Low Yield In Patients Research Articles

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

57-Year-Old Man With Vertigo

57-Year-Old Man With Vertigo

Abstract WMP69: Differential Risk Factor Profile in Cryptogenic Stroke Patients May Help Identify High Yield Candidates for Long-term Cardiac Monitoring in Detection of Paroxysmal Atrial Fibrillation

Introduction: Paroxysmal afib is the most common cause of cryptogenic strokes. Long-term insertable cardiac monitor (ICM) has been increasingly used for ongoing evaluation of afib in these patients. Due to financial affordability, it is important to identify appropriate candidates for its routine use. Methods: We reviewed EMRs of a cohort of cryptogenic stroke patients from February 2014 to May 2017 who received REVEAL LINQ ICMs. All patients met ESUS criteria prior to insertion and were enrolled in remote follow-up. At least one year monitoring was conducted if no afib was recorded. Patient demographics, stroke characteristics and risk factors were compared between patients with and without afib. Results: Among total 348 patients enrolled, 99 (28.5%) were found to have afib with median time to afib detection of 128 days. For patients without afib, the median length of follow up was 566 days. Patients with afib were significantly older (mean ± SD, 73.0 ± 9.42 vs. 64.4 ± 11.5, p<0.00001) and their left atrium size (mm) were significantly larger (37.9 ± 7.26 vs. 35.4 ± 5.81, p<0.005) than those patients without afib. Non-afib patients had statistically more frequent association with ongoing smoking or LDL ≥ 120 comparing with afib patients (p<0.05). Although not statistically significant, there was tendency that posterior circulation only strokes occurred less in afib group (p=0.08). However, intra- and extracranial atherosclerosis were comparable between afib and non-afib groups. Within the afib group, afib was detected within 30 days in 25 patients with median time to detection of 14 days. These patients had significant higher rate of intracranial stenosis (p=0.01) comparing with those patients with afib detected beyond 30 days. Conclusion: Paroxysmal afib related strokes account for about one-fourth of cryptogenic strokes in our cohort. Long term ICM may benefit more in older patients with enlarged left atrium and lack of risk factors such as smoking and high LDL. It likely has low yield in patients with posterior infarcts only. Noninvasive ambulatory ECG monitoring for 30 days may be considered first in patients with intracranial stenosis.

Early Echocardiography Has a Low Yield in Patients with Transient Ischemic Attack

Current guidelines recommend patients presenting with transient ischemic attack (TIA) undergo echocardiography to evaluate for a cardiac source. However, echocardiography is not available daily at many centers. We assessed the yield from early transthoracic echocardiography (TTE) in consecutive patients with TIA evaluated in an emergency department observation unit (EDOU) protocol. This observational cohort study took place in an academic medical center from January 1, 2011 to July 31, 2013. Patients seen in the emergency department, assigned to the EDOU for a TIA accelerated diagnostic protocol and discharged with a diagnosis of TIA were included. We retrospectively collected baseline patient characteristics, ABCD2 score, neuroimaging, telemetry, TTE, and 3-month clinical outcomes. Of 236 subjects (mean age 62 ± 15 years, 68% female, 57% African American, 17% with history of stroke, 27% with history of cardiac disease, mean ABCD2 score 3.8 ± 1.5, mean EDOU length of stay 18.6 ± 6.2 hours), abnormal bedside cardiac examination was identified in 19 (8%) patients, abnormal electrocardiogram (ECG)/telemetry in 41 (17%), and abnormal TTE in 64 (27%), 41 of which suggested a patent foramen ovale. Among 136 (58%) patients with no previous cardiac disease or stroke, a normal bedside cardiac examination, and normal ECG/telemetry, TTE identified no high-risk cardiac causes. In patients with TIA presenting to an EDOU with no previous cardiac disease or stroke, normal cardiac examination, and normal ECG/telemetry, early TTE had a low yield for identifying high-risk cardiac causes. In EDOUs where TTE is not available daily, outpatient TTE for this patient subgroup may be considered to limit prolonged lengths of stay.

Diagnostic yield of cystoscopy in the evaluation of recurrent urinary tract infection in women.

Due to a paucity of evidence-based guidelines, anecdotal practice patterns often dictate clinical management of recurrent urinary tract infection (UTI) in women. Our aim was to identify pathologic findings of the urinary tract through cystoscopy and imaging in women with recurrent UTI, and to determine if specific risk factors are associated with a higher rate of abnormal findings. In a single-institutional cohort, cystoscopy was performed for women with recurrent UTI between 1/2010 and 7/2014. All eligible patients were included in a maintained database and those with gross or microscopic hematuria were excluded. Abdominopelvic imaging was recommended and included in study data when completed. Associations between clinical risk factors (history of renal transplant, urogynecologic surgery, or urolithiasis) and abnormal findings were analyzed by Fisher's exact test. A total of 163 women (mean age 60.6 years) were included in final analysis. Abdominopelvic imaging was available in 133 (82%) cases. Cystoscopy identified 9 (5.5%) cases of significant clinical findings. Of these only 5 (3.8%) cases were uniquely identified on cystoscopy and missed on imaging modalities. When imaging was normal, cystoscopy was also normal in 94% of cases. The examined clinical risk factors were not associated with higher risk of abnormal cystoscopy (P = 0.49) or imaging (P = 0.42). Cystoscopy performed solely for recurrent UTI is low yield in patients with normal imaging studies, but a small number of abnormal findings may be missed by foregoing this element of the patient workup. No studied risk factor was predictive of an abnormal workup. Neurourol. Urodynam. 36:692-696, 2017. © 2016 Wiley Periodicals, Inc.

The prevalence of structural pituitary abnormalities by MRI scanning in men presenting with isolated hypogonadotrophic hypogonadism.

Hypogonadotrophic hypogonadism (HH) is commonly associated with ageing, obesity and type 2 diabetes. The indications for pituitary imaging are controversial, and current guidelines are based on small case series. Retrospective case series from a secondary/tertiary endocrinology referral centre. All men presenting to the Edinburgh Centre for Endocrinology and Diabetes with hypogonadotrophic hypogonadism (testosterone <10 nmol/l and normal prolactin) from 2006 to 2013, in whom pituitary MRI was performed (n = 281). All HH patients referred in 2011 (n = 86) were reviewed to assess differences between those selected for pituitary MRI and those who were not scanned. Pituitary MRI was normal in 235 men (83·6%), with 24 microadenomas (8·5%), 5 macroadenomas (1·8%) and 1 craniopharyngioma (0·4%) identified. The remaining 16 (5·7%) comprised a range of minor pituitary abnormalities including small cysts and empty sella. All men with abnormal imaging studies had otherwise normal pituitary function. Imaging abnormalities were associated with a significantly lower age at presentation (50 vs 54 years, P = 0·02), but no differences in testosterone or gonadotrophin levels were observed. Current Endocrine Society guidelines would have prompted imaging in only three of six patients with significant pituitary pathology. Structural pituitary disease is more common in isolated HH than in the general population, and current guidelines do not accurately identify 'at-risk' individuals. Full anterior pituitary function testing has a low yield in patients presenting with hypogonadism. The optimal strategy for determining the need for pituitary imaging remains uncertain.

Myocardial perfusion imaging in emergency department patients with negative cardiac biomarkers: yield for detecting ischemia, short-term events, and impact of downstream revascularization on mortality.

In patients with possible acute coronary syndromes, guidelines recommend routine provocative testing after negative cardiac biomarkers. We hypothesized that myocardial perfusion imaging would be low yield with limited short-term value and that early revascularization would not affect mortality. We identified consecutive patients referred from our emergency department between October 2004 and September 2011 who had myocardial perfusion imaging after negative troponin T tests and nondiagnostic ECGs. We assessed the incidence of abnormal myocardial perfusion imaging, coronary angiography, revascularization, and mortality. In a cohort of 5354 patients (58.7% female, age 59 ± 13, 78.6% thrombolysis in myocardial infarction [TIMI] ≤2), 9% had >5% and 3.6% had >10% ischemic myocardium. Among patients with TIMI scores ≤2, 6.1% had >5% ischemic myocardium compared with 19.6% of patients with TIMI scores ≥3 (P<0.001). At 30 days, 7 patients were deceased, 187 had revascularization, and 6 had revascularization for an acute myocardial infarction. Over 3.4 ± 1.9 years of follow-up, 347 patients died. In propensity-matched groups of patients with ischemia, there was no association between early revascularization and mortality (hazard ratio, 1.00; 95% confidence interval, 0.49-2.07). Routine provocative testing to detect ischemia before emergency department discharge is low yield in patients with negative troponins and TIMI scores ≤2 and modest yield in patients with TIMI scores ≥3. In all patients, 30 days events are rare. Finally, in patients with ischemia, we are unable to demonstrate a mortality benefit with early revascularization.

79-Year-Old Woman With Forgetfulness

79-Year-Old Woman With Forgetfulness

Random Biopsies During Colonoscopy in Patients with Primary Sclerosing Cholangitis and Ulcerative Colitis: Does it Impact Clinical Outcome?

Purpose: Patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) are at increased risk of dysplasia and/or colorectal cancer. We hypothesize that random biopsies may have low yield in patients without endoscopic features of previous severe inflammation. We wanted to evaluate the yield and clinical impact of random biopsies taken during colonoscopic surveillance of patients with both UC and PSC. Methods: In total, 54 patients with UC/PSC who underwent colonoscopy at the Cleveland Clinic were included in this study. Retrospective analysis of 142 colonoscopies (both for surveillance and symptomatic indication) in patients with UC and PSC performed from 2001 to 2010. Colonoscopy and pathology reports were reviewed to assess the yield and clinical impact of random biopsies. The main outcome measures are neoplasia yield per-colonoscopy and clinical impact per-patient of random biopsies. Results: Of the 142 colonoscopies, 111 were performed for surveillance(in 54 patients) during which 2,379 random biopsies were taken (median 16) calculated from the pathology report. Overall, neoplasia was detected in 16 colonoscopies (13 patients): in 8 colonoscopies(50%) by targeted biopsies only, in 4 (25%) by both targeted and random biopsies. Neoplasia was detected in random biopsies only in four (25%) colonoscopies in four patients. One patient had unifocal low-grade dysplasia (LGD) that could not be confirmed in two subsequent colonoscopies, while the other two patients with unifocal LGD did not have any evidence of dysplasia in the colectomy specimen. Only one patient had unifocal LGD on random biopsy and proctocolectomy confirmed the presence of multifocal LGD. Neoplasia was detected by only random biopsies in four surveillance colonoscopies (per-colonoscopy yield 25%), while the clinical impact was seen in three colonoscopies (per-colonoscopy yield 18.75%). However the real clinical significance was only seen in one colonoscopy (per-colonoscopy yield 6.25%) This patient had evidence of previous inflammation in the form of pseudopolyps. Increasing age (p=0.03), presence of pseudopolyps (p=0.004), active treatment for underlying UC (p=0.004) and target biopsies done during colonoscopy (p<0.001) independently predicted the presence of dysplasia during colonoscopy on multivariate analysis. (Table 1)Table 1: Multivariate adjusted odds ratio (aOR) for dysplasia during colonoscopyConclusion: Presence of endoscopic features of previous inflammation, increasing age and presence of suspicious lesions predict associated neoplasia in UC/PSC patients. Neoplasia was detected in only random biopsies in four patients of whom only one had significant lesion in the proctocolectomy specimen. Random biopsies may be of higher yield only in patients with previous inflammation on endoscopy even in this high risk population of UC/PSC.

The Utility of Repeat Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) for Suspected Pancreatic Cancer

Background: EUS-FNA is the gold standard for tissue diagnosis in patients with pancreatic cancer. The utility of repeat EUS-FNA in patients with clinical suspicion for pancreatic cancer after non-diagnostic EUS-FNA study is not well established. Aim: To determine the yield of repeat EUS-FNA in patients with suspected pancreatic cancer with prior non-diagnostic EUS-FNA. Methods: This was a retrospective review of prospectively collected data in searchable electronic database. All patients who underwent more then one EUS-FNA in our institution for evaluation of suspected pancreatic cancer were included in this analysis. Results: From 1/21/2002 to 11/25/2008 total of 3895 EUS procedures were performed in our institution. Of these, 31 patients (12 M, 19 F), (mean age 61.7, range 41-82) had repeat EUS-FNA done for the evaluation of possible pancreatic cancer. Pre-procedure CT or MRI showed definitive or possible pancratic mass in 29 (93.5%), and no desecrate mass in 1 (3.2%) patient. No imaging study was available in 1 (3.2%) patient. Initial EUS evaluation showed pancreatic mass in 25 (80.6%), and no mass in 5 (16.2%) patients. In 1 (3.2%) patient at the first EUS the mass was thought to arise from the duodenum but on the repeat EUS was found to also be a pancreatic lesion. The mean number of FNA passes on initial EUS was 4 (range 1-7). Cytologic evaluation was atypical/suspicious in 8 (25.8%), and benign/reactive in 23 (74.2%). At the second EUS-FNA definitive malignancy was diagnosed in 2 (6.45%) of the patients with prior atypical/suspicious findings at the first EUS-FNA, and in 3 (9.67%) of the patients with benign/reactive initial cytology. In 19 (59.3%) patients the lesion was located in the pancreatic head/uncinate, and in 12 (37.5%) in the neck/body/tail. Based on the location of the lesion, malignancy was diagnosed at the second EUS-FNA in 3 (15.78%) of the lesions in the head/uncinate process, and in 2 (25%) of the lesions in the neck, body and tail. The mean number of FNA passes on the repeat EUS examination was 4.14 (range 1-8). Overall repeat EUS-FNA established definitive tissue diagnosis of malignancy in 5/31 patients (16.2%). Conclusion: Repeat EUS-FNA has low yield in patients with suspected pancreatic cancer who had had prior negative EUS-FNA evaluation.

Cohen Cross-Trigonal Ureteral Reimplantation: Is a One-Year Postoperative Renal Ultrasound Scan Necessary After Normal Initial Postoperative Ultrasound Findings?

To determine the utility of the 1-year postoperative renal ultrasound scan in children undergoing uncomplicated Cohen cross-trigonal ureteral reimplantation. A retrospective review of 108 patients (233 ureters) who had undergone uncomplicated Cohen cross-trigonal ureteral reimplantation during a 6.5-year period with a postoperative follow-up of 1 year was performed. Renal ultrasound scans were obtained at 1 month and 1 year postoperatively. Of the 108 patients who had undergone ureteral reimplantation, 26 patients (24%) had mild to moderate hydronephrosis at 1 month postoperatively. Of these 26 patients, 20 had preexisting hydronephrosis and 6 had new hydronephrosis. Of the 20 patients with preoperative hydronephrosis, 19 (95%) had similar hydronephrosis on the 1-month postoperative ultrasound scan and in 1 (5%), the hydronephrosis had resolved. At 1 year, 13 (69%) of the 20 patients with preoperative hydronephrosis had stable hydronephrosis, and it resolved in 6 (31%). In the 6 patients with new-onset hydronephrosis at 1 month postoperatively, the hydronephrosis had resolved by 1 year in 4 patients (67%) and was mild in 2 (33%). Three patients developed transient obstruction requiring stent placement. It has been recommended that a renal ultrasound scan be obtained in children 1 year after open ureteral reimplantation to rule out delayed obstruction. Our results suggest this is of low yield in patients with uncomplicated open ureteral reimplantation.

MRI Screening in a Clinic Population with a Family History of Breast Cancer

Breast MRI is increasingly being used in patients at increased risk for breast cancer; however, guidelines for MRI screening are inadequately defined. We describe our experience with MRI screening in a large population of women with a family history of breast cancer. We retrospectively reviewed the Memorial Sloan-Kettering breast cancer surveillance program prospective database from April 1999 to July 2006. Patients with a family history of breast cancer and at least 1 year follow-up were identified. All patients were offered biannual clinical breast examination (CBE) and annual mammography (MMG). MRI screening was performed at the discretion of the physician and patient. Family history profiles revealed 1,019 eligible patients; median follow-up was 5.0 years. MRI screening was performed in 374 (37%) patients resulting in a total of 976 MRIs during the study period. Cancer was detected in 9/374 patients (2%) undergoing MRI screening. Seven cancers were detected by MRI only, for a cancer detection rate of 0.7% (7/976) for screening MRI. When stratified by family risk profile, the positive predictive value (PPV) of MRI was higher (13%) in those patients with the strongest family histories and lower (6%) in patients with less significant family histories. MRI screening can be a useful adjunct to CBE and MMG in patients with high-risk family histories of breast cancer, yet it has low yield in patients with lower-risk family histories. These data suggest that MRI screening should be reserved for those at highest risk.

Perihepatic Lymph Node Assessment in Patients Undergoing Partial Hepatectomy for Malignancy

To assess the value of preoperative imaging studies and the intraoperative assessment of perihepatic lymph nodes in patients undergoing partial hepatectomy for malignancy. Perihepatic lymph node status is an important prognostic factor for patients undergoing hepatic resection for 1(o) and metastatic cancer. The value of preoperative imaging studies and intraoperative assessment of perihepatic nodes is unknown. Perihepatic lymph nodes were sampled in 100 patients undergoing resection for 1(o) and metastatic hepatic malignancy. At the time of sampling, participating surgeons assigned a clinical suspicion score (scale, 1-5: 1 = clinically negative, 5 = clinically positive). Preoperative CT scans and PET scans were reviewed in a blinded fashion by 2 radiologists. Clinical assessment, CT, and PET scan results were analyzed in the context of the pathologic status of the lymph nodes. A mean of 3.2 +/- 0.2 nodes were sampled per patient. Fifteen patients had metastatic disease in perihepatic lymph nodes; 13 had suggestive findings on preoperative CT or PET, and 2 were clinically positive at exploration. Clinical assessment had a high negative predictive value (NPV) = 99% but a low positive predictive value (PPV) = 39%. Similarly, CT scans had a high NPV = 95% and a low PPV = 30%. PET scans had a NPV = 88% and a PPV of 100%. Of the 48 patients with both negative preoperative CT and PET scans, only 1 (2.1%) had metastatic nodal disease, and this was suspected based on the clinical assessment. Of the patients with negative CT and PET scans and a negative clinical assessment (n = 39), none had involved perihepatic nodes. In patients with 1(o) and metastatic liver cancer, the incidence of truly occult metastatic disease to perihepatic lymph nodes is low. Routine sampling of perihepatic lymph nodes will therefore have a low yield in patients without some evidence of disease on preoperative CT or PET scans or at the time of exploration.

Investigating syncope: a review

This review focuses on recent literature on the cardiovascular investigation of syncope. Syncope is a common and complex clinical entity with many varied etiologies, the diagnosis of which can often be elusive. Recent advances in the area of investigation in syncope include improvements in technologies for arrhythmia event monitoring and an increase in applicability and efficacy of traditional investigations. These advances have increased our ability to manage syncope. A better understanding of the etiology of syncope in certain cohorts has allowed tailoring of investigations and management of syncope. This is evident when syncope occurs in the presence of structural heart disease, which is associated with a higher incidence of arrhythmias and an increased 1-year mortality. Patients with left-ventricular dysfunction should be considered candidates for an implantable cardioverter defibrillator based on heart function and syncopal presentation. In the absence of significant heart disease, investigations need to be tailored to diagnose neurally mediated causes for syncope and detection of intermittent bradycardia. The improved understanding of syncope has arisen from studies using improved investigational tools for syncope, in particular loop recorders, which are able to monitor cardiac rhythm over long periods. In those without structural heart disease and undifferentiated syncope, neurally mediated causes should be pursed initially. Tilt testing and loop recorders are employed most often in this cohort. Electrophysiological studies have largely been supplanted by implantable cardioverter defibrillator use in structural heart disease, with a low yield in patients with preserved heart function.

Diagnostic Laparoscopy Prior to Planned Hepatic Resection for Colorectal Metastases

(1) A clinical risk score (CRS) is useful in selecting patients for diagnostic laparoscopy prior to planned resection of colorectal metastasis. (2) Preventing unnecessary celiotomy in these patients undergoing laparoscopy is associated with shorter hospital stays and earlier administration of systemic chemotherapy. Retrospective analysis of data collected in a prospective database. Tertiary cancer hospital. Two hundred seventy-six patients who underwent laparoscopy prior to planned partial hepatic resection (n = 264) for colorectal metastases or prior to hepatic artery infusion pump placement for colorectal metastases (n = 12). The yield of laparoscopy for patients with potentially resectable tumors was analyzed in the context of a CRS, calculated by assigning 1 point for each of the following adverse, disease-related factors: lymph node-positive primary tumor, disease-free interval less than 12 months, more than 1 hepatic tumor, hepatic tumor greater than 5 cm, and cardio embryonic antigen level less than 200 ng/mL. The CRS represents the sum for each patient. Length of hospital stay and time to initiation of chemotherapy were compared in those patients determined to be unresectable. Staging laparoscopy prevented nontherapeutic celiotomy in 10% of patients submitted to operation for a potentially curative partial hepatectomy (26 of 264) and in 33% of patients scheduled for pump placement only (4/12). The CRS correlated closely with the likelihood of identifying radiographically occult unresectable disease: 0 or 1, 4%; 2 or 3, 21%; and 4 or 5, 38%. Likewise, the percentage of patients avoiding an unnecessary celiotomy increased progressively with increasing CRS: 0 or 1, 0%; 2 or 3, 11%; and 4 or 5, 24%. Preventing an unnecessary celiotomy with laparoscopy was associated with a decreased length of hospital stay (P<.01) and earlier initiation of chemotherapy (P = .045). Diagnostic laparoscopy does not need to be performed routinely in all patients prior to hepatic resection for colorectal cancer metastasis. Laparoscopy has a very low yield in patients with a CRS of 1 or less and is unnecessary. The yield of laparoscopy increases with increasing CRS. Preventing celiotomy with laparoscopy is associated with a decreased length of hospital stay and earlier initiation of postoperative chemotherapy.

Screening for diabetes in general practice: cross sectional population study

Objective: To assess the policy proposed by the American Diabetes Association of universal screening in general practice of all patients aged over 45 years for diabetes.Design: Cross sectional population study.Setting:...

Utility of history, examination and laboratory tests in screening those returning to Europe from the tropics for parasitic infection.

To examine the utility of the different elements of screening expatriates and travellers returned from the tropics for parasitic disease (exposure history, symptoms, examination and laboratory tests). In phase 1 (conducted prospectively 1990-91), 1029 asymptomatic returnees had a detailed questionnaire and interview on risk-behaviour, physical examination and laboratory tests. In phase 2 (1997-98), 510 consecutive patients referred for routine screening (276 symptomatic and 234 asymptomatic) were screened with laboratory tests. Exposure history did not correlate reliably with parasite burden. In phase 1 physical examination revealed 387 abnormalities, only three of which indicated parasitic disease. Schistosomal serology was positive in 11% (CI 9-13) of these asymptomatic cases including patients with light or no reported freshwater exposure. Stool microscopy was positive in 19% (CI 16-22) of cases not correlated with reported eating habits, and eosinophilia was present in 8% (CI 6-10). In phase 2 reported symptoms did not correlate with parasitic disease. Schistosomiasis was present in 15% (CI 13-24) of asymptomatic and 18% (CI 13-22) of symptomatic individuals (OR 1.2 P = 0.46); stool microscopy was positive in 14% of both symptomatic and asymptomatic patients, and eosinophilia in 9% of symptomatic and 6% of asymptomatic individuals. Potentially serious asymptomatic infection is common in travellers. Detailed exposure history, symptom history and physical examination added little to detecting cases. Stool microscopy, schistosomal serology and eosinophil count all had good yield. Filarial serology had low yield in patients without eosinophilia.

Are routine arrhythmia inductions necessary in patients with pectoral implantable cardioverter defibrillators?

The value of ventricular arrhythmia inductions as part of routine implantable cardioverter defibrillator (ICD) follow-up in new-generation pectoral ICDs is unknown. We performed a retrospective analysis of a prospectively collected database analyzing data from 153 patients with pectoral ICDs who had routine arrhythmia inductions at predismissal, and 3 months and 1 year after implantation. Routine predismissal ventricular fibrillation (VF) induction yielded important findings in 8.8% of patients, all in patients with implantation defibrillation threshold (DFT) > or = 15 J or with concomitant pacemaker systems. At 3 months and 1 year, routine VF induction yielded important findings in 5.9% and 3.8% of tested patients, respectively, all in patients who had high DFT on prior testing. Ventricular tachycardia (VT) induction at predismissal, and 3 months and 1 year after implantation resulted in programming change in 37.4%, 28.1%, and 13.8% of tested patients, almost all in patients with inducible VT on baseline electrophysiologic study and clinical episodes since implantation. Although helpful in identifying potentially important ICD malfunctions, routine arrhythmia inductions during the first year after ICD implantation may not be necessary in all cases. VF inductions have a low yield in patients with previously low DFTs who lack concomitant pacemakers. VT inductions have a low yield in patients without baseline inducible VT and in the absence of clinical events. Definite recommendations regarding patient selection must await larger prospective studies as well as consensus in the medical community about what comprises an acceptable risk justifying avoidance of the costs and inconveniences of routine arrhythmia inductions.