Periprocedural Management and Multidisciplinary Care Pathways for Patients With Cardiac Implantable Electronic Devices: A Scientific Statement From the American Heart Association.

The rapid technological advancements in cardiac implantable electronic devices such as pacemakers, implantable cardioverter defibrillators, and loop recorders, coupled with a rise in the number of patients with these devices, necessitate an updated clinical framework for periprocedural management. The introduction of leadless pacemakers, subcutaneous and extravascular defibrillators, and novel device communication protocols underscores the imperative for clinical updates. This scientific statement provides an inclusive framework for the periprocedural management of patients with these devices, encompassing the planning phase, procedure, and subsequent care coordinated with the primary device managing clinic. Expert contributions from anesthesiologists, cardiac electrophysiologists, and cardiac nurses are consolidated to appraise current evidence, offer patient and health system management strategies, and highlight key areas for future research. The statement, pertinent to a wide range of health care professionals, underscores the importance of quality care pathways for patient safety, optimal device function, and minimization of hemodynamic disturbances or arrhythmias during procedures. Our primary objective is to deliver quality care to the expanding patient cohort with cardiac implanted electronic devices, offering direction in the era of evolving technologies and laying a foundation for sustained education and practice enhancement.

Long-term complications of COVID-19.

SARS-CoV-2 has rapidly spread across the globe and infected hundreds of millions of people worldwide. As our experience with this virus continues to grow, our understanding of both short-term and long-term complications of infection with SARS-CoV-2 continues to grow as well. Just as there is heterogeneity in the acute infectious phase, there is heterogeneity in the long-term complications seen following COVID-19 illness. The purpose of this review article is to present the current literature with regards to the epidemiology, pathophysiology, and proposed management algorithms for the various long-term sequelae that have been observed in each organ system following infection with SARS-CoV-2. We will also consider future directions, with regards to newer variants of the virus and their potential impact on the long-term complications observed.

Diagnosis and management of atherosclerotic cardiovascular disease in chronic kidney disease: a review.

Patients with chronic kidney disease (CKD) have a high prevalence of atherosclerotic cardiovascular disease, likely reflecting the presence of traditional risk factors. A greater distinguishing feature of atherosclerotic cardiovascular disease in CKD is the severity of the disease, which is reflective of an increase in inflammatory mediators and vascular calcification secondary to hyperparathyroidism of renal origin that are unique to patients with CKD. Additional components of atherosclerotic cardiovascular disease that are prominent in patients with CKD include microvascular disease and myocardial fibrosis. Therapeutic interventions that minimize cardiovascular events related to atherosclerotic cardiovascular disease in patients with CKD, as determined by well-designed clinical trials, are limited to statins. Data are lacking regarding other available therapeutic measures primarily due to exclusion of patients with CKD from major trials studying cardiovascular disease. Data from well-designed randomized controlled trials are needed to guide clinicians who care for this high-risk population in the management of atherosclerotic cardiovascular disease to improve clinical outcomes.

Mineral licks: motivational factors for visitation and accompanying disease risk at communal use sites of elk and deer.

Free-ranging cervids acquire most of their essential minerals through forage consumption, though occasionally seek other sources to account for seasonal mineral deficiencies. Mineral sources occur as natural geological deposits (i.e., licks) or as anthropogenic mineral supplements. In both scenarios, these sources commonly serve as focal sites for visitation. We monitored 11 licks in Rocky Mountain National Park, north-central Colorado, using trail cameras to quantify daily visitation indices (DVI) and soil consumption indices (SCI) for Rocky Mountain elk (Cervus elaphus) and mule deer (Odocoileus hemionus) during summer 2006 and documented elk, mule deer, and moose (Alces alces) visiting licks. Additionally, soil samples were collected, and mineral concentrations were compared to discern levels that explain rates of visitation. Relationships between response variables; DVI and SCI, and explanatory variables; elevation class, moisture class, period of study, and concentrations of minerals were examined. We found that DVI and SCI were greatest at two wet, low-elevation licks exhibiting relatively high concentrations of manganese and sodium. Because cervids are known to seek Na from soils, we suggest our observed association of Mn with DVI and SCI was a likely consequence of deer and elk seeking supplemental dietary Na. Additionally, highly utilized licks such as these provide an area of concentrated cervid occupation and interaction, thus increasing risk for environmental transmission of infectious pathogens such as chronic wasting disease, which has been shown to be shed in the saliva, urine, and feces of infected cervids.

Use of rhodamine B as a biomarker in a simulated oral vaccine deployment against bovine tuberculosis in white-tailed deer.

Introduction: Free-ranging white-tailed deer (Odocoileus virginianus) in northeastern lower Michigan, (United States) are a self-sustaining reservoir for bovine tuberculosis (bTB). Farm mitigation practices, baiting bans, and antlerless deer harvests have been ineffective in eliminating bTB in white-tailed deer and risks to cattle. The apparent prevalence has remained relatively constant in deer, prompting interest among wildlife researchers, managers, and veterinarians for an effective means of vaccinating deer against bTB. The commonly used human vaccine for bTB, Bacillus Calmette Guerin (BCG), is the primary candidate with oral delivery being the logical means for vaccinating deer. Materials and methods: We developed vaccine delivery units and incorporated the biomarker Rhodamine B before delivering them to deer to assess the level of coverage achievable. Following deployment of Rhodamine B-laden vaccine delivery units on 17 agricultural study sites in Alpena County, MI in Mar/Apr 2016, we sampled deer to detect evidence of Rhodamine B consumption. Results and discussion: We collected a total of 116 deer and sampled them for vibrissae/rumen marking and found 66.3% (n = 77) of the deer collected exhibited evidence of vaccine delivery unit consumption. Understanding the level of coverage we achieved with oral delivery of a biomarker in vaccine delivery units to deer enables natural resource professionals to forecast expectations of a next step toward further minimizing bTB in deer.

Feasibility and clinical implementation of MRI-guided surface brachytherapy.

Purpose: Best practices for high-dose-rate surface applicator brachytherapy treatment (SABT) have long relied on computed tomography (CT)-based imaging to visualize diseased sites for treatment planning. Compared with magnetic resonance (MR)-based imaging, CT provides insufficient soft tissue contrast. This work described the feasibility of clinical implementation of MR-based imaging in SABT planning to provide individualized treatment optimization. Material and methods: A 3D-printed phantom was used to fit Freiberg flap-style (Elekta, The Netherlands) applicator. Images were taken using an optimized pointwise encoding time reduction with radial acquisition (PETRA) MR sequence for catheter visualization, and a helical CT scan to generate parallel treatment plans. This clinical study included three patients undergoing SABT for Dupuytren's contracture/palmar fascial fibromatosis imaged with the same modalities.SABT planning was performed in Oncentra Brachy (Elekta Brachytherapy, The Netherlands) treatment planning software. A geometric analysis was conducted by comparing CT-based digitization with MR-based digitization. CT and MR dwell positions underwent a rigid registration, and average Euclidean distances between dwell positions were calculated. A dosimetric comparison was performed, including point-based dose difference calculations and volumetric segmentations with Dice similarity coefficient (DSC) calculations. Results: Euclidean distances between dwell positions from CT-based and MR-based plans were on average 0.68 ±0.05 mm and 1.35 ±0.17 mm for the phantom and patients, respectively. The point dose difference calculations were on average 0.92% for the phantom and 1.98% for the patients. The D95 and D90 DSC calculations were both 97.9% for the phantom, and on average 93.6% and 94.2%, respectively, for the patients. Conclusions: The sub-millimeter accuracy of dwell positions and high DSC's (> 0.95) of the phantom demonstrated that digitization was clinically acceptable, and accurate treatment plans were produced using MR-only imaging. This novel approach, MRI-guided SABT, will lead to individualized prescriptions for potentially improved patient outcomes.

A study combining microbubble-mediated focused ultrasound and radiation therapy in the healthy rat brain and a F98 glioma model.

Focused Ultrasound (FUS) has been shown to sensitize tumors outside the brain to Radiotherapy (RT) through increased ceramide-mediated apoptosis. This study investigated the effects of FUS + RT in healthy rodent brains and F98 gliomas. Tumors, or striata in healthy rats, were targeted with microbubble-mediated, pulsed FUS (220 kHz, 102-444 kPa), followed by RT (4, 8, 15 Gy). FUS + RT (8, 15 Gy) resulted in ablative lesions, not observed with FUS or RT only, in healthy tissue. Lesions were visible using Magnetic Resonance Imaging (MRI) within 72 h and persisted until 21 days post-treatment, indicating potential applications in ablative neurosurgery. In F98 tumors, at 8 and 15 Gy, where RT only had significant effects, FUS + RT offered limited improvements. At 4 Gy, where RT had limited effects compared with untreated controls, FUS + RT reduced tumor volumes observed on MRI by 45-57%. However, survival benefits were minimal (controls: 27 days, RT: 27 days, FUS + RT: 28 days). Histological analyses of tumors 72 h after FUS + RT (4 Gy) showed 93% and 396% increases in apoptosis, and 320% and 336% increases in vessel-associated ceramide, compared to FUS and RT only. Preliminary evidence shows that FUS + RT may improve treatment of glioma, but additional studies are required to optimize effect size.

Estimating body mass of wild pigs (Sus scrofa) using body morphometrics.

Wild pigs (Sus scrofa) are invading many areas globally and impacting biodiversity and economies in their non-native range. Thus, wild pigs are often targeted for eradication efforts. Age- and sex-specific body measurements are important for informing these eradication efforts because they reflect body condition, resource availability, and fecundity, which are common indicators of population trajectory. However, body mass is often difficult to collect, especially on large individuals that require specialized equipment or multiple people to weigh. Measurements that can be rapidly taken by a single land or wildlife manager on any size wild pig without aid from specialized equipment would be beneficial if they accurately infer wild pig body mass. Our goals were to assess whether morphometric measurements could accurately predict wild pig body mass, and to provide tools to directly input these measures and estimate wild pig body mass. Using linear models, we quantified the relationship between body mass and morphometric measurements (i.e., body length, chest girth, ear length, eye to snout length, hindfoot length, shoulder length, and tail length) from a subset (n = 102) of wild pigs culled at the Mississippi Alluvial Valley, Mississippi, USA. We evaluated separate models for each individual morphometric measurement. We then used the model coefficients to develop equations to predict wild pig body mass. We validated these equations predicting body mass of 1592 individuals collected across eight areas in Australia, Guam, and the USA for cross-validation. Each developed equation remained accurate when cross-validated across regions. Body length, chest girth, and shoulder length were the morphometrics that best predicted wild pig body mass. Our analyses indicated it is possible to use the presented equations to infer wild pig body mass from simple metrics.

Outcomes of conduction system pacing for cardiac resynchronization therapy in patients with heart failure: A multicenter experience.

BACKGROUND: Whether conduction system pacing (CSP) is an alternative option for cardiac resynchronization therapy (CRT) in patients with heart failure remains an area of active investigation. OBJECTIVE: The purpose of this study was to assess the echocardiographic and clinical outcomes of CSP compared to biventricular pacing (BiVP). METHODS: This multicenter retrospective study included patients who fulfilled CRT indications and received CSP. Patients with CSP were matched using propensity score matching and compared in a 1:1 ratio to patients who received BiVP. Echocardiographic and clinical outcomes were assessed. Response to CRT was defined as an absolute increase of ≥5% in left ventricular ejection fraction (LVEF) at 6 months post-CRT. RESULTS: A total of 238 patients were included. Mean age was 69.8 ± 12.5 years, and 66 (27.7%) were female. Sixty-nine patients (29%) had His-bundle pacing, 50 (21%) had left bundle branch area pacing, and 119 (50%) had BiVP. Mean follow-up duration in the CSP and BiVP groups was 269 ± 202 days and 304 ± 262 days, respectively (P = .293). The proportion of CRT responders was greater in the CSP group than in the BiVP group (74% vs 60%, respectively; P = .042). On Kaplan-Meier analysis, there was no statistically significant difference in the time to first heart failure hospitalization (log-rank P = .78) and overall survival (log-rank P = .68) between the CSP and BiVP groups. CONCLUSION: In patients with heart failure and reduced ejection fraction, CSP resulted in greater improvement in LVEF compared to BiVP. Large-scale randomized trials are needed to validate these outcomes and further investigate the different options available for CSP.

Tuning ultrasmall theranostic nanoparticles for MRI contrast and radiation dose amplification.

Background: The introduction of magnetic resonance (MR)-guided radiation treatment planning has opened a new space for theranostic nanoparticles to reduce acute toxicity while improving local control. In this work, second-generation AGuIX® nanoparticles (AGuIX-Bi) are synthesized and validated. AGuIX-Bi are shown to maintain MR positive contrast while further amplifying the radiation dose by the replacement of some Gd3+ cations with higher Z Bi3+. These next-generation nanoparticles are based on the AGuIX® platform, which is currently being evaluated in multiple Phase II clinical trials in combination with radiotherapy. Methods: In this clinically scalable methodology, AGuIX® is used as an initial chelation platform to exchange Gd3+ for Bi3+. AGuIX-Bi nanoparticles are synthesized with three ratios of Gd/Bi, each maintaining MR contrast while further amplifying radiation dose relative to Bi3+. Safety, efficacy, and theranostic potential of the nanoparticles were evaluated in vitro and in vivo in a human non-small cell lung cancer model. Results: We demonstrated that increasing Bi3+ in the nanoparticles is associated with more DNA damage and improves in vivo efficacy with a statistically significant delay in tumor growth and 33% complete regression for the largest Bi/Gd ratio tested. The addition of Bi3+ by our synthetic method leads to nanoparticles that present slightly altered pharmacokinetics and lengthening of the period of high tumor accumulation with no observed evidence of toxicity. Conclusions: We confirmed the safety and enhanced efficacy of AGuIX-Bi with radiation therapy at the selected ratio of 30Gd/70Bi. These results provide crucial evidence towards patient translation.

Arrhythmias in the COVID-19 patient.

Coronavirus disease 2019 (COVID-19) has encompassed the globe since it was first observed just under 2 years ago. Although the disease is predominantly a respiratory illness, there have been observed complications throughout the various organ systems. Namely, cardiovascular complications, and, more specifically, arrhythmic complications have been described throughout the pandemic in patients with COVID-19. Management of atrial arrhythmias, ventricular arrhythmias, and bradyarrhythmias in patients with COVID-19 infection has been largely guided by our prior experience in the management of these arrhythmias in similar patient populations without infection. However, this review aims to highlight the specific considerations as they pertain to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the various arrhythmic manifestations observed with this disease.

Practical Guidelines on Implementing Hypofractionated Radiotherapy for Prostate Cancer in Africa.

Among a growing body of literature in global oncology, several articles project increased cost savings and radiotherapy access by adopting hypofractionated radiotherapy (HFRT) in low- and middle-income countries (LMICs) like those in Africa. Clinical trials in Europe and the USA have demonstrated HFRT to be non-inferior to conventional radiotherapy for eligible patients with several cancers, including prostate cancer. This could be a highly recommended option to battle a severely large and growing cancer burden in resource-limited regions. However, a level of implementation research may be needed in limited resource-settings like in Africa. In this article, we present a list of evidence-based recommendations to practice HFRT on eligible prostate cancer patients. As literature on HFRT is still developing, these guidelines were compiled from review of several clinical trials and professionally accredited material with minimal resource requirements in mind. HFRT guidelines presented here include patient eligibility, prescription dose schedules, treatment planning and delivery techniques, and quality assurance procedures. The article provides recommendations for both moderately hypofractionated (2.4-3.4Gy per fraction) and ultrahypofractionated (5Gy or more per fraction) radiation therapy when administered by 3D-Conformal Radiotherapy, Intensity Modulated Radiation Therapy, or Image-Guided Radiotherapy. In each case radiation oncology health professionals must make the ultimate judgment to ensure safety as more LMIC centers adopt HFRT to combat the growing scourge of cancer.

Detection of two dissimilar chronic wasting disease isolates in two captive Rocky Mountain elk (Cervus canadensis) herds.

Chronic wasting disease (CWD) continues to spread in both wild and captive cervid herds in North America and has now been identified in wild reindeer and moose in Norway, Finland and Sweden. There is limited knowledge about the variety and characteristics of isolates or strains of CWD that exist in the landscape and their implications on wild and captive cervid herds. In this study, we evaluated brain samples from two captive elk herds that had differing prevalence, history and timelines of CWD incidence. Site 1 had a 16-year history of CWD with a consistently low prevalence between 5% and 10%. Twelve of fourteen naïve animals placed on the site remained CWD negative after 5 years of residence. Site 2 herd had a nearly 40-year known history of CWD with long-term environmental accrual of prion leading to nearly 100% of naïve animals developing clinical CWD within two to 12 years. Obex samples of several elk from each site were compared for CWD prion strain deposition, genotype in prion protein gene codon 132, and conformational stability of CWD prions. CWD prions in the obex from site 2 had a lower conformational stability than those from site 1, which was independent of prnp genotype at codon 132. These findings suggest the existence of different CWD isolates between the two sites and suggest potential differential disease attack rates for different CWD strains.

Deterring non-target birds from toxic bait sites for wild pigs.

Toxic baiting of wild pigs (Sus scrofa) is a potential new tool for population control and damage reduction in the US. Field trials testing a prototype toxic bait (HOGGONE 2 containing 5% sodium nitrite [SN]), though, revealed that wild pigs spilled small particles of toxic bait outside of bait stations which subsequently created hazards for non-target species that consumed those particles, primarily passerine birds. To deter non-target birds from consuming particles of spilled bait, we tested four deterrents at mock bait sites (i.e., baited with bird seed) in north-central Colorado, USA during April-May 2020. We found a programable, inflatable deterrent device (scare dancer) reduced bird visitation by an average of 96%. Then, we evaluated the deterrent devices at SN-toxic bait sites in north-central Texas, USA during July 2020, where the devices were activated the morning following deployment of SN-toxic bait. Overall, we found 139 dead wild pigs at 10 bait sites following one night of toxic baiting, which represented an average of 91% reduction in wild pigs visiting bait sites. We found that deterrent devices were 100% effective at deterring birds from toxic bait sites. We found two dead non-target mice at bait sites without deterrent devices. We noted that deploying toxic bait in mid-summer rather than late-winter/early-spring reduced hazards to migrating birds because they were not present in our study area during July. We recommend using deterrent devices (i.e., novel, programmable, battery operated, continuous and erratic movement, and snapping sounds) to reduce hazards to non-target birds at SN-toxic bait sites. We further recommend deploying SN-toxic bait during seasons when migrating birds are not as abundant until further research demonstrates minimal risks to migrating birds.

Reorganizing a Medicine Residency Program in Response to the COVID-19 Pandemic in New York.

The COVID-19 pandemic has been particularly severe in New York City, resulting in a rapid influx of patients into New York-Presbyterian Hospital/Columbia University Irving Medical Center. The challenges precipitated by this pandemic have required urgent changes to existing models of care. Internal medicine residents are at the forefront of caring for patients with COVID-19, including the critically ill. This article describes the exigent restructuring of the New York-Presbyterian Hospital/Columbia University Internal Medicine Residency Program. Patient care and educational models were fundamentally reconceptualized, which required a transition away from traditional hierarchical team structures and a significant expansion in the program's capacity and flexibility to care for large numbers of patients with disproportionately high levels of critical illness. These changes were made while the residency program maintained the priorities of patient care and safety, resident safety and well-being, open communication, and education. The process of adapting the residency program to the demands of the pandemic was iterative given the unprecedented nature of this crisis. The goal of this article is to share the experiences and lessons learned from this crisis, communicate the solutions that were designed, and inform others who may be facing the prospect of creating similar disaster response measures.

TpTe and TpTe/QT: novel markers to predict sudden cardiac death in ESRD?

INTRODUCTION: Reliable markers to predict sudden cardiac death (SCD) in patients with end stage renal disease (ESRD) remain elusive, but electrocardiogram (ECG) parameters may help stratify patients. Given their roles as markers for myocardial dispersion especially in high risk populations such as those with Brugada syndrome, we hypothesized that the Tpeak to Tend (TpTe) interval and TpTe/QT are independent risk factors for SCD in ESRD. METHODS: Retrospective chart review was conducted on a cohort of patients with ESRD starting hemodialysis. Patients were US veterans who utilized the Veterans Affairs medical centers for health care. Average age of all participants was 66 years and the majority were males, consistent with a US veteran population. ECGs that were performed within 18 months of dialysis initiation were manually evaluated for TpTe and TpTe/QT. The primary outcomes were SCD and all-cause mortality, and these were assessed up to 5 years following dialysis initiation. RESULTS: After exclusion criteria, 205 patients were identified, of whom 94 had a prolonged TpTe, and 61 had a prolonged TpTe/QT interval (not mutually exclusive). Overall mortality was 70.2% at 5 years and SCD was 15.2%. No significant difference was observed in the primary outcomes when examining TpTe (SCD: prolonged 16.0% vs. normal 14.4%, p=0.73; all-cause mortality: prolonged 55.3% vs. normal 47.7%, p=0.43). Likewise, no significant difference was found for TpTe/QT (SCD: prolonged 15.4% vs. normal 15.0%, p=0.51; all-cause mortality: prolonged 80.7% vs. normal 66.7%, p=0.39). CONCLUSIONS: In ESRD patients on hemodialysis, prolonged TpTe or TpTe/QT was not associated with a significant increase in SCD or all-cause mortality.

Exposure of a population of invasive wild pigs to simulated toxic bait containing biomarker: implications for population reduction.

BACKGROUND: An international effort to develop an acute and humane toxic bait for invasive wild pigs (Sus scrofa) is underway to curtail their expansion. We evaluated the ability to expose a population of wild pigs to a simulated toxic bait (i.e., placebo bait containing a biomarker, rhodamine B, in lieu of the toxic ingredient) to gain insight on potential population reduction. We used 28 GPS-collars and sampled 428 wild pigs to examine their vibrissae for evidence of consuming the bait. RESULTS: We estimated that 91% of wild pigs within 0.75 km of bait sites (total area = 16.8 km2 ) consumed the simulated toxic bait, exposing them to possible lethal effects. Bait sites spaced 0.75-1.5 km apart achieved optimal delivery of the bait, but wild pigs ranging ≥ 3 km away were susceptible. Use of wild pig-specific bait stations resulted in no non-target species directly accessing the bait. CONCLUSION: Results demonstrate the potential for exposing a large proportion of wild pigs to a toxic bait in similar ecosystems. Toxic baits may be an effective tool for reducing wild pig populations especially if used as part of an integrated pest management strategy. Investigation of risks associated with a field-deployment of the toxic bait is needed. © 2018 Society of Chemical Industry.

Persistent Spillback of Bovine Tuberculosis From White-Tailed Deer to Cattle in Michigan, USA: Status, Strategies, and Needs.

Free-ranging white-tailed deer (Odocoileus virginianus) are believed to be a self-sustaining reservoir for bovine tuberculosis (bTB) in northeastern Lower Michigan, USA. Although a comprehensive control program is in place and on-farm mitigation strategies to curtail bTB transmission between cattle and deer have been implemented for over a decade, cattle and deer continue to become infected with the disease. Thus, renewed motivation to eradicate bTB is needed if that is truly the goal. Recurrent detection of bTB in cattle in the region is of mounting concern for state and federal agricultural agencies, producers, and wildlife managers. Current on-farm mitigation efforts include fencing and refined cattle feeding and watering practices. Liberal removal of antlerless deer through hunter harvest and disease control permits (DCPs) issued to cattle producers and agency sharp shooters have also been ongoing. Although these strategies have merit and efforts to reduce prevalence in deer and occurrence of positive farms are elevated, additional actions are needed. Heightened management actions to combat bTB in deer could include deer vaccination programs, strategic habitat manipulations to redistribute deer from farms, and precision removal of deer in proximity to high-risk farms. Foundational research to address development and delivery of vaccine to free-ranging deer is complete. Strategic management and habitat manipulation could reduce and disperse local concentrations of deer while better meeting wildlife, forestry, and agricultural goals. The responses of local deer populations to targeted removal of individuals are generally understood and there is potential to reduce deer activity around agricultural operations while allowing them to persist nearby on natural foods. We summarize the history and progress to date, discuss the realized merit of novel management strategies, and suggest options to rid deer and cattle in Michigan of bTB.

Wide Complex Tachycardia Observed During Pregnancy.

This case describes a 39-year-old pregnant woman with intermittent, transient but rapid palpitations, some with momentary lightheadedness.