A devices' game of thrones: cardiac resynchronization therapy vs. pacemaker.

AIMS: Oversensing can interfere with biventricular pacing. Cardiac Resynchronization Therapy (CRT) output inhibition due to automatic brady mode change from a sensing to a pacing mode of a previously implanted pacemaker as it reached battery capacity depleted indicator has not been previously published in the medical literature. METHODS AND RESULTS: We report the first case of CRT output inhibition in a pacemaker dependent patient due to electrical stimuli from a previously right-sided implanted pacemaker, after unaware reversion of OVO mode (O = no chambers paced; V = ventricular sensing; O = no response to sensing) to backup VVI (V = ventricular pacing; V = ventricular sensing; I = inhibitory response to sensing) when it reached the elective replacement interval. CONCLUSION: This paper emphasizes the importance of knowing the distinct pacemaker brady mode behaviours after battery capacity depleted indicator has been reached, according to the pacemakers' manufacturer, including the possibility of automatic brady mode change from sensing to pacing mode. It also highlights the potential for severe bradycardia or asystole of this automatic brady mode change from a previously implanted pacemaker in pacemaker dependent patients submitted to CRT upgrade.

Transcatheter aortic valve implantation and requirements of pacing over time.

BACKGROUND: A permanent pacemaker (PPM) implantation is common after transcatheter aortic valve implantation (TAVI). We sought to evaluate requirements of pacing and incidence of pacemaker dependency during the first year after TAVI. METHODS: From August 2007 until May 2011, 65 patients underwent TAVI with self-expandable prosthesis. Five patients paced at baseline and two procedure-related deaths were excluded. Evaluation of ventricular pacing percentage (VP%) and look for spontaneous rhythm were performed at 3, 6, and 12 months. RESULTS: PPM implantation was required in 19/58 patients (33%). Mean VP% decreased between assessments (59% at 3 months, 48% at 6 months, 50% at 12 months), but overall VP% at 1 year was high (57% ± 43%) and most patients were paced ≥10% of time. A favorable annulus-to-aorta angle was associated with lower pacing requirements (60% of patients paced ≤10% of time vs 10% of patients paced >10% of time presented an angle ≤30°, P = 0.039). Pacemaker dependency was established in 27% of patients and could be predicted by the presence of porcelain aorta (odds ratio = 30, confidence interval 95% 1-638, P = 0.029). New postprocedural left bundle branch block (LBBB) had a negative impact on 1-year survival (58% vs 82% in non-LBBB group, P = 0.111). PPM implantation had no impact on 1-year survival. CONCLUSIONS: One third of patients required PPM after TAVI and full recovery of advanced conduction abnormalities seems unlikely. Unfavorable aortic root orientation may hinder the deployment of the valve and contribute to the continued impairment of the conduction system. Porcelain aorta was a strong predictor of pacemaker dependency.

Complete genome sequence of a sucrose-nonfermenting epidemic strain of Vibrio cholerae O1 from Brazil.

We report the genome sequence of Vibrio cholerae strain IEC224, which fails to ferment sucrose. It was isolated from a cholera outbreak in the Amazon. The defective sucrose phenotype was determined to be due to a frameshift mutation, and a molecular marker of the Latin American main epidemic lineage was identified.

Fetal and maternal immune responses to methylmercury exposure: a cross-sectional study.

Methylmercury (MeHg) is a ubiquitous environmental contaminant with known neurodevelopmental effects. In humans, prenatal exposures primarily occur through maternal consumption of contaminated fish. In this study, we evaluated the association between prenatal exposure to MeHg and titers of total immunoglobulins (Ig) and specific autoantibodies in both mothers and fetuses by analyzing maternal and cord blood serum samples. We examined multiple immunoglobulin isotypes to determine if these biomarkers could inform as to fetal or maternal responses since IgG but not IgM can cross the placenta. Finally, we evaluated serum cytokine levels to further characterize the immune response to mercury exposure. The study was conducted using a subset of serum samples (N=61 pairs) collected from individuals enrolled in a population surveillance of MeHg exposures in the Brazilian Amazon during 2000/2001. Serum titers of antinuclear and antinucleolar autoantibodies were measured by indirect immunofluorescence. Serum immunoglobulins were measured by enzyme-linked immunosorbent assay (ELISA) and BioPlex multiplex assay. Serum cytokines were measured by BioPlex multiplex assay. In this population, the geometric mean mercury level was within the 95th percentile for US populations of women of childbearing age but the upper level of the range was significantly higher. Fetal blood mercury levels were higher (1.35 times) than those in their mothers, but highly correlated (correlation coefficient [r]=0.71; 95% CI: 0.54, 0.89). Total IgG (r=0.40; 95% CI: 0.19, 0.62) and antinuclear autoantibody (odds ratio [OR]=1.05; 95% CI: 1.02, 1.08) levels in paired maternal and fetal samples were also associated; in contrast, other immunoglobulin (IgM, IgE, and IgA) levels were not associated between pairs. Total IgG levels were significantly correlated with both maternal (r=0.60; 95% CI: 0.25, 0.96) and cord blood mercury levels (r=0.61; 95% CI: 0.25, 0.97), but individual isotypes were not. Serum cytokines, interleukin-1ß (r=0.37; 95% CI: 0.01, 0.73), interleukin-6 (r=0.34; 95% CI: 0.03, 0.65), and tumor necrosis factor-α (r=0.24; 95% CI: 0.015, 0.47), were positively correlated between maternal and fetal samples. Antinuclear and antinucleolar autoantibody titer and serum cytokine levels, in either maternal or cord blood, were not significantly associated with either maternal or cord blood mercury levels. These data provide further evidence that there are likely IgG biomarkers of mercury-induced immunotoxicity in this population since IgG levels were elevated with increased, and associated with, mercury exposure. However, unlike previous data from adult males and non-pregnant females, we found no evidence that antinuclear and antinucleolar autoantibody titer is a reliable biomarker of mercury immunotoxicity in this population.

Long-term clinical outcomes after upgrade to resynchronization therapy: A propensity score-matched analysis.

BACKGROUND: Upgrade to cardiac resynchronization therapy (CRT) is common in Europe, despite little and conflicting evidence. OBJECTIVE: To compare long-term clinical outcomes in a cohort of patients receiving de novo or upgrade to CRT. METHODS: Single-center retrospective study of 295 consecutive patients submitted to CRT implantation between 2007 and 2018. Upgraded and de novo patients complying with a dedicated follow-up protocol were compared in terms of clinical (NYHA class improvement without major adverse cardiac events [MACE] in the first year of follow-up) and echocardiographic (left ventricle end-systolic volume reduction of >15% during the first year) response. RESULTS: No differences in the rate of clinical (59.3% vs 62.6%, P = .765) or echocardiographic response (72.2% vs 71.9%, P = .970) between groups were observed. Device-related complications were also comparable between groups (8.9% vs 8.4%, P = .892). Occurrence of MACE and all-cause mortality were analyzed over a median follow-up of 3 (interquartile range 1-6) years: MACE occurred less frequently in the de novo group (hazard ratio [HR]: 0.55, 95% confidence interval [CI]: 0.34-0.90, P = .018), but all-cause mortality was similar among groups (HR: 0.87, 95% CI: 0.46-1.64, P = .684). Propensity score-matching analysis was performed to adjust for possible confounder variables. In the propensity-matched samples, all-cause mortality (HR: 1.26, 95% CI: 0.56-2.77, P = .557) and MACE (HR: 0.84, 95% CI: 0.46-1.54, P = .574) were comparable between upgrade and de novo patients. CONCLUSION: Survival after upgrade to resynchronization therapy was comparable to de novo implants. Additionally, clinical and echocardiographic response to CRT in upgraded patients were similar to de novo patients.

Long-term outcomes after radiofrequency catheter ablation of the atrioventricular node: The experience of a Portuguese tertiary center.

INTRODUCTION: In patients with supraventricular arrhythmias and high ventricular rate, unresponsive to rate and rhythm control therapy or catheter ablation, atrioventricular (AV) node ablation may be performed. OBJECTIVES: To assess long-term outcomes after AV node ablation and to analyze predictors of adverse events. METHODS: We performed a detailed retrospective analysis of all patients who underwent AV node ablation between February 1997 and February 2019, in a single Portuguese tertiary center. RESULTS: A total of 123 patients, mean age 69±9 years and 52% male, underwent AV node ablation. Most of them presented atrial fibrillation at baseline (65%). During a median follow-up of 8.5 years (interquartile range 3.8-11.8), patients improved heart failure (HF) functional class (NYHA class III-IV 46% versus 13%, p=0.001), and there were reductions in hospitalizations due to HF (0.98±1.3 versus 0.28±0.8, p=0.001) and emergency department (ED) visits (1.1±1 versus 0.17±0.7, p=0.0001). There were no device-related complications. Despite permanent pacemaker stimulation, left ventricular ejection fraction did not worsen (47±13% vs. 47%±12, p=0.63). Twenty-eight patients died (23%). The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome (OR 1.8, 95% CI 1.24-2.61, p=0.002). CONCLUSIONS: Despite pacemaker dependency, the clinical benefit of AV node ablation persisted at long-term follow-up. The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome. AV node ablation should probably be considered earlier in the treatment of patients with supraventricular arrhythmias and HF, especially in cases that are unsuitable for selective ablation of the specific arrhythmia.

Correlation between blood mercury levels in mothers and newborns in Itaituba, Pará State, Brazil.

This study evaluated transplacental mercury transfer by measuring Hg in blood samples of mothers and newborns (umbilical cord) in hospitals in the municipality (county) of Itaituba, Pará State, Brazil. Epidemiological and mercury exposure data were collected, besides clinical birth data. Mercury tests were performed by cold-vapor atomic absorption spectrophotometry. A total of 1,510 women and an equal number of their newborns participated in the study. Mean blood mercury was 11.53 microg/L in mothers and 16.68 microg/L in newborns (umbilical cord). The highest Hg levels were in the 31-40-year maternal age group and their newborns, with 14.37 microg/L and 21.87 microg/L, respectively. However, in all age groups the mean mercury level was higher in newborns than in mothers. There was a strong positive correlation between Hg levels in newborns and mothers (r = 0.8019; p = 0.000), with a significant linear regression model (r = 0.5283; p = 0.000). The results highlight the importance of monitoring pregnant women exposed to mercury as part of public health surveillance.

Diabetes gestacional y pregestacional: características perinatales y morbilidad neonatal / Gestational and pregestational diabetes: Perinatal characteristics and neonatal morbidity

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Lead Extraction of Cardiac Rhythm Devices: A Report of a Single-Center Experience.

INTRODUCTION AND OBJECTIVES: The rate of implanted cardiac electronic devices is increasing as is the need to manage long-term complications. Lead removal is becoming an effective approach to treat such complications. We present our experience in lead removal using different approaches, analyzing the predictors of the use of mechanical extractors/surgical removal. METHODS: Retrospective analysis of lead extractions in a series of 76 consecutive patients (mean age 70.4 ± 13.8 years, 73.7% men) between January 2009 and November 2015. RESULTS: One hundred thirty-five leads from permanent pacemakers (single chamber 19.7%; dual-chamber 61.8%), implantable cardioverter defibrillators (5.3%), and cardiac resynchronization devices (CRT-P 2.6%; CRT-D 7.9%) were removed, 72.5 ± 73.2 months after implantation. A total of 45.9% were ventricular leads, 40.0% atrial leads, 8.9% defibrillator leads, and 5.2% leads in the coronary sinus; 64.4% had passive fixation. The most common indications for removal were pocket infection (77.8%), infective endocarditis (9.6%), and lead dislodgement (3.7%). A total of 76.3% of the leads were explanted, 20.0% were extracted, and 3.7% were surgically removed. Extraction of the entire lead was achieved in 96.3% of the procedures. After logistic regression (age adjusted), time since implantation was the sole predictor of the need of mechanical extractors/surgical removal. All patients were discharged without major complications. There were no deaths at 30 days. CONCLUSION: Our experience in lead removal was effective and safe. Performing these procedures by experienced electrophysiologists with an adequate cardiothoracic surgery team on standby to cope with any complications is required. Referral of high-risk patients to a high-volume center is recommended to optimize clinical success and minimize procedural complications.

Performance on neurological development tests by riverine children with moderate mercury exposure in Amazonia, Brazil.

The nervous system can be damaged when the population is exposed to methyl mercury (MeHg) by ingesting fish, and children deserve special attention due to their increased susceptibility as compared to adults. A comparative cross-sectional study was performed in order to investigate the use of a battery of neurological development tests in two groups of 209 riverine children from 3 to 7 years old: a group exposed to moderate levels of MeHg (n = 75) and a control group (n = 134). The study included a questionnaire, the collection of scalp hair samples for determination of total mercury concentration, and performance on a test for evaluating neurological function in children. Riverine children presented higher exposure to MeHg (mean hair Hg = 5.37 +/- 3.35 microg x g(-1)) in comparison to the control group (mean Hg = 2.08 +/- 1.37 microg x g(-1)). Both groups showed a high proportion of children with what was considered "non-normal" performance, suggesting that the results could not be related to mercury exposure and that this type of test presented limitations for use with river-dwelling Amazon communities.

Mercury levels assessment in hair of riverside inhabitants of the Tapajós River, Pará State, Amazon, Brazil: fish consumption as a possible route of exposure.

The study present evaluated the levels of mercury (Hg) and methylmercury (MeHg) in hair samples of people from Barreiras community, riverside inhabitants of the Tapajós River (Pará, Brazil), an area impacted by clandestine gold mining, as well as we analyzed the levels of Hg and Se (selenium) in nine fish species (carnivores and non-carnivorous) from the Tapajós River, which stand out as the main species consumed by riverside inhabitants, to evaluate a relationship between frequency of fish consumption and Hg concentration, and also to evaluate possible mechanisms of fish protection (or non-protection) to Hg exposure by Se. Furthermore we analyze the water quality to evaluate the environmental trophic state, fact responsible by creating conditions that can potentiate the effects of toxic mercury. Concentrations of Hg and MeHg were analyzed in hair samples of 141 volunteers in different age band. Of those, 84.40% of samples present values above the threshold for biological tolerance, which is 6.00µgg(-1) of total Hg in hair. Total Hg, in men there was a variation of 2.07-24.93µgg(-1), while for women the variation was 4.84-27.02µgg(-1). Consequently, the level of MeHg in men presented a variation of 1.49-19.57µgg(-1), with an average of 11.68µgg(-1), while with women the variation was from 3.73 to 22.35µgg(-1), with an average of 10.38µgg(-1). In fish species, Hg concentrations in carnivorous species had an average of 0.66µgg(-1), higher than that permitted by current legislation, ranging from 0.30 to 0.98µgg(-1), while the non-carnivorous species have values below the recommended by the legislation averaging 0.09µgg(-1), ranging between 0.02 and 0.44µgg(-1). For Se in fish, show that among carnivores, the contents of Se ranged between 0.18 and 0.54µgg(-1) with a mean of 0.34µgg(-1), while for non-carnivores these values were of the order of 0.16-0.56µgg(-1), with an average of 0.32µgg(-1). In surface water quality variables at the sampling points all showed values in accordance with the range established by current legislation. In this regard, the results provided by this study, while not conclusive, are strong indicators that despite not having been shown the relationship between the concentration of mercury in hair and feeding habits along the Tapajós River basin communities showed that a plausible correlation exists between levels of mercury and selenium in fish. This fact may serve as a subsidy to research human health, because in the Amazon, there is still a lot to examine with regards to the full understanding of the Se cycle.

Effect of Cinnamon Tea on Postprandial Glucose Concentration.

Glycaemic control, in particular at postprandial period, has a key role in prevention of different diseases, including diabetes and cardiovascular events. Previous studies suggest that postprandial high blood glucose levels (BGL) can lead to an oxidative stress status, which is associated with metabolic alterations. Cinnamon powder has demonstrated a beneficial effect on postprandial glucose homeostasis in animals and human models. The purpose of this study is to investigate the effect of cinnamon tea (C. burmannii) on postprandial capillary blood glucose level on nondiabetic adults. Participants were given oral glucose tolerance test either with or without cinnamon tea in a randomized clinical trial. The data revealed that cinnamon tea administration slightly decreased postprandial BGL. Cinnamon tea ingestion also results in a significantly lower postprandial maximum glucose concentration and variation of maximum glucose concentration (p < 0.05). Chemical analysis showed that cinnamon tea has a high antioxidant capacity, which may be due to its polyphenol content. The present study provides evidence that cinnamon tea, obtained from C. burmannii, could be beneficial for controlling glucose metabolism in nondiabetic adults during postprandial period.

Human exposure and risk assessment associated with mercury contamination in artisanal gold mining areas in the Brazilian Amazon.

Mercury (Hg) contamination is an issue of concern in the Amazon region due to potential health effects associated with Hg exposure in artisanal gold mining areas. The study presents a human health risk assessment associated with Hg vapor inhalation and MeHg-contaminated fish ingestion, as well as Hg determination in urine, blood, and hair, of human populations (about 325 miners and 321 non-miners) from two gold mining areas in the Brazilian Amazon (São Chico and Creporizinho, Pará State). In São Chico and Creporizinho, 73 fish specimens of 13 freshwater species, and 161 specimens of 11 species, were collected for total Hg determination, respectively. The hazard quotient (HQ) is a risk indicator which defines the ratio of the exposure level and the toxicological reference dose and was applied to determine the threat of MeHg exposure. The mean Hg concentrations in fish from São Chico and Creporizinho were 0.83 ± 0.43 and 0.36 ± 0.33 µg/g, respectively. More than 60 and 22 % of fish collected in São Chico and Creporizinho, respectively, were above the Hg limit (0.5 µg/g) recommended by WHO for human consumption. For all sampling sites, HQ resulted from 1.5 to 28.5, except for the reference area. In Creporizinho, the values of HQ are close to 2 for most sites, whereas in São Chico, there is a hot spot of MeHg contamination in fish (A2-São Chico Reservoir) with the highest risk level (HQ = 28) associated with its human consumption. Mean Hg concentrations in urine, blood, and hair samples indicated that the miners group (in São Chico: urine = 17.37 µg/L; blood = 27.74 µg/L; hair = 4.50 µg/g and in Creporizinho: urine = 13.75 µg/L; blood = 25.23 µg/L; hair: 4.58 µg/g) was more exposed to mercury compared to non-miners (in São Chico: urine = 5.73 µg/L; blood = 16.50 µg/L; hair = 3.16 µg/g and in Creporizinho: urine = 3.91 µg/L; blood = 21.04 µg/L, hair = 1.88 µg/g). These high Hg levels (found not only in miners but also in non-miners who live near the mining areas) are likely to be related to a potential hazard due to exposure to both Hg vapor by inhalation and to MeHg-contaminated fish ingestion.

[Mercury exposure evaluation among Pakaanóva Indians, Amazon Region, Brazil]. / Avaliação dos níveis de exposição ao mercúrio entre índios Pakaanóva, Amazônia, Brasil.

A cross-sectional study was conducted to evaluate mercury (Hg) exposure among 910 Pakaan va Indians from the counties of Guajar Mirim and Nova Marmor , Rond nia State, Brazil. Individual hair samples were taken from the occipital region, and Hg was measured by atomic absorption spectrometry with cold vapor generation. Mean Hg in hair samples was 8.37 micro g/g (range 0.52-83.89), indicating high exposure. Young children (< 2 years old) showed a mean Hg of 10.54 micro g/g, and children from 3 to 5 years old had a mean Hg of 9.34 micro g/g. Mercury levels in women (8,91 micro g/g) were higher than in men (7.55 micro g/g), and this difference was significant (t = 3.26; p < 0.01). These results indicate the need for surveillance programs and complementary studies including the Pakaan va Indians in Rond nia State.

[The elaboration of analgesic protocols for the elderly. The experience of a multidisciplinary group]. / Elaboration de protocoles antalgiques pour le sujet âgé. L'expérience d'un groupe pluridisciplinaire.

TAKING INTO CONSIDERATION THE PAIN: This has become a right for the patient, an ethical and deontological necessity for the physician, and a near-judicial obligation for care centres. The current regulations authorise nurses to apply analgesic treatments, within the framework of written protocols, signed and dated by the physician. A NEW METHOD: In order to determine the main acute pains of the elderly in institutions and to develop analgesic protocols permitting rapid and efficient relief, with priority given to non-medical treatments, a multidisciplinary group consisting of nurses and non-nursing care workers has been made up. Training tools have been created and distributed. CONCRETE RESULTS: After 14 months' work, the initial objective has been reached. Five analgesic protocols taking into account acute pain in the elderly have been drawn-up. All the care workers have been trained by their nursing colleagues. Following validation, the protocols have been applied for the past year in the department and are now being circulated to other care structures.

Mercury speciation in hair of children in three communities of the Amazon, Brazil.

Children from riverside communities located downstream of gold mining areas may be chronically exposed to relatively high levels of MeHg through the consumption of fish of this region. The objective of this study was to evaluate and compare levels of THg and MeHg in hair of children less than 12 years in communities near mines in the municipality of Itaituba and in communities far from prospecting areas in the city of Abaetetuba. The communities of Itaituba (Barreiras and São Luiz do Tapajós) had THg mean levels of 5.64±5.55 µg·g(-1) (0.43-27.82) and 11.41±7.16 µg.g(-1) (1.08-28.17), respectively, and an average count of MeHg relative to THg of 92.20% and 90.27%, respectively. In the Maranhão community, the THg average concentrations results were 2.27±2.11 µg·g(-1) (0.13-9.54) and the average values were 93.17% for MeHg. Children of Itaituba had average levels of mercury above the limit established by the World Health Organization (10 µg·g(-1)) and the strong correlation coefficient between the communities (R=0.968 and P=0.0001) suggests the hair as an excellent biomarker of human exposure to organic mercury in riverside populations of the Tapajós, which has the intake of fish daily as main source of protein dietary.

Population and genetic study of Vibrio cholerae from the amazon environment confirms that the WASA-1 prophage is the main marker of the epidemic strain that circulated in the region.

Vibrio cholerae is a natural inhabitant of many aquatic environments in the world. Biotypes harboring similar virulence-related gene clusters are the causative agents of epidemic cholera, but the majority of strains are harmless to humans. Since 1971, environmental surveillance for potentially pathogenic V. cholerae has resulted in the isolation of many strains from the Brazilian Amazon aquatic ecosystem. Most of these strains are from the non-O1/non-O139 serogroups (NAGs), but toxigenic O1 strains were isolated during the Latin America cholera epidemic in the region (1991-1996). A collection of environmental V. cholerae strains from the Brazilian Amazon belonging to pre-epidemic (1977-1990), epidemic (1991-1996), and post-epidemic (1996-2007) periods in the region, was analyzed. The presence of genes related to virulence within the species and the genetic relationship among the strains were studied. These variables and the information available concerning the strains were used to build a Bayesian multivariate dependency model to distinguish the importance of each variable in determining the others. Some genes related to the epidemic strains were found in environmental NAGs during and after the epidemic. Significant diversity among the virulence-related gene content was observed among O1 strains isolated from the environment during the epidemic period, but not from clinical isolates, which were analyzed as controls. Despite this diversity, these strains exhibited similar PFGE profiles. PFGE profiles were significant while separating potentially epidemic clones from indigenous strains. No significant correlation with isolation source, place or period was observed. The presence of the WASA-1 prophage significantly correlated with serogroups, PFGE profiles, and the presence of virulence-related genes. This study provides a broad characterization of the environmental V. cholerae population from the Amazon, and also highlights the importance of identifying precisely defined genetic markers such as the WASA-1 prophage for the surveillance of cholera.