Coronary Sinus Shocking Lead As Salvage In Patients with Advanced CHF and High Defibrillation Thresholds

Background: We report a series of three patients whose implantable cardioverter‐defibrillators (ICD) implants were unsuccessful due to inability to achieve defibrillation thresholds (DFT) at maximum available energy after failure of standard modification and enhancement procedures. All patients had advanced cardiomyopathy. Methods: Use of the coronary sinus (CS) for left ventricular (LV) shocking electrode placement resulted in acceptable DFTs in each patient. The position of the shocking coil in all three patients was posterior, and in two patients alongside a left ventricular CS pacing lead. The best shocking configuration tested was LV (CS) + CAN (Anode) to RV (cathode) in each patient. The short‐ and long‐term outcomes of these patients is presented and discussed. Conclusion: This approach is suggested as a salvage option for those problematic patients who have unacceptable DFT results at implantation of an endovascular ICD system. (PACE 2010; 967–972)     

CLINICAL SIGNIFICANCE OF DENUDED UROTHELIUM IN BLADDER BIOPSY

PURPOSE: Although to our knowledge the significance of denuded urothelium in bladder biopsies has not been studied previously, it is thought to be a problem because benign urothelial cells are cohesive and not expected to shed into the urine. We correlated the pertinent clinical features of patients with denuded bladder biopsies and/or specific pathological features of denuded bladder biopsy specimens with patient outcome in regard to bladder lesions to help predict the subsequent likelihood of diagnosing bladder carcinoma in a patient with a nondiagnostic denuded biopsy. MATERIALS AND METHODS: We studied 51 denuded bladder biopsies from 44 patients in which the average extent of epithelial denudation was 90%. RESULTS: Of the 27 male (69%) and 17 female (31%) patients 22 to 86 years old (mean age 62) 34% had no history of bladder neoplasms. In remainder there were flat carcinoma in situ with or without other tumors (26%), high (20%) and low (14%) grade papillary tumors without carcinoma in situ and miscellaneous conditions (6%). Overall 31% of patients were diagnosed with carcinoma in situ within 24 months (median 5.5) after the denuded specimen was obtained. Parameters that did not correlate with the subsequent diagnosis of carcinoma in situ included cystoscopic impression, history of intravesical chemotherapy, sex, age, tissue inflammation, percent of tissue fragments with any denudation, number of denuded tissue fragments and percent of overall denuded epithelium. A history of carcinoma in situ before denuded biopsy predicted a diagnosis of carcinoma in situ within 24 months after denuded biopsy in 54% of patients in contrast to 19% of those without a history of carcinoma in situ (p = 0.03). Factoring in a history of other bladder tumor types in various combinations did not predict carcinoma in situ after denuded biopsy. The other predictive factor was cold cup biopsy. Carcinoma in situ developed within 24 months in 45% of patients in whom the denuded specimen was obtained by cold cup biopsy in contrast to none who underwent hot wire loop biopsy (p = 0.007). Cold cup biopsy and a history of carcinoma in situ were independently predictive. Carcinoma in situ developed within 24 months in 75% of patients with a history of that condition and a subsequent cold cup biopsy showing denuded epithelium. However, only 29% of those who underwent cold cup biopsy and had no history of carcinoma in situ were diagnosed with carcinoma in situ. CONCLUSIONS: In bladder biopsies obtained by a hot wire loop denudation most likely results from thermal injury when there is a low risk of subsequent carcinoma in situ. When the denuded biopsy sample was obtained by cold cup biopsy, particularly when associated with a history of carcinoma in situ, most cases represent neoplastic cell denudation and a high risk for subsequent carcinoma in situ.     

Development and Reproducibility of a Brief Food Frequency Questionnaire for Assessing the Fat, Fiber, and Fruit and Vegetable Intakes of Rural Adolescents

Objective To describe the systematic development and reproducibility of a food frequency questionnaire (FFQ) designed to meet the specific research requirements of the Goals for Health cancer prevention intervention program for rural middle school children.

Design A 4-step process was used to develop a brief FFQ for scoring intakes of total fat, fiber, and fruits and vegetables. The resulting questionnaire consisted of 25 food frequency items and 10 supplemental questions. Reproducibility of the questionnaire was determined by comparing responses at the beginning and end of a 4-month interval.

Subjects Study subjects were sixth- and seventh-grade students attending middle schools in rural areas of Virginia and upstate New York. Seventh-grade students participated in the pilot study, and sixth-grade students participated in the reproducibility study. The final version of the FFQ was completed twice by 539 sixth graders. After exclusions for missing and unreliable data, the usable sample size was 415. Boys were somewhat more likely than girls to be excluded for missing data. African-American students comprised 32% of the population.

Statistical analyses performed Each food frequency item was associated with 3 scores—a fat score, a fiber score, and a combined score for the number of servings of fruits and vegetables. Means and standard deviations were determined for nutrient variables, differences between repeat administrations were tested for significance by paired t test, and Pearson correlation coefficients were calculated for nutrients and for individual food items.

Results Correlation coefficients for nutrient scores were 0.58 for fat, 0.49 for fiber, and 0.51 for fruits and vegetables. For individual food items, correlations ranged from 0.24 to 0.59 (mean=0.41).

Applications/conclusions Using a systematic approach to developing a study-specific FFQ for rural adolescents is feasible. Further, the reproducibility of the Goals for Health questionnaire was demonstrated for the 3 nutrient scores it was designed to measure. This developmental approach may be readily adapted to other populations, study designs, and nutrients of interest. The validity of the questionnaire remains to be tested. J Am Diet Assoc. 2001;101:1438-1446.     

Temporal Stability of Sequential Pulse Defibrillation Threshold

We have shown that sequential pulse defibrillation threshold voltage and total delivered energy do not change with maturation of the electrode tissue interface for up to 12 weeks after implantation of two different electrode configurations. This result is important to predict the future performance of an implantable defibrillator that is tested only at implant.     

ELEVATED SERUM NICKEL CONCENTRATION IN PSORIASIS VULGARIS

Background. Psoriasis vulgaris is a common skin disease afflicting 1–3% of the American population. Its pathogenesis remains unknown despite concerted research efforts. Our purpose was to study baseline serum nickel concentrations in psoriasis vulgaris subjects and in healthy control subjects. Methods. Sixteen psoriasis vulgaris subjects with active disease (in 14 of moderate to marked severity), and 11 age-and sex-matched healthy control subjects were studied. Serum nickel determinations were performed using electrothermal atomic absorption spectrophotometry (ETAAS). Results. Despite the relatively small sample size, significant elevation of mean serum nickel concentration was found in the psoriasis group compared to the control group (P = 0.019). Conclusions. Recognition of abnormal nickel homeostasis could point the way to greater understanding of the primary biochemical defect in the psoriatic process. Alternatively, this finding may mark an association without pathogenic significance. Further investigation is needed.     

Infections with Nonthoracotomy Implantable Cardioverter Defibrillators: Can These Be Prevented?

Nonthoracotomy ICDs are believed to be the best therapeutic modality for treatment of life-threatening ventricular arrhythmias. Little is known about the risk of infection with initial implantation of these devices. We studied the incidence, clinical characteristics, and risk factors associated with infections in 1,831 patients with nonthoracotomy ICD from the Endotak-C nonthoracotomy lead registry of Cardiac Pacemakers, Inc. A transvenous lead was implanted in 950 patients (51.9%) and a combination transvenous plus subcutaneous patch was used in 881 patients (48.1%). Nine preselected data variables were studied, and all investigators identified as having patients with infections were personally contacted. Infections occurred in 22 (1.2%) of 1,831 patients receiving this nonthoracotomy ICD system. The mean time to infection was 5.7 ± 6.5 months (range 1–25 months). Staphylococci were isolated in 58% of patients with reported infection. The presence of a subcutaneous defibrillator patch system was associated with the development of infection. Six of 950 patients (0.63%) with a totally transvenous lead system developed infection versus 16 of 838 (1.9%) patients with a transvenous lead plus subcutaneous patch system configuration (P = 0.015, Chi-square test), with an unadjusted estimated odds ratio of 3.06 (CI 1.19–7.86). The risk of infection encountered with the nonthoracotomy ICD is low, estimated from our data to be 1.2%. Placement of a subcutaneous defibrillator patch appears to be an independent risk factor for development of infection.     

Synthesis and biological evaluation of an iodinated iberiotoxin analogue, [mono-iodo-Tyr5, Phe36]-iberiotoxin

The synthesis and iodination of a structural analogue of the specific large-conductance calcium-activated potassium (BK) channel blocker, iberiotoxin (IbTX), a 37-amino acid scorpion neurotoxin, is reported. The synthesis of this analogue, [Tyr⁵, Phe³⁶]-IbTX, was accomplished using standard solid-phase Fmoc (9-fluorenylmethoxycarbonyl) chemistry protocols. The linear peptide was cyclized via the formation of three intramolecular disulfide bridges and subsequently iodinated at the Tyr⁵ position. Upon purification, the iodinated analogue, [mono-iodo-Tyr⁵, Phe³⁶]-IbTX, exhibited comparable biological activity to native IbTX in blocking BK-mediated currents. These findings suggest the synthesis and use of an ¹²⁵I labelled IbTX analogue for BK channel localization in autoradiography experiments. © Munksgaard 1996.     

The Restoration of Coronary Blood Flow in Acute Myocardial Infarction

When an acute coronary syndrome degenerates into a myocardial infarction the centerpiece of therapy is the normalization of myocardial blood flow to the extent that it can be achieved in the shortest interval possible after the onset of symptoms. A variety of strategies including mechanical intervention have been used to achieve this goal, but the benchmark therapy to which all other therapeutic alternatives must be compared involves the use of thrombolytic agents. However, given the availability of catheter laboratories and interventional expertise, mechanical reperfusion appears to be at least as good and probably better than thrombolytic therapy. Because of the universal access to thrombolytic therapy, certain clinical issues must be underscored. More important than pursuing the ideal thrombolytic agent is the administration of thrombolytic therapy at the earliest possible juncture after the onset of symptoms heralding myocardial infarction. Adjunctive therapy includes aspirin and intravenous heparin. Altering platelet activity by glycoprotein IIb/IIIa receptor blockers holds enormous promise for thrombolytic therapy and PTCA, but as yet enjoys limited availability on a global scale.     

Confirmation of Noise Exposure Levels by Analysis of the Audiometic Data in Long Service Underground Train Drivers

The results of 40 audiograms from otologically normal long-termunderground train drivers were compared with the predicted valuespublished by the National Physical Laboratory tables (Robinsonand Shipton, 1977). The age-corrected hearing threshold levelswere plotted as an arithmetic probability at varying frequenciesand compared with the corresponding predicted distributions. The results indicate that London Transport Underground traindrivers are subjected to a noise level of less than 85 dB(A)LEQ(8h),which substantiates the surveyed noise levels. Requests for reprints should be addressed to: Dr S. M. Malleson, Medical Officer, London Transport Medical Service, 32 Sydney Road, London N10 2LP, UK