High-Risk Apical Hypertrophic Cardiomyopathy Requiring an Implantable Cardioverter-Defibrillator: A Case Report of an Overlooked Etiology

Apical hypertrophic cardiomyopathy is a rare variant of hypertrophic cardiomyopathy characterized by abnormal heart muscle thickening, specifically affecting the left ventricle's apex. Classically revealing both giant T-wave inversions in the precordial leads of an electrocardiogram and a spade-like configuration of the left ventricular cavity on ventriculograms, the diagnosis of the apical variant has evolved with cardiac magnetic resonance imaging. Despite being well known among East Asian populations, the diagnosis of apical hypertrophic cardiomyopathy is often underestimated and overlooked among American patients due to the non-specific nature of echocardiography. In this case report, we present the diagnosis of apical hypertrophic cardiomyopathy in a middle-aged African American male with chronic palpitations. The diagnosis was confirmed using cardiac magnetic resonance imaging, which revealed extensive myocardial fibrosis. Ultimately, the patient was treated with an implantable cardioverter-defibrillator. Our case aims to enhance the understanding and facilitate the recognition and management of apical hypertrophic cardiomyopathy, particularly among non-Asian individuals. Current challenges revolve around robust risk stratification strategies for patients at high risk for sudden cardiac death that require device therapy.

Insufficient Sleep Syndrome: A Blind Spot in Our Vision of Healthy Sleep

Chronic sleep deficiency (CSD) poses a threat to physical health, mental well-being, and social functioning. The concept of behaviorally induced CSD has not changed much since it was first introduced four decades ago. Behaviorally induced CSD is currently referred to as insufficient sleep syndrome (ISS). In the latest edition of the International Classification of Sleep Disorders (ICSD-3, 2014), ISS is considered a disorder of central hypersomnolence with diagnostic codes ICD-9-CM 307.44 and ICD-10-CM F51.12. In this review, we will describe the biological importance of sleep, the ramifications of CSD on the individual and society, the nosological status and diagnostic features of ISS, and the apparent lack of attention to ISS in contemporary medical practice and public health programs. The last three decades have seen a global rise in voluntary sleep curtailment such that ISS may already be the leading cause of CSD, not only in adults but also in school-aged children and adolescents. Acknowledging ISS as a public health priority is a necessary first step in our response to the global threat of CSD and CSD-related health consequences. It is only by confronting ISS directly that we can hope to develop and implement effective educational and advocacy programs, along with more responsible public health policies and regulations.

Comparison of the Causes of Death Identified Using Automated Verbal Autopsy and Complete Autopsy among Brought-in-Dead Cases at a Tertiary Hospital in Sub-Sahara Africa

BACKGROUND

Over one-third of deaths recorded at health facilities in Zambia are brought in dead (BID) and the causes of death (CODs) are not fully analyzed. The use of automated verbal autopsy (VA) has reportedly determined the CODs of more BID cases than the death notification form issued by the hospital. However, the validity of automated VA is yet to be fully investigated.

OBJECTIVES

To compare the CODs identified by automated VA with those by complete autopsy to examine the validity of a VA tool.

METHODS

The study site was the tertiary hospital in the capital city of Zambia. From September 2019 to January 2020, all BID cases aged 13 years and older brought to the hospital during the daytime on weekdays were enrolled in this study. External COD cases were excluded. The deceased's relatives were interviewed using the 2016 World Health Organization VA questionnaire. The data were analyzed using InterVA, an automated VA tool, to determine the CODs, which were compared with the results of complete autopsies.

RESULTS

A total of 63 cases were included. The CODs of 50 BID cases were determined by both InterVA and complete autopsies. The positive predictive value of InterVA was 22%. InterVA determined the CODs correctly in 100% cases of maternal CODs, 27.5% cases of noncommunicable disease CODs, and 5.3% cases of communicable disease CODs. Using the three broader disease groups, 56.0% cases were classified in the same groups by both methods.

CONCLUSION

While the positive predictive value was low, more than half of the cases were categorized into the same broader categories. However, there are several limitations in this study, including small sample size. More research is required to investigate the factors leading to discrepancies between the CODs determined by both methods to optimize the use of automated VA in Zambia.

Detection of Coxiella burnetii DNA in sheep and goat milk and dairy products by droplet digital PCR in south Italy

Coxiella burnetii is a Gram-negative obligate intracellular bacterium that is responsible for Q fever, a common zoonosis which is present virtually worldwide. This microorganism infects a wide range of wild and domestic mammals, but the main reservoirs are cattle, goats and sheep, which also represent sources of human infection. A potential route of transmission of this pathogen to humans is the consumption of C. burnetii-contaminated raw milk or dairy products derived from contaminated raw milk, although the role of these foods as possible infection sources is controversial. The aims of this study were (i) to apply two ddPCR based assays targeting the C. burnetii IS1111 and icd genes for the detection and quantification of C. burnetii DNA, and (ii) to evaluate the occurrence of C. burnetii DNA in raw milk and raw milk products from sheep and goats in Apulia and Basilicata regions of Southern Italy. Of 413 milk and cheese samples tested, 78 were positive for the presence of C. burnetii DNA (18.9%), specifically, 68 of 285 milk samples (23.9%) and 10 of 128 cheese samples (7.8%) The presence of both IS1111 and icd genes was detected in only 2 (2.6%) of the 78 positive samples, while the remaining 76 (97.4%) were positive only for IS1111. C. burnetii DNA was specifically detected by the ddPCR method, whereas no cross-amplification was observed with the DNA of other foodborne bacterial pathogens. The sensitivity of the ddPCR method was determined as 0.35 and 0.56 copies/μL for IS1111 and icd genes, respectively. The findings of this study demonstrate the presence of C. burnetii DNA in a significant proportion of raw milk and dairy products. Although there is no conclusive epidemiological evidence that C. burnetii infection occurs via food, the presence of this organism in raw milk and dairy products made of raw milk should be considered a potential hazard. ddPCR is a useful tool to investigate the quality and safety of food products due to its sensitivity and precision, and could be applied to routine testing.

Classification of chronic pain for the International Classification of Diseases (ICD-11): results of the 2017 international World Health Organization field testing

ABSTRACT

Because chronic pain has been poorly represented in the International Statistical Classification of Diseases and Related Health Problems (ICD) despite its significant contribution to the burden of disease worldwide, the International Association for the Study of Pain (IASP) developed a classification of chronic pain that was included in the ICD-11 version as "MG30" and approved by the World Health Assembly in 2019. The objective of this field test was to determine how well the classification of chronic pain works in the context of the ICD-11. A web-based survey using the WHO-FiT platform recruited 177 healthcare professionals from all WHO regions. After a training on coding chronic pain hosted by the IASP Web site, participants evaluated 18 diagnostic codes (lines) of the 2017 frozen version of the ICD-11 and 12 vignettes (cases) describing chronic pain conditions. Correctness, ambiguity, and perceived difficulty of the coding were compared between the ICD-11 and the ICD-10 and the applicability of the morbidity rules for the ICD-11 verified. In the line coding, 43.0% of correct chronic pain diagnoses assigned with the ICD-10 contrasted with 63.2% with the ICD-11. Especially in cases in which the chronic pain is regarded as the symptom of an underlying disease, the ICD-11 (63.5%) commanded more correct diagnoses than the ICD-10 (26.8%). The case coding was on average 83.9% accurate, only in 1.6% of cases any difficulty was perceived. The morbidity rules were applied correctly in 74.1% of cases. From a coding perspective, the ICD-11 is superior to the ICD-10 in every respect, offering better accuracy, difficulty, and ambiguity in coding chronic pain conditions.

Remotely monitored inactivity due to COVID-19 lockdowns. Potential hazard for heart failure patients

OBJECTIVES

To study the impact of curfews during the COVID-19 pandemic, on the physical activity in patients of heart failure implanted withcardiac implantable electronic devices (CIEDs).

METHODS

This was a retrospective single-center study of heart failure patients inserted with remote monitoring (RM)-capable CIED. We analyzed the transmitted data of physical activity and fluid volume status of all patients, before, and during the lockdown periods between February and April 2020. The clinical status of the patients was also evaluated.  Results: Device data from 429 patients implanted with CIED capable of RM were initially evaluated. Patients with an implantable loop recorder, Brugada or Long QT syndromes, and patients with incomplete transmissions were excluded. Eighty-two patients with heart failure were included. The median age was 65 years (58-72), and 53 (64.6%) subjects were men. There was a 27.1% decline in physical activity, and the median physical activity of patients significantly declined from 2.4 to 1.8 hours/day (p=0.000010).  Conclusion: Data obtained by remotely monitored CIED in heart failure patients suggests a significant decline in physical activity during the country lockdown due to the pandemic. Awareness of the future potential hazards in this group of patients is warranted.

A Unique Interplay of Multiple Predisposing Factors Culminating in a Catastrophic QT Prolongation

Implantable cardioverter-defibrillators (ICDs) are used in patients without a reversible cause for long QT syndrome (LQTS) and secondary prevention in patients with LQTS-associated sudden cardiac arrest. We present a female patient with multiple reversible factors for QT prolongation, including the use of antidepressants, antidiarrheals, antiemetics, and antihistamines; chronic malabsorption from bariatric surgery; probable Gitelman syndrome and urinary losses of electrolytes, causing QT prolongation which leads to polymorphic ventricular tachycardia and a successfully resuscitated cardiac arrest. Our patient also had history suggestive of probable congenital LQTS with multiple childhood syncopal episodes and a history of seizures in first-degree relatives, further justifying the placement of an ICD. Also, this case gives us an opportunity to delve into the risks of catastrophic QT prolongation in the morbidly obese population undergoing bariatric surgery.

Proposal for a Scientifically Correct and Medically Actionable Disease Classification System (ICD) for Obesity

OBJECTIVE

Obesity is responsible for a huge burden of suffering and social costs, and yet many patients lack access to evidence-based therapies. The diagnostic term "obesity" and inadequate International Classification of Diseases(ICD) codes contribute to suboptimal efforts to prevent and treat obesity as a chronic disease. The goal of this review is to develop a medically actionable classification system based on the diagnostic term "adiposity-based chronic disease" (ABCD) that reflects disease pathophysiology and specific complications causing morbidity and mortality.

METHODS

A coding system based on the diagnosis of ABCD with four domains is proposed: A codes reflect pathophysiology, B codes indicate BMI classification, C codes specify specific biomechanical and cardiovascular complications remediable by weight loss, and D codes indicate the degree of the severity of complications. Supplemental codes identify aggravating factors that complicate care and that are relevant to a personalized therapeutic plan.

RESULTS

The coding system addresses pathophysiology and therapeutic goals and differential risk, presence, and severity of specific complications that are integral to ABCD as a chronic disease.

CONCLUSIONS

The scientifically correct and medically actionable approach to diagnosis and disease coding will lead to greater acknowledgement of ABCD as a disease and accessibility to evidence-based therapies on behalf of patients across the life cycle.

Devices in heart failure; diagnosis, detection and disease modification

INTRODUCTION/BACKGROUND

Implantable cardiac devices are widely used in chronic heart failure (CHF) therapy. This review covers current CHF treatment with electronic cardiac devices, areas of discussion and emerging technologies.

SOURCES OF DATA

A comprehensive search of available literature resources including Pubmed, MEDLINE and EMBASE was performed. National and international guidelines were accessed.

AREAS OF AGREEMENT

Excessive right ventricular pacing is detrimental to cardiac function. Cardiac resynchronization therapy is beneficial in specific individuals with CHF.

AREAS OF CONTROVERSY

Implantable cardioverter defibrillators might not benefit all. Optimizing CRT delivery. Remote monitoring seems not to be of benefit in CHF.

GROWING POINTS

Device-based optimization.

AREAS TIMELY FOR DEVELOPING RESEARCH

Personalization of device therapy. Focussing implantable cardioverter defibrillator therapy. What to do at implantable cardioverter defibrillator box change?

Impulse control disorders in patients with dopamine agonist-treated prolactinomas and nonfunctioning pituitary adenomas: a case-control study

OBJECTIVE

We aimed to assess the prevalence of impulse control disorders (ICDs) in patients with prolactin-secreting adenomas treated with dopamine agonists (DAs), to identify associated factors and to compare it with a group of patients with nonfunctioning pituitary adenoma.

SUBJECTS, DESIGN AND MEASUREMENT

In a postal survey, 77 patients from Group A (patients with prolactinomas and present or past use of DAs) and 70 patients from Group B (patients with nonfunctioning pituitary adenoma and no history of DA therapy) responded to a questionnaire on compulsive shopping, pathologic gambling, hypersexuality and punding. Associated clinical information was obtained through the survey and review of medical electronic records.

RESULTS

The total ICD prevalence was 24·68% in Group A and 17·1% in Group B (P = 0·31). Group A had an increased rate of hypersexuality (P = 0·03). Subgroup analysis revealed that men in Group A had a significantly increased frequency of total ICDs when compared with men in Group B (27·7 vs 3·7%, P = 0·01). No differences in rates of total ICDs were found between women of Groups A and B (20 vs 25·6%, P = 0·78). No association with type, dose or duration of treatment with DA was noted.

CONCLUSIONS

Males with prolactinomas treated with DAs were 9·9 times more likely to develop an ICD than their counterparts with nonfunctioning pituitary adenomas. Until prospective studies on the relationship of DA use in patients with prolactinoma and ICDs are available, the authors propose that patients with prolactinoma be forewarned of possible ICD development with DA therapy.

Toward the future of psychiatric diagnosis: the seven pillars of RDoC

BACKGROUND

Current diagnostic systems for mental disorders rely upon presenting signs and symptoms, with the result that current definitions do not adequately reflect relevant neurobiological and behavioral systems--impeding not only research on etiology and pathophysiology but also the development of new treatments.

DISCUSSION

The National Institute of Mental Health began the Research Domain Criteria (RDoC) project in 2009 to develop a research classification system for mental disorders based upon dimensions of neurobiology and observable behavior. RDoC supports research to explicate fundamental biobehavioral dimensions that cut across current heterogeneous disorder categories. We summarize the rationale, status and long-term goals of RDoC, outline challenges in developing a research classification system (such as construct validity and a suitable process for updating the framework) and discuss seven distinct differences in conception and emphasis from current psychiatric nosologies.

SUMMARY

Future diagnostic systems cannot reflect ongoing advances in genetics, neuroscience and cognitive science until a literature organized around these disciplines is available to inform the revision efforts. The goal of the RDoC project is to provide a framework for research to transform the approach to the nosology of mental disorders.

Thyroid function in heart failure and impact on mortality

OBJECTIVES

The aim of this study was to investigate whether patients with systolic heart failure (HF) and abnormal thyroid function are at increased risk for death.

BACKGROUND

Thyroid hormone homeostasis is vital to the optimal functioning of the cardiovascular system, but an independent prognostic effect of thyroid abnormalities in patients with HF has not been established.

METHODS

In SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial), which randomized patients with ischemic or nonischemic HF to placebo or amiodarone or implantable cardioverter-defibrillator therapy, thyroid-stimulating hormone (TSH) was measured at baseline and at 6-month intervals throughout the 5-year study.

RESULTS

Of 2,225 patients, the majority (87%) had normal TSH levels (0.3 to 5.0 μU/ml) at baseline, 12% had values suggestive of hypothyroidism, and 1% had values consistent with hyperthyroidism. Compared with euthyroid patients, those hypothyroid at baseline were older and included more women and Caucasians (all p values <0.05). Over the median follow-up period of 45.5 months, among patients euthyroid at baseline, 89 developed abnormally low TSH levels, and 341 developed abnormally high values. Patients randomized to amiodarone (median dose 300 mg) had an elevated risk for developing abnormal TSH levels compared with implantable cardioverter-defibrillator therapy or placebo (p < 0.0001). Patients with baseline or new-onset abnormal thyroid function had a higher mortality than those with normal thyroid function, even after controlling for other known mortality predictors (hazard ratio: 1.58; 95% confidence interval: 1.29 to 1.94; p < 0.0001 for hypothyroid; hazard ratio: 1.85; 95% confidence interval: 1.21 to 2.83; p = 0.0048 for hyperthyroid). Implantable cardioverter-defibrillator benefit did not vary with thyroid function.

CONCLUSIONS

Abnormal thyroid function in patients with symptomatic HF and ejection fractions ≤35% is associated with significantly increased risk for death, even after controlling for known mortality predictors.

Maternal mortality in Sweden 1988-2007: more deaths than officially reported

OBJECTIVE

To obtain more accurate calculations of maternal and pregnancy-related mortality ratios in Sweden from 1988 to 2007 by using information from national registers and death certificates.

DESIGN

A national register-based study, supplemented by a review of death certificates.

SETTING

Sweden, 1988-2007.

POPULATION

The deaths of 27 957 women of reproductive age (15-49 years).

METHODS

The Swedish Cause of Death Register, Medical Birth Register, and National Patient Register were linked. All women with a diagnosis related to pregnancy in at least one of these registers within 1 year prior to death were identified. Death certificates were reviewed to ascertain maternal deaths. Maternal mortality ratio (the number of maternal deaths/100 000 live births, excluding and including suicides), and pregnancy-related mortality ratio (number of deaths within 42 days after termination of pregnancy, irrespective of cause of death/100 000 live births) were calculated.

MAIN OUTCOME MEASURES

Direct and indirect maternal deaths and pregnancy-related deaths.

RESULTS

The maternal mortality ratio in Sweden, based on the current method of identifying maternal deaths, was 3.6. After linking registers and reviewing death certificates, we identified 64% more maternal deaths, resulting in a ratio of 6.0 (or 6.5 if suicides are included). The pregnancy-related mortality ratio was 7.3. A total of 478 women died within a year after being recorded with a diagnosis related to pregnancy.

CONCLUSIONS

By including the 123 cases of maternal death identified in this study, the mean maternal mortality ratio from 1988 to 2007 was 64% higher than reported to the World Health Organization.

Moving towards ICD-11 and DSM-V: Concept and evolution of psychiatric classification

A classification is as good as its theory. As the etiology of psychiatric disorders is still not clearly known, we still define them categorically by their clinical syndrome. There are doubts if they are valid discrete disease entities and if dimensional models are better to study them. We have come a long way till ICD-10 and DSM-IV, but there are shortcomings. With advances in genetics and neurobiology in the future, classification of psychiatric disorders should improve further. The concept, evolution, current status and challenges facing psychiatric classification are discussed in this review.

Cannabis withdrawal predicts severity of cannabis involvement at 1-year follow-up among treated adolescents

AIMS

Controversy exists regarding the inclusion of cannabis withdrawal as an indicator of dependence in the next revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). This study contrasted the concurrent and predictive validity of three operational definitions of cannabis withdrawal in a sample of treated adolescents.

DESIGN

Prospective study of treated adolescents with 1-year follow-up.

SETTING AND PARTICIPANTS

Adolescents (n=214) were recruited from intensive out-patient treatment programs for substance abuse, and followed at 1 year (92% retention). Youth who were included in the analyses reported regular cannabis use.

MEASUREMENTS

The number of DSM-IV cannabis abuse and dependence symptoms at baseline and 1-year follow-up, past year frequency of cannabis use at baseline and follow-up, and periods of abstinence at 1-year follow-up. Cannabis withdrawal was defined based on (i) the presence of two or more cannabis withdrawal symptoms; (ii) a definition proposed by Budney and colleagues (2006) that requires four or more withdrawal symptoms (four-symptom definition); and (iii) the use of latent class analysis to identify subgroups with similar cannabis withdrawal symptom profiles.

FINDINGS AND CONCLUSIONS

All three definitions of cannabis withdrawal demonstrated some concurrent validity. Only the four-symptom and latent class-derived definitions of withdrawal predicted severity of cannabis-related problems at 1-year follow-up. No cannabis withdrawal definition predicted frequency of use at follow-up. Further research is needed to determine the clinical utility and validity of the four-symptom definition, as well as alternative definitions of cannabis withdrawal, to inform revisions leading to DSM-V and ICD-11.

Defibrillation testing of the implantable cardioverter defibrillator: when, how, and by whom?

The implantable cardioverter-defibrillator (ICD) has become an integral part of treatment for a variety of patients with symptomatic, or at risk for, ventricular tachyarrhythmias. The ICD's effectiveness is attributed to its ability to promptly detect and terminate ventricular tachycardia (VT) and fibrillation (VF). The clinical trials that established the positive role of ICD therapy were based on patients who underwent some form of defibrillation testing at the time of implantation. Therefore, since its advent, intraoperative defibrillation testing of the ICD to assure reliable detection and termination of VT/VF has been a standard practice. But because of advances in defibrillator and lead technology, which now facilitates successful device implantation (i.e., low defibrillation energy requirement to allow for an adequate programmed safety margin) in the majority of patients, the necessity of defibrillation testing has been called into attention. Despite substantial progress, it is not altogether clear whether a wholesale abandonment of intraoperative ICD testing is appropriate at this point. We review pertinent data regarding pros and cons of ICD testing and offer a suggestion as to when, how, and who should test ICDs.

The implantable cardioverter-defibrillator: postcode prescribing in the UK 1998-2002

OBJECTIVE

To determine the rate of implantable cardioverter-defibrillator (ICD) implantation across the UK during the period 1998 to 2002.

DESIGN

Observational self reporting with cross checking.

SETTING

All ICD implanting centres coordinated by the National Pacemaker and ICD Database.

PATIENTS

Every patient receiving an ICD in the UK from 1998 to 2002.

MAIN OUTCOME MEASURES

Date of implantation and postcode of each ICD recipient during the study period.

RESULTS

ICD implantation increased in the UK in the five year period studied but fell far short of the European average and national targets. Implantation rates varied greatly by region.

CONCLUSIONS

The low rate of ICD implantation in the UK and the disparity between regions require further study to determine the barriers to this evidence based treatment.

Cardiac resynchronization--a heart failure perspective

Over the past 15-20 years the development of new heart failure pharmacologic therapy has lowered mortality by 30-40% for this serious and prevalent clinical syndrome, within clinical trials conducted in patients with a dilated cardiomyopathy phenotype. However, over the past 5 years progress in the development of additional effective drugs has slowed, in part due to the success of neurohormonal inhibitors, on which background new therapies must be developed. That there is not an absolute ceiling on the development of new heart failure therapies has been convincingly recently demonstrated in electrophysiologic device trials, conducted on the background of maximal neurohormonal inhibition. Two trials, COMPANION and CARE-HF, have demonstrated unambiguously that in advanced heart failure patients with a marker of mechanical intraventricular dyssynchrony, increased QRS duration, cardiac resynchronization therapy in the form of biventricular pacing can improve major clinical outcomes including mortality. In addition, COMPANION also demonstrated that the addition of an ICD further improved mortality reduction, by lowering the incidence of sudden death. These trials indicate that device/drug therapy is at least additive in the treatment of heart failure, and they herald a new era in the multi-modality approach to therapeutics.

Magnetic resonance imaging in patients with ICDs and pacemakers

Magnetic resonance (MR) imaging has unparalleled soft-tissue imaging capabilities. The presence of devices such as pacemakers and implantable cardioverter/defibrillators (ICDs), however, is historically considered a contraindication to MR imaging. These devices are now smaller, with less magnetic material and improved electromagnetic interference protection. This review summarizes the potential hazards of the device-MR environment interaction, and presents updated information regarding in-vivo and in-vitro experiments. Recent reports on patients with implantable pacemakers and ICDs who underwent MR scan shows that under certain conditions patients with these implanted systems may benefit from this imaging modality. The data presented suggests that certain modern pacemaker and ICD systems may indeed be MR safe. This may have major clinical implications on current imaging practice.