Prognostic value of left ventricular mechanical dyssynchrony by phase analysis in patients with non-ischemic cardiomyopathy with ejection fraction 35-50% and QRS < 150 ms.

BACKGROUND: Left ventricular mechanical dyssynchrony (LVMD) by phase analysis of gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is a useful tool for predicting response to cardiac resynchronization therapy and has prognostic value. While most of the studies were done on patients with ischemic cardiomyopathy or those with LV ejection fraction (EF) < 35%, there are little data on the prognostic value of LVMD in patients with non-ischemic cardiomyopathy (NICM), particularly those with mildly decreased systolic function and narrow or intermediate QRS duration. METHODS AND RESULTS: From the stress SPECT-MPI database at Cleveland Clinic, we identified 324 consecutive patients (mean age 62 ± 13 years, 62% male, 36% diabetics) with NICM, LVEF 35-50% (median [Q1,Q3] 45 [41,49]), and QRS < 150 ms (13% with QRS 120-149 ms). LVMD was determined from gated stress images and expressed as phase standard deviation (SD) and histogram BW (% R-R cycle). For easier graphical illustration, patients were divided into tertiles of LVMD. All-cause death was the primary endpoint and determined using the Social Security Death Index. Cox proportional hazard model was performed to determine the independent predictive value of LVMD, and next Cox models for incremental value. After a mean follow-up time of 1,689 days, 86 (26.5%) of patients died. These patients were older, had more diabetes, more use of diuretics, with wider QRS duration, and with a trend for higher phase SD and BW. After adjusting for age, hypertension, diabetes, aspirin, beta-blockers, diuretics, QRS, and EF, phase SD was an independent predictor of all-cause mortality with hazard ratio [95% CI] 1.97 [1.06,3.66] for the highest tertile, and added incremental prognostic value (P = .025). Similar findings were obtained using histogram BW. CONCLUSION: In patients with NICM, EF 35-50%, and QRS < 150 ms, increased LVMD on peak stress SPECT was an independent predictor of all-cause mortality. The utility and applicability of such findings in clinical practice need further evaluation in larger and prospective studies.

Novel treatment approach of localized juvenile spongiotic gingival hyperplasia with use of Nd:YAG laser.

INTRODUCTION: This article describes the management of two patients who presented with localized juvenile spongiotic gingival hyperplasia. This disease entity is poorly understood, and literature regarding successful treatment is scant. However, there are common themes to management including proper diagnosis and treatment via removal of the affected tissue. The biopsy demonstrates intercellular edema and neutrophil infiltrate with epithelial and connective tissue disease components, so surgical deepithelialization may not be adequate to definitively treat the disease. METHODS AND RESULTS: This article presents two cases of the disease and suggests the use of the Nd:YAG laser as an alternative management modality. CONCLUSION: To our knowledge, we present the first cases of localized juvenile spongiotic gingival hyperplasia treated with the Nd:YAG laser. KEY POINTS: Why are these cases new information? To our knowledge, this case series illustrates the first use of an Nd:YAG laser to treat the rare pathology localized juvenile spongiotic gingival hyperplasia. What are the keys to successful management of these cases? To properly manage this rare presentation, proper diagnosis is paramount. Following diagnosis with microscopic evaluation, deepithelialization and treatment of underlying connective tissue infiltrate via the Nd:YAG laser offers an elegant option to treat the pathology and maintain esthetic outcomes. What are the primary limitations to success in these cases? The primary limitations of these cases include the small sample size, which is attributable to the rarity of the disease.

Environmental variation shifts the relationship between trees and scatterhoarders along the continuum from mutualism to antagonism.

The conditional mutualism between scatterhoarders and trees varies on a continuum from mutualism to antagonism and can change across time and space, and among species. We examined 4 tree species (red oak [Quercus rubra], white oak [Quercus alba], American chestnut [Castanea dentata] and hybrid chestnut [C. dentata × Castanea mollissima) across 5 sites and 3 years to quantify the variability in this conditional mutualism. We used a published model to compare the rates of seed emergence with and without burial to the probability that seeds will be cached and left uneaten by scatterhoarders to quantify variation in the conditional mutualism that can be explained by environmental variation among sites, years, species, and seed provenance within species. All species tested had increased emergence when buried. However, comparing benefits of burial to the probability of caching by scatterhoarders indicated a mutualism in red oak, while white oak was nearly always antagonistic. Chestnut was variable around the boundary between mutualism and antagonism, indicating a high degree of context dependence in the relationship with scatterhoarders. We found that different seed provenances did not vary in their potential for mutualism. Temperature did not explain microsite differences in seed emergence in any of the species tested. In hybrid chestnut only, emergence on the surface declined with soil moisture in the fall. By quantifying the variation in the conditional mutualism that was not caused by changes in scatterhoarder behavior, we show that environmental conditions and seed traits are an important and underappreciated component of the variation in the relationship between trees and scatterhoarders.

Shock avoidance and the newer tachycardia therapy algorithms.

Sudden cardiac death is a leading cause of death in the United States and Europe. Implantable cardioverter defibrillators (ICDs) are a cornerstone of therapy for patients at risk of first occurrence of ventricular arrhythmia, or secondary prevention in those who have previously suffered cardiac arrest or life-threatening arrhythmias. Despite their efficacy, ICD shocks are associated with significant physical and psychological adverse effects. As technology has progressed, newer device programing methods have allowed for arrhythmia suppression and termination without the need for high-energy defibrillation, thus improving patient satisfaction, health, and outcomes.