Lower incidence of inappropriate shock therapy in patients with combined cardiac resynchronisation therapy defibrillators (CRT-D) compared with patients with non-CRT defibrillators (ICDs)

INTRODUCTION

A significant number of patients experience inappropriate shock therapy (IST) from implantable cardioverter-defibrillators (ICD). An increasing number of patients with advanced heart failure receive combined ICD and cardiac resynchronisation therapy devices (CRT-D). The incidence of IST in this group is less well described. We aimed to assess the incidence and predictors of IST in CRT-D patients.

METHODS

A retrospective cohort study of prospectively collected data on patients who received an ICD and CRT-D between October 2007 and January 2009 at our institution were studied. The primary outcome measures were the IST event rate and all-cause mortality.

RESULTS

A total of 185 patients with ICD/CRT-D (100/85) were included in the analysis. Eighteen patients experienced 35 episodes of IST during the follow-up (21 ± 13 months). There was a significantly lower IST cumulative event rate in the CRT-D vs. ICD group, 5% (CI: 1-13%) vs. 19% (95% CI: 11-30%) by 24 months, (p = 0.017). The majority of the IST was caused by atrial arrhythmias with atrial fibrillation accounting for 28 episodes of IST in nine patients. Multivariate analysis using Cox hazard model including baseline characteristics and coexisting appropriate shock therapy showed that a history of atrial fibrillation/flutter was the strongest independent predictor of IST with a hazard ratio of 3.53 (p = 0.019).

CONCLUSION

Patients with CRT-D had a significantly lower incidence of IST compared with patients receiving an ICD. Given that atrial arrhythmia remained the commonest trigger for IST, our finding lends support to the hypothesis that CRT may reduce atrial fibrillation burden in patients receiving CRT-D.

Concealed pregnancy: prevalence, perinatal measures and socio-demographics

A target group of women who concealed their pregnancy (n = 43) was compared to an aged-matched control group (n = 30) that experienced a crisis pregnancy. Comparisons were also made with a larger dataset (n = 6363) of births in University Hospital Galway (UHG) (normative group). Data was analysed using the Chi-square test and the Kolmogorov-Smirnoff two-sample test. The number of women from the target group that were from a rural background was 28 (65%), compared to 10 (33%) from the control group. The number of women from the target group that feared a negative parental reaction to the pregnancy was 34 (79%), compared to 12 (40%) from the control group. The birth weight in the target group was 4009 lower than the normative birth weight. The average age of women who concealed was 8 years lower than the normative age. The prevalence of concealed pregnancy in UHG was one in every 148 births.

Trends, indications and outcomes of cardiac implantable device system extraction: a single UK centre experience over the last decade

BACKGROUND

The rising number of device implantation has seen a parallel in the rising numbers of lead extraction. Herein we have analysed our experience in cardiac device and lead extraction in a single tertiary centre over the last decade.

METHOD

Retrospective analysis of all consecutive patients undergoing lead extractions performed between 2001 and 2010. Procedural success and complications as defined by the Heart Rhythm Society policy.

RESULTS

A total of 745 leads were extracted with a procedural success of 98.9% [382 cases; partial success in 6.9% (26) cases] and failure in 1.1% (4). Major complication rate was 1% (four cases) and minor complication rate was 3.6%. By both univariate and multivariate analysis only duration of lead implantation was an indicator for success (p < 0.0001). The mean implantation time for failed lead extraction was 203 ± 64 months compared with 71.8 ± 16.5 months in the successful cohort (p < 0.0001). Laser-assisted extraction was required in 176 cases. With regard to extraction indication, lead malfunction/recall showed a significant increase during the study period (p = 0.03). On time trend analysis the rise in coronary sinus (CS) lead extraction over time was significant. (p = 0.02) Despite a trend for increased laser use over time this did not achieve statistical significance, p = 0.06.

CONCLUSIONS

A decade's experience of percutaneous lead extraction suggests that a high procedural success rate with a low complication rate is achieved in a high-volume centre. During this time, an increase in both defibrillator and CS lead explantation and a rising trend in laser assistance with almost 50% of cases needing laser usage were observed.

Low mood and challenging behaviour in people with severe and profound intellectual disabilities

BACKGROUND

We investigated the relationship between low mood and challenging behaviour in people in the severe and profound range of intellectual disability, while controlling for the presence of potentially confounding variables such as diagnosis of autism, physical and sensory problems and ill health.

METHODS

The key workers of 52 people with severe and profound intellectual disability completed measures of depression, communication, challenging behaviour and provided information on relevant demographic and health variables.

RESULTS

Using the Mood, Interest and Pleasure Questionnaire for classification of mood, a significant difference was found between a 'low mood' and 'normothymic' group in the reported occurrence of challenging behaviour. This difference remained even when confounding variables such as the presence of autism, health and sensory difficulties were controlled. The frequency and severity of challenging behaviour was predicted by measures indicating the presence of low mood.

CONCLUSION

People with severe and profound show clear and measurable signs of low mood, and in this relatively small sample of institutionalised individuals, low mood was associated with challenging behaviour.

Use of mobile telephone short message service (SMS) as a reminder: the effect on patient attendance

AIM

To evaluate the operational and financial efficacy of sending short message service (SMS) mobile telephone text message to patients with outpatient clinic appointments.

STUDY DESIGN

Patients scheduled to attend an outpatient appointment at the Dept. Paediatric Dentistry, Edinburgh Dental Institute, Scotland, during October 2007 and who had mobile telephone contact details were sent a reminder SMS text 24hr prior to their appointment. An historical control group were selected from October 2006.

RESULTS

Data were available for 276 (F: 146; M: 130) and 433 (F: 228; M: 205) patient attendances during 2006 and 2007 respectively. Overall, 10.4% and 23.9% of the SMS and historical group failed to attend (FTA) respectively and the difference was statistically significant (Chi Square = 6.95, p = 0.008, 1 d.f). There was a reduction in the FTA rate for the specialist paediatric staff dentists from 29.2% to 24.4% for 2006 and 2007 respectively. The cost of sending text messages was 28.15 pound (approx. 30 euro) for October 2007.

CONCLUSIONS

The use of SMS text messages as a reminder may reduce the failure to attend rate for outpatient paediatric dental appointments.

Embryology of the acetabular labral-chondral complex

Damage to and repair of the acetabular labral-chondral complex are areas of clinical interest in the treatment of young adults with pain in the hip and in the prevention of degenerative arthritis of the hip. There are varying theories as to why most acetabular tears are located anterosuperiorly. We have studied the prenatal development of the human acetabular labral-chondral complex in 11 fetal hips, aged from eight weeks of gestation to term. There were consistent differences between the anterior and posterior acetabular labral-chondral complex throughout all ages of gestation. The anterior labrum had a somewhat marginal attachment to the acetabular cartilage with an intra-articular projection. The posterior labrum was attached and continuous with the acetabular cartilage. Anteriorly, the labral-chondral transition zone was sharp and abrupt, but posteriorly it was gradual and interdigitated. The collagen fibres of the anterior labrum were arranged parallel to the labral-chondral junction, but at the posterior labrum they were aligned perpendicular to the junction. We believe that in the anterior labrum the marginal attachment and the orientation of the collagen fibres parallel to the labral-chondral junction may render it more prone to damage than the posterior labrum in which the collagen fibres are anchored in the acetabular cartilage. The anterior intra-articular projection of the labrum should not be considered to be a pathological feature.

Exploring the role and perspectives of mental health nurse practitioners following psychosocial interventions training

Psychosocial interventions (PSI) offer a range of problem-centred activities designed to improve the health and quality of life of clients and their carers. The paper reports the findings of a study on the roles and perspectives of mental health nurse practitioners towards clients with enduring mental illness and their carers following completion of PSI training. Focus groups interviews were conducted with PSI mental health nurse practitioners (n = 8) and data were analysed for thematic content. The results of the study indicated that PSI practitioners developed positive attitudes towards their client following PSI training and this attitudinal change enabled clients to develop more confidence and autonomy in managing the symptoms of their illness in a more empowered way. Focus group participants observed reduced levels of anxiety among clients and their carers. This was attributed to the 'sense of hope' within the caring milieu which was established as a result of collaborative working with the client and family. The findings suggest that there is a need for further exploration of the PSI practitioner role with a particular focus on the centrality of positive attitudes on the development of the therapeutic milieu for clients with severe and enduring mental ill health.