Assessing risk of a prolonged QT interval–a survey of emergency physicians

Background

Although QT prolongation is associated with an increased risk of torsades de pointes (TdP), it is unclear how clinicians determine risk in individual patients with prolonged QT.

Aims

To investigate physicians’ interpretation of electrocardiogram (ECG) values in patients with a prolonged QT in reference to risk of TdP.

Methods

A survey was sent to Australasian emergency physicians (EPs) to investigate interpretation of ECG data in risk assessment for TdP. The survey contained three sections: demographic information, questions on heart rate correction and six sets of ECG data which the clinician ranked from low to high risk. Risk analysis for ECG values was performed by producing histograms of the distribution of responses for each of the six sets of ECG parameters. These distributions were compared to predicted distributions based on Bazett’s corrected QT>500 ms and the QT nomogram. The QT nomogram is a recently developed method for assessing whether QT-HR pairs are associated with increased risk of TdP by plotting them to determine if they are above an at risk line—the nomogram.

Results

Of 720 surveys sent out, 249 were returned (35%). A heart rate correction was used by 90% of respondents and the median “at risk” QTc judged by EPs was 450 ms [interquartile range (IQR): 440–500 ms]. Respondents were divided as to whether bradycardia increased the risk of TdP, with equal numbers responding “no change” and “more caution”. In four of the six sets of ECG parameters, EPs had a similar risk distribution to that predicted by Bazett. For one point predicted to be high risk by the QT nomogram, there was a uniform (undecided) risk distribution by EPs.

Conclusions

EPs mainly relied on Bazett’s correction as their method of TdP risk assessment, which may be problematic for bradycardic patients.     

A culture of change or a change of culture?

As organizations find themselves having to respond to quick changes in rapid succession, at some point the question of whether or not the pace is too much to sustain comes into play. At Sarasota Memorial Hospital, early cultural assessment led to implementation strategies that helped to overcome some of the barriers of major change.     

Diagnosis of Influenza: Only a Problem of Coding?

Objective

To evaluate the characteristics of hospital discharge diagnoses of influenza measured by using specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) codes.

Subjects and Methods

The study was conducted for the 3 years 2007, 2008 and 2011. The database included (1) administrative and clinical data on Sicilian patients admitted to acute care hospitals and (2) data from the influenza virological surveillance of 10 European countries (FluNet database). All Sicilian patients diagnosed with at least 1 ICD-9 CM code for influenza (487.0, 487.1 and 487.9) were considered influenza cases.

Results

Overall, 2,880 patients with an ICD-9 CM code attributable to influenza were hospitalized in Sicily: 2,119 (73.6%) were admitted from November to April, whereas 761 (26.4%) were admitted from May to October. In the 3 years studied, the analyzed European influenza surveillance systems recorded a peak of laboratory-confirmed influenza activity from November to April with 36,753 (99.7%) influenza cases, whereas only 124 cases (0.3%) were observed from May to October.

Conclusions

In Sicily, more than one quarter of all hospital admissions with an ICD-9 CM code for influenza were observed in the months with a negligible circulation of influenza viruses. Our findings show that several hospital discharge records included ICD-9 CM codes for influenza with low levels of sensitivity, specificity and/or appropriateness for clinical information and support the need for improving medical education on the epidemiology and hospital management of influenza cases.Key Words: Influenza, Hospital discharge records, Influenza-like illness, Epidemiology     

At home in a strange world? Study of reality perception of a demented elderly patient in a nursing home: an interpretation of various viewpoints

Only little is known about the personal experiences and feelings of demented elderly persons in geriatric care institutions. We conducted an intense qualitative case study with a 75-year old woman with Alzheimer dementia (Mrs. R.). Our main research method was participating observation during a period of almost four weeks. Information concerning the nursing staff's point of view was gathered by semi-structured interviews. The results indicated two different frames of reference. The past formed the basis for the present experience of Mrs. R. Her behaviour revealed a lot of signs of normality. This was especially evident during her daily stays in a corner seating unit of the living area. Mrs. R. behaved like feeling at home in that particular place. The behaviour and attitudes of the nursing staff were mainly determined by their perception of Mrs. R. as a frail and ill person. It seemed that the staff had only little knowledge of Mrs. R.'s biography that could have broadened their syndrome-oriented point of view.     

Plasticity of stem cells: a change of paradigm?

Until a few years ago, an interest in stem cells, mostly of hematopoietic origin, was limited to a relatively small representation of scientists and clinicians seeking to understand the role of these rare cells in tissue homeostasis and to utilize their remarkable potential to regenerate an adult tissue following transplantation. Over the last few years, an ability of bone marrow-, brain-, muscle- and other tissue-derived stem cells to branch off, move between tissues and contribute to their repair was discovered. According to this novel view, at least a subset of stem cells may alter their fate in a manner that is more plastic and dynamic than previously thought, causing a fascination with these cells to spread to nearly all clinical disciplines. Expectations are high: stem cells are considered a future remedy for major diseases of our civilization. There are more questions raised than answers, and pressure grows to extend the knowledge and accelerate its implementation.