Parents' and healthcare professionals' experiences of care after stillbirth in low- and middle-income countries: a systematic review and meta-summary.

BACKGROUND: Stillbirth has a profound impact on women, families, and healthcare workers. The burden is highest in low- and middle-income countries (LMICs). There is need for respectful and supportive care for women, partners, and families after bereavement. OBJECTIVE: To perform a qualitative meta-summary of parents' and healthcare professionals' experiences of care after stillbirth in LMICs. SEARCH STRATEGY: Search terms were formulated by identifying all synonyms, thesaurus terms, and variations for stillbirth. Databases searched were AMED, EMBASE, MEDLINE, PsychINFO, BNI, CINAHL. SELECTION CRITERIA: Qualitative, quantitative, and mixed method studies that addressed parents' or healthcare professionals' experience of care after stillbirth in LMICs. DATA COLLECTION AND ANALYSIS: Studies were screened, and data extracted in duplicate. Data were analysed using the Sandelowski meta-summary technique that calculates frequency and intensity effect sizes (FES/IES). MAIN RESULTS: In all, 118 full texts were screened, and 34 studies from 17 countries were included. FES range was 15-68%. Most studies had IES 1.5-4.5. Women experience a broad range of manifestations of grief following stillbirth, which may not be recognised by healthcare workers or in their communities. Lack of recognition exacerbates negative experiences of stigmatisation, blame, devaluation, and loss of social status. Adequately developed health systems, with trained and supported staff, are best equipped to provide the support and information that women want after stillbirth. CONCLUSIONS: Basic interventions could have an immediate impact on the experiences of women and their families after stillbirth. Examples include public education to reduce stigma, promoting the respectful maternity care agenda, and investigating stillbirth appropriately. TWEETABLE ABSTRACT: Reducing stigma, promoting respectful care and investigating stillbirth have a positive impact after stillbirth for women and families in LMICs.

Transoesophageal echocardiography: its role in the management of patients in a district general hospital.

The aim of this study was to assess the value of a transoesophageal echocardiography (TOE) service in a district general hospital (DGH). A series of 151 consecutive cases was analysed retrospectively to determine the relative additional benefit of TOE over transthoracic echocardiography (TTE) in establishing diagnoses and making therapeutic decisions. Of the 151 cases, 140 were suitable for the two procedures to be compared. In 56%, TOE provided useful information for patient management. This consisted of the detection of new major findings (33%) and the exclusion of significant abnormalities (23%), suspected either clinically or by TTE. TOE made a minor clinical contribution in 8% of cases, while in 30% there was concordance between the two studies. Finally, in 6% both examinations were inconclusive. We conclude that TOE has a significant complementary role to TTE in terms of clinical diagnosis and patient management in the DGH setting.

Effect of flecainide on atrial and ventricular refractoriness and conduction in patients with normal left ventricle. Implications for possible antiarrhythmic and proarrhythmic mechanisms.

We studied the effects of intravenous flecainide (2 mg.kg-1) on atrial and ventricular refractoriness and conduction during sinus rhythm, induced atrial fibrillation and atrial pacing at rates of 100, 120 and 150 ppm, in 14 patients with normal left ventricle. Flecainide caused a significant increase in QRS duration during sinus rhythm (mean +/- SD: 87.2 +/- 8.4 ms vs 102.8 +/- 9.1 ms, P < 0.001), atrial fibrillation (87.8 +/- 10.0 ms vs 108.8 +/- 13.7 ms, P < 0.001) and at all paced rates. The duration of the atrial electrogram was significantly increased during sinus rhythm (54.9 +/- 13.2 ms vs 64.8 +/- 16.6 ms, P = 0.003) and at all pacing rates. The PA interval was also significantly prolonged, as was the pacing stimulus-to-atrial-electrogram interval at all pacing rates. There was increased QRS duration and atrial electrogram prolongation at higher pacing rates. Atrial refractoriness was prolonged during sinus rhythm (216.4 +/- 28.2 vs 228.6 +/- 36.1, P = 0.02), but not during atrial pacing at any rate. The QT interval, but not the JT interval or ventricular refractoriness, was significantly prolonged during sinus rhythm and at all pacing rates. Flecainide slows atrial conduction in a use dependent manner and increases atrial refractoriness during sinus rhythm but not during faster atrial pacing, thus not displaying a use-dependent effect. QRS duration is prolonged in a use-dependent manner without a commensurate increase in ventricular refractoriness. In the presence of rapidly conducted atrial fibrillation, which was not found to be slowed by flecainide, this effect may constitute a proarrhythmic mechanism even in patients with no apparent myocardial abnormality.

Differences in autonomic nerve function in patients with silent and symptomatic myocardial ischaemia.

BACKGROUND: Autonomic neuropathy provides a mechanism for the absence of symptoms in silent myocardial ischaemia, but characterisation of the type of neuropathy is lacking. AIM: To characterise and compare autonomic nerve function in patients with silent and symptomatic myocardial ischaemia. METHODS AND RESULTS: The Valsalva manoeuvre, heart rate variation (HRV) in response to deep breathing and standing, lower body negative pressure, isometric handgrip, and the cold pressor test were performed by patients with silent (n = 25) and symptomatic (n = 25) ambulatory ischaemia and by controls (n = 21). No difference in parasympathetic efferent function between patients with silent and symptomatic ischaemia was recorded, but both had significantly less HRV in response to standing than the controls (p < 0.005 for silent and p < 0.01 for symptomatic). Patients with silent ischaemia showed an increased propensity for peripheral vasodilatation compared with symptomatic patients (p < 0.02) and controls (p < 0.04). Impaired sympathetic function was found in patients with pure silent ischaemia (n = 4) compared with the remaining patients with silent ischaemia whose pain pathways were presumed to be intact. CONCLUSIONS: Patients with silent ischaemia and pain pathways presumed to be intact have an enhanced peripheral vasodilator response, and if this applied to the coronary vasculature it could provide a mechanism for limiting ischaemia to below the pain threshold. Patients with pure silent ischaemia have evidence of sympathetic autonomic dysfunction.

Pathophysiology of supraventricular tachycardia.

Supraventricular tachycardia is due to altered automaticity, triggered activity or most commonly, reentry. Atrial flutter is most frequently due to reentry with counterclockwise activation in the right atrium with the left atrium acting as a bystander. The small wavefronts demonstrated during atrial fibrillation are less random than was previously thought. In the study of atrioventricular (AV) nodal reentrant tachycardia, recent evidence suggests that multiple pathways involving intranodal and perinodal tissue are probably involved. In the Wolff-Parkinson-White (WPW) syndrome, accessory pathways near the AV node have been demonstrated with decremental properties, suggesting conduction through accessory AV nodal tissue. The mechanism for atrial fibrillation in the WPW syndrome is poorly understood, but there is evidence that accessory pathways are branched and may themselves support micro-reentry. In Mahaim nodoventricular pathways, the atrium is not essential for reentry, unlike atriofascicular reentrant circuits. Atriofascicular pathways consist of AV node-like tissue and are usually located in the right atrial free wall.

Regional sympathetic innervation of the heart by means of metaiodobenzylguanidine imaging in silent ischemia.

Metaiodobenzylguanidine was used to determine regional cardiac sympathetic innervation and whether it is reduced in silent ischemia. Patients with silent ischemia (group 1, n = 6) and angina (group 2, n = 5) and normal subjects (n = 6) underwent single-photon emission tomography at 4 hours. From base to midventricle, uptake increased in group 1 (p < 0.006), group 2 (p < 0.01), and the normal subjects (p < 0.004). In group 1 anterior ventricular uptake was greater than inferior uptake at the midventricle (p < 0.03) and apex (p < 0.05). In group 2 the same relationship was demonstrated at midventricle (p < 0.01) and apex (p < 0.05). Group 2 uptake was only significantly greater than group 1 at midventricle (p < 0.05). Innervation is greatest in midventricle and the apex of the left ventricle and greater in the anterior wall compared with the inferior wall. There is no evidence of reduced innervation in silent ischemia.

New and combined sensors for adaptive-rate pacing.

A new potential indication for cardiac pacing is chronotropic incompetence, that is, an inadequate cardiac rate response to exercise and other metabolic demands. Many patients who have been paced for indications such as complete heart block or sick sinus syndrome also have chronotropic incompetence. Such patients are not adequately treated when fitted with a constant rate pacemaker. Adaptive-rate pacemakers increase the pacing rate in proportion to signals derived from a biosensor which is sensitive to exertion and possibly to other metabolic requirements. These pacemakers have proven valuable for patients with overt chronotropic incompetence. However, no single sensor/algorithm is ideal and improvement has been sought by introducing new sensors, adjusting the algorithms by which biosensor signals are converted to the most appropriate pacing rate, or by combining sensors in such a way that a composite biosensor signal is derived which bears a close linear relationship with the appropriate heart rate. An example of a new sensor is the accelerometer, which is sensitive to a fuller range of movements than the piezo crystal. A successful new algorithm is the rate augmentation algorithm for use with minute ventilation, which provides a better initial pacing rate response. A combination of minute ventilation sensed by impedance changes and movement sensed with piezo crystals maintains the rapid response from the piezo crystal and overcomes its lack of proportionality. Another successful new combination of sensors is QT sensing from the evoked ventricular potential and motion sensing with a piezo crystal. As yet, these innovations have not been exhaustively tested and shown to confer clinical benefit but the improvements are such that an advantage can be expected.

Arrhythmia and hypertrophic cardiomyopathy.

Atrial fibrillation is the commonest arrhythmia observed in hypertrophic cardiomyopathy, and is associated with an acute deterioration in symptoms. Digoxin is the drug of choice in established atrial fibrillation and amiodarone the drug of choice in paroxysmal atrial fibrillation and ventricular arrhythmia. Non-sustained ventricular tachycardia occurs in 20% of patients and is the single best predictor of sudden death in adults. Sustained monomorphic ventricular tachycardia occurs only rarely. The mechanism of sudden death is likely to involve initiating factors such as arrhythmia and peripheral autonomic dysfunction causing haemodynamic instability and myocardial ischaemia. Myocardial disarray may provide the arrhythmogenic substrate such that haemodynamic instability and ischaemia results in ventricular fibrillation and sudden death.

Is angiographic ventriculography necessary for the assessment of ischemic patients?

A total of 53 patients with a provisional diagnosis of ischemic heart disease and without any clinical evidence of valvular, congenital, or primary muscle heart disease were studied by echocardiography and biplane left ventricular cineangiography. For angiographic ejection fraction analysis, a program developed in our department for use on an Apple Macintosh computer interfaced to a digitizing tablet was employed. Echocardiographic outlines of systolic and diastolic images were traced with a digitizing system on the screen and ejection fractions were calculated by a program incorporated in the echo machine. Good echo windows allowing ejection fraction calculations were present in 35 patients. There was a good correlation between angiographic and echocardiographic ejection fraction (r = 0.7, SEE = 0.09), and wall motion assessment revealed no significant discrepancies between the two image modalities. The remaining 18 patients had poor echo windows, preventing accurate echocardiographic determination of the ejection fraction. However, limited assessment of left ventricular size and wall motion was possible in all patients and allowed the identification of those who had impaired left ventricular function as judged by angiography (angiographic ejection fraction < 35%). We conclude that even in patients with poor echo windows echocardiographic assessment of left ventricular function provides clinical information similar to angiography which should not be considered mandatory for the investigation of ordinary ischemic patients.

Benefits of the advances in cardiac pacemaker technology.

Pacemaker technology has expanded rapidly in the last thirty years. Each phase of development has been marked by both improvements in clinical benefit and disadvantageous interactions of physiology and technology. Each phase of development has led to smaller, more reliable devices with greater programmability. Advances in generator technology and battery design have increased longevity of devices. The first devices used asynchronous pacing which had a significant effect in reducing the mortality of surgically induced complete heart block. Ventricular demand pacemakers overcame the problems of asynchronous competitive pacing, but exposed the pacemaker syndrome. Atrioventricular sequential pacing restored atrioventricular synchrony, resulting in hemodynamic improvement, but created the phenomenon of pacemaker-mediated tachycardia. Alternative dual chamber modes and algorithms have largely resolved this. Adaptive-rate devices have been of benefit to patients with chronotropic incompetence, and are now incorporating an increasing variety of biosensors. Almost all the problems of pacing have been overcome, but the increasing complexity of pacemaker technology is now a major limitation to its proper use.