Single-lead electrocardiogram Artificial Intelligence model with risk factors detects atrial fibrillation during sinus rhythm

AIMS

Guidelines recommend opportunistic screening for atrial fibrillation (AF), using a 30 s single-lead electrocardiogram (ECG) recorded by a wearable device. Since many patients have paroxysmal AF, identification of patients at high risk presenting with sinus rhythm (SR) may increase the yield of subsequent long-term cardiac monitoring. The aim is to evaluate an AI-algorithm trained on 10 s single-lead ECG with or without risk factors to predict AF.

METHODS AND RESULTS

This retrospective study used 13 479 ECGs from AF patients in SR around the time of diagnosis and 53 916 age- and sex-matched control ECGs, augmented with 17 risk factors extracted from electronic health records. AI models were trained and compared using 1- or 12-lead ECGs, with or without risk factors. Model bias was evaluated by age- and sex-stratification of results. Random forest models identified the most relevant risk factors. The single-lead model achieved an area under the curve of 0.74, which increased to 0.76 by adding six risk factors (95% confidence interval: 0.74-0.79). This model matched the performance of a 12-lead model. Results are stable for both sexes, over ages ranging from 40 to 90 years. Out of 17 clinical variables, 6 were sufficient for optimal accuracy of the model: hypertension, heart failure, valvular disease, history of myocardial infarction, age, and sex.

CONCLUSION

An AI model using a single-lead SR ECG and six risk factors can identify patients with concurrent AF with similar accuracy as a 12-lead ECG-AI model. An age- and sex-matched data set leads to an unbiased model with consistent predictions across age groups.

[Eructonesius: a little known symptom of myocardial ischaemia]

BACKGROUND

A timely diagnosis of myocardial ischaemia is important. However, patients frequently present with rather atypical complaints. Eructonesius, or belching, is such an atypical complaint but may be considered an equivalent of angina.

CASE DESCRIPTION

A 86-year-old male with known arterial hypertension was referred with longstanding eructonesius. The complaint was initially clearly exercise-induced, but over time the belching became more intense and appeared in rest. No other cardiac or gastro-intestinal complaints were present. Gastro-intestinal examinations were uneventful. Ultimately, typical angina pectoris appeared and the patient was referred for cardiac examination. Coronary angiography revealed a significant stenosis on the circumflex artery, which was subsequently stented. After the procedure, the patient became completely asymptomatic.

CONCLUSION

Myocardial ischaemia does not necessarily present with typical angina. More often patients present with vague, atypical complaints. Therefore, a low-threshold to consider myocardial ischaemia in the differential diagnosis of such complaints remains important, especially if other diagnostic clues are present.

P08.03.A Conversation tool for brain tumor patients - tailor-made support and guidance for the patient and their proxies

Background

An evaluation by the Dutch Neuro-Oncology Society (LWNO) showed that screening for psychosocial problems and the need for psychosocial care in glioma patients and their proxies is currently not optimal. Although tools to screen for psychosocial issues such as the Distress Thermometer exist, in daily practice they appear to be insufficient to discuss all disease-specific problems patients with brain tumors may encounter. We describe the development of a conversation tool to support the consultation between the patient with a brain tumor, their proxies and the health care professionals (HCPs).

Material and Methods

The development of the conversation tool for brain tumors was based on the tool used by the AYA Care Network in the Netherlands. Topics of importance for the entire care process were identified in a brainstorming session with 15 people (comprising HCPs, patients and proxies). Subsequently, the content of the conversation tool was determined by members of the LWNO and members of the LWNO-working group of nurses specialized in neuro-oncology (LWNO-v). Each topic in the conversation tool is supported by a visual, which was developed by a graphic design company in close collaboration with patients, proxies and HCPs.

Results

The conversation tool contains a total of 35 different topics covering six domains: physical health, daily life activities, psychological health, social relationships, loss of health and life, practical issues, all illustrated by a visual. The conversation tool can be given to the patient in booklet form before an appointment with the HCP, so they can prepare the conversation upfront. In addition, cards per domain will be available in the consultation room to be used during the appointment.

Conclusion:

By using the conversation tool, optimal individual guidance and support of patients with brain tumors is facilitated, as this patient population has unique issues that are often not covered by exiting tools. Using the conversation tool also promotes a nationally uniform way of working. Currently, an interactive tool for HCPs is being developed in which an overview of available interventions and best practices for the topics in the conversation tool are described, to ensure the needs of patients can be adequately addressed. The process of development of this tool can serve as an example for other cancer types.

Rapid Exclusion of COVID Infection With the Artificial Intelligence Electrocardiogram

OBJECTIVE

To rapidly exclude severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection using artificial intelligence applied to the electrocardiogram (ECG).

METHODS

A global, volunteer consortium from 4 continents identified patients with ECGs obtained around the time of polymerase chain reaction-confirmed COVID-19 diagnosis and age- and sex-matched controls from the same sites. Clinical characteristics, polymerase chain reaction results, and raw electrocardiographic data were collected. A convolutional neural network was trained using 26,153 ECGs (33.2% COVID positive), validated with 3826 ECGs (33.3% positive), and tested on 7870 ECGs not included in other sets (32.7% positive). Performance under different prevalence values was tested by adding control ECGs from a single high-volume site.

RESULTS

The area under the curve for detection of acute COVID-19 infection in the test group was 0.767 (95% CI, 0.756 to 0.778; sensitivity, 98%; specificity, 10%; positive predictive value, 37%; negative predictive value, 91%). To more accurately reflect a real-world population, 50,905 normal controls were added to adjust the COVID prevalence to approximately 5% (2657/58,555), resulting in an area under the curve of 0.780 (95% CI, 0.771 to 0.790) with a specificity of 12.1% and a negative predictive value of 99.2%.

CONCLUSION

Infection with SARS-CoV-2 results in electrocardiographic changes that permit the artificial intelligence-enhanced ECG to be used as a rapid screening test with a high negative predictive value (99.2%). This may permit the development of electrocardiography-based tools to rapidly screen individuals for pandemic control.

Validation in French of the Montreal Cognitive Assessment 5-Minute, a brief cognitive screening test for phone administration

BACKGROUND

The prevalence of cognitive impairment and dementia is high and steadily increasing. Early detection of cognitive decline is crucial since some interventions can reduce the risk of progression to dementia. However, there is a lack of manageable scales for assessing cognitive functions outside specialized consultations. Recently, the MoCA-5min, a short version of the Montreal Cognitive assessment (MoCA), phone-administered, was validated for screening for vascular cognitive impairment. The aim of the present study was to validate the MoCA-5min in French in diverse clinical populations.

METHODS

The Cantonese version of the MoCA-5min was adapted for French language. Healthy volunteers and patients with possible or established cognitive impairment (Alzheimer's disease or related disorders, Parkinson's disease, Huntington's disease, type-2 diabetes) participated in the study. The original MoCA and the MoCA-5min were administered, by phone, with a 30-day interval. Alternate forms were used to reduce learning effects.

RESULTS

The scores of the original MoCA and MoCA-5min correlated significantly (Spearman rho=0.751, P<0.0001, 95% confidence interval 0.657 to 0.819). Internal consistency was good (Cronbach alpha=0.795). The area under the ROC curve was 0.870 and the optimal cut-off value for separating patients with and without cognitive impairment with the MoCA-5min was≤27 with 87.32% sensitivity and 76.09% specificity. Interrater and test-retest reliability were adequate.

CONCLUSION

This study demonstrates that the French version of the MoCA-5min is a valid and reliable scale for detecting cognitive impairment in different clinical populations. It is administrable by phone and thus suitable for remote assessment as well as for large-scale screening and epidemiological studies.

The neural correlates of the visual consciousness in schizophrenia: an fMRI study

In the current literature, two distinct and opposite models are suggested to explain the consciousness disorders in schizophrenia. The first one suggests that consciousness disorders rely on a low-level processing deficit, when the second model suggests that consciousness disorders rely on disruption in the ability to consciously access information, with preserved unconscious processing. The current study aims to understand the mechanisms associated with visual consciousness disorder in order to pave the road that will settle the debate regarding these hypotheses. During a functional magnetic resonance imaging session, 19 healthy participants (HC) and 15 patients with schizophrenia (SCZ) performed a visual detection task to compare the neural substrates associated with the conscious access to the visual inputs. The visual detection threshold was significantly higher in SCZ than in HC [t(32) = 3.37, p = 0.002]. Whole-brain ANOVA demonstrated that around the visual detection threshold patients with SCZ failed to activate a large network of brain areas compared to HC. (1) During conscious vision, HC engaged more the left cuneus and the right occipital cortex than patients with SCZ, (2) during unconscious vision, HC engaged a large network that patients with SCZ failed to activate, and finally, (3) during the access to consciousness process, patients with SCZ failed to activate the anterior cingulate cortex. These results suggest that the consciousness disorders in schizophrenia rely on specific dysfunctions depending on the consciousness stage. The disorders of the conscious vision are associated with dysfunction of occipital areas while the ones associated with unconscious vision rely on a large widespread network. Finally, the conscious access to the visual inputs is impaired by a dysfunction of the anterior cingulate cortex. The current study suggests that none of the two suggested models can explain consciousness disorders in schizophrenia. We suggest that there is an alternative model supporting that the conscious access to visual inputs is due to a disengagement of the supragenual anterior cingulate during the unconscious processing of the visual inputs associated with a sensory deficit.

Looking back on 15 years of ultrasound-guided alcohol septal ablation for hypertrophic obstructive cardiomyopathy

Background: Septal reduction remains an important target of current therapeutic modalities in hypertrophic obstructive cardiomyopathy (HOCM). Surgical septal myectomy has long been considered the gold standard in pharmacotherapy-refractory severely symptomatic patients with marked left ventricular outflow tract (LVOT) obstruction. In recent years, percutaneous alcohol septal ablation (ASA) has matured into the preferred strategy for patients with favourable anatomy and no other coexisting surgically amenable disease.Methods: We discuss 26 HOCM patients with persistent dyspnoea, angina or syncope despite optimal medical treatment. Baseline septal wall thickness was 20 ± 3 mm, with peak resting/provoked LVOT gradients of 53 ± 35/112 ± 40 mmHg. Guided by echocardiography, alcohol injection could be restricted to the first septal coronary artery in 85% of patients, provoking basal septal infarction with average troponin rise of 3.0 ng/ml.Results: Eighty-six per cent of patients experienced sustained clinical improvement, associated with a reduction of septal wall thickness to 15 ± 3 mm and resting LVOT gradient to 21 ± 15 mmHg. One of the two non-responders underwent additional septal myectomy 11 years after ASA. Notable adverse events during the follow-up of 7.2 ± 4.7 years included: persistent conduction disturbances (65%) necessitating early postprocedural permanent pacemaker implantation (15%); atrial fibrillation (32%); ventricular tachycardia (4%) and aortic stenosis (14%). Six patients died, of which only 1 cardiac death.Conclusions: Our case series underscores the efficacy of ASA at relieving LVOT obstruction and improving symptoms in properly selected HOCM patients, with acceptably low procedural and long term mortality and morbidity.

Left Ventricular End-Systolic Dimension and Outcome in Patients With Heart Failure Undergoing Percutaneous MitraClip Valve Repair for Secondary Mitral Regurgitation

Recent MitraClip heart failure (HF) trials suggest that baseline left ventricular (LV) remodeling may be critical for patient selection. We, therefore, investigated whether baseline LV remodeling affects safety, efficacy, and clinical outcomes in HF patients with symptomatic secondary mitral regurgitation (MR) undergoing percutaneous mitral valve repair using MitraClip. LV remodeling was assessed by LV end-systolic dimension index (LVESDi) on transthoracic baseline echocardiography. Early and late outcome was reported using Mitral Valve Academic Research Consortium-criteria. A total of 107 consecutive HF patients (73 ± 10 years, 70% male) who underwent MitraClip intervention for secondary MR were studied. The study population was stratified by median LVESDi between nonadvanced (<28 mm/m², n = 49) and advanced LV remodeling (≥28 mm/m², n = 58). Both groups had similar acute procedural success, in hospital bleeding and nonbleeding complications and significant improvement in MR severity and symptoms, sustained up to 36 months (all p >0.05). LVESDi, but not LV end-diastolic diameter index nor LV ejection fraction, independently related to HF hospitalization (hazard ratio 1.11, 95% confidence interval 1.05 to 1.16, p <0.001) and mortality (hazard ratio 1.11, 95% confidence interval 1.06 to 1.17, p <0.001). At 1 and 3 years, survival free of HF hospitalization was higher in patients without versus with advanced LV remodeling (89% vs 66% and 65% vs 37%, p = 0.002) and mortality was lower (9% vs 24% and 36% vs 47%, p = 0.074), respectively. Annual HF hospitalization rate only decreased in the nonadvanced LV remodeling group (-43%, p = 0.025). Advanced LV remodeling, assessed by LVESDi, in HF patients who underwent MitraClip therapy does not influence therapeutic safety nor efficacy, but implies increased HF hospitalization and mortality risk. This parameter may be valuable for MitraClip therapy patient selection.

243Reviewing electronic health records with the use of natural language processing to determine the prognostic impact of AF and anticoagulation therapy in patients undergoing PCI

Introduction

Between 10-15% of patients undergoing percutaneous coronary intervention (PCI) have a history of atrial fibrillation (AF), and require both oral anticoagulant (OAC) as well as antiplatelet therapy following PCI.  However this combination puts the patient at a high risk of serious or fatal bleeding complications.  Using big data from electronic health records (EHR) provides the unique opportunity to observe to what extent AF and anticoagulant therapy affect the outcome of patients undergoing PCI in routine clinical practice.

Purpose

We analysed whether a history of AF and the use of OAC upon discharge was independently associated with short-term, mid-term and long-term mortality in large single institution cohort of patients undergoing PCI.

Methods

This retrospective EHR study was approved by the institutional review board and data privacy officer.  The study population comprised all patients undergoing either planned or urgent PCI between 2012 and 2018.  SNOMED time coded past and current medical diagnosis, procedures and drug therapy were extracted from the medical correspondence using natural language processing, procedural characteristics were obtained from the PCI database, and hospital admission data, billing cost, length of stay and vital status were added from the hospital administrative software.  Vital status was obtained in all patients. The independent predictors of mortality were analysed using a stepwise multivariate logistic linear regression analysis, with automated forward selection of variables.  For each variable the odds ratio with confidence intervals were derived from the regression model.  The validity of the model was tested with the Hosmer and Lemeshow test.

Results

During a 6 year period 5223 patients were identified who underwent a total of 6854 PCI’s, of which 74% were men with a median age of 71 years.  At the time of PCI, 256 patients had  AF and were not treated with OAC, 549 patients had AF and were treated with OAC, 284 patients developed AF during follow up and 5765 were in sinus rhythm. Patients with a history of AF or ensuing AF were older, more often had multivessel coronary disease, a history of CABG and MI, renal failure, diabetes mellitus and a lower ejection fraction. AF was found to be a strong independent predictor of mortality at 30 days (OR: 2,8), 120 days (OR: 2), 1 year (OR: 1,9) and 5 years (OR: 1,7) following PCI. By contrast OAC was associated with lower odds ratios of mortality at 30 days (OR: 0,4), 120 days (OR: 0,4), 1 year (OR: 0,7) and 5 years (OR: 0,7).  Also the occurence of AF post PCI was linked with an increased mortality

Conclusions

In this large data set of patients undergoing PCI in routine clinical practice, a history of AF was independently associated with increased short-term, mid-term and long-term mortality. On the other hand, OAC was associated with improved short-term, mid-term and long-term mortality survival following PCI.

Abstract Figure.

A quality project for radiation reduction in the cath lab

The radiation exposure in the cath lab of patients, cardiologists, and nurses was measured during three consecutive periods of 8 weeks. The first 8 weeks the baseline radiation exposure was obtained. In the second period standard incidences for coronarography and frame rate were changed, without compromising the image quality of the examination. In the third period, a pelvic shield covered the lower part of the patient. This pilot quality project demonstrates that further significant reduction in radiation exposure of 37% is possible for patients. A significant reduction in radiation exposure of 53 and 62% was obtained among cardiologists and nurses working in the cath lab, even with the already diminished radiation exposure over the last years by better equipment and general radioprotection measures.

Cognitive behavioural therapy for anxiety disorders in Parkinson's disease: Design of a randomised controlled trial to assess clinical effectiveness and changes in cerebral connectivity

BACKGROUND

Anxiety disorders occur in up to 35% of patients with Parkinson's disease (PD) and have a negative effect on motor symptoms and quality of life. To date, no clinical trials specifically targeting anxiety in PD patients have been published.

OBJECTIVE

To describe the rationale and methodology of a randomised controlled trial (RCT) that aims to study the clinical effectiveness, alterations in brain circuitry, and cost-effectiveness of cognitive behavioural therapy (CBT) for anxiety in PD.

METHODS

This study is a prospective, two-centre RCT in which sixty PD patients with anxiety will be randomised to CBT treatment and clinical monitoring (intervention group) or to clinical monitoring only (control group). The CBT module used in this study was specifically developed to address symptoms of anxiety in PD patients. Participants will undergo standardised clinical, cognitive and behavioural assessment at baseline and at 2 follow-up measurements, as well as resting-state fMRI and DTI scanning before and after the intervention. The primary outcome measure is changes in severity of anxiety symptoms. Secondary outcome measures involve long-term changes in anxiety symptoms, changes in functional and structural connectivity between limbic and frontal cortices, and cost-effectiveness of the treatment. The study is registered at the ClinicalTrials.gov database under registration number NCT02648737.

CONCLUSION

This study is the first that evaluates both the clinical effectiveness, cost-effectiveness, as well as the biological impact of CBT for anxiety in PD patients that, if proven effective, will hopefully contribute to a better and evidence-based approach for these non-motor symptoms.

Functional connectivity disruptions correlate with cognitive phenotypes in Parkinson's disease

Cognitive deficits in Parkinson's disease are thought to be related to altered functional brain connectivity. To date, cognitive-related changes in Parkinson's disease have never been explored with dense-EEG with the aim of establishing a relationship between the degree of cognitive impairment, on the one hand, and alterations in the functional connectivity of brain networks, on the other hand.

This study was aimed at identifying altered brain networks associated with cognitive phenotypes in Parkinson's disease using dense-EEG data recorded during rest with eyes closed. Three groups of Parkinson's disease patients (N = 124) with different cognitive phenotypes coming from a data-driven cluster analysis, were studied: G1) cognitively intact patients (63), G2) patients with mild cognitive deficits (46) and G3) patients with severe cognitive deficits (15). Functional brain networks were identified using a dense-EEG source connectivity method. Pairwise functional connectivity was computed for 68 brain regions in different EEG frequency bands. Network statistics were assessed at both global (network topology) and local (inter-regional connections) level.

Results revealed progressive disruptions in functional connectivity between the three patient groups, typically in the alpha band. Differences between G1 and G2 (p < 0.001, corrected using permutation test) were mainly frontotemporal alterations. A statistically significant correlation (ρ = 0.49, p < 0.001) was also obtained between a proposed network-based index and the patients' cognitive score. Global properties of network topology in patients were relatively intact.

These findings indicate that functional connectivity decreases with the worsening of cognitive performance and loss of frontotemporal connectivity may be a promising neuromarker of cognitive impairment in Parkinson's disease.

•

We test the use of dense-EEG to identify altered brain networks associated with cognitive phenotypes in Parkinson's disease.

•

The functional connectivity decreases with the worsening of cognitive performance

•

The loss of frontotemporal connectivity may be a promising neuromarker of cognitive impairment in Parkinson's disease.

French consensus procedure for assessing cognitive function in Parkinson's disease

INTRODUCTION

One of the objectives of the French expert centers for Parkinson's disease (NS-Park) network was to determine a consensus procedure for assessing cognitive function in patients with Parkinson's. This article presents this procedure and briefly describes the selected tests.

METHODS

A group of 13 experts used the Delphi method for consensus building to define the overall structure and components of the assessment procedure. For inclusion in the battery, tests had to be validated in the French language, require little motor participation, have normative data and be recognized by the international community. Experimental tasks and tests requiring specific devices were excluded.

RESULTS

Two possibilities were identified, depending on whether an abbreviated or comprehensive assessment of cognitive function was necessary. For an abbreviated assessment, the experts recommended the Montreal Cognitive Assessment (MoCA) as a screening test for cognitive impairment or dementia. For a comprehensive neuropsychological assessment, the experts recommended assessing global efficiency plus the five main cognitive domains (attention and working memory, executive function, episodic memory, visuospatial function and language) that may be impaired in Parkinson's disease, using two tests for each domain.

DISCUSSION AND CONCLUSION

A common procedure for assessing cognitive function is now available across the French network dedicated to Parkinson's disease, and is recommended for both research and clinical practice. It will also help to promote standardization of the neuropsychological assessment of Parkinson's disease.

Non-compaction cardiomyopathy: a genetically and clinically heterogeneous disorder

Left ventricular non-compaction (LVNC) is a rare disease that can occur isolated or in association with other disorders, including congenital heart disease and musculoskeletal disorders. It is characterized by a two-layered myocardium with excessive trabeculation of the left ventricle. Diagnosis is challenging as left ventricular trabeculations can be pathological yet can also be a normal finding in athletes and black people, leading to overdiagnosis. Echocardiography and CMR are important diagnostic tools. LVNC is often complicated by ventricular dysfunction, arrhythmias and thromboembolic events. Based on two cases, we review the pathogenesis, genetic background, clinical features and treatment of LVNC according to the available guidelines.

L’apathie : définitions, diagnostic, épidémiologie et retentissement

L’apathie est un trouble invalidant, présent dans de nombreuses pathologies neurologiques et psychiatriques. Il s’agit d’un trouble de la motivation caractérisé par des manifestations comportementales, cognitives et émotionnelles telles qu’une perte d’intérêt et une moindre participation aux activités de la vie quotidienne, un manque d’initiative, peu de persévérance dans les activités entamées, une indifférence et un émoussement affectif. Il ne s’agit pas uniquement d’un symptôme de la dépression ou d’un signe d’entrée dans la démence mais l’apathie existe en tant que syndrome à part entière. Elle a été longtemps sous-diagnostiquée en raison d’une absence de consensus au sujet de sa définition. Néanmoins, des critères de diagnostic ont récemment été publiés et leur validité a été éprouvée et démontrée dans plusieurs maladies neuropsychiatriques . De plus, un certain nombre d’échelles sont aujourd’hui reconnues pour leur validité dans le dépistage ou l’évaluation du syndrome apathique . D’un point de vue physiopathologique, les mécanismes à l’origine du syndrome apathique restent encore à élucider mais il est généralement admis que les comportements motivés mettent en œuvre le système limbique. Le circuit striato-frontal ventral (reliant le striatum ventral aux régions ventro-médianes du cortex préfrontal) semble particulièrement impliqué. Le rôle des voies dopaminergiques est également démontré même si d’autres neuro-modulateurs semblent également impliqués. L’apathie accroît fortement le fardeau des aidants et compte tenu de son impact sur le niveau fonctionnel et la qualité de vie des patients, elle mérite une attention particulière, notamment un dépistage systématique et une prise en charge précoce.

[Continuous subcutaneous infusion of apomorphine in Parkinson's disease: retrospective analysis of a series of 81 patients]

BACKGROUND

Continuous subcutaneous infusion of apomorphine (CAI) has shown efficacy in the treatment of motor fluctuations but its place in the therapeutic arsenal remains poorly defined in terms of indication, acceptability and long-term tolerance. Indeed, few studies have been carried out with a follow-up greater than 12 months. The main objective was to assess the quality of life of Parkinson's disease (PD) patients treated with CAI. We also evaluate the effectiveness on the motor fluctuations, the long-term tolerance of this treatment with its causes of discontinuation and the treatment regimens used.

METHODS

We conducted a retrospective study of 81 PD patients treated with CAI between April 2003 and June 2012. Data were collected from medical records. A repeated measures analysis of variance by the linear mixed model was used (significance level: 5%).

RESULTS

In August 2012, 27/81 patients were still treated with CAI with a mean duration of 28 months, 46/81 discontinued CAI (9 precociously), and 8 were lost to view. We didn't show improvement in the quality of life nor efficacy of CAI on the UPDRS IV score (P=0.54) and dyskinesia score (P=0.95). The CGI score patient also reflects this result with a majority response suggesting no significant change with CAI. We observed relative good cognitive and psychiatric tolerance. Adverse events were frequent but often benign. The average (±SD) rate of apomorphine was 3.15±1.71 mg/h and the oral dopaminergic treatment was decreased by 37.8%.

DISCUSSION

The results are consistent with the literature except for the lack of efficiency on motor fluctuations which may be due to the use of too small doses of apomorphine. This seems to be a leading cause of discontinuation of CAI, especially when it is associated with side effects or important constraints. For better efficiency on motor fluctuations, we recommend the use of apomorphine at higher doses to obtain an optimal continuous dopaminergic stimulation.

Brugada syndrome presenting as an acute coronary syndrome

Syncope, non-specific ST-segment alterations and elevated troponin (cTn) are suspicious of an acute coronary syndrome (ACS). While an ACS is excluded when the coronary angiogram returns normal, the raised cTn should prompt a search for other potentially lethal diseases, such as pulmonary embolism, myocarditis or malignant ventricular arrhythmias. Here we describe a 42-year-old man presenting with syncope, ST-segment elevation, cTn rise and a normal angiogram. He was ultimately diagnosed with Brugada syndrome.

Haemolysis and acute renal failure after mitral valve repair

We present a case of severe haemolysis and acute renal failure 5 weeks following mitral valve repair of mitral valve prolapse. Intravascular haemolysis in this patient was caused by fragmentation of a mitral regurgitant jet due to residual prolapse and partial dehiscence of the mitral valve repair ring. Urgent redo mitral valve repair was successful in resolving the mitral regurgitation and haemolysis, but renal function parameters could not be restored to normal values.

[Apathy in Parkinson's disease: clinical features, mechanisms and assessment]

Apathy is a loss of motivation compared to the previous level of functioning of the subject. It affects the subject's behavior, cognition and emotional state. It is one of the main behavioral manifestations of Parkinson's disease. Although it may be a symptom of depression, it often exists as an isolated syndrome in Parkinson's disease patients. Apathy is usually not related to the severity of the motor symptoms, but frequently associated with the severity of cognitive impairment. Apathy is also a possible complication of treatment by stimulation of the subthalamic nucleus. Screening and assessment of apathy require the use of specific tools, some of which are validated in Parkinson's disease. From a pathophysiological point of view, apathy results from a dysfunction of the limbic circuit connecting the ventral striatum to orbitofrontal and anterior cingulate cortex. The dopaminergic denervation in these regions seems to play a key role, but other mechanisms are probably involved. Further studies are warranted to progress in the therapeutic management of this invalidating syndrome.

Anxiety and motor fluctuations in Parkinson's disease: a cross-sectional observational study

BACKGROUND

Some studies have suggested a relationship between anxiety and motor fluctuations in patients with Parkinson's disease (PD).

AIM

To describe the nature of the relationship between anxiety symptoms and motor fluctuations and to describe the anxiety symptoms encountered during 'off', 'on' and 'on with dyskinesia' phases.

DESIGN AND METHODS

In this cross-sectional study, 250 patients with idiopathic PD, of whom 118 had motor fluctuations, underwent a standardized clinical assessment including the Unified Parkinson's Disease Rating Scale (UPDRS), the DSM IV criteria for major depression and anxiety disorders, the Hamilton Depression Rating Scale (HAMD), and the Hamilton Anxiety Rating Scale (HARS). In addition, patients with motor fluctuations were administered a questionnaire to assess the presence of anxiety symptoms and their relation to motor states.

RESULTS

Patients with motor fluctuations suffer from generalized anxiety disorder more often than patients without motor fluctuations. When patients with motor fluctuations have anxiety symptoms, the majority report that these have no temporal relationship with specific motor states. When there was a relationship, symptoms were almost always related to 'off' periods. However, a minority of patients experience anxiety symptoms during 'on' or "on with dyskinesia" periods exclusively.

CONCLUSION

Our findings suggest that the relationship between anxiety and motor fluctuations is more complex than can be explained solely by 'wearing off' phenomena of levodopa. Further studies investigating the temporal dynamics of anxiety and motor fluctuations are needed.

Diagnostic criteria for apathy in clinical practice

BACKGROUND

Apathy is an important and distressing behavioural symptom in Alzheimer's disease and in various neuropsychiatric disorders. Recently, diagnostic criteria for apathy have been proposed.

OBJECTIVES

In groups of patients suffering from different neuropsychiatric diseases, (i) to estimate the prevalence of patients meeting the proposed diagnostic criteria; (ii) to estimate the concurrent validity of the criteria with the neuropsychiatric inventory (NPI) apathy item; (iii) to identify the most frequently met criteria or sub-criteria in each specific neuropsychiatric disease and (iv) to estimate the inter-observer reliability of the diagnostic criteria for apathy.

METHODS

This cross-sectional, multicentric, observational study was performed on 306 patients. Each of the participating centres had to check the presence of apathy according to the diagnostic criteria for apathy in consecutive patients belonging to the following diagnoses list: Alzheimer disease (AD), mixed dementia, mild cognitive impairment (MCI), Parkinson's disease (PD), Schizophrenia (DSM-IV) and major depressive episode. In addition to the clinical interview, the assessment included the Mini Mental Score Examination (MMSE) and the NPI. At the end of the visit, clinicians were required to check the diagnostic criteria for apathy.

RESULTS

Using the diagnostic criteria for apathy, the frequency of apathy was of 53% in the whole population, 55% in AD, 70% in mixed dementia, 43% in MCI, 27% in PD, 53% in schizophrenia and 94% in major depressive episode. In AD, mixed dementia, MCI and PD, the NPI apathy score was significantly higher for patient fulfilling the apathy criteria. Goal-directed cognitive activity (criteria B2-Cognition) was the most frequently observed domain followed by goal-directed behaviour (criteria B1-Behaviour) and emotion (criteria B3), respectively. Inter-rater reliability was high for the overall diagnostic (κ coefficient = 0.93; p = 0.0001) and for each criteria.

CONCLUSION

This study is the first one to test the diagnostic criteria for apathy in clinical practice. Results make the diagnostic criteria useful for clinical practice and research.

An unusual cause of carcinoid heart disease

Carcinoid heart disease (CHD) is a rare form of valvular heart disease characterized by right-sided heart valve dysfunction. Carcinoid heart disease occurs most frequently when carcinoid tumour cells metastasize from a primary site in the gut to the liver, so that vasoactive substances produced by the tumour are able to reach the systemic circulation. By contrast, in ovarian carcinoid tumours carcinoid heart disease develops in the absence of liver metastasis, because vasoactive substances can be released directly into the systemic circulation, bypassing the first-pass metabolism of the liver. There are only a few case reports in the world literature of carcinoid heart disease caused by ovarian carcinoid tumour. We report a case of an 85-year-old woman with carcinoid heart disease caused by a bilateral ovarian carcinoid tumour metastasized from a primary ileal site.