Incubation Alone Is Adequate as a Culturing Technique for Cardiac Rhythm Management Devices

There exist no standardized methods for culturing cardiac rhythm management devices. To identify the most optimal culturing method, we compared various techniques that comprise vortex, sonication, and incubation or combinations thereof. Incubation alone yielded bacterial colony counts similar to those of other culturing combinations and is the least labor-intensive.Permanent pacemakers (PPM) and implantable cardioverter-defibrillators (ICD) are being utilized increasingly because of an aging population (5, 9). About 180,284 PPM and 57,436 ICD were inserted into cardiac patients in the United States in 2003 (10), and worldwide there are 3 million functioning PPM and 180,000 indwelling ICD (2). Infection is the most common serious complication of PPM and ICD, which are collectively referred to as cardiac rhythm management devices (CRMD). The rates of infection of CRMD range from 0.13% to 19.9% (3, 7) with an average rate of 4% (4). Staphylococcus epidermidis and Staphylococcus aureus collectively account for 70 to 95% of CRMD infections (1, 6). A National Hospital Discharge Survey from 1996 to 2003 indicated that along with the rising use of cardiac medical devices, there has been a disproportional increase in the number of infections of such devices (10). The average cost of combined medical-surgical treatment of an infected CRMD was estimated at $35,000 (4).There are no standardized methods for culturing explanted cardiac generators and leads of the CRMD. Although it has been demonstrated that sonication increases the yield of bacterial cultures from prosthetic joints (8), the utility of this diagnostic approach for CRMD has not been published. To identify the most optimal culturing method, we compared the bacterial yield of various techniques that comprise incubation, vortex, sonication and combinations thereof.     

Discordance between physician's and parent's global assessments in juvenile idiopathic arthritis

OBJECTIVE: To investigate the discrepancy between physician's and parent's global assessments of disease status and the factors explaining discordance in patients with juvenile idiopathic arthritis (JIA). METHODS: The mothers of 197 patients with JIA rated the child's overall well-being on a 10 cm visual analogue scale (VAS) and the attending physician rated the child's overall disease activity on a 10 cm VAS. A discordance score was calculated by subtracting the physician's global assessment from that of the parent's, leading to the definition of three patient groups: (1) no discordance, when physician's and parent's assessments were within 1 cm of each other; (2) negative discordance, when parent's assessment was underrated relative to the physician; and (3) positive discordance, when parent's assessment was over-rated relative to the physician. Negative and positive discordance was defined as 'marked' when the difference between the two assessments was greater than 3 cm. RESULTS: No discordance was found in 40.6% of the patients. Negative discordance was found in 51.3% of the patients, with 34% showing marked discordance. Positive discordance was found in 8.1% of the patients, with 2% showing marked discordance. Significant differences between groups included a shorter disease duration among patients with a markedly positive discordance (P = 0.02) and a greater frequency of ongoing second-line drug therapy among patients with no discordance or with positive discordance (P = 0.008). Patients with no discordance or with marked positive discordance had a significantly lower joint counts (P = 0.02-0.004). CONCLUSION: Parents and physicians often perceive the health status of children with JIA differently, with parents providing most frequently lower rating.     

The patient with slightly elevated pancreatic enzymes and abdominal complaints

Abdominal complaints in combination with slightly elevated serum pancreatic enzymes represent a classical clinical challenge. These symptoms may be due to coincidental unrelated harmless disorders, benign pancreatic alterations which are fairly easily treatable such as mild acute pancreatitis or uncomplicated chronic pancreatitis. However, serious, often insidious diseases such as pancreatic tumours may also present with this constellation as their first signs. Diagnostic procedures need to be stratified according to acuteness and severity of symptoms. While patients with acute onset of symptoms and severe complaints need immediate and combined laboratory and imaging investigations to allow adequate therapy, chronic and mild complaints usually justify a stepwise diagnostic approach consecutively using abdominal ultrasound, CT/MRI and endoscopic ultrasound as imaging procedures and reserving ERCP for cases which remain unclear or in which interventional therapy is needed. Diagnosis and follow-up are often particularly demanding in patients with cystic tumours of the pancreas. In chronic pancreatitis patients pain therapy and adequate control of pancreatic exocrine insufficiency may pose major problems. Patients with refractory pain may ultimately require surgical intervention. Another important indication for surgery in chronic pancreatitis is suspicion of cancer that cannot be ruled out by dedicated diagnostic procedures. This also applies to cystic tumours of the pancreas, which have a high risk of malignant transformation or may even already represent pancreatic cancer at the time of diagnosis.     

Cerebral palsy and aging

Cerebral palsy (CP), the most common major disabling motor disorder of childhood, is frequently thought of as a condition that affects only children. Deaths in children with CP, never common, have in recent years become very rare, unless the child is very severely and multiply disabled. Thus, virtually all children assigned the diagnosis of CP will survive into adulthood. Attention to the adult with CP has been sparse, and the evolution of the motor disorder as the individual moves through adolescence, young adulthood, middle age, and old age is not well understood. Nor do we know what happens to other functional domains, such as communication and eating behavior, in adults with CP. Although the brain injury that initially causes CP by definition does not progressively worsen through the lifetime, the effects of CP manifest differently throughout the lifespan. The aging process must inevitably interact with the motor disorder, but we lack systematic, large-scale follow-up studies of children with CP into adulthood and through adulthood with thorough assessments performed over time.
In this paper we summarize what is known of the epidemiology of CP throughout the lifespan, beginning with mortality and life expectancy, then survey what is known of functioning, ability, and quality of life of adults with CP. We conclude by describing a framework for future research on CP and aging that is built around the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) and suggest specific tools and approaches for conducting that research in a sound manner.     

PLM detection by actigraphy compared to polysomnography: a validation and comparison of two actigraphs

ObjectiveTo compare periodic leg movement (PLM) counts obtained with polysomnography (PSG) to those obtained from actigraphy with two devices (Actiwatch and PAM-RL).MethodsTwenty-four patients underwent full night actigraphy with Actiwatch from both legs and simultaneous PSG. Out of these patients, 10 had additional actigraphy with PAM-RL. Bilateral and unilateral PLM indices (PLMI) for both actigraphs were calculated for time in bed and compared to polysomnographic PLMI. Additionally, a comparison between the two different actigraphs was performed.ResultsPLMI obtained with Actiwatch were significantly lower than those obtained with PSG (21.2 ± 25.6/h versus 34.4 ± 30.7/h; p < 0.001), whereas the PLMI from PAM-RL were significantly higher than in PSG (63.6 ± 39.3/h versus 37.0 ± 33.5/h; p = 0.009). In direct comparison, Actiwatch gave significantly lower PLMI than the PAM-RL (p = 0.005). The correlations between Actiwatch and PSG (rho = 0.835, p < 0.001), PAM-RL and PSG (rho = 0.939, p < 0.001), and Actiwatch and PAM-RL (rho = 0.915, p < 0.001) were significant. Unilateral actigraphy compared to standard PSG gave less consistent findings. When comparing different settings of the PAM-RL, manual threshold setting resulted in PLMI that were no longer different from PSG (p = 0.074), in contrast to the default threshold setting.ConclusionsThe Actiwatch underestimated and the PAM-RL overestimated PLMI compared to PSG. Whereas PLMI obtained with two actigraphs and PSG were highly correlated, they differed in mean values. Therefore, PSG, actigraphy and also the different actigraphs cannot be interchanged in longitudinal studies, and actigraphy should not be used for diagnostic decision making based on PLM indices. The best approximation to PSG PLMI was achieved by using manual threshold setting with the PAM-RL.     

The relation between abnormal behaviors and REM sleep microstructure in patients with REM sleep behavior disorder

ObjectiveTo investigate the temporal relation between rapid eye movement (REM) sleep microstructure (REMs, EMG activity) and motor events in REM sleep behavior disorder (RBD).MethodsPolysomnographic records of eight patients with RBD were analyzed and compared with those of eight sex- and age-matched controls. We examined sleep microstructure for REM sleep with and without REMs and phasic chin EMG activity and their temporal relation to motor events on video.ResultsAll types of motor events were either more frequent in RBD patients than in controls (P ? 0.007) or present solely in RBD patients. In RBD, major motor events were significantly more frequent during REM sleep with REMs than during REM sleep without REMs (violent, 84.0% vs. 16.0%, P < 0.001; complex/scenic behavior, 78.1% vs. 23.2%, P < 0.001; major jerks, 77.5% vs. 20.3%, P < 0.001), whereas minor motor activity was evenly distributed (54.1% vs. 45.9%, P = 0.889). Controls showed predominantly minor motor activity with rare myoclonic body jerks. The distribution of motor events did not differ between REM sleep with and without REMs (40.9% vs. 59.1%, P = 0.262).ConclusionsIn RBD, major motor activity is closely associated with REM sleep with REMs, whereas minor jerks occur throughout REM sleep. This finding further supports the concept of a dual nature of REM sleep with REMs and REM sleep without REMs and implies a potential gate control mechanism of REM sleep with REMs for the manifestation of elaborate or violent behaviors in RBD.