Characterization and financial impact of implantable cardioverter-defibrillator patients without interventions 5 years after implantation

Background: Implantable cardioverter defibrillators (ICD's) are increasingly used for primary and secondary prevention of sudden cardiac death. However, data on how many ICD patients indeed receive appropriate ICD therapy during long-term follow-up is scarce. Aim: The aim of our study was to determine the number of patients without appropriate ICD therapy 5 years after ICD implantation, to identify predicting factors, to assess the occurrence of late first ICD therapy and to quantify the financial impact of ICD therapy in a real-world setting. Design: Prospective observational study. Methods: We prospectively enrolled 322 consecutive ICD patients. Baseline data were collected at implantation and patients were followed for a median of 7.3 years (IQR 5.8-9.2 years). Time to first appropriate ICD therapy (either antitachycardia pacing or cardioversion) was documented. Results: Five years after implantation, 139 patients (43%) had not received appropriate ICD therapy. In multivariable analysis, a primary prevention indication and negative electrophysiological studies prior to ICD implantation were independent predictors of freedom from ICD therapy. Of the patients without ICD therapy, 5 years after implantation, 25% had experienced inappropriate ICD shocks. Two hundred and seven devices (1.5 devices per patient) were needed for the 139 patients without ICD intervention within 5 years, accounting for €31 784 per patient. During an additional follow-up of 3 years, 12% of the patients with unused ICD received a late first appropriate ICD therapy. Conclusions: About half of the ICD patients receive appropriate ICD therapy within 5 years after implantation. Furthermore, there is a significant proportion of patients receiving late first shocks after five initially uneventful year

Prediction of the haemodynamic response to tracheal intubation: comparison of laser-Doppler skin vasomotor reflex and pulse wave reflex

Background. The laser-Doppler skin vasomotor reflex (SVmR) caused by tetanic stimulation of the ulnar nerve may be a test that can predict the haemodynamic response to tracheal intubation. A decrease in pulse wave amplitude (pulse wave reflex, PWR) may be an alternative index of this response. We compared the abilities of PWR and SVmR to predict the haemodynamic response to tracheal intubation and studied how alfentanil, muscle relaxation, stimulation site and stimulation pattern affected the two reflexes. Methods. Anaesthesia was induced and maintained with 2% sevoflurane and 50% nitrous oxide in two groups of 10 ASA status I patients. Tetanic stimuli were applied to the flexor muscles of the forearm and the ulnar nerve before and after administration of vecuronium. The change in skin blood flow (laser-Doppler) and pulse wave amplitude (pulse oximetry) after a 5 and 10 s stimulation was measured on the opposite hand. If skin blood flow (laser-Doppler) decreased by more than 10%, a computer-controlled infusion of alfentanil was started and the target plasma concentration was increased in steps until this response was suppressed (<10%). The trachea was intubated and arterial pressure and heart rate responses were recorded. Plasma alfentanil concentration was measured. Results. When PWR and SVmR were suppressed, the haemodynamic response to tracheal intubation was reduced in 100 and 53% of patients respectively. PWR and SVmR responses decreased with increasing plasma alfentanil concentration. The SVmR response to muscle stimulation was reduced by muscle relaxants. The pulse wave response to both muscle and neural stimulation was reduced by relaxants. The responses to 5 and 10 s stimulations were similar. Conclusion. An absent SVmR does not predict a blunted arterial pressure or heart rate response to tracheal intubation. The PWR may be a better predicto

Optimal cutoff-value of Siemens cardiac troponin I assay in patients with kidney disease for the early diagnosis of acute myocardial infarction

Purpose: The recent introduction of more sensitive cardiac troponin (cTn) assays improved the early diagnosis of acute myocardial infarction (AMI). However, its diagnostic utility has never been tested in patients with kidney disease (KD), who are known to have elevated levels of cTn already in the absence of AMI, which may lead to a lower diagnostic value of more sensitive cTn in this high-risk subgroup. Methods: We conducted an international multicenter study to examine the diagnostic accuracy of the Siemens cTnI Ultra assay in 1997 consecutive patients presenting to the emergency department with symptoms suggestive of AMI, of whom 343 (17%) were determined to have KD (MDRD GFR <60ml/min/1.73m2) and to derive the optimal cutoff-value for the diagnosis of AMI in patients with KD. The diagnostic accuracy was further compared to a conventional cTn assay (Roche Troponin T fourth generation). The final diagnosis was adjudicated by two independent cardiologists based on hs-cTnT. Results: AMI was the final diagnosis in 35% (n=120) of all KD-patients as compared to 18% in patients with normal kidney function (p<0.001). Among KD-patients with other diagnoses than AMI, baseline hs-cTnI-levels were elevated above the 99thpercentile in 20%, In patients with KD the diagnostic accuracy at presentation, quantified by the area under the receiver-operator-characteristic curve (AUC), was significantly greater for Siemens cTnI as compared to the standard cTnT assay (AUC for cTnI, 0.88 vs. AUC for the standard assay, 0.82, p=0.013). In patients presenting within three hours after the onset of chest pain, the superiority of Siemens cTnI over conventional cTnT was even more pronounced (AUC 0.86 vs. 0.72, p=0.005). In KD, the optimal hs-cTnI cutoff derived from the ROC curve was 46 ng/l compared to 19 ng/l in patients with normal kidney function (standard 99th percentile 40 ng/l, provided by the manufacturer). Conclusions: The Siemens cTnI Ultra assay has a very high diagnostic accuracy also in KD-patients and is superior to a conventional cTnT-assay. Mild cTnI elevations are common in non-AMI patients. The optimal cutoff-level in KD-patients seems to be around the 99th percentile of a standard population, whereas the optimal cutoff-level in patients with normal kidney function tends to be only half of the suggested cutoff-value. ClinicalTrials.gov number, NCT0047058

Big data in economics: evolution or revolution?

The Big Data Era creates a lot of exciting opportunities for new developments in economics and econometrics. At the same time, however, the analysis of large datasets poses difficult methodological problems that should be addressed appropriately and are the subject of the present chapter

High Pressure Insulator-Metal Transition in Molecular Fluid Oxygen

We report the first experimental evidence for a metallic phase in fluid molecular oxygen. Our electrical conductivity measurements of fluid oxygen under dynamic quasi-isentropic compression show that a non-metal/metal transition occurs at 3.4 fold compression, 4500 K and 1.2 Mbar. We discuss the main features of the electrical conductivity dependence on density and temperature and give an interpretation of the nature of the electrical transport mechanisms in fluid oxygen at these extreme conditions.Comment: RevTeX, 4 figure

Patches of Bare Ground as a Staple Commodity for Declining Ground-Foraging Insectivorous Farmland Birds

Conceived to combat widescale biodiversity erosion in farmland, agri-environment schemes have largely failed to deliver their promises despite massive financial support. While several common species have shown to react positively to existing measures, rare species have continued to decline in most European countries. Of particular concern is the status of insectivorous farmland birds that forage on the ground. We modelled the foraging habitat preferences of four declining insectivorous bird species (hoopoe, wryneck, woodlark, common redstart) inhabiting fruit tree plantations, orchards and vineyards. All species preferred foraging in habitat mosaics consisting of patches of grass and bare ground, with an optimal, species-specific bare ground coverage of 30–70% at the foraging patch scale. In the study areas, birds thrived in intensively cultivated farmland where such ground vegetation mosaics existed. Not promoted by conventional agri-environment schemes until now, patches of bare ground should be implemented throughout grassland in order to prevent further decline of insectivorous farmland birds

High-Pressure Amorphous Nitrogen

The phase diagram and stability limits of diatomic solid nitrogen have been explored in a wide pressure--temperature range by several optical spectroscopic techniques. A newly characterized narrow-gap semiconducting phase $\eta$ has been found to exist in a range of 80--270 GPa and 10--510 K. The vibrational and optical properties of the $\eta$ phase produced under these conditions indicate that it is largely amorphous and back transforms to a new molecular phase. The band gap of the $\eta$ phase is found to decrease with pressure indicating possible metallization by band overlap above 280 GPa.Comment: 5 pages, 4 figure

Consistent Anisotropic Repulsions for Simple Molecules

We extract atom-atom potentials from the effective spherical potentials that suc cessfully model Hugoniot experiments on molecular fluids, e.g., $O_2$ and $N_2$. In the case of $O_2$ the resulting potentials compare very well with the atom-atom potentials used in studies of solid-state propertie s, while for $N_2$ they are considerably softer at short distances. Ground state (T=0K) and room temperatu re calculations performed with the new $N-N$ potential resolve the previous discrepancy between experimental and theoretical results.Comment: RevTeX, 5 figure