Age‐Specific Differences in Women with Implantable Cardioverter Defibrillators: An International Multi Center Study

Background: Common psychological adjustment difficulties have been identified for groups of implantable cardioverter defibrillator patients, such as those who are young (<50 years old), have been shocked, and are female. Specific aspects and concerns, such as fears of death or shock and body image concerns, that increase the chance of distress, have not been examined in different aged female implantable cardioverter defibrillator (ICD) recipients. The aim of the study was to investigate these areas of adjustment across three age groups of women from multiple centers. Methods: Eighty‐eight female ICD patients were recruited at three medical centers: Shands Hospital at the University of Florida, Brigham and Women's Hospital in Boston, and Royal North Shore Hospital in Sydney, Australia. Women completed individual psychological assessment batteries, measuring the constructs of shock anxiety, death anxiety, and body image concerns. Medical record review was conducted for all patients regarding cardiac illnesses and ICD‐specific data. Results: Multivariate and univariate analyses of variance revealed that younger women reported significantly higher rates of shock and death anxiety (Pillai's F = 3.053, P = 0.018, η²_p= 0.067) and significantly greater body image concerns (Pillai's F = 4.198, P = 0.018, η²_p= 0.090) than middle‐ and older‐aged women. Conclusions: Women under the age of 50 appear to be at greater risk for the development of psychosocial distress associated with shock anxiety, death anxiety, and body image. Clinical‐based strategies and interventions targeting these types of adjustment difficulties in younger women may allow for improved psychosocial and quality of life outcomes.     

Gender Differences in the Clinical Characteristics and Atrioventricular Nodal Conduction Properties in Patients With Atrioventricular Nodal Reentrant Tachycardia

Gender Differences in Patients With AVNRT. Introduction: The detailed electrophysiological characteristics of the gender differences associated with atrioventricular nodal reentrant tachycardia (AVNRT) have not been clarified. This study investigated the gender‐related electrophysiological differences in a large series of patients undergoing radiofrequency catheter ablation. Methods and Results: A total of 2,088 consecutive AVNRT patients (men/women 869/1,219) who underwent catheter ablation were enrolled in this study. We evaluated the gender differences in their electrophysiological characteristics. Women had a significantly younger age of onset, higher incidence of multiple jumps, shorter AH interval, atrial effective refractory period (ERP), anterograde fast pathway ERP, anterograde slow pathway ERP, and retrograde slow pathway ERP, and longer ventricular ERP than men. The incidence of baseline ventriculoatrial dissociation was lower in women than in men. Women needed less isoproterenol/atropine to induce AVNRT. No gender differences in the radiation exposure time, procedure time, complication rate, acute success rate, or second procedure rate were noted. Both typical and atypical AVNRT were more predominant in women. In the patients with atypical AVNRT, there was no significant gender difference in incidence of baseline ventriculoatrial dissociation; however, the retrograde slow pathway ERP was significantly shorter in women than in men. Women of premenopausal age (≤50 years old) had a significantly higher incidence of anterograde multiple jumps and a retrograde jump phenomenon, and a shorter anterograde slow pathway ERP and retrograde slow pathway ERP than those of women over 50 years old. Conclusion: Gender differences in the anterograde and retrograde AV nodal electrophysiology were noted in the patients with AVNRT. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1114‐1119)     

The Novel Electrophysiology of Complex Fractionated Atrial Electrograms: Insight from Noncontact Unipolar Electrograms

Unipolar Characteristics of CFAEs. Background: The noncontact mapping (NCM) system possesses the merit of global endocardial recording for unipolar and activation mapping. Objective: We aimed to evaluate the unipolar electrogram characteristics and activation pattern over the bipolar complex fractionated atrial electrogram (CFAE) sites during atrial fibrillation (AF). Methods: Twenty patients (age 55 ± 11 years old, 15 males) who underwent NCM and ablation of AF (paroxysmal/persistent = 13/7) were included. Both contact bipolar (32–300 Hz) and NCM virtual unipolar electrograms (0.5–300 Hz) were simultaneously recorded along with the activation pattern (total 223 sites, 11 ± 4 sites/patient). A CFAE was defined as a mean bipolar cycle length of ≤ 120 ms with an intervening isoelectric interval of more than 50 ms (Group 1A, n = 63, rapid repetitive CFAEs) or continuous fractionated activity (Group 1B, n = 59, continuous fractionated CFAEs), measured over a 7.2‐second duration. Group 2 consisted of those with a bipolar cycle length of more than 120 ms (n = 101). Results: The Group 1A CFAE sites exhibited a shorter unipolar electrogram cycle length (129 ± 11 vs 164 ± 20 ms, P < 0.001), and higher percentage of an S‐wave predominant pattern (QS or rS wave, 63 ± 13% vs 35 ± 13%, P < 0.001) than the Group 2 non‐CFAE sites. There was a linear correlation between the bipolar and unipolar cycle lengths (P < 0.001, R = 0.87). Most of the Group 1A CFAEs were located over arrhythmogenic pulmonary vein ostia or nonpulmonary vein ectopy with repetitive activations from those ectopies (62%) or the pivot points of the turning wavefronts (21%), whereas the Group 1B CFAEs exhibited a passive activation (44%) or slow conduction (31%). Conclusions: The bipolar repetitive and continuous fractionated CFAEs represented different activation patterns. The former was associated with an S wave predominant unipolar morphology which may represent an important focus for maintaining AF. (J Cardiovasc Electrophysiol, Vol. 21, pp. 640‐648, June 2010)     

Clinical Use of Permanent Pacemaker for Conversion of Intraatrial Reentry Tachycardia in Children

The use of the implanted atrial-based pacemaker to overdrive postsurgical intraatrial reentry tachycardia (IART) was evaluated in a large group of pediatric patients over a 14-year study period. The authors sought to determine the feasibility of this noninvasive technique in the management of this specialized population and to determine factors associated with successful conversion. They examined 128 manual overdrive attempts performed on 22 consecutive patients. There were 10 patients with post-Fontan repair, 7 with post-Mustard/Senning procedure, and 5 with miscellaneous lesion types. The number of IART episodes for overdrive pacing per patient ranged from 1 to 15. The first overdrive pacing attempt was successful in 63% (14/22) of the patients. The mean IART cycle length was 278 +/- 59 ms. The mean pacing rate for effective conversion of IART was 66 +/- 10% faster than the IART rate. By controlling for repeated measures for individual patients, three factors were found to be independently associated with a successful outcome: (1) lesion type other than Fontan surgery (P = 0.007), (2) lack of acceleration of IART with the overdrive attempt (P < 0.001), and (3) patient use of amiodarone with attempt (P = 0.005). There were three procedural complications: two inadvertent overdrive pacing episodes, and one episode of acceleration of IART cycle length and conduction resulting in need for cardioversion. Manual pacemaker overdrive conversion of IART is a useful adjunct in the management of postsurgical IART in the pediatric population and should be considered as an initial treatment option.     

X‐linked hereditary motor sensory neuropathy (type 1) presenting with a stroke‐like episode

X‐linked hereditary motor sensory neuropathy type 1 (CMTX 1) is caused by mutation in the GJB1 gene that codes for the connexin 32 protein. Central nervous system involvement with or without white matter changes on magnetic resonance imaging (MRI) has rarely been reported in this condition. We report the case of a 7‐year‐old, previously well male who presented with a stroke‐like episode that manifested as left hemiparesis and dysphasia. An initial brain MRI showed white matter signal changes affecting the corpus callosum and periventricular areas with a posterior predominance. Our patient made a complete clinical recovery in 36 hours. Clinical examination at this stage showed no evidence of a peripheral neuropathy. A repeat brain MRI 6 weeks later showed almost complete resolution of the changes seen initially. Subsequent investigations showed a Val177Ala mutation in the GJB1 gene. This mutation has so far not been described in the Caucasian population and has been only described once before. Electrophysiological studies showed a mixed demyelinating and axonal sensorimotor neuropathy in keeping with CMTX 1. Five months after the initial presentation our patient developed clinical evidence of a peripheral neuropathy in the form of absent ankle reflexes, weak dorsiflexors, and evertors of both feet.     

PENICILLINASE-PRODUCING NEISSERIA GONORRHOEA AS A CAUSE OF NEONATAL AND ADULT OPHTHALMIA

A retrospective analysis of 80 cases of gonococcal ophthalmia revealed six (7.5%) to be due to penicillinase-producing Neisseria gonorrhoeae (PPNG), five neonatal cases and one adult. All six cases were finally cured, but best results were obtained with topical chloramphenicol and single-dose spectinomycin (40 mg/kg) given intramuscularly. All gonococcal isolates should be tested promptly for penicillinase production, and if this is present systemic treatment, modified to spectinomycin or penicillinase-stable cephalosporin, should be given as single-dose treatment.     

1992 and the Consumer

This paper summarises the journey so far towards the ‘single market’. Consumers may expect to benefit from increased choice and cheaper prices but the possibility that quality, as judged by % of characterising ingredient, will be lowered, is a cause for concern. The consumer will have to rely increasingly on labels, assuming that the label information is adequate. Quantitative ingredient information is desirable but provides technical difficulties for manufacturers. A voluntary ‘quality mark’ scheme could be a satisfactory replacement for compositional standards but would have to be carefully controlled by independent assessors. The abolition of frontier controls creates a dilemma between the desire to have free trade within the community and the need to give a high priority to public health.     

The prevention of tobacco-related disease

The key components of a strategy to prevent tobacco–related disease are outlined. These measures aim to increase the cessation of tobacco use and reduce its uptake. Components are wide–ranging, including a taxation policy, a ban on advertising and promotion, a comprehensive health promotion programme including advice from primary health care professionals and the development of campaigning skills, particularly by the medical profession. The prevention of tobacco–related disease has moved into the domain of campaigners and lobbyists at political, economic and international levels. The key target is countering the activities, especially the unethical trade practices, of the wealthy and powerful tobacco industry.