Introduction: Subcutaneous implantable cardioverter defibrillator (S-ICD) eligibility is determined by QRST morphology across three sensing vectors; primary (P), secondary (S) and alternate (A), with small R:T ratios conferring an unacceptable risk of T wave over sensing.Between 3% and 8% of patients have no suitable sensing vector and are ineligible for an S-ICD.Screening failure rates increase to between 13% and 16% in patients with congenital heart disease or hypertrophic cardiomyopathy.R:T ratio is determined by the position from which electrocardiogram is recorded.Varying the position alters the absolute amplitude (distance from the isoelectic line) of both R and T.However, given that defibrillation efficacy has been demonstrated in the current S-ICD position, significant alterations in lead position to accommodate an individual's unique R and T wave axes is impractical.Mathematical vector rotation, using signal sensed from the current S-ICD position, is however achievable.This novel technique allows identification of every patient's 'personalised vector', the sensed vector with maximal R:T ratio for that individual.We hypothesise that use of the personalised vector will significantly increase R:T ratio and therefore substantially increase S-ICD eligibility.We believe that incorporation of this sensing algorithm would remove the need for pre-implant S-ICD screening, with universal device eligibility on the basis of QRST morphology.Method: We performed standardised S-ICD screening on adult patients with transvenous defibrillators and <1% ventricular pacing.This identified S-ICD ineligible patients, those with no suitable vectors, who were subsequently fitted with a two channel Holter recorder to simultaneously record vectors P and A for one minute.These two data sets were downloaded in 1000Hz ASCII format.A single PQRST complex was isolated from each vector and the signals were aligned.R:T ratios in P and A were calculated.Given that the primary and alternate S-ICD vectors approximate a right angled triangle in the frontal plane, simulated clockwise rotation of the secondary vector (P,A) was performed at 5 degree intervals up to 360 degrees.This produced 72 new 'Pz' vectors, as Pz ¼ [P x cos z] þ [A x sin z], where z is the angle of rotation.R:T ratio was measured in every new vector and standardised S-ICD screening was performed against the 'personalised vector' for each patient.Results: 92 patients (age 64.9 6 2.7 years, 79% male, 33% EF < 0.35) underwent S-ICD screening and 3.3% were found to have no suitable vector.The mean sensed R:T ratio in this ineligible cohort was 2.50 (2.14 -2.85).Use of the personalised vector significantly increased the mean R:T ratio in this group to 5.94 (4.55 -7.33, paired t-test p < 0.05).Furthermore every personalised vector passed S-ICD screening, increasing overall S-ICD eligibility from 96.7% to 100%.Conclusions: The generation of personalised vectors using mathematical vector rotation significantly increases R:T ratio and S-ICD eligibility.This novel technique represents a significant development in S-ICD sensing.This technique has potential future applications in reducing inappropriate therapies from T wave over sensing, improving rhythm discrimination algorithms and potentialy removing the need for S-ICD screening altogether.A -The effect of rotation on vector appearance.B -The personalised vector (top) is compared to the primary (middle) and alternate (bottom) vectors for a given patient.
Symptomatic recurrence of an histologically verified intra- and suprasellar Rathke's cleft cyst (RCC) was observed 4 months following transsphenoidal microsurgery. The space-occupying cyst was treated by endocavitary irradiation with colloidal rhenium-186 via a previously implanted catheter with an attached subcutaneous reservoir. The calculated dose of 4.4 Gy was able to stop the production of cyst fluid. Follow-up after intracavitary irradiation extends over 13 months. The cyst, with an initial size of 3 x 3 x 4 cm, has been reduced to 1.1 x 1.06 x 1.2 cm. The production of cyst fluid has decreased from 25 - 30 ml within 2 months before treatment to zero. The patient's visual and mental status as well as her quality of life are normal.
In the pursuit of improved clinical outcomes and patient experience in health care, shared decision-making (SDM) stands as a pivotal concept garnering increasing attention, but SDM utilization varies widely, often leading to confusion regarding team members' roles. This study explores knowledge, skills, and attitudes of oncology clinicians engaged in a pioneering educational initiative at a comprehensive cancer care center, aimed at enhancing frontline SDM capabilities.
Zusammenfassung Es wird über Erfahrungen mit dem 99mTc-markierten monoklonalen Antikörper BW 250/183 zum Entzündungsnachweis berichtet. Die Validisierung erfolgte an 160 von 354 untersuchten Patienten. Es ergab sich mit einer Sensitivität von 91 % und einer Spezifität von 82% eine hohe diagnostische Treffsicherheit. Ein in 72 Fällen durchgeführter Vergleich zwischen konventioneller 3-Phasen-Knochenszintigraphie und der Granulozytenszintigraphie ergab einen positiven immunszintigraphischen Entzündungsnachweis in 76% der positiven Knochenszintigramme. Bei 84 Erstuntersuchten und 6 Zweituntersuchten wurden die HAMA-Titer 1 bis 12 Monate nach Applikation untersucht. Es zeigte sich bei den Zweituntersuchten lediglich 1 Patient mit einem mäßig erhöhten HAMA-Titer. Hieraus wird der Schluß gezogen, daß der monoklonale Antikörper BW 250/183 sehr gut zum szintigraphischen Entzündungsnachweis geeignet ist.
Increasing numbers of women are surviving breast cancer, and survivorship care is becoming more complex. Primary care physicians provide care for most survivors of breast cancer in the Canadian province of British Columbia. The present study offers insight into the confidence of primary care physicians in their abilities to provide such care. It also explores potential ways to assist those providers in enhancing this aspect of their practice.A questionnaire was mailed to 1000 primary care physicians caring for survivors of breast cancer. The questionnaire explored the perspectives of the responding physicians on their ability to manage various aspects of survivorship care for breast cancer patients, identified preferences for the content and format of communication from oncologists at the time of transition from active oncology treatment to survivorship, and determined the means most commonly used to obtain knowledge about breast cancer. This 1-page, 31-item checkbox and open-answer questionnaire assessed the perceptions of primary care physicians about the care of breast cancer survivors after completion of active treatment and their personal preferences for resources providing information about breast cancer.The questionnaire response rate was 59%. Primary care physicians reported being most confident in screening for recurrence and managing patient anxiety; they were least confident in managing lymphedema and providing psychosocial counselling. Compared with physicians following fewer survivors of breast cancer, those who followed more breast cancer survivors had higher confidence in managing the biomedical aspects of follow-up and in providing counselling about nutrition and exercise. Most physicians found discharge letters from oncologists to be useful. Point-form discharge information was preferred by 43%; detailed description, by 19%; and both formats, by 38%. The most useful information items identified for inclusion in a discharge letter were a diagnosis and treatment summary and the recommended surveillance and endocrine therapy. Continuing medical education events and online resources were the means most commonly used to obtain knowledge about breast cancer.Primary care physicians who provide follow-up for survivors of breast cancer report that they are confident in managing care and satisfied with discharge letters containing a diagnosis and treatment summary, and recommendations for surveillance and endocrine treatment. At the time of patient discharge, additional information about common medical and psychosocial issues in this patient population would be useful to primary care physicians. Preferred means to access current breast cancer information include continuing medical education events and online resources.
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