Patient barriers to implantable cardioverter defibrillator implantation for the primary prevention of sudden cardiac death in patients with heart failure and reduced ejection fraction

<p><b>INTRODUCTION</b>Device therapy is efficacious in preventing sudden cardiac death (SCD) in patients with reduced ejection fraction. However, few who need the device eventually opt to undergo implantation and even fewer reconsider their decisions after deliberation. This is due to many factors, including unresolved patient barriers. This study identified the factors that influenced patients' decision to decline implantable cardioverter defibrillator (ICD) implantation, and those that influenced patients who initially declined an implant to reconsider having one.</p><p><b>METHODS</b>A single-centre survey was conducted among 240 patients who had heart failure with reduced ejection fraction and met the ICD implantation criteria, but had declined ICD implantation.</p><p><b>RESULTS</b>Participants who refused ICD implantation were mostly male (84%), Chinese (71%), married (72%), currently employed (54%), and had up to primary or secondary education (78%) and monthly income of < SGD 3,000 (51%). Those who were more likely to reconsider their decision were aware that SCD was a consequence of heart failure with reduced ejection fraction, knowledgeable of the preventive role of ICDs, currently employed and aware that their doctor strongly recommended the implant. Based on multivariate analysis, knowledge of the role of ICDs for primary prophylaxis was the most important factor influencing patient decision.</p><p><b>CONCLUSION</b>This study identified the demographic and social factors of patients who refused ICD therapy. Knowledge of the role of ICDs in preventing SCD was found to be the strongest marker for reconsidering ICD implantation. Measures to address this information gap may lead to higher rates of ICD implantation.</p>

Singapore rhabdomyosarcoma (RMS) experience: shall we change our practice?

INTRODUCTION: Although rhabdomyosarcoma (RMS) constitutes nearly 4% of all children diagnosed with cancer in the ethnically diverse small island city of Singapore, it is unknown how children with RMS fare. MATERIALS AND METHODS: This study investigated 50 children with RMS from April 1993 to December 2010 from KK Women's and Children's Hospital (KKH) and National University Hospital (NUH). They were treated either as per Intergroup Rhabdomyosarcoma Study Group (IRSG) or Société Internationale Pediatrique D'Oncologie (SIOP) regimens. RESULTS: Median age of diagnosis was 5.1 years (range, 0.1 to 17.3 years) with a median follow-up of 3.3 years (range, 0.4 to 15.6 years). According to IRSG classifi cation, 18 (36%) were staged as low-risk (LR); 19 (38%) were intermediate-risk (IR), 12 (24%) were high-risk (HR) and it was unknown in 1 patient. Twenty-nine (58%) were of embryonal subtype, 17 (34%) were alveolar and subclassification was not available in 4. The primary sites of tumour were: head and neck region (n = 22); genitourinary (n = 19); extremity (n = 10); and abdomen/retroperitoneal (n = 5). At the time of analysis, 80% were alive with no evidence of disease, 9 were dead of disease, and 2 were alive with disease. By disease risk group, the 5-year event-free survival (EFS) for LR group disease was 81.3% (95% CI, 62.0 to 100.0), IR group was 61.4% (95% CI, 32.3 to 90.4) and HR group was 25.0% (95% CI, 0.0 to 49.5) respectively (P <0.001). The 5-year EFS for risk by chemotherapy received as per SIOP vs per IRSG revealed: LR 83.3% vs 75.0% (P = 0.787); IR 83.3% vs 43.8% (P = 0.351); HR 0.0% vs 42.9% (P = 0.336) respectively. Of 15 relapses (HR, n = 7), at median of 2 years, 4 of 6 patients treated as per SIOP regimen were dead of disease and 3 of 8 treated as per IRSG were alive. CONCLUSION: Radiation therapy (RT) can be avoided in LR classification although those in higher risk classification need RT to local and distant metastatic disease. The outcome of children with RMS in Singapore can be further improved by coming together as a cooperative group to provide the best total care. Improved communication, multidisciplinary team collaboration, standardisation of protocols and rigorous data collection are keys.