Patients with a high defibrillation threshold: Approaches to management.

Implantable cardioverter-defibrillators (ICDs) have revolutionized the prognosis for patients at elevated risk of ventricular tachyarrhythmias. For safety, defibrillation should be effective with a minimum of 10 J below the device's maximum energy. While modern ICDs rarely deliver ineffective shocks in primary prevention, the surge in managing severe heart failure patients has led to an increased number of patients with high defibrillation thresholds (DFTs). This article elucidates the potential causes of high DFT, including clinical factors, lead and device placement, the presence of a Left Ventricular Assist Device (LVAD), prolonged ventricular arrhythmias, shock vectors, waveform tilt, medications, and manufacturer-specific options. We also detail management strategies, highlighting alternative shock coil placements, practical recommendations, and case studies from our institution. Our management algorithm suggests addressing preventable causes, re-evaluating coil positions, considering non-invasive system modifications, upgrading to a higher-capacity device, and adding extra coil(s).

Establishing a Comprehensive Wound Care Team and Program.

A comprehensive, interdisciplinary wound care team is of great importance to the management of acute, chronic, and recurrent wounds. This management functions best for the patient when all members of the team are in regular discussion regarding the wound care plan, providing more efficient and timelier patient-centered care. This article reviews the roles of different disciplines in the management of wounds. These disciplines include rehabilitation physicians, wound care nurses, registered nurses and certified nursing assistants, surgical teams, specialists of infectious diseases and mental health, dieticians, and patients and caregivers. A case study is also provided.

Emerging Technologies in the Wound Management Field.

Technological advances are incorporated into wound care management to enhance prevention through specialty mattresses and pressure mapping, assessment using modern imaging, and treatment with dressings and active therapies. We review specific equipment and evidence-based practice in the context of managing pressure injuries in patients with spinal cord injury.

Clinical experience with wearable cardioverter defibrillators at a tertiary electrophysiology program.

BACKGROUND: A wearable cardioverter defibrillator (WCD) is an alternative for patients who are not immediate candidates for an implantable cardioverter defibrillator (ICD). METHODS: Retrospective analysis of 242 patients prescribed a WCD from January 2014 through March 2015 with 1-year follow-up. RESULTS: A WCD was prescribed to 242 patients during the 15-month period. Forty-one patients were excluded due to lack of complete follow-up. The remaining 201 patients received a WCD for primary or secondary prevention of SCD. Seventy-nine percent of WCDs were prescribed by nonelectrophysiologists. Underlying etiologies for the WCD prescription included: 38% nonischemic cardiomyopathy, 25% recent myocardial infarction, 16% newly diagnosed ischemic cardiomyopathy, 12% documented ventricular arrhythmia, 6% ICD lead extraction, and 3% had high risk conditions for sudden cardiac death. During 1-year follow-up, 96 patients (48%) received an ICD and five patients (2.5%) received appropriate shocks and one patient (0.5 %) received an inappropriate shock. Other 105 (52%) patients subsequently did not require an ICD due to either improvement in ejection fraction, refusal of ICD therapy, or death. CONCLUSIONS: About half of patients prescribed a WCD subsequently receive an ICD and the rate of appropriate shock therapy from the WCD is 2.5%.

MHC class II tetramers containing influenza hemagglutinin and EBV EBNA1 epitopes detect reliably specific CD4(+) T cells in healthy volunteers.

Tracking antigen specific T cells with major histocompatibility complex (MHC) tetramers has provided us with insights into the dynamics of the adaptive immune system and holds great promise to aid in patient management and drug and vaccine development. Progress has been made primarily using MHC class I tetramers to monitor CD8(+) T cells, whereas corresponding efforts to stain CD4(+) T cells with class II tetramers have not been as successful. Two major reasons have been proposed for this lack of progress: (1). The frequency of antigen-specific CD4(+) T cells is lower than the frequency of CD8(+) T cells and (2). some, but not all, antigen- specific CD4(+) T cells can bind tetramer because of low functional avidity. In this study, we asked if CD4(+) T cells specific for common human viruses (e.g., influenza and Epstein-Barr) can be detected in healthy individuals previously exposed to them. We were able to clearly detect specific CD4(+) T cells in all donors after in vitro expansion of peripheral blood mononuclear cells. Furthermore, we observe a clear separation of tetramer negative and tetramer positive CD4(+) T cells in most samples similar to patterns commonly seen with class I tetramers. The data indicate that MHC class II tetramers can be used reliably for the identification of CD4(+) T cells specific for ubiquitous infectious agents in normal donors.