Bridging a Temporary High Risk of Sudden Arrhythmic Death. Experience with the Wearable Cardioverter Defibrillator (WCD)

The implantable cardioverter defibrillator (ICD) is able to reduce sudden arrhythmic death in patients who are considered to be at high risk. However, the arrhythmic risk may be increased only temporarily as long as the proarrhythmic conditions persist, left ventricular ejection fraction remains low, or heart failure prevails. The wearable cardioverter defibrillator (WCD) represents an alternative approach to prevent sudden arrhythmic death until either ICD implantation is clearly indicated or the arrhythmic risk is considered significantly lower or even absent. The WCD is also indicated for interrupted protection by an already implanted ICD, temporary inability to implant an ICD, and lastly refusal of an indicated ICD by the patient. The WCD is not an alternative to the ICD, but a device that may contribute to better selection of patients for ICD therapy. The WCD has the characteristics of an ICD, but does not need to be implanted, and it has similarities with an external defibrillator, but does not require a bystander to apply lifesaving shocks when necessary. The WCD was introduced into clinical practice about 8 years ago, and indications for its use are currently expanding. This article describes the technological aspects of the WCD, discusses current indications for its use, and reviews the clinical studies with the WCD. Additionally, data are reported on the clinical experience with the WCD based on 354 patients from Germany hospitalized between 2000 and 2008 who wore the WCD for a mean of 3 months. (PACE 2010; 33:353–367)     

Cardiac Resynchronization Therapy Device Implantation in Patients with Therapeutic International Normalized Ratios

Background: Many patients who need cardiac resynchronization therapy (CRT) require chronic anticoagulation. Current guidelines recommend discontinuation of warfarin and the initiation of anticoagulant “bridging” therapy during these procedures. We evaluated the safety of CRT‐device (CRT‐D) implantation without interruption of warfarin therapy. Methods: A total of 123 consecutive patients requiring CRT‐D therapy were enrolled, 49 identified as high risk for thromboembolic events who received either intravenous heparin, low molecular weight heparin, or warfarin therapy. The control group comprised 74 patients with low risk of thromboembolic events who required only cessation of warfarin perioperatively. Patients were evaluated at discharge and 15 and 30 days postoperatively for pocket hematomas, thromboembolic events, and bleeding. Patients’ length of stay was also catalogued. Results: Patients in the bridging arm had a significant increase in the rate of pocket hematomas (4.1%[control] vs 5.0%[warfarin] vs 20.7%[bridging], P = 0.03) and subsequent longer length of stay (1.6 ± 1.6 [control] vs 2.9 ± 2.7 [warfarin] vs 3.7 ± 3.2 [bridging], P < 0.001). Hematoma formation postoperatively was not different among patients undergoing an upgrade procedure versus those without preexisting cardiac rhythm devices (12% vs 6.2%, P = NS). Patients with a prosthetic mechanical mitral valve had a higher incidence of pocket hematoma formation (1.8% vs 20%, P = 0.03). Conclusions: Our findings suggest that implantation of CRT‐Ds without interruption of warfarin therapy in patients at high risk of thromboembolic events is a safe alternative to routine bridging therapy. This strategy is associated with reduced risk of pocket hematomas and shorter length of hospital stay. (PACE 2010; 400–406)     

Dangerous universal donors; II. Further observations on in vivo and in vitro behavior of isoantibodies of immune type present in group O blood

1. Severe hemolytic reactions were observed in 3 group A (subgroup A₁) recipients transfused with group O whole blood or plasma. In one case, 10 ml. of acommerical preparation of soluble A and B factors had been added to 500 ml. ofwhole blood prior to the transfusion and it is believed that the reaction mighthave been even more serious had not this material been added.

2. The anti-A antibodies in the serum of the dangerous universal donors causingthe hemolytic reactions fixed complement, acted as hemolysins, were difficult toneutralize with soluble A and B factors, were capable of giving positive Coombstests and their ability to agglutinate A cells was enhanced by the presence of normal human serum. These characteristics were similar to those observed in serumfrom donors known to be actively immunized against the A factor, but the stimulusfor development of "immune" anti-A antibodies in the dangerous group O donorswas not apparent.

3. Small amounts of immune A antibody were consistently demonstrated in 12of 100 random group O sera which, after neutralization, produced indirect Coombstests with A₁ cells and agglutinated A₁ cells suspended in compatible normal humanserum.

4. Screening procedures for elimination of dangerous group O donors are discussed.

Note: ACKNOWLEDGMENTSIt is a pleasure to thank Mrs. Jane Peters, Mrs. Nieves Dole and Miss Jean Dorothy for technicalassistance and Dr. R. Wendell Davis for collaboration in the study of Case 1.

     

PERNICIOUS ANEMIA IN CHILDHOOD REPORT OF CASE IN SIX YEAR OLD GIRL RESPONDING TO REFINED LIVER EXTRACT, FOLIC ACID AND VITAMIN B12 IN SUCCESSIVE RELAPSES

A case of megaloblastic anemia without specific neurologic complications in a6 year old girl is presented as an example of pernicious anemia in childhood despitethe fact that a small amount of free hydrochloric acid was present in the gastricjuice after injection of histamine. Prompt hematologic response was obtained following administration of refined liver extract, folic acid and vitamin B₁₂ in successive relapses.

     

Role of interstitial brachytherapy in oral and oropharyngeal carcinoma: Reflection of a series of 1344 patients treated at the time of initial presentation

Our study focuses on a series of 1344 cases of carcinoma of the oral cavity and oropharynx treated between 1973 and 1992. Brachytherapy was always performed with iridium 192, either alone or in combination with external-beam irradiation or with surgery for the treatment of the primary tumor. For the oral cavity, we studied 565 cases of mobile tongue. The local control and overall survival rates, respectively, at 5 years are as follows: for T1, 92% and 70%; for T2, 62% and 42%; and for T3, 50% and 29%. For the subgroup T1T2N0, there was a better prognosis for treatment by brachytherapy of the primary lesion alone (p < 0.0001). Two hundred seven cases of floor-of-mouth carcinoma have been reported. The T3T4 patients were not considered surgical candidates. The local control and overall survival rates, respectively, at 5 years are as follows: for T1, 97% and 71%; for T2, 72% and 42%; and for T3, 51% and 35%. Ninety-seven patients were treated by postoperative brachytherapy. These were patients for whom the margins after surgery were positive or narrow. A technique termed the modified bridge is described for lesions located in the mandible. Carcinomas of the buccal mucosa are rare in our country; only 42 cases were treated in this comparison of two techniques, and the overall survival rate was 48%. Epidermoid carcinomas of the oropharynx have nearly always been treated by a combination of external-beam irradiation and brachytherapy because of the bilateral node risk. Seventy-two patients with epidermoid cancers of the base of the tongue had an overall survival rate of 44%. The tonsil, soft palate, and pillars benefited from the use of the loop technique of brachytherapy combined with external-beam irradiation. Three hundred sixty-one patients were treated. Among these patients were two groups with different prognoses. Patients with tonsil, soft palate, and posterior pillar carcinomas had a local control rate of 84% and an overall survival rate of 57%. Conversely, the anterior pillar and the pharyngoglossal sulcus have a local control rate of only 65% and an overall survival rate of 38%.Statistical analysis revealed the prognostic factors for local control. The complications were classified into four grades: minor (20%), moderate (9%), major (4%), or inducing death (0.2%). The bone complications of grade 2 or 3 are more frequent for the floor of the mouth than for other locations. (Otolaryngol Head Neck Surg 1996:115:519-26.)     

Enzymatic degradation of BISGMA/TEGDMA-polymers causing decreased microhardness and greater wear in vitro

Abstract – The microhardness of the surfaces of BISGMA/TEGDMA-polymers decreased after treatment with pork liver esterase for 48 h in concentrations 0.05 U/ml. This softening effect on BISGMA/TEGDMA-polymer surfaces was also shown as an increased wear rate of the polymers in the presence of esterase measured by a laboratory abrasion method. In this method, polymer cylinders were vigorously shaken in an aqueous slurry containing abrasive particles. The shaking was performed for 3 s followed by a rest period of either 100 or 200 s. This was repeated for 24 h. A greater mean loss of weight of the cylinders was measured when esterase was present in the slurry and the loss of weight increased significantly from 6.7% to 23.8% (P<0.001) when the rest period was increased from 100 s to 200 s. The results indicate that enzymatic hydrolytic activity in the mouth will contribute to a breakdown of composite resin fillings.     

Treatment of adult female epispadias without exstrophy in the presence of rhabdosphincter function

Female epispadias without exstrophy is a very rare entity. Symptoms of female epispadias are primary urinary incontinence and anatomical abnormal features. A 24-year-old married women with two children presented with primary urinary incontinence. Due to previous failure of correct diagnosis and ineffective medical treatment, the patient developed psychological problems (anxiety and depression). In the presence of minimal rhabdosphincter function we could achieve socially acceptable urinary continence by bladder neck plication and a Burch colposuspension. The patient did not consent to a major reconstruction.     

Organizing Quality Assurance in a Maternal-Child Heath Division

The 10-step monitoring and evaluation process is described and applied to a maternal-child health division of a 300-bed tertiary care hospital. Examples of specific important aspects of care and indicators are given. The organized plan developed for this division is examined using the Joint Commission on Accreditation of Healthcare Organization's guidelines.