Local staging of esophageal cancer using endoscopic magnetic resonance imaging: prospective comparison with endoscopic ultrasound

Thyroid cancer is associated with abnormal thyroid peroxidase (TPO) expression as shown by abolition of immunodetection by monoclonal antibody 47 (Mab 47). The purpose of this study was to determine the relation of this abnormality with differentiation and proliferative potential of follicular tumors evaluated by analyzing thyroglobulin (TG) expression and proliferative cell nuclear antigen (PCNA) index. TPO, TG, and PCNA immunostaining were performed in a series of 30 thyroid follicular tumors ranging from adenoma to invasive carcinoma. Our findings confirmed that TPO abnormalities and PCNA index were correlated with malignancy, and that PCNA as well as TPO could be used to determine the growth potential of follicular proliferations in fine-needle aspirates. The most discriminant parameter was the ratio between the percentage of Mab-47 and PCNA positive cells. Ratios under 0.6 were correlated with malignancy in 90% of the cases, with only 3 cases of atypical adenomas being misdiagnosed as carcinomas. An inverse correlation was found between TPO and PCNA expression, but TG, which persisted at high levels in several actively growing follicular carcinomas, did not appear directly linked to cellular proliferation. These findings confirm that, unlike a decrease in TG synthesis that merely reflects the progressive loss of differentiation occurring in high-grade proliferations, alteration of TPO is an early marker of thyroid follicular tumors, closely related to acceleration of tumor growth in the first stages of malignant transformation.     

Spiral computed tomography and operative staging of gastric carcinoma: a comparison with histopathological staging

BACKGROUND: Much controversy exists as to the value of computed tomography (CT) in the preoperative staging of gastric cancer, because of its limited ability to identify correctly lymph node (LN) metastases, invasion of adjacent organs, or hepatic and peritoneal metastases. Spiral CT scanners have a number of potential advantages over conventional scanners, including the absence of respiratory misregistration, image reconstruction smaller than scan collimation permitting overlapping slices and optimisation of intravenous contrast enhancement. AIM: To compare the performance of spiral CT and operative assessment against formal (TNM) pathological staging. PATIENTS AND METHODS: A study of 105 consecutive patients who underwent both spiral CT and operative staging was performed. All CT scans were reviewed by a radiologist who commented on tumour location and size, evidence of adjacent organ invasion, lymph node metastases to both N1 and N2 nodes, and evidence of hepatic and peritoneal metastases. All patients underwent careful operative assessment at the time of surgery, along the lines suggested by Rohde and colleagues. RESULTS: Spiral CT remained poor at identifying LN metastases to both N1 and N2 lymph nodes, with sensitivity ranging from 24 to 43%; specificity, however, was 100%. Operative staging was superior, with sensitivities between 84 and 94%, but specificity was much lower (63-74%). Spiral CT correctly detected 13 of 17 cases of invasion of either the colon or the mesocolon (sensitivity 76%) compared with 16 of 17 cases at operative staging (sensitivity 94%). Spiral CT correctly identified three of six cases with invasion of the pancreas (sensitivity 50%) compared with six of six cases on operative staging (sensitivity 100%). Spiral CT correctly identified 12 of 17 cases of peritoneal metastases (sensitivity 71%) and four of seven cases of hepatic metastases (sensitivity 57%). CONCLUSION: Whilst spiral CT remains poor at identifying lymph node metastases, it correctly identified most cases with invasion of either the colon or the mesocolon and half the cases of pancreatic invasion. It was of value in detecting peritoneal metastases and some cases with hepatic metastases. At present, at Leeds General Infirmary spiral CT is performed routinely on all patients with gastric cancer and a selective staging laparoscopy policy is adopted in those patients in whom the status of the peritoneal cavity and liver is in doubt.     

Evaluation of the cochlear aqueduct patency: comparison of 2 noninvasive techniques

Variations in cephalo-rachidian fluid pressure can be transmitted to the middle ear through the cochlear aqueduct (CA). This gives us a non-invasive manner to evaluate any changes in fluid pressure by measuring middle ear impedance (impedancemetry). The present study compared two indirect methods for measuring intracranial pressure: a) impedancemetry during evoked jugulo-tympanic reflex (JTR) and b) study of the tympanic membrane (TM) fine motility using a MMS-10 analyzer. The latter is a new procedure involving the indirect evaluation of the fluid pressure. In fact, when the CA is open the labyrinthine fluid pressure is transmitted to the oval window, the stapes platina and, finally, to the tympanic membrane where it can be measured with an MMS-10 unit. This equipment can measure nanoliter shifts in the TM. In particular, comparison between the clinostatic and orthostatic tympanic motility measurements enable one to establish whether the CA is patent or not. In the present study 15 subjects were examined using both a) impedancemetry during jugular compression and b) analysis of the TM shift using an MMS-10 unit. In 14 of the 15 cases there was good correlation between the data obtained using both methods: in all but one case it proved possible to record a JTR-induced variation in impedance whenever the MMS-10 indicated that the CA was open. The results suggest that, in clinical practice, the two methods can be used in parallel for non-invasive monitoring of variations in intracranial pressure in patients with neurological involvement. On the other hand, in the E.N.T. field these techniques could be used to study inner ear pathologies causing dynamic alterations of the endolabyrinth fluids (endolymphatic hydrops, labyrinthine fistula).     

Bronchoscopic biopsy techniques in the diagnosis and staging of lung cancer

The t(1;19)(q23;p13), detected cytogenetically in 5-6% of cases, is one of the most common translocations in childhood acute lymphoblastic leukemia (ALL). Most t(1;19)+ ALLs are pseudodiploid or contain fewer than 50 chromosomes, are classified as pre-B based on expression of cytoplasmic, but not surface, immunoglobulin (clg+/slg-), express a characteristic pattern of cell surface antigens, and contain E2A-PBX1 fusion mRNAs. A minority of cases are early pre-B (clg-/slg-), do not express the characteristic pattern of cell surface antigens, and lack E2A-PBX1 fusion mRNAs. These latter cases are frequently hyperdiploid, with a modal chromosome number of 55-57. The incidence of the t(1;19) in adults with ALL (approximately 3%) appears to be similar to that observed in children, but the genetic and immunophenotypic features of adult t(1;19)+ ALL have not been described extensively. We report a case of t(1;19)+ ALL occurring in a 38-year-old man in the setting of hyperdiploidy > 50. Despite this feature, this case was pre-B, conformed to the classic t(1;19) immunophenotype, and expressed E2A-PBX1 fusion mRNAs. This prompted us to review the published literature on ploidy and genetic features of t(1;19)+ ALLs. Overall, E2A-PBX1 fusion occurred in 95% (102/107) of t(1;19)+ B-lineage ALLs with 50 or fewer chromosomes, 80% of which were pseudodiploid, vs. only 25% (2/8) of t(1;19)+ ALLs with more than 50 chromosomes.     

A comparison between lymphangiography and pelvic node dissection in the staging of prostatic cancer

On 40 consecutive patients with prostatic cancer who had pedal lymphangiography during the initial evaluation and, subsequently, underwent pelvic node dissection or biopsy, a surprisingly high number had falsely positive (59 per cent) or negative (36 per cent) x-ray findings. Initially the tumors were considered clinically to be stage B in 24 cases, stage C in 13 and stage D in 3. After lymph node dissection only 17 tumors were still considered to be stage B and 7 were stage C, while 16 tumors were actually stage D. This surgical staging is important for the further management of the patient as well as the prognosis, Pedal lymphangiogrpahy alone is unreliable for accurate assessment of the regional lymph node status in clinically localized prostatic cancer.     

Gastric cancer. Radiologic staging

CT scan and EUS play complementary roles in staging gastric cancer. CT scan is initially performed to detect local and distant metastases. Depending on institutional expertise, EUS may be considered for local staging. Laparoscopic staging may also be helpful in select patients. It is hoped that further improvements in these techniques will improve the ability to stage gastric cancer and thereby optimize patient treatment and outcome.     

Providing relaxation training to cancer chemotherapy patients: A comparison of three delivery techniques.

This study evaluated the effectiveness of three strategies for delivering relaxation training to cancer chemotherapy patients who were experiencing treatment-related side effects. Forty-five patients were randomly assigned to one of four treatment conditions: (a) progressive muscle-relaxation training (PMRT) and guided relaxation imagery (GI) provided by a professional therapist, (b) PMRT and GI provided by a trained volunteer (i.e., paraprofessional) therapist, (c) PMRT and GI provided by professionally prepared audiotapes, or (d) standard treatment (i.e., antiemetic only) control. All patients were assessed on self-report, physiological, and nurse observation measures during five sequential chemotherapy sessions. Overall, the results indicated that professionally administered PMRT and GI reduced emotional distress and physiological arousal and increased food intake in cancer patients undergoing chemotherapy. Furthermore, professionally administered relaxation training was found to be superior to both audiotaped and paraprofessionally administered training; the latter two alternative strategies of delivery did not reduce symptoms more than the standard treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Coping with a breast cancer diagnosis: A prospective study.

Employing the stress and coping theory of R. S. Lazarus and S. Folkman (1984), this study followed 117 women age 40+ regarding personality, cognitive appraisal, coping, and mood variables before breast biopsy, after diagnosis, and, for those who had cancer, after surgery. Upon biopsy, 36 received a cancer diagnosis, and 81 received a benign diagnosis. The 2 groups did not differ on appraisals, coping, or affect before diagnosis. With prebiopsy affect controlled, cancer patients reported more negative affect postbiopsy than did benign patients. Postsurgery, cancer patients expressed less vigor and more fatigue than benign patients, but the groups did not differ on other negative emotions. Prebiopsy, psychosocial predictors accounted for 54% and 29% of the variance in negative and positive emotion, respectively. Prebiopsy variables also predicted postbiopsy and postsurgery mood; cognitive coping was a particularly important predictor of high distress and low vigor. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Laparoscopic ultrasonography as compared with static or dynamic cholangiography at laparoscopic cholecystectomy. A prospective multicenter trial

We compared laparoscopic ultrasonography (LICU) with static (S) or dynamic (D) cholangiography (IOC) for assessment of duct anatomy an calculi in 209 patients. LICU visualized ducts in 88% compared with 93% for IOC (P = 0.046). Nineteen patients (9%) had stones: 17 were found by LICU (89%) and 10 (53%) by IOC (P = 0.032). Time to perform LICU (7 +/- 3 min) was less than IOC (13 +/- 6 min) (P < 0.0001). Time to perform SIOC (12 +/- 5 min) and DIOC (14 +/- 6 min) did not differ (P = 0.48), nor did these tests differ in accuracy. LICU provided useful anatomical information but IOC better defined anatomic anomalies. LICU required less time but was less reliable at defining anatomy and complete duct visualization. LICU was more sensitive for stones. SIOC and DIOC did not differ objectively. LICU and IOC are complementary.     

Laparoscopic hernia repair: a prospective comparison of TAPP and IPOM techniques

AIMS: To investigate changes in morphology of the developmental stages of Enterocytozoon bieneusi and symptomatic relief observed in AIDS patients after treatment with furazolidone. METHODS: Six AIDS patients with symptomatic E bieneusi infection of the small intestine were treated with a course of furazolidone. All patients had a weekly monitoring of parasite shedding in stool by light microscopy during and after treatment. At the end of the treatment, duodenal biopsy specimens obtained from three patients were studied by transmission electron microscopy by two pathologists who were unaware of the patients' treatment. RESULTS: All patients showed both clinical and parasitological response with transient clearance or decrease of spore shedding in stool. After treatment, alterations in faecal spores were observed in all patients by light microscopy, and ultrastructural changes in E bieneusi at all stages of the life cycle were demonstrated in biopsy specimens of the three patients who underwent post-treatment endoscopy. CONCLUSIONS: The clinical benefit seen after treatment with furazolidone in six AIDS patients with E bieneusi intestinal infection may be due to damage to the developmental stages causing a partial inhibition to reproduction of the parasite.     

A prospective, multicenter study of a pneumonia practice guideline

Two-dimensional 1H detected 13C NMR spectroscopy has been used to study the intracellular metabolism of [3-(13)C]pyruvate in Halobacterium salinarium. The method, resulting in considerable improvement in spectral resolution and signal-to-noise ratio, is well suited for studying transient metabolic intermediates. Pyruvate utilization by the bacterium is a double exponential function with rate constants of 49.13 and 4.67x10(-3) per min. The relative 13C enrichment is the fastest for C-3 glutamate. Glutamate C-4 labeling decreases initially and increases later on during incubation, while glutamine C-3 is high to begin with and exhibits a declining trend. The glutamate labeling indicates a high initial flux through pyruvate carboxylase and extensive randomizing of the label in the tricarboxylic acid cycle.     

Morbidity and mortality after D2 gastrectomy for gastric cancer: results of the Italian Gastric Cancer Study Group prospective multicenter surgical study

PURPOSE: To investigate whether pancreas preservation together with a strict quality-control system could ameliorate the outcome of D2 resections for gastric cancer in Western patients. PATIENTS AND METHODS: Italian patients with potentially curable proven adenocarcinoma of the stomach were registered from nine general and/or university hospitals in the area of Turin, Northern Italy. The study was performed according to the guidelines of the Japanese Research Society for Gastric Cancer (JRSGC). A strict quality-control system was guaranteed by a supervising surgeon of the reference center, who had stayed at the National Cancer Center Hospital, Tokyo, to learn the standard D2 gastrectomy. The standard procedure entailed removal of the level 1 and 2 lymph nodes. During total gastrectomy, the pancreas was preserved according to the Maruyama technique. RESULTS: Between May 1994 and December 1996, 191 eligible patients were entered onto the study. The mean number of lymph nodes removed was 39. The overall morbidity rate was 20.9%. Surgical complications were observed in 16.7% of patients. Reoperation was necessary in six patients and was always successful. The overall hospital mortality rate was 3.1%; it was higher after total gastrectomy (7.46%) than after distal gastrectomy (0.8%). The average length of hospital stay was 17 days. CONCLUSION: Given that postoperative morbidity and mortality rates are favorably comparable with those reported after the Western standard gastrectomy, the more extensive Japanese procedure with pancreas preservation can be regarded as a safe radical treatment of gastric cancer for selected Western patients treated in experienced centers.     

A multicenter, randomized, double-blind comparison of roxatidine with ranitidine in the treatment of patients with uncomplicated benign gastric ulcer disease. The Multicenter Roxatidine Cooperative Study Group

Roxatidine (150 mg, 312 patients) was compared with ranitidine (300 mg, 308 patients) in a randomized, double-blind, parallel-group, 6-week therapeutic study for the treatment of patients with uncomplicated, benign gastric ulcer disease. The study end points (verified by using endoscopy results) were fully healed ulcers at 4 or 6 weeks. The results of roxatidine therapy were comparable to those of ranitidine therapy: healing rates of 52% and 54% at week 4 and 77% and 76% at week 6 were recorded for roxatidine and ranitidine, respectively. The drugs produced comparable reductions in ulcer diameters and decreases in abdominal pain. Adverse events associated with both roxatidine (27%) and ranitidine (28%) were headache, diarrhea, and dizziness; rash was associated in 6 of 8 cases and in only 1 case with roxatidine. In this trial, roxatidine 150 mg once daily was as efficacious and safe as ranitidine 300 mg once daily for treatment of patients with uncomplicated, benign gastric ulcer disease.     

A comparison of noninvasive imaging modalities in the melanoma patient

The results of radionuclide (RN) liver scans, computed tomography (CT), and ultrasonography (US) were compared in 163 patients. Thirty-eight patients had all three studies, while ten were examined by CT and RN liver scans. One hundred fifteen patients had only US and RN studies. Radionuclide liver scanning demonstrated more false positive and negative studies than CT or US. Also, CT and US demonstrated more areas of metastasis during a single examination than RN liver scans. Ultrasonography displayed roughly the same accuracy of CT when a technically adequate examination was obtained. However, US was hampered by technically inadequate studies in 19% of 153 patients because of interfering intestinal gas. Computed tomography proved the most accurate and reliable modality in 48 patients.     

Silicone oil in the repair of complex retinal detachments. A prospective observational multicenter study

OBJECTIVE: This study aimed to report anatomic and visual acuity outcomes and complications after 1000-centistoke silicone oil was used as a retinal tamponade for the treatment of complex retinal detachments. DESIGN: Prospective observational multicenter study conducted at community and university-based ophthalmology clinics. PARTICIPANTS: The study cohort consisted of 2439 patients (2573 eyes) treated for complex retinal detachments associated with cytomegalovirus (CMV) necrotizing retinitis or a non-CMV etiology, including proliferative diabetic retinopathy, giant retinal tears, proliferative vitreoretinopathy, or ocular trauma. INTERVENTION: Vitrectomy surgery was performed for complex retinal detachment with 1000-centistoke silicone oil as the retinal tamponade. MAIN OUTCOME MEASURES: Anatomic outcomes were complete retinal attachment and macular attachment. Visual acuity outcomes were ambulatory vision (> or = 4/200) and preservation of preoperative visual acuity. Complications were rates of secondary intraocular pressure elevation (> or = 30 mmHg), hypotony (< or = 5 mmHg), corneal opacification (including band keratopathy, corneal edema, and corneal abrasions), oil emulsification, and cataract. Outcomes were assessed 6, 12, and 24 months after surgery. RESULTS: At the 6-month examination, the retina was completely attached in 178 (78%) of 228 CMV eyes and in 855 (70%) of 1219 non-CMV eyes. The macula was attached in 216 (95%) of 228 and 1062 (89%) of 1189 CMV and non-CMV eyes, respectively. Ambulatory vision was noted in 151 (65%) of 234 CMV eyes and in 480 (38%) of 1251 non-CMV eyes. Visual acuity was preserved in 106 (46%) of 230 and 1035 (84%) of 1229 CMV and non-CMV eyes, respectively. The corresponding rates of complications for CMV and non-CMV eyes were: elevated intraocular pressure, 0 (0%) of 196 and 35 (3%) of 1196; hypotony, 11 (6%) of 196 and 228 (19%) of 1196; corneal opacity, 13 (6%) of 229 and 326 (26%) of 1248; emulsification, 3 (1%) of 211 and 29 (3%) of 959; and cataract in phakic eyes, 118 (64%) of 185 and 50 (63%) of 80. CONCLUSIONS: Retinal reattachment was achieved in the majority of eyes using vitrectomy and silicone oil retinal tamponade. Complication rates generally were less frequent in CMV eyes, but follow-up was shorter in this group of patients, largely because of reduced life expectancy. Cataract frequently developed in phakic eyes of study patients. Use of 1000-centistoke silicone oil can be considered in the management of complex retinal detachments associated with multiple etiologies.     

Treatment of hypercholesterolemia and combined hyperlipidemia with simvastatin and gemfibrozil in patients with NIDDM. A multicenter comparison study

To evaluate rectal mucosal hemodynamics in patients with chronic hepatitis, we employed reflectance spectrophotometry and examined the results in relation to the presence and severity of chronic hepatitis. Twenty-six patients with histologically diagnosed chronic hepatitis and 21 controls were examined for rectal vascular findings by endoscopy. Indices (I) of rectal mucosal oxygen saturation (ISO2) and rectal mucosal hemoglobin (IHb) concentration were measured. To minimize the effects of systemic anemia, the IHb was divided by blood Hb concentration, giving the rectal index for Hb (RHb). The relationship between rectal mucosal hemodynamics and the histological grade of chronic hepatitis was studied. Rectal vascular lesions were observed in three patients with chronic hepatitis (11.5%). The RHb in patients with chronic hepatitis was significantly higher than that in the controls (5.74 +/- 0.71 and 4.82 +/- 1.12, respectively; P < 0.01). There was no significant difference in ISO2 levels (44.23 +/- 5.84 and 41.94 +/- 4.91, respectively). No significant correlation was observed between rectal mucosal hemodynamics and the histological severity of chronic hepatitis, although rectal mucosal hemodynamics changed in patients with chronic hepatitis. Early vascular changes were observed in the rectal mucosa of patients with chronic hepatitis.     

Mesh configurations in laparoscopic extraperitoneal herniorrhaphy. A comparison of techniques

BACKGROUND: Laparoscopic total extraperitoneal (TEP) hernia repair utilizes slit mesh that is placed around the spermatic cord to secure the prosthesis and prevent recurrence. Because of concern that encircling of the cord might increase pain and morbidity, we compared patients with mesh repairs using encircled and nonencircled techniques. METHODS: The 191 male patients who underwent bilateral TEP repairs were divided into three groups. In 100 consecutive patients (group A), the slit mesh was closed around both spermatic cords; in 56 patients (group B), the slit mesh was tucked under the spermatic cords but not closed; in 35 consecutive patients (group C), the slit was closed around one cord and tucked under the other, in a randomized fashion. RESULTS: The groups had similar operative times (A: 83 +/- 25 min; B: 79 +/- 21; C; 77 +/- 24), use of pain medication (A: 2.7 +/- 2.5 days; B: 2.4 +/- 1.9; C: 3.1 +/- 2.4), and recovery before return to work (A: 7.9 +/- 7.0 days; B: 8.2 +/- 6.1; C: 6.7 +/- 4.8). The incidence of indirect hernias was similar in all groups. Complication rate was 20% in A, 20% in B, and 14% in C (p = NS). Chronic pain was more frequent in A (A: 6, B: 0, p = 0. 06). In group C, fluid collections were more common on the closed side (closed: 3, tucked: 0; p = 0.08). There were no recurrences in any group. CONCLUSIONS: Closing the slit around the spermatic cord in laparoscopic inguinal hernia repair is not essential for prevention of early recurrence. Fluid collections tended to be more frequent when the mesh was closed around the cord, and chronic pain was more frequent in the group with closed mesh bilaterally.     

Accuracy of endoscopic ultrasonography in the diagnosis and staging of gastric cancer and lymphoma

BACKGROUND: There is a need to assess the sensitivity, specificity, and predictive value of endoscopic ultrasonography (EUS) in the diagnosis and staging of gastric cancer and lymphoma. METHODS: A prospective study was performed on 86 patients with endoscopic gross appearance suspicious for cancer or lymphoma. Biopsies with endoscopic forceps were always carried out before EUS. All patients underwent laparotomy for final diagnosis, staging, and eventually treatment. The results of EUS were correlated with the histologic findings of the resected specimens, when possible, or with the surgical findings. There were 42 gastric cancers and 44 primary gastric lymphomas. RESULTS: EUS made a correct diagnosis of cancer in 35 of 42 patients, with a sensitivity of 83%. Positive predictability was 87%, specificity was 97%, and negative predictability was 96%. Diagnostic accuracy was 95%. In the evaluation of cancer depth invasion, EUS was correct in 91% of cases. EUS displayed perigastric metastatic lymph nodes in 14 of 25 patients, with a sensitivity of 56%. Positive predictive value was 93%, specificity was 93%, and negative predictive value was 54%. Diagnostic accuracy was 69%. EUS made a correct diagnosis of lymphoma in 39 of 44 patients, with a sensitivity of 89%. Positive predictability was 87%, specificity was 97%, and negative predictability was 97%. Diagnostic accuracy was 95%. In the evaluation of lymphoma depth invasion, EUS was correct in 92% of cases. EUS displayed metastatic perigastric lymph nodes in 8 of 18 patients, with a sensitivity of 44%. Positive predictability was 100%, specificity was 100%, and negative predictability was 72%. Diagnostic accuracy was 77%. CONCLUSIONS: From these data it appears that in these diseases EUS has demonstrated specific ultrasonographic features that allow correct diagnosis and staging in the majority of patients. In difficult cases EUS may help to achieve the correct diagnosis. EUS also appear to be a useful tool for staging of gastric cancer and lymphoma. It shows not only tumor depth and local spread but also the passage from a pathologic to a normal wall and lymph node metastasis. With this accurate noninvasive staging procedure, in the near future many patients will no longer undergo exploratory laparotomy for surgical staging. Thanks to EUS, the choice of conservative or surgical treatment can be strongly affected. In case of surgery, EUS can orient the kind of surgical approach. Moreover, the use of EUS for evaluation of therapy during follow-up will probably become of major importance.     

A comparison of four warm-up techniques for initiating encounter groups.

16 groups, composed of 3 male and 3 female community college evening students, experienced 1 of 4 warm-up conditions prior to a 45-min leaderless encounter group: (a) nonverbal exercises, (b) modeling of intensive group interaction using an edited tape recording of an encounter group, (c) autobiographical information exchanged among group members, (d) no warm-up . The nonverbal exercises seemed to promote the largest increases in self-ratings of extraversion. The modeling condition was most effective in fostering a group atmosphere rated as "active" and in stimulating intentions for further self-disclosures to the group. A correlational analysis of the dependent variables provided clues to the process components of the successful encounter group. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective randomized repeat-crossover comparison of antitachycardia pacing with low-energy cardioversion

BACKGROUND: Multiprogrammable antiarrhythmia devices can treat monomorphic ventricular tachycardia (VT) with autodecremental overdrive pacing and/or with low-energy cardioversion. These two methods provide the opportunity to decrease patient discomfort typically experienced with high-energy pulses. Although both therapies are known to be effective, controversy persists over their relative safety and efficacy. METHODS AND RESULTS: The purpose of this study was to examine the safety and efficacy of autodecremental overdrive pacing and low-energy cardioversion in reproducibly terminating monomorphic VT in 24 patients with multiprogrammable antiarrhythmia devices. The protocol required that identical ECG morphology VT be reproducibly induced four times to assess the outcome of antitachycardia pacing and cardioversion twice for each patient in a randomized fashion. Each episode of VT was induced via the implanted device. Autodecremental overdrive pacing initially began with seven stimuli at 97% of the VT cycle length, decrementing by 10 msec per stimulus to a minimum coupling interval of 200 msec. If ineffective, autodecremental overdrive pacing was allowed to iterate three more times for a total of four pacing interventions. With each iteration, one stimulus was added to the pacing train. Similarly, with low-energy cardioversion, up to four therapeutic attempts were made, beginning with a 0.2-J pulse. If ineffective, pulse energy was increased to 0.4, 1.0, and finally 2.0 J. All interventions were automatic without human interference. VT (cycle length, 306 +/- 42 msec) was repeatedly terminated in 15 of 24 patients (63%) by autodecremental overdrive pacing and in 18 of 24 patients (75%) by low-energy cardioversion (p = 0.53). Eight of the 24 patients (33%) had their VT terminated repeatedly by both therapies. VT accelerated to faster VT or ventricular fibrillation by autodecremental overdrive pacing in four of 24 patients (17%) and by low-energy cardioversion in five of 24 (21%) (p = 0.88). Only one of the 24 patients (4%) accelerated with both therapies. No patient was unaffected by either therapy. CONCLUSIONS: In the manner programmed, autodecremental overdrive pacing and low-energy cardioversion have similar efficacy and acceleration rates. Response to one therapy does not predict response to the other.