Biventricular Function is Impaired in Right Ventricular Septal Pacing-A Prospective Study Using Myocardial Strain Imaging.

BACKGROUND: Left ventricular (LV) dysfunction is known to occur after right ventricular (RV) pacing; the effect on RV function is less well studied. The aim of this study was to assess the impact of RV mid-septal pacing upon RV function using the novel parameters of speckle-tracking derived RV global longitudinal strain (RV GLS) and RV free wall strain (RV FWS), as well as the conventional parameters RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and tricuspid annular systolic velocity (RV S'). METHODS: Thirty-two (32) consecutive patients with normal baseline LV and RV function requiring permanent pacemaker insertion (for high-grade AV block or sinus node dysfunction) were prospectively recruited. Echocardiography was performed prior to implantation, at 1 day, 1 month and 1 year after implantation, with 29 patients completing follow-up. RESULTS: After 1 year, three patients (10%) with otherwise normal RV parameters developed abnormal RV strain patterns. Compared to 1 day after implantation, at 1 year significant reductions were observed in mean RV GLS (-24.8 to -21.8%) RV S' (15.1 to 12.2 cm/s), TAPSE (24.2 to 21.9 mm), RV GLS (-24.8 to -21.8%), left ventricular ejection fraction (LVEF) (66.0 to 57.9%), LV GLS (-19.9 to 17.0), all p<0.01. There was a non-significant reduction for RV FWS (-29.0 to -26.7%, p=0.06) and there was no change in RV FAC (49.1 to 46.9%, p=0.24). CONCLUSION: We report abnormalities of RV strain developing 1 year after pacemaker insertion. Measurement of myocardial strain is emerging as an additional method to detect patients at risk of RV dysfunction in those who have undergone pacemaker implantation.

Late recurrence of atrial fibrillation and flutter in patients referred for elective electrical cardioversion.

Aim    The primary aim was to ascertain long-term rates of atrial fibrillation (AF) recurrence in this all-comer patient population undergoing elective electrical cardioversion (DCR). Secondary aims included procedural DCR success, clinical predictors of long-term maintenance of sinus rhythm (SR) and AF related hospitalizations.Material and Methods    A retrospective cohort study was conducted. Consecutive patients (n=316) undergoing elective DCR were included.Results    Successful immediate reversion to SR was attained in 266 (84 %) of patients. 224 (84 %) patients were followed up for a median period of 3.5 years (IQR 2.7-4.3). Most patients (150 [67 %]) had recurrence of AF / flutter at a median time of 240 days. Clinical predictors of AF recurrence included a history of AF (HR 0.63, p=0.038) and a dilated left atrium (HR 4.13, p=0.048). Maintenance of SR was associated with fewer unplanned hospitalizations for AF (HR 3.25, p<0.01).Conclusion    There was high procedural success post DCR. However, long-term rates of AF recurrence were high, and AF recurrences were associated with increased hospitalizations. These findings underscore the importance of clinical vigilance and multi-modal management as part of a comprehensive and effective rhythm control strategy.

Safety and Long-Term Clinical Outcomes of Fractional Flow Reserve Guided Coronary Revascularisation.

BACKGROUND: Increasingly, fractional flow reserve (FFR) is employed to assess coronary artery stenoses although there is limited real world long-term outcome data with a recent report questioning its safety. This study aimed to assess the in-hospital complications and clinical outcomes up to 10 years after FFR-guided revascularisation at a tertiary Australian hospital. METHODS: The cohort comprised 274 consecutive patients undergoing FFR from 2010 to 2015 with follow-up to 2020. In-hospital complications and long-term outcomes were compared between patients with FFR≤0.80 and FFR>0.80. Major adverse cardiac events (MACE) comprised cardiac death, myocardial infarction (MI) and target vessel revascularisation (TVR). RESULTS: The FFR was ≤0.80 in 166 and >0.80 in 108 patients. Stable coronary disease was present in 95%. Revascularisation was undertaken in 86.7% of the FFR≤0.80 group and in 2.8% of the group with an FFR>0.80. In-hospital adverse events were 3.3% with no pressure wire-related coronary dissection, stroke or death. At median follow-up of 5 years, patients with FFR≤0.80 and FFR>0.80 had a similar rate of cardiac death (2.6% versus 5.0%, p=0.335) and MI (2.6% versus 6.9%, p=0.154). In the FFR>0.80 group, MACE (17.8% v 7.9%; p=0.018) and TVR (12.9% v 5.3%; p=0.033) were significantly higher. CONCLUSION: This observational study highlights the safety and long-term effectiveness of FFR-guided coronary revascularisation in patients with predominantly stable disease.

Multiparametric magnetic resonance imaging for prostate cancer-a comparative study including radical prostatectomy specimens.

PURPOSE: To evaluate the diagnostic and staging ability of multiparametric MRI (mpMRI) compared to radical prostatectomy (RP) specimens after dissemination of this technology to several centres. mpMRI is an evolving technique aiming to improve upon the diagnostic sensitivity of prostate biopsy for the diagnosis of prostate cancer. Differences in interpretation, expertise and application of mpMRI are responsible for the range of reported results. METHODS: This retrospective clinical study was conducted with consecutive patients through an electronic database of tertiary hospitals and adjacent private urology practices in Australia. Patients having undergone RP were assessed for the presence of a pre-operative mpMRI performed between 2013 and 2015 which was evaluated against the reference standard of the RP whole-mount specimen. MRI reports were evaluated using the Prostate Imaging Reporting and Data System (PI-RADS). RESULTS: In our cohort of 152 patients, the sensitivity and specificity of mpMRI (PI-RADS ≥ 4) for prostate cancer (Gleason ≥ 4 + 3) detection were 83 and 47%, respectively. For the identification of extraprostatic disease, the sensitivity and specificity were 29 and 94%, respectively. CONCLUSION: These results represent a 'real-world' approach to mpMRI and appear comparable to other single-centre studies. MRI staging information should be interpreted in context with other risk factors for extraprostatic disease. mpMRI has a useful role as an adjunct for prostate cancer diagnosis and directing management towards improving patient outcomes.

Epicardial CRT-D in a Pacing Dependant Patient Without Transvenous Options.

Implantable cardioverter-defibrillator (ICD) and cardiac resynchronisation therapy (CRT) is generally limited to transvenous techniques especially in pacing-dependant patients. We describe a novel case in which an epicardial CRT-D system was successfully implanted with a two-year follow-up in a pacing-dependant patient.

Extended-spectrum beta-lactamase-producing Enterobacteriaceae in hospital urinary tract infections: incidence and antibiotic susceptibility profile over 9 years.

PURPOSE: Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae are an increasing concern regarding antibiotic resistance and their potential to cause serious infections which are difficult to treat. The purpose of this surveillance programme was to assess the incidence of ESBL in adults amongst urinary isolates, identify risk factors, and detail the antibiotic susceptibility profile in order to guide empirical treatment. METHODS: From 2006 to 2014, we reviewed 21,414 positive urine cultures for E. coli and Klebsiella sp. from a University hospital in the UK and found 1420 ESBL-positive specimens. Susceptibility testing was performed by British Society of Antimicrobial Chemotherapy disc diffusion testing. ESBL screening was performed on samples resistant to cefpodoxime and confirmed by double disc diffusion (Oxoid Ltd, Basingstoke, UK). Patient gender, age, inpatient status, and catheterisation were assessed as risk factors. RESULTS: ESBL production amongst E. coli urine cultures increased 44 %, from 4.6 to 6.6 % of all E. coli isolates. ESBL-positive organisms were associated with increases in drug resistance, particularly amongst fluoroquinolones, trimethoprim, and cephalexin. Multidrug resistance was a feature with 75 % of ESBL+ Klebsiella sp.-resistant ≥6 antibiotic classes. ESBL producers remained largely susceptible to carbapenems. Male gender, urinary catheterisation, inpatient status, and increasing age were identified as risk factors for ESBL infection or colonisation. CONCLUSION: We demonstrate that the incidence of ESBL-producing E. coli in urine cultures is increasing and that such isolates are multidrug resistant. Carbapenems and nitrofurantoin for E. coli infections remain effective, which may guide empirical antibiotic therapy.

Accuracy of wrist-worn heart rate monitors for rate control assessment in atrial fibrillation.

BACKGROUND: Wrist-worn heart rate (HR) monitors are increasingly popular. A paucity of data exists on their accuracy in atrial fibrillation (AF) in ambulatory patients. We sought to assess the HR accuracy of two commercially available smart watches [SW] (Fitbit Charge HR [FB] and Apple Watch Series 3 [AW]) compared with Holter monitoring in an ambulant patient cohort. METHODS: Thirty-two participants ≥18 years referred for 24-hour Holter monitoring were prospectively recruited. Each participant was randomly allocated to wear either a FB or AW along with their Holter monitor. RESULTS: Across all devices, 53,288 heart rate values were analysed from 32 participants. Twenty wore the AW (17 had persistent AF and 3 had sinus rhythm [SR]) while 12 participants wore the FB (9 in persistent AF and 3 in SR). Participants in SR demonstrated strong agreement compared to Holter monitoring (bias <1 beat, limits of agreement [LoA] -11 to 11 beats). In AF, both devices underestimated HR measurements (bias -9 beats, LoA -41 to 23). The degree of underestimation was more pronounced when HR > 100 bpm (bias of -28 beats for HR range 100-120 bpm, -48 for 120-140 bpm, and -69 for >140 bpm) compared to a slower HR (bias of -6 for HR range 80-100 bpm, <1 for 60-80 bpm, and -1 for <60 bpm). CONCLUSION: In ambulatory patients, smartwatches underestimated HR in AF particularly at HR ranges >100 bpm. Further improvements in device technology are needed before integrating them into the clinical management of rate control in AF.

Electrical remodelling and response following cardiac resynchronization therapy: A novel analysis of intracardiac electrogram using a quadripolar lead.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves morbidity and mortality in patients with heart failure. Although structural remodelling correlates with improved long-term outcomes, the role of electrical remodelling is poorly understood. This study aimed to evaluate electrical remodelling following CRT using a quadripolar left ventricular (LV) lead and to correlate this with structural remodelling. METHODS: Consecutive patients undergoing initial CRT implantation using a quadripolar LV lead were enrolled. Patients were followed up for 12 months. Twelve lead ECG, transthoracic echocardiogram, and evaluation of intracardiac electrograms (EGM) were performed. Measures included right and left ventricular lead intrinsic delay, RV-pacing to LV-sensing (RVp-LVs) delay, and LV-pacing to RV-sensing (LVp-RVs) delay. The electrical changes were then correlated with echocardiographic response to CRT, defined by ≥15% relative reduction in LVESV and ≥ 5% absolute improvement in EF on TTE. Activation sequence was determined using the quadripolar lead. RESULTS: Forty patients were enrolled. Mean intrinsic RV-LV EGM values decreased from 121.9 ± 14.7 ms to 109.1 ± 15.0 ms (P < .01), mean RVp-LVs EGM values from 146.7 ± 16.7 ms to 135.1 ± 13.1 ms, (P < .01), and mean LVp-RVs EGM values from 155.7 ± 18.1 ms to 144.2 ± 17.1 ms (P < .01). The improvement in intrinsic RV-LV EGM was 14.9 ± 8.5 ms in responders vs 8.9 ± 7.9 ms in nonresponders to CRT (P < .05). Changes in activation sequence did not correlate with CRT response. CONCLUSIONS: This novel study used EGMs from a quadripolar LV lead to demonstrate electrical remodelling occurs following CRT. A nonsignificant trend suggests that electrical remodelling in CRT is greater in responders compared to nonresponders, although further study is needed.

Prevention of sepsis prior to prostate biopsy.

PURPOSE: Urosepsis is the most feared complication of transrectal prostate biopsy. The incidence may be increasing from <1% to 2%-3% in contemporary series. Historically, fluoroquinolones have been effective antibiotic prophylaxis to prevent infective complications but antibiotic resistance is increasing. The increase in antibiotic resistance may contribute to reported increases in urosepsis and hospitalization after transrectal biopsy. This article will review other methods clinicians may employ to reduce the incidence of infective complications after prostate biopsy. MATERIALS AND METHODS: A systematic review of the literature was conducted using literature databases PubMed and Ovid MEDLINE in August 2015 in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) criteria. RESULTS: Effective strategies to reduce infective complications after transrectal prostate biopsy include augmented prophylaxis with other antibiotics, rectal swab culture directed antibiotic prophylaxis or a transperineal biopsy approach. Needle disinfection, minimizing the number of biopsy needles and rectal disinfectants may also be of use. These methods may be of particular utility in patients with risk factors for developing urosepsis such as recent antibiotic use and overseas travel. CONCLUSIONS: The scientific literature describes various techniques designed to reduce infective complications caused by prostate biopsy. Clinicians should consider incorporating these novel techniques into their contemporary practice.

Vancomycin resistant enterococci in urine cultures: Antibiotic susceptibility trends over a decade at a tertiary hospital in the United Kingdom.

PURPOSE: Enterococci are a common cause of urinary tract infection and vancomycin-resistant strains are more difficult to treat. The purpose of this surveillance program was to assess the prevalence of and determine the risk factors for vancomycin resistance in adults among urinary isolates of Enterococcus sp. and to detail the antibiotic susceptibility profile, which can be used to guide empirical treatment. MATERIALS AND METHODS: From 2005 to 2014 we retrospectively reviewed 5,528 positive Enterococcus sp. urine cultures recorded in a computerized laboratory results database at a tertiary teaching hospital in Cambridge, United Kingdom. RESULTS: Of these cultures, 542 (9.8%) were vancomycin resistant. No longitudinal trend was observed in the proportion of vancomycin-resistant strains over the course of the study. We observed emerging resistance to nitrofurantoin with rates climbing from near zero to 40%. Ampicillin resistance fluctuated between 50% and 90%. Low resistance was observed for linezolid and quinupristin/dalfopristin. Female sex and inpatient status were identified as risk factors for vancomycin resistance. CONCLUSIONS: The incidence of vancomycin resistance among urinary isolates was stable over the last decade. Although resistance to nitrofurantoin has increased, it still serves as an appropriate first choice in uncomplicated urinary tract infection caused by vancomycin-resistant Enterococcus sp.

Magnetic resonance imaging for prostate cancer: Comparative studies including radical prostatectomy specimens and template transperineal biopsy.

PURPOSE: Multiparametric magnetic resonance imaging (mpMRI) is an emerging technique aiming to improve upon the diagnostic sensitivity of prostate biopsy. Because of variance in interpretation and application of techniques, results may vary. There is likely a learning curve to establish consistent reporting of mpMRI. This study aims to review current literature supporting the diagnostic utility of mpMRI when compared with radical prostatectomy (RP) and template transperineal biopsy (TTPB) specimens. METHODS: MEDLINE and PubMed database searches were conducted identifying relevant literature related to comparison of mpMRI with RP or TTPB histology. RESULTS: Data suggest that compared with RP and TTPB specimens, the sensitivity of mpMRI for prostate cancer (PCa) detection is 80-90% and the specificity for suspicious lesions is between 50% and 90%. CONCLUSIONS: mpMRI has an increasing role for PCa diagnosis, staging, and directing management toward improving patient outcomes. Its sensitivity and specificity when compared with RP and TTPB specimens are less than what some expect, possibly reflecting a learning curve for the technique of mpMRI.

Current role of multiparametric magnetic resonance imaging in the management of prostate cancer.

The purpose of this review was to evaluate the current role of multiparametric magnetic resonance imaging (mp-MRI) in the management of prostate cancer (PC). The diagnosis of PC remains controversial owing to overdetection of indolent disease, which leads to overtreatment and subsequent patient harm. mp-MRI has the potential to equilibrate the imbalance between detection and treatment. The limitation of the data for analysis with this new technology is problematic, however. This issue has been compounded by a paradigm shift in clinical practice aimed at utilizing this modality, which has been rolled out in an ad hoc fashion often with commercial motivation. Despite a growing body of literature, pertinent clinical questions remain. For example, can mp-MRI be calibrated to reliably detect biologically significant disease? As with any new technology, objective evaluation of the clinical applications of mp-MRI is essential. The focus of this review was on the evaluation of mp-MRI of the prostate with respect to clinical utility.