[Simultaneous utilization of an implantable automatic defibrillator in a patient with previously implanted bi-ventricular pacemaker for end-stage heart failure]

We report a case of implantable cardioverter defibrillator (ICD) use after previous biventricular pacemaker insertion for end-stage heart failure. A 75-year-old man with inoperable three-vessel coronary artery disease, permanent atrial fibrillation and end-stage heart failure underwent bi-ventricular pacemaker insertion and His bundle ablation for symptomatic control. NYHA class decreased from class III to II after this procedure. Four months after implant the patient developed paroxysmal sustained, symptomatic ventricular tachycardia. ICD implantation was undertaken. No potentially serious ICD-pacemaker interaction was noted during subsequent follow-up. We conclude that ICD implantation is feasible after previous bi-ventricular pacemaker insertion, without the need to explant the bi-ventricular pacing device.

Retrospective comparison of the Amplatz thrombectomy device with modified pulse-spray pharmacomechanical thrombolysis in the treatment of thrombosed hemodialysis access grafts

PURPOSE

To retrospectively evaluate the Amplatz thrombectomy device (ATD) in the treatment of thrombosed hemodialysis grafts and compare it with modified pulse-spray pharmacomechanical thrombolysis (PPT).

MATERIALS AND METHODS

During a 4-month period, 79 patients presented with 126 episodes of graft occlusion. Percutaneous recanalization was performed by using the ATD (n = 57) or the modified PPT technique (n = 69). Evaluation included the technical success, complications, and primary patency rates.

RESULTS

Technical success was achieved in 93% (53 to 57) of the cases treated with the ATD and in 96% (66 of 69) of the cases treated with modified PPT (P = .70). Complications occurred in 6% (four of 69) of modified PPT procedures and 16% (nine of 57) of ATD procedures. This difference was not statistically significant (P = .08); however, there were significantly more local complications in the ATD group (P = .04). The primary patency rates at 30, 90, and 180 days were 65% and 65%, 36% and 50%, and 26% and 33% for modified PPT and ATD, respectively. Survival curves were found not to differ significantly (P = .49).

CONCLUSION

The ATD and modified PPT were similarly successful in the recanalization of thrombosed hemodialysis access grafts and achieved comparable primary patency rates. The higher rate of local complications and technical difficulties encountered with use of the 8-F ATD limit its usefulness for this indication.

Randomization-based methods for correcting for treatment changes: examples from the Concorde trial

We develop analysis methods for clinical trials with time-to-event outcomes which correct for treatment changes during follow-up, yet are based on comparisons of randomized groups and not of selected groups. A causal model relating observed event times to event times that would have been observed under other treatment scenarios is fitted using the semi-parametric approach of Robins and Tsiatis (avoiding assumptions about the relationship between treatment changes and prognosis). The methods are applied to the Concorde trial of immediate versus deferred zidovudine, to investigate how the results would have differed if no participant randomized to deferred zidovudine had started treatment before reaching ARC or AIDS. We consider issues relating to model choice, non-constant treatment effects and censoring.

Memory card: A tool to assess patient compliance with peritoneal dialysis

Lack of compliance with prescribed peritoneal dialysis (PD) therapy is a common cause of inadequate dialysis and poor outcomes. Because measurements of delivered doses are performed infrequently, the values obtained may not reflect actual delivered therapy. To evaluate compliance with therapy and to record accurate and complete treatment history for each patient undergoing automated PD, a memory card with the capability to track and store 2 months of treatment data was developed and incorporated into a commercial PD cycler. The memory card is brought to the clinic during the monthly visit. The data is downloaded into a personal computer (PC) with specific software. The following parameters can be retrieved and displayed as a graph or chart: the time of the exchange, length of the exchange, solution transit time, drain time, automated exchanges and last fill, inflow and drain volume, net ultrafiltration, and times of drain alarms. The data can be displayed as daily therapy, mean of therapy values, or total therapy. With the information available, the renal team can incorporate changes into the prescription and provide feedback to the patient based on his/her compliance record. The data can be transferred to a central data pool via modem. This data collection system can also be used for quality improvement, to model delivered therapy, and to compare compliance scores among centers and by cohorts of patients according to demographic or comorbid conditions.

Evaluation of biatrial pacing, right atrial pacing, and no pacing in patients with drug refractory atrial fibrillation

It has been suggested biatrial pacing may prevent the recurrence of atrial fibrillation (AF). To further evaluate this hypothesis, we performed a randomized, single-blinded study in 19 patients with drug refractory AF. The study compared biatrial pacing with conventional right atrial (RA) pacing and a control period of inhibited pacing. The pacing modes utilized were DDD with a base rate of 70 beats/min for biatrial and RA pace (with and without biatrial resynchronization, respectively) and 40 beats/min for the control period. The duration of each pacing mode was 3 months. The number of AF episodes and their duration were obtained from pacemaker Holter memory (Chorus RM ELA Medical). Comparison of the control period (n = 11) with either pacing strategy showed a significant decrease in the total duration of AF (control 27 +/- 35 days, biatrial 8 +/- 15 days p = 0.02, RA 11 +/- 27 days p = 0.04). However, there was no effect on the number of AF episodes (control 79 +/- 108, biatrial 36 +/- 75 p = 0.32, RA 41 +/- 80 p = 0.11). The total percentage of atrial pacing also significantly increased when the control period (6 +/- 9%) was compared with both RA pace (62 +/- 33%, p = 0.008) and biatrial pace (63 +/- 31, p = 0.003). When biatrial pacing was compared with RA pace (n = 19), there was no significant difference in either the duration of AF (biatrial 16 +/- 26 days vs RA 19 +/- 31 days, p = 0.7) or the number of AF episodes (biatrial 56 +/- 91 vs RA 87 +/- 106, p = 0.34). In conclusion, pacing (either type) at a base rate of 70 beats/min has an antifibrillatory effect when compared with inhibited pacing at 40 beats/min. No additional benefit of biatrial pacing over right atrial pacing was demonstrated in this study.

Relationship of internalized racism to abdominal obesity and blood pressure in Afro-Caribbean women

Racism is associated with increased psychosocial stress and blood pressure in blacks. However, little is known of the relationship of racism to other features of insulin resistance syndrome. This study examined the relationship of internalized racism to abdominal obesity and elevated blood pressure in a population of black Caribbean women aged 20-55 years. One hundred thirty-three randomly selected women from the island of Barbados comprised the study sample. Data collected included anthropometric and blood pressure measurements, and information about internalized racism, anxiety, and depression. The stress measures including anxiety, depression, and internalized racism were significantly correlated with waist circumference (r = .25, r = .21, and r = .25). After adjusting for age, education, anxiety, and depression, internalized racism remained significantly correlated with waist circumference. The odds ratio associated with development of abdominal obesity among those with high internalized racism (OR = 2.4 [95% CI, 1.1,5.3]) was significant (P < .05) after adjusting for age, education, and body mass index. Blood pressure was not independently related to internalized racism. Studies comparing black-white differences in diseases for which abdominal obesity is a risk factor (eg, diabetes and cardiovascular disease) should take into account the potential role of internalized racism in defining the differences between ethnic groups.

Immunization with amyloid-beta attenuates Alzheimer-disease-like pathology in the PDAPP mouse

Amyloid-beta peptide (Abeta) seems to have a central role in the neuropathology of Alzheimer's disease (AD). Familial forms of the disease have been linked to mutations in the amyloid precursor protein (APP) and the presenilin genes. Disease-linked mutations in these genes result in increased production of the 42-amino-acid form of the peptide (Abeta42), which is the predominant form found in the amyloid plaques of Alzheimer's disease. The PDAPP transgenic mouse, which overexpresses mutant human APP (in which the amino acid at position 717 is phenylalanine instead of the normal valine), progressively develops many of the neuropathological hallmarks of Alzheimer's disease in an age- and brain-region-dependent manner. In the present study, transgenic animals were immunized with Abeta42, either before the onset of AD-type neuropathologies (at 6 weeks of age) or at an older age (11 months), when amyloid-beta deposition and several of the subsequent neuropathological changes were well established. We report that immunization of the young animals essentially prevented the development of beta-amyloid-plaque formation, neuritic dystrophy and astrogliosis. Treatment of the older animals also markedly reduced the extent and progression of these AD-like neuropathologies. Our results raise the possibility that immunization with amyloid-beta may be effective in preventing and treating Alzheimer's disease.

Biventricular implantable cardioverter defibrillator use in a patient with heart failure and ventricular tachycardia secondary to Emery-Dreifuss syndrome

We report a case of fully transvenous single-unit biventricular implantable cardioverter defibrillator (ICD) use in a 43-year-old woman with a manifesting carrier form of muscular dystrophy (Emery-Dreifuss syndrome). The indication for biventricular ICD use was progressive heart failure with ventricular arrhythmia, permanent atrial fibrillation and previous VVIR pacemaker insertion. Single-unit transvenous biventricular ICD implantation was undertaken without complication. No potentially serious device malfunction was noted during subsequent follow-up. We conclude that single-unit biventricular ICD implantation is feasible for pacing and ventricular tachyarrhythmia control in patients with underlying atrial fibrillation.

Initial experience in the extraction of chronically implanted pacemaker leads using the Excimer laser sheath

OBJECTIVE

To assess the safety and efficiency of the Excimer laser sheath in extracting chronically implanted pacemaker leads.

PATIENTS

Eight patients were studied (one female, mean age 62 years, range 34 to 77) with 17 pacemaker leads (five atrial, 10 ventricular, two implantable defibrillator). The mean implantation time was 65 months (range 23 to 188). The indications for lead extraction were chronic infection (7), superior vena cava obstruction (4), lead malfunction (4), and pain (2).

METHODS

A prospective analysis of the use of the Excimer laser sheath in extracting chronically implanted pacemaker leads. Laser sheath extraction was undertaken if conventional extraction techniques with simple traction or traction with a locking stylet had failed. If laser sheath extraction was unsuccessful, basket retrieval of the lead from the groin was performed.

RESULTS

Complete lead removal was achieved in 16 leads (94%). In one case the electrode tip was left behind without complication. Extraction was achieved with the laser sheath alone in 16 leads. Basket retrieval was required in one case after laser failure. There were no complications.

CONCLUSIONS

The Excimer laser sheath appears to be an effective and safe technique for extracting chronically implanted pacemaker leads. It can be used in combination with the currently available techniques for successful lead extraction.

Stabilisation of medically refractory ventricular arrhythmia by intra-aortic balloon counterpulsation

OBJECTIVE

To review the efficacy of intra-aortic balloon counterpulsation (IABCP) in medically refractory ventricular arrhythmia.

DESIGN

Retrospective analysis of the outcome of patients with ventricular arrhythmia treated with IABCP after transfer between 1992 and 1997.

SETTING

Tertiary cardiac referral centre.

PATIENTS

21 patients (mean age 58 years) who underwent IABCP for control of ventricular arrhythmia. All had significant left ventricular impairment (mean ejection fraction 28.6%); 18 had coronary artery disease.

RESULTS

Before IABCP, 10 patients had incessant monomorphic ventricular tachycardia and 11 had paroxysmal ventricular tachycardia and/or ventricular fibrillation (VT/VF). IABCP resulted in suppression of ventricular arrhythmia in 18 patients, of whom 13 were weaned from IABCP. After stabilisation of ventricular arrhythmia, 10 patients were maintained on medical treatment alone and one underwent endocardial resection. IABCP was maintained until cardiac transplantation in five patients. One patient had a fatal arrest before discharge and one died from progressive heart failure. IABCP failed to control ventricular arrhythmia in three patients and was subsequently discontinued. A cardiac assist device was employed in one of these until cardiac transplantation; the other two were eventually stabilised on medical treatment. Nineteen patients were discharged from hospital. Overall survival was 95% at mean follow up of 25.7 months.

CONCLUSIONS

IABCP can be an effective means of controlling refractory ventricular arrhythmia, allowing time for the institution of more definitive treatment.

The use of a "side-wire" permanent transvenous pacing electrode for left ventricular pacing

It has been reported that biventricular pacing can improve the symptomatic status of patients with heart failure. However, using currently available transvenous left ventricular pacemaker leads the implantation procedure is difficult and has a high failure rate. We report the successful use of a new type of left ventricular pacing lead, the 'side-wire' pacing lead. This lead is initially introduced through a specifically designed guiding sheath to aid coronary sinus cannulation and then over a pre-positioned guide wire to aid final positioning. The more widespread introduction of this type of left ventricular pacing lead may reduce the difficulty of left ventricular pacing via the coronary sinus and thus improve the overall success rate of this therapeutic approach.

Calculating the interindividual geometric standard deviation for use in the integrated exposure uptake biokinetic model for lead in children

The integrated exposure uptake biokinetic (IEUBK) model, recommended for use by the U.S. Environmental Protection Agency at residential Superfund sites to predict potential risks to children from lead exposure and to establish lead remediation levels, requires an interindividual geometric standard deviation (GSDi) as an essential input parameter. The GSDi quantifies the variability of blood lead concentrations for children exposed to similar environmental concentrations of lead. Estimates of potential risks are directly related to the GSDi, and therefore the GSDi directly impacts the scope of remediation at Superfund sites. Site-specific GSDi can be calculated for sites where blood lead and environmental lead have been measured. This paper uses data from blood and environmental lead studies conducted at the Bingham Creek and Sandy, Utah, Superfund sites to calculate GSDi using regression modeling, box modeling, and structural equation modeling. GSDis were calculated using various methods for treating values below the analytical method detection and quantitation limits. Treatment of nonquantifiable blood lead concentrations affected the GSDi more than the statistical method used to calculate the GSDi. For any given treatment, the different statistical methods produced similar GSDis. Because of the uncertainties associated with data in the blood lead studies, we recommend that a range of GSDis be used when analyzing site-specific risks associated with exposure to environmental lead instead of a single estimate. Because the different statistical methods produce similar GSDis, we recommend a simple procedure to calculate site-specific GSDi from a scientifically sound blood and environmental lead study.

A Bayesian semiparametric accelerated failure time model

A Bayesian semiparametric approach is described for an accelerated failure time model. The error distribution is assigned a Pólya tree prior and the regression parameters a noninformative hierarchical prior. Two cases are considered: the first assumes error terms are exchangeable; the second assumes that error terms are partially exchangeable. A Markov chain Monte Carlo algorithm is described to obtain a predictive distribution for a future observation given both uncensored and censored data.

Prevalence of disabling conditions among African-American children and youth

This article reports on the prevalence of disabling conditions among children and youth in the African-American subpopulation. The health status of the African-American population as a whole is discussed as well as the disabling conditions among African-American children and youth specifically. The unique social, economic, and health conditions relative to African-American children and youth are highlighted. Recommendations for future research, policy, and practice are made to alleviate problems surrounding African-American children and their families.

Student performance appraisal: an approach to evaluation of attitudes in medical laboratory technology students

This paper describes the development and implementation of a new evaluation format for assessing professional attitudes in medical laboratory technology students--the performance appraisal. This tool measures attitudes considered desirable in the ¿ideal technologist¿, and links the presence or absence of these attitudes to behaviors which can be observed in the student. The performance appraisal functions not only as an evaluation instrument for instructors, but as a learning tool for students, who can identify behavioral objectives, assess their own progress, and set goals and strategies for development of professional attitudes. Details regarding the administration of the evaluation instrument, such as rating scales, remedial planning, and responsibilities of faculty, clinical coordinators, and students are presented. In addition, controversies regarding the evaluation of professional attitudes are discussed, including: optimizing instructor objectivity; timing and grading of evaluations; forwarding of evaluations from one instructor to another; identification of mandatory and desirable attitudes; and criterion referencing of objectives. Plans for future development of the system are included.

A comparison of epidural ropivacaine infusion alone and in combination with 1, 2, and 4 microg/mL fentanyl for seventy-two hours of postoperative analgesia after major abdominal surgery

Our aim in this prospective, randomized, double-blinded study was to compare the analgesic effectiveness and side effects of epidural infusions with ropivacaine 2 mg/mL alone (Group R; n = 60) and in combination with fentanyl 1 microg/mL (R1F; n = 59), 2 microg/mL (R2F; n = 62), and 4 microg/mL (R4F; n = 63) for up to 72 h after major abdominal surgery. Effective epidural neural blockade was established before surgery; postoperatively, the infusion rate was titrated to a maximum of 14 mL/h for analgesia. No additional analgesics other than acetaminophen were permitted during the infusion. The median of individual visual analog scale score with coughing were <20 mm for all groups (0 = no pain, 100 = worst pain) and was significantly lower (P < 0.01) for Group R4F at rest and with coughing (compared with Group R). Infusions were discontinued due to inability to control pain in significantly fewer patients in Group R4F (16%) than the other groups (34% to 39%; P < 0.01). For all groups, >90% of patients had no detectable motor block after 24 h. Hypotension, nausea, and pruritus were more common with the larger dose of fentanyl. We conclude that, after major abdominal surgery, an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL provided significantly more effective pain relief over a 3-day period than ropivacaine alone or ropivacaine with lower concentrations of fentanyl.

IMPLICATIONS

Postoperative epidural analgesic infusions are widely used, but there is little information regarding optimal strengths of opioid with local anesthetic. In this blinded, prospective study, we compared four different epidural infusion solutions for efficacy and side effects over a clinically useful postoperative period and conclude that an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL was most effective.