OBJECTIVES: Total annual costs for syncope-related hospitalizations were $2.4 billion in 2000. The aim of this study was to examine the type and number of tests ordered for patients admitted with syncope and whether these tests helped establish the cause.

METHODS: We studied the records of 1038 patients coded as "syncope" in billing records, and 167 fulfilled the eligibility criteria. The main outcome measures were the diagnostic yield of the ordered tests, the incremental cost/incremental benefit, and the number of admissions that can be averted if risk stratification were used in the evaluation.

RESULTS: The etiology of the syncope was identified in 48.3% of the patients. Postural blood pressure measurement has the highest diagnostic yield at 58.7%, whereas history taking diagnosed 19.7% of cases. The diagnostic yields of telemetry, electrocardiogram, radionuclide stress test, echocardiography, and troponin measurement were 4.76%, 4.24%, 3.44%, 0.94%, and 0.62%, respectively. Chest x-ray, carotid ultrasonography, 24-hour Holter monitoring, brain computed tomography, and brain magnetic resonance imaging did not yield the diagnosis in any of the patients. Only 1.9% of the money spent in the evaluation of syncope was effective in leading to a definitive diagnosis. The orthostatic blood pressure measurement was ranked first in the incremental cost/incremental benefit ratio and the radionuclide stress test was ranked last (17.03 vs 42,369.0, respectively). Approximately 6% of the patients did not meet the admission criteria.

CONCLUSIONS: Physicians ordered unnecessary tests that have a low yield and are not cost-effective. A standardized algorithmic approach should be the cornerstone in the evaluation of syncope.

OBJECTIVES: Total annual costs for syncope-related hospitalizations were $2.4 billion in 2000. The aim of this study was to examine the type and number of tests ordered for patients admitted with syncope and whether these tests helped establish the cause.

METHODS: We studied the records of 1038 patients coded as "syncope" in billing records, and 167 fulfilled the eligibility criteria. The main outcome measures were the diagnostic yield of the ordered tests, the incremental cost/incremental benefit, and the number of admissions that can be averted if risk stratification were used in the evaluation.

RESULTS: The etiology of the syncope was identified in 48.3% of the patients. Postural blood pressure measurement has the highest diagnostic yield at 58.7%, whereas history taking diagnosed 19.7% of cases. The diagnostic yields of telemetry, electrocardiogram, radionuclide stress test, echocardiography, and troponin measurement were 4.76%, 4.24%, 3.44%, 0.94%, and 0.62%, respectively. Chest x-ray, carotid ultrasonography, 24-hour Holter monitoring, brain computed tomography, and brain magnetic resonance imaging did not yield the diagnosis in any of the patients. Only 1.9% of the money spent in the evaluation of syncope was effective in leading to a definitive diagnosis. The orthostatic blood pressure measurement was ranked first in the incremental cost/incremental benefit ratio and the radionuclide stress test was ranked last (17.03 vs 42,369.0, respectively). Approximately 6% of the patients did not meet the admission criteria.

CONCLUSIONS: Physicians ordered unnecessary tests that have a low yield and are not cost-effective. A standardized algorithmic approach should be the cornerstone in the evaluation of syncope.

This guidance details the needs of children, and the qualities of parenting that meet those needs. Parental mental disorders can damage the foetus during pregnancy through the action of drugs, prescribed or abused. Pregnancy and the puerperium can exacerbate or initiate mental illness in susceptible women. After their birth, the children may suffer from the social disadvantage associated with severe mental illness. The parents (depending on the disorder, its severity and its persistence) may have intermittent or prolonged difficulties with parenting, which may sometimes result in childhood psychological disturbance or child maltreatment. This guidance considers ways of preventing, minimizing and remedying these effects. Our recommendations include: education of psychiatrists and related professions about the effect of parental mental illness on children; revision of psychiatric training to increase awareness of patients as caregivers, and to incorporate relevant assessment and intervention into their treatment and rehabilitation; the optimum use of pharmacological treatment during pregnancy; prebirth planning when women with severe mental illness become pregnant; development of specialist services for pregnant and puerperal women, with assessment of their efficacy; community support for parenting by mothers and fathers with severe mental disorders; standards of good practice for the management of child maltreatment when parents suffer from mental illness; the importance of multi-disciplinary teamwork when helping these families, supporting their children and ensuring child protection; the development of child and adolescent mental health services worldwide.

This guidance details the needs of children, and the qualities of parenting that meet those needs. Parental mental disorders can damage the foetus during pregnancy through the action of drugs, prescribed or abused. Pregnancy and the puerperium can exacerbate or initiate mental illness in susceptible women. After their birth, the children may suffer from the social disadvantage associated with severe mental illness. The parents (depending on the disorder, its severity and its persistence) may have intermittent or prolonged difficulties with parenting, which may sometimes result in childhood psychological disturbance or child maltreatment. This guidance considers ways of preventing, minimizing and remedying these effects. Our recommendations include: education of psychiatrists and related professions about the effect of parental mental illness on children; revision of psychiatric training to increase awareness of patients as caregivers, and to incorporate relevant assessment and intervention into their treatment and rehabilitation; the optimum use of pharmacological treatment during pregnancy; pre-birth planning when women with severe mental illness become pregnant; development of specialist services for pregnant and puerperal women, with assessment of their efficacy; community support for parenting by mothers and fathers with severe mental disorders; standards
of good practice for the management of child maltreatment when parents suffer from mental illness; the importance of multi-disciplinary teamwork when helping these families, supporting their children and ensuring child protection; the development of child and adolescent mental health services worldwide.
Key words: Parenting, severe mental illness, mother-infant relationship, substance abuse, childhood mental disorders, child maltreatment, child and adolescent mental health services
(World Psychiatry 2011;10:93-102)
PMID: 21633678 [PubMed] Free PMC Article

Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management, and outcome are sparse.This international multicentre registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553 729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed, at 214 centres in 35 countries. In 78 centres 138 patients [0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (P < 0.0001)] were diagnosed with an oesophageal fistula. Peri-procedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0–60) days and 21 (15, 29.5; range: 2–63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0–42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8% and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) [odds ratio 7.463 (2.414, 23.072) P < 0.001].Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.

BACKGROUND: Transient gene expression utilizing syringe agroinfiltration offers a simple and efficient technique for different transgenic applications. Leaves of Nicotiana benthamiana show reliable and high transformation efficiency, but in quantitative assays also a certain degree of variation. We used a nested design in our agroinfiltration experiments to dissect the sources of this variation.

RESULTS: An intron containing firefly luciferase gene was used as a reporter for agroinfiltration. A number of 6 week old tobacco plants were infiltrated for their top leaves, several samples were punched from the leaves after 2 days of transient expression, and protein extracts from the samples were repeatedly measured for luciferase activity. Interestingly, most of the variation was due to differences between the sampling spots in the leaves, the next important source being the different leaves on each plant. Variation between similar experiments, between plants and between repetitive measurements of the extracts could be easily minimized.

CONCLUSIONS: Efforts and expenditure of agroinfiltration experiments can be optimized when sources of variation are known. In summary, infiltrate more plants but less leaves, sample more positions on the leaf but run only few technical replicates.