Procedural outcome and risk prediction in patients with implantable cardioverter-defibrillator (ICD) undergoing transvenous lead extraction: a GALLERY subgroup analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Device complications, such as infection or lead dysfunction necessitating transvenous lead extraction (TLE) are continuously rising amongst patients with indwelling transvenous implantable cardioverter-defibrillator (ICD).

Objectives

Aim of this study was to characterize the procedural outcome and risk factors of patients with indwelling 1- and 2-chamber ICD undergoing TLE.

Methods

We conducted a subgroup analysis of all 1- and 2-chamber ICD patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) database. Predictors for procedural failure and all-cause mortality were assessed.

Results

A total of 854 patients with ICD undergoing TLE were identified, who were younger (62.9±13.8 vs. 70.7±13.0 years; p<0.001), less likely to be female (20.8 vs. 27.1%; p<0.001) and had a higher proportion of patients with coronary artery disease (51.5 vs. 38.6%; p<0.001) and highly reduced ejection fraction (32.0 vs. 23.0%; p>0.001), when compared to non-ICD patients. Leading extraction indication was lead dysfunction (48.0 vs. 21.9%; p<0.001), followed by device-related infection (45.6 vs. 73.0%; p<0.001). There were no differences in overall procedural complications (4.3 vs. 4.3%; p=0.980), clinical success rate (97.9 vs. 97.8%; p=0.861) or procedure-related (0.8 vs. 0.5%; p=0.292) and all-cause mortality (3.4 vs. 3.7%; 0.742) between groups. Multivariate analysis revealed lead age≥10 years (OR:5.75, 95%CI:2.0-16.2; p=0.001) as independent predictor for procedural failure. Systemic infection as extraction indication (OR:9.57, 95%CI:2.2-42.4; p=0.003) and procedural complications (OR:8.0, 95%CI:2.8-23.3; p<0.001) were identified as risk factors for all-cause mortality. Predictors for systemic infection in ICD patients were atrial fibrillation (OR: 2.22, 95%CI: 1.51-3.27; p<0.001), diabetes mellitus (OR: 2.28, 95%CI: 1.59-3.25; p<0.001) and chronic kidney disease (OR: 2.0, 95%CI: 1.39-2.89; p<0.001).

Conclusions

Transvenous lead extraction is safe and efficacious in patients with 1- and 2-chamber ICD. Although lead dysfunction is the leading indication for extraction, systemic device-related infection is the main driver of all-cause mortality for ICD patients undergoing TLE.

Increased prevalence of metabolic syndrome in patients with bipolar disorder compared to a selected control group-a Northern Netherlands LifeLines population cohort study

OBJECTIVES

Metabolic syndrome (MetS) is highly prevalent among patients with bipolar disorder (BD). The aims of this cross-sectional study were to determine the prevalence of MetS in Dutch BD subjects and compare it with a control group, to examine the association of demographic and clinical characteristics with MetS in BD, and to determine the extent to which metabolic dysregulation is treated in those patients.

METHODS

493 Dutch adult patients (≥ 18 years) with BD receiving psychotropic drugs and 493 matched control subjects were compared using data from the biobank Lifelines. We determined MetS according to the National Cholesterol Education Program Adult Treatment Panel III-Adapted (NCEP ATP III-A) criteria. The difference in the prevalence of MetS and the associations with characteristics were analyzed with logistic regression.

RESULTS

BD subjects (30.6%) showed a significantly higher prevalence of MetS compared to the control group (14.2%) (p < .001, OR:2.67, 95% CI:1.94-3.66). Univariate analysis showed that smoking, body mass index (BMI) and antidepressant drug use were associated with MetS. Multivariate analysis showed that smoking (OR:2.01) was independently associated with MetS in BD. For hypertension, hyperglycemia and lipid disorder pharmacological treatment was provided to respectively 69.5%, 24% and 18.4% of the BD subjects in our sample.

LIMITATIONS

Duration of illness of BD subjects was unknown.

CONCLUSIONS

This study demonstrated a higher prevalence of MetS in Dutch BD subjects compared to persons without BD. In addition, a remarkable undertreatment of some of the components of MetS was found.

1255Comprehensive analysis of pacemaker patients with and without abandoned leads undergoing transvenous lead extraction: A GALLERY subgroup analysis

OnBehalf

GALLERY investigators

Background

The number of cardiac implantable electronic device (CIED)-associated complications such as infection, lead dysfunction or thrombotic events is continuously rising and thus making transvenous lead extraction (TLE) an ever more needed procedure in clinical practice today. Patients with abandoned leads represent a special cohort with a potentially higher susceptibility to CIED-related infections and vascular complications. Moreover, according to literature abandoned leads seem to be associated with more procedural complications and mortality during TLE. 

Aim

 

The aim of this study was to provide an insight on safety, procedural outcome and risk prediction on pacemaker patients with abandoned leads undergoing TLE from the largest national laser-sheath registry to date.

Methods + Results:

We conducted a retrospective analysis of the GALLERY database, which collected 2533 patients undergoing TLE in Germany between 2013 and 2017. Out of 903 pacemaker patients, who underwent TLE, 226 patients (25.0%) with abandoned leads were identified. Those patients had a higher number of leads per patient (3.2 ± 0.8 vs. 1.9 ± 0.3; ns) and longer lead dwell-times (168.0 ± 89.7 vs. 123.0 ± 69.2 months; p &lt; 0.0001) compared to pacemaker patients without abandoned leads. There were no differences in age (71.5 vs. 72.3 years; ns), body mass index (26.5 ± 4.5 vs. 26.78 ± 4.8 kg/m2; ns) or gender distribution (69.0 vs. 66.5% male; ns). Leading indication for TLE was device infection with no difference between groups (79.7 vs 77.8 %; ns). There were no differences in terms of pacemaker dependency, length of hospitalization or comorbidities. Patients with abandoned leads had longer procedure times (112.0 ± 69.0 vs. 86.4 ± 53.0 minutes; p &lt; 0.0001) and a higher incidence of procedural complications (6.6 vs. 3.1%; p = 0.03), but there were no differences in neither procedural and clinical success rates (96.5 vs. 97.3%; ns), nor all-cause mortality (1.33 vs. 2.66%; ns). Multivariate logistic regression revealed abandoned leads (OR 2.1, CI 1.0-4.4, p = 0.04) and female gender (OR 2.4, CI 1.2-4.9, p = 0.02) as independent predictors for procedural complications. Systemic infection (OR 5.4, CI 2.0-14.8, p = 0.001) and chronic kidney disease (OR 4.0, CI 1.5-10.7, p = 0.007) were strong predictors for all-cause mortality in patients with indwelling pacemaker. Patient age &gt; 75 years (OR 3.9, CI 2.7-5.6, p &lt; 0.0001) and a lead dwell-time &gt; 10 years (OR 1.6, CI 1.1-2.2, p = 0.01) were identified as risk factors for an infectious cause for TLE. 

Conclusion

Abandoned leads are frequently encountered in pacemaker patients undergoing TLE and pose an important risk factor for procedural complications. Systemic CIED-related infections are the strongest driver of mortality in this patient cohort and urgently call for further improvements in early diagnosis and prevention.

The utility of PET-CT in the staging and management of advanced and recurrent malignant melanoma

BACKGROUND

Accurate pre-operative staging and correct surgical selection of patients with malignant melanoma reduces unnecessary morbidity and mortality, improves distant control and may improve survival. ¹⁸F-fluorodeoxyglucose Positron Emission Tomography Computed Tomography (¹⁸F-FDG PET-CT) has been shown to be useful in exclusion of metastatic sites and aids in surgical planning in stage III and potentially resectable stage IV disease. The primary objective of the study was to determine whether the use of PET-CT alters the initial staging and management of patients with advanced and recurrent melanoma.

METHOD

Retrospective analysis of clinical records of patients with malignant melanoma referred for staging PET-CT over a three-year period at our institution was performed. Pre- and post-PET-CT stage was recorded and a descriptive analysis was done to determine whether PET-CT resulted in a change in stage grouping and whether this change effected a change in clinical management.

RESULTS

A change in stage grouping occurred in 21/39 (53.8%) of patients, 76.2% of which were up-staged and 23.8% down staged. On analysis of stage III/IV and recurrent melanoma, a change in stage occurred in 90% of stage III, 50% of stage IV and 50% of recurrent melanoma patients. This effected a change in management in 86.7% of patients with stage III, IV and recurrent melanoma collectively.

CONCLUSION

PET-CT is a useful tool in the staging and subsequent management of melanoma. Its utility is pronounced in advanced and recurrent melanoma.

The distress thermometer as a prognostic tool for one-year survival among patients with lung cancer

INTRODUCTION

The use of patient-reported outcome measures is increasingly advocated to support high-quality cancer care. We therefore investigated the added value of the Distress Thermometer (DT) when combined with known predictors to assess one-year survival in patients with lung cancer.

METHODS

All patients had newly diagnosed or recurrent lung cancer, started systemic treatment, and participated in the intervention arm of a previously published randomised controlled trial. A Cox proportional hazards model was fitted based on five selected known predictors for survival. The DT-score was added to this model and contrasted to models including the EORTC-QLQ-C30 global QoL score (quality of life) or the HADS total score (symptoms of anxiety and depression). Model performance was evaluated through improvement in the -2 log likelihood, Harrell's C-statistic, and a risk classification.

RESULTS

In total, 110 patients were included in the analysis of whom 97 patients accurately completed the DT. Patients with a DT score ≥5 (N = 51) had a lower QoL, more symptoms of anxiety and depression, and a shorter median survival time (7.6 months vs 10.0 months; P = 0.02) than patients with a DT score <5 (N = 46). Addition of the DT resulted in a significant improvement in the accuracy of the model to predict one-year survival (P < 0.001) and the discriminatory value (C-statistic) marginally improved from 0.69 to 0.71. The proportion of patients correctly classified as high risk (≥85% risk of dying within one year) increased from 8% to 28%. Similar model performance was observed when combining the selected predictors with QoL and symptoms of anxiety or depression.

CONCLUSIONS

Use of the DT allows clinicians to better identify patients with lung cancer at risk for poor outcomes, to further explore sources of distress, and subsequently personalize care accordingly.

Investigation of the potential of buffalo and couch grasses to grow on AFIs and for removal of nutrients from paper mill wastewater

The potential growth of buffalo grass (Stenotaphrum secundatum) and couch grass (Cynodon dactylon) on artificial floating islands (AFIs) and their ability to remove total nitrogen (TN) and total phosphorus (TP) from a simulated paper mill wastewater was studied. This was done to assess the potential of AFIs for removal of nutrients from aerated stabilization basins (ASBs) that had occasional growth of blue-green algae (BGA) to bloom levels. Small scale AFIs were prepared using polyethylene foam and planted with the grasses in 30 L of tested water. Trials were conducted in a plastic covered greenhouse over a three-month period where temperatures ranged from 15 to 44 °C. The results showed that both buffalo and couch grasses can adapt to planting in AFIs showing increases of 125% and 148% in wet weight, respectively. Nutrient uptake by buffalo grass and couch grass were found to be similar. Percentage uptakes of TP and TN from the synthetic water by the buffalo grass were 82% and 47%, whereas by couch grass, uptakes were 83% and 45%, respectively.

Physiological movement disorder-like features during typical motor development

AIM

To compare physiological age-relatedness between dyskinesia (dystonia/choreoathetosis), dystonia and ataxia rating scale scores in healthy children.

METHOD

Three movement disorders specialists quantified dyskinetic-like features in healthy children (n = 52; 4-16 years) using the Dyskinesia Impairment Scale (DIS = DIS-choreoathetosis (DIS-C) + DIS-dystonia (DIS-D)). We compared the age-related regression coefficients of the DIS with data processed from previous studies on dystonia and ataxia rating scales (Burke-Fahn-Marsden Movement and Disability Scales (BFMMS and BFMDS) and Scale for Assessment and Rating of Ataxia (SARA), International Cooperative Ataxia Rating Scale (ICARS) and Brief Ataxia Rating Scale (BARS)).

RESULTS

Dyskinetic scores were obtained in 79% (DIS); 65% (DIS-D) and 17% (DIS-C) versus dystonic and ataxic scores in 98% (BFMMS) and 89% (SARA/ICARS/BARS) of the children. Age-related DIS and DIS-D scores (B = -0.90 and 0.77; p < 0.001) were correlated with age-related BFMMS scores (B = -0.49; p < 0.001; r = 0.87; p < 0.001), whereas DIS-C scores were age-independent. Ataxic scores revealed stronger age-related regression coefficients than dyskinetic and dystonic scores (4-8 years; p < 0.05).

INTERPRETATION

In healthy children, comparison between physiological dyskinesia, dystonia and ataxia rating scale scores revealed: 1. inverse age-relatedness for dystonic and ataxic scores, but not for choreoathetotic scores, 2. interrelated dystonic DIS-D and BFMMS scores, 3. the strongest age-related expression by ataxic scores. In healthy children, these physiological movement disorder-like features are interpreted as an expression of the developing underlying motor centres.

[The dysregulated brain - Consequences of spatial and temporal brain complexity for bipolar disorder pathophysiology and diagnosis]

BACKGROUND

Despite the existence of several pathophysiological theories about bipolar disorder, it has so far been difficult to find diagnostic biomarkers and to develop new pharmacologic treatments based on the more novel theories.

AIM

To reflect on the causes and consequences of problems that beset pathophysiological research into psychiatric disorders in general and bipolar disorder in particular.

METHOD

In this essay we address the problems facing professionals engaged in research into bipolar disorder and we interpret these problem in the light of brain complexity.

RESULTS

The complexity of the brain can be divided into two types: spatial complexity, which reflects the various physiological levels of the central nervous system (genetic, molecular, cellular, neuronal circuits and phenomenological levels), and temporal complexity, i.e. neurodevelopment. We discuss the consequences of these two types of complexity and make suggestions relating to clinical practice and pathophysiological psychiatric research.

CONCLUSION

To achieve further progress in the field of brain research, we need to acquire a deeper understanding of the spatial and temporal complexity of the brain and consider the possible consequences of such knowledge for the pathophysiology and treatment of psychiatric illnesses such as bipolar disorder.

Evaluation of a smartphone human activity recognition application with able-bodied and stroke participants

Background

Mobile health monitoring using wearable sensors is a growing area of interest. As the world’s population ages and locomotor capabilities decrease, the ability to report on a person’s mobility activities outside a hospital setting becomes a valuable tool for clinical decision-making and evaluating healthcare interventions. Smartphones are omnipresent in society and offer convenient and suitable sensors for mobility monitoring applications. To enhance our understanding of human activity recognition (HAR) system performance for able-bodied and populations with gait deviations, this research evaluated a custom smartphone-based HAR classifier on fifteen able-bodied participants and fifteen participants who suffered a stroke.

Methods

Participants performed a consecutive series of mobility tasks and daily living activities while wearing a BlackBerry Z10 smartphone on their waist to collect accelerometer and gyroscope data. Five features were derived from the sensor data and used to classify participant activities (decision tree). Sensitivity, specificity and F-scores were calculated to evaluate HAR classifier performance.

Results

The classifier performed well for both populations when differentiating mobile from immobile states (F-score > 94 %). As activity recognition complexity increased, HAR system sensitivity and specificity decreased for the stroke population, particularly when using information derived from participant posture to make classification decisions.

Conclusions

Human activity recognition using a smartphone based system can be accomplished for both able-bodied and stroke populations; however, an increase in activity classification complexity leads to a decrease in HAR performance with a stroke population. The study results can be used to guide smartphone HAR system development for populations with differing movement characteristics.

Highly efficient and scalable chemoenzymatic syntheses of (R)- and (S)-lactaldehydes

Biocatalytic asymmetric reductions have been key steps in the synthesis of 1,1-dimethoxy-2-propanone, catalyzed by suitable ketoreductases to (S)- and (R)-1,1-dimethoxy-2-propanol, obtained in ≥99.9% ee and excellent yield. Removal of the protecting group gave the (S)- and (R)-lactaldehydes in excellent yield and purity.

Anxiety and depression during pregnancy in Central America: a cross-sectional study among pregnant women in the developing country Nicaragua

BACKGROUND

Around the world, maternal psychopathology during pregnancy is associated with a range of negative consequences for mother and child. Nevertheless, in Central America the magnitude of this public health problem is still unknown. The objective of this first explorative study was to investigate the prevalence and severity of anxiety and depression during pregnancy in the Central American developing country Nicaragua, as well as the availability of mental health care and to compare with a developed country.

METHODS

A population-based cohort of pregnant women in Nicaragua (N = 98) was compared with a parallel cohort in the Netherlands (N = 4725) on symptoms of anxiety (Spielberger State Trait Anxiety Inventory) and depression (Edinburgh Postnatal Depression Scale). Associations with the women's knowledge how to reach professional psychological support were assessed using multivariable linear regression analyses.

RESULTS

Of the Nicaraguan women, 41 % had symptoms of anxiety and 57 % symptoms of depression, versus 15 % and 6 % of the Dutch women. Symptom scores of both anxiety and depression were significantly higher in Nicaragua (p < 0.001). However, only 9.6 % of the women indicated that professional psychological help was available for the Nicaraguan pregnant women, which was associated with an increased anxiety score.

CONCLUSIONS

In Nicaragua, both prevalence and severity of symptoms of antenatal anxiety and depression are substantially higher than in developed countries. However, availability of psychological help is very limited for pregnant Nicaraguan women. These findings indicate that there is need for further research and support for these women, to prevent negative consequences for both mother and child.

A comparison of the University of New Brunswick Test of Prosthetic Function and the Assessment of Capacity for Myoelectric Control

BACKGROUND

Valid outcome measures are required for gathering evidence on when, how and using which prosthetic components to start prosthetic fitting to children with congenital upper limb deficiencies and those following acquired upper limb amputation. We have been using the University of New Brunswick Test of Prosthetic Function (UNB, which measures skill and spontaneity of prosthetic use) in our country since 1996, and the Assessment of Capacity for Myoelectric Control (ACMC, which was developed for persons using a myoelectric prosthesis) since 2008.

AIM

We wanted to explore whether the UNB and the ACMC measure the same construct (i.e., assess convergent validity), and whether the ACMC can also be used for assessing children and adolescents who use a body-powered upper-limb prosthesis.

DESIGN

Observational.

SETTING

Inpatient.

POPULATION

All the 19 children and adolescents who were visiting the outpatient clinic for rehabilitation of children with upper limb deficiencies and amputations at our institute from January 2010 to December 2011 and had a myoelectric (15 participants) or body-powered prosthesis (4 participants).

METHODS

The participants were assessed by the age-appropriate UNB subtest; 60 assessments were performed in total. Two tests (moving a plastic glass half-full with water from table to the sink, and tying apron at the back) were added to obtain the ACMC scores.

RESULTS

Simple and autocorrelation-adjusted correlation and regression analyses demonstrated that ACMC score is highly positively correlated with UNB spontaneity and skill score in children and adolescents who use a myoelectric prosthesis. Neither of the two associations could be observed in children and adolescents who use a body-powered prosthesis.

CONCLUSION

The results suggest that both tests can be used for assessing children and adolescents who use a myolectric prosthesis, but only the UNB appears to be appropriate for those who use a body-powered prosthesis.

CLINICAL REHABILITATION IMPACT

This small study indicates that either the ACMC or the UNB are applicable for assessing children and adolescents who use a myolectric upper-limb prosthesis because of congenital upper limb deficiencies or acquired upper limb amputation, but only the UNB seems to be applicable for those children or adolescents who use a body-powered prosthesis.

Melatonin treatment in children with therapy-resistant monosymptomatic nocturnal enuresis

OBJECTIVE

To evaluate the effects of exogenous melatonin on the frequency of wet nights, on the sleep-wake cycle, and on the melatonin profile in children with therapy-resistant MNE.

PATIENTS AND METHODS

24 patients were included. Patients had to maintain a diary including time of sleep and arousal, and whether they had a dry or a wet bed in the morning. We measured baseline melatonin profiles in saliva. Hereafter, patients were randomized to synthetic melatonin or placebo. After 3 and 6 months we evaluated the frequency of enuresis and the melatonin profiles.

RESULTS

11 patients were randomized to melatonin, 13 to placebo. We evaluated melatonin profiles of 7 patients in the melatonin group and of 8 in the placebo group. We observed a change in profile in the melatonin group, but we did not observe a difference in the sleep-wake cycle or the frequency of wet nights in either group.

CONCLUSION

This is the first time exogenous melatonin has been evaluated in the treatment of MNE. Although we observed a change in melatonin profile after the use of exogenous melatonin, we did not observe a change in enuresis frequency or in the sleep-wake cycle of this select group of patients.