Unmappable ventricular tachycardia after an old myocardial infarction. Long-term results of substrate modification in patients with an implantable cardioverter defibrillator.

PURPOSE: The frequent occurrence of ventricular tachycardia can create a serious problem in patients with an implantable cardioverter defibrillator. We assessed the long-term efficacy of catheter-based substrate modification using the voltage mapping technique of infarct-related ventricular tachycardia and recurrent device therapy. METHODS: The study population consisted of 27 consecutive patients (age 68 ± 8 years, 25 men, mean left ventricular ejection fraction 31 ± 9%) with an old myocardial infarction and multiple and/or hemodynamically not tolerated ventricular tachycardia necessitating repeated device therapy. A total of 31 substrate modification procedures were performed using the three-dimensional electroanatomical mapping system. Patients were followed up for a median of 23.5 (interquartile range 6.5-53.2) months before and 37.8 (interquartile range 11.7-71.8) months after ablation. Antiarrhythmic drugs were not changed after the procedure, and were stopped 6 to 9 months after the procedure in patients who did not show ventricular tachycardia recurrence. RESULTS: Median ventricular tachycardias were 1.6 (interquartile range 0.7-6.7) per month before and 0.2 (interquartile range 0.00-1.3) per month after ablation (P = 0.006). Nine ventricular fibrillation episodes were registered in seven patients before and two after ablation (P = 0.025). Median antitachycardia pacing decreased from 1.6 (interquartile range 0.01-5.5) per month before to 0.18 (interquartile range 0.00-1.6) per month after ablation (P = 0.069). Median number of shocks decreased from 0.19 (interquartile range 0.04-0.81) per month before to 0.00 (interquartile range 0.00-0.09) per month after ablation (P = 0.001). One patient had a transient ischemic attack during the procedure, and another developed pericarditis. Nine patients died during follow-up, eight patients due to heart failure and one patient during valve surgery. CONCLUSION: Catheter-based substrate modification using voltage mapping results in a long-lasting reduction of cardioverter defibrillator therapy in patients with multiple and/or hemodynamically not tolerated infarct-related ventricular tachyarrhythmia.

Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care.

OBJECTIVE: To test whether a disclosure intervention improves subjective health and reduces medical consumption and sick leave in somatising patients in general practice. DESIGN: Non-blind randomised controlled trial. SETTING: 10 general practices in the Netherlands. PARTICIPANTS: 161 patients who frequently attended general practice with somatising symptoms. INTERVENTION: Patients in the intervention group were visited two to three times and invited to disclose emotionally important events in their life. Control patients received normal care from their general practitioners. MAIN OUTCOME MEASURES: Use of medical services (drugs and healthcare visits), subjective health, and sick leave assessed by self completion questionnaires after 6, 12, and 24 months. RESULTS: Of the 161 patients, 137 completed the trial (85%). Both groups were comparable at baseline. The intervention had no effect on the main outcome measures at any point. Intervention patients made one more visit to health care (95% confidence interval -4 to 6); the use of medicines did not change in both groups (-1 to 1); subjective health improved 3.6 points more in the control group (-11.2 to 4.3); and disclosure patients were on sick leave one more week (-1 to 3). Patients often had a depression or anxiety disorder for which they were not receiving adequate care. CONCLUSION: Although the intervention was well received by patients and doctors, disclosure had no effect on the health of somatising patients in general practice.

Indicators of childhood adversity in somatisation in general practice.

OBJECTIVE: To identify medical and psychosocial indicators of childhood adversity in somatising patients in primary care. DESIGN: Retrospective questionnaires and interviews. SETTING: Primary health care in The Netherlands. SUBJECTS: Three-hundred-and-seventy-four somatising frequent attenders in 27 general practices between 20 and 45 years of age. MAIN OUTCOME MEASURES: Major problems in childhood. RESULTS: The questionnaire on childhood problems reflected acceptable validity against a structured interview in 77 patients (correlation 0.69); however, the item "abuse" was underreported in the questionnaire. Four out of five patients reported one or more major childhood problems. Childhood adversity was indicated independently by chronic difficulties in present relations and by genital-sexual symptoms of patients. CONCLUSION: When GPs want to take a more active approach towards somatisers they may show interest in the childhood and life story of patients, especially when patients are known with chronic difficulties in relations and genital-sexual symptoms.

Somatisation in primary care: clinical judgement and standardised measurement compared.

BACKGROUND: In daily practice general practitioners (GPs) generally rely on their clinical judgement in assessing whether patients somatise distress. Nevertheless, conclusions derived from research on somatisation in primary care are largely based on standardised measurements of somatisation. We investigated the relation between GPs' clinical judgement of somatisation and a somatisation research instrument (DSM-III-R), and examined how both operationalisations of somatisation related to other important variables. METHODS: In nine general practices, 407 frequently attending patients answered a questionnaire on somatisation symptoms, while the GPs gave their judgement on somatisation and communication for each patient. Other variables were extracted from the registered health status of the patients. RESULTS: We found a weak association (correlation: 0.27) between the GPs' judgement and the research instrument; however, relations with other variables showed that both operationalisations were very similar constructs. The research instrument incorporated more psychological problems (depression and anxiety), while the GPs' judgement of somatisation was more influenced by attendance rate and by aspects of communication with the patient. CONCLUSION: For research addressing somatisation in primary care as a practical clinical problem, the operationalisation of somatisation should include the clinical judgement of the practitioner as well, thereby widening the focus from co-morbid mental disturbances to communication aspects.

A troubled youth: relations with somatization, depression and anxiety in adulthood.

BACKGROUND: Childhood experiences profoundly affect later functioning as an adult. Family practitioners are well-placed to discover the links between childhood troubles and later somatization, depression or anxiety. OBJECTIVES: We aimed to study the interrelation of somatization, depressive and anxiety disorders in frequently attending patients in general practice; to investigate whether these problems are related to a childhood history of illness experiences, deprivation, life events and abuse; and to determine the independent contributions of these childhood factors to the prediction of adult somatization, depressive and anxiety disorders. METHODS: One hundred and six adult general practice patients with high consultation frequency were studied. Somatization was operationalized as a more comprehensive version of DSM-III-R somatization disorder (5 complaints; SSI 5/5). For depression (ever depressive and/or dysthymic) and anxiety (panic, phobias and/or generalized anxiety) DSM-III-R criteria were used. Using a structured questionnaire we assessed illness experiences, deprivation of parental care, abuse (sexual/physical) and other life events before age 19. RESULTS: The overlap between somatization, depression and anxiety was largely accounted for by 16 patients with a triple problem: somatization and depression and anxiety. Somatization was specifically related to deprivation, depression to other life events. Abuse (prevalence 16%) independently predicted psychiatric problems in general. Youth experiences before age 12 were most important. CONCLUSIONS: The high prevalence of triple problems suggests a need to reconsider concepts like somatic anxiety and anxious depression. The specificity of the relation between deprivation and somatization and of the relation between other life events and depression indicates that distinct causal mechanisms (in youth) contribute to these problems.

Somatization in frequent attenders of general practice.

The DSM-III-(R) definition of somatization disorder is too restrictive for use in general practice. A more comprehensive definition, the "somatic symptom index" (SSI) has shown good validity in open populations. However, a definition has to differentiate validly within a population of frequent attenders to be a useful diagnostic instrument in general practice. We studied a threshold of five complaints (nearly identical to the SSI) in 80 Dutch general practice patients. Patients were selected on age (20-44 years), history of back, neck or abdominal complaints, and on frequency of consultation- at least 12 consultations in the previous 3 years, corrected for consultations with compelling somatic reason for encounter. Prevalence of somatization in this group was 45%. Women had a 2 times higher risk of somatization. A relation with age was not found. Somatization was related to depressive complaints (relative risk 2.5) and probably also to anxiety. Somatizing patients consulted their general practitioner more often and had more health problems (especially psychic problems) than non-somatizers. These results support the validity of this definition. The distinction between our definition of somatization and somatization defined as a symptom of psychiatric (e.g. depressive or anxiety) disorder is emphasized.