Cohort study on immune checkpoint inhibitor-associated acute kidney injury: Incidence, risk factors, and management strategies.

INTRODUCTION: Case studies and retrospective chart reviews of health system data have demonstrated an increased risk of nephrotoxicity in patients receiving immune checkpoint inhibitors compared to clinical trials. This study investigated the frequency, causes, and risk factors for acute kidney injury in a real-world, rural setting. METHODS: This was a retrospective cohort study of patients who received at least one dose of a checkpoint inhibitor at a rural health system from May 2013 to February 2020 and who received at least one dose of a checkpoint inhibitor. Electronic and manual chart review helped to determine the incidence of, risk factors for, and renal outcomes and management strategies of checkpoint inhibitor-related acute kidney injury. Multivariable Fine and Gray subdistribution hazard models were used to assess the impact of patient characteristics on the incidence of sustained acute kidney injury and checkpoint inhibitor-induced acute kidney injury. RESULTS: After exclusion criteria, 906 patients who received at least one dose of a checkpoint inhibitor at Marshfield Clinic Health System during the study period were included. The incidence of acute kidney injury of any duration and due to any cause was 36.1%, while sustained acute kidney injury occurred in 28.7% of patients. Checkpoint inhibitor-related acute kidney injury was thought to have occurred in 2.7% of patients. Baseline estimated glomerular filtration rate < 60 was the sole predictor of checkpoint inhibitors-related acute kidney injury. Most patients with suspected checkpoint inhibitor-related acute kidney injury were managed with corticosteroids, and 62.5% experienced complete renal recovery. CONCLUSIONS: Ours is the first retrospective cohort study to test whether baseline Eastern Cooperative Oncology Group score and checkpoint inhibitor place in therapy were associated with checkpoint inhibitor-related acute kidney injury, and neither of these data points were found to be predictive. Even after expanding the parameters and methodologies of our study as compared to other retrospective cohort studies, we found only three baseline characteristics to be predictive of sustained acute kidney injury: Baseline eGFR, loop diuretic, and spironolactone use. For checkpoint inhibitor-related baseline, eGFR alone was predictive.

Single-Dose Intraprocedural Steroid Administration Does Not Impact Early Atrial Fibrillation Recurrence.

PURPOSE: To evaluate the effect of single-dose intravenous dexamethasone on atrial fibrillation (AF) recurrence following radiofrequency catheter ablation. METHODS: A cohort of 84 adult patients (> 18 years) underwent catheter ablation at Mayo Clinic Rochester from January to March 2019. Only first-time ablation patients were included, with all re-do ablations excluded to minimize heterogeneity. Administration of intraoperative dexamethasone 4 mg or 8 mg was determined by chart review from the procedure. At our institution, intraoperative intravenous steroids are administered for postoperative nausea and vomiting (PONV) prophylaxis at the discretion of the anesthesiologist. AF recurrence was determined by ECG or cardiac monitoring within 3 months or between 3 and 12 months post-ablation with an in-person follow-up visit. RESULTS: A total of 31 (36.9%) patients received intravenous dexamethasone compared to 54 (63.1%) who did not (approximating a 2:1 comparison group). The incidence of documented AF or atrial flutter, lasting greater than 30 s, within the first 3 months post-ablation was 29.0% in the dexamethasone group versus 24.5% in the non-dexamethasone group (p value 0.80). AF or atrial flutter recurrence at 3-12 months post-ablation was 3.2% in the dexamethasone group compared to 9.4% in the non-dexamethasone group (p value 0.41). CONCLUSION: These data suggest that intraoperative intravenous dexamethasone administered during AF ablation for postoperative nausea and vomiting prophylaxis may not have a significant effect on AF recurrence rates.

Psychological Well-Being and Coping Strategies among Pakistani Heads of Households during COVID-19 Pandemic: An Online Survey.

Background: Coronavirus Disease (COVID-19) pandemic can affect mental health. Heads of the household are at higher risk of this effect because of their financial and social responsibilities. This study aimed to assess the psychological well-being and its associated factors during the COVID-19 pandemic among heads of households in Pakistan. Methods: We conducted an online survey in May 2020. A convenience sampling strategy was used to enroll the heads of the households from all regions of Pakistan. A validated English and Urdu version of the WHO-5 well-being scale was used to assess well-being. The prevalence of poor well-being and its associated factors among heads of the households was measured using logistic regression. Results: A total of 509 heads of households participated in the survey. About 35% of the participants were dependent on financial sources other than salary. The news was considered a source of fear as 70% assumed that avoiding such news may reduce the fear. The most common coping strategies used during lockdown were; spending quality time with family, eating healthy foods, adequate sleep and talking to friends on the phone. The prevalence of poor well-being was found to be 41% (95% CI: 36.62-45.51). Individuals with any chronic illness were at a higher risk of poor wellbeing adjusted odds ratio of 1.64 (95% CI: 1.04-2.59). Worriedness was also found to be associated with a higher risk of poor wellbeing adjusted OR 1.13 (95% CI: 1.06-1.19). Reading books showed a protective association with poor mental wellbeing adjusted OR 0.64 (95% CI: 0.42-0.98). Conclusion: There was a high prevalence of poor mental wellbeing among heads of households in Pakistan. Worriedness related to the pandemic and having chronic illness were significant predictors of poor psychological wellbeing. Actions are required in the form of targeted mass psychological support systems for the heads of the families to improve their mental health during the COVID-19 crises.

Factors associated with quality of life among joint and nuclear families: a population-based study.

BACKGROUND: Advantages and disadvantages associated with joint and nuclear family systems can affect quality of life (QOL). However, there is scarcity of literature about QOL among joint and nuclear family systems. This study aimed to assess the factors associated with QOL in joint and nuclear family systems. METHODS: We conducted a population based cross sectional study in all 52 Union Councils (UCs) of District Abbottabad, Khyber Pakhtunkhwa province, Pakistan from March 2015 to August 2015. Multistage cluster sampling technique was used to select participants from both nuclear and joint family houses. The validated Urdu version of World Health Organization Quality of Life Questionnaire-Brief Version (WHOQOL-BREF) was used to assess quality of life among participants. Univariate and multivariate analyses were performed to explore the associations of different socio demographic variables with QOL among both family systems. Also a multilevel linear regression using backward analysis to obtain final model for each domain was performed to find out the variables that are associated with QOL score in each of family systems. RESULTS: A total of 2063 participants were included in this study (51.0% joint family, 49.0% nuclear family) with the response rate of 97.4%. In multiple linear regression analysis of each domain for joint and nuclear family systems, rural residence compared to urban (p < 0.001), being female (p < 0.001), older age (p < 0.001), having comorbidity (p < 0.001) and lower socioeconomic status (p < 0.001) were found to be a strong predictor of poorer QOL. Furthermore, social capital (p < 0.001) had a positive effect on joint and nuclear family QOL scores. CONCLUSION: This study was the first of its kind which determined the factors of QOL in joint and nuclear families using the validated Urdu version of WHOQOL-BREF in Pakistan. Male gender, urban residence, younger age, higher socioeconomic status and social capital were positive predictors of QOL score while older age and presence of illness were associated with lower QOL scores among both family systems.

Assessing the quality of life among Pakistani general population and their associated factors by using the World Health Organization's quality of life instrument (WHOQOL-BREF): a population based cross-sectional study.

BACKGROUND: Measuring quality of life (QOL) in a population is important for the predictions of health and social care needs. In Pakistan, health related quality of life data exist but there are no quality of life data of general population. In this study, quality of life was assessed among the Pakistani general population and their associated factors by using the World Health Organization's quality of life instrument (WHOQOL-BREF). METHODOLOGY: A population-based cross-sectional study was carried out in all 52 Union Councils of District Abbottabad, Khaber Pkutunkhua province, Pakistan from March 2015 to August 2015. Multi-stage cluster sampling technique was employed in this study. Quality of life was measured by using the validated WHOQOL-BREF instrument, along with socioeconomic, demographic, and World Bank social capital questions in this population- based study. The data were collected through households, utilizing face to face interviews. The association between socio-demographic variables and quality of life domains were determined by using both univariate and multivariate analysis. Descriptive statistics were derived, and a multilevel linear regression using backward analysis allowing to obtain final model for each domain was achieved to recognize the variables that affect quality of life score. RESULTS: A total of 2063 participants were included in this study (51.2% male, 48.2% female). Mean age of participants was 37.9, SD = 13.2; ranging from 18 to 90. Mean score of quality of life domains (physical, psychological, social relationship and environmental domains) were 65.0 (SD = 15.2), 67.4 (SD = 15.0), 72.0 (SD = 16.5), 55.5 (SD = 15.0), respectively. Overall, socioeconomic status was established to be the strongest predictor of poorer quality of life for all domains as a change in SES from high to low results in reduction about (ß = - 5.85, ß = - 9.03, ß = - 8.33, ß = - 9.98, p < 0.001). Similarly, type of residency was negatively associated with physical, psychological and environmental domains while age and sex were negatively associated with physical, psychological and relationship domains in final model. Furthermore social capital (ß = 0.09, ß = 0.13, ß =0.14, ß =0.15, p < 0.001) had a positive effect on Pakistani quality of life. Overall, subjective quality of life was found to be low in our population and extremely varied by socio-demographic variables. CONCLUSIONS: Increasing age, having average and lower socioeconomic status and living in the rural area were found to be the strong predictor of poorer quality of life in all domains, while total social capital score had a positive effect on Pakistani quality of life scores.

Level of satisfaction and its predictors among joint and nuclear family systems in District Abbottabad, Pakistan.

Background: Family system has been found to affect the satisfaction level among the family members. The objective of our study was to determine the satisfaction level and its predictors among joint and nuclear family systems in District Abbottabad, Pakistan. Methods: We conducted a population-based cross-sectional study in all 52 Union Councils (UCs) of District Abbottabad, Khyber Pakhtunkhwa province, Pakistan from March 2015 to August 2015. Multistage cluster sampling technique was used to select 2063 participants from both nuclear and joint family houses. Proportionate sampling was done for selecting mohalla from each UCs, and then subsequently households from respective mohalla's. Simple random sampling was done for selecting the 18 years and above-aged participant for the study. A structured demographic questionnaire was used to collect information from study participants. Univariate and multivariate logistic regression analysis was done to find out the predictors of satisfaction level among joint and nuclear family systems using SPSS version 20 A p-value of <0.05 was considered as significant. Results: Level of satisfaction was found to be higher among people living in the joint family system i.e., 87.5 % v/s 81 % (<0.001) compared to the nuclear family system. Multivariate regression analysis of nuclear family system showed that people having higher education level and higher socioeconomic status (SES) were more satisfied as compared to no education & low SES respectively. While, in the joint family system, only high SES was a significant predictor of satisfaction in the joint family system as compared to low SES. Conclusion: Our study reported a high level of satisfaction among joint and nuclear family systems in Pakistan. High education level and high SES were identified as important predictors of satisfaction among both systems.

Differential achievements in childhood immunization across geographical regions of Pakistan: analysis of wealth-related inequality.

BACKGROUND: Childhood immunization is one of the most cost-effective interventions for child health. Still, many children are not able to receive completed immunization status. Wealth - related inequality in immunization is considered a major reason for equitable coverage of immunization in Pakistan. Therefore, we examine wealth-related inequality in completed childhood immunization and to assess achievement indices across geographical regions in Pakistan. METHODS: The analysis was based on a nationally representative demographic and health survey (DHS) of Pakistan, conducted in 2012-13. We examined completed childhood (12-23 months) immunization in the various regions of the country and we used concentration, extended concentration and achievement indices to demonstrate inequality across geographical regions in Pakistan. RESULTS: Inequality in completed childhood immunization was seen in Pakistan with concentration index (CI) of 0.181 (95% CI: 0.164-0.209). Regions with high average of complete immunization showed lower inequality except for Sindh. Despite having better average immunization coverage in Kyber Pakhtunkhwa, the relative change of 128% in concentration index (CI) from C2 (standard CI) to C5 (when poorer quantile received highest weights) shows this to be also the most inequitable regions. Four parameters of inequality aversion (v = 2, 3, 4 & 5) demonstrated that 'dis - achievement' in completed immunization is densely concentrated among the poorer regions. Balochistan, Sindh and Gilgit Baltistan exhibited broader inequality gaps (93.75%, 83.35%, and 54.93%, respectively) at higher aversion parameter. CONCLUSIONS: As hypothesized, achievement index uncovers 'penalized' immunization coverage amongst the poorest population. Thus any policy that stringently focuses on improving average immunization rate without any strategy to deal with inequality will only improve immunization rate within wealthier groups. Based on these results, it is advisable to public health policy makers to use both aspect of information: average and degree of inequality in immunization coverage.

Computer-Aided Surgical Simulation in Head and Neck Reconstruction: A Cost Comparison among Traditional, In-House, and Commercial Options.

BACKGROUND: Computer-aided surgical simulation (CASS) has redefined surgery, improved precision and reduced the reliance on intraoperative trial-and-error manipulations. CASS is provided by third-party services; however, it may be cost-effective for some hospitals to develop in-house programs. This study provides the first cost analysis comparison among traditional (no CASS), commercial CASS, and in-house CASS for head and neck reconstruction. METHODS: The costs of three-dimensional (3D) pre-operative planning for mandibular and maxillary reconstructions were obtained from an in-house CASS program at our large tertiary care hospital in Northern Virginia, as well as a commercial provider (Synthes, Paoli, PA). A cost comparison was performed among these modalities and extrapolated in-house CASS costs were derived. The calculations were based on estimated CASS use with cost structures similar to our institution and sunk costs were amortized over 10 years. RESULTS: Average operating room time was estimated at 10 hours, with an average of 2 hours saved with CASS. The hourly cost to the hospital for the operating room (including anesthesia and other ancillary costs) was estimated at $4,614/hour. Per case, traditional cases were $46,140, commercial CASS cases were $40,951, and in-house CASS cases were $38,212. Annual in-house CASS costs were $39,590. CONCLUSIONS: CASS reduced operating room time, likely due to improved efficiency and accuracy. Our data demonstrate that hospitals with similar cost structure as ours, performing greater than 27 cases of 3D head and neck reconstructions per year can see a financial benefit from developing an in-house CASS program.

Psychometric properties of the Urdu version of the World Health Organization's quality of life questionnaire (WHOQOL-BREF).

Background: The present study was conducted to translate and validate the World Health Organization's Quality-of-Life Scale - BREF into local language of Pakistan. Methods: A forward- backward translation procedure was followed to develop the Pakistani version of the questionnaire. Through a multi- stage clustered sampling technique, a sample of individuals aged 18 years and above completed the questionnaire in Abbottabad district, Pakistan. Psychometric properties of the instrument including reliability (internal consistency and test-retest analysis), validity (known group comparison and items' correlation) and their domains were assessed. Satisfactory results were also shown in the correlation matrix in all domains. Results: A total of 2060 participants were recruited in this study. Participants' mean age was 35.51 (SD= 14.31) years in healthy individuals and 39.29 (SD= 14.31) years in diseased individuals. The internal consistency of the WHOQOL-BREF (Pakistani Version) was 0.86. Moreover, the physical, psychological, and environmental domains had acceptable reliability (alpha= 0.78, 0.75, and 0.73, respectively), but reliability was low (alpha= 0.56) in the social domain. Reproducibility of the WHOQOL-BREF was as follows: ICC range: 0.72-0.92 at 2-week retest interval. After performing comparison analysis, the results indicated that the questionnaire significantly segregated the study groups in all QoL domains, except for social relationship. Conclusion: The study provided strong exploratory evidence for the reliability and validity of the WHOQOL-BREF for use in Pakistan. However, more exploration is needed to improve the reliability results in the social domain.

Efficacy And Safety Of Interlocked Intramedullary Nailing For Open Fracture Shaft Of Tibia.

BACKGROUND: Due to increasing population and changing human habits the number of accidents and high energy trauma is rising. Management of open fracture tibia is a complex problem and is a challenge for both orthopaedic and plastic surgeons. The study was carried out to ascertain the efficacy and safety of interlocked intra-medullary nailing for open shaft tibial fractures in patients presenting at or after 24hr of injury. METHODS: In this descriptive case series, over a period of 6 moths, 163 consecutive cases of open fracture of tibial shaft were reviewed in terms of clinical profile, time of presentation, and gender distribution. RESULTS: In this study mean age was 30±0.02 years. Males comprised 85% of study population while 15% were females. Gustilo-I type fracture and Gustilo-II type fracture was diagnosed in 90% and 10% patients respectively. Thirty three percent patients had wound infection while fracture union was found in 15% cases. Moreover interlocked intramedullary nailing for open fracture shaft of tibia was safe in 80% patients while this procedure was effective in 85%. CONCLUSIONS: Un-reamed, interlocked intra-medullary nailing may be considered as a suitable option for treatment of open fractures of tibia.

INSPIRATION FOR SMOKING AMONG MEDICAL STUDENTS OF ABBOTTABAD, PAKISTAN.

BACKGROUND: Doctors are the best person to persuade their patients to quit smoking. Trend of smoking among young doctors is increasing day by day. The present study was conducted to observe the source of inspiration and smoking trends among medical students. METHODS: An observational study was conducted through a self-administered questionnaire from medical students of Ayub Medical College Abbottabad. RESULTS: A total of 230 students participated in this study and out of these 210 were males and 20 were females. Forty-eight students (20.86%) started smoking at the age of less than 15 years and 143 students (62.17%) started smoking between the age of 15-20 years and 39 students (16.95%) started smoking after 20 years of age. A total of 147 students (63.91%) were inspired by their friends, 32 (13.91%) by media, 39 (16.95%) by family members. Out of these 230 students 87 students (37.82%) smoked more than 10 cigarettes per day and 143 students (62.17%) smoked less than 10 cigarettes per day. CONCLUSION: Most of students started smoking at young age and their friends were source of inspiration.

EARLY RESPONSE OF LOCAL STEROID INJECTION VERSUS MINI INCISION TECHNIQUE IN TREATMENT OF CARPAL TUNNEL SYNDROME.

BACKGROUND: Carpal tunnel syndrome (CTS) is one of the commonest peripheral neuropathies which effects mainly middle aged women. Different techniques are being tried to decrease the postoperative pain in patients operated for CTS. The objective of this study was to compare effectiveness of local injection of steroid and mini incision technique in the treatment of carpal tunnel syndrome. METHODS: This randomized control trial was conducted at department of Orthopedics and department of Neurosurgery, Ayub Teaching Hospital, Abbottabad from Aug 2011 to Feb 2013. A total of 116 patients of CTS were randomly allocated to either of the two groups.58 Patient in Group A were subjected to local steroid injection and the same number of patient in Group B underwent mini incision technique. All patients of were advised to report to the OPD after one month to determine intervention effectiveness in terms of improvement in at least one grade of pain. RESULTS: In this study mean age of the patients was 32.8 +/- 5.1 years. Female gender was in dominance with 99 (86.3%) cases. In this study we compared the effectiveness of local steroid injection and mini incision technique in the treatment of carpel tunnel syndrome. We found out that the steroid injection was effective in 69.0% cases while mini incision technique was effective in 56.9% cases. The difference being statistically insignificant with a p-value of 0.17. CONCLUSION: The difference in pain after 1 month of the intervention was not statistically significant.

SUCCESSFUL TREATMENT OF MULTIDRUG-RESISTANT ACINETOBACTOR BAUMANII BLISTERS ON THE KNEE.

Acinetobacter baumannii (A. baumannii), nosocomial infections, especially those due to multi-drug resistant (MDR) strains, are increasingly detected. This study reports the case of a 50-year-old man with blisters on the right knee for 8 months, first admitted through the outpatient department for incisional biopsy. Microbiological and histo-pathological examination confirmed the diagnosis of blisters extending deeply up to the knee joint caused by MDR- A. baumannii. A broad spectrum antibiotic therapy was administered and later readjusted according to the results of microbiological culture and biopsy report. Intensive hemodynamic support was required. An extensive surgical debridement was promptly performed and repeated until complete control of the infection with intravenous colistins. Blisters were excised; wounds were dressed daily with chlorhexidine dressings and polymyxine-impregnated dressing. Wounds were finally covered with split-thickness skin grafts. The infection was overcome 120 days after admission. The graft take was 40%. Postoperative rehabilitation was required because of the functional limitation of lower limb movements at the knee joint. Follow-up at 8 months showed no functional deficit and an acceptable aesthetic result. AB-MDR affecting soft tissues is a life-threatening disease, especially in patients with poor immunity and limited access to health facilities, whose clinical diagnosis may sometimes be challenging. Early recognition and treatment represent the most important factors influencing survival.

Interdisciplinary Deprescribing of Aspirin Through Prescriber Education and Provision of Patient-Specific Recommendations.

BACKGROUND: Inappropriate aspirin use can lead to increased frequency of bleeding events and poor patient outcomes. OBJECTIVES: Compare current aspirin prescribing to guideline recommendations and analyze the impact of pharmacist education for clinicians with provision of patient-specific recommendations. METHODS: Internal medicine residents received 1 educational session on appropriate aspirin use. Over a 5-month period post-education, 100 patients on aspirin with a clinic appointment were screened and their charts reviewed. Aspirin use was classified based on guideline recommendations as follows: (1) recommended, (2) weigh the risk and benefits, (3) not recommended, (4) dose change recommended, or (5) outside of guideline recommendation. A recommendation for aspirin deprescribing was then communicated to the clinician prior to the patient's appointment. Prescriber practice following the appointment was collected and analyzed. RESULTS: Inappropriate aspirin use occurred in 29% (n = 29) of patients prior to their appointment. Of these, aspirin was not recommended in 65.5% (n = 19), and a dose reduction from 325 mg to 81 mg was recommended in 34.5% (n = 10). Of the 81 patients who kept their appointment, pharmacist recommendations to deprescribe aspirin were communicated to the clincian for 20 patients (24.7%) and resulted in a 55% aspirin deprescription. CONCLUSIONS: The majority of patients identified as using aspirin inappropriately fell into 3 groups: (1) patients taking 325 mg aspirin, (2) patients taking aspirin for primary prevention, and (3) patients taking aspirin concomitantly with an anticoagulant. Strategies that may lead to optimization of aspirin use include lectures and patient-specific chart reviews with pharmacist recommendation.

Gender Difference In Awareness And Behaviours Of Medical And Dental Students About Corona Virus Disease (Covid-19) In Pakistan.

BACKGROUND: Medical and dental students are the future of health workforce and a potential volunteer pool in the COVID-19 crises. This study aimed to assess the level and gender differences in the awareness, attitude and behaviours of medical and dentals students about COVID-19 in Pakistan. METHODS: An online cross-sectional survey was conducted among medical and dental undergraduate students in Khyber Pakhtunkhwa province. Data was collected using a structured questionnaire having four sections: socio-demographics, knowledge, attitude and practices. RESULTS: A total of 1770 medical and dental students participated and completed the questionnaire. About 1239 (70%) of the respondents were female and 1526 (87%) were MBBS students. We found that 1685 (95%) of the students had adequate knowledge. Majority, 1565 (89%) of the students was concerned about COVID-19 and 1480 (84%) believed that disease will ultimately be controlled. Only about 1129 (64%) of the participants in our study had adequate practices. Male gender was associated with higher risk of inadequate practices. CONCLUSIONS: There were good knowledge and attitudes about COVID-19 among medical and dental students. However, one third of the participants did not have adequate practices and female had better practices than male students. This gap in the knowledge and practice calls for urgent interventions to improve practices.

Blastomycosis-Induced Acute Respiratory Distress Syndrome.

Blastomycosis is a systemic mycosis endemic to the Midwestern and South Central United States. Infection is caused by inhaling spores of Blastomyces dermatitidis (B. dermatitidis) that inhabit soil. Acute respiratory distress syndrome (ARDS) is a rare complication of pulmonary blastomycosis with a significantly high mortality rate. We present a case of blastomycosis associated with severe ARDS treated with traditional prone position ventilation (PPV) and neurally adjusted ventilator assist (NAVA) along with antifungal therapy, steroids, and supportive care in a rural setting with no access to extracorporeal membrane oxygenation (ECMO). This case demonstrates that traditional therapies such as prone position ventilation can help patients with blastomycosis-associated ARDS especially in rural settings where advanced therapies such as ECMO are lacking. The use of NAVA in blastomycosis-associated ARDS needs further research.

Safety and efficacy outcomes of atrial fibrillation ablation in patients with rheumatoid arthritis.

Background: Rheumatoid arthritis (RA) is an immune-mediated inflammatory disease associated with atrial fibrillation (AF) and stroke. Objective: The purpose of this study was to evaluate the safety and efficacy of AF ablation in patients with RA. Methods: All patients with RA undergoing AF ablation at our institution from 2010 to 2021 were propensity matched to patients without RA using 9 baseline characteristics. The primary outcome was procedural efficacy defined by clinical AF recurrence, the need for antiarrhythmic drugs (AADs), and repeat catheter ablation. Secondary outcome was safety. Results: A total of 45 patients with RA (age 66.3 ± 7.7 years) were matched to 45 patients without a history of RA (age 68.0 ± 7.3 years). Both groups had similar procedural and periprocedural characteristics. Before ablation, RA patients had statistically higher C-reactive protein (CRP) levels (P ≤.01) and erythrocyte sedimentation rates (ESRs) (P <.05) compared to non-RA patients. After ablation, RA patients had statistically significant higher rates of AF recurrence (P = .006), were more likely to be taking AADs (P <.05), and more likely to undergo repeat ablations (P <.05). The use of immunosuppression or corticosteroids at the time of ablation did not influence the primary endpoint of AF recurrence, AADs, or repeat ablation. Multivariate regression analysis showed CRP and ESR were independent predictors of AF recurrence. CRP was an independent predictor of repeat ablation. Conclusion: Patients with RA are at higher risk of clinical AF recurrence, and are more likely to be taking AADs and require repeat ablation. Preablation CRP and ESR are independent predictors of AF recurrence, and CRP is an independent predictor of repeat catheter ablation.

Novel insights into the substrate involved in maintenance of ventricular fibrillation: results from continuous multipolar mapping in a canine model.

BACKGROUND: While the triggers for ventricular fibrillation (VF) are well-known, the substrate required for its maintenance remains elusive. We have previously demonstrated dynamic spatiotemporal changes across VF from electrical induction of VF to asystole. Those data suggested that VF drivers seemed to reside in the distal RV and LV. However, signals from these areas were not recorded continuously. The aim of this study was to map these regions of significance with stationary basket electrodes from induction to asystole to provide further insights into the critical substrate for VF rhythm sustenance in canines. METHODS: In six healthy canines, three multipolar basket catheters were positioned in the distal right ventricle (RV), RV outflow tract, and distal left ventricle (LV), and remained in place throughout the study. VF was induced via direct current application from an electrophysiologic catheter. Surface and intracardiac electrograms were recorded simultaneously and continuously from baseline, throughout VF, and until asystole, in order to get a complete electrophysiologic analysis of VF. Focused data analysis was also performed via two defined stages of VF: early VF (immediately after induction of VF to 10 min) and late VF (after 10 min up to VF termination and asystole). RESULTS: VF was continuously mapped for a mean duration of 54 ± 9 min (range 42-70 min). Immediately after initiation of VF in the early phase, the distal LV region appeared to drive the maintenance of VF. Towards the terminal stage of VF, the distal RV region appeared to be responsible for VF persistence. In all canines, we noted local termination of VF in the LV, while VF on surface ECG continued; conversely, subsequent spontaneous termination of VF in the RV was associated with termination of VF on surface ECG into a ventricular escape rhythm. Continuous mapping of VF showed trends towards an increase in peak-to-peak ventricular electrogram cycle length (p = 0.06) and a decrease in the ventricular electrogram amplitude (p = 0.06) after 40 min. Once we could no longer discern surface QRS activity, we demonstrated local ventricular myocardial capture in both the RV and LV but could not reinitiate sustained VF despite aggressive ventricular burst pacing. CONCLUSIONS: This study describes the evolution of VF from electrical initiation to spontaneous VF termination without hemodynamic support in healthy canines. These data are hypothesis-generating and suggest that critical substrate for VF maintenance may reside in both the distal RV and LV depending on stage of VF. Further studies are needed to replicate these findings with hemodynamic support and to translate such findings into clinical practice. Ventricular fibrillation maintenance may be dependent on critical structures in the distal RV. ECG: electrocardiogram; LV: left ventricle; RV: right ventricle; RVOT: right ventricular outflow tract; VF: ventricular fibrillation.

Ventricular nanosecond pulsed electric field delivery using active fixation leads: a proof-of-concept preclinical study.

BACKGROUND: Mid-myocardial ventricular arrhythmias are challenging to treat. Cardiac electroporation via pulsed electric fields (PEFs) offers significant promise. We therefore tested PEF delivery using screw-in pacemaker leads as proof-of-concept. METHODS: In 5 canine models, we applied nanosecond PEF (pulse width 300 ns) across the right ventricular (RV) septum using a single lead bipolar configuration (n = 2) and between two leads (n = 3). We recorded electrograms (EGMs) prior to, immediately post, and 5 min after PEF. Cardiac magnetic resonance imaging (cMRI) and histopathology were performed at 2 weeks and 1 month. RESULTS: Nanosecond PEF induced minimal extracardiac stimulation and frequent ventricular ectopy that terminated post-treatment; no canines died with PEF delivery. With 1 lead, energy delivery ranged from 0.64 to 7.28 J. Transient ST elevations were seen post-PEF. No myocardial delayed enhancement (MDE) was seen on cMRI. No lesions were noted on the RV septum at autopsy. With 2 leads, energy delivery ranged from 56.3 to 144.9 J. Persistent ST elevations and marked EGM amplitude decreases developed post-PEF. MDE was seen along the septum 2 weeks and 1 month post-PEF. There were discrete fibrotic lesions along the septum; pathology revealed dense connective tissue with < 5% residual cardiomyocytes. CONCLUSIONS: Ventricular electroporation is feasible and safe with an active fixation device. Reversible changes were seen with lower energy PEF delivery, whereas durable lesions were created at higher energies. Central illustration: pulsed electric field delivery into ventricular myocardium with active fixation leads.

Assessment of knowledge and foot self-care practices among diabetes mellitus patients in a tertiary care centre in Makkah, Saudi Arabia: a cross-sectional analytical study.

Introduction: diabetic foot is a common long-term complication of uncontrolled diabetes mellitus. Knowledge about foot self-care practices among diabetic patients in Saudi Arabia is limited. Thus, the aim of this study was to assess the level of patients´ knowledge and practices regarding self-care of diabetic foot among diabetic patients. Methods: a cross-sectional analytical study was conducted using a sample of diabetic patients attending outpatient clinics at Heraa Diabetic Center, Ministry of Health, Makkah City, Saudi Arabia from June 2020 to July 2020. The participants were interviewed through a self-administered questionnaire inquiring sociodemographic factors, patients´ knowledge and practices regarding foot self-care. Results: a total of 409 patients were included in this study. Respondents' ages ranged between 6 and 75 years with a mean of 42.5 years and standard deviation of 13.9 years. Females represented 51.1% of the participants. Type 2 diabetes represented 85.6% of the responses. Overall, most of the participants (72.4%) had a poor level of knowledge whereas only 4.2% expressed a good level of knowledge. Being employed (P = 0.046), type II diabetes patients (P = 0.047) and those whose main source of information was health staff (P = 0.026) were more knowledgeable compared to their peers. Almost two-thirds (63.3%) of patients showed a poor level of practice related to diabetic foot self-care. Conclusion: low level of knowledge and practice of foot care are prevalent among diabetic patients attending outpatient clinics at Heraa Diabetic Center. Designed interventions should be implemented to enhance diabetic foot self-care.