Impact of high‐grade atrioventricular block and cumulative frequent pacing on atrial arrhythmias

Background

The relationship between high‐grade atrioventricular block (HGAVB) with cumulative frequent pacing and risk of atrial arrhythmias (AAs) has not been well characterized. We hypothesized HGAVB and pacing may have significant impact on incidence and prevalence of AAs by modulating atrial substrate.

Objective

To determine impact of HGAVB and pacing on AAs including atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia (AT).

Methods

All consecutive patients who underwent dual‐chamber pacemaker implantation for HGAVB from 2005 to 2011 at the University of Chicago were included. AAs and percent of pacing were detected through device interrogation. Patients’ data were collected from electronic medical records and clinic visits.

Results

A total of 166 patients (mean age 71 ± 15 years; 54% female, 56% African American) were studied. AF was documented in 27% of patients before pacemaker implantation. During a mean 5.8 ± 2.2 years of follow‐up, 47% had device‐detected AF, 10% AFL, and 26% AT. New‐onset AF was documented in 40 of the 122 patients without prior AF (33%). Continuous (≥ 99%) right ventricular pacing was associated with significantly decreased AF prevalence (34% vs 59%, P = 0.005), and correlated with lower incidence (26% vs 41%, P = 0.22). Pacing suppressed AF in 14% of patients with baseline AF; those patients had lower atrial pacing (3.2% vs 45%, P < 0.0001). Left atrial dilation was the only independent predictor of AF with frequent pacing (P = 0.009).

Conclusions

HGAVB is associated with high incidence and prevalence of AAs with and without pacing. Cumulative frequent (≥99%) ventricular pacing reduces risk of AF in patients with HGAVB.

     

Reducing central venous catheters in chronic hemodialysis—a commitment to arteriovenous fistula creation in children

Background

An internal permanent vascular access [arteriovenous fistula (AVF) or arteriovenous graft (AVG)] is preferred over central venous catheters (CVC) for chronic hemodialysis. However, CVC remain the most commonly used access in children. The objective of this study was to evaluate our experience with AVF.

Methods

We conducted a retrospective chart review of children aged 1–18 years on chronic hemodialysis from 2001 to 2012. Patients were divided into three time periods: 2001–2005, 2006–2009 and 2010–2012. A systematic approach to AVF placement was introduced in our department in 2006 which resulted in a greater number of AVF being placed and used, but the access failure rate was still higher than desired. In 2010, a more experienced vascular surgeon was contacted to perform AVF surgery in our most difficult AVF candidates.

Results

Sixty-five AVF were created in 55 patients (67.3 % male). The median age of the patients was 14 (3–18) years. Forty-one (63.1 %) AVF were used successfully, and this number increased from 52.6 to 57.6 to 92.3 % over the three time periods, respectively. Over time, AVF use rates increased and CVC use decreased. By 2012 only 7.7 % of our patients were using a CVC. The primary patency rate was 42.9 % at 1 year; secondary patency rates were 100 and 93.8 % at 1 and 2 years, respectively. Infection and hospitalization rates were higher for CVC than for AVF [0.8 vs. 0.1 infections per access-year (p?p?Conclusions With a dedicated approach and vascular access team it is possible to decrease CVC and increase AVF use in children on hemodialysis. In our study, increased AVF use resulted in decreased access-related infection and hospitalization rates.     

Acute visual loss in a child with autosomal recessive polycystic kidney disease: case report and review of the literature.

Acute visual loss secondary to ischemic optic neuropathy in children is extremely rare. The causes are usually hypotension or anemia. We describe the clinical course of a 9-year-old boy with a functional renal transplant who presented to the emergency room hemodynamically stable after waking up with complete bilateral loss of vision (no light perception). Examination showed that he had suffered massive nocturnal blood loss from esophageal varices secondary to portal hypertension. The patient's end-stage renal disease was secondary to autosomal recessive polycystic kidney disease (ARPKD), an entity comprised of renal cysts and hepatic fibrosis. Ophthalmologic findings in ARPKD are rarely cited in the literature. A literature search revealed 3 other cases of sudden visual loss reported in nonophthalmologic journals in patients with ARPKD. Funduscopic examination showed bilateral optic nerve head pallor and swelling with associated flame hemorrhages. The fact that this patient already had mildly pale nerves on presentation, along with hemodynamically compensated blood pressure and pulse, suggested chronic as well as acute ischemia. Based on our findings and other reported cases in the literature, ophthalmologic examinations may be indicated in all patients with ARPKD.     

Barriers to live donor kidney transplants in the pediatric population: A single‐center experience

A decrease in live donor pediatric kidney transplants has occurred in the United States. This study investigates barriers that may influence access to live donor kidney transplants in children. Retrospective chart review was conducted for 91 children (69% male, mean age 11.9 years) who underwent pretransplant workup from 2005 to 2015 at an urban pediatric hospital. Fifty‐four percent were African American, 32% Caucasian, 8% Arabic, 3% Hispanic, and 3% Others. Government‐sponsored insurance (Medicaid/Medicare) was utilized by 73%, and 54% had dual caregivers. Only nine of 68 kidney transplants were live donor transplants. Live donor transplants (11%) were significantly (P=.008) lower than deceased donor transplants (59%) in African Americans. Private insurance was reported by 56% of live donor recipients and 25% of deceased donor recipients. Among live donor recipients, 78% were from dual caregiver families. Caregiver, health‐related, financial, and religious/cultural barriers to live donor transplants were reported, several of which may be amenable to positive intervention.     

Conventional versus 3-Dimensional Miniplate in Management of Mandibular Fracture: A Prospective Randomized Study

Objective The aim of this study was to compare conventional miniplate (Champy's) and 3-dimensional miniplate fixation in the management of mandibular fracture. Study Design Prospective study. Setting The study was carried out in the Department of Oral and Maxillofacial Surgery, Govt. Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak, India. Subjects and Methods A prospective randomized clinical trial was carried out in 50 patients. Patients were randomly assigned to receive a 2.0-mm 3-dimensional miniplate (group A) or a 2.0-mm conventional miniplate (group B). All patients were followed up for 12 weeks postoperatively. Complications were analyzed according to the type of plate used and the site of fracture. Results Twenty-eight fracture sites were treated with the 3-dimensional miniplate and 28 with the conventional miniplate. Five complications occurred, representing 8.9% of the total. Two complications occurred in group A and 3 in group B, with complication rates equaling 7.14% and 10.71%, respectively. When comparing the overall complication rates according to plates used, the χ(2) test showed no statistically significant difference between the 2 groups (P > .05). Conclusion No major difference in terms of treatment outcome is observed in both systems, and both are equally effective in managing mandibular fracture.     

Hemoglobin sickle cell disease and systemic lupus erythematosus

An unusual association of hemoglobin sickle cell disease with systemic lupus erythematosus in an 11-year-old girl highlights the diagnostic dilemma that may arise because of the similarity of symptomatology.     

The quest for quality and productivity in health services

The leaders of health care organizations across the country are facing significant pressures to improve the quality of their services while reducing the rate of cost increases within the industry. Total Quality Management (TQM) has been credited, by many leaders in the manufacturing industry, as an effective tool to manage their organizations. This article presents key concepts of TQM as discussed by quality experts, namely, Deming, Juran, and Crosby. It discusses 12 key concepts that have formed the foundation of TQM implementation at Henry Ford Health System. The process of implementation is presented in detail, and the role of TQM in clinical applications is discussed. Success factors and visible actions by senior management designed to reinforce the implementation of TQM in any organization are presented.