and to determine valuable clinic characteristics and projected outcomes. We searched Embase, Cochrane, Medline, PubMed, and Web of Science through April 2017 for studies that included ≥ 2 physician specialties in a MDCC for lung cancer. A total of 2374 unique articles were identified, of which 13 met the inclusion criteria. All the studies were either retrospective or qualitative, with many having small sample sizes. The most commonly reported quantitative outcome for MDCCs was a decreased time from diagnosis to treatment; however, this was only statistically significant in 2 studies. Evidence was conflicting regarding improved patient survival. Several studies of MDCCs reported improved qualitative outcomes, including increased patient satisfaction, increased collaboration, and cohesive communication among care providers, although the sample sizes were small. The few studies of MDCCs that included a care coordinator, in addition to physicians from multiple specialties, reported improvements in patient satisfaction. Overall, our review of the reported data revealed a paucity of evidence regarding the value of MDCCs for lung cancer patients, highlighting the need for further studies to understand the optimal medical model to deliver care.

The Characteristics of Treated Pulmonary Arterial Hypertension Patients in Ontario.

Background. There are no Canadian prevalence studies on pulmonary arterial hypertension (PAH) to date. We described the characteristics of treated PAH patients and the healthcare utilization and costs associated with PAH in a population of public drug plan beneficiaries in Ontario, Canada. Methods. A retrospective cross-sectional analysis was conducted between April 2010 and March 2011 to identify treated PAH patients using population-based health administrative databases. We investigated demographic and clinical characteristics of treated PAH patients and conducted a cohort study to determine treatment patterns, healthcare utilization, and associated costs, over a one-year follow-up period (March 2012). Results. We identified 326 treated PAH cases in Ontario's publicly funded drug plan. Overall mean age was 59.4 years (±20.3 years) and over 77% of cases were women (n = 251). Combination therapy was used to treat 22.9% (n = 69) of cases, costing an average of $4,569 (SD $1,544) per month. Median monthly healthcare costs were $264 (IQR $96-$747) for those who survived and $2,021 (IQR $993-$6,399) for those who died over a one-year period, respectively (p < 0.01). Conclusions. PAH care in Ontario is complex and has high healthcare costs. This data may help guide towards improved patient management.