Complications in Device Therapy: Spectrum, Prevalence, and Management.

PURPOSE OF REVIEW: Cardiac implantable electronic device implant numbers are continually increasing due to the expanding indications and ageing population. This review explores the complications associated with device therapy and discusses ways to minimise and manage such complications. RECENT FINDINGS: Complications related to device therapy contribute to mortality and morbidity. Recent publications have detailed clear guidelines for appropriate cardiac device selection, as well as consensus documents discussing care quality and optimal implantation techniques. There have also been advances in device technologies that may offer alternative options to patients at high risk of/or already having encountered a complication. Adherence to guidelines, appropriate training, and selection of device, in addition to good surgical technique are key in reducing the burden of complications and improving acceptability of device therapy.

Dalbavancin as sequential therapy for infective endocarditis due to Gram-positive organisms: a review.

Dalbavancin is a parenteral lipoglycopeptide antibiotic derived from teicoplanin, an analogue of vancomycin. It is mainly used for skin and soft tissue infections. The sustained half-life of approximately 14 days makes dalbavancin a novel option for potential use as sequential treatment in infections such as infective endocarditis, which require prolonged antibiotic courses. However, only a few studies have been reported in the literature, and the use of dalbavancin remains limited. This article is a review of the currently available literature using dalbavancin for the treatment of infective endocarditis due to Gram-positive organisms. Almost all patients received dalbavancin as sequential therapy following standard-of-care antibiotics. The overall clinical efficacy of dalbavancin was approximately 90%, and it appeared to be well tolerated.

Unintended consequences of long-sleeved gowns in a critical care setting during the COVID-19 pandemic.

At the peak of the coronavirus disease 2019 (COVID-19) pandemic, hand hygiene audits indicated decreased compliance in a 12-bed critical care (CC) area with ventilated COVID-19 patients, where staff used personal protective equipment (PPE), including sessional use of long-sleeved gowns in accordance with the recommendations of Public Health England. There was also a cluster of three central venous catheter (CVC) infections along with increases in the number of patients from whom enteric Gram-negative bacteria (GNB) were isolated from sterile sites. Environmental sampling of near-patient surfaces and frequently touched sites demonstrated that 11.5% of areas were contaminated with enteric GNB in the COVID-19 CC area, compared with 2.6% and 2.7% in COVID-19 and non-COVID-19 general wards, respectively. Following a risk assessment, hospital policy was changed to replace long-sleeved gowns with short-sleeved gowns. The CC unit underwent enhanced cleaning with hypochlorite-based disinfectant and was resampled 8 days later. On resampling, no GNB were isolated from the CC unit. Following this change in PPE, hand hygiene compliance returned to baseline standards and no further CVC infections were identified. Staff reported a preference for short-sleeved gowns. No evidence currently exists that PPE beyond that recommended for pandemic influenza (respiratory protection plus standard PPE) adds to the protection of healthcare workers (HCWs) from severe acute respiratory syndrome coronavirus-2. Long-sleeved gowns prevent HCWs performing hand hygiene effectively. While it is imperative that HCWs are adequately protected, protection of patients from infection hazards is equally important. Further studies are necessary to establish risks from PPE to inform a review of current guidance.

Hoechst 33342: the dye that enabled differentiation of living X-and Y-chromosome bearing mammalian sperm.

Hoechst 33342 is the fluorophore used routinely to measure DNA in X- and Y-chromosome-bearing mammalian sperm so they can be separated by flow sorting. A difference of <3% in DNA mass can be detected. This synthetic dye consists of two adjacent benzimidazole rings with N-methyl-piperazine and phenolic groups at the ends. The molecule permeates the cell membrane of living cells and binds selectively to A-T base pairs exposed in the minor-groove of double stranded DNA. Capability to distinguish and separate X- and Y-chromosome-bearing sperm has led to artificial insemination of somewhere around a million female mammals. Offspring with obvious abnormalities are no more frequent than after insemination of unsorted sperm into cows, horses, humans, pigs, sheep, rabbits, dolphins and other mammals. There is no apparent genotoxic effect from exposure of sperm to Hoechst 33342, although information on cellular toxicity or development of embryos resulting from Hoechst 33342-stained sperm is less reassuring. Little is known about the fate of sperm-delivered Hoechst dye in the female reproductive tract or on progeny of resultant offspring.

Investigation and management of an outbreak of mucormycosis in a paediatric oncology unit.

Mucormycosis is an aggressive and often fatal infection, despite conventional methods of treatment, which predominantly affects immunocompromised patients. This report describes an outbreak of rhinocerebral mucormycosis in a university hospital paediatric oncology department secondary to water damage in a linen store and parents' shower room. The source of the outbreak was successfully determined using simple environmental sampling techniques. Sampling allowed timely and successful implementation of infection control measures to contain the source and protect patients. Two cases were treated with posaconazole and made a complete recovery, with no discernible impact on the management of their cancer. Fifteen other children identified as having a high risk of developing infection were given posaconazole prophylaxis. None of the children, including one that was only five years old, experienced any adverse events from taking posaconazole.

History of commercializing sexed semen for cattle.

Although the basic principles controlling the sex of mammalian offspring have been known for a relatively long time, recent application of certain modern cellular methodologies has led to development of a flow cytometric system capable of differentiating and separating living X- and Y-chromosome-bearing sperm in amounts suitable for AI and therefore, commercialization of this sexing technology. After a very long history of unsuccessful attempts to differentiate between mammalian sperm that produce males from those that produce females, a breakthrough came in 1981 when it was demonstrated that precise DNA content could be measured. Although these initial measurements of DNA content killed the sperm in the process, they led to the ultimate development of a sperm sorting system that was capable, not only of differentiating between live X- and Y-sperm, but of sorting them into relatively pure X- and Y-sperm populations without obvious cellular damage. Initial efforts to predetermine the sex of mammalian offspring in 1989 required surgical insemination, but later enhancements provided sex-sorted sperm in quantities suitable for use with IVF. Subsequent advances in flow sorting provided minimal numbers of sperm sufficient for use in AI. It was not until the flow cytometric sorting system was improved greatly and successful cryopreservation of sex-sorted bull sperm was developed that efficacious approaches to commercialization of sexed semen could be implemented worldwide in cattle. A number of companies now offer sex-sorted bovine sperm. Innovative approaches by a diverse group of scientists along with advances in computer science, biophysics, cell biology, instrumentation, and applied reproductive physiology provided the basis for commercializing sexed semen in cattle.

The use of a simple three-level bronchoscopic assessment of inhalation injury to predict in-hospital mortality and duration of mechanical ventilation in patients with burns.

Major burn centres in Australia use bronchoscopy to assess severity of inhalation injuries despite limited evidence as to how best to classify severity of inhalational injury or its relationship to patient outcomes. All patients with burns who were admitted to the intensive care unit (ICU) at The Alfred Hospital between February 2010 and July 2014 and underwent bronchoscopy to assess inhalational injury, were reviewed. Age, total body surface area burnt, severity of illness indices and mechanisms of injury were extracted from medical histories and local ICU and burns registries. Inhalational injury was classified based on the Abbreviated Injury Score and then grouped into three categories (none/mild, moderate, or severe injury). Univariable and multivariable analyses were undertaken to examine the relationship between inhalational injury and outcomes (in-hospital mortality and duration of mechanical ventilation). One hundred and twenty-eight patients were classified as having none/mild inhalational injury, 81 moderate, and 13 severe inhalation injury. Mortality in each group was 2.3% (3/128), 7.4% (6/81) and 30.7% (4/13) respectively. Median (interquartile range) duration of mechanical ventilation in each group was 26 (11-82) hours, 84 (32-232) hours and 94 (21-146) hours respectively. After adjusting for age, total body surface area burnt and severity of illness, only the severe inhalation injury group was independently associated with increased mortality (odds ratio 20.4 [95% confidence intervals {CI} 1.74 to 239.4], P=0.016). Moderate inhalation injury was independently associated with increased duration of ventilation (odds ratio 2.25 [95% CI 1.53 to 3.31], P <0.001), but not increased mortality. This study suggests that stratification of bronchoscopically-assessed inhalational injury into three categories can provide useful prognostic information about duration of ventilation and mortality. Larger multicentre prospective studies are required to validate these findings.

Effects of resistance training protocols on nonlinear analysis of heart rate variability in metabolic syndrome.

Despite the various standard non-linear measurements used in autonomic modulation (AM) assessments usually being applied to long time-series, such analyses can sometimes be applied to shorter term series. To overcome this disadvantage, chaotic global methods were formulated by putting together heart rate variability (HRV) linear methods. Chaos provides information about vegetative function control related to cardiovascular risks. Applying this method can be useful to investigate the complexity of the health condition after resistance training protocols, as a therapeutic intervention in AM in metabolic syndrome individuals (MetS). This study aimed to compare the effects of two resistance training programs (conventional vs functional) in MetS using nonlinear analysis of AM. MetS subjects (n=50) of both sexes aged 40 to 60 years were randomly divided into two programs; a group of 12 people served as a control group. Both groups performed 30 sessions of training. AM was assessed in the chaos domain by chaotic global techniques. The main results showed that both resistance training, functional and conventional, increased chaos when compared to the control group, respectively, observed by chaotic forward parameter (CFP)1 (13.9±17.9 vs 12.8±14.4 vs -2.23±7.96; P≤0.05) and CFP3 (15.4±19.8 vs 21.9±13.2 vs -4.82±11.4; P≤0.05). In addition, 30 sessions of both resistance programs increased chaos, and non-linear analysis enabled discrimination of AM after interventions when compared to the control group.

Metabolic and psychological changes during refeeding in anorexia nervosa.

OBJECTIVE: This study aimed to examine resting metabolic rate (RMR) and psychological changes during refeeding in 10 women with anorexia nervosa participating in a partial hospitalization eating disorder program. RESULTS: Participants' admission RMRs, as assessed by the MedGem Analyzer, were below their RMRs predicted by the Harris- Benedict equation, t(1,9)=5.77, p<0.01. Correlational analyses revealed a trend toward smaller increases in RMR being associated with higher admission BMI (r=-0.49, p=0.08), but not with highest lifetime BMI. Over the course of treatment, RMR per pound of Fat-Free Mass (FFM) increased from the beginning to the middle, t(1,9)=-3.02, p<0.05, and to the end stage of treatment, t(1,9)=-2.53, p<0.05. Scores on the Eating Attitudes Test-26, Eating Disorder Inventory-2, Brief Symptom Inventory (BSI), BSI Depression subscale, and Mizes Anorectic Cognitions scale significantly improved throughout treatment (all p<0.05); however, body dissatisfaction did not improve. DISCUSSION: Results suggest that weight restoration programs for anorexia nervosa cannot rely on FFM or standard formulas to predict caloric needs throughout refeeding, and that admission BMI is one factor to be considered in predicting caloric needs during refeeding. Furthermore, ways to improve body dissatisfaction during refeeding needs to be more of a treatment focus.

Intestinal transport of weak electrolytes: Determinants of influx at the luminal surface.

The determinants of weak electrolyte influx into everted segments of rat small intestine have been studied. Preliminary experiments showed that the observed influxes could be described as unidirectional, diffusional fluxes of the nonionized compound uncomplicated by a parallel ionic component. It is shown that the determinants of weak electrolyte influx in this situation may be described in terms of the resistance of the unstirred layer to movement from the bulk phase to the cell surface, the degree of ionization of the weak electrolyte at the cell surface, and the cellular permeability to the nonionized weak electrolyte. Quantitative considerations indicated that the unstirred layer was totally rate-limiting in the cases of some poorly ionized, or highly permeant compounds, but the unstirred layer was not totally rate limiting for most of the compounds studied. Calculation of cellular permeabilities for the nonionized forms of weak electrolytes required assumptions to be made concerning the pH value in the surface fluid layer. A uniform set of permeability data including both weak acids and weak bases was obtained only when it was assumed that the pH in the surface fluid layer was equal to that in the bulk phase, and it was concluded that these studies do not support the concept of a microclimate of distinctive pH at the epithelial surface as a determinant of weak electrolyte transport.

Monophasic versus biphasic transthoracic countershock after prolonged ventricular fibrillation in a swine model.

OBJECTIVE: We sought to compare the defibrillation efficacy of a low-energy biphasic truncated exponential (BTE) waveform and a conventional higher-energy monophasic truncated exponential (MTE) waveform after prolonged ventricular fibrillation (VF). BACKGROUND: Low energy biphasic countershocks have been shown to be effective after brief episodes of VF (15 to 30 s) and to produce few postshock electrocardiogram abnormalities. METHODS: Swine were randomized to MTE (n = 18) or BTE (n = 20) after 5 min of VF. The first MTE shock dose was 200 J, and first BTE dose 150 J. If required, up to two additional shocks were administered (300, 360 J MTE; 150, 150 J BTE). If VF persisted manual cardiopulmonary resuscitation (CPR) was begun, and shocks were administered until VF was terminated. Successful defibrillation was defined as termination of VF regardless of postshock rhythm. If countershock terminated VF but was followed by a nonperfusing rhythm, CPR was performed until a perfusing rhythm developed. Arterial pressure, left ventricular (LV) pressure, first derivative of LV pressure and cardiac output were measured at intervals for 60 min postresuscitation. RESULTS: The odds ratio of first-shock success with BTE versus MTE was 0.67 (p = 0.55). The rate of termination of VF with the second or third shocks was similar between groups, as was the incidence of postshock pulseless electrical activity (15/18 MTE, 18/20 BTE) and CPR time for those animals that were resuscitated. Hemodynamic variables were not significantly different between groups at 15, 30 and 60 min after resuscitation. CONCLUSIONS: Monophasic and biphasic waveforms were equally effective in terminating prolonged VF with the first shock, and there was no apparent clinical disadvantage of subsequent low-energy biphasic shocks compared with progressive energy monophasic shocks. Lower-energy shocks were not associated with less postresuscitation myocardial dysfunction.

The heterogeneity of anorexia nervosa. Bulimia as a distinct subgroup.

Bulimia is a poor prognostic sign in anorexia nervosa. This raised the question of whether bulimia represented an "end stage" of chronic anorexia nervosa or whether bulimic patients were a distinct subgroup. All subjects seen by us personally from 1970 to 1978 were included in this study provided they met modified criteria of Feighner et al (1972). Of this group, 68 experienced bulimia and 73 did not (restricters). Bulimic patients had a history of weighing more and were more commonly premorbidly obese. Bulimic patients were those who vomited and misused laxatives. The bulimic group displayed a variety of impulsive behaviors, including use of alcohol and street drugs, stealing, suicide attempts, and self-mutilation. With regard to family history, the high frequency of obesity in the mothers of bulimic patients was noteworthy. The two groups share features common to patients with primary anorexia nervosa. However, these results suggest a different group of women are predisposed to have anorexia nervosa develop with bulimia.

Fluoroscopy and Paget's disease of the breast.

A case report concerning a 36-year-old woman having developed Paget's disease of the breast subsequent to multiple fluoroscopies as a child for the investigation of Fallot's anomaly/pulmonary atresia is presented. This case is discussed with a brief review of the relevant literature regarding current theories as to the pathogenesis of Paget's disease of the breast, ionizing radiation and its role in dysplastic breast disease and their possible interrelation.

A new technique for producing myocardial infarction using coronary artery balloon occlusion.

Many techniques for producing myocardial infarction have required the potential physiological altering effects of a thoracotomy. Previous techniques have used the variable and therefore unpredictable effects of coronary artery injection of occlusive agents, intravascular plugs, and externalized coronary balloon catheters. Previous investigators have reported a survival rate of 50-70%. In the present study a new closed chest dog technique was used in which a catheter with an inflatable detachable balloon was placed in the aorta via the carotid artery. The catheter could be readily lodged into any portion of the right, left anterior, or circumflex coronary artery. The proximal left anterior descending and circumflex arteries were occluded in 15 dogs. This new coronary artery balloon occlusion technique may be used to produce a chronic myocardial infarction with a high survival rate of 90% through the use of short acting anaesthesia and rapid reversal of the effect of morphine with naloxone hydrochloride. The rapid recovery of the dog permits earlier study of haemodynamic variables and arrhythmia due to myocardial infarction in the best physiological state.

Verapamil induced ventricular hypertrophy in conscious dogs.

Verapamil is used clinically in the treatment of various cardiac diseases including hypertrophic cardiomyopathy. Its long term effects on ventricular mass are not well known. In 11 conscious dogs heart rate, aortic and left ventricular pressures, cardiac output, a methoxamine induced stress ventricular function test and left ventriculography were performed. These variables were measured prior to and following a mean 7.2 month infusion of verapamil at 0.005 or 0.01 mg.kg-1.min-1 using a subcutaneously implanted pump. Resting haemodynamic variables and left ventricular ejection fraction [60(SD 6) v 55(6)%] were unchanged between baseline and chronic verapamil studies, but the slope of the methoxamine induced stress ventricular function test decreased from 3.9(0.8) to 2.1 (1.3). After verapamil was discontinued the mean slope of the stress ventricular function test returned to the baseline 4.0(1.7). Total ventricular weight increased 22% from 176.1(17.5) g.m-2 in controls to 215.6(29.5) g.m-2 (p less than 0.01) in the verapamil animals. The right ventricular weight increased 25% from 46(5.9) to 57.6(9.1) g.m-2 (p less than 0.01); the septum weight increased 26% from 42.5(4.1) to 53.7(7.2) g.m-2 (p less than 0.001); and the left ventricular free wall weight increased 19% from 87.4(9.8) to 103.9(15.7) g.m-2 (p less than 0.01). The increase in ventricular weights was not due to fibrosis or oedema since hydroxyproline contents and wet/dry ratios were not increased. In conclusion, a chronic infusion of verapamil in conscious dogs caused no change in resting haemodynamic variables but produced reversible depression of stress ventricular function and biventricular and septal hypertrophy.

Prevalence of Type A behavior in untreated hypertensive individuals.

Type A behavior has been associated with coronary heart disease as well as high cholesterol and smoking, major risk factors for coronary heart disease, but the data indicating a similar association with hypertension are inconsistent. Since past studies have usually based hypertension on a single blood pressure assessment or have often included treated hypertensive patients, this inconsistency is not surprising. The current study compared the prevalence of Type A behavior (assessed by Rosenman's structured interview) between 109 untreated hypertensive subjects and 109 age-, sex-, ethnic-, and occupation-matched normotensive subjects. Hypertension status was based on five repeated assessments over a 5-month period. Results indicated that Type A behavior is more prevalent in untreated, mildly hypertensive employed individuals than occupationally matched normotensive subjects. Type A component analysis confirmed the importance of hostility and certain vigorous voice stylistics in predicting cardiovascular conditions. These findings, taken together with the evidence linking Type A behavior with high cholesterol and cigarette smoking, further support the view that this behavior pattern is associated with increased risk of coronary heart disease.

Cognitive style of patients with bulimic and diet-restricting anorexia nervosa.

Recent studies have reported that subjects with bulimic anorexia nervosa are more behaviorally impulsive than those with diet-restricting anorexia nervosa. This study found that bulimic anorexic patients made significantly more errors on the Matching Familiar Figures Test than restricting anorexic and comparison groups. This preliminary finding leads to the speculation that bulimic patients are more cognitively impulsive than restricting anorexic patients.

The validity of the distinction between bulimia with and without anorexia nervosa.

The purpose of this study was to examine the relationship between bulimia in women with anorexia nervosa and bulimia of a similar severity in normal-weight women and to determine the support for the distinction between these two groups according to DSM-III criteria. Results indicated that bulimic women with anorexia nervosa (N = 59) and bulimic normal-weight women (N = 59) resembled each other on most variables and were more similar to each other than to women with anorexia nervosa who rigidly restricted food intake (N = 59). The results failed to support the diagnostic distinction between bulimia in anorexic women and bulimia of equal severity in normal-weight women.

The differentiation of vomiting/weight loss as a conversion disorder from anorexia nervosa.

The authors studied patients with weight loss and vomiting, distinguishing by means of objective criteria those who had what they feel is a conversion disorder from those with anorexia nervosa. The group of patients with conversion disorder were quite different from those with anorexia nervosa and could be considered as suffering from less pervasive psychological deficits. Medical and psychotherapeutic intervention must take into account the differences between these two groups for treatment to achieve maximal benefit.

Comparison of cognitive-behavioral and supportive-expressive therapy for bulimia nervosa.

OBJECTIVE: The authors compared the effectiveness of 4 months (18 sessions) of cognitive-behavioral and supportive-expressive therapy for bulimia. METHOD: Sixty patients obtained from clinical referrals to an eating disorders program who met modified DSM-III-R criteria for bulimia nervosa were randomly assigned to the two conditions. Treatments were delivered in an individual format, on an outpatient basis, by experienced therapists using treatment manuals. The primary outcome measures were self-induced vomiting, binge eating, and attitudes toward body weight and shape, which were assessed by self-report and structured interview. RESULTS: Fifty patients completed treatment, 25 in each condition. Both treatments led to significant improvements in specific eating disorder symptoms and in psychosocial disturbances. Supportive-expressive therapy was just as effective as cognitive-behavioral therapy in reducing binge eating. Where treatment differences were found, they favored cognitive-behavioral therapy. Cognitive-behavioral therapy was marginally superior in reducing the frequency of self-induced vomiting; 36% of the patients who received cognitive-behavioral therapy and 12% of those who received supportive-expressive therapy abstained from vomiting in the last month of treatment. Cognitive-behavioral therapy was significantly more effective in ameloriating disturbed attitudes toward eating and weight, depression, poor self-esteem, general psychological distress, and certain personality traits. CONCLUSIONS: These results moderately favor cognitive-behavioral therapy over supportive-expressive therapy for bulimia nervosa, but follow-up is required to determine the durability of outcome with both modalities. The findings must be interpreted with caution since the selected clinical sample in this study may not represent the bulimia nervosa population.