Junctional Tachycardia: A Critical Reassessment.

Junctional tachycardia (JT) is typically considered to have an automatic mechanism originating from the distal atrioventricular node. When there is 1:1 retrograde conduction via the fast pathway, JT would resemble the typical form of atrioventricular nodal re-entrant tachycardia (AVNRT). Atrial pacing maneuvers have been proposed to exclude AVNRT and suggest a diagnosis of JT. However, after excluding AVNRT, one should consider the possibility of an infra-atrial narrow QRS re-entrant tachycardia, which can exhibit features that resemble AVNRT as well as JT. Pacing maneuvers and mapping techniques should be performed to assess for infra-atrial re-entrant tachycardia before concluding that JT is the mechanism of a narrow QRS tachycardia. Distinguishing JT from typical AVNRT or infra-atrial re-entrant tachycardia has notable implications regarding the approach to ablation of the tachycardia. Ultimately, a contemporary review of the evidence on JT raises some questions as to the mechanism and source of what has traditionally been considered JT.

Novel bleeding prediction model in atrial fibrillation patients on new oral anticoagulants.

OBJECTIVE: Clinical models such as the HAS-BLED (standing for Hypertension, Abnormal liver/renal function, Stroke history, Bleeding history or predisposition, Labile INR, Elderly, Drug/alcohol usage) were developed to predict risk of major bleeding on vitamin K antagonists/antiplatelet therapy. We aimed to develop a model that will improve the ability to predict major bleeding events in patients with non-valvular atrial fibrillation (AF) treated with new oral anticoagulants (NOACs). METHODS: Clalit Health Services is the largest of four integrated healthcare organisations in Israel, which insures 4.7 million patients (53% of the population). We identified in Clalit Health Services all patients with AF, new users of an NOAC (2013-2017), and followed them until first occurrence of a major bleeding event, death, switch to another oral anticoagulant, 30 days after discontinuation of NOAC or end of follow-up (31 December 2019). Importance of the candidate model variables was estimated by inclusion frequencies across forward selection algorithm applied to 50 bootstrap samples. Then, backward selection algorithm using the modified Bayesian Information Criterion for competing risks was applied to select predictors for the final model. RESULTS: 47 623 patients with AF prescribed NOAC were studied. 28 055 patients with AF, initiators of apixaban (mean age 78.7, SD 9.0), were included in the first phase and had 662 major bleeding events. Nine variables were selected for inclusion in a final points-based risk-scoring system: male sex, anaemia, thrombocytopaenia (<99×103/µL), concurrent antiplatelet therapy, hypertension, prior major bleeding, risk factors for a fall, low cholesterol level and low estimated glomerular filtration rate, with apparent area-under-curve (AUC) of 0.6546. Applicability of the model was then shown for 14 118 and 5450 patients with AF, initiators of dabigatran and rivaroxaban, where the score achieved c indices of 0.62 and 0.61, respectively. CONCLUSIONS: We present a novel and simple risk score for prediction of major bleeding in patients with non-valvular AF treated with NOACs. Validation in additional cohorts is warranted.

Exploring the effectiveness of a patient-tailored integrative oncology program on emotional distress during chemotherapy for localized cancer.

STUDY OBJECTIVE: There is a need to explore how patient-tailored integrative oncology (IO) programs reduce emotional distress. This study set out to bridge the IO research gap between non-specific, quality of life-related and specific emotional-related concerns in chemotherapy-treated patients. METHODS: This pragmatic, prospective and preference-controlled study examined patients attending an integrative-physician consultation and weekly IO treatments during adjuvant/neo-adjuvant chemotherapy for localized cancer. Patients choosing to attend ≥4 IO sessions (highly adherent to integrative care, AIC) were compared to low AIC patients using the ESAS (Edmonton Symptom Assessment Scale) anxiety, depression and sleep; and the EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) emotional functioning scale, at baseline, 6 and 12 weeks. Emotional distress was assessed by ESAS anxiety and depression, considered as the primary study outcomes. RESULTS: Of 439 participants, 260 (59%) were high-AIC and 179 low-AIC, both with similar baseline demographic and cancer-related characteristics. At 6 weeks, high-AIC patients reported greater improvement on ESAS sleep (p = 0.044); within-group improvement on ESAS anxiety and; and EORTC emotional functioning. Compared with low-AIC, high-AIC patients showed greater improvement on ESAS depression (p = 0.022) and sleep (p = 0.015) in those with high baseline ESAS anxiety scores (≥7); and ESAS anxiety (p = 0.049) for patients moderately anxious (4-6) at baseline. CONCLUSIONS: High-AIC was associated with significantly reduced anxiety, depression and sleep severity at 6 weeks, especially those with high-to-moderate baseline anxiety levels. These findings reduce the research gap, suggesting specific emotional-related effects of IO.

Impact of a combined integrative oncology and palliative care program on quality of life of patients with advanced cancer.

Many oncology centers provide integrative oncology (IO) care, many within palliative care settings. The primary study objective was to examine the impact of IO-palliative patient-tailored program on quality of life (QoL) among patients with advanced cancer. In this pragmatic prospective controlled study, patients with advanced cancer undergoing chemotherapy/palliative care were referred by their oncology healthcare providers to an integrative physician (IP) consultation and weekly IO treatments. Patients with high adherence to integrative care (AIC; ≥ 4 IO sessions/6 weeks) were compared with moderate (2-3 sessions) or low AIC patients (regarded as control group). Outcomes were assessed at 6- and 12-week follow-up with Edmonton Symptom Assessment Scale (ESAS) and EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) tools. Change in QoL scores (ESAS fatigue in particular) was considered a primary study outcome. Of 225 eligible patients, 153 underwent baseline and 6-week optimal assessment (high AIC, 100; moderate AIC, 22; low AIC, 31). High AIC patients reported greater improvement on ESAS scores for fatigue (vs. low-moderate AIC, P < 0.001), depression (vs. moderate AIC, P = 0.01) at 6 weeks, and sleep (P = 0.007) at 12 weeks. High AIC patients had significantly improved EORTC global health status/QoL at 6 weeks (vs. moderate-low AIC, P = 0.01), cognitive functioning (vs. moderate AIC, P = 0.043), and social functioning (vs. moderate AIC, P = 0.032). High AIC patients had lower rates of hospitalizations at 12 weeks (19% vs. 35% in low AIC, P = 0.02; 44% in moderate AIC, P = 0.003), hospitalization days (vs. low AIC, P = 0.003), and opioid use (vs. low AIC, P < 0.001). High adherence to integrative care was associated with a significant effect on fatigue, depression, global QoL at 6 weeks, and need for hospitalizations at 12 weeks.

The utility of a novel mapping algorithm utilizing vectors and global pattern of propagation for scar-related atrial tachycardias.

BACKGROUND: Activation maps of scar-related atrial tachycardias (AT) can be challenging to interpret due to difficulty in inaccurate annotation of electrograms, and an arbitrarily predefined mapping window. A novel mapping software integrating vector data and applying an algorithmic solution taking into consideration global activation pattern has been recently described (Coherent™, Biosense Webster "Investigational"). OBJECTIVE: We aimed to assess the investigational algorithm to determine the mechanism of AT compared with the standard algorithm. METHODS: This study included patients who underwent ablation of scar-related AT using the Carto 3 and the standard activation algorithm. The mapping data were analyzed retrospectively using the investigational algorithm, and the mechanisms were evaluated by two independent electrophysiologists. RESULTS: A total of 77 scar-related AT activation maps were analyzed (89.6% left atrium, median tachycardia cycle length of 273 ms). Of those, 67 cases with a confirmed mechanism of arrhythmia were used to compare the activation software. The actual mechanism of the arrhythmia was more likely to be identified with the investigational algorithm (67.2% vs. 44.8%, p = .009). In five patients with dual-loop circuits, 3/5 (60%) were correctly identified by the investigational algorithm compared to 0/5 (0%) with the standard software. The reduced atrial voltage was prone to lead to less capable identification of mechanism (p for trend: .05). The investigational algorithm showed higher inter-reviewer agreement (Cohen's kappa .62 vs. .47). CONCLUSIONS: In patients with scar-related ATs, activation mapping algorithms integrating vector data and "best-fit" propagation solution may help in identifying the mechanism and the successful site of termination.

Correlation between an integrative oncology treatment program and survival in patients with advanced gynecological cancer.

OBJECTIVE: Integrative oncology (IO) is increasingly becoming part of palliative cancer care. This study examined the correlation between an IO treatment program and rates of survival among patients with advanced gynecological cancer. METHODS: Patients were referred by their oncology healthcare professionals to an integrative physician (IP) for consultation and IO treatments. Those undergoing at least 4 treatments during the 6 weeks following the consultation were considered adherence to the integrative care program (AIC), versus non-adherent (non-AIC). Survival was monitored for a period of 3 years, comparing the AIC vs. non-AIC groups, as well as controls who did not attend the IP consultation. RESULTS: A total of 189 patients were included: 71 in the AIC group, 44 non-AIC, and 74 controls. Overall 3-year survival was greater in the AIC group (vs. non-AIC, p = 0.012; vs. controls, p = 0.003), with no difference found between non-AIC and controls (p = 0.954). Multimodal IO programs (≥ 3 modalities) were correlated in the AIC group with greater overall 3-year survival (p = 0.027). Greater rates of survival were also found in the AIC group at 12 (p = 0.004) and 18 months (p = 0.001). When compared with the AIC group, a multivariate analysis found higher crude and adjusted hazard ratios for 3-year mortality in the non-AIC group (HR 95% CI 2.18 (1.2-3.9), p = 0.010) and controls (2.23 (1.35-3.7), p = 0.002). CONCLUSION: Adherence to an IO treatment program was associated with higher survival rates among patients with advanced gynecological cancer. Larger prospective trials are needed to explore whether the IO setting enhances patients' resilience, coping, and adherence to oncology treatment.

Should fast pathway ablation be reconsidered in typical atrioventricular nodal re-entrant tachycardia?

INTRODUCTION: Atrioventricular nodal re-entry tachycardia (AVNRT) is the most common, regular narrow-complex tachycardia. The established treatment is catheter ablation of the AV nodal slow pathway (SP). However, in a select group of patients with long PR intervals in sinus rhythm, SP ablation can lead to AV block due to the absence of robust anterograde conduction through the fast pathway (FP). This report aims to demonstrate that AV nodal FP ablation is a reasonable approach in patients with AVNRT and poor or absent anterograde FP conduction. METHODS AND RESULTS: Standard electrophysiology study techniques were used in the electrophysiology laboratory. Catheter ablations were performed using radiofrequency energy. Mapping of intracardiac activation was performed with electroanatomical mapping systems. Outcomes were assessed acutely during the procedure and during routine clinical follow-up. Six patients with first-degree AV block and recurrent AVNRT who underwent ablation of their tachycardia at our institution are presented. One patient underwent ablation of AV nodal SP resulting in high-degree AV block necessitating pacemaker implantation. The remaining five patients underwent ablation of the AV nodal FP guided by electroanatomical mapping of the earliest atrial activation in tachycardia. These five had successful treatment of the tachycardia with preservation of anterograde AV nodal conduction. Mapping and ablation approach to eliminate retrograde FP conduction are described. CONCLUSION: In select patients with AVNRT and poor anterograde FP conduction, retrograde FP ablation is reasonable and is less likely to result in AV block and pacemaker dependency.

Recurrent Atrial Fibrillation After Initial Long-Term Ablation Success: Electrophysiological Findings and Outcomes of Repeat Ablation Procedures.

BACKGROUND: Atrial fibrillation recurrence after initial long-term success of catheter ablation has been described, yet not well studied. We assessed the electrophysiological findings and outcomes of repeat ablation procedures in this setting. METHODS AND RESULTS: Between 2000 and 2015, 10 378 patients underwent atrial fibrillation ablation and were enrolled in a prospectively maintained data registry. From this registry, we included all 137 consecutive patients who had initial long-term success, defined as freedom from recurrent arrhythmia for >36 months off antiarrhythmics, then underwent repeat ablation for recurrent atrial fibrillation. The median arrhythmia-free period that defined long-term success was 52 months (41-68 months). In redo ablations, reconnection along at least one of the pulmonary veins (PVs) was found in 111 (81%) patients. Reconnection along a left superior, left inferior, right superior, and right inferior PV was found in 64%, 62%, 50%, and 54% of patients, respectively, and were reisolated. Additional non-PV ablations were performed in 127 (92.7%) patients: posterior wall (46%), septal to right PVs (49%), superior vena cava (35%), roof lines (52%), and cavotricuspid isthmus (33%). After a median follow-up of 17 months (5-36.9 months), 103 patients (75%) were arrhythmia free (79 off antiarrhythmics, 24 on antiarrhythmics). CONCLUSIONS: PV reconnection is the most common electrophysiological finding in patients with atrial fibrillation recurrence after long-term success, but with lower rates than what had been reported for early recurrences. In our experience, repeat ablations in this setting involve complex ablation approaches to reisolate the PVs and modify the atrial substrate and are associated with good success rates.

Microbiologic Data in Acute Cholecystitis: Ten Years' Experience from Bile Cultures Obtained during Percutaneous Cholecystostomy.

BACKGROUND: The aim of the study was to describe the microbiology and susceptibility patterns in acute cholecystitis by examining bile culture results from patients who underwent percutaneous cholecystostomy and examine concordance with empiric treatment. PATIENTS AND METHODS: A total of 124 patients with acute cholecystitis underwent percutaneous cholecystostomy between 2003 and 2012 at Emek Medical Center, Israel. Data on bile and blood culture results, isolate susceptibility, and clinical outcomes were retrieved from patient files. RESULTS: Bile cultures obtained from 116 patients were positive in 70 (60.3%) patients. Blood cultures obtained from 77 patients were positive in 23 (31.1%). Escherichia coli was the most common isolate in 28.6% of bile cultures and 43.5% of blood cultures. The concordance between empiric treatment coverage and culture isolate susceptibility was 67.6%. In most discordant cases, the isolates were Enterobacter spp. (40.9%) and Enterococcus spp. (31.8%). Overall, the in-hospital mortality rate was 7%: 2% in patients with concordant treatment compared with 14% in patients with discordant treatment (p = 0.09). Empiric antibiotic regimens were adequate in only two-thirds of patients. CONCLUSIONS: There might be a trend for poorer outcome in patients treated with inadequate antibiotic agents, emphasizing the importance of tailoring antibiotic treatment.

Randomized Study of Persistent Atrial Fibrillation Ablation: Ablate in Sinus Rhythm Versus Ablate Complex-Fractionated Atrial Electrograms in Atrial Fibrillation.

BACKGROUND: Achieving long-term successful outcomes with ablation of persistent atrial fibrillation (AF) remains a clinical and procedural challenge. We aimed to assess 2 ablation strategies for persistent AF: pulmonary vein antral isolation (PVAI) in sinus rhythm after direct current cardioversion versus PVAI and ablation targeting complex-fractionated atrial electrograms while in AF. METHODS AND RESULTS: Between June 2009 and July 2013, patients with continuous persistent AF for ≥3 months were prospectively randomized to either direct current cardioversion before PVAI and posterior wall/septum ablation while in sinus rhythm (group 1), versus same ablation in group 1 in addition to complex-fractionated atrial electrogram ablation while in AF (group 2). The procedural profiles and clinical outcomes of the 2 strategies were compared. Ninety patients were randomized to group 1 (n=46) or group 2 (n=44). There were no differences in baseline characteristics between groups. Over 365 days of follow-up after the index procedure, 16 patients (35%) in group 1 and 13 patients (30%) in group 2 remained arrhythmia-free off antiarrhythmic medications. Over long-term follow-up (median, 867 days), arrhythmia-free survival off antiarrhythmic medications was more likely in group 1 than in group 2 in Kaplan-Meier analysis (Log Rank P=0.04). Group 1 ablation was associated with significantly shorter procedural duration and fluoroscopy time (231±72 versus 273±76 min; P=0.008 and 54 [Q1-Q3: 46-67] versus 66 (Q1-Q3: 53-83] min; P=0.018, respectively). CONCLUSIONS: In patients with persistent AF, PVAI in sinus rhythm after direct current cardioversion is associated with higher success and shorter procedural and fluoroscopy times compared with PVAI in AF with additional complex-fractionated atrial electrogram ablation. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02429648.

The Effect of Vitamin D Supplementation on Thrombin Generation Assessed by the Calibrated Automated Thrombogram.

Observational and in vitro studies suggest that vitamin D may have antithrombotic activity. This study aimed to examine the relationship between vitamin D supplementation and thrombin generation. Serum 25-hydroxyvitamin D (25(OH)D) and thrombin generation parameters were measured in 73 healthy volunteers. Participants with serum 25(OH)D <50 nmol/L (n = 53) were treated with vitamin D3and tested for 25(OH)D and thrombin generation at the end of treatment. Lag time and time to peak decreased after treatment by a mean of -0.49 ± 0.51 minute (P< .001) and -0.76 ± 0.70 minute (P< .001), respectively, whereas endogenous thrombin potential and peak height increased after treatment by a mean of 170.1 ± 339.8 nmol/L minute (P= .001) and 34.2 ± 47.8 nmol/L (P< .001), respectively. Treatment with vitamin D supplementation seems to have prothrombotic effect in patients with vitamin D insufficiency. These findings should be interpreted with caution and need to be replicated in future studies.

Evolving strategies to prevent stroke and thromboembolism in nonvalvular atrial fibrillation.

Stroke prevention in patients with nonvalvular atrial fibrillation relies on an assessment of the individual risks for stroke and bleeding. Patients at high risk for stroke are candidates for anticoagulant therapy. Anticoagulants, however, have substantial bleeding risks that must be weighed in the therapeutic decision. Warfarin has been the traditional choice, but the recently introduced novel oral anticoagulants offer similar efficacy with less bleeding risk. Additionally, they do not require monitoring and have fewer drug interactions and dietary restrictions than warfarin. Several devices, which isolate the left atrial appendage, have become available as treatment options for patients with elevated risks of both thromboembolism and bleeding complications.

Chloramphenicol use and susceptibility patterns in Israel: a national survey.

BACKGROUND: Due to increasing antimicrobial resistance, there has been renewed interest in old drugs that have fallen into disuse because of toxic side effects. One such drug is chloramphenicol. Data on the use and susceptibility patterns to chloramphenicol in developed countries in recent years are limited. OBJECTIVES: To assess the susceptibility of bacteria to chloramphenicol, and evaluate the use of chloramphenicol in Israeli hospitals as influenced by infectious disease specialists' attitudes with regard to its potential harms. METHODS: A national survey was conducted in all Israeli hospitals. Questionnaires were sent to the directors of infectious disease units and included items on chloramphenicol susceptibility in clinical isolates, use of chloramphenicol for the treatment of inpatients, local recommendations for use of chloramphenicol, and concerns regarding side effects. RESULTS: Chloramphenicol is used in 83.3% of hospitals, mostly for the treatment of aspiration pneumonia. While 22.2% of infectious disease unit directors believe that chloramphenicol should be avoided because of dangerous side effects, 88.9% believe there is a place for chloramphenicol in the treatment of patients in this era of increasing antibiotic resistance. Chloramphenicol susceptibility is routinely assessed in 44.4% of hospitals, with high susceptibility rates found among gram-positive, gram-negative and anaerobic bacteria. CONCLUSIONS: In an era of increasing antibiotic resistance, many Israeli infectious disease unit directors believe that chloramphenicol has a role in the treatment of respiratory tract and other infections in hospitalized patients.

Clostridium difficile and inflammatory bowel disease: role in pathogenesis and implications in treatment.

Clostridium difficile (C. difficile) is the leading cause of antibiotic associated colitis and nosocomial diarrhea. Patients with inflammatory bowel disease (IBD) are at increased risk of developing C. difficile infection (CDI), have worse outcomes of CDI-including higher rates of colectomy and death, and experience higher rates of recurrence. However, it is still not clear whether C. difficile is a cause of IBD or a consequence of the inflammatory state in the intestinal environment. The burden of CDI has increased dramatically over the past decade, with severe outbreaks described in many countries, which have been attributed to a new and more virulent strain. A parallel rise in the incidence of CDI has been noted in patients with IBD. IBD patients with CDI tend be younger, have less prior antibiotic exposure, and most cases of CDI in these patients represent outpatient acquired infections. The clinical presentation of CDI in these patients can be unique-including diversion colitis, enteritis and pouchitis, and typical findings on colonoscopy are often absent. Due to the high prevalence of CDI in patients hospitalized with an IBD exacerbation, and the prognostic implications of CDI in these patients, it is recommended to test all IBD patients hospitalized with a disease flare for C. difficile. Treatment includes general measures such as supportive care and infection control measures. Antibiotic therapy with either oral metronidazole, vancomycin, or the novel antibiotic-fidaxomicin, should be initiated as soon as possible. Fecal macrobiota transplantation constitutes another optional treatment for severe/recurrent CDI. The aim of this paper is to review recent data on CDI in IBD: role in pathogenesis, diagnostic methods, optional treatments, and outcomes of these patients.

Characteristics, treatment, and outcomes of periprocedural cerebrovascular accidents during electrophysiologic procedures.

OBJECTIVES: We sought to identify the characteristics, treatment, and outcomes of periprocedural cerebrovascular accident (PCVA) during electrophysiologic (EP) procedures. BACKGROUND: Periprocedural cerebrovascular accident is one of the most feared complications during EP procedures with very few data regarding its characteristics, management, and outcomes. METHODS: Between January 1998 and December 2008, we reviewed 30,032 invasive EP procedures for PCVA occurrence and characteristics. Management and outcomes were also determined. RESULTS: Thirty-eight CVAs were identified. Twenty (53 %) were intraprocedural and 18 (47 %) postprocedural. Thirty-two (84 %) were classified as strokes and six (16 %) as transient ischemic attacks. All CVAs except one (37, 97 %) were ischemic and the vast majority occurred during ablation procedures (36, 95 %). Among the 31 patients with ischemic stroke, 11 (35 %) were treated with reperfusion (eight catheter-based therapy and three intravenous t-PA) of whom five (46 %) had complete recovery, three (27 %) had partial recovery, and three (27 %) had no recovery. No hemorrhagic transformations occurred. CONCLUSION: Periprocedural cerebrovascular accident during EP procedures is rare and is almost always ischemic. It occurs more frequently during ablation procedures. Reperfusion therapy is feasible and safe.

The risk of all-cause mortality is inversely related to serum 25(OH)D levels.

CONTEXT AND OBJECTIVES: Vitamin D plays a key role in maintaining bone health, but evidence for its nonskeletal effects is inconsistent. This study aims to examine the association between serum 25-hydroxyvitamin D [25(OH)D] levels and all-cause mortality in a large general population cohort. DESIGN, PARTICIPANTS, AND SETTING: Using the computerized database of the largest health care provider in Israel, we identified a cohort of subjects 20 years old or older with serum 25(OH)D levels measured between January 2008 and December 2009. Vital status was ascertained through August 2011. RESULTS: Median follow-up was 28.5 months (interquartile range 23.8-33.5 months); 7,247 of 182,152 participants (4.0%) died. Subjects who died had significantly lower serum 25(OH)D levels (mean 44.8 ± 24.2 nmol/liter) than those alive at the end of follow-up (51.0 ± 23.2 nmol/liter), P < 0.001. After adjustment for age, gender, ethnicity, and seasonality, the hazard ratio (HR) for all-cause mortality was 2.02 [95% confidence interval (CI) 1.89-2.15] for the lowest serum 25(OH)D quartile (<33.8 nmol/liter) compared with the highest. After further adjustment for comorbidity, use of vitamin D supplements and statins, smoking, socioeconomic status, and body mass index, the HR was 1.81 (95% CI 1.69-1.95). This remained, even after adjustment for serum low-density lipoprotein, high-density lipoprotein, calcium level (corrected for serum albumin levels), and glomerular filtration rate, 1.85 (95% CI 1.70-2.01). The fully adjusted HR associated with being in the second 25(OH)D quartile (33.8-49.4 nmol/liter) was 1.25 (95% CI 1.16-1.34). CONCLUSIONS: All-cause mortality is independently and inversely associated with serum 25(OH)D levels at levels less than 50 nmol/liter.

The longitudinal variability of serum 25(OH)D levels.

BACKGROUND: The extent to which a single serum 25(OH)D measurement represents long-term vitamin D status remains unclear. This study aims to assess the variability of serum 25(OH)D between tests taken at different time intervals. METHODS: Using the computerized database of the largest healthcare provider in Israel, we identified subjects in whom a serum 25(OH)D test was performed on at least two different occasions between January 2008 and September 2011 (n = 188,771). For these subjects we selected the first and the last dated tests, then we identified those who were not treated with supplements during the last 6 months before the first and before the last test (n = 94,418). Of these we analyzed subjects in whom the first and the last tests were performed in the same month of the year (n = 8881). RESULTS: The mean serum 25(OH)D level at the first test was 51.7 ± 24.0 nmol/L and was 56.7 ± 24.7 at the last test (P<0.001); the overall correlation was 0.63 (P < 0.001). For vitamin D status in two categories (<50 versus ≥ 50 nmol/L), the percentage of agreement between the first and last tests was 74.4%, and was 50.8% for vitamin D status in four categories (<30, 30-49.9, 50-74.9, and ≥ 75 nmol/L). The correlation decreased with increasing time between the tests ranging from 0.83 for tests done at the same year to 0.55 after 3 years. The more the first levels were higher or lower, the more likely subjects remain in their first category (≥ 50 versus <50 nmol/L). CONCLUSIONS: Long-term month specific serum 25(OH)D levels are relatively stable.

Electrophysiologic characteristics and catheter ablation of ventricular tachyarrhythmias among patients with heart failure on ventricular assist device support.

BACKGROUND: Ventricular tachyarrhythmias (VT) are common among ventricular assist device (VAD) recipients, yet electrophysiologic (EP) characteristics and catheter ablation outcomes remain uncharacterized. OBJECTIVE: To evaluate the EP characteristics and catheter ablation outcomes for VTs among heart failure patients on VAD support. METHODS: The Cleveland Clinic registry of consecutive patients undergoing VAD placement in 1991-2010 with medically refractory, symptomatic VT referred for EP study and catheter ablation. RESULTS: Among 611 recipients of VAD (mean age 53.3 ± 12.4 years, 80% men), 21 patients (3.4%) were referred for 32 EP procedures, including 11 patients (52%) presenting with implantable cardioverter-defibrillator therapy (13 shocks, 26 antitachycardia pacing). Data from 44 inducible tachycardias (mean cycle length 339 ± 59 ms) demonstrated monomorphic VT (n = 40, 91%; superior axis 52%, right bundle branch block morphology 41%) and polymorphic ventricular tachycardia (PMVT)/ventricular fibrillation (n = 4, 8%). Electroanatomic mapping of 28 tachycardias in 20 patients demonstrated reentrant VT related to intrinsic scar (n = 21 of 28, 75%) more commonly than the apical inflow cannulation site (n = 4 of 28, 14%), focal/microreentry VT (n = 2 of 28, 7%), or bundle branch reentry (n = 1 of 28, 3.5%). Catheter ablation succeeded in 18 of 21 patients (86%). VT recurred in 7 of 21 patients (33%) at a mean of 133 ± 98 days, and 6 patients (29%) required repeat procedures, with subsequent recurrence in 4 of 21 patients (19%). CONCLUSIONS: Catheter ablation of VT is effective among recipients of VAD. Intrinsic myocardial scar, rather than the apical device cannulation site, appears to be the dominant substrate.

Vitamin D status in primary hyperparathyroidism.

BACKGROUND: Hypovitaminosis D worsens the manifestations of primary hyperparathyroidism (PHPT). Only a few studies have assessed the status of vitamin D in PHPT. The objective of this study was to determine the prevalence of 25(OH)D levels<50 nmol/L in PHPT in comparison to a population without PHPT. METHODS: Subjects with PHPT were identified from the computerized database of the Clalit Health Services in Israel and were included only if they had an available serum 25(OH)D test result in 2009 and were not taking vitamin D supplements in 2008-2009 prior to the 25(OH)D test result. Subjects with renal failure were excluded (included n=1180). All other subjects with an available 25(OH)D value in 2009 constituted the control group (n=184,479). RESULTS: Subjects with PHPT and 25(OH)D<50 nmol/L had higher levels of serum PTH, alkaline phosphatase, and calcium levels compared to those with 25(OH)D levels≥50 nmol/L (P<0.02). The mean serum 25(OH)D level was 47.7±22.5 nmol/L compared to 52.1±24.5 nmol/L in the control group (P<0.001). 59.6% of subjects with PHPT had 25(OH)D levels<50 nmol/L as compared to 49.5% in the control group (P<0.001). Logistic regression, controlling for gender, ethnicity, age, and seasonality, showed that PHPT independently predicted 25(OH)D levels<50 nmol/L; OR=1.61(95% CI, 1.43-1.82). CONCLUSIONS: Serum 25(OH)D levels<50 nmol/L are frequent in PHPT, are more common than in controls, and are associated with more severe bone disease based on higher serum PTH and bone turnover biomarkers.

Vitamin D Status in Israeli subjects before the initiation and after the cessation of vitamin D supplements.

Vitamin D supplements are often recommended to restore sufficiency, although the adherence to treatment is low. This study assessed vitamin D status at different time intervals following the cessation of treatment. The database of Clalit-Health-Services (CHS), a not-for-profit HMO covering more than half of the Israeli population, was retrospectively searched for all members with available serum 25OHD test results in 2009 (245,493). We then identified those who filled any cholecalciferol prescription in 2008-2009 (121,817). Subjects were included in the final analysis only if they started treatment in 2009, had serum 25OHD < 50 nmol/l before the first prescription in 2009, and had at least one additional test result after the last dated prescription in 2009 (5,461). Serum 25OHD increased from 32 ± 11 nmol/l at baseline to 58.6 ± 22.3 nmol/l after treatment (P < 0.001). The proportion of subjects with sufficient vitamin D after treatment increased with increasing cholecalciferol daily dose and treatment duration (P < 0.001) and decreased with increasing time from cessation of treatment (P < 0.001). The effect of time from treatment cessation persisted after controlling for baseline serum 25OHD, daily cholecalciferol dose, treatment duration, seasonality, gender, age, ethnicity, and BMI; the ORs for sufficient vitamin D were 2.02 (95% CI 1.66-2.45), 1.67 (1.39-2.01), and 1.23 (1.04-1.47) for >30-60, 61-99, and 100-155 days compared to >155 days, respectively. Long-term vitamin D treatment is needed to maintain sufficient levels in those with baseline serum 25OHD below 50 nmol/l.