Myocardial oxygen consumption, cardiac work, and myocardial efficiency in children

At least one study has questioned the safety of electroconvulsive therapy (ECT) in the very old. In this study, the authors reviewed a 5-year experience with ECT at two university psychiatric services for patients 75 years of age or older. Both outcomes and complications were reviewed. Nineteen of 22 patients (86.3%) were ECT responders. Five patients (22.7%) suffered complications which varied from minor to substantial. ECT was found to be an effective and reasonably safe treatment for depression in the very old.     

Cardiovascular morbidity in high-risk patients during ECT

OBJECTIVE: Cardiovascular events are the principal cause of medical morbidity in patients receiving ECT. To assess the risks of ECT for individuals with preexisting cardiovascular disease, the authors examined medical complications in older patients treated with ECT during a 1-year period. METHOD: A case-control design was used in a review of the charts of 80 consecutive patients who received ECT from August 1990 to August 1991. On the basis of accepted clinical criteria, patients over 50 years of age were divided into two groups: one at increased risk for cardiac complications (N = 26) and one at standard cardiac risk (N = 27). Outcome was measured with a scale designed to assess clinically relevant medical complications. RESULTS: The risk group was older and had received more medical consultations before ECT than the nonrisk group. Although patients in the risk group were more likely to develop minor complications during ECT, they did not differ significantly from the comparison group in the rate of major complications. No patients died or sustained permanent cardiac morbidity during ECT. CONCLUSIONS: In contrast to a similar study at the same site 15 years earlier, the current study found ECT to be relatively safe in an unselected study group of elderly patients with preexisting cardiac risk factors. The findings underscore the advances in ECT technique over the past 15 years and the importance of identifying and carefully managing patients with cardiac risk factors before and during ECT.     

Use of ECT in the United States in 1975, 1980, and 1986

OBJECTIVE: The objective was to analyze nationally representative data from the National Institute of Mental Health (NIMH) to update trends in the use of ECT in the United States. METHOD: The data are estimates from the NIMH Sample Survey Program for 1975, 1980, and 1986, which include representative samples of inpatients in psychiatric facilities in the United States. The authors' analyses use trend data from public general hospitals, private general hospitals, private psychiatric hospitals, and state and county mental hospitals. They report on 126,739 patients who received ECT in 1975, 1980, and 1986, focusing on data from 1980 and 1986. RESULTS: In 1986, 36,558 patients received ECT. This represents a decrease from the 1975 figure (58,667 patients) but no change from 1980 (31,514 patients). ECT was used primarily in private general hospitals (64%) and private psychiatric hospitals and much less often in public general hospitals and state and county mental hospitals. In 1986 over 90% of ECT recipients were white, and 84% had an affective disorder diagnosis. Although 71% of the patients who received ECT were women, hospital type and age were more important than gender in predicting ECT use. Individuals 65 years of age and older received ECT out of proportion to their numbers in inpatient care. CONCLUSIONS: The declining use of ECT in the United States ended in the 1980s. Few African Americans receive ECT, and its use is becoming more targeted toward patients with affective disorders. The amount of services research done on this modality is very small. Basic questions have yet to be answered, including who refers patients for ECT and why, and how ECT fits into the overall course of treatment.     

A successful treatment of drug-resistant depression with electroconvulsive therapy

A woman aged 56 had been treated at the age of 23 for a psychotic depression with vital characteristics in the context of a bipolar disorder. The treatment included electroconvulsive therapy (ECT). From the age of 47, she suffered relapses; drug treatment proved inadequate. For the last 3 years, ECT was administered, which resulted in a good condition. ECT is an effective treatment in patients with depression resistant to medication. However, in spite of continuation pharmacotherapy, the proportion of patients relapsing within 6 months after successful ECT is large. For these patients, continuation ECT may be an efficacious method.     

Dr Med. Alexander Rydzewski (obituary)]

Three patients with intractable thalamic pain unresponsive to a range of previous treatments received a course of six bilateral electroconvulsive therapy (ECT) treatments over 2 weeks. There was no evidence of any improvement in the intensity of the pain, pain relief or mood as measured on visual analogue scales and with standard measures. Propofol was used as the anaesthetic induction agent. Two patients showed wide changes in blood pressure during ECT but all three patients showed prompt recovery. In the light of the negative findings of this study and those of a previous study of the use of unilateral ECT in similar patients it is concluded that ECT is not an effective treatment for post-stroke thalamic pain.     

Clinical interview skills and identification of emotional disorders in primary care

BACKGROUND: This study focuses on the detection of medically compromised dental patients in the Netherlands by means of a validated patient-administered medical risk-related history (MRRH). Due to social changes and scientific innovations in the past decade, more medically compromised patients will be needing special dental treatment. METHODS: The medical problems of 29,424 dental patients (age 18 years and over) from 50 dental practices in the Netherlands were registered by means of the MRRH. The patients were classified according to the ASA risk-score system, which was modified for dental treatment. An inventory of the number and nature of medical problems and the modified ASA risk score was drawn up in relation to dental treatment and age. RESULTS: The average age of the patients was 37.1 +/- 13.5 years. According to the current guidelines, dental treatment must be modified if the patient has an ASA score of III or IV. A relatively high percentage of patients ages 65-74 (23.9%) and 75 or over (34.9%) did have an ASA score of III or IV. Furthermore, the medical problems were classified into 10 categories, and the relationship to age was examined. The conditions that increased with age were hypertension and cardiovascular, neurological, endocrinological, infectious, and blood diseases. CONCLUSIONS: For the dental practice, these results mean that the MRRH can play an important role in adapting dental treatment to the specific needs of patients. This is especially important in the case of elderly patients.     

Temporary results only in electroconvulsive therapy in therapy-resistant depression; retrospective study

OBJECTIVE: To evaluate the use and efficacy of electroconvulsive therapy (ECT) in refractory major depression according to DSM-III-R criteria, and to look for factors predicting response in the acute phase and the occurrence of relapse or recurrence after recovery. DESIGN: Retrospective. SETTING: University Hospital Rotterdam, The Netherlands. METHODS: Of all patients who received ECT between January 1988 and July 1993 data were collected by study of clinical records and of information by treating physicians after discharge. Every patient was visited once, or received an outpatient department appointment, to obtain informed consent, take a follow-up history and evaluate social functioning by scoring Global Assessment of Functioning and Sickness Impact Profile rating scales. RESULTS: 35 patients received ECT. In clinical practice, the guidelines of the Netherlands Psychiatric Association were not violated; most patients had received adequate pharmacological pretreatment before the decision to start ECT was made. Two patients died in hospital (not from ECT). In the acute phase 25 of the 33 patients still alive upon discharge showed good recovery. Seven of these suffered relapse within six months. The number of patients with a return of depressive symptoms rose to 12 by the end of the first year of follow-up. Sociodemographic variables and treatment characteristics did not appear to influence the result of treatment in the acute phase, nor the occurrence of relapse or recurrence. With less intensive pre- and post-ECT drug treatment the chances of relapse were increased. CONCLUSIONS: ECT is an effective treatment in the acute phase of a depression. Results after a longer period of follow-up are less satisfactory.     

Management of myocardial infarction in patients over 75 years of age compared to patients under 75 years of age. Apropos of 594 consecutive cases admitted between 1991 and 1994

This study analyses the patients consecutively admitted for myocardial infarction between January 1991 and December 1994. The study population consisted of 594 patients divided into two groups: 446 patients under the age of 75 years and 178 patients over the age of 75 years. The sex-ratio showed a male predominance (84%) before 75 years, and a female predominance (57%) after 75 years. A history of angina was more frequent in elderly patients (45% vs 30%, p < 0.001), who were admitted later (22.5% vs 46.6% before the 6th hour, p < 0.001). Thrombolysis was administered in 49.6% of subjects under the age of 75 years and in 17.3% of elderly patients. The course was uneventful in 56.7% of subjects under the age of 75 years and in 28.2% of elderly patients. Mortality was 6-fold higher in this group (22% vs 3.7%, p < 0.01). The cause of death was usually heart failure with a 10-fold higher frequency of cardiogenic shock (13.5% vs 1.4%, p < 0.001). Coronary angiography was performed in 81.4% of subjects under the age of 75 years and in 30% of the elderly patients. Multi-vessel lesions were more frequent in elderly subjects (78.4% vs 47.5%, p < 0.01). Revascularization by angioplasty or bypass graft was performed with a similar frequency (50%) in the two groups of patients investigated by coronary angiography. The mortality of myocardial infarction was high in the elderly, usually due to heart failure, and partly explained by the severity of the coronary lesions; in contrast, elderly patients were less frequently submitted to active management (thrombolysis-coronary angiography), while recent data of the literature argue in favour of primary angiography in these patients.     

Age-related trends in short- and long-term survival after acute myocardial infarction: a 20-year population-based perspective (1975-1995)

This study examines age-related differences and temporal trends in hospital and long-term survival after acute myocardial infarction (AMI) over a 2-decade-long (1975 to 1995) experience. A total of 8,070 patients with validated AMI hospitalized in all acute care hospitals in the Worcester, Massachusetts, metropolitan area (1990 census population 437,000) were studied over 10 one-year periods between 1975 and 1995. This population included 1,326 patients aged <55 years (16.4%), 1,768 patients aged 55 to 64 years (21.9%), 2,325 patients aged 65 to 74 years (28.8%), 1,880 patients aged 75 to 84 years (23.3%), and 771 patients aged > or = 85 years (9.6%). Compared with patients <55 years, patients 55 to 64 years were 2.2 times more likely to die during hospitalization for AMI, whereas patients 65 to 74, 75 to 84, and > or = 85 years were at 4.2, 7.8, and 10.2 times greater risk of dying, respectively. Similar age disparities in the risk of dying were seen when controlling for additional prognostic factors. Despite the adverse impact of increasing age on hospital survival after AMI, declining in-hospital death rates were seen in each of the age groups under study, with declining magnitude of these trends with advancing age. Among discharged hospital patients, increasing age was related to a significantly poorer long-term prognosis. Trends toward improving long-term prognosis were seen in patients discharged in the mid-1990s compared with those discharged in the mid- to late 1970s for patients aged <85 years. The present results demonstrate the marked impact of advancing age on survival after AMI. Despite the adverse impact of age on prognosis, encouraging trends in prognosis were observed in all age groups, although to a lesser extent in the oldest elderly patients. These findings emphasize the low death rates in middle-aged patients with AMI and the need for targeted secondary prevention efforts in elderly patients with AMI.     

Changing practice patterns in the management of acute myocardial infarction complicated by cardiogenic shock: elderly compared with younger patients

BACKGROUND: Cardiogenic shock continues to be an ominous complication of acute myocardial infarction (AMI). Evidence from retrospective analyses, registries and observational studies suggests that aggressive management using emergent revascularization strategies can bring about significant improvement in survival in this setting. Several studies have identified age as an independent predictor of survival. OBJECTIVE: To study retrospectively the possible changes in practice patterns in the management of patients with AMI complicated by cardiogenic shock in a tertiary care referral centre, and to determine what effect these changes may have had on survival of the patients, stratified by age. METHODS: From 1989 to 1995, 115 patients fulfilled the study criteria of cardiogenic shock based on pump failure and of presenting within 48 h of onset of shock. Prespecified data were extracted from medical records. All available coronary angiograms (n = 72) were analyzed by two experienced angiographers and consensus of findings was obtained. RESULTS: The study revealed a significant increase in the use of cardiac catheterization, interventional procedures and intra-aortic balloon pump (IABP) support in patients in the age groups 65 years or less, 66 to 75 years, and older than 75 years in 1989 to 1990, through 1991 to 1992, to 1993 to 1995. Significantly fewer patients aged older than 75 years received cardiac catheterization, coronary intervention and IABP support throughout the study period and even in the final period analyzed. In-hospital survival improved from 4% in 1989-90 to 33% in 1991-92, and 44% in 1993-95 (P = 0.001). Patients aged 65 years or less improved from 10% in 1989-90 to 59% in 1993-95 (P = 0.032). Only 20% of patients aged older than 75 years survived in the 1993-95 period. By univariate analysis, use of coronary angiography (catheterization 46% versus no catheterization 5%; P < 0.0001), coronary intervention procedures (percutaneous transluminal coronary angioplasty or coronary artery bypass grafting) (intervention 48% versus no intervention 9%; P < 0.0001) and IABP support (IABP 41% versus no IABP 18%; P = 0.0096) were all associated with improved in-hospital survival. Use of thrombolytic therapy showed possible survival benefit only in patients aged older than 75 years (thrombolysis 33% versus no thrombolysis 5%; P = 0.10). Patients who underwent coronary intervention were younger (P = 0.002), had a lower incidence of previous myocardial infarction (P = 0.0002), lower heart rate (P = 0.04), higher peak creatine phosphokinase (P = 0.04) and fewer vessels with at least 70% stenosis (P < 0.0001). On multivariate analysis only lower age, lower heart rate and presence of coronary intervention procedures were found to have an independent effect on survival. CONCLUSIONS: Use of invasive treatment strategies has increased significantly since 1989-90 in the management of patients with AMI complicated by cardiogenic shock. This increase has been associated with improved in-hospital survival in all age groups except possibly the very elderly. Patients undergoing coronary interventional procedures are significantly different in baseline clinical characteristics from patients not undergoing these procedures. These observations underscore the need for randomized trials to define the optimal treatment strategies in these patients. Efficacy of invasive treatment strategies in elderly patients aged older than 75 years-deserves special attention.     

Electroconvulsive therapy of acute manic episodes: a review of 50 years' experience

OBJECTIVE: The most common indication for electroconvulsive therapy (ECT) is major depression. It is less recognized that ECT is effective also in the treatment of acute mania. This article aims to provide a comprehensive and critical review of the literature on the use of ECT for manic patients. METHOD: All published papers in the English language on the use of ECT in acute mania that could be found were reviewed with regard to efficacy, frequency and number of treatments, bilateral versus unilateral electrode placement, predictors of antimanic response, stability of therapeutic response, cognitive consequences, and other relevant issues. RESULTS: The evidence indicates that ECT is associated with remission or marked clinical improvement in 80% of manic patients and that it is an effective treatment for patients whose manic episodes have responded poorly to pharmacotherapy. Manic patients do not require a high frequency or prolonged course of treatments to respond to ECT. The seizure threshold appears to be lower in manic patients than in depressed patients. The issues of relapse following response to ECT, cognitive consequences of ECT, and the relative merits of unilateral versus bilateral ECT in manic patients require further study. CONCLUSIONS: ECT is an effective and safe treatment for acute mania. Remission of mania following ECT reflects a primary therapeutic effect rather than a secondary consequence of an ECT-induced organic brain syndrome.     

Electroconvulsive shocks exacerbate the heightened acoustic startle response in stressed rats.

Electroconvulsive therapy (ECT) has been successfully used in the treatment of depression, particularly when the illness is refractory to pharmacological therapy. A recent study has shown that ECT is also effective in reducing both depressive and posttraumatic stress disorder (PTSD) symptoms in patients with major depression (MDD) and co-occurring PTSD. This raises the possibility that ECT might be effective in the treatment of PTSD, a disease whose prevalence has increased substantially in recent years. A characteristic symptom of PTSD is an exaggerated reactivity to startling sounds (acoustic startle response; ASR). In the present study, we investigated the effects of electroconvulsive shocks (ECS) on the ASR, in a rat model of traumatic stress. The animals were subjected to a restraint/tailshock paradigm and then administered ECS. ASR measurements were obtained at several time points following ECS administration. Although ECS had no effect in control rats, it significantly exacerbated the already potentiated ASR in the stressed group. While ECT may prove to be an effective treatment for certain symptoms of co-occurring MDD/PTSD or PTSD alone, it may exacerbate heightened arousal associated with PTSD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A depressive syndrome responsive to lithium. An analysis of 20 cases

The authors analyze a series of 20 patients seen over the past 4 years who have shown a dramatic improvement following the introduction of lithium carbonate to their therapy. The results indicate that these patients showed a consistent syndrome with the following features: a) anergic endogenous depression; b) positive family history in first degree probands; c) obsessional personality traits and symptoms; d) hypochondriasis and somatic symptoms; e) failure to respond to previous antidepressant therapy with tricyclic and MAOI compounds as well as ECT. A previous study by Gittleson showed that one third of a series of psychotic depressives admitted to the Maudsley Hospital, London, also displayed obsessional symptoms and hypochondriasis. These patients, however, seemed to do as well with standard antidepressant treatment as a control group of psychotic depressives without obsessional features. However, in this series, there was a 7 per cent residue whose obsessional symptoms worsened, even after recovery from their depression. The authors' group of patients represented approximately 3 per cent of all psychotic depressives seen over the 4-year period and could, therefore, coincide with Gittleson's residue. The mean age of onset of illness in the authors' depressive group was 45.5 years, and this finding, coupled with the high incidence of psychotic depression in first degree relatives, indicates that these patients were suffering from a psychotic depression modified by personality traits, rather than an atypical obsessional neurosis. The consistency of clinical features and specificity of response to lithium therapy appear to indicate that this is a clearly definable clinical syndrome worthy of further investigation.     

Dexmedetomidine failed to block the acute hyperdynamic response to electroconvulsive therapy

BACKGROUND: Orally administered clonidine (0.2-0.3 mg) has been reported to decrease the acute hypertensive response to electroconvulsive therapy (ECT) without prolonging early recovery. This preliminary study was designed to evaluate the acute hemodynamic effects of the investigational alpha2-adrenergic agonist, dexmedetomidine, in patients undergoing a series of ECT treatments. METHODS: Six patients undergoing a series of three to six consecutive ECT treatments were studied according to a randomized, double-blind, placebo-controlled protocol All patients received either saline or dexmedetomidine, 0.5 or 1.0 microg/kg intravenously, 10-30 min before induction of anesthesia for ECT using a standardized anesthesia protocol. In addition to assessing the cardiovascular variables, the duration of seizure activity, degree of sedation, and time to discharge from the Phase I recovery unit were assessed. RESULTS: Although dexmedetomidine produced dose-related increases in the level of sedation before the ECT procedure, it failed to decrease the peak blood pressure and heart rate responses after the ECT treatment. The 0.5 and 1.0 microg/kg doses of dexmedetomidine prolonged the times to orientation and to discharge from the Phase I unit. CONCLUSIONS: The results of this pilot study suggest that dexmedetomidine (0.5-1.0 microg/kg given intravenously) is not beneficial in controlling the acute hyperdynamic response after ECT.     

Diagnostic difficulties of myocardial infarct in an admissions and emergency service: influence of age

OBJECTIVE: To analyze the clinical signs and electrocardiographic and enzyme data in patients admitted to an emergency ward for myocardial infarction in order to highlight diagnostic pitfalls. PATIENTS AND METHODS: All patients admitted to our emergency ward between October 1995 and October 1996 with elevated myoglobulin or creatinine phosphokinase (CPK) levels (n = 457 patients) were included in the study series. Patient files were randomly selected (n = 257 files) for review by an emergency ward specialist and a cardiologist to identify cases of myocardial infarction (n = 88 patients, mean age 73.4 +/- 15.2 years). Clinical, electrical and enzyme data (including CPK-MB) were analyzed. RESULTS: The patients had been referred for chest pain (69%), dyspnea (24%) or another disorder (7%). Pain was located in the retrosternal area in 51%, in the lower chest in 19% and elsewhere in 30%. Delay between onset of pain and transfer to the emergency ward was 5 h 20 min +/- 6 h. Signs of left heart failure were observed in 50% of the patients. The admission electrocardiogram showed complete criteria for myocardial infarction in 43% of the cases, incomplete criteria in 21% and was non-contributive in 36%. Enzyme results were elevated in 78% of the cases at the first assay and in 98.2% at the second assay. Both typical chest pain and ECG were observed in only 30% of the cases. Chest pain was present in 55% of the patients over 75 years of age and in 81% of those under 75 years (p = 0.007). CONCLUSION: A typical syndrome is observed in less than one-third of all patients with myocardial infarction admitted to emergency wards. The frequency of atypical presentations increases with age.     

Alfentanil or fentanyl during isoflurane-based anaesthesia for day-care knee arthroscopy?

Previously published ultrasound screening programmes for abdominal aortic aneurysm (AAA) have concentrated on males in the 65 to 75 year age range, suggesting this as the most cost-effective cohort to target. In this unique study we have broadened the criteria for screening. General practitioners in one health district were approached to supply details of all males aged 50 years and over to be offered aortic ultrasound scanning. Over a period of 18 months, 4145 individuals were asked to attend and 3030 (73%) have attended. Attendance rates were: between 50 and 64 years, 73%; between 65 and 79 years, 75%; for 80 years and over, 64%--significantly less (p = 0.01-0.001) than the other two age bands. Aortic dilatation (diameter > or = 2.5 cm) was found in 6.3% of the 50 to 64 year age group, 16.8% of the 65 to 79 year age group, and 23.3% of the 80 years and over age group. An established aneurysm (> or = 4.6 cm) was found in 0.3%--6 individuals (50-64 years), 2.5% (65-79 years) and 4.1% (> or = 80 years). The results suggest that aortic screening may be worthwhile extending to a wider age band. By focusing follow-up, this should give greater value for younger men in terms of community productivity and allows for selective intervention in the elderly.     

Electroconvulsive therapy increases circadian amplitude and lowers core body temperature in depressed subjects

BACKGROUND: Reduced amplitude of the circadian temperature rhythm and elevated nocturnal body temperature normalize after successful pharmacotherapy of major depression. METHODS: Core body temperature was continually monitored in three groups: a) 6 depressed patients before an electroconvulsive therapy (ECT) course and b) after an ECT course; and c) 6 healthy, sex-matched controls of similar age. RESULTS: The 24-hour profile of temperature was significantly different in patients pre-ECT than in patients post-ECT or in controls. Post-ECT subjects and controls manifested 24-hour profiles similar to one another. Circadian temperature rhythm amplitude increased after ECT. The mean asleep and mean 24-hour temperatures were significantly higher in patients pre-ECT than post-ECT and controls. CONCLUSIONS: We find that ECT restores a disrupted circadian temperature rhythm in depressed patients.     

Treatment of mallet finger fractures by the extension-block K-wire technique

OBJECTIVES: This report describes successful anaesthesia and electroconvulsive therapy (ECT) in a patient with an unruptured basilar artery aneurysm. ECT is associated with a hyperdynamic state characterised by arterial hypertension, tachycardia, and considerably increased cerebral blood flow rate and velocity. These responses pose an increased risk for subarachnoid haemorrhage when an intracranial aneurysm coexists. METHODS: A 54 year old woman presented for ECT. She had a 20 year history of major depression which was unresponsive to three different antidepressant drugs. There was also an unruptured 5 mm saccular aneurysm at the basilar tip, which had been documented by cerebral angiography, but its size had remained unchanged for the previous four years. After she declined surgical intervention, she gave informed consent for ECT. During a series of seven ECT sessions middle cerebral artery flow velocity was recorded by a pulsed transcranial Doppler ultrasonography system. She was pretreated with 50 mg oral atenolol daily, continuing up to the day of the last ECT and immediately before each treatment, sodium nitroprusside was infused at a rate of 30 microg/min, to reduce systolic arterial pressure to 90-95 mm Hg. RESULTS: Systolic flow velocity during the awake state ranged from 62-75 cm/s, remaining initially unchanged with sodium nitroprusside infusion. After induction of anaesthesia (0.5 mg/kg methohexitone and 0.9 mg/kg succinylcholine), flow velocities decreased to 39-54 cm/s, reaching maximal values of 90 cm/s (only 20% above baseline) after ECT. These flow velocities recorded post-ECT were considerably below the more than twofold increase recorded when no attenuating drugs were used. Systolic arterial blood pressure reached maximal values of 110-140 mm Hg and heart rate did not exceed 66 bpm. Rapid awakening followed each treatment, no focal or global neurological signs were apparent, and the patient was discharged in remission. CONCLUSION: In a patient with major depression and a coexisting intracerebral saccular aneurysm who was treated with ECT, the combination of beta blockade with atenolol and intravenous infusion of sodium nitroprusside prevented tachycardia and hypertension, and greatly attenuated the expected increase in flow velocity in the middle cerebral artery.