Incidence of pacing-induced cardiomyopathy in pacemaker-dependent patients is lower with leadless pacemakers compared to transvenous pacemakers.

INTRODUCTION: Frequent right AQ4ventricular pacing (≥40%) with a transvenous pacemaker (TVP) is associated with the risk of pacing-induced cardiomyopathy (PICM). Leadless pacemakers (LPs) have distinct physical and mechanical differences from TVP. The risk of PICM with LP is not known. To identify incidence, predictors, and long-term outcomes of PICM in LP and TVP patients. METHODS: The study comprised all pacemaker-dependent patients with LP or TVP who had left ventricular ejection fraction (LVEF) of ≥50 from 2014 to 2019. The incidence of PICM (≥10% LVEF drop) was assessed with an echocardiogram. Predictors for PICM were identified using multivariate analysis. Long-term outcomes after cardiac resynchronization (CRT) were assessed in both groups. RESULTS: A total of 131 patients with TVP and 67 with LP comprised the study. All patients in the TVP group and the majority in the LP group underwent atrioventricular node ablation. The mean follow-up duration in TVP and LP groups was 592 ± 549 and 817 ± 600 days, respectively. A total of 18 (13.7%) patients in TVP and 2 (3%) in LP developed PICM after a median duration of 254 (interquartile range: 470) days. The incidence of PICM was significantly higher with TVP compared with LP (p = .02). TVP as pacing modality was a positive (odds ratio [OR]: 1.07) while age was negative (OR: 0.94) predictor for PICM on multivariable analysis. Both patients in LP and all except two in the TVP group responded to CRT. CONCLUSION: Incidence of PICM is significantly lower with LP compared with TVP in pacemaker-dependent patients. Age and TVP as pacing modality were predictors for PICM.

Topical Desoximetasone 0.25% Spray and Its Vehicle Have Little Potential for Irritation or Sensitization.

BACKGROUND: Topical corticosteroids are the most common dermatologic medications and are available in numerous different vehicles. Adherence is limited by traditional vehicles because they are messy and time consuming to apply. The preferred spray formulations have the advantage of being applied with ease, resulting in improved adherence and subsequently improved psoriasis. One limitation of topical treatments, especially spray vehicles, is the potential for irritation and sensitization.

OBJECTIVE: To evaluate the irritation and sensitization potential of topical desoximetasone spray formulation.

METHODS: A multicenter, double-blinded, randomized, controlled study assessed the irritancy and sensitization of 0.25% and 0.05% topical desoximetasone spray. Controls included vehicle, a positive control (0.1% sodium lauryl sulfate), negative control (0.9% saline), and an active comparator control (clobetasol spray). The primary outcome of the study was to evaluate the difference in mean cumulative irritation and potential sensitization response of desoximetasone 0.25% and 0.05% topical sprays.

RESULTS: Of the 297 enrolled, 269 completed the study per protocol for the irritation phase and 250 completed the protocol for the sensitization phase. At 22 days, desoximetasone 0.25 and 0.5% spray were less irritating than clobetasol 0.05% spray; mean irritation score difference of -0.46 and -0.57, respectively. Median total irritation score over the 22 days was 0 for all products. No subjects demonstrated any sensitization reaction to any of the six products. No serious adverse reactions were reported.

LIMITATIONS: Selection bias, use of a healthy population, limits the external validity. In addition, the duration of the study was short lived, unlike numerous inflammatory skin diseases. CONCLUSIONS: Desoximetasone spray has little potential for irritation or sensitization. The availability of another spray option for patients desiring less messy treatment may facilitate better adherence and treatment outcomes.

J Drugs Dermatol. 2017;16(8):755-758.

Approaches for Successful Implantation of Cardiac Implantable Devices in Patients with Persistent Left Superior Vena Cava.

Persistent left superior vena cava (PLSVC) is the most common congenital thoracic venous anomaly, with 0.47% of patients undergoing pacemaker or cardiac implantable device placement found to have PLSVC. This review article describes challenges and interventions to successfully insert cardiac implantable electronic device leads into patients with PLSVC by providing multiple unique case examples.

Subcutaneous cardiac rhythm monitors: state of the art review.

Introduction: Subcutaneous cardiac rhythm monitors (SCRMs) provide continuous ambulatory electrocardiographic monitoring for surveillance of known and identification of infrequent arrhythmias. SCRMs have proven to be helpful for the evaluation of unexplained symptoms and correlation with intermittent cardiac arrhythmias. Successful functioning of SCRM is dependent on accurate detection and successful transmission of the data to the device clinic. As the use of SCRM is steadily increasing, the amount of data that requires timely adjudication requires substantial resources. Newer algorithms for accurate detection and modified workflow systems have been proposed by physicians and the manufacturers to circumvent the issue of data deluge.Areas covered: This paper provides an overview of the various aspects of ambulatory rhythm monitoring with SCRMs including indications, implantation techniques, programming strategies, troubleshooting for issue of false positive and intermittent connectivity and strategies to circumvent data deluge.Expert opinion: SCRM is an invaluable technology for prolonged rhythm monitoring. The clinical benefits from SCRM hinge on accurate arrhythmia detection, reliable transmission of the data and timely adjudication for possible intervention. Further improvement in SCRM technology is needed to minimize false-positive detection, improve connectivity to the central web-based server, and devise strategies to minimize data deluge.

Resource Use and Economic Implications of Remote Monitoring With Subcutaneous Cardiac Rhythm Monitors.

OBJECTIVES: This study reports resource use and economic implications of rhythm monitoring with subcutaneous cardiac rhythm monitors (SCRMs). BACKGROUND: SCRMs generate a substantial amount of data that requires timely adjudication for appropriate clinical care. Resource use for SCRM monitoring is not known. METHODS: The study included consecutive transmissions during 4 weeks from 1,811 SCRMs. Resource use was quantified by assessment of time commitment of device clinic personnel and electrophysiologists for data adjudication. Incidence and characteristics of false positive (FP) episodes were assessed. Impact of custom programming for arrhythmia detection on incidence of FP episodes and resource use was analyzed. RESULTS: A total of 1,457 transmissions (alerts = 462; full downloads = 995) were received during study period. Average device clinic personnel time for adjudication of 1 transmission was 15 ± 6 min. This totaled to 364 h spent (2.3 full-time staff) over the 4-week period, which translated into a salary cost of $12,000 U.S. dollars (USD). Average time spent by an electrophysiologist for 1 transmission was 1.5 ± 1 min and totaled to 37 h for 4 weeks, which translated into an estimated cost of $9,600 USD. Of 1,457 total transmissions, 512 (35%) represented multiple transmissions from the same patients, which resulted in no additional reimbursement. Incidence of FP episodes in the entire cohort was 50% and was variable in alert (60%) and full download (49%) (p = 0.04) transmissions. When SCRMs with manufacturer suggested nominal programming and institutional custom programming were compared, there was a reduction in FP episodes (55% vs. 16%; p = 0.01), which translated to a 34% reduction in resource use for data adjudication. CONCLUSIONS: SCRM data adjudication requires significant resources. Custom programming for SCRMs may overcome the data deluge.

Biologics monitoring: incongruity between recommendations and clinician monitoring trends.

Background: Biologics are commonly used for moderate to severe psoriasis. Monitoring laboratory tests may provide little definitive benefit to patients.Objective: We queried a Humana database to gain insight regarding dermatologists' laboratory monitoring practices for psoriasis patients on biologics.Methods: Data were obtained from the Humana database. Our cohort included 333 patients with primary ICD-9 diagnosis of psoriasis (696.1) between the years 2008 and 2013 who are prescribed any biologic medication. Subjects on methotrexate, acitretin, or cyclosporine were excluded from the study. We separately queried laboratory tests by CPT codes and quantified based on frequency over a 2-year time period. Percentages of demographic group receiving a laboratory test at a given frequency category were calculated.Results: About 46% and 47% of patients received >4 comprehensive metabolic panel and complete blood count tests 2 years after starting a biologic. About 18% of individuals age >50 received greater than four Basic Metabolic Panel tests 2 years after starting a biologic.Limitations: Patient comorbidities might confound some of our findings, as these laboratory tests may have been ordered for a comorbidity rather than for biologics side effect monitoring.Conclusions: There are inconsistencies between current monitoring practices and guidelines. Clarifying biologics monitoring recommendations in psoriasis patients may reduce healthcare costs and provider workload.

Screening for depression in rosacea patients.

Rosacea patients often are burdened with embarrassment, social anxiety, and psychiatric comorbidities. The Patient Health Questionnaire 9 (PHQ-9) is a validated and reliable self-administered tool for diagnosis of depression and designation of depression severity. This study aimed to examine the relationship between rosacea severity scores and level of depression using a validated rosacea self-assessment tool and the PHQ-9, respectively. Our results indicated that there is a direct relationship between rosacea severity and level of depression, and the PHQ-9 could prove useful in screening for depression in rosacea patients given the high incidence of psychiatric comorbidities in this patient population.

Spotlight on brimonidine topical gel 0.33% for facial erythema of rosacea: safety, efficacy, and patient acceptability.

BACKGROUND: Brimonidine tartrate is a highly selective alpha 2 agonist that induces direct vasoconstriction of small arteries and veins, thereby reducing vasodilation and edema. OBJECTIVE: To review the current literature regarding the safety, efficacy, and patient acceptability of brimonidine 0.33% gel. METHODS: A PubMed search was performed using the terms brimonidine 0.33% gel, rosacea, safety, efficacy, and acceptability. Peer-reviewed clinical trials and case reports from 2012 to 2016 were screened for inclusion of safety, efficacy, and/or patient acceptability data. RESULTS: Brimonidine topical gel 0.33% is associated with mild, transient skin-related adverse reactions. Efficacy may be achieved within 30 minutes of administration with maximal reductions in erythema 3-6 hours after administration. Patient satisfaction with use of brimonidine topical gel is superior to vehicle gel for facial appearance, treatment effect, facial redness, and daily control of facial redness. LIMITATIONS: Studies were typically limited to 1-year follow-up. Only one study has examined the use of brimonidine topical gel in combination with other rosacea and acne medications. DISCUSSION: Brimonidine topical gel 0.33% is a safe, effective, and patient-accepted treatment for facial erythema of rosacea.

Psoriasis, Depression, and Inflammatory Overlap: A Review.

Psoriasis has an enormous impact on patients' lives and is frequently associated with depression. Depression in psoriasis may be attributed, at least in part, to elevated proinflammatory cytokines rather than the psychosocial impact of psoriasis itself. Biologics that target inflammatory cytokines treat the clinical manifestations of psoriasis, but may also play a role in reducing associated depression. Multiple biologics have decreased symptoms of depression during clinical trials in psoriasis; however, these studies used a variety of depression screening tools, which limits comparison. Furthermore, it is difficult to distinguish whether improved depression is the result of the direct anti-inflammatory effect of the biologic, or the indirect effect of improved psoriasis leading to better psychological status. Future studies evaluating depression in patients with psoriasis could benefit from a standardized depression screening tool to mitigate discrepancies and facilitate comparison across treatment types. Here, we highlight the inflammatory overlap between psoriasis and depression by examining the pathophysiology of depression, and reviewing psoriasis clinical studies that assessed depression as an outcome measure.

Interventions to increase adherence to acne treatment.

BACKGROUND: Adherence to acne medication is poor and is a major reason why treatment plans are ineffective. Recognizing solutions to nonadherence is critical. OBJECTIVE: The purpose of this study is to describe the hurdles associated with acne nonadherence and to provide mechanisms on how to ameliorate them. METHODS: PubMed database was searched. Of the 419 search results, 29 articles were reviewed to identify hurdles to adherence and corresponding solutions. RESULTS: Hurdles to primary nonadherence where the medication is not even started, include lack of knowledge, confusion about usage, weak physician-patient relationship, fear of adverse reactions, and cost. Secondary nonadherence hurdles where the medication is started but is not taken as directed include lack of results, complex regimens, side effects, busy lifestyle, forgetfulness, inconvenience, and psychiatric comorbidity. Solutions to these hurdles include treatment simplification, technology, and dynamic education. LIMITATIONS: Adherence is affected by numerous factors, but available literature analyzing acne adherence and interventions to improve adherence to treatment is limited. CONCLUSION: There are several hurdles in adhering to acne treatment. Recognition of these hurdles and finding appropriate solutions may be as important to treatment outcomes as choosing the right medication to prescribe.