Feasibility study for echocardiography-guided lead insertion for permanent cardiac implantable electronic devices.

BACKGROUND: Permanent cardiac implantable electronic devices (CIEDs) are traditionally implanted with the assistance of fluoroscopy. While clinically effective, this technique exposes both patients and providers to radiation which is associated with adverse health effects and represents an occupational hazard. In this study, we investigate the safety and feasibility of permanent CIED placement under the guidance of transthoracic echocardiography (TTE). There is also increasing interest in use of non-fluoroscopic options for noninvasive cardiac electrophysiologic procedures. METHODS: Fifteen patients consecutively consented for initial implant of CIEDs, specifically dual chamber pacemakers (DCPM) and dual chamber implantable cardioverter defibrillators (DCICDs). Patients were excluded if they had previous implants, abandoned leads, or anatomic anomalies including congenital and known persistent left superior vena cava (PLSVC). We used TTE to guide and implant atrial and ventricular leads. RESULTS: Eleven patients received DCPMs and four patients received DCICDs. The procedure duration was 49.3 min for DCICD and 52.3 min for DCPM, p = .807. The average number of right atrial lead attempts was 1.6 for DCPMs and 1.8 for DCICD, p = .860. The average number of right ventricular lead attempts for DCPMs was 2.2 and 1.0 attempt for DCICDs, p = .044. There were no complications at 90-day follow-up. CONCLUSION: We demonstrate the feasibility of TTE-guided DCPM/DCICD implantation without use of fluoroscopy. We present this method as a safe alternative for permanent CIED placement that may reduce risk of radiation exposure and cost while maintaining safety and efficacy. No operators wore lead aprons during the procedure.

School-Based Approaches to Prevent Depression in Adolescents.

Depression is one of the highest prevalent mental illnesses and is one of the common illnesses that can have its onset during childhood or adolescence. It is estimated that up to 20% of children experience mental illness worldwide. Preventing the onset of depression in children and adolescents should be a vital public health goal that will improve public health and decrease health care costs. We reviewed literature that described school-based interventions to prevent the onset of depression, reduce the severity of depressive symptoms, and enhance global functioning in adolescents. Our research also provides strategies for school-based intervention programs that are mainly categorized into three main subtypes. We also discussed each subtype and its advantages and limitations. The goal is to bring the readers an understanding of the importance of preventing depression on a community level, beginning at schools.

An Unusual Clinical Presentation of Immunoglobulin A Vasculitis in an Elderly Patient.

Immunoglobulin A (IgA) vasculitis (IgAV), also known as Henoch-Schonlein purpura, is an IgA-mediated leukocytoclastic vasculitis predominantly affecting the gastrointestinal tract, kidneys, and skin. IgAV appears to be more common in children and is relatively rare in the adult population. We describe a case of a 72-year-old man who presented with bilateral lower extremity swelling, nausea, vomiting, abdominal pain, and weight loss, in which a diagnosis of IgAVs was established with a skin biopsy. This case highlights a rare and unusual clinical presentation of IgAV in an older patient and the need for prompt diagnosis and treatment.

Ischemic Stroke in a Patient With Atrial Tachycardia, Methylenetetrahydrofolate Reductase Mutation and New-Onset Atrial Fibrillation: Is Early Initiation of Anticoagulation Therapy Indicated?

Atrial fibrillation is the most common dysrhythmia, affecting about 6 million people in the United States. Atrial fibrillation has been shown to be an independent risk factor for stroke. Atrial tachycardia are common findings on Holter monitoring in the general population and may be associated with the development of atrial remodeling and atrial fibrillation inducibility. Studies have shown that atrial tachycardia is associated with the development of atrial fibrillation and subsequent stroke. The American Heart Association current guidelines recommend the use of oral anticoagulants in patients with atrial fibrillation and an elevated CHA2DS2-VASc ≥2 in men or ≥3 in women. However, anticoagulant therapy is not currently recommended in patients with atrial tachycardia despite increasing evidence of its association with the development of stroke. We report the case of a 68-year-old woman with a past medical history significant for repetitive atrial tachycardia and methylenetetrahydrofolate reductase mutation who presented to an outside emergency department following a fall, weakness and associated aphasia while in atrial fibrillation. Thrombolysis and control of the patient's rhythm resulted in an initial improvement in the patient symptoms and reversal to normal sinus rhythm. She was subsequently referred to a tertiary stroke center for further management.

Association of Opioid Use With Cardiometabolic Disease Risk Factors: Evidence From the 2009-2018 National Health and Nutrition Examination Survey.

Objective To investigate the association between opioid drug use and cardiometabolic risk factors in an adult sample data acquired from the National Health and Nutrition Examination Survey (NHANES). Methods A retrospective cross-sectional analysis was performed using the data from the NHANES for the period 2009-2018 provided by the Centers for Disease Control and Prevention (CDC), amounting to a total of N = 10,032 eligible participants. The data were analyzed to study the relationship between opioid drug use (dividing into four dichotomy groups: drug use (DU) group, illicit drug use (IDU) group, repeated drug use (RDU) group, and current drug use (CDU) group) and cardiometabolic disease risk factors (CDRF) (i.e., hypertension, abnormal triglyceride levels, low-level of high-density lipoproteins (HDLs), high waist circumference, insulin resistance, serum cotinine levels, higher C-reactive protein, hypercholesterolemia, and increased BMI). The statistical correlation was evaluated using the chi-square analysis, and a p-value of less than 0.05 was considered statistically significant. Alcohol use, age, race, ethnicity, education level, and poverty to income ratio (PIR) were analyzed as covariates.  Results Overall, our analysis found that males were more likely than females (p ≤ 0.001) to have ever reported using drugs at least once in their lifetime. In fact, males were more likely than females to report ever using cocaine (p = 0.01), heroin (p = 0.01), and marijuana (p = 0.01). Additionally, males were significantly more likely than females to disclose the current use of illicit drugs (p = 0.002), and also tend to have consumed more with at least 12 alcoholic beverages per year (p < 0.001). Overall, we found no association between substance use and having a cluster of three or more CDRF variables for both males and females. Conclusion Study results highlight the prevalence of gender differences in DU and its reporting. With the rising popularity of illicit drugs, clinicians must be aware of its association with CDRF.

Ventricular Fibrillation 7 Years After Left Ventricular Assist Device Implantation.

BACKGROUND Congestive heart failure (CHF) affects over 23 million individuals worldwide and over 5.8 million individuals in the United States. Left ventricular assist device (LVAD) implantation is used as both a bridging and destination therapy for patients with advanced CHF. LVADs are reported to cause ventricular arrhythmias. Ventricular tachycardia and ventricular fibrillation (VF) are common fatal arrhythmias in patients with severe CHF if left untreated. We report a case in which a patient with an LVAD without an implantable cardioverter device (ICD) developed VF with non-classical symptoms with an unknown duration prior to defibrillation. CASE REPORT A 74-year old man was brought to the hospital via Emergency Medical Services (EMS) with a 1-day history of altered mental status, somnolence, and slurred speech. His past medical history was significant for CHF with LVAD Heart Mate II. An initial electrocardiogram (ECG) done by EMS was abnormal but was presumed to be an artifact secondary to LVAD. A 12-lead ECG done in the Emergency Center revealed VF. He required electrical defibrillation. Due to ongoing multiple organ failure, he was admitted to the Intensive Care Unit (ICU) for further care. CONCLUSIONS In the management of VF, the time to defibrillation is of paramount importance. LVAD patients could be in VF and present with non-specific symptoms. EMS personnel should be aware of this, as it can appear to be an artifact on ECG.