Mind the past: A systematic review on psychological autopsy.

Psychological Autopsy (PA) has become widespread to the point of being applied in many diverse fields. However, it is difficult to identify a standard model. In this systematic review, we focused on PA studies assessing mental illness as a major risk factor for suicide. The research, performed on Scopus, Embase, and Pubmed to cover the last 20 years led to 321 reports of which 15 met the inclusion criteria. Results confirmed mental illness as the main risk factor for suicide, followed by specific socio-demographic factors and life events. The analysis of methodologies depicted a still highly heterogeneous scenario, especially regarding data collection and variables included. However, concerning psychiatric evaluations, an initial standardization process of PA models emerged. In conclusion, the approach is in evolution, and novel guidelines are needed to promote the application of PA as a fundamental tool to inform suicide prevention efforts and to assist forensic examiners in court.

Machine Learning and Criminal Justice: A Systematic Review of Advanced Methodology for Recidivism Risk Prediction.

Recent evolution in the field of data science has revealed the potential utility of machine learning (ML) applied to criminal justice. Hence, the literature focused on finding better techniques to predict criminal recidivism risk is rapidly flourishing. However, it is difficult to make a state of the art for the application of ML in recidivism prediction. In this systematic review, out of 79 studies from Scopus and PubMed online databases we selected, 12 studies that guarantee the replicability of the models across different datasets and their applicability to recidivism prediction. The different datasets and ML techniques used in each of the 12 studies have been compared using the two selected metrics. This study shows how each method applied achieves good performance, with an average score of 0.81 for ACC and 0.74 for AUC. This systematic review highlights key points that could allow criminal justice professionals to routinely exploit predictions of recidivism risk based on ML techniques. These include the presence of performance metrics, the use of transparent algorithms or explainable artificial intelligence (XAI) techniques, as well as the high quality of input data.

Sleep architecture modifications after double chronotherapy: A case series of bipolar depressed inpatients.

The aim of this study is to objectively evaluate sleep architecture changes of depressed bipolar subjects treated with chronoterapeutics. Eleven depressed bipolar inpatients received 3 cycles of Total Sleep Deprivation, followed by daily light therapy sessions for one week. Polysomnography was performed before and after the treatment. Depressive symptoms significantly reduced, and sleep architecture changed with significant differences in N2% and N3% and REM density. Change in N3% was also positively correlated to depressive symptoms reduction. Although, previous studies reported sleep architecture changes after chronoterapeutics in unipolar depression, this is the first study to demonstrate changes also in bipolar depressed subjects.

Relation of QRS Duration to Response to Cardiac Resynchronization Therapy in Patients With Left Bundle Branch Block.

Left ventricular (LV) dyssynchrony (LVdys) is a necessary condition for successful cardiac resynchronization therapy (CRT). Despite left bundle branch block (LBBB) representing a reliable surrogate of LVdys, not all LBBB patients will respond to CRT. Our aim was to investigate the relation between QRS duration and LVdys in patients with LBBB who underwent CRT. We retrospectively studied 165 patients with LBBB who underwent CRT implantation according to the current guidelines. A 6-month reduction of LV end-systolic volume ≥15% identified responders to CRT. Baseline LVdys was defined as the delay between peak systolic velocities of the interventricular septum and lateral wall assessed by color-coded tissue Doppler imaging. Baseline characteristics of responders (61%) and nonresponders (39%) were comparable except for larger QRS complex (172 ± 24 vs 160 ± 16 ms, p <0.001) and lower degree of LVdys (46 ± 42 vs 72 ± 31 ms, p <0.001) in nonresponders. Receiver-operating characteristic curve analysis demonstrated that an optimal cut-off value of 3 for the ratio of QRS duration and LVdys (QRS/LVdys) yielded a sensitivity of 66% and specificity of 80% to predict nonresponsiveness to CRT; QRS/LVdys >3 remained an independent predictor at multivariate analysis. In patients with nonischemic origin of cardiomyopathy, the linear regression analysis documented a significant inverse relation between QRS duration and LVdys, as dyssynchrony progressively decreased as QRS widening increased (p = 0.006). This was not evident in patients with ischemic origin. In conclusion, in LBBB patients with nonischemic origin and marked QRS widening, the absence of LVdys may account for a lower response to CRT compared with patients with intermediate QRS widening.

Relation of QRS duration to response to cardiac resynchronization therapy.

Left bundle branch block (LBBB) is the most reliable electrocardiographic predictor of responsiveness to cardiac resynchronization therapy (CRT). However, not all patients with LBBB will respond to CRT. Our aim was to investigate the interaction between QRS duration, LBBB-type morphology, and the responsiveness to CRT. We retrospectively analyzed electrocardiograms of 243 patients who underwent CRT implantation according to current clinical indications. A 6-month reduction of left ventricular end-systolic volume >15% was used to identify CRT responders. The clinical end point consisted of death, hospitalization for heart failure and sustained rapid ventricular tachyarrhythmias. An LBBB morphology was present in 169 patients (70%) and 101 of these (60%) were responders to CRT. Analyzing the interaction between QRS duration and CRT responsiveness in patients with LBBB, a "U shaped" distribution resulted, with nonresponders clustered between 120 and 130 ms and above 180 ms. The receiver operating characteristic curve analysis identified 178 ms as the optimal cut-off value of QRS to predict a nonresponsiveness to CRT (area under the curve = 0.67 [95% confidence interval 0.57 to 0.76]). At multivariate analysis, only an ischemic cause and a QRS ≥178 ms were independent predictors of nonresponsiveness to CRT (area under the curve = 0.75). Patients with LBBB with QRS ≥178 ms had greater likelihood of adverse clinical events during a mean follow-up of 32 months (p = 0.049). In conclusion, in patients with LBBB undergoing CRT, a marked QRS widening (i.e., ≥178 ms) is related to worse echocardiographic responsiveness and lower event free survival rate compared with patients with an intermediate QRS widening.

Intravenous administration of flecainide or propafenone in patients with recent-onset atrial fibrillation does not predict adverse effects during 'pill-in-the-pocket' treatment.

BACKGROUND: Pill-in-the-pocket treatment should be prescribed only if the administration of a loading oral dose of flecainide or propafenone has been proved safe in hospital, since major adverse effects have been reported in 5% of patients during in-hospital treatment. However, in emergency rooms, the oral administration of these drugs for the conversion of atrial fibrillation (AF) is very rarely used because it is time consuming. Objective To investigate whether tolerance to intravenous administration of flecainide or propafenone might predict the safety of pill-in-the-pocket treatment-the out-of-hospital self-administration of these drugs after the onset of palpitations-in patients with AF of recent onset. METHODS: One hundred and twenty-two patients with AF of recent onset who were successfully treated (conversion of AF within 2 h without major adverse effects) in hospital with intravenous flecainide or propafenone were discharged on pill-in-the-pocket treatment. RESULTS: During a mean follow-up of 11+/-4 months, 79 patients self-treated 213 arrhythmic episodes; treatment was successful in 201 episodes (94%). Major adverse events occurred in five patients (6%) and in four (5%) of these during the first oral treatment (one syncope, two presyncope, one sinus arrest). No patient reported symptoms attributable to bradyarrhythmia or hypotension during the self-treatment of arrhythmic recurrences when the first oral treatment was not accompanied by any major adverse effects. The study was prematurely terminated because of the high incidence of major adverse effects during the first out-of-hospital treatment. CONCLUSION: The patient's tolerance of intravenous administration of flecainide or propafenone does not seem to predict adverse effects during out-of-hospital self-administration of these drugs.

[Upstream therapy of atrial fibrillation in patients with heart failure]. / Il trattamento "upstream" della fibrillazione atriale nei pazienti con scompenso cardiaco.

Experimental data, results of retrospective studies and of small randomized trials suggest an efficacy of upstream therapy of atrial fibrillation (AF) with angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers, statins and n-3 polyunsaturated fatty acids (PUFA). These drugs seem to act by antagonizing the renin-angiotensin system, inflammation, oxidative stress and endothelial dysfunction, all factors that play an important role in the genesis of the substrate of AF and atrial remodeling. However, the recent Italian GISSI-AF study, which is the first large, multicenter, prospective and randomized trial (valsartan vs placebo) dealing with upstream therapy in the secondary prevention of AF, offered negative results. A trend toward a lower incidence of AF recurrence was apparent only in the valsartan group in patients presenting with heart failure, even if statistical significance was not reached. On the basis of these recent data, we analyzed the contributions offered by the literature on upstream therapy of AF in patients with heart failure in order to evaluate a possible use of this treatment in clinical practice. Six retrospective studies dealing with the primary prevention of AF (3 with ACE-inhibitors/angiotensin receptor blockers and 3 with statins) have been published; in these studies, upstream therapy was constantly effective. A recent meta-analysis, which included trials dealing with the primary prevention of AF with ACE-inhibitors/angiotensin receptor blockers, showed that patients with heart failure benefited the most. Up to now, the contributions on upstream therapy in the secondary prevention of AF in patients with heart failure are very few. These results are still not enough to recommend the clinical use of upstream therapy of AF in patients with heart failure because of the retrospective design of the studies. However, it emerges a background to plan a large-scale prospective, randomized trial on upstream therapy in the primary prevention of AF in patients with heart failure.

Current treatment of recurrent vasovagal syncope: between evidence-based therapy and common sense.

Vasovagal syncope is very frequent and benign and the vast majority of subjects do not need any specific treatment, but only reassurance and education. An unknown but small percentage of patients require specific treatment when syncope is very frequent or is responsible for major trauma. For these patients, there are some evidence-based therapies available and some first-line treatments appear to be established. The therapeutic choice mainly depends on the presence and duration of prodromal symptoms. In subjects aged < 70 years with well recognizable prodromes, the first-line treatment is counterpressure manoeuvres. In patients with no or minimal prodromes, but with tilt testing and carotid sinus massage (CSM) both positive, cardiac pacing appear to be the first-line therapy. However, an area of uncertainty remains, represented by patients with no or minimal prodromes and negative CSM. For these patients, appropriate treatment (drugs, tilt training, cardiac pacing, relaxation-based treatment) can be chosen by considering the clinical context, the risk of trauma and possible comorbidities, in addition to utilizing the little or controversial knowledge available, as well as common sense.

Successful treatment of electrical storm with oral quinidine in Brugada syndrome.

A patient implanted with a cardioverter-defibrillator for symptomatic Brugada syndrome was referred to our hospital 17 months later because of recurrent shocks due to ventricular fibrillation (VF). Isoprenaline was intravenously infused and prevented VF episodes, but VF recurred after every attempt of drug discontinuation. A total of 34 shocks were recorded over 25 days. Subsequently, we treated the patient with oral quinidine and the drug suppressed the electrical storm and prevented VF episodes during a follow-up period of 3 years. This case report, together with few others reported in the literature, suggests a role of oral quinidine in the treatment of electrical storm in Brugada syndrome.

The fusion band in V1: a simple ECG guide to optimal resynchronization? An echocardiographic case report.

BACKGROUND: Patients with left bundle branch block have a preserved right bundle branch conduction and the efficacy of left ventricular pacing could be explained with the fusion between artificial pulse delivered in the left lateral wall and the spontaneous right ventricular activation. Moreover, the efficacy of left ventricular pacing could be enhanced with an optimal timing between the spontaneous right ventricular activation and the left ventricular pulse. CASE PRESENTATION: We evaluated a patient (male, 47 yrs) with surgically corrected mitral regurgitation, sinus rhythm and left bundle branch block, heart failure (NYHA class III) despite medical therapy and low ejection fraction (25%): he was implanted with a biventricular device. We programmed ventricular pacing only through the left ventricular lead. We defined what we called electrocardiographic "fusion band" as follow: programming OFF the stimulator, we recorded the native electrocardiogram and measured, through the device, the intrinsic atrioventricular interval. Then, atrioventricular interval was progressively shortened by steps of 20 ms down to 100 ms. Twelve leads electrocardiogram was recorded at each step. The fusion band is the range of AV intervals at which surface electrocardiogram (mainly in V1 lead) presents an intermediate morphology between the native left bundle branch block (upper limit of the band) and the fully paced right bundle branch block (lower limit). The patient underwent echocardiographic examination at each atrioventricular interval chosen inside the fusion band. The following parameters were evaluated: ejection fraction, diastolic filling time, E wave deceleration time, aortic velocity time integral and myocardial performance index. All the echocardiographic parameters showed an improvement inside the fusion band, with a "plateau" behaviour. As the fusion band in this patient ranged from an atrioventricular delay of 200 ms to an atrioventricular delay of 120 ms, we chose an intermediate atrioventricular delay of 160 ms, presuming that this might guarantee the persistence of fusion even during any possible physiological (autonomic, effort) atrioventricular conduction variation. CONCLUSION: In this heart failure patient with left bundle branch block, tailoring of the atrioventricular interval resynchronized myocardial contraction with left ventricular pacing alone, utilizing a sensed right atrial activity and the surface electrocardiographic pattern.

Antiarrhythmic drugs in patients with recurrent atrial fibrillation: where are we?

In patients with recurrent atrial fibrillation (AF), the hallmark of treatment has long been the use of antiarrhythmic drugs. The following strategies are available: a) any antiarrhythmic treatment; b) out-of-hospital episodic treatment ("pill-in-the-pocket" approach); c) prophylactic antiarrhythmic therapy; and d) hybrid therapy. The following patients with recurrent AF should not undergo any antiarrhythmic therapy: after the first AF episode; patients with rare, hemodynamically well-tolerated and short-lasting (a few hours) AF episodes; patients with perioperative AF, without history of recurrent AF; patients with AF during acute myocardial infarction or other acute diseases, without history of recurrent AF; and "holiday heart" syndrome. In patients with infrequent AF episodes (< 1 per month) and hemodynamically well-tolerated, but long enough to require emergency room intervention or hospitalization, a good treatment might be the "pill-in-the-pocket" approach, consisting of a single-dose oral ingestion of flecainide or propafenone at the time and place of palpitation onset. A recent Italian study has shown that this treatment is effective and safe. When AF episodes are frequent and/or hemodynamically badly tolerated, the treatment of choice is the prophylactic therapy with antiarrhythmic drugs. When these drugs fail (ineffective or not tolerated) a non-pharmacological treatment or a hybrid therapy may be indicated.

Feasibility and safety of noninvasive pacemaker stress echocardiography with externally triggered stimulation.

The aim of this study was to assess the feasibility and safety of stress echocardiography by triggering an implanted pacemaker through an external stimulator. The implanted pacemaker was set in triggered mode with unipolar sensitivity of <2 mV. The external stimulator, connected to 2 skin electrodes, tracked the implanted pacemaker at increasing rates. Fifteen patients (mean age 65 +/- 8 years) with suspected coronary artery disease entered the study, and complete tests were performed in all patients. No adverse effects were reported. The method of externally triggered stimulation is feasible, safe, and allows a diagnosis in every patient with a pacemaker without additional cost.

Sexual activity with and without the use of sildenafil: risk of cardiovascular events in patients with heart disease.

The data in the literature on the relationship between sexual activity, with and without the use of sildenafil, and the occurrence of cardiovascular events (ventricular arrhythmias, nonfatal myocardial infarction, stroke and death) have been reviewed in patients with heart disease. To date, only patients with ischemic heart disease (IHD) have been investigated. The prevalence of premature ventricular beats during sexual intercourse is similar to that observed during other daily activities. Therefore, sexual activity does not seem to have a relevant arrhythmogenic effect. The incidence of sustained ventricular tachycardia during sexual intercourse in unknown. The relative risk of nonfatal myocardial infarction is 2.7 in males and 1.3 in females; however, the absolute risk appears extremely low and is similar in normal subjects and in patients with and without IHD. The risk appears to be restricted to the 2-hour time period after sexual intercourse. The incidence of stroke during sexual intercourse appears very low, but clear data are lacking. The incidence of death during sexual activity is unknown; the few available data suggest that it is very low. Extramarital sexual intercourse seems to increase the risk of death. The incidence of cardiovascular events after sildenafil administration has been investigated in placebo-controlled studies in patients with IHD. The incidence of nonfatal myocardial infarction, stroke and death did not significantly differ between sildenafil-treated and placebo-treated patients; therefore, sildenafil does not appear contraindicated in subjects with IHD. However, the drug should be administered with caution in patients with recent myocardial infarction or stroke, in those with active coronary ischemia and in patients with episodes of heart failure. The drug is absolutely contraindicated in patients using nitrates.