Permanent-temporary pacemakers in the management of patients with conduction abnormalities after transcatheter aortic valve replacement

Background

Damage to the cardiac conduction system requiring permanent pacemaker (PPM) implantation is a known adverse outcome of transcatheter aortic valve replacement (TAVR). A permanent-temporary pacemaker (PTPM) is a device that involves an active-fixation lead attached to an external pulse generator taped to the skin. We reviewed the utility of PTPMs as a temporary bridge measure after TAVR in patients with conduction abnormalities that do not meet conventional criteria for PPM placement.

Methods

Between January 01, 2013 and December 31, 2015, we analyzed 67 patients who received PTPM after TAVR. Baseline demographics, comorbidities, type and size of the valve, pre-TAVR electrocardiograms (ECGs), post-TAVR ECGs at 1 day, 1 month, and 6 months, and pacemaker interrogation results were reviewed for each patient if available.

Results

The mean age of patients was 80.5?±?9.1 years. PTPM were placed for 2.3?±?2.4 days. Among these patients, 44.8% (n?=?30) received a PPM prior to discharge. Male gender (OR 2.84, 95% CI 1.05–7.69, p?=?0.05) and an increase in QRS duration post-TAVR (p?=?0.01) were associated with PPM placement. Pacemaker interrogation data of 11 patients with PPM revealed that 27% (n?=?3) had <?1% V-pacing requirements and <?10% A-pacing requirements.

Conclusions

In post-TAVR patients who develop conduction abnormalities that do not meet conventional PPM implantation indications, PTPM safely provides a time period for further assessment and may prevent unnecessary PPM implantation. Male gender and an increase in QRS duration post-TAVR are associated with PPM implantation. Additionally, some patients may recover from their conduction disturbances and demonstrate low pacemaker utilization.

     

Determinants of patient and health care services delays for tuberculosis diagnosis in Italy: a cross-sectional observational study

Background

Prompt diagnosis of active tuberculosis (TB) has paramount importance to reduce TB morbidity and mortality and to prevent the spread of Mycobacterium tuberculosis. Few studies so far have assessed the diagnostic delay of TB and its risk factors in low-incidence countries.

Methods

We present a cross-sectional multicentre observational study enrolling all consecutive patients diagnosed with TB in seven referral centres in Italy. Information on demographic and clinical characteristics, health-seeking trajectories and patients’ knowledge and awareness of TB were collected. Diagnostic delay was assessed as patient-related (time between symptoms onset and presentation to care) and healthcare-related (time between presentation to care and TB diagnosis). Factors associated with patient-related and healthcare-related delays in the highest tertile were explored using uni- and multivariate logistic regression analyses.

Results

We enrolled 137 patients, between June 2011 and May 2012. The median diagnostic delay was 66?days (Interquartile Range [IQR] 31–146). Patient-related and healthcare-related delay were 14.5?days (IQR 0–54) and 31?days (IQR: 7.25–85), respectively. Using multivariable analysis, patients living in Italy for <?5?years were more likely to have longer patient-related delay (>?3?weeks) than those living in Italy for >?5?years (Odds Ratio [OR] 3.47; 95% Confidence Interval [CI] 1.09–11.01). The most common self-reported reasons to delay presentation to care were the mild nature of symptoms (82%) and a good self-perceived health (76%). About a quarter (26%) of patients had wrong beliefs and little knowledge of TB, although this was not associated with longer diagnostic delay. Regarding healthcare-related delay, multivariate analysis showed that extra-pulmonary TB (OR 4.3; 95% CI 1.4–13.8) and first contact with general practitioner (OR 5.1; 95% CI 1.8–14.5) were both independently associated with higher risk of healthcare-related delay >?10?weeks.

Conclusions

In this study, TB was diagnosed with a remarkable delay, mainly attributable to the healthcare services. Delay was higher in patients with extra-pulmonary disease and in those first assessed by general practitioners. We suggest the need to improve knowledge and raise awareness about TB not only in the general population but also among medical providers. Furthermore, specific programs to improve access to care should be designed for recent immigrants, at significantly high risk of patient-related delay.

Trial registration

The study protocol was registered under the US National Institute of Health ClinicalTrials.gov register, reference number: NCT01390987. Study start date: June 2011.

     

Outcome of mid-urethral sling procedures in Korean women with stress urinary incontinence according to body mass index

BACKGROUND: The objective of this study was to determine whether the outcome of mid-urethral sling procedures is influenced by the body mass index of Korean women suffering from stress urinary incontinence (SUI). METHODS: A total of 285 women, ranging in age from 28 to 80 years (mean 55.4), all of whom were followed up for at least 6 months, were ultimately included in this study. The patients were classified as follows: normal weight, 18.5-23 kg/m2; overweight, 23-27.5 kg/m2; obesity, 27.5 kg/m2 or higher. RESULTS: We noted bladder perforations in 11 cases (4.9%, 3.8% and 2.2% in the normal weight, overweight, and obesity groups, respectively; P = 0.449). We determined there to be no significant differences among the three groups with regard to cure rate (P = 0.173). The rates of postoperative urinary retention were 9.9% in the normal weight group, 10.1% in the overweight group, and 15.6% in the obesity group (P = 0.396). We determined there to be no significant differences among the three groups with regard to the persistence of urgency (P = 0.312). Seventy-nine patients (27.7%) exhibited symptoms indicative of voiding disorder (hesitancy, poor flow, or sensations of incomplete emptying). The postoperative development of these voiding symptoms was not significantly different among the three groups (P = 0.106). CONCLUSION: Our results demonstrate both the feasibility and the safety of mid-urethral sling procedures for obese Korean women who suffer from SUI. Additional studies, including prospective randomized trials with longer follow-up periods, will be required in order to confirm these findings.     

Clinical usefulness of cognitive evoked potentials to assess cognitive deficits in cerebrovascular diseases

Background: The aim of the present study is to evaluate the clinical applicability and usefulness of cognitive evoked potentials (CEP) to identify a cognitive deficit in patients with cerebrovascular diseases (CVD). Methods: The P3 latencies, amplitudes and latency to amplitude ratios (LAR) of CEP were measured in 25 healthy control subjects and 35 inpatients with CVD. The association of CEP with variables including age, sex, mini‐mental state examination (MMSE) score, CVD types, loci of hemiplegic limbs, duration, education, brief psychiatric rating scale (BPRS), instrumental activities of daily living (IADL) and daily living function assessment (DLFA) was also analyzed. Results: (i) The P3 latencies (447.87 ± 113.06 msec) and LAR (65.83 ± 43.25) were prolonged in CVD (P < 0.05), while the amplitudes (8.18 ± 2.51 µV ) were not changed; (ii) the P3 latencies (537.31 ± 101.14msec) and LAR (94.89 ± 46.44 in CVD with a MMSE score <24 were prolonged, and the amplitudes (6.45 ± 1.98 µV ) were reduced (P < 0.05, respectively); (iii) the BPRS, IADL and DLFA in CVD with a MMSE score <24 were different from MMSE ≥24 (P < 0.05); (iv) there was no difference in CEP between CVD caused by infaction and hemorrhage; (v) the P3 latencies were correlated positively with age, BPRS and IADL, while negatively with MMSE and DLFA. The amplitudes were correlated positively with MMSE and DLFA, while negatively with age, BPRS and IADL. The LAR were correlated positively with age, BPRS and IADL, while negatively with MMSE and DLFA; and (vi) on analyzing association of CEP with variables in CVD with MMSE <24, the P3 latencies were correlated positively with BPRS and DLFA, while negatively with MMSE and DLFA. The amplitudes were positively correlated with age. The LAR were positively correlated with IADL. Conclusions: The P3 latencies and LAR of CEP seemed to be useful clinical measures to assess cognitive disorders in CVD as well as in vascular dementia.     

Morphology of sweat glands in determining time of death

This study demonstrates post-mortem autolytic alterations in the skin at cellular and subcellular levels and identifies parameters which may assist in determining the time of death in the first few hours post-mortem. Serial skin samples from the ventral surface of the arm were taken at intervals of 3, 6, 9 and 12 h after death in 29 subjects of various ages, with no signs of skin disease; causes of death were various. Three types of tests were performed: cytochemical (hematoxylin-eosin and alcian-PAS), immunohistochemical (S-100, CEA, Cytokeratin, ASM) and ultrastructural (electron microscopy). Electron microscopy proved useful for identifying transformations which were found to be specific for each chronological step considered: reduction of intracellular glycogen in clear cells and reduction of secretory granules in dark cells are typcial signs of the first stage (3 h) after death; mitochondrial dilatation and rarefaction of cristae in clear and dark cells are typical of the second stage (6 h); rarefaction of microvilli in dark and clear cells is a sign of the last stage (12 h). Cytochemistry and immunohistochemistry supply useful information — not for all the chronological stage considered here, but for individual phases (3 h for hematoxylin-eosin and 6 h for alcian-PAS). However, it is particularly important to use the results from all such techniques simultaneously, so that the question of the exact time of death within the first 12 h post-mortem may be more accurately answered.     

性腺切除及急性饥饿对大鼠垂体-甲状腺功能的影响

本实验采用性腺摘除或经假摘除手术的两性SD大鼠,其中部分动物分别予以睾酮(T)或雌二醇(E_2),观察它们在急性饥饿或非饥饿状态下血清T_4、TSH与T浓度变化。结果提示急性饥饿可使雄鼠甲状腺合成或分泌T_4和性腺分泌睾酮减少,从而不完全地抑制了雄激素所介导的对垂体TSH分泌的兴奋作用。外源性T替代虽然可以使去势雄鼠血清T浓度恢复正常,但却无兴奋TSH分泌的作用;饥饿组去势雄鼠接受外源性T后血清TSH更为减少。提示外源性T可抑制此组雄鼠垂体TSH合成及(或)释放。     

Effect of diabetes on fast response to norepinephrine in rat aorta.

The fast and slow components of the mechanical response to 1 microM norepinephrine (NE) were measured in aortic rings isolated from eight spontaneously diabetic rats, six streptozocin-induced diabetic (STZ-D) rats, six STZ-D rats treated with 2.5 U insulin/day during the 4 days before being killed, and six age- and sex-matched control rats. The total contraction to NE (i.e., the sum of fast and slow components) was similar in the four groups: spontaneously diabetic, 16.53 +/- 1.72 mN; STZ-D, 15.68 +/- 1.41 mN; insulin-treated, 16.17 +/- 2.05 mN; and control, 15.27 +/- 0.96 mN (NS). The fast component, measured graphically in a total contraction in 1.35 mM Ca, was greater in spontaneously diabetic (12.61 +/- 1.07 mN, P less than 0.05) and STZ-D (12.25 +/- 0.89 mN, P less than 0.05) rats compared with control (9.14 +/- 0.74 mN) or insulin-treated (8.58 +/- 1.23 mN) rats. The same increase of the fast component was detectable after 3 min of incubation in Ca-free medium + 2 mM EGTA (control 6.54 +/- 0.47 mN, spontaneously diabetic 9.07 +/- 0.76 mN, P less than 0.05; STZ-D 8.82 +/- 0.72 mN, P less than 0.05), and it was also abolished by insulin treatment (insulin-treated 6.29 +/- 0.36 mN). We conclude that the diabetic state increases the fast component of NE-induced contraction either in the absence or presence of Ca in the medium. This suggests that such an increase depends on a larger release of Ca from intracellular stores.