Postmarketing surveillance of the safety profile of infliximab in 5000 Japanese patients with rheumatoid arthritis

OBJECTIVES

A large-scale postmarketing surveillance (PMS) study was carried out to determine the safety profile of infliximab in Japanese patients with rheumatoid arthritis (RA).

METHODS

The PMS study was performed for all patients with RA who were treated with infliximab. They were consecutively registered in the PMS study at the initiation of infliximab treatment and were prospectively monitored with all adverse events noted for a period of 6 months. All case reports, which include safety-related events, were collected monthly.

RESULTS

Adverse drug reactions (ADRs) were assessed for 6 months in 5000 patients who were consecutively enrolled in the PMS study. The incidence rates of total and serious ADRs were 28.0% and 6.2%, respectively. "Infections" or "respiratory disorders" were most commonly observed among serious ADRs. Bacterial pneumonia developed in 2.2%, tuberculosis in 0.3%, suspected Pneumocystis jiroveci pneumonia (PCP) in 0.4% and interstitial pneumonitis in 0.5%. Bacterial pneumonia (for which individuals of male gender, of older age and those with advanced rheumatoid arthritis and comorbid respiratory disease were most at risk) began to develop immediately after the start of treatment, while tuberculosis, PCP and interstitial pneumonitis developed about 1 month later. Serious infusion reactions were observed in 0.5% and were more likely to occur in patients who had participated in previous clinical trials of infliximab.

CONCLUSION

This postmarketing surveillance study of patients treated with infliximab showed that infliximab in combination with low-dose MTX was well tolerated in Japanese patients with active RA.

Seizure risk in patients with attention-deficit-hyperactivity disorder treated with atomoxetine

The comorbidity of seizures, epilepsy, and attention-deficit-hyperactivity disorder (ADHD) prompted the examination of whether atomoxetine use for ADHD is associated with an increased risk of seizures. Seizures and seizure-related symptoms were reviewed from two independent Eli Lilly and Company databases: the atomoxetine clinical trials database and the atomoxetine postmarketing spontaneous adverse event database. Review of clinical trial data indicated that the crude incidence rates of seizure adverse events were between 0.1 and 0.2%, and were not significantly different between atomoxetine, placebo, and methylphenidate. Only 2% of the postmarketing spontaneous reports of seizure events were classified as having no clear contributing or confounding factors, and the reporting rate (8 per 100 000 patients exposed) was within the expected range of population-based incidence. Although children with ADHD are increasingly recognized as being at an elevated risk for seizures, treatment of ADHD symptoms with atomoxetine does not appear to elevate this risk further. The shared vulnerability between ADHD and seizure activity should be taken into account when making treatment decisions for populations of children with epilepsy and children with ADHD.

The safety of quetiapine: results of a post-marketing surveillance study on 1728 patients in England

The safety of the atypical antipsychotic quetiapine as used in general practice in England was examined by prescription-event monitoring (PEM). Patients were identified from dispensed National Health Service (NHS) prescriptions issued by general practitioners (GPs) for quetiapine between October 1997 and July 1999. The outcome data were event reports obtained by sending questionnaires ('green forms') to the prescribing doctor at Least 6 months after the first prescription for an individual patient. Green forms with clinically useful information on 1728 patients (median age 39 years (IQR 30-56); 53% female) were received. The most frequently reported event during the first month of treatment was 'drowsiness/sedation' (47; 3% cohort). This was also the most frequently reported specified adverse drug reaction (ADR) to quetiapine (7; 11% of 65 reported ADRs) and the highest reported clinical reason for stopping quetiapine (51; 6% of the 734 reported reasons for stopping). There was a low incidence of extrapyramidal disease (21 during treatment, 1% of cohort) and hyperprolactinaemia (three during treatment, 0.2%) in this study. Three cases of diabetes mellitus in this cohort were reported to be a new diagnosis. Six pregnancies were reported during treatment with quetiapine, five of which were exposed during the first trimester only. There were four Live births with no reported congenital abnormaLities. Fifty-six deaths were reported during this study (3% cohort). The most frequently reported causes of death reLated to the cardiovascular (18) and respiratory (15) systems. The results of this post-marketing surveillance study demonstrated that quetiapine is generally well-tolerated when used in general practice.

Novel statistical tools for monitoring the safety of marketed drugs

Robust tools for monitoring the safety of marketed therapeutic products are of paramount importance to public health. In recent years, innovative statistical approaches have been developed to screen large post-marketing safety databases for adverse events (AEs) that occur with disproportionate frequency. These methods, known variously as quantitative signal detection, disproportionality analysis, or safety data mining, facilitate the identification of new safety issues or possible harmful effects of a product. In this article, we describe the statistical concepts behind these methods, as well as their practical application to monitoring the safety of pharmaceutical products using spontaneous AE reports. We also provide examples of how these tools can be used to identify novel drug interactions and demographic risk factors for adverse drug reactions. Challenges, controversies, and frontiers for future research are discussed.

An evaluation of computer-aided disproportionality analysis for post-marketing signal detection

To understand the value of computer-aided disproportionality analysis (DA) in relation to current pharmacovigilance signal detection methods, four products were retrospectively evaluated by applying an empirical Bayes method to Merck's post-marketing safety database. Findings were compared with the prior detection of labeled post-marketing adverse events. Disproportionality ratios (empirical Bayes geometric mean lower 95% bounds for the posterior distribution (EBGM05)) were generated for product-event pairs. Overall (1993-2004 data, EBGM05> or =2, individual terms) results of signal detection using DA compared to standard methods were sensitivity, 31.1%; specificity, 95.3%; and positive predictive value, 19.9%. Using groupings of synonymous labeled terms, sensitivity improved (40.9%). More of the adverse events detected by both methods were detected earlier using DA and grouped (versus individual) terms. With 1939-2004 data, diagnostic properties were similar to those from 1993 to 2004. DA methods using Merck's safety database demonstrate sufficient sensitivity and specificity to be considered for use as an adjunct to conventional signal detection methods.

Hepatic safety profile and glycemic control of pioglitazone in more than 20,000 patients with type 2 diabetes mellitus: postmarketing surveillance study in Japan

The prospective observational study was designed to identify factors affecting glycemic control with pioglitazone and to confirm the hepatic safety of the drug in patients with type 2 diabetes. Baseline patient characteristics, changes in serum hemoglobin A1c (A1c) and alanine aminotransferase (ALT), other treatments for diabetes mellitus, and hepatobiliary adverse reactions were examined. In total, 24,993 patients, representing 28,008 patient-years, were included in the safety evaluation and 20,447 patients in the efficacy evaluation. No case of hepatic failure was reported, and neither temporal nor dose relations were found between pioglitazone and ALT abnormalities. Serum A1c was clearly reduced in patients with baseline body mass index <25 kg/m(2) or baseline fasting immunoreactive insulin <5.0 microU/mL. Among the patients treated for more than 6 months, the change in A1c was -1.0% at 6 months with both monotherapy and combination therapy and remained stable up to 18 months. The overall rate of achievement of A1c<7% in patients with baseline A1c above 7% was 34.1%; notably, the achievement rate of A1c<7% was approximately 30% even in patients with high baseline A1c (mean 8.8%) taking multiple antidiabetic medications, including sulfonylurea, for whom insulin therapy is usually indicated in Japan.

Communicating the risks and benefits of medicines

Pharmaceutical innovation, together with rising education, sanitation and wealth, prolonged life expectancy in industrialised countries throughout the 20th century. At the turn of the 21st century, with many, formerly common, lethal diseases confined to the developing world, the benefits of medical intervention are taken for granted in industrialized countries, and the expectations of safety have risen considerably. The perception and tolerance of risk has changed largely in the absence of immediate, population-wide health threats. Here, we review selected examples of drug withdrawals and adverse drug effects, and their impact on public perception. We analyse the role of major players, such as the media, patients, prescribers, regulators and pharmaceutical companies, and what actions are needed to better describe and communicate the risks and benefits of medicines to the public.

Illusions of objectivity and a recommendation for reporting data mining results

OBJECTIVE

Data mining algorithms (DMAs) are being applied to spontaneous reporting system (SRS) databases in the hope of obtaining timely insights into post-licensure safety data. Some DMAs have been characterized as "objective" screening tools. However, there are numerous available modifiable configuration parameters to choose from, including choice of vendor, that may affect results. Our objective is to compare the data mining results on pre-selected drug-event combinations (DECs) between two commonly used software programs using similar protocols.

METHODS

Two DMAs, using three thresholds, were retrospectively applied to the USFDA safety database through Q2 2005 to a set of eight pre-selected DECs.

RESULTS

Differences between the two vendors were found for the number of cases associated with a signal of disproportionate reporting (SDR), first year of SDRs, and the magnitude of the SDR scores for the selected DECs. These were deemed to be potentially significant for 45.8% (11/24) of the data points.

CONCLUSION

The observed differences between vendors could partially be explained by their differing methods of data cleaning and transformation as well as by the specific features of individual algorithms. The choices of vendors and available data mining configurations maximize the exploratory capacity of data mining, but they also raise questions about the claimed objectivity of data mining results and can make data mining exercises susceptible to confirmation bias given the exploratory nature of data mining in pharmacovigilance. When reporting results, the vendor and all data mining configuration details should be specified.

Estimating post-marketing exposure to pharmaceutical products using ex-factory distribution data

The pharmaceutical industry has an obligation to identify adverse reactions to drug products during all phases of drug development, including the post-marketing period. Estimates of population exposure to pharmaceutical products are important to the post-marketing surveillance of drugs, and provide a context for assessing the various risks and benefits, including drug safety, associated with drug treatment. This paper describes a systematic approach to estimating post-marketing drug exposure using ex-factory shipment data to estimate the quantity of medication available, and dosage information (stratified by indication or other factors as appropriate) to convert the quantity of medication to person time of exposure. Unlike the non-standardized methods often used to estimate exposure, this approach provides estimates whose calculations are explicit, documented, and consistent across products and over time. The methods can readily be carried out by an individual or small group specializing in this function, and lend themselves to automation. The present estimation approach is practical and relatively uncomplicated to implement. We believe it is a useful innovation.

Observation of Time-Dependent Adverse Events and the Influence of Drop-Out Thereon in Long-Term Safety Studies—Simulation Study Under the Current Practice of Post-marketing Safety Evaluation in Japan

Safety assessment of a new drug should be continuously carried out in the premarketing phase as well as in the postmarketing phase. Considering the actual conditions and problems of postmarketing safety studies in Japan, i.e., the lack of attention to the extent of patients' exposure to the drug (duration and the number of patients), we simulated the number of adverse events to be observed after specified intervals of exposure. This was done by applying different sets of hazard functions for a Weibull distribution under the circumstances that a certain number of patients has dropped out, focusing on rare and delayed adverse events associated with chronically used drugs. By using the result of these simulations, we point out potential problems of underestimating adverse event rates in situations where the hazard rate of the event escalates over time. Patients drop-out from the study also deteriorates the ability to observe such time-dependent adverse events. The simulation can also serve as a useful tool to examine the necessary sample size and the duration of exposure in order to observe and characterize potentially expected adverse events. It is important to take the two key factors into consideration: the change of hazard function over time and the effect of drop-out in designing, analyzing, and evaluating safety studies for new drugs.

Survival rates as a guide to implanted cardioverter-defibrillator replacement strategies for device recalls--adding statistical insight to clinical intuition

BACKGROUND

Recalls and advisories of implanted cardioverter-defibrillators (ICDs) have become an unfortunate reality of cardiac rhythm management. With a paucity of data available on which to base replacement decisions, our goal is to model the potential risks and benefits of ICD generator replacement. The estimated risks are varied through a wide range to determine the potential range of outcomes.

METHODS AND RESULTS

Using initial estimates of risk derived from real data on 2915 advisory devices from 17 implanting centers, a decision analysis and Markov model were used to estimate survival according to device replacement decision. Survival rates at 5 years with and without device replacement were estimated at 60.38% and 60.66%, respectively. This difference was not significantly different on comparative analysis, using variability determined by Monte Carlo simulation. One-way and two-way sensitivity analyses are presented, demonstrating the minimal effect of varying estimates of risk. Only variation in risk of device failure had a differential effect on survival, with a survival benefit at 7 years if annual risk of device failure is at least 1.8%. Little differential effect on survival was demonstrated by variation of estimates of arrhythmia risk, nonarrhythmic mortality, and postprocedure infection rate.

CONCLUSIONS

Survival rates with a generator replacement or nonreplacement strategy in response to ICD recalls are similar and decrease nearly in parallel over time. The main factor with differential effect on survival is risk of device failure, although the level of this risk required to confer a survival advantage to a replacement strategy is quite large.

Application of the Bradford Hill Criteria to Assess the Causality of Cisapride-Induced Arrhythmia

INTRODUCTION

The Bradford Hill criteria are a widely used, useful tool for the assessment of biomedical causation. We have examined their application to pharmacovigilance using the example of cisapride-induced QTc interval prolongation/arrhythmia.

METHODS

A literature search was conducted using MEDLINE, EMBASE, Reactions Weekly and regulatory websites to identify evidence for the association between cisapride and QTc interval prolongation/arrhythmia that had been published in the English language. Two hundred and five publications were identified as being potentially suitable for the study. After excluding irrelevant articles, studies on high-risk populations and review articles, 70 publications were assessed using the Bradford Hill criteria. These included 24 case reports, case series or spontaneous report summaries; eight epidemiological studies; 22 clinical studies; and 16 experimental (in vivo and in vitro) publications.

RESULTS

The most compelling evidence for an association between cisapride use and QTc interval prolongation/arrhythmia came from case/spontaneous reports and biological plausibility. Considering the rare incidence of serious cardiac events, these criteria formed the basis for the strength of the association. The number of reports from different populations showed consistency. Specificity was supported by clinical and cardiographic characterisation of the events. There were temporal relationships between the events and the initiation of cisapride treatment, increases in the dosage and the receipt of interacting medications. The relationships between the adverse events and the latter two factors exhibited biological gradients. Experimental evidence could be found from biological models, as well as reports of positive dechallenge and/or rechallenge found in individual patients. Cisapride was found to bind the human ether-a-go-go-related gene (HERG) potassium channel, which provides a plausible mechanism for QTc interval prolongation/arrhythmia. Other QTc interval-prolonging/arrhythmic drugs that also bind to HERG provided an analogy for cisapride causing QTc interval prolongation/arrhythmia via this mechanism. The evidence provided by clinical studies was inconsistent, and epidemiological studies failed to demonstrate an association. Nevertheless, this did not prevent the assessment of causation.

DISCUSSION

This study showed how different types of evidence found in pharmacovigilance can be evaluated using the Bradford Hill criteria. Further work is required to examine how the criteria can be applied to different types of adverse events and how they may be applied to pharmacovigilance.

Safety Profile of Rosuvastatin

BACKGROUND AND OBJECTIVE

Rosuvastatin is a lipid-lowering drug, the newest of a class of drugs called HMG-CoA reductase inhibitors, or 'statins', launched in the UK in March 2003. Our objective was to monitor the post-marketing safety of this drug, prescribed in primary care in England, using prescription-event monitoring.

METHODS

An observational cohort study in which patients were identified from dispensed prescriptions issued by primary care physicians/general practitioners (GPs) between August and December 2003. Demographic and clinical-event data were collected from questionnaires posted to GPs at least 6 months after the date of first prescription for each patient. Stratified analysis of specific events by starting dose of rosuvastatin was conducted. Follow-up and causality assessment of medically significant events was undertaken.

RESULTS

The cohort comprised 11,680 patients (median age 64 years); 50.3% were males (5880 of 11,680). The median period of treatment was 9.8 months. Of these patients, 72.7% (n = 8494) were started on rosuvastatin 10 mg/day. A total of 17.5% (n = 2047) of the patients were reported to have stopped treatment with rosuvastatin. Myalgia was the most frequent reason for stopping rosuvastatin and the most frequently reported clinical event. A 2.5-fold increase in the rate of abnormal liver-function tests (LFTs) was observed for patients started on rosuvastatin 40 mg/day compared with those started on 10 mg/day (2.71; 95% CI 1.53, 4.53). No case of rhabdomyolysis was reported in this cohort.

CONCLUSION

Rosuvastatin was considered to be a reasonably well tolerated drug. In the majority of patients, rosuvastatin was prescribed in line with recommendations. Abnormality of LFTs was found to be more frequent with the 40 mg/day dosage of rosuvastatin. Results from this study should be taken into account together with those of other clinical and pharmacoepidemiological studies of rosuvastatin.

Safety of Zafirlukast

OBJECTIVES

A prescription event monitoring (PEM) postmarketing surveillance study was carried out to examine the safety of zafirlukast as used in general practice in England.

METHODS

Exposure data were obtained from the first National Health Service (NHS) prescription dispensed for patients whose prescription details were processed by the Prescription Pricing Authority between August 1998 and December 2000. Outcome data were obtained from 'green form' questionnaires sent to general practitioners (GPs) at least 6 months following the first prescription issued. Incidence densities (IDs) were calculated for events reported per 1000 months of patient exposure and ID differences between the first month of treatment and months 2-6 combined were analysed. Events of medical interest were followed up by postal questionnaire sent to GPs.

RESULTS

21 557 green forms were sent to 8051 doctors, of which 9124 (42.3%) were returned. Useful clinical data was obtained for 7976 patients of which 4664 (58.5%) were female and 3265 (40.9%) were male. The patient's sex was not specified in 47 (0.6%) forms. The median age of the cohort was 53 years (interquartile range 38-66 years). The most frequently reported primary indication was the licensed indication of asthma, but for a small proportion of the cohort it was prescribed 'off label'.A total of 152 events in 120 (1.5%) patients were reported as adverse drug reactions (ADRs) by GPs on the green forms. ADRs with the highest reported frequency were headache and nausea. There were 3514 reasons for stopping zafirlukast in 3148 (39.5%) patients, the most frequently reported of which was that the drug was 'ineffective' (2008 patients; 25.2%). The most frequently reported specified clinical reason for stopping was headache (82 patients; 1.0%). There were 28 pregnancies reported in this cohort, 20 of which were reported to have exposure to zafirlukast during the first trimester. Nine live births with no recorded congenital abnormalities were reported for pregnancies with exposure in the first trimester. There were 151 deaths reported during the study period (1.9%). The most frequently reported causes of death were related to the respiratory system (57; 37.7%), including chronic obstructive pulmonary disease, asthma and bronchopneumonia.

CONCLUSION

This study showed that zafirlukast, as used in general practice in England, is a generally well tolerated drug with few associated adverse events.

Effectiveness and Satisfaction with Zolmitriptan 5mg Nasal Spray for??Treatment of Migraine in??Real-Life Practice

OBJECTIVE

Addressing the needs of migraineurs by actively seeking patient feedback on disease-related disability and treatment satisfaction may lead to improved management and treatment outcomes. Patient feedback can be collected in postmarketing surveillance (PMS) studies. The objective of this PMS study was to evaluate the efficacy and tolerability of zolmitriptan 5 mg nasal spray in the acute treatment of migraine attacks.

PATIENTS AND METHODS

Patients received zolmitriptan 5 mg nasal spray to treat migraine attacks of any severity and were followed up after a maximum of 4 months. Patients evaluated the efficacy and tolerability of zolmitriptan nasal spray, and were asked whether they wished to continue using zolmitriptan nasal spray and their preference compared with previous treatments. Physicians also assessed the efficacy and tolerability of zolmitriptan nasal spray.

RESULTS

A total of 1838 patients (84.8% females) participated in the study. Within 30 minutes of administration of zolmitriptan nasal spray, 85.0% of patients reported improvements in headache pain, with 25.1% reporting an improvement within 10 minutes. At 1 hour post-dose, 57.9% of patients were pain free and 61.7% were able to resume usual daily activities. Most patients (72.9%) rated zolmitriptan nasal spray as 'better' than previous therapy. The majority (88.8%) expressed a wish to continue using zolmitriptan nasal spray. Physicians evaluated the efficacy of zolmitriptan nasal spray as 'excellent' or 'good' in 89.4% of patients. Tolerability was evaluated as 'excellent' or 'good' in 91.6% of patients.

CONCLUSIONS

Zolmitriptan 5 mg nasal spray provides favourable efficacy and tolerability in the acute treatment of migraine attacks. Most patients assessed zolmitriptan nasal spray as 'better' than previous treatment, with nearly all wishing to continue using it.

Continuous monitoring of long-term outcomes with application to hip prostheses

The CUSUM continuous monitoring method could be a valuable tool in evaluating the performance (revision experience) of prostheses used in hip replacement surgery. The dilemma when applying the CUSUM in this context is the choice of statistical model for the outcome (revision). The Bernoulli model is perhaps the most straightforward approach but the Poisson model is a plausible, and could be argued, preferable alternative for long-term outcomes such as this, provided the rate of revision with time from surgery can be assumed to be constant. However, a rate (or hazard) varying according to the Weibull distribution appears to be a better representation of a prosthesis lifetime. We show how to adapt the Poisson approach to allow for the hazard to vary according to the Weibull model as well as other parametric survival models. Application to data on a known poorly performing prosthesis shows both the Poisson and Weibull CUSUMs could have given early warning of the poor performance, with the Weibull chart alerting before the Poisson. Simulation work to investigate the robustness of the Poisson and Weibull CUSUM to departures from the underlying survival model highlights the need for correct specification of the model for the outcome.

Wie sicher sind Blutzuckermesssysteme?

Since implementation of the Directive 98/79/EC of the European Parliament and of the Council on in vitro Diagnostic Medical Devices (IVD Directive), issues and field corrective actions on in vitro diagnostic medical devices (IVDMD) have to be reported to the national competent authorities. In Germany these are the BfArM and the Paul Ehrlich Institute; the latter is responsible for Annex II products used for immune hematology, tissue typing and infectiology testing. Between the beginning of 1999 and the end of 2005 BfArM received n=653 notifications on IVDMD. From these n=128 concerned analyzers and sensors (test strips) for self monitoring of blood glucose. A similar quantity of cases was reported by users and manufacturers (44.5%). In n=31 of these cases a product defect was not confirmed after the investigation of the products by the manufacturers. Product failures were confirmed in n=35 cases. The remaining cases were caused by user errors (n=29) or the data were inconclusive (n=33), predominantly because the products were not or only partly available for investigation by the manufacturers. In those cases where product failure had been verified n=24 affected the sensors (test strips) and n=11 the analyzers. Corrective actions were performed by the manufacturers in n=34 cases. From these n=27 were cases in which a product failure had been detected. However, in n=7 cases the investigations of the manufacturers were followed by preventive corrective actions because the manufacturers became aware of potential causes of future product failures. The obtained results and experiences since 1999 show that the governmental system for post-marketing surveillance of products for self testing of blood glucose is an established tool to ensure product safety. Regarding the proportion of notifications concerning these over the counter (OTC) products, it becomes obvious that they are a focus for action for the competent surveillance authorities.

Serious hazards of transfusion: a decade of hemovigilance in the UK

The Serious Hazards of Transfusion (SHOT) scheme is a UK-wide, independent, professionally led hemovigilance system focused on learning from adverse events. SHOT was established in 1996 as a confidential reporting system for significant transfusion-related events, building an evidence base to support blood safety policy decisions, clinical guidelines, clinician education, and improvements in transfusion practice. Recommendations are formulated by an independent steering group drawn from medical royal colleges and professional bodies. Ten years after its inception, SHOT has analyzed 2630 transfusion safety events, published 8 annual reports with recommendations, and presented data nationally and internationally. These recommendations have underpinned key initiatives, in particular the UK Department of Health "Better Blood Transfusion" strategy. SHOT has encouraged open reporting of adverse events and "near-misses" in a supportive, learning culture, vigilance in hospital transfusion practice, and evaluation of information technology to support this process. The importance of education and training has been emphasized. Detailed analysis of events has identified weaknesses in the transfusion chain. A collaborative initiative between SHOT, the Chief Medical Officer for England's National Blood Transfusion Committee, and the National Patient Safety Agency aims to reduce ABO-incompatible transfusions by improving bedside practice. Cumulative SHOT data have documented the decline in transfusion-related graft vs host disease after implementation of leucodepletion and have highlighted transfusion-related acute lung injury and bacterial contamination of platelets as important causes of death and morbidity. The UK blood services have developed strategies to reduce these risks. Future SHOT data will evaluate the success of these and other blood safety improvements.

Psychological Distress in Patients with ICD Recall

BACKGROUND

Multiple clinical trials have shown that a properly functioning implantable cardioverter-defibrillator (ICD) is capable of interrupting sudden death caused by ventricular tachyarrhythmias. However, ICDs are complex medical devices, and they do not always perform as expected or they may fail completely. Exposure of ICD recipients to professional or media reports that their specific device type is potentially malfunctioning could negatively influence their psychological status.

METHODS

This study aimed to evaluate and quantify psychological distress in patients implanted with an ICD-recall device. Thirty patients implanted with ICD-recall devices (ICD-recall group) and 25 patients with unaffected ICD devices (ICD-control group) were interviewed using the Brief Symptom Inventory (a psychological self-report symptom scale).

RESULTS

Mean values of all primary psychiatric distress symptom dimensions and global indices were within the normal range for both the ICD-recall and the ICD-control group. New York Heart Association (NYHA)class was a predictor of higher distress symptoms in all categories, independently of the ICD group. NYHA II group patients tended toward higher stress levels than the NYHA I group, but only somatization was significantly different. An upward, but not significant, trend in 7 of the 12 scales was associated with symptomatic shock experience.

CONCLUSION

This study demonstrates that psychological distress was not significantly increased in patients recently informed about a potential malfunction of their device.