Drugs to be avoided in patients with long QT syndrome: Focus on the anaesthesiological management

Anesthesia-related postoperative oncological surgical outcomes: a comparison of total intravenous anesthesia and volatile anesthesia. A meta-analysis

Introduction

In patients undergoing cancer surgery, it is ambiguous whether propofol-based total intravenous anesthesia (TIVA) elicits a significantly higher overall survival rate than volatile anesthetics (VA). Consequently, evaluating the impact of TIVA and VA on long-term oncological outcomes is crucial.

Aim

This study compared TIVA versus VA for cancer surgery patients and investigated the potential correlation between anesthetics and their long-term surgical outcomes.

Material and methods

A comprehensive search of Medline, EMBASE, Scopus, and Cochrane Library identified English-language peer-reviewed journal papers. The statistical measurements of hazard ratio (HR) and 95% CI were calculated. We assessed heterogeneity using Cochrane Q and I2 statistics and the appropriate p-value. The analysis used RevMan 5.3.

Results

The meta-analysis included 10 studies with 14036 cancer patients, 6264 of whom received TIVA and 7777 VA. In this study, we examined the long-term oncological outcomes of cancer surgery patients with TIVA and VA. Our data show that the TIVA group had a considerably higher overall survival rate (HR = 0.49, 95% CI: 0.30-0.80) and recurrence-free survival rate (HR = 0.56, 95% CI: 0.32-0.97). Each outcome was statistically significant (p < 0.05).

Conclusions

The present study concludes that TIVA is a more effective anesthetic agent than VA in obtaining better long-term oncological outcomes in cancer patients after surgery as it provides a higher overall survival rate, a higher recurrence-free survival rate and fewer post-operative pathological findings in patients who have undergone surgery for cancer as compared to VA.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Pronounced QT Prolongation During General Anesthesia in a Child with Left Ventricular Noncompaction Cardiomyopathy: A Case Report

We report the case of an 8-year-old boy with left ventricular noncompaction cardiomyopathy (LVNC) and QT prolongation who experienced further prolongation of the QTc during general anesthesia for extraction of a maxillary mesiodens. Pronounced prolongation of the QTc was observed after induction of general anesthesia with thiamylal and during emergence. No notable fluctuations in blood pressure, heart rate, and estimated continuous cardiac output were observed. We considered it likely that the QT prolongation was triggered by thiamylal and increased sympathetic nervous system activity. During general anesthesia for children with LVNC and QT prolongation, it is necessary to monitor intraoperative hemodynamic fluctuations and prepare for the possible occurrence of arrhythmias.

Anesthetic Considerations for Cesarean Delivery in a Parturient With Severe Gitelman Syndrome

Gitelman syndrome is an autosomal recessive inherited disorder that impairs the function of thiazide-sensitive sodium-chloride cotransporters in the distal convoluted tubule of the nephron. During labor and delivery, avoidance of sympathetic overactivity, meticulous hemodynamic monitoring, and expedited repletion of potassium and magnesium are required to avoid adverse outcomes. We present a parturient with severe Gitelman syndrome, requiring continuous electrolyte and fluid infusions, who underwent successful cesarean delivery. Potential severe morbidity was avoided with multidisciplinary planning and management.

Recent Updates and Technological Developments in Evaluating Cardiac Syncope in the Emergency Department

Syncope is a commonly encountered problem in the emergency department (ED), accounting for approximately 3% of presenting complaints. Clinical assessment of syncope can be challenging due to the diverse range of conditions that can precipitate the symptom. Annual mortality for patients presenting with syncope ranges from 0-12%, and if the syncope is secondary to a cardiac cause, then this figure rises to 18-33%. In ED, it is paramount to accurately identify those presenting with syncope, especially patients with an underlying cardiac aetiology, initiate appropriate management, and refer them for further investigations. In 2018, the European Society of Cardiology (ESC) updated its guidelines with regard to diagnosing and managing patients with syncope. We highlight recent developments and considerations in various components of the workup, such as history, physical examination, investigations, risk stratification, and novel biomarkers, since the establishment of the 2018 ESC guidelines. We further discuss the emerging role of artificial intelligence in diagnosing cardiac syncope and postulate how wearable technology may transform evaluating cardiac syncope in ED.

Oliceridine- Opioid of the 21st Century

Oliceridine (Olinvyk® Trevena, PA, USA) was approved by the United States Food and Drug Administration for clinical use on Aug 8, 2020. Even though, the indication of its approval is very restrictive (to manage moderate-to-severe acute pain in adults when the pain is severe enough), for such an innovative opioid, off-label indications are bound to abound. What could be described as the “opioid of the century,” it aims to overcome some of the stubbornest barriers to opioid prescribing, namely addiction liability, respiratory depression, and gastrointestinal (GI) side effects, just to name a few. The novel opioid accomplishes this by a unique mechanism of action. By selectively acting on the G-protein sub-pathway in preference to the beta-arrestin, it aims to mitigate these unwanted µ-opioid receptors-associated opioid side effects, while preserving its analgesic activity. What remains to be seen, however, is if these observations seen in phases 2 and 3 trials will be borne in actual large-scale clinical use, both inside and outside the USA. Unfortunately, the field of anesthesia is rife with innovations that have shown enormous promise at the research stage, only to end up as damp squibs when released to the clinicians for general use. Rapcuronium and althesin are some such examples. We aim to present some of the contentious and emerging issues associated with this drug and some of the potential pitfalls of this new opioid.

Preoperative Management of Gastrointestinal and Pulmonary Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement

Perioperative medication management is integral to preoperative optimization but remains challenging because of a paucity of literature guidance. Published recommendations are based on the expert opinion of a small number of authors without collaboration from multiple specialties. The Society for Perioperative Assessment and Quality Improvement (SPAQI) recognized the need for consensus recommendations in this area as well as the unique opportunity for its multidisciplinary membership to fill this void. In a series of articles within this journal, SPAQI provides preoperative medication management guidance based on available literature and expert multidisciplinary consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of gastrointestinal and pulmonary medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then used a modified Delphi approach to review the literature and to generate consensus recommendations.

Peripartum Management of Gitelman Syndrome for Vaginal Delivery: A Case Report and Review of Literature

We describe the anesthetic management of a spontaneous vaginal delivery at 38 weeks' gestation in a 36-year-old patient with Gitelman syndrome (GS). GS is a rare autosomal recessive renal tubulopathy characterized by hypomagnesemia, hypocalciuria, and secondary aldosteronism, which results in hypokalemia and metabolic alkalosis. To minimize any increase in catecholamine levels and consequent risk of ventricular arrhythmias, a labor epidural analgesia was administered using ropivacaine and fentanyl, along with intravenous magnesium and potassium supplementation. Ropivacaine was substituted for routine bupivacaine to decrease the risk of drug-induced cardiotoxicity. In the event of a cesarean section, the anesthetic plan was to continue with top-up epidural anesthesia and in case of failure, to convert to general anesthesia using propofol and rocuronium for induction. Delivery outcome was successful and uneventful.

Efficacy and Safety of Fospropofol Disodium for Injection in General Anesthesia Induction for Adult Patients: A Phase 3 Trial

Background: Fospropofol disodium for injection (Fospropofol_FD) is a prodrug that is metabolized into propofol to produce a general anesthesia effect when administered intravenously.

Objective: This study aimed to assess the efficacy and safety of Fospropofol_FD in comparison with propofol medium/long-chain fat emulsion injections (propofol-MCT/LCT) for general anesthesia induction in adult patients undergoing elective surgeries.

Setting: Nine academic medical centers in China.

Method: This multicenter, randomized, double-blind, double-simulated, controlled, and non-inferiority trial evaluated 540 eligible adult patients randomly assigned (2:1) to the intervention (20 mg/kg Fospropofol_FD) or control (2 mg/kg propofol-MCT/LCT) groups.

Main Outcome Measure: The primary efficacy endpoint was the success rate, defined as a Modified Observer’s Assessment of Alertness/Sedation Scale score of 1 within 5 min after study drug administration. The safety endpoints consisted of adverse events (AEs) related to consciousness, cognitive function, hemodynamic status, liver and kidney function, and blood tests.

Results: A total of 347 (96.3%) and 175 (97.2%) patients in the intervention and control groups, respectively, completed the study. The success rate for the primary outcome was 97.7% for both study drugs. The most frequent AEs in the intervention group were abnormal feeling (62.0%), blood pressure reduction (13.5%), and injection site pain (13.3%). No AEs related to consciousness and mental and cognitive functions or serious adverse events were reported.

Conclusion: Fospropofol_FD (20 mg/kg) is not inferior to propofol-MCT/LCT (2 mg/kg) in general anesthesia induction for American Society of Anesthesiologists (ASA) physical status I-II adult patients undergoing elective surgeries. It is safe and effective for clinical use under anesthesiologist monitoring.

Impact on Practice Statement: Fospropofol_FD can produce a general anesthesia effect and reduce the incidence of pain at the site of injection.

Comparison Between the Effects of Bupivacaine and Levobupivacaine for Spinal Anesthesia on QT Dispersion

BACKGROUND

Bupivacaine and Levobupivacaine are frequently used local anesthetic drugs in spinal anesthesia practice. Both agents have arrhythmic effects on the heart. However, there is no clear information about which agent is more arrhythmogenic.

OBJECTIVE

The aim of this article is to investigate the effects of bupivacaine and its S (-)-enantiomer, levobupivacaine, on cardiac arrhythmias in patients.

METHODS

The study included 40 patients scheduled for inguinal hernia surgery. Patients were randomly divided into the following two groups using a sealed envelope method: Group I, the bupivacaine group (n = 20); and Group II, the levobupivacaine group (n = 20). The QT values were taken preoperatively and during the 10th of the spinal block, the 10th of the surgical incision, and the 10th postoperative minute. Additionally, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), oxygen saturation (SO₂), and heart rate (HR) values, in addition to motor block (Bromage scale) levels and durations, were recorded for each patient.

RESULTS

HR values measured at 10 min after spinal block were significantly higher than the baseline values in the levobupivacaine group (p < 0.05). The corrected QT interval (QTc) values increased significantly at 10 minutes after spinal block and at 10 min postoperatively in the bupivacaine group (p < 0.05). QTd and QTcd measurements were taken at the 10th minute of spinal anesthesia, the 10th minute of the incision, and the 10th minute postoperatively. When compared to the levobupivacaine group, a statistically significant increase was found in the bupivacaine group (p < 0.05).

CONCLUSION

Levobupivacaine allows greater hemodynamic stability, while bupivacaine affects QTc and QTd measurement times more. As such, we believe that levobupivacaine may be a better alternative to bupivacaine during clinical practice, particularly in patients with cardiac problems.

Recurrent Pregnancy Loss and Concealed Long-QT Syndrome

Background

Recurrent pregnancy loss affects 1% to 2% of couples attempting childbirth. A large fraction of all cases remains idiopathic, which warrants research into monogenic causes of this distressing disorder.

Methods and Results

We investigated a nonconsanguineous Estonian family who had experienced 5 live births, intersected by 3 early pregnancy losses, and 6 fetal deaths, 3 of which occurred during the second trimester. No fetal malformations were described at the autopsies performed in 3 of 6 cases of fetal death. Parental and fetal chromosomal abnormalities (including submicroscopic) and maternal risk factors were excluded. Material for genetic testing was available from 4 miscarried cases (gestational weeks 11, 14, 17, and 18). Exome sequencing in 3 pregnancy losses and the mother identified no rare variants explicitly shared by the miscarried conceptuses. However, the mother and 2 pregnancy losses carried a heterozygous nonsynonymous variant, resulting in p.Val173Asp (rs199472695) in the ion channel gene KCNQ1. It is expressed not only in heart, where mutations cause type 1 long‐QT syndrome, but also in other tissues, including uterus. The p.Val173Asp variant has been previously identified in a patient with type 1 long‐QT syndrome, but not reported in the Genome Aggregation Database. With heterologous expression in CHO cells, our in vitro electrophysiologic studies indicated that the mutant slowly activating voltage‐gated K+ channel (I_Ks) is dysfunctional. It showed reduced total activating and deactivating currents (P<0.01), with dramatically positive shift of voltage dependence of activation by ≈10 mV (P<0.05).

Conclusions

The current study uncovered concealed maternal type 1 long‐QT syndrome as a potential novel cause behind recurrent fetal loss.

Management of Long QT Syndrome in Women Before, During, and After Pregnancy

Congenital long QT syndrome (LQTS) is a primary genetic and electrical disorder that increases risk for torsades de pointes, syncope, and sudden death. Post-pubertal women with LQTS require specialized multidisciplinary management before, during, and after pregnancy involving cardiology and obstetrics to reduce risk for cardiac events in themselves and their fetuses and babies. The risk of potentially life-threatening events is lower during pregnancy but increases significantly during the 9-month postpartum period. Treatment of women with LQTS with a preferred β-blocker at optimal doses along with close monitoring are indicated throughout pregnancy and during the high-risk postpartum period.

Role of Pharmacogenetics in Adverse Drug Reactions: An Update towards Personalized Medicine

Adverse drug reactions (ADRs) are an important and frequent cause of morbidity and mortality. ADR can be related to a variety of drugs, including anticonvulsants, anaesthetics, antibiotics, antiretroviral, anticancer, and antiarrhythmics, and can involve every organ or apparatus. The causes of ADRs are still poorly understood due to their clinical heterogeneity and complexity. In this scenario, genetic predisposition toward ADRs is an emerging issue, not only in anticancer chemotherapy, but also in many other fields of medicine, including hemolytic anemia due to glucose-6-phosphate dehydrogenase (G6PD) deficiency, aplastic anemia, porphyria, malignant hyperthermia, epidermal tissue necrosis (Lyell's Syndrome and Stevens-Johnson Syndrome), epilepsy, thyroid diseases, diabetes, Long QT and Brugada Syndromes. The role of genetic mutations in the ADRs pathogenesis has been shown either for dose-dependent or for dose-independent reactions. In this review, we present an update of the genetic background of ADRs, with phenotypic manifestations involving blood, muscles, heart, thyroid, liver, and skin disorders. This review aims to illustrate the growing usefulness of genetics both to prevent ADRs and to optimize the safe therapeutic use of many common drugs. In this prospective, ADRs could become an untoward "stress test," leading to new diagnosis of genetic-determined diseases. Thus, the wider use of pharmacogenetic testing in the work-up of ADRs will lead to new clinical diagnosis of previously unsuspected diseases and to improved safety and efficacy of therapies. Improving the genotype-phenotype correlation through new lab techniques and implementation of artificial intelligence in the future may lead to personalized medicine, able to predict ADR and consequently to choose the appropriate compound and dosage for each patient.

Clinical characterization and outcome of prolonged heart rate-corrected QT interval among children with syndactyly

Prolonged heart rate-corrected QT (QTc) interval is an independent risk factor for sudden cardiac death, which is the hallmark of Timothy syndrome (TS). There are little data on children with syndactyly and QTc prolongation.To evaluate the characteristics and long-term outcomes in children with syndactyly, and to attempt to identify TS in patients with syndactyly and QTc prolongation.This is a retrospective case-control study of children with syndactyly who visited Beijing Jishuitan Hospital between July 2003 and February 2013. The patients with prolonged QTc intervals are matched 1:4 with patients without prolongation. Genetic testing of the CACNA1C gene is routinely performed in patients with QTc prolongation.The mean age at admission is 3.4 ± 2.3 years. Compared with the normal QTc group, those with QTc prolongation showed higher frequencies of congenital heart disease (11.8% vs 1.5%, P = .042), mental retardation and facial dysmorphia (11.8% vs 0, P = .004), and T wave alternans (23.5% vs 4.4%, P = .01). In the multivariable analysis, only T wave alternans (OR = 10.61, 95%CI: 1.39-81.16, P = .023) is independently associated with QTc prolongation in patients with syndactyly. One child with QTc prolongation had a mutation in the CACNA1C gene. No patients with prolonged QTs interval met the threshold for TS.Children with syndactyly and prolonged QTc interval had more multisystem diseases and electrocardiography abnormalities. T wave alternans is independently associated with QTc prolongation in patients with syndactyly.

An unusual cause of polymorphic ventricular tachycardia: Acquired long QT syndrome from atypical variant of stress-induced cardiomyopathy

A 55-year-old woman with a recent history of surgically and radioiodine treated thyroid cancer experienced a run of polymorphic ventricular tachycardia with hemodynamic perturbation during anaesthetic induction with propofol, fentanyl and rocuronium for elective surgical excision of right hip metastasis. Electrocardiography showed new T-wave inversion and QT prolongation that subsequently resolved. Cardiac enzymes were elevated but invasive coronary angiography showed unobstructed epicardial coronary arteries. Cardiovascular magnetic resonance showed not only normal biventricular size and systolic function but also a striking pattern of patchy myocardial oedema involving the basal-to-mid anterior, septal and inferior walls and some associated hypertrophy in the anteroseptum (representing focal myocardial swelling from the oedema) but no focal or diffuse myocardial fibrosis. All these abnormalities resolved on subsequent convalescent imaging. A diagnosis of multifactorial acquired long QT syndrome secondary to atypical variant stress-induced cardiomyopathy was made with the likely provoking factors in this case having been the female sex, understandable pre-operative anxiety, anaesthetic drugs, supraglottic airway placement and thyroid dysfunction. An implantable loop recorder during follow-up detected no further significant arrhythmias and she remains well and asymptomatic to date on a low dose of beta-blocker.

Inherited cardiac arrhythmias

The main inherited cardiac arrhythmias are long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia and Brugada syndrome. These rare diseases are often the underlying cause of sudden cardiac death in young individuals and result from mutations in several genes encoding ion channels or proteins involved in their regulation. The genetic defects lead to alterations in the ionic currents that determine the morphology and duration of the cardiac action potential, and individuals with these disorders often present with syncope or a life-threatening arrhythmic episode. The diagnosis is based on clinical presentation and history, the characteristics of the electrocardiographic recording at rest and during exercise and genetic analyses. Management relies on pharmacological therapy, mostly β-adrenergic receptor blockers (specifically, propranolol and nadolol) and sodium and transient outward current blockers (such as quinidine), or surgical interventions, including left cardiac sympathetic denervation and implantation of a cardioverter-defibrillator. All these arrhythmias are potentially life-threatening and have substantial negative effects on the quality of life of patients. Future research should focus on the identification of genes associated with the diseases and other risk factors, improved risk stratification and, in particular for Brugada syndrome, effective therapies.

Comparison of General Anesthesia (Sevoflurane) and Spinal Anesthesia (Levobupivacaine) Methods on QT Dispersion in Inguinal Hernia Operations

Introduction Arrhythmias are one of the most frequently seen issues during surgical operations. In this study, we investigated and compared the effects on the QT dispersion of patients when using a method of volatile inhalation mask anesthesia with sevoflurane (VIMA: Group I) and when spinal anesthesia was performed with levobupivacaine (Group II). Methods The study included 40 patients who had American Society of Anesthesiology scores of I-II (ASA I-II), were aged from 18 to 65 years, and were scheduled for inguinal hernia operations. Approval of the university ethics committee was obtained before the study began. All patients had measurements taken for non-invasive blood pressure, including systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and mean arterial pressure (MAP), heart rate (HR), and oxygen saturation (SO2) values. The QT intervals were measured using the 12-derivation electrocardiogram (ECG) device (Cardiofax V). Our study was performed with randomization using the closed envelope method. Results When the percentage differences of the HR values from the initial period in both groups were compared, we observed significant differences between the groups, with increases in the VIMA group at the second period as well as increases in the VIMA group at the fourth, fifth, sixth, seventh, and ninth periods but decreases in the spinal anesthesia group for these periods. There were statistically significant differences between the two groups at the third and fifth periods when the percentage differences of the QTc values from the initial period were compared. We observed increases in the spinal anesthesia group. Conclusion In our study, we suggest that the tendency toward arrhythmia may be reduced by choosing general anesthesia with sevoflurane rather than levobupivacaine in patients with cardiac complaints who are undergoing regional anesthesia and/or taking medication that affects QT intervals.

Concealed congenital long QT syndrome during velopharyngeal dysfunction correction: a case report

The congenital long QT syndrome (LQTS) is an inherited cardiac disorder characterized by increased QT intervals and a tendency to experience ventricular tachycardia, which can cause fainting, heart failure, or sudden death. A 4-year-old female patient undergoing velopharyngeal correction surgery under general anesthesia suddenly developed Torsades de pointes. Although the patient spontaneously resolved to sinus rhythm without treatment, subsequent QT prolongation persisted. Here, we report a case of concealed LQTS with a literature review.

Anaesthesia for emergency caesarean section in a patient with Gitelman syndrome

Gitelman syndrome is a rare autosomal recessive salt-losing disorder of renal tubules, which results in hypokalemic metabolic alkalosis. Associated hypomagnesaemia and hypocalcaemia are also seen. Gitelman syndrome is a variant of renal Bartter's syndrome. Anaesthetic management of these obstetric patients is challenging and requires a careful multidisciplinary approach. Close monitoring of potassium and magnesium levels and their supplementation is required to avoid complications to mother and baby.

The effects of acetylcholinesterase inhibitors on morbidity after general anesthesia and surgery

Non-depolarizing neuromuscular blocking agents are used during general anesthesia to facilitate intubation and optimize surgical conditions. When patients leave the operating room after surgery, postoperative residual neuromuscular block occurs frequently, increasing vulnerability to respiratory complications such as hypoxemia and unplanned postoperative mechanical ventilation. To restore neuromuscular transmission and skeletal muscle strength, anesthesiologists typically administer peripherally acting acetylcholinesterase inhibitors such as neostigmine. However, neostigmine's desirable effects have a narrow therapeutic range. Even at recommended dose (15-50 μg/kg), neostigmine induces nicotinic (upper airway muscle weakness leading to dysphagia and upper airway obstruction, and decreased maximum inspiratory airflow) and muscarinic (blurred vision, bronchial constriction, abdominal cramping and nausea) side effects. Recent data have questioned as to whether neostigmine reversal of neuromuscular blockade improves relevant patient outcomes such as postoperative respiratory and perioperative cardiovascular complications. A central strategy to avoid side effects of neuromuscular blocking agents is their judicious use based on quantitative monitoring of neuromuscular transmission using repetitive peripheral nerve stimulation (train-of-four ratio). Peripherally acting acetylcholinesterase inhibitors such as neostigmine should then only be administered when indicated and dosed based on results of the train-of-four ratio.

QT prolongation in HIV-positive patients: Review article

Introduction

Antiretrovirals have immensely increased the average life expectancy of HIV-positive patients. However, the incidence of QT interval prolongation and other arrhythmias has also increased.

Methods

Pubmed and Google Scholar were searched for relevant literature published between 1990 and 2019.

Results and discussion

HIV-positive patients with high viral load, low CD4 count, chronic inflammation, and autonomic neuropathy can develop QT interval prolongation. Another factor prolonging QT interval includes exposure to the HIV transactivator protein, which inhibits hERG K (+) channels controlling IKr K (+) currents in cardiomyocytes. Protease inhibitors inhibiting the CYP3A4 enzyme can also lead to QT interval prolongation. QT interval prolongation can potentially be exacerbated by opioids, antipsychotics, antibiotics, and antifungals, the adjunct medications often used in HIV-positive patients. Hepatic insufficiency in seropositive patients on antiretrovirals may also increase the risk of QT interval prolongation.

Conclusion

Baseline and follow-up EKG in the susceptible population is suggested.

Long QT syndrome is associated with an increased burden of diabetes, psychiatric and neurological comorbidities: a nationwide cohort study

Objective

Studies have suggested a shared genetic aetiology between congenital long QT syndrome (LQTS) and diabetes, epilepsy and mental disorders. We investigated the prevalence of metabolic, neurological and psychiatric comorbidities in LQTS patients.

Methods

This retrospective cohort study was based on data from nationwide Danish registries, 2003-2017. LQTS patients were matched 1:5 with controls on sex and age.

Results

We matched 463 LQTS patients with 2315 controls from the background population. Mean age was 35.7 (SD 21.0) years, and 38% were males in both groups. LQTS patients had a higher prevalence of atrial fibrillation (6.5% vs 2.3%, p<0.001), diabetes (3.7% vs 1.8 %, p=0.011) and hearing loss (3.2% vs 1.7%, p=0.027). LQTS patients had a higher prevalence of psychiatric disorders overall (13.0% vs 9.1%, p=0.01) but the difference could not be attributed to a specific psychiatric disease subgroup. LQTS patients had a higher prevalence of neurological disorders (22.0% vs 13.2%, p<0.001), largely driven by epilepsy (6.7% vs 1.6%, p<0.001). In 20/27 (74%) of the LQTS patients, the epilepsy diagnosis did not reappear in the registries after the LQTS diagnosis was established.

Conclusions

In this nationwide cohort, patients with LQTS had a significantly increased burden of diabetes, neurological and psychiatric comorbidities, compared with the background population. The higher prevalence of neurological comorbidities was largely driven by epilepsy, despite a high rate of potentially misdiagnosed patients prior to LQTS diagnosis. Our data support that LQTS may be considered a multiorgan disease and suggest that patient management should be adjusted accordingly.

Effects of esmolol on QTc interval changes during tracheal intubation: a systematic review

INTRODUCTION AND AIMS

Esmolol is an ultra-short-acting β₁ antagonist that has been shown to attenuate the corrected QT (QTc) interval prolongation associated with laryngoscopy and endotracheal intubation (LTI). Prolongation of the QTc interval can precipitate arrhythmias, the most serious of which is torsades de pointes . The aim of this systematic review was to compare esmolol and placebo on QTc changes occurring during LTI.

MATERIALS AND METHODS

PubMed, EMBASE, Cochrane Registry of Clinical Trials and CINAHL databases (up to August 2018) were screened for randomised controlled trials comparing esmolol and placebo on QTc changes during LTI in cardiac and non-cardiac surgeries. The primary outcome was QTc changes during LTI and secondary outcome was related to adverse effects from esmolol such as bradycardia and hypotension.

RESULTS

Seven trials were identified involving 320 patients, 160 patients receiving esmolol or placebo apiece. A shortening of the QTc post-LTI was evident in the esmolol group compared with the placebo in four studies. Compared with the baseline, the QTc was reduced post-LTI in the esmolol group. In the placebo group, the QTc was prolonged compared with the baseline post LTI. Nonetheless, esmolol did not prevent QTc prolongation in the remaining three studies, and much of this was attributed to employing QTc prolonging agents for premedication and anaesthetic induction. No significant adverse events were noted.

CONCLUSION

Compared with placebo, esmolol reduced the LTI-induced QTc prolongation when current non-QTc prolonging agents were chosen for tracheal intubation. Future studies should explore whether transmural dispersion (a marker of torsadogenicity) is also affected during LTI by analysing parameters such as the Tp-e interval (interval between the peak to the end of the T-wave) and Tp-e/QTc (rate corrected Tp-e interval).

TRIAL REGISTRATION NUMBER

CRD42018090282.

Evaluation of the Effects of a Monthly Buprenorphine Depot Subcutaneous Injection on QT Interval During Treatment for Opioid Use Disorder

Extensive 12‐lead electrocardiogram monitoring and drug concentrations were obtained during development of BUP‐XR, a monthly subcutaneous injection for the treatment of opioid use disorder (OUD). Matched QT and plasma drug concentrations (11,925) from 1,114 subjects were pooled from 5 studies in OUD. A concentration‐QT model was developed, which accounted for confounding factors (e.g., comedications) affecting heart rate and heart rate‐corrected QT interval (QTc). Bias‐corrected nonparametric two‐sided 90% confidence intervals (CIs) were derived for the mean predicted effect of BUP‐XR on QTc (ΔQTc) at therapeutic and supratherapeutic doses. Changes in QTc were associated with age, central vs. noncentral reading, sex, methadone, and barbiturates. The upper 90% CI of ΔQTc was 0.29, 0.67, and 1.34 ms at the steady‐state peak concentration (C_max) for 100, 300, and 2 × 300 mg doses, respectively. An effect of BUP‐XR on QT can be ruled out at therapeutic and supratherapeutic doses of BUP‐XR, after accounting for covariates that may influence heart rate and QT interval in OUD.

Drug Interactions With Oral Inhaled Medications

Objective: To evaluate the potential for drug interactions with oral inhaled medications (OIMs). OIMs include bronchodilators (β-agonists and antimuscarinics), corticosteroids, combination products (2 or more agents combined within a single inhalation device), antibiotics, prostacyclins, anesthetics, acetylcysteine, mucolytics, insulin, antivirals, nitric oxide, and nicotine replacement. Data Sources: A systemic literature search (1980 to May 2018) was performed using PubMed and EBSCO to locate relevant articles. The MESH terms used included each specific medication available as an OIM as well as "drug interactions." DAILYMED was used for product-specific drug interactions. Study Selection and Data Extraction: The search was conducted to identify drug interactions with OIMs. The search was limited to those articles studying human applications with OIMs and publications using the English language. Case reports, clinical trials, review articles, treatment guidelines, and package labeling were selected for inclusion. Data Synthesis: Primary literature and package labeling indicate that OIMs are subject to pharmacokinetic and pharmacodynamics interactions. The most frequently identified clinically significant drug interaction is an inhaled corticosteroid when combined with a potent CYP 450 inhibitor such as a protease inhibitor or antifungal. Conclusions: The available literature indicates that OIMs are associated with clinically significant drug interactions and subsequent adverse reactions. Clinicians in all practice settings should be mindful of this potential to minimize adverse effects and optimize therapy.

Disease Modifiers of Inherited SCN5A Channelopathy

To date, a large number of mutations in SCN5A, the gene encoding the pore-forming α-subunit of the primary cardiac Na⁺ channel (Na_V1.5), have been found in patients presenting with a wide range of ECG abnormalities and cardiac syndromes. Although these mutations all affect the same Na_V1.5 channel, the associated cardiac syndromes each display distinct phenotypical and biophysical characteristics. Variable disease expressivity has also been reported, where one particular mutation in SCN5A may lead to either one particular symptom, a range of various clinical signs, or no symptoms at all, even within one single family. Additionally, disease severity may vary considerably between patients carrying the same mutation. The exact reasons are unknown, but evidence is increasing that various cardiac and non-cardiac conditions can influence the expressivity and severity of inherited SCN5A channelopathies. In this review, we provide a summary of identified disease entities caused by SCN5A mutations, and give an overview of co-morbidities and other (non)-genetic factors which may modify SCN5A channelopathies. A comprehensive knowledge of these modulatory factors is not only essential for a complete understanding of the diverse clinical phenotypes associated with SCN5A mutations, but also for successful development of effective risk stratification and (alternative) treatment paradigms.

Cochlear implantation in children with congenital long QT syndrome: Introduction of an evidence-based pathway of care

Congenital long QT syndrome (cLQTS) is an inherited cardiac ion channelopathy characterized by a long corrected-QT interval on the ECG, associated with a risk of syncope and sudden death as a result of arrhythmias. The archetypal arrhythmia associated with cLQTS is torsade de pointes which may degenerate into ventricular fibrillation. Children with Jervell and Lange-Neilsen syndrome have the combination of cLQTS and congenital sensorineural deafness and may present for cochlear implantation (CI). Sympathetic stimulation and administration of QT-prolonging medications may trigger arrhythmias in children with cLQTS and thus the perioperative period is a time of increased risk of adverse events, with deaths reported in the CI literature. Our Paediatric Cochlear Implant Programme had previously elected to discontinue offering CI to children with cLQTS following a perioperative death. However, subsequent demand for this service by parents led us to develop and introduce a multidisciplinary, evidence-based pathway of care. This pathway modifies the perioperative management of these children to reduce the associated risk. We present the cases of four children with cLQTS who underwent CI in our specialist children's hospital.

QT Prolongation and Malignant Arrhythmia: How Serious a Problem?

QT prolongation constitutes one of the most frequently encountered electrical disorders of the myocardium. This is due not only to the presence of several associated congenital syndrome but also, and mainly, due to the QT-prolonging effects of several acquired conditions, such as ischaemia and heart failure, as well as multiple medications from widely different categories. Propensity of repolarization disturbances to arrhythmia appears to be inherent in the function of and electrophysiology of the myocardium. In the present review the issue of QT prolongation will be addressed in terms of pathophysiology, arrhythmogenesis, treatment and risk stratification approaches. Although already discussed in literature, it is hoped that the mechanistic approach of the present review will assist in improved understanding of the underlying changes in electrophysiology, as well as the rationale for current diagnostic and therapeutic approaches.

Anaesthesia for electroconvulsive therapy: An overview with an update on its role in potentiating electroconvulsive therapy

Despite advances in pharmacotherapy, electroconvulsive therapy (ECT) remains a mainstay treatment option in psychiatry since its introduction in 1930s. It can be used primarily in severe illnesses when there is an urgent need for treatment or secondarily after failure or intolerance to pharmacotherapy. The 'unmodified' technique of ECT was practised initially, with a high incidence of musculoskeletal complications. Several modifications including general anaesthesia and muscle relaxation are used to increase the safety and patient acceptability of ECT. Various anaesthetic techniques including medications are considered to provide adequate therapeutic seizure, simultaneously controlling seizure-induced haemodynamic changes and side effects. A brief review of literature on choice of these anaesthetic techniques is discussed. This article is intended to reinforce the knowledge of clinicians, who may have limited exposure to ECT procedure. Importance is given to the recent updates on the role of induction agents in potentiating therapeutic response to ECT in psychiatric disorders.

Anaesthesia management of a case of Jervell and Lange-Nielsen syndrome for minimally invasive bilateral thoracoscopic cervicothoracic sympathectomy

Long QT syndrome (LQTS) is an arrhythmogenic cardiac disorder resulting from the malfunction of cardiac ion channels. Patient with LQTS may present with syncope, seizures or sudden cardiac death secondary to polymorphic ventricular tachycardia (VT) or torsades de pointes. Patient may be asymptomatic in the pre-operative period but may develop VT for the first time in operation theatre. We are reporting anaesthetic management of a child with LQTS planned for bilateral thoracoscopic cervicothoracic sympathectomy.

Using an Electronic Decision Support Tool to Reduce Inappropriate Polypharmacy and Optimize Medicines: Rationale and Methods

BACKGROUND

Polypharmacy and inappropriate continuation of medicines can lead to a significant risk of adverse drug events and drug interactions with patient harm and escalating health care costs as a result. Thorough review of patients' medications focusing on the need for each drug can reduce the potential for harm. Limitations in performing effective medicine reviews in practice include consultation time constraints and funding for pharmacy services. We will aim to overcome these problems by designing an automatic electronic decision support tool (the medicines optimization/review and evaluation (MORE) module) that is embedded in general practice electronic records systems. The tool will focus on medicines optimization and reducing polypharmacy to aid prescribers in reviewing medicines and improve patient outcomes.

OBJECTIVE

The objectives of this study are: (1) to develop an electronic decision support tool to assist prescribers in performing clinical medication reviews with a particular focus on patients experiencing multimorbidity and polypharmacy, and (2) evaluate and assess the use of the electronic decision support tool, providing pilot data on its usefulness in supporting prescribers during consultations with patients.

METHODS

The first three study phases involve development of clinical rules outlining clinical interventions and the creation and validation of the MORE decision support tool. Phase four is a community-based, single-blind, prospective, 6-month controlled trial involving two interventions and two control general practices, matched for practice demographics. We will be measuring the number of times prescribers engage with the tool, total number of interventions suggested by the tool, and total number of times prescribers change medicines in response to recommendations. There will also be prospective follow-up of patients in the intervention group to examine whether changes to medications are upheld, and to determine the number of hospitalizations or emergency department visits within 6 months of a medicine intervention. Comparisons between control and intervention practices will measure the changes in proportions of patients with polypharmacy and inappropriately prescribed medicines before and after the introduction of the electronic decision support tool, proportions of patients receiving appropriate treatment in each practice, and changed, maintained, or improved health status, hospitalizations, and deaths in the study year. Initiation rates of inappropriately prescribed medicines will be measured as a secondary outcome. As well as external assessment of the extent of use and application of the tool, prescribers will receive monthly practice progress reports detailing the proportion of their patients experiencing polypharmacy and taking inappropriately prescribed medicines identified for review.

RESULTS

Phase one has now been completed and the decision support tool is under development. Final data analysis is expected to be available in December 2016.

CONCLUSIONS

This study will establish whether the MORE decision support tool stands up to real world conditions and promotes changes in prescribing practice.

Gender Differences in Cardiovascular Drugs

The different responses of women and men to cardiovascular drugs reflect gender -specific variances in pharmacokinetic profiles and drug sensitivities coupled to inherent differences in the underlying physiology of each sex. Thus, many common cardiovascular drugs exhibit gender -specific therapeutic and adverse effects. For example, the QT interval of the electrocardiogram is longer in women compared to men, and accordingly, drugs that prolong the QT interval are more likely to cause lethal ventricular arrhythmias in female than male patients. As more clinical drug trials include women subjects, our improved knowledge base for assessing the risk/benefit ratio for cardiovascular drugs in women will enable us to consider gender as one factor in prescribing drugs and adjusting drug loading and maintenance dosages. This short review will present evidence for gender- related differences in the responses to common cardiovascular drugs including statins, antiplatelet and antithrombotic agents, β-blockers, digoxin, vasodilator therapies, and drugs associated with the Long QT Syndrome.

Safe Anaesthesia Management in a Child with Congenital Long QT Syndrome

Long QT syndrome is a cardiac repolarisation disorder that can occur with clinical symptoms such as dizziness, fainting, life-threatening arrhythmias and sudden cardiac death, and its incidence is increasing in the general population. A careful anaesthetic management is required for patients with this syndrome because of the risk of torsades de pointes and malignant arrhythmias. In this case report, we discuss the anaesthetic management of a seven-year-old patient with congenital long QT syndrome that was diagnosed during the preoperative evaluation.

Characterization of Conserved Toxicogenomic Responses in Chemically Exposed Hepatocytes across Species and Platforms

BACKGROUND

Genome-wide expression profiling is increasingly being used to identify transcriptional changes induced by drugs and environmental stressors. In this context, the Toxicogenomics Project-Genomics Assisted Toxicity Evaluation system (TG-GATEs) project generated transcriptional profiles from rat liver samples and human/rat cultured primary hepatocytes exposed to more than 100 different chemicals.

OBJECTIVES

To assess the capacity of the cell culture models to recapitulate pathways induced by chemicals in vivo, we leveraged the TG-GATEs data set to compare the early transcriptional responses observed in the liver of rats treated with a large set of chemicals with those of cultured rat and human primary hepatocytes challenged with the same compounds in vitro.

METHODS

We developed a new pathway-based computational pipeline that efficiently combines gene set enrichment analysis (GSEA) using pathways from the Reactome database with biclustering to identify common modules of pathways that are modulated by several chemicals in vivo and in vitro across species.

RESULTS

We found that some chemicals induced conserved patterns of early transcriptional responses in in vitro and in vivo settings, and across human and rat genomes. These responses involved pathways of cell survival, inflammation, xenobiotic metabolism, oxidative stress, and apoptosis. Moreover, our results support the transforming growth factor beta receptor (TGF-βR) signaling pathway as a candidate biomarker associated with exposure to environmental toxicants in primary human hepatocytes.

CONCLUSIONS

Our integrative analysis of toxicogenomics data provides a comprehensive overview of biochemical perturbations affected by a large panel of chemicals. Furthermore, we show that the early toxicological response occurring in animals is recapitulated in human and rat primary hepatocyte cultures at the molecular level, indicating that these models reproduce key pathways in response to chemical stress. These findings expand our understanding and interpretation of toxicogenomics data from human hepatocytes exposed to environmental toxicants.

Diagnosis and Management of Delirium in Critically Ill Infants: Case Report and Review

Delirium in children is common but not widely understood by pediatric practitioners, often leading to underdiagnosis and lack of treatment. This presents a significant challenge in the young patients in the PICU who are most at risk for delirium and in whom the core features of delirium are difficult to assess and treat. However, because of the potential increased morbidity and mortality associated with untreated delirium in adults and children, it remains important to address it promptly. The literature for delirium in this age group is limited. Here we present the case of an infant with multiple underlying medical risk factors who exhibited waxing and waning motor restlessness with disrupted sleep-wake cycles contributing significantly to destabilization of vital parameters. Making a diagnosis of delirium was key to guiding further treatment. After appropriate environmental interventions are implemented and underlying medical causes are addressed, antipsychotic medications, although not Food and Drug Administration-approved in infants, are the mainstay of pharmacotherapy for delirium in older age groups. They may lengthen corrected QT interval (QTc) intervals, presenting a challenge in infants who frequently have other coexisting risks for QTc prolongation, as in our case. The risk from QTc prolongation needs to be balanced against that from untreated delirium. Low doses of risperidone were successfully used in this patient and without side effects or worsening of QTc interval. This case illustrates the importance of increased recognition of delirium in children, including infants, and the role for cautious consideration of atypical antipsychotics in the very young.

Risk assessment and anesthetic management of patients with Williams syndrome: a comprehensive review

Since the first description in 1961, several case reports have documented an increased incidence of anesthesia-related cardiac arrest in patients with Williams-Beuren syndrome, commonly known as Williams syndrome (WS). Widespread arteriopathy secondary to an elastin gene defect results in various cardiac defects, including supravalvar aortic stenosis (SVAS) and coronary artery anomalies, which can increase the risk of myocardial ischemia. Even though patients with WS are known to have increased risk of adverse events during anesthesia and sedation, they often undergo several procedures that require anesthesia during their lifetimes, and cases of perianesthetic cardiac arrest continue to be reported. To date, no prospective studies have been reported that quantify anesthetic risk in individual patients with WS. In this article, we review the clinical manifestations of WS, propose a consensus, expert-informed method to estimate anesthetic risk based on the current literature, and provide recommendations for periprocedural management of this patient population.

Lack of effect of perampanel on QT interval duration: Results from a thorough QT analysis and pooled partial seizure Phase III clinical trials

INTRODUCTION

Perampanel is a selective, noncompetitive AMPA receptor antagonist approved as adjunctive treatment for partial seizures. To assess potential for delayed cardiac repolarization, a Phase I thorough QT study was performed, supplemented by plasma concentration-QT data modeled from 3 pooled Phase III studies.

METHODS

The Phase I thorough QT study (double-blind, combined fixed-sequence, parallel-group) quantified the effect of perampanel (6 mg once daily for 7 days, followed by dose escalation to a single 8-mg dose, a single 10-mg dose, then 12 mg once daily for 7 days), moxifloxacin positive control (single 400-mg dose on Day 16), and placebo on QT interval duration in healthy subjects (N = 261). Electrocardiograms were recorded at baseline, Day 7 (post 6 mg dose), and Day 16 (post 12 mg dose). Statistical comparisons were between the highest approved perampanel dose (12 mg) versus placebo, a "mid-therapeutic" dose (6 mg) versus placebo, and moxifloxacin versus placebo. Acknowledging that the Phase I thorough QT study could not incorporate a true "supratherapeutic" dose due to length of titration and tolerability concerns in healthy subjects, Phase III studies of perampanel included expanded electrocardiogram safety evaluations specifically intended to support concentration-QT response modeling. The lack of effect of perampanel on the QT interval is shown from pooled analysis of 3 double-blind, placebo-controlled, 19-week, Phase III studies with perampanel doses ≤ 12 mg (N = 1038, total perampanel; and N=442, placebo) in patients with partial seizures. QT measures were corrected for heart rate using Fridericia's (QTcF; the primary endpoint) and Bazett's (QTcB) formulas.

RESULTS

In the Phase I thorough QT study, the positive control moxifloxacin caused peak time-matched, baseline-adjusted, placebo-corrected (ΔΔ) QTcF of 12.15 ms at 4h postdose, confirming a drug effect on QTc interval and study assessment sensitivity. Mean baseline-adjusted (Δ) QTcF versus nominal time curves were comparable between perampanel 12 mg and placebo, with most ΔQTcF values being slightly negative. Healthy subjects receiving perampanel 6 and 12 mg doses for 7 days showed no evidence of effects on cardiac repolarization. Peak ΔΔQTcF was 2.34 ms at 1.5h postdose for perampanel 6 mg and 3.92 ms at 0.5h postdose for perampanel 12 mg. At every time point, the upper 95% confidence limit of ΔΔQTcF for perampanel 6 and 12 mg was <10 ms. Phase III studies revealed no clinically significant difference between patients with partial seizures treated with perampanel or placebo in QTcF and QTcB values >450 ms, with no dose-dependent increases or large incremental changes from baseline of >60 ms. Regression analysis of individual plasma perampanel concentrations versus corresponding QTc interval values in Phase I thorough QT and Phase III studies demonstrated no relationship between perampanel concentrations and QT interval duration.

CONCLUSION

Treatment with perampanel 6 mg and 12 mg for 7 days did not delay cardiac repolarization in healthy volunteers. In a population analysis of 1480 patients with partial seizures treated with perampanel doses ≤ 12 mg or placebo, no clinically significant trends in QT interval data were noted. Based on the thorough QT study and evaluations from pooled Phase III studies, there is no evidence of prolonged QT interval duration with perampanel treatment.