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A patient who underwent prior heterotopic cardiac transplantation had persistent complaints of dyspnea, palpitations, and fatigue in spite of normal pump function of the donor heart. Repeated Holter monitoring excluded paroxysmal arrhythmias. It was thought that synchronization of both heart rates might alleviate his symptoms. The intrinsic heart rate of the donor heart was 90 beats/min, the recipient heart was 60 beats/min with acceleration up to 130 beats/min on exercise. A DDD pacemaker was implanted, the atrial lead was positioned in the right ventricle of the donor heart and (he ventricular lead in the atrium of the recipient heart. Search for an optimal AV interval was evaluated by echo-DoppIer and intraarterial pressure recordings. By increasing the AV interval from 125 to 300 msec, (he maximum aortic flow velocity of the recipient heart increased from 1.0 to 1.2m/sec. Left ventricular end-diasiolic diameter remained unchanged, left ventricular end-systolic diameter decreased from 52 to 48 mm. Wall motion of the recipient left ventricle improved. At an AV interval of 125 msec there was alternate systolic contraction of both hearts, resulting in arterial pressure waves at a rate of 180/min. This did not relieve his symptoms and he complained further of headaches. At an AV interval of 300 msec contraction of the recipient heart just preceded that of the donor heart, resulting in arterial pressure waves at a rate of 90/min, normalization of the waveform, relief of symptoms, and improvement of exercise tolerance. [ABSTRACT FROM AUTHOR]

Background: During the course of their disease, patients are, apart from suffering physical discomfort, also confronted with psychological, social, and spiritual challenges. However, healthcare professionals often lack the knowledge and skills to address the spiritual dimension and are in need of support for taking this responsibility. Spiritual caregivers are experts in spiritual care, but their contribution to the integration of this care by other healthcare professionals is largely unknown., Objective: The aim of this study was to investigate how Dutch spiritual caregivers view their role in increasing the integration of spiritual care in daily healthcare practice as provided by other healthcare professionals in the Netherlands, and how they address this role., Methods: An online survey was conducted from May until June 2021 among spiritual caregivers working in Dutch healthcare. Data were analysed using descriptive statistics., Results: The majority of the 174 respondents answered that they already fulfil a role in the integration of spiritual care by, for example, providing education, coaching on the job, or participating in multidisciplinary consultation. However, the majority of respondents experienced barriers to their contribution, such as confusion of terminology and use of language while collaborating with other healthcare professionals and reluctance to share information., Conclusions: While spiritual caregivers realise having the potential to make important contributions to the further process of integration of spiritual care into the daily practice of other healthcare professionals, some practices and perceptions, especially from within their own discipline, may hamper this.

Objective: Point-of-care testing (POCT) cardiac troponin (cTn) measurements are being used increasingly, despite the fact that evidence on the safety of their use is outdated, not taking into account current 'gold standard' high-sensitivity cardiac troponin (hs-cTn) assays. In the present study, we aimed to compare the analytical and diagnostic performance of the AQT90-flex POCT cTnT assay (which is the POCT assay with the lowest reported 99th percentile cutoff currently available) with the laboratory-based Roche Modular E170 hs-cTnT assay., Materials and Methods: During a 4-month prospective observational cohort study, laboratory-based hs-cTnT and POCT cTn were measured simultaneously in 261 undifferentiated chest-pain patients presenting to the emergency department (ED) of the Medical Centre Leeuwarden to determine the diagnostic accuracy of both assays in predicting acute myocardial infarction (AMI) at presentation., Results: The POCT cTn assay had a lower sensitivity [68 (49-82) vs. 91 (75-98)] and a lower negative predictive value [95 (91-97) vs. 98 (95-100)%] for the prediction of AMI at presentation compared with the hs-cTnT assay. Furthermore, in three patients, the POCT cTnT assay yielded unexpectedly high results, whereas hs-cTnT results were negative. None of these patients had an AMI, and no possible explanation could be found., Conclusion: The AQT90-flex POCT cTnT assay is not yet sensitive and reliable enough to be used to exclude AMI in the ED with a single blood draw at the time of presentation in the ED, and therefore, may have limited applicability in the ED setting.

Background: Acute coronary syndrome (ACS) can be a diagnostic challenge in the emergency department (ED). Recently, the HEART score was developed, a simple bedside scoring system that quantifies risk of ischaemic events in patients with undifferentiated chest pain presenting in the ED., Objective: In this prospective cohort study, we compared the diagnostic accuracy of HEART score and clinical gestalt (clinical judgement) for diagnosing ACS in an unselected population of patients with chest pain presenting to the ED., Methods: HEART score (0-10) and clinical gestalt (low risk, intermediate risk or high risk of ACS) were prospectively determined in the ED in 255 patients presenting with chest pain by the treating physician. The reference standard was the presence of ACS, which was defined as either acute myocardial infarction (AMI) or the occurrence of a major adverse cardiac event within 6 weeks after presentation in the ED., Results: 75 out of 255 patients (29%) had an ACS. A HEART score ≤3 had a lower negative likelihood ratio (0.15 (0.06-0.36)) for ACS than a low risk based on clinical gestalt (0.35 (0.19-0.64)), whereas a high HEART score ≥7 had a higher positive likelihood ratio (5.2 (3.2-8.5) vs 3.1 (2.2-4.4)). However, c-statistic of HEART score was not significantly different from clinical gestalt (0.81 (0.76-0.86) vs 0.79 (0.73-0.84), p=0.13)., Conclusions: Our study demonstrates that HEART score and clinical gestalt have similar diagnostic accuracy for diagnosing ACS in an unselected population of patients with chest pain presenting in the ED., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

A 19-year-old woman is presented with high-spiking fever, pericardial tamponade and respiratory failure. A diagnosis of adult onset Still's disease was made. This is a rare inflammatory disease with an unknown aetiology. The diagnosis is made by exclusion and with the help of diagnostic criteria. Treatment with corticosteroids met with a good response.