Heart rate variability for rapid risk stratification of emergency patients with malignant disease.

INTRODUCTION: Neoplasms are the second most common diseases in western countries. Many patients with malignant diseases repeatedly present themselves in the emergency department (ED). Due to limited capacities, appropriate risk stratification strategies for cancer patients have to be developed. This study assesses if deceleration capacity (DC) of heart rate as a parameter of heart rate variability predicts mortality in emergency patients with malignant diseases. METHODS: Prospectively, 140 adults with different entities of malignant diseases who presented in the medical ED were included. Primary and secondary endpoints were intrahospital mortality and mortality within 180 days, respectively. We calculated DC from short-term ECG readings of the surveillance monitors. Additionally, the Modified Early Warning Score (MEWS) and laboratory parameters such as white blood cells (WBC), lactate dehydrogenase, serum hemoglobin, and serum creatinine were determined. RESULTS: The median age of the patients was 65 ± 14 years. 19.3% of the patients died within the hospital stay and 57.9% died within 180 days. DC and WBC were independent predictors of intrahospital death reaching a hazard ratio (HR) of 0.79 (95% confidence interval (CI) 0.63-0.993, p = 0.043) and of 1.00 (95% CI 1.00-1.00, p = 0.003), respectively. DC and serum creatinine independently predicted death within 180 days (HR 0.90, 95% CI 0.82-0.98, p = 0.023 and HR 1.41, 95% CI 1.05-1.90, p = 0.018, respectively). CONCLUSION: Deceleration capacity of heart rate is suitable for rapid risk assessment of emergency patients with malignant diseases.

Point-of-care testing of cardiac autonomic function for risk assessment in patients with suspected acute coronary syndromes.

BACKGROUND: Impaired cardiac autonomic function has been linked to adverse outcomes in patients with acute coronary syndromes (ACS) but is not included in clinical risk models. This is the first study to investigate whether point-of-care testing of cardiac autonomic function by means of short-term deceleration capacity (DC) of heart rate improves risk assessment in patients with suspected ACS. METHODS: 1821 patients with suspected ACS were prospectively enrolled if they were older than 17 years and in sinus rhythm. Short-term DC was automatically assessed from monitor recordings at hospital admission. The Global Registry of Acute Coronary Events (GRACE) score was used as gold standard risk predictor. Primary endpoint was the composite of intrahospital and 30-day mortality. Secondary endpoint was 180-day mortality. RESULTS: Of the 1,821 patients with suspected ACS, 28 (1.5%) and 60 (3.3%) reached the primary and secondary endpoints, respectively. DC was a highly significant predictor of both endpoints, yielding areas under the curve (AUC) of 0.784 (95% CI 0.714-0.854) and 0.781 (0.727-0.832) (p < 0.001 for both), respectively. Implementing DC into the GRACE-risk model leads to a significant increase of the C-statistics from 0.788 (0.703-0.874) to 0.825 (0.750-0.900; p < 0.01 for difference) and from 0.814 (0.759-0.864) to 0.851 (0.808-0.889; p < 0.01 for difference) for the primary and secondary endpoints, respectively. Stratification by dichotomized DC was especially powerful in patients with GRACE score <140. CONCLUSIONS: In patients with suspected ACS, point-of-care testing of cardiac autonomic function by means of DC is feasible and improves risk assessment by the GRACE score. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov NCT01486589.

Insertable cardiac monitors after cryptogenic stroke--a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation.

BACKGROUND AND PURPOSE: Recently, the CRYSTAL AF trial detected paroxysmal atrial fibrillation (AF) in 12.4% of patients after cryptogenic ischaemic stroke (IS) or cryptogenic transient ischaemic attack (TIA) by an insertable cardiac monitor (ICM) within 1 year of monitoring. Our aim was (i) to assess if an AF risk factor based pre-selection of ICM candidates would enhance the rate of AF detection and (ii) to determine AF risk factors with significant predictive value for AF detection. METHODS: Seventy-five patients with cryptogenic IS/TIA were consecutively enrolled if at least one of the following AF risk factors was present: a CHA2DS2-VASc score ≥4, atrial runs, left atrium (LA) size >45 mm, left atrial appendage (LAA) flow ≤0.2 m/s, or spontaneous echo contrast in the LAA. The electrocardiographic and echocardiographic criteria were chosen as they have been repeatedly reported to predict AF; the same applies for four of the six items of the CHA2DS2-VASc score. The study end-point was the detection of one or more episodes of AF (≥2 min). RESULTS: Seventy-four patients underwent implantation of an ICM; one patient had AF at the date of implantation. After 6 months, AF was detected in 21/75 patients (28%), after 12 months in 25/75 patients (33.3%). 92% of AF episodes were asymptomatic. LA size >45 mm and the presence of atrial runs were independently associated with AF detection [hazard ratio 3.6 (95% confidence interval 1.6-8.4), P = 0.002, and 2.7 (1.2-6.7), P = 0.023, respectively]. CONCLUSIONS: The detection rate of AF is one-third after 1 year if candidates for an ICM after cryptogenic IS/TIA are selected by AF risk factors. LA dilation and atrial runs independently predict AF.

[Inactivation of the intracardial cardioverter/defibrillator (ICD) antitachycardial function in dilated cardiomyopathy. Driver can again work in her occupation]. / Ausschalten der antitachykarden ICD-Funktion bei dilatativer Kardiomyopathie. Kraftfahrerin kann Beruf wieder ausüben.

HISTORY: Cardiac synchronization treatment with implanted cardiac defibrillator (CRT-ICD) had been given to a 52-year old women because she had markedly reduced left ventricular function and a left bundle branch block. She had already improved to NYHA class II two weeks after the initial diagnosis and treatment of a non-ischemic dilated cardiomyopathy at another hospital. A lorry drinving license was denied to her, a professional lorry driver. TREATMENT AND COURSE: By the time that the patient asked for a second opinion at our hospital six months later, left ventricular function had improved as a result of CRT and cardiac medication. There was thus no longer an indication for primary preventive ICD implantation, left ventricular function no longer being present. As the rhythmogenic hazard was comparable to that without implanted device (in which case professional driving would be allowed), anti-tachycardic ICD function was inactivated so that the patient could work again as a lorry driver. CONCLUSION: This case underlines the impact of the significance of the interval between diagnosis of a cardiac disease and primary preventive insertion of an ICD, as suggested by the guidelines, especially in patients with non-ischemic dilated cardiomyopathy.

Transient outward potassium current in rabbit atrium is depressed after short-time rapid atrial pacing but recovers after a longer pacing period.

In rabbit, after short-time rapid atrial pacing (RAP), atrial ion currents are reduced similarly as in human chronic atrial fibrillation (AF). Using the rabbit model, time-course of transient outward potassium current (I(to)) remodeling due to RAP was studied. RAP (600 bpm) was applied via an atrial lead for 0 (control), 24 and 120 h, n = 4 animals/group. Using patch clamp technique in whole-cell mode, current densities and biophysical properties were measured in isolated atrial myocytes. After 24 h of RAP, a reduction of peak I(to) (mean +/- SEM, test potential +50 mV, +37 degrees C) was observed (60.3 +/- 5.4 pA/pF (control, n = 20) vs. 28.0 +/- 2.5 pA/pF (24 h, n = 21)). Inactivation of I(to) was slower after 24 h, other biophysical properties were unaltered. However, I(to) recovered after 120 h: 51.7 +/- 4.5 pA/pF (n = 26, p = n.s. vs. control). Inactivation tended to also recover to initial values but was still different to control. Early I(to) remodeling due to RAP in rabbits seems to be more complex than previously thought: a time course of I(to) remodeling with swayings has to be considered when using the rabbit model of RAP in order to study early remodeling or rather its therapeutic manipulation.

Sweet liking, novelty seeking, and gender predict alcoholic status.

BACKGROUND: The relationship between a hedonic response to sweet taste and a propensity to excessive alcohol drinking is supported by both animal and human studies. There is evidence indicating that the tendency to rate more concentrated sweet solutions as the most pleasurable (i.e., sweet liking) is associated with the genetic vulnerability to alcoholism. However, sweet liking by itself is insufficient to predict the alcoholic status of the individual. Our previous study indicated that alcoholic status can be predicted by a combination of hedonic response to sweet taste and personality profile as measured by the Tridimensional Personality Questionnaire (TPQ). This study was designed to further test this hypothesis. METHODS: Participants were 165 patients admitted to a residential treatment program for the treatment of alcoholism, drug dependence and/or interpersonal problems secondary to substance-abusing family members. In addition to a routine medical examination, on the 24th day after admission, patients completed the TPQ, the standard sweet taste test was conducted, and paternal family history of alcoholism was evaluated. RESULTS: Sweet liking was strongly associated with a paternal history of alcoholism. The odds of receiving an alcohol dependence diagnosis were shown to increase, on the average, by 11% for every one-point increase in the TPQ novelty-seeking score in sweet-liking but not in sweet-disliking subjects. Gender contributed independently to the probability of alcohol dependence, with males exhibiting higher rates of alcoholism than females. CONCLUSIONS: These findings support the hypothesis that a hedonic response to sweet taste is associated with a genetic risk for alcoholism. Alcoholic status may be predicted by a combination of sweet liking, the TPQ novelty-seeking score, and gender in a mixed group of alcoholic, polysubstance-dependent, and psychiatric patients.

Association between sweet preference and paternal history of alcoholism in psychiatric and substance abuse patients.

BACKGROUND: The relationship between preference for stronger sweet solutions and propensity to excessive alcohol drinking is supported by both animal and human studies. This study was designed to test the hypothesis that sweet preference is associated with the genetic risk of alcoholism as measured by a paternal history of alcoholism. METHODS: Participants were 180 patients admitted to a residential treatment program for the treatment of alcoholism, drug dependence, or psychiatric conditions. In addition to a routine medical examination, patients completed the standard sweet preference test twice (on the 9th and 24th days after admission), and the family history of alcoholism was evaluated. RESULTS: Sweet preference was shown to be stable over time. It was strongly associated with a paternal history of alcoholism, with family history-positive patients approximately 5 times more likely to prefer stronger sweet solutions than family history-negative subjects. Such factors as dependence on alcohol, cocaine, opiates, cannabis, other drugs (including prescription drugs), and tobacco smoking, as well as demographics (gender and age), did not significantly interfere with association between sweet preference and paternal history of alcoholism. CONCLUSIONS: These findings provide some support for the hypothesis that preference for stronger sweet solutions is associated with a genetic predisposition to alcoholism as measured by a paternal history of alcoholism.

[Rectal, oral and nasal premedication using midazolam in children aged 1-6 years. A comparative clinical study]. / Rektale, orale und nasale Prämedikation mit Midazolam bei Kindern im Alter von 1-6 Jahren. Eine vergleichende klinische Untersuchung.

Midazolam is often used for the premedication of children in the pre-school age group. Different noninvasive routes of administration have been described. In a prospective study we compared the effects of oral, rectal, and nasal midazolam in commonly used dosages. PATIENTS AND METHODS. Ninety children undergoing surgery under general anesthesia were assigned to oral (0.4 mg/kg) (MO), rectal (0.5 mg/kg) (MR), or nasal (0.2 mg/kg) midazolam (MN), according to the child's and/or parent's preferred route of administration, after having obtained the parent's informed consent. It was applied on the ward before transport to the operating room. The following parameters were assessed by the observer and the anesthesiologist at different times: sedation, acceptance (child, anesthesiologist), mood, emotion, resistance, pain, nausea and vomiting, blood pressure, and heart and respiratory rates. The Wilcoxon test (P less than 0.05) was used for statistical analysis. RESULTS. All groups were comparable with respect to age, weight, and surgery experience. There was no difference in the anesthesiologist's acceptance of the premedication or the cooperation of the children. The children accepted MO significantly better compared to MN and MR. The fastest onset of sedation was found after MR. Immediately after MN many children became euphoric, and it turned out that the effect of MN was rather euphoric than sedative. The effect of MO was good in many children, but less predictable. This led to a significant delay in transport to the operating room. MO children experienced more nausea and vomiting (P less than 0.05) in the postoperative period. There were no differences in physiological parameters. DISCUSSION AND CONCLUSIONS. The results can be explained by the different characteristics of absorption and patient acceptance. The route of administration according to the child's or parent's choice can be recommended but does not guarantee success. MR had the fastest onset of sedative action due to faster absorption of the drug. MN had a euphoric effect that resulted almost immediately. Oral premedication was best accepted, nasal administration worst. MO produced more side effects than MR and MN in the postoperative period. If the child accepts the rectal route of administration, this should be preferred because of the high success rate and few side effects.