A close shave? Performance of P2/N95 respirators in healthcare workers with facial hair: results of the BEARDS (BEnchmarking Adequate Respiratory DefenceS) study.

P2/N95 filtering face piece respirators (FFRs) protect healthcare workers (HCWs) from airborne infections. This study assessed the impact of facial hair on quantitative respirator fit in 105 male HCWs, of whom 38 were clean shaven, and assessed the prevalence of male facial hair at the study facility. Only 34 (32%) male HCWs overall achieved an adequate FFR fit, including 47% of clean-shaven men. No full-bearded HCWs achieved a fit. Adequate respirator fit decreased significantly with increasing facial hair (P<0.01 for trend). Facial hair was present on 49% of male employees. This study supports quantitative fit testing prior to P2/N95 respirator use.

Persistent histone modifications at the BDNF and Cdk-5 promoters following extinction of nicotine-seeking in rats.

Drugs of addiction lead to a wide range of epigenetic changes at the promoter regions of genes directly implicated in learning and memory processes. We have previously shown that the histone deactylase inhibitor, sodium butyrate (NaB), accelerates the extinction of nicotine-seeking and provides resistance to relapse. Here, we explore the potential molecular mechanisms underlying this effect. Rats received intravenous nicotine or saline self-administration, followed by 6 days of extinction training, with each extinction session followed immediately by treatment with NaB or vehicle. On the last day of extinction, rats were killed and the medial ventral prefrontal cortex retained for chromatin immunoprecipitation and quantitative polymerase chain reaction (qPCR). A history of nicotine exposure significantly decreased H3K14 acetylation at the brain-derived neurotrophic factor (BDNF) exon IV promoter, and this effect was abolished with NaB treatment. In contrast, nicotine self-administration alone, resulted in a significant decrease in histone methylation at the H3K27me3 and H3K9me2 marks in the promoter regions of BDNF exon IV and cyclin-dependent kinase 5 (Cdk-5). Quantitative PCR-identified changes in several genes associated with NaB treatment that were independent of nicotine exposure; however, an interaction of nicotine history and NaB treatment was detected only in the expression of BDNF IV and BDNF IX. Together these results suggest that nicotine self-administration leads to a number of epigenetic changes at both the BDNF and Cdk-5 promoters, and that these changes may contribute to the enhanced extinction of nicotine-seeking by NaB.

Predictors of Atrial Fibrillation Recurrence after Catheter Ablation: Data from the German Ablation Registry.

Catheter ablation (CA) for atrial fibrillation (AF) has emerged as a widespread first or second line treatment option. However, up to 45% of patients (pts) show recurrence of AF within 12 month after CA. We present prospective multicenter registry data comparing characteristics of pts with and without recurrence of AF within the first year after CA. This study comprises all pts with complete follow-up one year after CA (1-y-FU; n = 3679). During 1y-FU in 1687 (45.9%) pts recurrence of AF occurred. The multivariate analysis revealed female sex and AF type prior to the procedure as predictors for AF recurrence. Furthermore, comorbidities such as valvular heart disease and renal failure as well as an early AF relapse were also predictors of AF recurrence during 1-y-FU. However, despite an AF recurrence rate of 45.9%, the majority of these pts (72.4%) reported a significant alleviation of clinical symptoms. In conclusion in pts with initially successful CA for AF female sex, AF type, in-hospital AF relapse and comorbidities such as renal failure and valvular heart disease are independent predictors for AF recurrence during 1-y-FU. However, the majority of pts deemed their interventions as successful with significant reduction of symptoms irrespective of AF.

New implantable cardiac monitor with three-lead ECG and active noise detection.

BACKGROUND: A new implantable cardiac monitor (BioMonitor, Biotronik) with a continuous remote monitoring option was prospectively implanted in patients with suspected arrhythmias or for therapy control after atrial fibrillation (AF) ablation. A three-lead ECG detection was intended to make the implantation more independent of the implantation site and the electrical heart axis. Because noise is a frequent problem in implantable cardiac monitors, an active noise detection algorithm was implemented. The aim of the trial was to evaluate the clinical performance of the device. METHODS: The device performance was evaluated in a prospective nonrandomized multicenter study with a follow-up of 12 months. Study endpoints were device-related serious adverse events at 3 months, appropriate QRS detection in direct comparison with synchronized Holter ECG recordings, sensitivity and positive predictive value of arrhythmia detection in comparison with Holter ECG and independent of it, and noise burden during the entire follow-up period. RESULTS: The implantation was successful in all 152 patients. Two device-related serious adverse events (pocket infections) occurred by 3 months. The mean QRS amplitude of 0.3 ± 0.2 mV at implantation remained stable over 12 months. QRS sensing performance indicated little over- and undersensing in most patients. More than 80 % of the patients had more than 22 h of noise-free monitoring per day. CONCLUSION: BioMonitor effectively detects patients with bradycardia, tachycardia, AF, or asystole. Active noise detection seems to reduce the transmission of meaningless data without diminishing the positive predictive value of the device.

[Anticoagulation in high thromboembolic risk after catheter ablation for atrial fibrillation: results from the German Ablation Registry]. / Antikoagulationssituation bei hohem thromboembolischem Risiko nach Vorhofflimmerablation: Daten des Ablations-Qualitätsregisters.

BACKGROUND: Catheter ablation (CA) for atrial fibrillation (AF) is an effective therapeutic option for the treatment of symptomatic drug-refractory AF. According to current guidelines, the prevention of stroke and embolism is the most important therapeutic goal in AF and the recommendations for anticoagulation (OAC) after successful CA are based upon the CHA2DS2-VASc-Score 3. The aim of this study was to evaluate the use of OAC in patients with a high risk for thromboembolic events 1 year after CA and to identify predictor variables for discontinuation of OAC. METHODS: Between January 2007 and January 2010 13092 patients were enrolled in the study. A total of 52 German electrophysiological centers agreed to participate in this prospective multicenter registry. 41 centers included patients undergoing CA for AF. Analysis included patients who were discharged with OAC after CA and had a CHA2DS2-VASc-Score ≥ 2. A centralized 1 year follow-up (FU) was conducted via telephone. RESULTS: 1300 patients fulfilled the inclusion criteria. One year after CA 51.8 % of these patients were on OAC. Factors significantly associated with discontinuation of OAC included no AF recurrence in FU (adjusted odds ratio (OR): 2.14, [95 % confidence interval (CI): 1.73-2.66], P < 0.001) and paroxysmal AF (OR: 1.53 [95 % CI: 1.29-1.81], P < 0.001). Factors associated with continuation of OAK were patient age (OR per 10 years: 0.79 [95 % CI: 0.68-0.91], P = 0.002), valvular heart disease (OR: 0.67 [95 % CI: 0.48-0.92], P = 0.013), an implanted pacemaker, defibrillator or a cardiac resynchronization therapy system (OR: 0.55 [95 % CI: 0.41-0.74], P < 0.001) and neurological events in hospital or during FU (OR: 0.40 [95 % CI: 0.18-0.88], P < 0.022). CONCLUSION: Almost half of the patients with an indication for OAC are not adequately anticoagulated one year after CA for AF. Paroxysmal AF or freedom from AF is significantly associated with discontinuation of OAC.

Methyl CpG binding domain ultra-sequencing: a novel method for identifying inter-individual and cell-type-specific variation in DNA methylation.

Experience-dependent changes in DNA methylation can exert profound effects on neuronal function and behaviour. A single learning event can induce a variety of DNA modifications within the neuronal genome, some of which may be common to all individuals experiencing the event, whereas others may occur in a subset of individuals. Variations in experience-induced DNA methylation may subsequently confer increased vulnerability or resilience to the development of neuropsychiatric disorders. However, the detection of experience-dependent changes in DNA methylation in the brain has been hindered by the interrogation of heterogeneous cell populations, regional differences in epigenetic states and the use of pooled tissue obtained from multiple individuals. Methyl CpG Binding Domain Ultra-Sequencing (MBD Ultra-Seq) overcomes current limitations on genome-wide epigenetic profiling by incorporating fluorescence-activated cell sorting and sample-specific barcoding to examine cell-type-specific CpG methylation in discrete brain regions of individuals. We demonstrate the value of this method by characterizing differences in 5-methylcytosine (5mC) in neurons and non-neurons of the ventromedial prefrontal cortex of individual adult C57BL/6 mice, using as little as 50 ng of genomic DNA per sample. We find that the neuronal methylome is characterized by greater CpG methylation as well as the enrichment of 5mC within intergenic loci. In conclusion, MBD Ultra-Seq is a robust method for detecting DNA methylation in neurons derived from discrete brain regions of individual animals. This protocol will facilitate the detection of experience-dependent changes in DNA methylation in a variety of behavioural paradigms and help identify aberrant experience-induced DNA methylation that may underlie risk and resiliency to neuropsychiatric disease.

[Treatment of syncope]. / Therapie der Synkope.

The therapy of patients with syncope is oriented to the underlying pathophysiological mechanisms. Patients with reflex syncope require careful education regarding recognition of warning signs and the avoidance of trigger factors. Treatment with beta blockers is nowadays obsolete. Even other drugs have failed to show any benefit. Pacemaker therapy should only be considered if syncope attacks are frequent and if there is a correlation between symptoms and the electrocardiogram (ECG). Because autonomic failure in patients with orthostatic hypotension is often drug-induced, reduction of the dosage or the complete elimination is the treatment of choice in these patients. A higher than normal salt and fluid intake as well as general measures to avoid delayed venous backflow, e.g. elastic stockings, may also be helpful. A change in blood pressure medication can be decisive for therapy success, especially in elderly patients with arterial hypertension. Pacemaker and defibrillator therapy is the treatment of choice in patients with bradycardia and tachycardia arrhythmias, respectively. Although these measures are simple but effective, in individual cases it is still difficult to find clinical proof that arrhythmic disorders are the causal factors for the syncope. However, also in these patients cardiac pacing should be based on a symptom ECG correlation. The recently conducted market release of the injectable miniaturized ECG recorder will alleviate the diagnostic process. The limits of this approach, however, become obvious when there is the suspicion of a life-threatening rhythm disorder, because the only difference between syncope and sudden cardiac death is that in one case the patient wakes up again.

[Implantable cardioverter defibrillator]. / Implantierbarer Kardioverter/Defibrillator.

This article aims to give an overview over important articles in the field of implantable cardioverter defibrillator (ICD) therapy in 2012. Important publications concern analyses on therapy efficacy and safety of the subcutaneous ICD, gender-specific differences in the complication rate and prognosis after ICD implantation, the necessity of intraoperative testing of the defibrillation threshold and the impact of preventive measures to reduce ICD therapies on prognosis after device implantation. The relevance of the study findings for daily clinical practice is briefly discussed.

Republished: Improving hand hygiene in a paediatric hospital: a multimodal quality improvement approach.

BACKGROUND: Effective hand hygiene has long been recognised as an important way to reduce the transmission of bacterial and viral pathogens in healthcare settings. However, many studies have shown that adherence to hand hygiene remains low, and improvement efforts have often not delivered sustainable results. The Children's Hospital at Westmead is the largest tertiary paediatric hospital in Sydney, Australia. The hospital participated in a state-wide 'Clean hands save lives' campaign which was initiated in 2006. INTERVENTION: Strong leadership, good stakeholder engagement, readily accessible alcohol-based hand rub at the point of patient care, a multifaceted education programme, monitoring of staff, adherence to recommended hand hygiene practices and contemporaneous feedback of performance data have significantly improved and maintained compliance with hand hygiene. RESULTS: Hand hygiene compliance has increased from 23% in 2006 to 87% in 2011 (p<0.001). Sustained improvement in compliance with hand hygiene has been evident in the last 4 years. A decline in a set of hospital-acquired infections (including rotavirus, multiresistant organism transmission, and nosocomial bacteraemia) has also been noted as hand hygiene rates have improved. Monthly usage of alcohol-based hand rub has increased from 16 litres/1000 bed days to 51 litres/1000 bed days during this same period. CONCLUSION: This project has delivered sustained improvement in hand hygiene compliance by establishing a framework of multimodal evidence-based strategies.

Improving hand hygiene in a paediatric hospital: a multimodal quality improvement approach.

BACKGROUND: Effective hand hygiene has long been recognised as an important way to reduce the transmission of bacterial and viral pathogens in healthcare settings. However, many studies have shown that adherence to hand hygiene remains low, and improvement efforts have often not delivered sustainable results. The Children's Hospital at Westmead is the largest tertiary paediatric hospital in Sydney, Australia. The hospital participated in a state-wide 'Clean hands save lives' campaign which was initiated in 2006. INTERVENTION: Strong leadership, good stakeholder engagement, readily accessible alcohol-based hand rub at the point of patient care, a multifaceted education programme, monitoring of staff, adherence to recommended hand hygiene practices and contemporaneous feedback of performance data have significantly improved and maintained compliance with hand hygiene. RESULTS: Hand hygiene compliance has increased from 23% in 2006 to 87% in 2011 (p<0.001). Sustained improvement in compliance with hand hygiene has been evident in the last 4 years. A decline in a set of hospital-acquired infections (including rotavirus, multiresistant organism transmission, and nosocomial bacteraemia) has also been noted as hand hygiene rates have improved. Monthly usage of alcohol-based hand rub has increased from 16 litres/1000 bed days to 51 litres/1000 bed days during this same period. CONCLUSION: This project has delivered sustained improvement in hand hygiene compliance by establishing a framework of multimodal evidence-based strategies.

Use of empiric antimicrobial therapy in neutropenic fever. Australian Consensus Guidelines 2011 Steering Committee.

Administration of empiric antimicrobial therapy is standard practice in the management of neutropenic fever, but there remains considerable debate about the selection of an optimal regimen. In view of emerging evidence regarding efficacy and toxicity differences between empiric treatment regimens, and strong evidence of heterogeneity in clinical practice, the current guidelines were developed to provide Australian clinicians with comprehensive guidance for selecting an appropriate empiric strategy in the setting of neutropenic fever. Beta-lactam monotherapy is presented as the treatment of choice for all clinically stable patients while early treatment with combination antibiotic therapy is considered for patients at higher risk. Due consideration is given to the appropriate use of glycopeptides in this setting. Several clinical caveats, accounting for institution- and patient-specific risk factors, are provided to help guide the judicious use of the agents described. Detailed recommendations are also provided regarding time to first dose, timing of blood cultures, selection of a first-line antibiotic regimen, subsequent modification of antibiotic choice and cessation of therapy.

[ICD therapy for primary prevention. The patient in the early post-infarct phase]. / ICD-Therapie zur Primärprävention. Der Patient in der frühen Postinfarktphase.

There is high mortality during the first few weeks after an acute myocardial infarction. However, according to the guidelines, the prophylactic implantation of an ICD, given the corresponding risk constellation, is recommended not earlier than 1 month after acute myocardial infarction. This article analyzes available data and highlights that the recently published IRIS study supports current clinical practise.

Venous thromboembolism in a general hospital. An update with low molecular weight heparin prophylaxis.

BACKGROUND: Patients admitted to hospital for surgery or acute medical illnesses have a high risk for venous thromboembolism (VTE). Today's widespread use of low molecular weight heparins (LMWH) for VTE prophylaxis is supposed to have reduced VTE rates substantially. However, data concerning the overall effectiveness of LMWH prophylaxis is sparse. PATIENTS AND METHODS: We prospectively studied all patients with symptomatic and objectively confirmed VTE seen in our hospital over a three year period. Event rates in different wards were analysed and compared. VTE prophylaxis with Enoxaparin was given to all patients at risk during their hospital stay. RESULTS: A total of 50 464 inpatients were treated during the study period. 461 examinations were carried out for symptoms suggestive of VTE and yielded 89 positive results in 85 patients. Seventy eight patients were found to have deep vein thrombosis, 7 had pulmonary embolism, and 4 had both deep venous thrombosis and pulmonary embolism. The overall in hospital VTE event rate was 0.17%. The rate decreased during the study period from 0.22 in year one to 0,16 in year two and 0.13 % in year three. It ranged highest in neurologic and trauma patients (0.32%) and lowest (0.08%) in gynecology-obstetrics. CONCLUSIONS: With a simple and strictly applied regimen of prophylaxis with LMWH the overall rate of symptomatic VTE was very low in our hospitalized patients. Beside LMWH prophylaxis, shortening hospital stays and substantial improvements in surgical and anesthesia techniques achieved during the last decades probably play an essential role in decreasing VTE rates.

[Epidemiology of sudden cardiac death]. / Epidemiologie des akuten Herz-Kreislaufstillstandes.

Sudden cardiac death remains a major challenge that we are still facing today. The complexity of the trigger mechanisms makes it difficult to achieve a reliable identification of high-risk patients. Three suggestions are made that might help to overcome this epidemiological catastrophe "Sudden Cardiac Death". 1. In patients with known heart disease risk stratification has to be improved by developing new methods to identify specifically those individuals, who are at risk for sudden rather than non-sudden cardiac death. 2. The general population contains an unknown proportion of individuals with advanced coronary disease, which is commonly asymptomatic. In these so called "normal population" classical risk stratification does not work. However, since there is a close relationship between the prevalence of risk factors for coronary disease and sudden death, a consequent treatment of risk factors should have a positive effect on sudden death rate as well. 3. The success rate of resuscitation has to be improved by strengthening each single link of the "chain of survival". Laypersons trained in basic and advanced life support techniques have to play a much major role on this scene.