The side effects of dopamine receptor agonist drugs in Chinese prolactinoma patients: a cross sectional study.

BACKGROUND: Recently, side effects from Dopamine Receptor Agonist Drugs (DAs) in treating pituitary prolactinoma have raised widespread concern. This study explores the incidence and influencing factors of DAs-related side effects in Chinese prolactinoma patients. METHODS: A cross-sectional study was conducted. 51 prolactinoma patients treated with DAs, 12 prolactinoma or pituitary microadenoma patients without DAs treatment, and 33 healthy controls were included. The Barratt impulsivity scale-11, Patient Health Questionnaire 9, and the ICD screening questionnaire were all used to evaluate the psychological and physical side effects of DAs. Clinical data of all subjects were collected from their electronic medical records. RESULTS: The incidence of ICDs in the treated group, the untreated group, and control group was 9.8% (5/51), 16.7% (2/12), and 9.1% (3/33), respectively. In the treated group in particular, there were 1 patient (2%, 1/51), 2 patients (3.9%, 2/51), and 2 patients (3.9%, 2/51) with positive screening for punding, compulsive shopping, and hypersexuality, respectively. In terms of depression, the incidence of "minimal", "mild" and "moderate" depression in the treated group was 62.8% (32/51), 25.5% (13/51), and 5.9% (3/51), respectively. The incidence of physical symptoms was 51.0% (26/51) in the treated group and gastrointestinal symptoms were the most common symptoms (33.3%, 17/51). In addition, we found that the various parameters of DAs treatment had no association with the occurrence of physical symptoms or ICDs (all P > 0.05). CONCLUSIONS: Chinese prolactinoma patients treated with DAs had a lower incidence of ICDs (9.8%), while gastrointestinal symptoms were common. In this way, more attention should be paid to side effects, especially physical symptoms, in Chinese prolactinoma patients with DAs therapy during follow-up regardless of dose.

Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis.

INTRODUCTION: Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services. OBJECTIVES: We examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge. METHODS: We used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong. RESULTS: Among 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge. CONCLUSION: Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes. TRIAL REGISTRATION: Trial registration number:  https://doi.org/10.1186/ISRCTN83902145.

Documentation of shared decision making around primary prevention defibrillator implantations.

INTRODUCTION: Patients eligible for primary prevention implantable cardioverter-defibrillator (ICD) therapy are faced with a complex decision that needs a clear understanding of the risks and benefits of such an intervention. In this study, our goal was to explore the documentation of primary prevention ICD discussions in the electronic medical records (EMRs) of eligible patients. METHODS: In 1523 patients who met criteria for primary prevention ICD therapy between 2013 and 2015, we reviewed patient charts for ICD-related documentation: "mention" by physicians or "discussion" with patient/family. The attitude of the physician and the patient/family toward ICD therapy during discussions was categorized into negative, neutral, or positive preference. Patients were followed to the end-point of ICD implantation. RESULTS: Over a median follow-up of 442 days, 486 patients (32%) received an ICD. ICD was mentioned in the charts of 1105 (73%) patients, and a discussion with the patient/family about the risks and benefits of ICD was documented in 706 (46%) charts. On multivariable analyses, positive cardiologist (hazard ratio [HR]: 7.9, 95% confidence of intervals [CI]: 1.0-59.7, P < .05), electrophysiologist (HR: 7.7, 95% CI: 1.9-31.7, P < .001), and patient/family (HR: 9.9, 95% CI: 6.2-15.7, P < .001) preferences toward ICD therapy during the first documented ICD discussion were independently associated with ICD implantation. CONCLUSIONS: In a large cohort of patients eligible for primary prevention ICD therapy, a discussion with the patient/family about the risks and benefits of ICD implantation was documented in less than 50% of the charts. More consistent documentation of the shared decision making around ICD therapy is needed.

Mechanisms and management of inappropriate therapy in subcutaneous implantable cardioverter defibrillators.

Subcutaneous implantable cardioverter defibrillators (S-ICDs) provide reliable defibrillation and have enhanced supraventricular tachycardia discrimination and fewer infection rates compared with traditional transvenous systems. However, inappropriate shocks remain a frequent problem. Herein, we review the various mechanisms of these inappropriate therapies, some of which are unique to S-ICDs, and propose an algorithm for preventing recurrences. Proper screening of preimplants is essential to help minimize inappropriate therapies, but patients with hypertrophic cardiomyopathy, Brugada syndrome, and arrhythmogenic right ventricular cardiomyopathy are at particular risk and may require additional measures.

Early-Life Nutrition Is Associated Positively with Schooling and Labor Market Outcomes and Negatively with Marriage Rates at Age 20-25 Years: Evidence from the Andhra Pradesh Children and Parents Study (APCAPS) in India.

Background: India's Integrated Child Development Services (ICDS) is among the world's largest public nutritional programs, providing daily nutritional supplements and other public health and educational services to pregnant and nursing women, children aged <6 y, and adolescent girls. Objective: We estimated the long-term association between early-childhood ICDS nutrition and adult outcomes. Methods: We used follow-up data from a controlled nutritional trial conducted during 1987-1990 in 29 villages near the city of Hyderabad. In 15 intervention villages, a balanced protein-calorie supplement-made from locally available corn-soya ingredients and called upma-was offered to pregnant women and to children <6 y old. No supplement was offered in the 14 control villages. During 2010-2012, adults born during the trial were re-surveyed (n = 715 in the intervention arm and n = 645 in the control arm). We used probit regression and propensity score-matching methods to estimate the association between birth in an intervention village and rates of secondary and graduate education completion, marriage, and employment or enrollment in higher education of these adults. Results: Adults born in the intervention group during the trial, compared with the control group, were 9% (95% CI: 0.04, 0.14; P < 0.01) more likely to complete secondary school and 11% (95% CI: 0.06, 0.15; P < 0.01) more likely to complete graduate education, were 6% (95% CI: -0.11, -0.01; P < 0.05) less likely to be ever-married at age 20-25 y, and were 5% (95% CI: 0, 0.11; P < 0.05) more likely to be employed or enrolled in higher education. The estimated associations for graduate education completion and employment-study rates were greater for men, whereas the associations for secondary education and ever-married rates were greater for women. Conclusion: Exposure to nutritional supplement in utero or during the first 3 y of life was associated with improved adult educational and employment outcomes and lower marriage rates in India.

Remaining longevity and evidence of failure of cardiac implantable electrophysiology devices recovered from funeral homes.

BACKGROUND: Given the prohibitive cost of pacemakers and defibrillators for medically underserved patients in low-income countries, these devices are sometimes recovered from funeral homes for charitable reimplantation. Many devices are implanted near the end of the patients' lives, meaning that recovered devices from funeral homes have the potential for significant remaining longevity. METHODS: After sending letters asking funeral directors in the Philadelphia area to donate explanted pacemakers and defibrillators, 78 devices were recovered. Sixty-seven of these devices were successfully interrogated, and 64 devices reported estimates of remaining battery life in years. Twenty-one defibrillators were also interrogated for evidence of failure. RESULTS: Twenty-two percent of the 64 devices had greater than 4 years of longevity. Fourteen percent of the devices had between 1 and 4 years of longevity, and the remaining 64% had less than 1 year of remaining battery life. We found no evidence from 21 recovered defibrillators that the patient's cause of death was because of defibrillator failure. In almost half (10/21) of the defibrillators, however, the arrhythmia logs were nondecipherable given the entire log was replaced by episodes of signal noise likely occurring after death. CONCLUSIONS: A significant percentage of devices explanted in funeral homes have suitable remaining battery life for reuse. While no evidence of defibrillator device failure could be found, the analysis was limited by postmortem signal artifact, which may preclude accurate assessment of rates of failure in devices explanted postmortem.

Standardized programming to reduce the burden of inappropriate therapies in implantable cardioverter defibrillators - Single centre follow up results.

BACKGROUND: Current algorithms and device morphology templates have been proposed in current Implantable Cardioverter-Defibrillators (ICDs) to minimize inappropriate therapies (ITS), but this has not been completely successful. AIM: Assess the impact of a deliberate strategy of using an atrial lead implant with standardized parameters; based on all current ICD discriminators and technologies, on the burden of ITS. METHOD: A retrospective single-centre analysis of 250 patients with either dual chamber (DR) ICDs or biventricular ICDs (CRTDs) over a (41.9 ± 27.3) month period was performed. The incidence of ITS on all ICD and CRTD patients was chronicled after the implementation of standardized programming. RESULTS: 39 events of anti-tachycardial pacing (ATP) and/or shocks were identified in 20 patients (8% incidence rate among patients). The total number of individual therapies was 120, of which 34% were inappropriate ATP, and 36% were inappropriate shocks. 11 patients of the 250 patients received ITS (4.4%). Of the 20 patients, four had ICDs for primary prevention and 16 for a secondary prevention. All the episodes in the primary indication group were inappropriate, while seven patients (43%) of the secondary indication group experienced inappropriate therapies. CONCLUSIONS: The burden of ITS in the population of patients receiving ICDs was 4.4% in the presence of atrial leads. The proposed rationalized programming criteria seems an effective strategy to minimize the burden of inappropriate therapies and will require further validation.

Decision-Making Experiences of Patients with Implantable Cardioverter Defibrillators.

BACKGROUND: When patients are not adequately engaged in decision making, they may be at risk of decision regret. Our objective was to explore patients' perceptions of their decision-making experiences related to implantable cardioverter defibrillators (ICDs). METHODS: Cross-sectional, mailed survey of 412 patients who received an ICD without cardiac resynchronization therapy for any indication between 2006 and 2009. Patients were asked about decision participation and decision regret. RESULTS: A total of 295 patients with ICDs responded (72% response rate). Overall, 79% reported that they were as involved in the decision as they wanted. However, 28% reported that they were not told of the option of not getting an ICD and 37% did not remember being asked if they wanted an ICD. In total, 19% reported not wanting their ICD at the time of implantation. Those who did not want the ICD were younger (<65 years; 74% vs 43%, P < 0.001), had higher decision regret (31/100 vs 11/100, P < 0.001), and reported less participation in decision making (the doctor "totally" made the decision, 9% vs 3%; P < 0.001). CONCLUSIONS: A considerable number of ICD recipients recalled not wanting their ICD at the time of implantation. While these findings may be prone to recall bias, they likely identify opportunities to improve ICD decision making.

Atrioventricular Nodal Reentrant Tachycardia in Implantable Cardioverter Defibrillators: Diagnosis and Troubleshooting.

Inappropriate therapies are frequent in patients with implantable cardioverter defibrillators (ICDs) and are associated with adverse outcomes, including increased mortality. Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common reentrant supraventricular tachycardia (SVT) and a cause of inappropriate therapies in these patients. In the present article we review the problem of AVNRT in ICD patients with a focus on diagnosis and the available algorithms to improve arrhythmia discrimination and prevent inappropriate shocks.

Early Childhood Nutrition Is Positively Associated with Adolescent Educational Outcomes: Evidence from the Andhra Pradesh Child and Parents Study (APCAPS).

BACKGROUND: India's Integrated Child Development Scheme, which provides supplementary nutrition and other public health services to >91 million women and children aged <6 y, is the largest program of its kind in the world. OBJECTIVE: We estimated the long-term associations of maternal and early childhood nutrition provided under the Integrated Child Development Scheme with educational outcomes when the children became adolescents. METHODS: We used longitudinal data from a controlled nutrition trial conducted near the city of Hyderabad, India. From 1987 to 1990, a balanced protein-energy supplement (corn-soya meal, called upma) was offered to pregnant women and children aged <6 y in 15 intervention villages, whereas no supplementation was offered in 14 control villages. Both groups had equal access to other public programs such as immunization and anemia control in pregnancy. Children born during the original trial period were resurveyed (654 intervention and 511 control group children) in 2003-2005. We used propensity score matching methods to correct for estimation bias in our regression models to assess the associations of supplementary nutrition with school enrollment, schooling grades completed, and academic test performance of these adolescents. RESULTS: Children born in intervention villages were 7.8% (95% CI: 0.1%, 15.4%; P < 0.05) more likely to be enrolled in school and completed 0.84 (95% CI: 0.28, 1.39; P < 0.005) more schooling grades than children born in control villages. We found no association between supplementary nutrition and academic performance, as measured by school test scores. CONCLUSION: Offering a nutritional supplement to pregnant women and children <6 y of age during the Hyderabad Nutrition Trial was associated with improved school enrollment and completion of more schooling grades when the children became adolescents.

Fortification of foods with vitamin D in India: strategies targeted at children.

Vitamin D deficiency is endemic in India, despite abundant sunshine, due to several socioeconomic and cultural constraints. Fortification of staple foods with vitamin D is a viable population-based strategy for the general population in India. These strategies are discussed in the review article entitled, "Fortification of Foods With Vitamin D in India" [1]. The quantity of foods consumed by children is much smaller compared to adults. Therefore, children need energy-dense and micronutrient-dense foods to meet their daily nutritional requirements. Targeted food fortification programs are needed to meet the special needs of children. This review explores potential strategies that could be used for fortification of foods with vitamin D for children in India. Sattu has the potential to be a valuable vehicle for vitamin D fortification in India. The salient characteristics and merits of sattu as an ideal food to be fortified with micronutrients, especially vitamin D, are reviewed here. Key teaching points: • Fortification of foods with vitamin D, specifically targeted towards the nutritional requirements of infants and children, is a viable strategy in the Indian scenario. •Government programs targeting the nutritional needs of children in India, especially via midday meal programs in schools, should incorporate indigenous ready-to-eat foods fortified with micronutrients including vitamin D. These foods would need to have longer shelf life, require minimal preparation, and have economic and technological feasibility. • Sattu, a protein rich Indian fast food, comprised of roasted flour made from cereals and legumes, has immense potential to serve as an economically and technologically feasible fortification vehicle for vitamin D fortification strategies.

An assessment of facilities and services at Anganwadi centers under the Integrated Child Development Service scheme in Northeast District of Delhi, India.

OBJECTIVE: The current study was aimed to assess the facilities and services being provided at the Anganwadi Centres (AWCs) by the Anganwadi workers with regards to the norms laid down by Integrated Child development Service (ICDS) scheme, with special emphasis on the children of 0-6 years of age. DESIGN: Cross-sectional study. SETTING: A resettlement colony of North-West District of Delhi, having a population of hundred thousand. PARTICIPANTS: A total of 41 AWCs were present in the study area and were included in our study. The Anganwadi workers at these AWCs were interviewed. MAIN OUTCOME MEASURES: The outcome measures were the facilities present at the AWCs and knowledge of Anganwadi workers regarding the services to be provided and revised supplementary nutrition norms laid down by ICDS. RESULTS: The AWCs in the area were covered under three projects namely Project A, B and C consisting of 18, 9 and 14 AWCs, respectively. The mean room size for all the AWCs was 108.97 ± 62.18 square feet. A weighing machine was present in 29 (70.7%) of the AWCs. Growth charts for growth monitoring of children were present in 28 (68.3%) of AWCs. A drug kit was not present in 14 (34.1%) of the 41 AWCs. The mean number of children of 0-3 years enrolled per AWC was 45.78 ± 14.07. However, the mean number of children present at the time of the visit at the AWCs was 6.24 ± 5.39. Knowledge of Anganwadi workers regarding revised norms for calorie and protein for beneficiaries was found to be poor. CONCLUSION: This study showed a lack of facilities at the AWCs and poor knowledge of Anganwadi workers. Thus a regular training and supportive supervision of the Anganwadi workers is recommended along with the availability of adequate facilities and infrastructures.

Implantable cardioverter defibrillators (ICDs) in octogenarians.

Octogenarians are a growing section of the community. Implantable cardioverter defibrillator (ICD) implantations and replacements in this age group are becoming frequent. There are no randomised control trials or large observational studies of octogenarians and indications for ICD implantations are extrapolated from published primary and secondary prevention trials, where the age group has been in its sixties. About 75% of ICDs are implanted for primary prevention guided by patient's ejection fraction. Most patients who have ICDs do not have a clear idea about the function and limitation of ICDs. Patient education about ICDs is an important aspect which deserves consideration, particularly in this age group. The use of ICDs in octogenarians should be individualised and carefully scrutinised. It should take into consideration overall health status, symptom severity, co-morbidities and intermediate and long-term prognosis. There should be detailed discussion about patient preference and expectations. Physicians must provide a realistic appraisal of potential benefits and risks and address device management issues at end of life. This discussion should also take place when ICD replacement is considered.

Increasing Knowledge about Implantable Cardioverter Defibrillators at the End of Life, an Effective Approach for Hospice Workers to Improve Patient Care.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) decrease mortality in high-risk patients but can also cause distressing shocks near death. Patients who lack knowledge about their ICDs are more likely to have an active device at the end of life. Many hospice workers lack sufficient knowledge to educate patients about ICDs. MEASURES: An ICD educational video created for use in a diverse, underserved patient population was shown to hospice workers from two large community hospices and attendees of a regional conference. A validated 10 question survey was given to participants before and after the video. OUTCOMES: Significant improvement in ICD knowledge scores was seen in all participants (W = 3119.5, P < 0.0001). While doctors and nurses showed higher pretest knowledge, post-test knowledge scores equalized across all participants. CONCLUSIONS/LESSONS LEARNED: An ICD patient educational video designed for a diverse, underserved patient population effectively improved ICD knowledge to a uniform excellent level for a broad range of hospice workers.

Impact of atrial fibrillation on 1-year outcome in patients with implantable cardioverter defibrillator or cardiac resynchronization therapy with defibrillator: results from the German DEVICE Registry.

Background: Atrial fibrillation (AF) is a cardiac arrhythmia frequently documented in patients requiring implantable cardioverter defibrillators (ICDs) and/or cardiac resynchronization therapy with defibrillator (CRT-D). Patients with diagnosed AF at the point of ICD or CRT-D implantation may have an impaired follow-up outcome. Methods: The German DEVICE I-II registry is a nationwide prospective multicentre database of patients implanted with ICD and CRT-D with clinical follow-up data. We analysed a 1-year follow up of implanted patients with AF and with sinus rhythm (SR). Results: A total of 4,929 ICD/CRT patients are included in the present analysis: 946 (19.2%) were in AF and 3,983 (80.8%) were SR at time of device implantation. AF patients had a significantly more comorbid profile including older age {72 [interquartile range (IQR), 66-77] vs. 66 (IQR, 56-73) years; P<0.001}, and higher rate of patients with left ventricular ejection fraction <30% (68.2% vs. 61.0%; P<0.001), peripheral artery disease (4.5% vs. 2.7%; P=0.002), diabetes (33.6% vs. 25.5%; P<0.001), hypertension (58.4% vs. 51.1%; P<0.001) and renal failure (22.6% vs. 15.3%; P<0.001). The intra-hospital complication rate was 4.3% in the AF and 3.6% in the SR group (P=0.38). In 1-year follow-up AF patients experienced a significantly higher rate of defibrillator shocks (25% vs. 15.3%; P<0.001). One-year estimated mortality was 10.8% in the AF and 5.9% in the SR group (P<0.001), while estimated 1-year major adverse cardiac and cerebrovascular events (MACCE) rate was 11.2% vs. 7.0% (P<0.001). The effects of AF on electrical shocks and mortality persisted after adjusting for age, sex, advanced New York Heart Association (NYHA) class, severely impaired left ventricular ejection fraction (LVEF), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), chronic renal failure (CRF), QRS duration, and type of indication for electronic device implantation. Conclusions: Our clinical data on an extended cohort of contemporary patients confirm the significant impact of AF, and its associated comorbidities, upon mortality and major adverse events after implantation of ICD/CRT.

Innovative P-wave detection for discrimination between ventricular and supraventricular tachycardia in single-chamber ICDs: is the P-wave invisible during tachycardia?

AIMS: Differentiation between supraventricular tachycardia (SVT) and ventricular tachycardia (VT) remains a substantial clinical challenge in patients with single-chamber implantable cardioverter-defibrillators (ICDs) due to absence of visible P waves. Innovative optimization of intrathoracic electrogram (EGM) configuration will facilitate P-wave detection and rhythm differentiation during tachycardia. METHODS AND RESULTS: Innovative optimization of EGM configuration was originally performed to improve patient care. In this retrospective cohort study, we examined our database for records of 140 consecutive patients undergoing single-chamber ICD implantation. During the follow-ups of 61 included patients with optimized EGM configuration, 27 patients were identified to have VT and/or SVT. EGMs in the Can (generator) to superior vena cava (Can-SVC) configuration were compared with those conventionally from the Can to right ventricular coil (Can-RV coil) source in the same patients. In Can-SVC EGMs, the ratio of P/QRS amplitude was 14-fold higher (0.57 ± 0.08 vs. 0.04 ± 0.00, P < 0.001) compared with those in Can-RV coil EGMs during sinus rhythm. With Can-SVC configuration, the odds of atrioventricular dissociation detection in patients with VT was increased 15-fold (61.9% vs. 9.5% with Can-RV coil; odds ratio, 15.4; 95% confidence interval, 2.8 to 84.7; P = 0.0009). In patients with SVT, P-waves or retrograde P-waves were markedly more identifiable in Can-SVC configuration compared with Can-RV coil (odds ratio, 40; 95% confidence interval, 3.6 to 447.1; P = 0.0010). CONCLUSION: P-wave recognition by optimizing EGM configuration provides a novel diagnostic tool for differentiation between VT and SVT in single-chamber ICDs. A potential discrimination algorithm would provide a cost-effective approach to improving the qualitative outcomes.

Cardiac pacing and defibrillation in children and young adults.

The population of children and young adults requiring a cardiac pacing device has been consistently increasing. The current generation of devices are small with a longer battery life, programming capabilities that can cater to the demands of the young patients and ability to treat brady and tachyarrhythmias as well as heart failure. This has increased the scope and clinical indications of using these devices. As patients with congenital heart disease (CHD) comprise majority of these patients requiring devices, the knowledge of indications, pacing leads and devices, anatomical variations and the technical skills required are different than that required in the adult population. In this review we attempt to discuss these specific points in detail to improve the understanding of cardiac pacing in children and young adults.

Radiofrequency catheter ablation of idiopathic right ventricular outflow tract arrhythmias.

Idiopathic ventricular arrhythmias (VA) consist of various subtypes of VA that occur in the absence of clinically apparent structural heart disease. Affected patients account for approximately 10% of all patients referred for evaluation of ventricular tachycardia (VT). Arrhythmias arising from the outflow tract (OT) are the most common subtype of idiopathic VA and more than 70-80% of idiopathic VTs or premature ventricular contractions (PVCs) originate from the right ventricular (RV) OT. Idiopathic OT arrhythmias are thought to be caused by adenosine-sensitive, cyclic adenosine monophosphate (cAMP) mediated triggered activity and, in general, manifest at a relatively early age. Usually they present as salvos of paroxysmal ventricular ectopic beats and are rarely life-threatening. When highly symptomatic and refractory to antiarrhythmic therapy or causative for ventricular dysfunction, ablation is a recommended treatment with a high success rate and a low risk of complications.

An Ethical Analysis of Withdrawal of Therapy in Patients with Implantable Cardiac Electronic Devices: Application of a Novel Decision Algorithm.

Patients with cardiovascular implantable electronic devices (CIEDs), which include pacemakers and implantable cardioverter-defibrillators (ICDs), may request deactivation of their devices as they approach the end of life. The Heart Rhythm Society (2010) has stated that "ethically, and legally, there are no differences between refusing CIED therapy and requesting withdrawal of CIED therapy." On the basis of the principle that there is no ethical distinction between withholding and withdrawing treatment, this professional organization has suggested that both the antibradycardia and antitachycardia features of these devices may be disabled at the patient's request. We argue that disabling ICD shocks is analogs to a do-not-resuscitate order and is ethically permissible whereas withdrawing pacing from a pacemaker-dependent patient is an act of intentionally hastening death and not morally licit.

A study to compare the performance of anganwadi workers in owned and rented anganwadi centers in a district of the western part of India.

Introduction: The Integrated Child Development Services (ICDS) scheme is one of the flagship programs, and under this, various activities like non-formal education on one hand and breaking the vicious cycle of malnutrition, morbidity, and mortality on the other hand are carried out by anganwadi worker (AWW). The aim of this study is to assess the AWWs performance and beneficiary participation in respect to the ICDS scheme. Methodology: This is a community-based, cross-sectional study done in two stages using a simple random sampling technique. Ahmedabad Municipal Corporation (AMC) area is divided into 10 parts called ghatak, and out of these 10 ghataks, 6 were chosen in the first stage, and in the second stage, 12 anganwadi centers were selected from these 6 selected ghataks using simple random sampling. Result: In this study, 58.3% of anganwadi workers were graduates. While talking about work related to "Home Visit" and "Immunization Sessions," there was no statistically significant difference between owned and rented anganwadi center noted. While in "Nutrition & health education"-related work, there was a statistically significant difference between owned and rented anganwadi centers observed. Accuracy of weighing, plotting, and interpretation skill was more than 90% found in both the rented and owned anganwadi center. An almost similar level of nutritional status was observed in both owned and rented centers. Conclusion: In terms of performance and participation, there was not much difference between corporation own and rented anganwadi centers, although there were shared concerns related to frequent changes of place of rented anganwadi centers affecting the participation of beneficiaries.