Symptom Class Research Articles

Mental Health Treatment Patterns in Perinatally HIV-Infected Youth and Controls

Youths perinatally infected with HIV often receive psychotropic medication and behavioral treatment for emotional and behavioral symptoms. We describe patterns of intervention for HIV-positive youth and youth in a control group in the United States. Three hundred nineteen HIV-positive youth and 256 controls, aged 6 to 17 years, enrolled in the International Maternal Adolescent AIDS Clinical Trials 1055, a prospective, 2-year observational study of psychiatric symptoms. One hundred seventy-four youth in the control group were perinatally exposed to HIV, and 82 youth were uninfected children living in households with HIV-positive members. Youth and their primary caregivers completed Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-referenced symptom-rating scales. Children's medication and behavioral psychiatric intervention histories were collected at entry. We evaluated the association of past or current psychiatric treatment with HIV status, baseline symptoms, and impairment by using multiple logistic regression, controlling for potential confounders. HIV-positive youth and youth in the control group had a similar prevalence of psychiatric symptoms (61%) and impairment (14% to 15%). One hundred four (18%) participants received psychotropic medications (stimulants [14%], antidepressants [6%], and neuroleptic agents [4%]), and 127 (22%) received behavioral treatment. More HIV-positive youth than youth in the control group received psychotropic medication (23% vs 12%) and behavioral treatment (27% vs 17%). After adjusting for symptom class and confounders, HIV-positive children had twice the odds of children in the control group of having received stimulants and >4 times the odds of having received antidepressants. Caregiver-reported symptoms or impairment were associated with higher odds of intervention than reports by children alone. HIV-positive children are more likely to receive mental health interventions than control-group children. Pediatricians and caregivers should consider available mental health treatment options for all children living in families affected by HIV.

W1866 Examining the Relationship Between Esophageal Symptoms and Psychological Distress: A Pilot Study

Background: Previous research has demonstrated that psychological factors play a role in the manifestation of esophageal symptoms. However, the interaction between psychological distress and esophageal symptoms remains unclear. Aims: Our aims were to 1) determine the presence of psychological distress in a sample of patients seeking care for esophageal symptoms and 2) examine the relationship between depression, anxiety, and esophageal symptoms. Methods: 67 pts from gastroenterology and otolaryngology clinics were asked to complete three measures: Hospital Depression A SD 2.8). 71% of respondents scored within normal range on the anxiety subscale of the HADS (M=6.1; SD 4.3). Scores on the state (M=33.9; SD=11.3) and trait (M=33.5; SD=11.1) dimensions of the STAI were elevated in 51% of the sample. State-dependent (situational) and trait (generalized) anxiety were correlated with HADS anxiety (rs = .66 to .68, p<.001). Scores on all anxiety measures were correlated with depression (.39 to .46, p≤.001). Primary symptom classes were created based on ESQ subscale scores. Globus scores were significantly associated with depression (rs=.37, p=.001), HADS anxiety (rs=.28, p<.05), and trait anxiety (rs=.26, p<.05). Dysphagia was not significantly associated with psychological distress. Reflux was significantly associated with all measures of anxiety: HADS (rs =.35, p=.01), state (rs =.36,p<.01) and trait anxiety (rs =.47,p=.001). There were no significant differences on psychological distress between symptom classes. Conclusion: Our results support previous research establishing a modest link between psychological distress and esophageal symptoms. 29% of respondents reported clinically significant anxiety on the HADS compared to 51% on the STAI, suggesting that the STAImay bemore sensitive in detecting anxiety in this population. Given our observations, we recommend that future studies include clinical interviews aimed at improving the accuracy of reporting psychological distress, include measures assessing somatization, alexithymia, and quality of life, and gather additional psychometric data to assess the reliability and validity of standard psychological measures in this population.

W1869 Development of Esophageal Symptoms Questionnaire (ESQ) for Assessment of Globus Sensation: Preliminary Findings

Background: Previous research has demonstrated that psychological factors play a role in the manifestation of esophageal symptoms. However, the interaction between psychological distress and esophageal symptoms remains unclear. Aims: Our aims were to 1) determine the presence of psychological distress in a sample of patients seeking care for esophageal symptoms and 2) examine the relationship between depression, anxiety, and esophageal symptoms. Methods: 67 pts from gastroenterology and otolaryngology clinics were asked to complete three measures: Hospital Depression A SD 2.8). 71% of respondents scored within normal range on the anxiety subscale of the HADS (M=6.1; SD 4.3). Scores on the state (M=33.9; SD=11.3) and trait (M=33.5; SD=11.1) dimensions of the STAI were elevated in 51% of the sample. State-dependent (situational) and trait (generalized) anxiety were correlated with HADS anxiety (rs = .66 to .68, p<.001). Scores on all anxiety measures were correlated with depression (.39 to .46, p≤.001). Primary symptom classes were created based on ESQ subscale scores. Globus scores were significantly associated with depression (rs=.37, p=.001), HADS anxiety (rs=.28, p<.05), and trait anxiety (rs=.26, p<.05). Dysphagia was not significantly associated with psychological distress. Reflux was significantly associated with all measures of anxiety: HADS (rs =.35, p=.01), state (rs =.36,p<.01) and trait anxiety (rs =.47,p=.001). There were no significant differences on psychological distress between symptom classes. Conclusion: Our results support previous research establishing a modest link between psychological distress and esophageal symptoms. 29% of respondents reported clinically significant anxiety on the HADS compared to 51% on the STAI, suggesting that the STAImay bemore sensitive in detecting anxiety in this population. Given our observations, we recommend that future studies include clinical interviews aimed at improving the accuracy of reporting psychological distress, include measures assessing somatization, alexithymia, and quality of life, and gather additional psychometric data to assess the reliability and validity of standard psychological measures in this population.

The Importance of ADHD Subtype Classification for Educational Applications of DSM-V

Objective: An examination of the academic achievement of children with ADHD by stimulant treatment status must consider this heterogeneity of the disorder. With the dissemination of the final wave of data, the Special Education Elementary Longitudinal Study presents an opportunity to examine the academic achievement of students with ADHD using a large, community-based, and nationally representative sample over 4 years. Method: In Study 1, the association between stimulant treatment and academic achievement is examined over 4 years. In Study 2, the association between stimulant treatment and academic achievement is examined acknowledging the influence of subtype symptoms of ADHD using growth mixture modeling. Results: Results indicate significant differences in academic achievement according to long-term stimulant treatment status within each subtype symptom class. Conclusion: Research should acknowledge the influence of subtype symptoms when examining outcomes such as academic achievement. The upcoming DSM-V should consider the results as indicating the educational relevance of ADHD subtype classification. (J. of Att. Dis. 2010; 13(6) 573-583)

Abstract 4852: Changes In Left Ventricular Structure And Function Over 12 Months In Patients With Mild Or Asymptomatic Heart Failure With Previous Symptoms In The Resynchronization Reverses Remodelling In Systolic Left Ventricular Dysfunction (reverse) Study

Background: Cardiac Resynchronization Therapy (CRT) induces LV reverse remodeling that translates into symptom relief and improved survival in New York Heart Association (NYHA) symptom class III/IV heart failure (HF). We hypothesized that CRT would also result in LV reverse remodeling in NYHA class I/II (asymptomatic or minimally symptomatic) HF and slow disease progression. Method: All patients in the RE synchronization re VE rses R emodeling in S ystolic left v Entricular dysfunction (REVERSE) study had an EF&lt;40% and a QRS&gt;120ms and had optimal HF therapy for at least 1 month. Echograms were obtained at baseline, pre-hospital discharge (PHD), 6 and 12 months. At the PHD visit two limited echos were performed (one with CRT OFF and one with CRT ON), to assess the acute mechanical effect of pacing. LV volume indices, EF, LV mass and severity of mitral regurgitation (MR) were quantified at all time points by a Core Echo lab. Results: Of 610 patients, 82% had NYHA class II and 18% had class I HF. Patients were randomized 2:1 to CRT ON (n=419) or CRT OFF (n=191). LV volume indices at end-systole and end-diastole decreased and EF increased significantly from baseline to 12 months in CRT ON, but did not change in CRT OFF. LV mass and severity of MR did not change in either group at 12 months (Table ). When CRT ON was switched to CRT OFF at PHD, there were no significant acute changes in LV size or function. Conclusion: CRT results in major structural and functional LV reverse remodeling in patients with NYHA class I/II HF that may delay the natural disease progression. The progressive reverse LV remodeling is demonstrated on top of the attenuation seen with optimal medical therapy in NYHA class I/II (CRT OFF group). The echo findings in REVERSE may have important clinical implications for use of CRT in the optimal therapy of patients with NYHA class I/II heart failure. Table. Mean ± S.D. (n) Echocardiographic Parameters: CRT ON vs. CRT OFF

Clustering of symptoms associated with fibromyalgia in a Finnish Twin Cohort

The objective was to assess the prevalence and heritability of symptoms associated with fibromyalgia in a population-based working-age twin sample. The study was based on the 12,502 like-sexed twins of the Finnish Twin Cohort and 49 diagnosed fibromyalgia patients who answered the same questionnaire in 1990–1992. Questions that were considered to best match symptoms of fibromyalgia were validated between the twins and the fibromyalgia patients. Latent class analysis was used to classify the subjects into more homogeneous groups with respect to the symptom items. The pairwise distribution of symptom classes in relation to zygosity and gender was modelled using quantitative genetic models to estimate heritability. Responses to all fibromyalgia-related items were obtained from 10,608 twins. A similar proportion of men (12%) and women (13%) was placed in the third latent class, which best represented possible fibromyalgia patients. Subjects in this class had a similar symptom profile as the diagnosed fibromyalgia patient group, but they were less severely affected. The two other latent classes represented subjects that were virtually symptom free and subjects with some symptoms. The heritability of liability to symptom class membership was estimated to be 51% (95% CI 45–56%). The prevalence of symptoms associated with fibromyalgia in our population-based sample unselected for disease status was comparable to the prevalence of widespread pain reported in population based studies. The symptoms known to be associated with fibromyalgia seem to have a strong genetic background.

Isovolumic Cardiac Contraction on High-Temporal-Resolution Cine MR Images: Study in Heart Failure Patients and Healthy Volunteers

To prospectively implement high-temporal-resolution cine magnetic resonance (MR) imaging protocol to compare cardiac preejection contraction (PEC) and prefilling relaxation (PFR) times between heart failure (HF) patients and healthy control subjects and to assess accuracy of PEC times to stratify HF patients, with ejection fraction (EF) and New York Heart Association (NYHA) symptom class as reference standards. Following institutional review board approval of this HIPAA-compliant study and written informed consent, 18 healthy volunteers (10 women, eight men; mean age, 43 years +/- 14 [standard deviation]) and 18 HF patients (five women, 13 men; mean age, 49.8 years +/- 3) were imaged (breath-hold true fast imaging with steady-state precession, with temporal resolution of 5.6 msec at 1.5 T). By using left ventricular (LV) outflow tract acquisition, PEC phase was defined as time at QRS trigger to immediately before aortic valve opening. PFR was defined as time from initial aortic valve closure to immediately before mitral valve opening. Group means were compared (unpaired Student t test). Accuracy of PEC parameters in stratifying participants with severe systolic HF on the basis of EF and NYHA symptom class was assessed (receiver operating characteristic curve analysis). Compared with control subjects, HF patients had prolonged mean PEC time (40.4 msec +/- 11.8 vs 91.3 msec +/- 26, P < .001) and mean PFR time (68.3 msec +/- 26.8 vs 103.7 msec +/- 41.8, P < .01). PEC time correlated with global EF (r = -0.73, P < .001) and LV mass (r = 0.69, P < .001). For identification of patients with severe LV systolic dysfunction (EF <or= 35%), PEC time was highly accurate (area under the curve [AUC], 0.900 [P < .001]). For identification of patients with moderate-to-severe HF symptoms (NYHA class > 2), PEC time had good accuracy (AUC, 0.875 [P < .001]). It is feasible to assess isovolumic PEC and PFR phases of the cardiac cycle with high-frame-rate cine MR images, and PEC time is a surrogate measure of moderate-to-severe systolic HF.

Left Thoracotomy for Multiple-Time Redo Mitral Valve Surgery Using On-Pump Beating Heart Technique

There are limited reports describing multiple-time redo mitral valve surgery using a left thoracotomy approach and on-pump beating heart technique. A retrospective review of medical records for 16 patients from March 2002 to June 2007 was performed. Mean age was 54 +/- 17 (mean +/- SD) years (8 males). Preoperative mitral valve regurgitation was 3.6 +/- 0.6 in 14, and 2 had severe mitral valve stenosis. New York Heart Association symptom class was 2.9 +/- 1.0 and ejection fraction was 0.4 +/- 0.15 (range, 0.2 to 0.6). Previous cardiac operations were performed twice in 14 and three times in 2 patients with an interval of 4.8 +/- 5.5 years since the last. The procedures included repair (5), replacement (8), and re-replacement (3). All were performed through a fifth intercostal space, left posterolateral thoracotomy with the heart beating on cardiopulmonary bypass (32 to 37 degrees C). Left femoral artery or descending thoracic aorta inflow and left femoral vein or left main pulmonary artery venous drainage with vacuum assist were used. Operation time was 221 +/- 51 minutes and cardiopulmonary bypass time was 71 +/- 27 minutes. Postoperative ventilation time was 10.0 +/- 7.7 hours, intensive care unit stay was 2.9 +/- 1.9 days, and hospital stay was 6.2 +/- 2.4 days. There were two 30-day mortalities and two died late with a follow-up of 30 +/- 22 months. Left thoracotomy using the on-pump beating heart technique is safe, effective, and should be considered for multiple-time redo mitral valve surgery.

An evaluation of the effects of Tai Chi Chuan and Chi Kung training in patients with symptomatic heart failure: a randomised controlled pilot study

Objective: To study the effect of Tai Chi on exercise tolerance in patients with moderate heart failure. Design: Randomised parallel group study balanced for baseline variables. Setting: Cardiology Department, Royal...

Use of coronary calcium scanning for predicting inducible myocardial ischemia: Influence of patients’ clinical presentation

The selection of patients for cardiac stress tests is generally based on assessment of chest pain symptoms, age, gender, and risk factors, but recent data suggest that coronary artery calcium (CAC) measurements can also be used to predict inducible myocardial ischemia. However, the potential influence of clinical factors on the relationship between CAC measurements and inducible ischemia has not yet been investigated. We prospectively performed CAC scanning in 648 patients undergoing exercise myocardial perfusion single photon emission computed tomography. The frequency of ischemia on myocardial perfusion single photon emission computed tomography was assessed according to CAC magnitude after dividing patients according to chest pain symptom class and Bayesian likelihood of angiographically significant coronary artery disease (ASCAD). Estimates of ASCAD likelihood and CAC scores were poorly correlated. The frequency of inducible myocardial ischemia was very low among patients with a low ASCAD likelihood if CAC scores were less than 400. By contrast, the threshold for increasing ischemia occurred at low CAC scores among patients with a high ASCAD likelihood. When characterized by chest pain classification, asymptomatic and nonanginal chest pain patients had a low frequency of ischemia if CAC scores were less than 400, whereas lower CAC scores did not exclude ischemia among typical angina or atypical angina patients. CAC scores predict myocardial ischemia, with a threshold score of greater than 400 among patients with a low likelihood of ASCAD and those who are asymptomatic or have nonanginal chest pain. These data appear to extend the pool of patients for whom CAC scanning may be useful in ascertaining the need for cardiac stress testing.

Left Ventricular Reconstruction by Modified Linear Technique with Absorbable Suture

Linear and endoventricular techniques of left ventricular (LV) reconstruction often utilise prosthetic material for epicardial reinforcement or endocardial patch. We report a technique of LV aneurysm repair using absorbable suture without prosthetic material. Between November 1999 and August 2004, 55 patients underwent linear LV reconstruction, for ischaemic cardiomyopathy, using only continuous 3/0 polydioxanone suture. Survival, functional class and echocardiographic outcomes are reported. Fifty-two patients (mean age 64+/-10 years) were studied. There was no perioperative mortality and the Kaplan-Meier survival at five years was 81%. Fifty-one patients underwent postoperative follow up (mean 28 months) with echocardiography (mean 20 months). There were no recurrent aneurysms. The postoperative LV eccentricity index (EI) was 0.72 (CI 0.48-0.9). Mean LV ejection fraction increased from 0.33+/-0.09 preoperatively to 0.41+/-0.15 at late follow up (mean within patient change 0.08+/-0.15, p=0.003). Mean symptom class improved from 3.3+/-0.8 to 1.6+/-0.7 (mean within patient improvement 1.6+/-1.0, p<0.001). Mitral regurgitation of grade 2/4 was identified in six patients and grade 3/4 in one patient. Linear repair with absorbable suture material and without prosthetic material may be safely undertaken with good early and mid-term results.

Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Death in Heart Failure

The demonstrated efficacy of implantable cardioverter-defibrillators (ICDs) for reducing sudden death in heart failure trial populations presents a critical challenge to those responsible for the allocation of healthcare resources.1–3 The current cost, multiplied by the prevalence of heart failure deemed high-risk, threatens to make this one enterprise the highest priced intervention for the Medicare population. The elegant cost-effectiveness analysis contributed by Dr Mark and colleagues from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) in this issue of Circulation provides an exemplary insight into this challenge.4 These investigators’ favorable conclusions are consistent with those from a meta-analysis by Sanders et al5 and with the slightly more conservative implications from the recent cost-effectiveness analysis of the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II by Zwanziger et al.6 Article p 135 This editorial will offer an alternative conclusion based on both back-of-the-envelope estimations and scrutiny of model assumptions regarding different phases of survival for heart failure populations. ICDs for primary prevention of sudden death in the heart failure population may be less cost-effective than other recommended heart failure therapies, which are prescribed to modify disease progression and symptoms, decreasing costly hospitalizations as well as mortality. Formal cost-effectiveness analysis is complex, but it may be illustrative to begin from simple considerations. A reasonable threshold for cost-effective intervention is often assigned as $40 000 per life-year saved, in line with the present article4 suggesting a cost of $38 389 per life-year saved and $41 530 per quality-adjusted life-year saved. This is approximately equal to the cost of the defibrillator device and implantation, as currently assessed for reimbursement. (The costs would be lower for the simpler device used in SCD-HeFT, which is not available now, and for outpatient implantation, which was common in SCD-HeFT but not the current standard.) This …

A methodology for defining homogeneous water bodies in estuaries – Application to the transitional systems of the EU Water Framework Directive

A methodology is developed and tested for division of estuarine and coastal systems into water bodies for monitoring and management purposes. This division is often implicit in the choice of sampling stations and in pollution abatement measures applied to different locations – it is now an explicit requirement of European Union Directive 2000/60/EC (Water Framework Directive) and recommended by United States Agencies such as EPA and NOAA. The approach considers both natural characteristics and the human dimension, by means of a stepwise methodology, which considers, on the one hand, morphology and salinity distribution, and, on the other, appropriate indicators of pressure and state. In the present application, nitrogen and phosphorus loading was used as the pressure component and chlorophyll a and dissolved oxygen as indicators of state. The criteria for system division were defined based on (1) an adimensional shape factor and salinity classes for the natural component; and (2) a normalised pressure index and (ASSETS) eutrophication symptom classes for the human dimension. Water quality databases and GIS were used to develop spatial distributions for the various components, and the results were aggregated into a final water body division, using tidal excursion as a “common sense” test. The methodology was applied to three well-studied systems in Portugal, a tubular estuary (Mondego), a wide lagunal estuary (Sado) and a coastal barrier island system (Ria Formosa). Although a final definition of water bodies will usually be a policy decision, this type of approach for the division of coastal systems into management units scientifically informs the decision-making process.

Efficacy of atomoxetine in adult attention-Deficit/Hyperactivity Disorder: a drug-placebo response curve analysis

BackgroundThe objective of this study was to evaluate the efficacy of atomoxetine, a new and highly selective inhibitor of the norepinephrine transporter, in reducing symptoms of attention-deficit/hyperactivity disorder (ADHD) among adults by using drug-placebo response curve methods.MethodsWe analyzed data from two double-blind, placebo-controlled, parallel design studies of adult patients (Study I, N = 280; Study II, N = 256) with DSM-IV-defined ADHD who were recruited by referral and advertising. Subjects were randomized to 10 weeks of treatment with atomoxetine or placebo, and were assessed with the Conners Adult ADHD Rating Scales and the Clinical Global Impression of ADHD Severity scale before and after treatment.ResultsThose treated with atomoxetine were more likely to show a reduction in ADHD symptoms than those receiving placebo. Across all measures, the likelihood that an atomoxetine-treated subject improved to a greater extent than a placebo-treated subject was approximately 0.60. Furthermore, atomoxetine prevented worsening of most symptom classes.ConclusionFrom these findings, we conclude that atomoxetine is an effective treatment for ADHD among adults when evaluated using several criteria.

Chronic heart failure patients with restrictive LV filling pattern have significantly less benefit from cardiac resynchronization therapy than patients with late LV filling pattern

Background Cardiac resynchronization fails to improve symptoms in up to one third of patients meeting criteria for this treatment, for reasons which are unclear. Indeed, the very mechanism of benefit from resynchronization is controversial. Resynchronization may work by improving ventricular filling: we tested the hypothesis that benefit from resynchronization depends on filling pattern. Methods and results We assessed symptoms (NYHA class) and LV filling of 40 patients with chronic heart failure and prolonged QRS who underwent resynchronization. Fifteen had restrictive filling pattern ( E velocity ≥1.0 m/s, E/ A ratio >1 and E wave deceleration time ≤140 ms) and 25 had late filling pattern (single isolated A wave or summation wave filling in late diastole). At 6 months, the patients with restrictive filling failed to show the improvements observed in those with late filling. They failed to reduce NYHA class (ΔNYHA: 27% improved one class, 66% unchanged, 7% worsened one class, P=NS; vs. 8% improved two classes, 72% improved one class and 20% unchanged, P<0.001; difference between groups, P<0.001). They failed to reduce LV end-diastolic dimension (ΔLVEDD −0.04 cm, P=NS; vs. −0.6, P<0.001; difference between groups, P<0.05) or end-systolic dimension (ΔLVESD −0.01 cm, P=NS; vs. −0.6, P<0.001; difference between groups, P<0.05). They failed to improve cardiac cycle efficiency (Δtotal isovolumic [wasted] time 2.1 s/min, P=NS; vs. −5.4 s/min; difference between groups, P<0.001). Conclusion Among patients routinely eligible for resynchronization, those with restrictive filling may show significantly less (and possibly no) improvement in symptom class and ventricular dimensions after resynchronization. Their failure to improve cardiac cycle efficiency may account for their attenuated clinical benefit.

Reduction in hospitalization rates following cardiac resynchronisation therapy in cardiac failure: experience from a single centre

Frequent, lengthy hospital admissions for congestive cardiac failure (CCF) result in excessive health care costs. Cardiac resynchronisation therapy (CRT) is a novel treatment option for patients with CCF and associated cardiac conduction defects. We investigated whether CRT resulted in significant improvements in New York Heart Association (NYHA) symptom class, exercise tolerance, and hospitalization rates in such patients. Twenty-seven patients who underwent CRT in a single centre were studied, with NYHA symptom class, exercise tolerance and hospitalization rates noted in the 12 months prior to and following CRT. Following 12 months of CRT, NYHA symptom class improved from 3.3 +/- 0.5 to 2.1 +/- 0.4 (P < 0.05). Exercise tolerance, assessed by 6 min hall walk test increased by 64% from 195 +/- 114 m to 320 +/- 85 m (P = 0.007). Days in hospital for stabilisation of cardiac failure decreased by 98% from 472 to 9 days (P < 0.001). Significant hospitalization cost savings of 201,684 euros were calculated, with an overall saving of 12,420 euros. These data demonstrate that CRT results in significant improvement in clinical parameters, and considerable reductions in hospital admissions, and costs in patients with CCF.

Left ventricular reconstruction: Early and late results

Abstract Objectives In patients with coronary disease and poor left ventricular function, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. This study reports results achieved with ventricular reconstruction in 285 patients who had akinesia or dyskinesia associated with relative wall thinning. Methods Data were prospectively collected. Reconstruction on the beating heart was accomplished by a modified linear closure plus septoplasty, when indicated, (dyskinetic septum). Preoperatively, 237 (83%) were in symptom class III or IV with congestive heart failure (n =174; 61%), angina (n = 157; 55%), or ventricular tachycardia (n = 107; 38%). Average ejection fraction was 24% ± 11%, and 144 (51%) had preoperative grade 2+ mitral regurgitation. Operative procedures included coronary artery bypass grafting in 262 (92%), septoplasty in 64 (22%), ablation of ventricular tachycardia in 118 (41%), and a mitral valve procedure in 6 (2%). Results Operating room mortality was 2.8%. Perioperative support included intra-aortic balloon pumping in 49 (17%) and inotropic drugs in 154 (54%). During a mean follow-up of 63 ± 48 months, 8 patients required transplantation (interval of 49 ± 41 months), 2 needed mitral valve replacement, and 9 required use of an implantable cardioverter-defibrillator for ventricular tachycardia. At 1, 5, and 10 years actuarial survivals were 92%, 82%, and 62%. Freedom from sudden death was 99%, 97%, and 94%. Among survivors, symptom class improved in 140 of 208 patients (67%), mean improvement 1.3 ± 1.1 functional class per patient. Average increase in ejection fraction postoperatively was 10% ± 9%. Conclusions Using wall thinning as a criterion for patient selection, left ventricular reconstruction can be performed with low operative mortality, provides good control of symptoms, excellent long-term survival, and freedom from sudden death. This approach should be considered in all patients with coronary disease, poor left ventricular function, and relative wall thinning.

Left ventricular reconstruction: Early and late results

ObjectivesIn patients with coronary disease and poor left ventricular function, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. This study reports results achieved with ventricular reconstruction in 285 patients who had akinesia or dyskinesia associated with relative wall thinning. MethodsData were prospectively collected. Reconstruction on the beating heart was accomplished by a modified linear closure plus septoplasty, when indicated, (dyskinetic septum). Preoperatively, 237 (83%) were in symptom class III or IV with congestive heart failure (n =174; 61%), angina (n = 157; 55%), or ventricular tachycardia (n = 107; 38%). Average ejection fraction was 24% ± 11%, and 144 (51%) had preoperative grade 2+ mitral regurgitation. Operative procedures included coronary artery bypass grafting in 262 (92%), septoplasty in 64 (22%), ablation of ventricular tachycardia in 118 (41%), and a mitral valve procedure in 6 (2%). ResultsOperating room mortality was 2.8%. Perioperative support included intra-aortic balloon pumping in 49 (17%) and inotropic drugs in 154 (54%). During a mean follow-up of 63 ± 48 months, 8 patients required transplantation (interval of 49 ± 41 months), 2 needed mitral valve replacement, and 9 required use of an implantable cardioverter-defibrillator for ventricular tachycardia. At 1, 5, and 10 years actuarial survivals were 92%, 82%, and 62%. Freedom from sudden death was 99%, 97%, and 94%. Among survivors, symptom class improved in 140 of 208 patients (67%), mean improvement 1.3 ± 1.1 functional class per patient. Average increase in ejection fraction postoperatively was 10% ± 9%. ConclusionsUsing wall thinning as a criterion for patient selection, left ventricular reconstruction can be performed with low operative mortality, provides good control of symptoms, excellent long-term survival, and freedom from sudden death. This approach should be considered in all patients with coronary disease, poor left ventricular function, and relative wall thinning.

Syndromes of behavioural and psychological symptoms in mild Alzheimer's disease.

Behavioural and psychological symptoms of dementia (BPSD) are common in Alzheimer's disease (AD), and are associated with significant distress for patient and carer. Certain behavioural and psychological symptoms have been associated with each other, leading to the suggestion that differences in symptom patterns among patients with AD may represent different syndromes within AD. The purpose of this study is to see if patients with AD could be meaningfully classified into syndromes, based on the relationships between their BPSD. The sample was recruited through a memory clinic. Two hundred and forty first visit patients with a diagnosis of very mild to mild AD were included. BPSD were assessed using the BEHAVE-AD. Latent class analysis was used to assess for different classes or groups of patients within the sample, based on their behavioural and psychological symptoms. Three classes were identified; Class 1 with a low prevalence of behavioural and psychological symptoms; Class 2 an anxiety/depressive symptom class and Class 3 an aggressive symptom class. The three classes (or groups) of patients obtained by LCA in this sample may be explained by a 'latent', as yet, unidentified factor. Further research is required to determine if these classes are stable over time, and to identify possible latent variables.

Ventricular reconstruction for ischemic cardiomyopathy

Left ventricular surgical reconstruction has been advocated for patients with coronary artery disease, prior myocardial infarction, and poor left ventricular function. The objective of the approach is to resect or exclude all akinetic or dyskinetic nonfunctioning portions of the ventricular cavity and to restore the left ventricle size and shape toward normal as much as possible. We review the pathophysiology of ischemic cardiomyopathy and suggest guidelines for preoperative assessment and patient selection for ventricular reconstruction. Because of the prevalence and prognostic significance of ventricular arrhythmias in this patient population we include in our operative approach a visually directed ablation procedure in those with significant septal scarring. We describe our operative technique and review results achieved with this approach. The procedure results in a significant decrease in ventricular volume, increase in ejection fraction and improvement in apical geometry. We conclude that in selected patients with ischemic cardiomyopathy, left ventricular reconstruction can be accomplished with low operative mortality and results in significant improvement in left ventricular function. During follow up symptom class is decreased in most patients and overall survival at 5 years is 84% and freedom from sudden death is 96%. Ventricular reconstruction should be considered in all patients with coronary artery disease and akinetic or dyskinetic scar.