Association of the Timing and Extent of Cardiac Implantable Electronic Device Infections With Mortality.

Importance: Cardiac implantable electronic device (CIED) infection is a potentially devastating complication with an estimated 12-month mortality of 15% to 30%. The association of the extent (localized or systemic) and timing of infection with all-cause mortality has not been established. Objective: To evaluate the association of the extent and timing of CIED infection with all-cause mortality. Design, Setting, and Participants: This prospective observational cohort study was conducted between December 1, 2012, and September 30, 2016, in 28 centers across Canada and the Netherlands. The study included 19 559 patients undergoing CIED procedures, 177 of whom developed an infection. Data were analyzed from April 5, 2021, to January 14, 2023. Exposures: Prospectively identified CIED infections. Main Outcomes and Measures: Time-dependent analysis of the timing (early [≤3 months] or delayed [3-12 months]) and extent (localized or systemic) of infection was performed to determine the risk of all-cause mortality associated with CIED infections. Results: Of 19 559 patients undergoing CIED procedures, 177 developed a CIED infection. The mean (SD) age was 68.7 (12.7) years, and 132 patients were male (74.6%). The cumulative incidence of infection was 0.6%, 0.7%, and 0.9% within 3, 6, and 12 months, respectively. Infection rates were highest in the first 3 months (0.21% per month), reducing significantly thereafter. Compared with patients who did not develop CIED infection, those with early localized infections were not at higher risk for all-cause mortality (no deaths at 30 days [0 of 74 patients]: adjusted hazard ratio [aHR], 0.64 [95% CI, 0.20-1.98]; P = .43). However, patients with early systemic and delayed localized infections had an approximately 3-fold increase in mortality (8.9% 30-day mortality [4 of 45 patients]: aHR, 2.88 [95% CI, 1.48-5.61]; P = .002; 8.8% 30-day mortality [3 of 34 patients]: aHR, 3.57 [95% CI, 1.33-9.57]; P = .01), increasing to a 9.3-fold risk of death for those with delayed systemic infections (21.7% 30-day mortality [5 of 23 patients]: aHR, 9.30 [95% CI, 3.82-22.65]; P < .001). Conclusions and Relevance: Findings suggest that CIED infections are most common within 3 months after the procedure. Early systemic infections and delayed localized infections are associated with increased mortality, with the highest risk for patients with delayed systemic infections. Early detection and treatment of CIED infections may be important in reducing mortality associated with this complication.

Impact of Choice of Prophylaxis on the Microbiology of Cardiac Implantable Electronic Device Infections: Insights From the Prevention of Arrhythmia Device Infection Trial (PADIT).

BACKGROUND: The Prevention of Arrhythmia Device Infection Trial (PADIT) investigated whether intensification of perioperative prophylaxis could prevent cardiac implantable electronic device (CIED) infections. Compared with a single dose of cefazolin, the perioperative administration of cefazolin, vancomycin, bacitracin, and cephalexin did not significantly decrease the risk of infection. Our objective was to compare the microbiology of infections between study arms in PADIT. METHODS: This was a post hoc analysis. Differences between study arms in the microbiology of infections were assessed at the level of individual patients and at the level of microorganisms using the Fisher exact test. RESULTS: Overall, 209 microorganisms were reported from 177 patients. The most common microorganisms were coagulase-negative staphylococci (CoNS; 82/209 [39.2%]) and S. aureus (75/209 [35.9%]). There was a significantly lower proportion of CoNS in the incremental arm compared with the standard arm (30.1% vs 46.6%; P = .04). However, there was no significant difference between study arms in the frequency of recovery of other microorganisms. In terms of antimicrobial susceptibility, 26.5% of microorganisms were resistant to cefazolin. CoNS were more likely to be cefazolin-resistant in the incremental arm (52.2% vs 26.8%, respectively; P = .05). However, there was no difference between study arms in terms of infections in which the main pathogen was sensitive to cefazolin (77.8% vs 64.3%; P = .10) or vancomycin (90.8% vs 90.2%; P = .90). CONCLUSIONS: Intensification of the prophylaxis led to significant changes in the microbiology of infections, despite the absence of a decrease in the overall risk of infections. These findings provide important insight on the physiopathology of CIED infections. TRIAL REGISTRATION: NCT01002911.

Transport of a Single Cold Ion Immersed in a Bose-Einstein Condensate.

We investigate transport dynamics of a single low-energy ionic impurity in a Bose-Einstein condensate. The impurity is implanted into the condensate starting from a single Rydberg excitation, which is ionized by a sequence of fast electric field pulses aiming to minimize the ion's initial kinetic energy. Using a small electric bias field, we study the subsequent collisional dynamics of the impurity subject to an external force. The fast ion-atom collision rate, stemming from the dense degenerate host gas and the large ion-atom scattering cross section, allow us to study a regime of frequent collisions of the impurity within only tens of microseconds. Comparison of our measurements with stochastic trajectory simulations based on sequential Langevin collisions indicate diffusive transport properties of the impurity and allows us to measure its mobility. Our results open a novel path to study dynamics of charged quantum impurities in ultracold matter.

Risk Factors for Infections Involving Cardiac Implanted Electronic Devices.

BACKGROUND: Cardiac implantable electronic device infection is a major complication that usually requires device removal. PADIT (Prevention of Arrhythmia Device Infection Trial) was a large cluster crossover trial of conventional versus incremental antibiotics. OBJECTIVES: This study sought to investigate independent predictors of device infection in PADIT and develop a novel infection risk score. METHODS: In brief, over 4 6-month periods, 28 centers used either conventional or incremental prophylactic antibiotic treatment in all patients. The primary outcome was hospitalization for device infection within 1 year (blinded endpoint adjudication). Multivariable logistic prediction modeling was used to identify the independent predictors and develop a risk score for device infection. The prediction models were internally validated with bootstrap methods. RESULTS: Device procedures were performed in 19,603 patients, and hospitalization for infection occurred in 177 (0.90%) within 1 year of follow-up. The final prediction model identified 5 independent predictors of device infection (prior procedures [P], age [A], depressed renal function [D], immunocompromised [I], and procedure type [T]) with an optimism-corrected C-statistic of 0.704 (95% confidence interval: 0.660 to 0.744). A PADIT risk score ranging from 0 to 15 points classified patients into low (0 to 4), intermediate (5 to 6) and high (≥7) risk groups with rates of hospitalization for infection of 0.51%, 1.42%, and 3.41%, respectively. CONCLUSIONS: This study identified 5 independent predictors of device infection and developed a novel infection risk score in the largest cardiac implantable electronic device trial to date, warranting validation in an independent cohort. The 5 independent predictors in the PADIT score are readily adopted into clinical practice. (Prevention of Arrhythmia Device Infection Trial [PADIT Pilot]; NCT01002911).

Precision Spectroscopy of Negative-Ion Resonances in Ultralong-Range Rydberg Molecules.

The level structure of negative ions near the electron detachment limit dictates the low-energy scattering of an electron with the parent neutral atom. We demonstrate that a single ultracold atom bound inside a Rydberg orbit forming an ultralong-range Rydberg molecule provides an atomic-scale system that is highly sensitive to electron-neutral scattering and thus allows for detailed insights into the underlying near-threshold anion states. Our measurements reveal the so-far unobserved fine structure of the ^{3}P_{J} triplet of Rb^{-} and allows us to extract parameters of the associated p-wave scattering resonances that deviate from previous theoretical estimates. Moreover, we observe a novel alignment mechanism for Rydberg molecules mediated by spin-orbit coupling in the negative ion.

Prevention of Arrhythmia Device Infection Trial: The PADIT Trial.

BACKGROUND: Infection of implanted medical devices has catastrophic consequences. For cardiac rhythm devices, pre-procedural cefazolin is standard prophylaxis but does not protect against methicillin-resistant gram-positive organisms, which are common pathogens in device infections. OBJECTIVE: This study tested the clinical effectiveness of incremental perioperative antibiotics to reduce device infection. METHODS: The authors performed a cluster randomized crossover trial with 4 randomly assigned 6-month periods, during which centers used either conventional or incremental periprocedural antibiotics for all cardiac implantable electronic device procedures as standard procedure. Conventional treatment was pre-procedural cefazolin infusion. Incremental treatment was pre-procedural cefazolin plus vancomycin, intraprocedural bacitracin pocket wash, and 2-day post-procedural oral cephalexin. The primary outcome was 1-year hospitalization for device infection in the high-risk group, analyzed by hierarchical logistic regression modeling, adjusting for random cluster and cluster-period effects. RESULTS: Device procedures were performed in 28 centers in 19,603 patients, of whom 12,842 were high risk. Infection occurred in 99 patients (1.03%) receiving conventional treatment, and in 78 (0.78%) receiving incremental treatment (odds ratio: 0.77; 95% confidence interval: 0.56 to 1.05; p = 0.10). In high-risk patients, hospitalization for infection occurred in 77 patients (1.23%) receiving conventional antibiotics and in 66 (1.01%) receiving incremental antibiotics (odds ratio: 0.82; 95% confidence interval: 0.59 to 1.15; p = 0.26). Subgroup analysis did not identify relevant patient or site characteristics with significant benefit from incremental therapy. CONCLUSIONS: The cluster crossover design efficiently tested clinical effectiveness of incremental antibiotics to reduce device infection. Device infection rates were low. The observed difference in infection rates was not statistically significant. (Prevention of Arrhythmia Device Infection Trial [PADIT Pilot] [PADIT]; NCT01002911).

Observation of Rydberg Blockade Induced by a Single Ion.

We study the long-range interaction of a single ion with a highly excited ultracold Rydberg atom and report on the direct observation of an ion-induced Rydberg excitation blockade mediated over tens of micrometer distances. Our hybrid ion-atom system is directly produced from an ultracold atomic ensemble via near-threshold photoionization of a single Rydberg excitation, employing a two-photon scheme that is specifically suited for generating a very low-energy ion. The ion's motion is precisely controlled by small electric fields, which allows us to analyze the blockade mechanism for a range of principal quantum numbers. Finally, we explore the capability of the ion as a high-sensitivity, single-atom-based electric field sensor. The observed ion-Rydberg-atom interaction is of current interest for entanglement generation or studies of ultracold chemistry in hybrid ion-atom systems.

Rydberg Molecules for Ion-Atom Scattering in the Ultracold Regime.

We propose a novel experimental method to extend the investigation of ion-atom collisions from the so far studied cold, essentially classical regime to the ultracold, quantum regime. The key aspect of this method is the use of Rydberg molecules to initialize the ultracold ion-atom scattering event. We exemplify the proposed method with the lithium ion-atom system, for which we present simulations of how the initial Rydberg molecule wave function, freed by photoionization, evolves in the presence of the ion-atom scattering potential. We predict bounds for the ion-atom scattering length from ab initio calculations of the interaction potential. We demonstrate that, in the predicted bounds, the scattering length can be experimentally determined from the velocity of the scattered wave packet in the case of ^{6}Li^{+}-^{6}Li and from the molecular ion fraction in the case of ^{7}Li^{+}-^{7}Li. The proposed method to utilize Rydberg molecules for ultracold ion-atom scattering, here particularized for the lithium ion-atom system, is readily applicable to other ion-atom systems as well.

Ionic Impurity in a Bose-Einstein Condensate at Submicrokelvin Temperatures.

Rydberg atoms immersed in a Bose-Einstein condensate interact with the quantum gas via electron-atom and ion-atom interaction. To suppress the typically dominant electron-neutral interaction, Rydberg states with a principal quantum number up to n=190 are excited from a dense and tightly trapped micron-sized condensate. This allows us to explore a regime where the Rydberg orbit exceeds the size of the atomic sample by far. In this case, a detailed line shape analysis of the Rydberg excitation spectrum provides clear evidence for ion-atom interaction at temperatures well below a microkelvin. Our results may open up ways to enter the quantum regime of ion-atom scattering for the exploration of charged quantum impurities and associated polaron physics.

Effect of stray fields on Rydberg states in hollow-core PCF probed by higher-order modes.

The spectroscopy of atomic gases confined in hollow-core photonic crystal fiber (HC-PCF) provides optimal atom-light coupling beyond the diffraction limit, which is desirable for various applications such as sensing, referencing, and nonlinear optics. Recently, coherent spectroscopy was carried out on highly excited Rydberg states at room temperature in a gas-filled HC-PCF. The large polarizability of the Rydberg states made it possible to detect weak electric fields inside the fiber. In this Letter, we show that by combining highly excited Rydberg states with higher-order optical modes, we can gain insight into the distribution and underlying effects of these electric fields. Comparisons between experimental findings and simulations indicate that the fields are caused by the dipole moments of atoms adsorbed on the hollow-core wall. Knowing the origin of the electric fields is an important step towards suppressing them in future HC-PCF experiments. Furthermore, a better understanding of the influence of adatoms will be advantageous for optimizing electric-field-sensitive experiments carried out in the vicinity of nearby surfaces.

Photoassociation of Trilobite Rydberg Molecules via Resonant Spin-Orbit Coupling.

We report on a novel method for the photoassociation of strongly polar trilobite Rydberg molecules. This exotic ultralong-range dimer, consisting of a ground-state atom bound to the Rydberg electron via electron-neutral scattering, inherits its polar character from the admixture of high-angular-momentum electronic orbitals. The absence of low-L character hinders standard photoassociation techniques. Here, we show that for suitable principal quantum numbers the resonant coupling of the orbital motion with the nuclear spin of the perturber, mediated by electron-neutral scattering, hybridizes the trilobite molecular potential with the more conventional S-type molecular state. This provides a general path to associate trilobite molecules with large electric dipole moments, as demonstrated via high-resolution spectroscopy. We find a dipole moment of 135(45) D for the trilobite state. Our results are compared to theoretical predictions based on a Fermi model.

Calibration with confidence: a principled method for panel assessment.

Frequently, a set of objects has to be evaluated by a panel of assessors, but not every object is assessed by every assessor. A problem facing such panels is how to take into account different standards among panel members and varying levels of confidence in their scores. Here, a mathematically based algorithm is developed to calibrate the scores of such assessors, addressing both of these issues. The algorithm is based on the connectivity of the graph of assessors and objects evaluated, incorporating declared confidences as weights on its edges. If the graph is sufficiently well connected, relative standards can be inferred by comparing how assessors rate objects they assess in common, weighted by the levels of confidence of each assessment. By removing these biases, 'true' values are inferred for all the objects. Reliability estimates for the resulting values are obtained. The algorithm is tested in two case studies: one by computer simulation and another based on realistic evaluation data. The process is compared to the simple averaging procedure in widespread use, and to Fisher's additive incomplete block analysis. It is anticipated that the algorithm will prove useful in a wide variety of situations such as evaluation of the quality of research submitted to national assessment exercises; appraisal of grant proposals submitted to funding panels; ranking of job applicants; and judgement of performances on degree courses wherein candidates can choose from lists of options.

Hybridization of Rydberg Electron Orbitals by Molecule Formation.

The formation of ultralong-range Rydberg molecules is a result of the attractive interaction between a Rydberg electron and a polarizable ground-state atom in an ultracold gas. In the nondegenerate case, the backaction of the polarizable atom on the electronic orbital is minimal. Here we demonstrate how controlled degeneracy of the respective electronic orbitals maximizes this backaction and leads to stronger binding energies and lower symmetry of the bound dimers. Consequently, the Rydberg orbitals hybridize due to the molecular bond.

Bounds on the attractor dimension for magnetohydrodynamic channel flow with parallel magnetic field at low magnetic Reynolds number.

We investigate aspects of low-magnetic-Reynolds-number flow between two parallel, perfectly insulating walls in the presence of an imposed magnetic field parallel to the bounding walls. We find a functional basis to describe the flow, well adapted to the problem of finding the attractor dimension and which is also used in subsequent direct numerical simulation of these flows. For given Reynolds and Hartmann numbers, we obtain an upper bound for the dimension of the attractor by means of known bounds on the nonlinear inertial term and this functional basis for the flow. Three distinct flow regimes emerge: a quasi-isotropic three-dimensional (3D) flow, a nonisotropic 3D flow, and a 2D flow. We find the transition curves between these regimes in the space parametrized by Hartmann number Ha and attractor dimension d(att). We find how the attractor dimension scales as a function of Reynolds and Hartmann numbers (Re and Ha) in each regime. We also investigate the thickness of the boundary layer along the bounding wall and find that in all regimes this scales as 1/Re, independently of the value of Ha, unlike Hartmann boundary layers found when the field is normal to the channel. The structure of the set of least dissipative modes is indeed quite different between these two cases but the properties of turbulence far from the walls (smallest scales and number of degrees of freedom) are found to be very similar.

Strongly Correlated Growth of Rydberg Aggregates in a Vapor Cell.

The observation of strongly interacting many-body phenomena in atomic gases typically requires ultracold samples. Here we show that the strong interaction potentials between Rydberg atoms enable the observation of many-body effects in an atomic vapor, even at room temperature. We excite Rydberg atoms in cesium vapor and observe in real time an out-of-equilibrium excitation dynamics that is consistent with an aggregation mechanism. The experimental observations show qualitative and quantitative agreement with a microscopic theoretical model. Numerical simulations reveal that the strongly correlated growth of the emerging aggregates is reminiscent of soft-matter type systems.

From molecular spectra to a density shift in dense Rydberg gases.

In Rydberg atoms, at least one electron is excited to a state with a high principal quantum number. In an ultracold environment, this low-energy electron can scatter off a ground state atom allowing for the formation of a Rydberg molecule consisting of one Rydberg atom and several ground state atoms. Here we investigate those Rydberg molecules created by photoassociation for the spherically symmetric S-states. A step by step increase of the principal quantum number up to n=111 enables us to go beyond the previously observed dimer and trimer states up to a molecule, where four ground state atoms are bound by one Rydberg atom. The increase of bound atoms and the decreasing binding potential per atom with principal quantum number results finally in an overlap of spectral lines. The associated density-dependent line broadening sets a fundamental limit, for example, for the optical thickness per blockade volume in Rydberg quantum optics experiments.

Rydberg atoms in hollow-core photonic crystal fibres.

The exceptionally large polarizability of highly excited Rydberg atoms-six orders of magnitude higher than ground-state atoms--makes them of great interest in fields such as quantum optics, quantum computing, quantum simulation and metrology. However, if they are to be used routinely in applications, a major requirement is their integration into technically feasible, miniaturized devices. Here we show that a Rydberg medium based on room temperature caesium vapour can be confined in broadband-guiding kagome-style hollow-core photonic crystal fibres. Three-photon spectroscopy performed on a caesium-filled fibre detects Rydberg states up to a principal quantum number of n=40. Besides small energy-level shifts we observe narrow lines confirming the coherence of the Rydberg excitation. Using different Rydberg states and core diameters we study the influence of confinement within the fibre core after different exposure times. Understanding these effects is essential for the successful future development of novel applications based on integrated room temperature Rydberg systems.

Alignment of D-state Rydberg molecules.

We report on the formation of ultralong-range Rydberg D-state molecules via photoassociation in an ultracold cloud of rubidium atoms. By applying a magnetic offset field on the order of 10 G and high resolution spectroscopy, we are able to resolve individual rovibrational molecular states. A full theory, using a Fermi pseudopotential approach including s- and p-wave scattering terms, reproduces the measured binding energies. The calculated molecular wave functions show that in the experiment we can selectively excite stationary molecular states with an extraordinary degree of alignment or antialignment with respect to the magnetic field axis.

Dermatological conditions in military conscripts.

BACKGROUND: Published studies regarding skin conditions in the military are mainly cross-sectional studies from clinical encounters during war campaigns and military training. AIMS: To determine the incidence and spectrum of dermatological conditions in a cohort of military conscripts in Singapore. Soldiers diagnosed with contact dermatitis (CD) were further analysed for body area involvement, possible occupational and/or environmental causative agent and restrictions issued. METHODS: Retrospective cohort study. Subjects' diagnoses and demographic variables were extracted from electronic medical records. Medical records of CD cases were reviewed to characterize the nature of exposure and operational impact on training. RESULTS: The incidence of reporting of new dermatological complaints was 24.5 per 100 military conscripts per year. Dermatological conditions with the highest incidence over the period of full-time military service included fungal skin infection (6.7/100 conscripts/year), non-specific dermatitis (4.9/100 conscripts/year) and insect bite reaction (1.8/100 conscripts/year). The annual incidence of contact dermatitis over the same period was 0.4/100 conscripts. CONCLUSIONS: In a military population based in the tropics fungal skin infections, non-specific dermatitis and insect bite reactions were the commonest reasons for dermatological consultation. CD incidence was 0.4 per 100 conscripts per year.

Evidence for strong van der Waals type Rydberg-Rydberg interaction in a thermal vapor.

We present evidence for Rydberg-Rydberg interaction in a gas of rubidium atoms above room temperature. Rabi oscillations on the nanosecond time scale to different Rydberg states are investigated in a vapor cell experiment. Analyzing the atomic time evolution and comparing to a dephasing model, we find a scaling with the Rydberg quantum number n that is consistent with van der Waals interaction. Our results show that the interaction strength can be larger than the kinetic energy scale (Doppler width), which is the requirement for realization of thermal quantum devices in the GHz regime.