Background: QT segment prolongation is a high risk factor for fatal arrhythmias. Several studies have indicated a possible relation between low testosterone levels and QT interval prolongation. 

Objectives: To compare the QT interval length in elderly patients with prostate carcinoma who were on anti-testosterone treatment and those who were not.

Methods: We screened the electrocardiograms (ECGs) of 100 prostate cancer patients divided into two groups: 50 patients on anti-testosterone drug treatment and 50 patients not. QT interval length was measured according to the accepted methods.

Results: The mean QTc 12 leads in the entire group was 0.45 ± 0.04 sec, which is close to the upper limit. Mean QTc was actually longer in the control group and there was no QTc difference between the groups after adjustment for possible confounders. Prolonged QTc 12-lead ECG (48% in treated and 54% in non-treated) and lead L2 QT interval (50% in treated and 56% in non-treated) did not differ significantly between the groups. The analysis of QTc 12-lead ECG indicated no significant effects of anti-testosterone drug treatment. Only the use of furosemide was associated with QT prolongation. 

Conclusions: The results of this preliminary study do not support our initial concern of an alarmingly prolonged QT interval in the anti-testosterone treated group. However, further prospectively designed studies are needed. In the meanwhile we call for a close follow-up of the QT interval length in patients receiving anti-testosterone treatment. 

 

Background: Appropriate antibiotic use is of both clinical and economic significance to any health system and should be given adequate attention. Prior to this study, no in-depth information was available on antibiotic use patterns in the emergency department of Hadassah Medical Center.

Objectives: To describe the use and misuse of antibiotics and their associated costs in the emergency department of Hadassah Medical Center.

Methods: We analyzed the charts of 657 discharged patients and 45 admitted patients who received antibiotics in Hadassah Medical Center’s emergency department during a 6 week period (29 April – 11 June 2007). A prescription was considered appropriate or inappropriate if the choice of antibiotic, dose and duration by the prescribing physician after diagnosis was considered suitable or wrong by the infectious diseases consultant evaluating the prescriptions according to Kunin’s criteria.

Results: The overall prescribing rate of antibiotics was 14.5% (702/4830) of which 42% were broad- spectrum antibiotics. The evaluated antibiotic prescriptions numbered 1105 (96 prescriptions containing 2 antibiotics, 2 prescriptions containing 3 antibiotics), and 54% of them were considered appropriate. The total inappropriate cost was 3583 NIS[1] (1109 USD PPP[2]) out of the total antibiotic costs of 27,300 NIS (8452 USD PPP). The annual total antibiotic cost was 237,510 NIS (73,532 USD PPP) and the annual total inappropriate cost was 31,172 NIS (9648 USD PPP). The mean costs of inappropriate prescriptions were highest for respiratory (112 NIS, 35 USD PPP) and urinary tract infection (93 NIS, 29 USD PPP). There were more cases when the optimal cost was lower than the actual cost (N=171) than when optimal cost was higher than the actual cost (N=9). In the first case, the total inappropriate costs were 3805 NIS (1,178 USD PPP), and in the second case, -222 NIS (68.7 USD PPP).

Conclusions: The use of antibiotics in emergency departments should be monitored, especially in severely ill patients who require broad-spectrum antibiotics and for antibiotics otherwise restricted in the hospital wards. Our findings indicate that 12% of the total antibiotic costs could have been avoided if all prescriptions were optimal.

Background: Little is known of the outcome of pregnant patients with previously diagnosed dilated cardiomyopathy. These patients are usually firmly advised against continuation of the pregnancy.

Objectives: To examine the usefulness of serial echocardiographic follow-up and plasma N-terminal pro-B type natriuretic peptide levels in the management of pregnant women with preexisting DCM[1].

Methods: We prospectively enrolled pregnant women with DCM either known or diagnosed in the first trimester. Clinical examination and serial echocardiography studies at baseline, 30 weeks gestation, peripartum, and 3 and 18 months postpartum were performed. Blinded NTproBNP[2] levels were obtained at 30 weeks, delivery and 3 months postpartum.

Results: Between June 2005 and October 2006 we enrolled seven women who fulfilled the study criteria. Delivery and postpartum were complicated in 3 patients (42%): 2 with acute heart failure, which resolved conservatively, and 1 with major pulmonary embolism. The left ventricular ejection fraction was stable throughout the pregnancy (35% ± 2.8 at baseline, 33% ± 2.9 at 30 weeks) and postpartum (35% ± 2.8 at 1 day, 34% ± 3.1 at 90 days). Similar stable behavior was observed regarding left ventricular dimensions: LV[3] end-systolic diameters 43.3 ± 2.7 mm and LV end-diastolic diameters 57.3 ± 3.3 mm at baseline compared with 44.1 ± 3.1 mm and 58.7 ± 3.1 mm postpartum, respectively. The NT-ProBNP levels rose significantly peripartum in all three patients with complications.

Conclusions: Serial NT-proBNP levels, as compared to echocardiography, may be a better clinical tool in monitoring and management of pregnant women with preexisting DCM. An early rise in NT-ProBNP level appears to predict the occurrence of adverse events.

Background: Spontaneous coronary reperfusion occurs in 7–27% of patients with ST elevation myocardial infarction, and is an independent predictor of myocardial salvage, percutaneous coronary intervention success, and improved outcome.

Objectives: To determine the optimal PCI[1] time for patients admitted to the hospital due to STEMI[2] with SCR[3].

Methods: We performed a retrospective analysis of all patients admitted to the coronary care unit between July 2002 and November 2004 with a diagnosis of STEMI with SCR.

Results: The study group comprised 86 patients. There was not a single reinfarction episode during an observation period of 6579 patient hours. Cardiac catheterization was executed early (< 24 hours from pain onset) in 26 patients and late (> 24 hours) in 55. Pre-PCI angiographic TIMI flow 2–3 was seen in > 95% in both groups. PCI was performed more frequently in the “early” group (P = 0.024), while multi-vessel coronary artery disease (P = 0.094) requiring coronary bypass surgery (P = 0.056) was observed more frequently in the “late catheterization” group. Myocardial infarction and angina pectoris at 30 days occurred more frequently in the early catheterization group (P = 0.039), however no difference in any major adverse cardiac events was detected during long-term follow-up (491 ± 245 days).

Conclusions: Reinfarction after STEMI with SCR is a rare event. Early PCI in patients with STEMI and SCR, even when executed with aggressive anti-platelet therapy, seems to result in an excess of early MACE, without any long-term advantage. Prospective randomized trials should determine the optimal PCI timing for these patients.

Background: Echocardiographic assessment of left ventricular function includes calculation of ejection fraction and regional wall motion analysis. Recently, speckle imaging was introduced for quantification of left ventricular function.

Objectives: To assess LVEF[1] by speckle imaging and compare it with Simpson’s method, and to assess the regional LV strain obtained by speckle imaging in relation to conventional echocardiographic scores.

Methods: Thirty consecutive patients, 28 with regional LV dysfunction, underwent standard echocardiographic evaluation. LV end-diastolic volume, LV end-systolic volume and EF were calculated independently by speckle imaging and Simpson’s rule. The regional peak systolic strain presented by speckle imaging as a bull's-eye map was compared with the conventional visual estimate of echo score.

Results: Average EDV[2] obtained by speckle imaging and by Simpson’s method were 85.1 vs. 92.7 ml (P = 0.38), average ESV[3] was 49.4 vs. 48.8 ml (P = 0.94), calculated EF was 43.9 vs. 50.5% (P = 0.08). The correlation rate with Simpson’s rule was high: 0.92 for EDV, 0.96 for ESV, and 0.89 for EF. The peak systolic strain in two patients without wall motion abnormality was 17.3 ± 4.7; in normal segments of patients with regional dysfunction, peak systolic strain (13.4 ± 4.9) was significantly higher than in hypokinetic segments  (10.5 ± 4.5) (P < 0.000001). The strain in hypokinetic segments was significantly higher than in akinetic segments (6.2 ± 3.6) (P < 0.000001).

Conclusions: Speckle imaging can be successfully used for the assessment of LV volumes and EF. Bull's-eye strain map, created by speckle imaging, can achieve an accurate real-time segmental wall motion analysis.

Objectives: To describe the dynamic changes of the coronary sinus during the cardiac cycle.

Methods: The angiographic feature of the coronary sinus was evaluated in 30 patients undergoing diagnostic and therapeutic coronary angiography.

Results: Prolonged angiographic imaging following coronary injections permitted accurate demonstration of the coronary sinus in all 30 patients. We report, for the first time, that the coronary sinus can be divided into two angiographic functional/anatomic portions, upper and lower. The lower part is prone to a highly dynamic contraction/relaxation pattern, observed in 12 of the 30 patients, while 10 patients had normal and 8 had low contractile pattern on angiography. Clinical assessment of these patients did not identify an association with this motion pattern.

Conclusions: The coronary sinus is an important anatomic/functional structure that should be further investigated in patients with various forms of heart disease.

Background: Cardiac rupture is a rare but ominous complication of myocardial infarction.

Objectives: To study the clinical presentation, medical course, outcome and echocardiographic predictors of patients with myocardial rupture.

Methods: We evaluated 15 consecutive patients with cardiac rupture during a 4 year period in our department. The current report explores the presence of potential risk factors, timing, relation to the thrombolysis, coronary interventions and outcome.

Results: The index event in all patients was first ST elevation myocardial infarction. In seven patients rupture occurred in the first 24 hours. Pericardial effusion on admission with a clot was present in three patients. Five patients received thrombolytic therapy. Only three patients underwent coronary angioplasty, but in one case it was performed late and in two patients the culprit artery could not be opened. Six patients reached the operating room, of whom three survived.

Conclusions: The lack of early mechanical reperfusion in acute myocardial infarction and thrombolytic therapy are risk factors for cardiac rupture. Pericardial effusion on admission and evidence of a clot are echocardiographic indicators of cardiac rupture and should alert the medical team to further assess the possibility of cardiac rupture.