Pocket Hematoma: A Call for Definition

Pocket hematoma is a common complication of cardiac implantable electronic device procedures and a potential risk factor for device infections, especially in patients on oral anticoagulation or antiplatelet treatment. There is a wide variability in the incidence of pocket hematoma and bleeding complications in the literature and the major cause for this seems to be the variability of the used definitions for hematomas. The lack of generally accepted definition for pocket hematoma renders the comparisons across the studies difficult. In this article, we briefly review the current literature on this issue and propose a uniform definition for pocket hematoma and criteria for grading the severity of hematoma in clinical practice and research.     

Transient sputum eosinophilia may occur over time in non‐eosinophilic asthma and this is not prevented by salmeterol

Background and Objective: Symptomatic, steroid‐naïve asthmatic patients may have low sputum eosinophil numbers. The aim of the study was to determine whether low sputum eosinophil numbers persisted over time, during treatment with salmeterol monotherapy. Methods: Forty steroid‐naïve, symptomatic asthmatic patients, with sputum eosinophils <3%, were randomized to receive open‐label salmeterol (50 µg twice a day, n = 30) or fluticasone (125 µg twice a day, n = 10) and were then assessed at 1, 3 and 6 months. All patients underwent spirometry, a methacholine challenge test and sputum induction at each visit. Symptom scores and peak expiratory flow were recorded throughout the study. Patients were permitted to withdraw from the study at any time, if they experienced exacerbations or deterioration of symptoms. Results: The average sputum eosinophil percentage remained normal (≤1.9%) in both groups over the study period. The eosinophil percentages were ≤1.9% in 65 of the 80 samples obtained from salmeterol‐treated patients throughout the study period. Eight patients had an asthma exacerbation or deterioration, during which one developed sputum eosinophilia. Twelve patients, 11 of whom were randomized to salmeterol and one to fluticasone, developed transient sputum eosinophilia at least once during the study. This was not associated with asthma exacerbation (except for one patient). Sputum neutrophil percentage did not change in either group. Conclusions: Low sputum eosinophil numbers persisted over 6 months in a majority of patients with non‐eosinophilic asthma who received salmeterol monotherapy. However, transient sputum eosinophilia occurred in 40% indicating that non‐eosinophilic asthma may not be a stable phenotype.     

Long-term immunogenicity and safety of an inactivated hepatitis A vaccine in haemophilic patients

Summary. As a consequence of recent outbreaks of HAV infection by blood products, 91 patients, haemophiliacs and subjects with bleeding disorders (10 of whom were also anti-HIV positive) susceptible to HAV infection received a formalin-inactivated hepatitis A vaccine (HAVRIX 720 Elisa Units, SmithKline Beecham). Subcutaneous injections were given in the deltoid region at 0, 1 and 6 months. The seroconversion rates and litres, expressed in GMT IU/1, were determined at 1, 2, 6, 7, 12, 18 and 24 months. No adverse reactions to the vaccine were observed. The highest percentage of responders observed was 98.7% in anti-HIV negative and 71.4% in anti-HIV positive patients. The anti-HAV GMT titres were higher in anti-HIV negative than in anti-HIV positive patients. The inactivated hepatitis A vaccine is safe, clinically well tolerated, and provides long-term protection against HAV infection.     

Multigenetic lesions in infant acute leukaemias: correlations with ALL-1 gene status

The large majority of childhood B-precursor cell acute lymphoblastic leukaemia cases present IgH and TCRδ gene rearrangements. These rearrangements have been widely used as specific markers for monitoring minimal residual disease. However, their prognostic value still remains unclear. In order to determine whether IgH and TCRδ gene rearrangements have any influence on relapse and event-free survival (EFS), we analysed the clinical impact of these genetic characteristics in 51 B-precursor acute lymphoblastic leukaemia patients. 46/51 patients (90.2%) showed IgH gene rearrangements by Southern blot and/or polymerase chain reaction (PCR) analysis. No statistically significant associations were found between IgH gene rearrangement pattern and age, sex, WBC count, immunophenotype, risk factor, relapse or EFS. 27/41 patients (66%) showed Vδ₂Dδ₃ recombination by Southern blot and/or PCR analysis. At a median follow-up of 53 months the estimated 5-year EFS probability was 78 ± 3% for the whole group. The EFS probability among patients with a Vδ₂Dδ₃ recombination pattern in the TCRδ locus was 90 ± 3%, whereas for patients without Vδ₂Dδ₃ recombination was 39 ± 13% ( P  < 0.005).
IgH rearrangement patterns do not appear to influence relapse or EFS probability. However, TCRδ gene rearrangement patterns have a relevant impact on the relapse rate and the EFS probability. Patients with Vδ₂Dδ₃ recombination have better clinical outcome than patients without this recombination, independent of any other prognostic factors.     

Catheter Induced Distal Intra-Hisian Right Bundle Branch Block in a Patient with Persistent Proximal Intra-Hisian Complete A-V Block

We describe a patient with complete intra-Hisian A-V block and narrow QRS who developed catheter-induced right bundle branch block during an electrophysiological study. Selective His bundle pacing was performed during complete intra-Hisian A-V block and right bundle branch block pattern; the distal His bundle pacing normalized the QRS complex, while a more proximal His bundle stimulation showed a right bundle branch block configuration with the persistence of the proximal intra-Hisian lesion responsible for the complete A-V block. These electrophysiological findings suggest that the catheter-induced right bundle branch block in our patient was due to a focal lesion in the distal part of the main His bundle. To our knowledge, this is the first report of documented multilevel lesions within the His bundle in man.     

Transthoracic Sensor for Noninvasive Assessment of Left Ventricular Contractility: Validation in A Minipig Model of Chronic Heart Failure

Background: Invasively measured left ventricular (LV) dP/dt is the accepted standard for measuring acute and chronic directional changes in LV contractility. Recently, we developed a noninvasive force sensor based on an accelerometer positioned on the chest, which measures the vibrations generated by isovolumic myocardial contraction. The aim of this paper was to compare noninvasive (accelerometer) versus invasive (LV dP/dt) indices of myocardial contractility in a chronic minipig model of pacing‐induced heart failure (HF). Comparative assessment was performed both at rest and following dobutamine infusion. Methods: In adult male minipigs (n = 6), LV contractility was simultaneously assessed both invasively (LV dP/dt, Millar catheter) and noninvasively (accelerometer) at rest and following dobutamine (up to 7.5 mcg/kg/min), both before and after development of HF by pacing the LV at 180 beats/min for 3 weeks. Results: Invasive and noninvasive assessments were obtained in 24 conditions (12 at rest and 12 after dobutamine infusion). Sensor‐based cardiac force changes were significantly related to positive peak LV dP/dt_max changes following dobutamine infusion both in normal (r = 0.88, P < 0.001) and failing heart (r = 0.89, P < 0.001). The force‐frequency relation showed a tight correlation between invasive and noninvasive assessment (r = 0.68, P = 0.02). Conclusions: The force‐frequency relation can be assessed noninvasively by a transthoracic sensor based on an accelerometer. The method can efficiently detect the development of resting dysfunction and the contractile reserve at different HF steps, with potential for wearable HF monitoring. (PACE 2010; 795–803)