Diagnosis and management of patients who present with narrow complex tachycardia in the emergency department.

INTRODUCTION: While narrow complex tachycardia (NCT) is a common presentation to the emergency department (ED), little is known about its incidence in the ED or about emergency physician expertise in its diagnosis and management. We sought to compare cases of NCT due to primary arrhythmias to those with a rapid heart rate secondary to a medical issue, as well as to determine the accuracy of ED physician diagnosis and appropriateness of treatment. METHODS: We conducted a health records review at a large academic hospital ED staffed by 95 physicians and included consecutive adult patients over 7 months (2020-2021) with NCT (heart rate ≥ 130 bpm and QRS < 120 ms). Cases were reviewed for accuracy of ECG diagnosis and for correctness of treatment as per guidelines by an adjudication committee. RESULTS: We identified 310 ED visits (0.8% of all ED visits), mean age 65.1 years, 52.6% female. Primary arrhythmias accounted for 54.8%. ED physicians correctly interpreted 86.6% of ECGs. The most common arrhythmias and accuracy of ED physician ECG interpretation were atrial fibrillation 44.5% (95.1%), sinus tachycardia 24.2% (90.5%), atrial flutter 15.8% (61.5%), and supraventricular tachycardia (SVT) 12.9% (81.6%). Treatments were judged optimal in 96.5% of primary NCT and 99.3% in secondary NCT. Treatments were suboptimal for failure to reduce heart rate < 100 bpm prior to discharge in 2.1% of primary cases and failure to treat underlying cause in 0.7% of secondary cases. CONCLUSION: NCT was found in 0.8% of all ED visits, with more being primary NCT. ED physicians correctly interpreted 86.6% of ECGs but had difficulty differentiating atrial flutter and SVT. They implemented appropriate care in most cases but sometimes failed to adequately control heart rate or to treat the underlying condition, suggesting opportunities to improve care of NCT in the ED.

RéSUMé: INTRODUCTION: Bien que la tachycardie à complexe QRS étroite (narrow complex tachycardia [NCT]) soit une présentation courante au service des urgences (SU), on sait peu de choses sur son incidence dans le SU ou sur l'expertise des médecins urgentistes dans son diagnostic et sa prise en charge. Nous avons cherché à comparer les cas de NCT dus à des arythmies primaires à ceux avec une fréquence cardiaque rapide secondaire à un problème médical, ainsi que pour déterminer l'exactitude du diagnostic de médecin ED et la pertinence du traitement. MéTHODES: Nous avons effectué un examen des dossiers médicaux dans les urgences d'un grand hôpital universitaire où travaillent 95 médecins et avons inclus des patients adultes consécutifs sur 7 mois (2020-2021) présentant une NCT (fréquence cardiaque ≥ 130 bpm et QRS < 120 ms). Les cas ont été examinés par un comité d'adjudication pour vérifier l'exactitude du diagnostic ECG et la justesse du traitement conformément aux directives. RéSULTATS: Nous avons recensé 310 visites aux urgences (0,8 % de toutes les visites aux urgences), l'âge moyen étant de 65,1 ans, 52,6 % de femmes. Les arythmies primaires représentaient 54,8 %. Les médecins urgentistes ont correctement interprété 86,6 % des ECG. Les arythmies les plus fréquentes et la précision de l'interprétation de l'ECG par le médecin de l'urgence étaient la fibrillation auriculaire 44,5 % (95,1 %), la tachycardie sinusale 24,2 % (90,5 %), le flutter auriculaire 15,8 % (61,5 %) et la tachycardie supraventriculaire (TSV) 12,9 % (81,6 %). Les traitements ont été jugés optimaux dans 96,5 % des NCT primaires et 99,3 % des NCT secondaires. Les traitements étaient sous-optimaux en raison de l'incapacité à réduire la fréquence cardiaque < 100 bpm avant la sortie de l'hôpital dans 2,1 % des cas primaires et de l'incapacité à traiter la cause sous-jacente dans 0,7 % des cas secondaires. CONCLUSION: Une NCT a été constatée dans 0,8 % de toutes les visites aux urgences, la plupart étant des NCT primaires. Les médecins des services d'urgence ont interprété correctement 86,6 % des ECG mais ont eu des difficultés à différencier le flutter auriculaire et la TSV. Ils ont mis en œuvre des soins appropriés dans la plupart des cas, mais n'ont parfois pas réussi à contrôler adéquatement la fréquence cardiaque ou à traiter l'affection sous-jacente, ce qui laisse entrevoir des possibilités d'améliorer la prise en charge des NCT aux urgences.

Diagnosis and management of wide complex tachycardia in the emergency department.

INTRODUCTION: While wide complex tachycardia (WCT) is potentially lethal, little is known about its incidence in the ED or about expertise of ED physicians in diagnosing and treating it. We sought to compare WCT ED cases that were primary arrhythmias versus those with rapid heart rate secondary to medical issues, as well as the accuracy of ED diagnosis and appropriateness of treatment. METHODS: We conducted a health records review at a large academic hospital ED staffed by 95 physicians and included consecutive patients over 28 months (2018-2020) with WCT (heart rate ≥ 120 bpm and QRS ≥ 120 ms). Cases were adjudicated for the accuracy of ECG diagnosis versus the cardiology read and for correctness of treatment as per guidelines by two ED physicians and one cardiologist. RESULTS: We identified 306 eligible cases (0.2% of all ED visits): mean age 73.9 years, male 66.0%, admitted 53.3%, died in ED 2.3%. Primary arrhythmias and secondary tachycardias were each 50.0% (95% CI 44.4-55.6%). ED physicians correctly interpreted 81.2% of ECGs. The most common presenting arrythmias and % correct were: atrial fibrillation 42.7% (95.0%), atrial flutter 22.2% (63.5%), sinus tachycardia 12.0% (78.6%), and supraventricular tachycardia (SVT) 11.1% (68.0%). Treatments were judged optimal in 84.3% of primary WCT and 86.9% in secondary WCT. Treatments were suboptimal for: inappropriate drug (3.9% for primary versus 1.3% for secondary), failure to reduce heart rate < 100 prior to discharge home (9.1% for primary versus 34.4% for secondary), and not treating the underlying cause in 5.9% of secondary WCT. CONCLUSIONS: WCT cases were evenly split between primary arrhythmias and secondary cases. ED physicians interpreted the ECG correctly in 81% but over-called atrial flutter and SVT. They implemented appropriate care in most cases but sometimes failed to adequately control heart rate or to treat the underlying condition, suggesting opportunities to improve care of WCT in the ED.

RéSUMé: INTRODUCTION: Bien que la tachycardie à complexe large (wide complex tachycardia WCT) soit potentiellement mortelle, on sait peu de choses sur son incidence aux urgences ou sur l'expertise des médecins des urgences en matière de diagnostic et de traitement. Nous avons cherché à comparer les cas WCT aux urgences qui étaient des arythmies primaires par rapport à ceux avec une fréquence cardiaque rapide secondaire à des problèmes médicaux, ainsi que la précision du diagnostic des urgences et la pertinence du traitement. MéTHODES: Nous avons effectué un examen des dossiers médicaux dans les urgences d'un grand hôpital universitaire où travaillent 95 médecins et avons inclus des patients consécutifs sur 28 mois (2018-2020) présentant un WCT (fréquence cardiaque ≥120 bpm et QRS ≥120 ms). Les cas ont été jugés par deux médecins des urgences et un cardiologue pour l'exactitude du diagnostic ECG par rapport à la lecture cardiologique et pour l'exactitude du traitement conformément aux directives. RéSULTATS: Nous avons identifié 306 cas éligibles (0,2 % de toutes les visites aux urgences) : âge moyen 73,9 ans, hommes 66,0 %, admis 53,3 %, décédés aux urgences 2,3 %. Les arythmies primaires et les tachycardies secondaires étaient chacune de 50,0 % (IC 95 % 44,4-55,6 %). Les médecins des urgences ont interprété correctement 81,2 % des ECG. Les arythmies les plus fréquentes et les pourcentages d'interprétation correcte étaient les suivants : fibrillation auriculaire 42,7 % (95,0 %), flutter auriculaire 22,2 % (63,5 %), tachycardie sinusale 12,0 % (78,6 %) et tachycardie supraventriculaire (TSV) 11,1 % (68,0 %). Les traitements ont été jugés optimaux dans 84,3 % des WCT primaires et 86,9 % des WCT secondaires. Les traitements étaient sous-optimaux pour les raisons suivantes : médicament inapproprié (3,9 % pour le primaire contre 1,3 % pour le secondaire), incapacité à réduire la fréquence <100 avant le retour à domicile (9,1 % pour le primaire contre 34,4 % pour le secondaire) et absence de traitement de la cause sous-jacente dans 5,9 % du WCT secondaire. CONCLUSIONS: Les cas de WCT étaient répartis uniformément entre les arythmies primaires et les cas secondaires. Les médecins du service d'urgence ont correctement interprété l'ECG dans 81 % des cas, mais ont surévalué le flutter auriculaire et la TSV. Ils ont mis en œuvre des soins appropriés dans la plupart des cas, mais n'ont pas toujours réussi à contrôler adéquatement la fréquence cardiaque ou à traiter la maladie sous-jacente, ce qui laisse entrevoir des possibilités d'améliorer les soins de WCT au service d'urgence.

Primary Sertoli Cell Cultures From Adult Mice Have Different Properties Compared With Those Derived From 20-Day-Old Animals.

Cultures of Sertoli cells isolated from 20-day-old mice are widely used in research as substitutes for adult Sertoli cell cultures. This practice is based on the fact that Sertoli cells cease to proliferate and become mature in vivo by 16 to 20 days after birth. However, it is important to verify whether cultured Sertoli cells derived from 20-day-old mice do not proliferate ex vivo and whether they have the same properties as cultured adult Sertoli cells. Herein we described an isolation/culture method of Sertoli cells from 10-week-old adult mice with > 90% purity. Properties of these cultured adult Sertoli cells were then compared with those of cultured Sertoli cells derived from 20-day-old mice (also > 90% purity). By cell counting, bromo-2-deoxyuridine incorporation, and metaphase plate detection, we demonstrated that only adult Sertoli cells did not proliferate throughout 12 culture days. In contrast, Sertoli cells derived from 20-day-old mice still proliferated until Day 10 in culture. The morphology and profiles of intracellular lipidomics and spent medium proteomics of the 2 cultures were also different. Cultured adult Sertoli cells were larger in size and contained higher levels of triacylglycerols, cholesteryl esters, and seminolipid, and the proteins in their spent medium were mainly engaged in cellular metabolism. In contrast, proteins involved in cell division, including anti-Mullerian hormone, cell division cycle protein 42 (CDC42), and collagen isoforms, were at higher levels in Sertoli cell cultures derived from 20-day-old mice. Therefore, cultured Sertoli cells derived from 10-week-old mice, rather than those from 20-day-old animals, should be used for studies on properties of adult Sertoli cells.

Properties, metabolism and roles of sulfogalactosylglycerolipid in male reproduction.

Sulfogalactosylglycerolipid (SGG, aka seminolipid) is selectively synthesized in high amounts in mammalian testicular germ cells (TGCs). SGG is an ordered lipid and directly involved in cell adhesion. SGG is indispensable for spermatogenesis, a process that greatly depends on interaction between Sertoli cells and TGCs. Spermatogenesis is disrupted in mice null for Cgt and Cst, encoding two enzymes essential for SGG biosynthesis. Sperm surface SGG also plays roles in fertilization. All of these results indicate the significance of SGG in male reproduction. SGG homeostasis is also important in male fertility. Approximately 50% of TGCs become apoptotic and phagocytosed by Sertoli cells. SGG in apoptotic remnants needs to be degraded by Sertoli lysosomal enzymes to the lipid backbone. Failure in this event leads to a lysosomal storage disorder and sub-functionality of Sertoli cells, including their support for TGC development, and consequently subfertility. Significantly, both biosynthesis and degradation pathways of the galactosylsulfate head group of SGG are the same as those of sulfogalactosylceramide (SGC), a structurally related sulfoglycolipid important for brain functions. If subfertility in males with gene mutations in SGG/SGC metabolism pathways manifests prior to neurological disorder, sperm SGG levels might be used as a reporting/predicting index of the neurological status.