Prevalence of faecal-borne parasites in colony stray cats in northern Italy

Endoparasitic infections are common in stray cats. Many of these parasites are responsible for zoonoses, and stray cats can be a source of environmental contamination. The prevalence of parasites in 139 stray colony cats in the city of Milan, northern Italy, was investigated by faecal examination. The overall prevalence of endoparasites was 50.4%, with 11 different parasites found. Parasites with zoonotic potential were detected in 49.6% of cats. Concurrent infections with two or more zoonotic parasites were recorded in 14.3% of cats. Among the parasites found, the most common was Toxocara cati (33.1%; P <0.0001). The other species found by coproscopic examination were: Ancylostoma tubaeformae (7.2%), Isospora species (4.3%), Trichuris vulpis (2.9%), Dipylidium caninum (2.9%), Aelurostrongylus abstrusus (2.9%), Eucoleus aerophilus (syn Capillaria aerophila) (1.4%), Spirometra species (1.4%), Taenia pisiformis (0.7%) and Hymenolepis nana (0.7%). Coproantigen specific for Giardia duodenalis was detected in 2.9% of the samples. Pseudoparasites (eggs of mites) were found in 4.3% of the samples. No sample contained Toxoplasma gondii oocysts, despite the fact that 70 cats tested positive for T gondii-specific IgG antibodies, and none of the diarrhoetic samples tested positive for Cryptosporidium species oocysts. Variables linked to infection were body condition score (BCS), the presence of diarrhoea and infection with G duodenalis. Cats infected with G duodenalis were more likely to have a low BCS (odds ratio (OR) = 11.5, P = 0.02) and diarrhoea (OR = 30.7, P = 0.0007). The results of the present study confirm that endoparasitic infections, most of which have zoonotic potential, are distributed in stray colony cats of Milan.

Pacing of the interventricular septum versus the right ventricular apex: a prospective, randomized study

BACKGROUND

Left ventricular (LV) function may be impaired by right ventricular (RV) apical pacing. The interventricular septum is an alternative pacing site, but randomized data are limited. Our aim was to compare ejection fraction (EF) resulting from pacing the interventricular septum versus the RV apex.

METHODS

RV lead implantation was randomized to the apex or the mid-septum. LVEF and RVEF were determined at baseline and after 1 and 4 years by radionuclide angiography.

RESULTS

We enrolled 59 patients, of whom 28 were randomized to the apical group and 31 to the septal group, with follow-up available in 47 patients at 1 year and 33 patients at 4 years. LVEF in the apical and in the septal groups was 55 ± 8% vs. 46 ± 15% (p=0.021) at 1 year and 53 ± 12% vs. 47 ± 15% (p=0.20) at 4 years. Echocardiography confirmed a mid-septal lead position in only 54% of patients in the septal group, with an anterior position in the remaining patients. In the septal group, LVEF decreased significantly in patients with an anterior RV lead (-10.0 ± 7.7%, p=0.003 at 1 year and -8.0 ± 9.5%, p=0.035 at 4 years), but not in patients who had a mid-septal lead. Left intraventricular dyssynchrony was significantly increased in case of an anterior RV lead. RVEF was not significantly impaired by RV pacing, regardless of RV lead position.

CONCLUSIONS

Pacing at the RV septum confers no advantage in terms of ventricular function compared to the apex. Furthermore, inadvertent placement of the RV lead in an anterior position instead of the mid-septum results in reduced LV function.

Seroprevalence of feline immunodeficiency virus, feline leukaemia virus and Toxoplasma gondii in stray cat colonies in northern Italy and correlation with clinical and laboratory data

Stray cat colonies in urban and rural areas of Lombardy, northern Italy, were surveyed for seroprevalence of feline immunodeficiency virus (FIV) antibodies, feline leukaemia virus (FeLV) antigen and Toxoplasma gondii IgG. Of 316 cats tested, 6.6% were positive for FIV and 3.8% were positive for FeLV infection; 203 cats were tested for T gondii IgG antibodies and a prevalence of 30.5% was detected. Statistical analysis tested the influence of provenience, age, gender, health status and laboratory results on seroprevalence and found male gender and adult age were risk factors for FIV infection. FIV-infected cats were more likely to have a decreased red blood cell count than FIV seronegative cats. No predictors were significantly associated with FeLV and T gondii seropositivity. Colony cats in this study posed a limited risk for retrovirus infection to pet cats allowed outdoors, whereas toxoplasmosis exposure was comparable with the worldwide data.

QRS pattern and improvement in right and left ventricular function after cardiac resynchronization therapy: a radionuclide study

Background

Predicting response to cardiac resynchronization therapy (CRT) remains a challenge. We evaluated the role of baseline QRS pattern to predict response in terms of improvement in biventricular ejection fraction (EF).

Methods

Consecutive patients (pts) undergoing CRT implantation underwent radionuclide angiography at baseline and at mid-term follow-up. The relationship between baseline QRS pattern and mechanical dyssynchrony using phase analysis was evaluated. Changes in left and right ventricular EF (LVEF and RVEF) were analyzed with regard to baseline QRS pattern.

Results

We enrolled 56 pts, 32 with left bundle branch block (LBBB), 4 with right bundle branch block (RBBB) and 20 with non-specific intraventricular conduction disturbance (IVCD). A total of 48 pts completed follow-up. LBBB pts had significantly greater improvement in LVEF compared to RBBB or non-specific IVCD pts (+9.6 ± 10.9% vs. +2.6 ± 7.6%, p = 0.003). Response (defined as ≥ 5% increase in LVEF) was observed in 68% of LBBB vs. 24% of non-specific IVCD pts (p = 0.006). None of the RBBB pts were responders. RVEF was significantly improved in LBBB (+5.0 ± 9.0%, p = 0.007), but not in non-specific IVCD and RBBB pts (+0.4 ± 5.8%, p = 0.76). At multivariate analysis, LBBB was the only predictor of LVEF response (OR, 7.45; 95% CI 1.80-30.94; p = 0.006), but not QRS duration or extent of mechanical dyssynchrony.

Conclusions

Presence of a LBBB is a marker of a positive response to CRT in terms of biventricular improvement. Pts with non-LBBB pattern show significantly less benefit from CRT than those with LBBB.

Biatrial pacing improves atrial haemodynamics and atrioventricular timing compared with pacing from the right atrial appendage

AIMS

Patients with interatrial conduction delay may have suboptimal left atrioventricular (AV) timing due to delayed contraction of the left atrium with foreshortening of ventricular filling. This may be an issue in pacemaker patients, especially those requiring resychronization therapy. Pacing from the high interatrial septum (IAS) or the distal or proximal coronary sinus (CSD and CSP) may improve left AV synchrony compared with pacing from the right atrial appendage (RAA). Our aim was to compare haemodynamics of these pacing sites.

METHODS AND RESULTS

A total of 24 patients undergoing radiofrequency ablation for paroxysmal atrial fibrillation were studied. Left atrial pressures were recorded in sinus rhythm, and during pacing from the RAA, IAS, CSD, CSP, and with biatrial (BiA) pacing from the IAS + CSD. Amplitudes, +dP/dT(max), and timing of the a-wave were compared between recordings. Left atrial contractility, measured by +dP/dT(max), was greatest during BiA pacing (P ≤ 0.03 for all comparisons). There was a marked reduction in delay to peak a-wave when pacing from all sites compared with the RAA, with BiA pacing yielding the shortest delay (P ≤ 0.001). However, AV conduction was shortened by all alternative pacing sites, which mitigated the anticipation of left atrial contraction with respect to ventricular activation, except for BiA pacing (P < 0.001). Pacing of the IAS did not result in any improvement in haemodynamics or AV synchrony.

CONCLUSION

Multisite atrial pacing results in favourable acute atrial haemodynamics and left AV synchrony. This may be a solution in pacemaker patients with interatrial conduction delay.

Long-term follow-up of patients with syncope evaluated by head-up tilt test

BACKGROUND

Clinicians may be tempted to consider a positive head-up tilt test (HUTT) an unfavorable prognostic indicator. We investigated whether results of routine HUTT predict long-term recurrence of syncope.

METHODS

We analyzed syncope recurrence at long-term among 107 patients (mean age 51 +/- 20 years) receiving HUTT for diagnostic evaluation of unexplained/suspected neurocardiogenic syncope in our Institute.

RESULTS

HUTT was positive in 76 patients (vasodepressive response, n = 58; cardioinhibitory, n = 5; mixed, n = 13). During a median follow-up of 113 months (range, 7-161), 34 (32%) patients experienced recurrence (24 [32%] with positive HUTT during 110 months (7-159); 10 [32%] with negative HUTT during 120 [22-161] months). Actuarial freedom from recurrence at 10 years did not significantly differ for patients with positive/negative test results (after passive/active phases) or with different positive response patterns (vasodepressive, cardioinhibitory, mixed). By contrast, history of >4 syncopes in the 12 months preceding HUTT stratified risk of recurrence, irrespective of HUTT positivity/negativity. At Cox proportional hazards analysis, history of >4 syncopes in the 12 months preceding HUTT was the single independent risk factor for recurrence both in the overall study population (HR, 1.7; 95% CI, 1.07-2.69) and within the subset of patients who tested positive (HR, 1.83; 95% CI, 1.07-3.17).

CONCLUSIONS

This long-term follow-up study reinforces the concept that a positive HUTT should not be considered an unfavorable prognostic indicator; frequency of recent occurrences may be a more valid predictor.

Radionuclide angiographic determination of regional left ventricular systolic function during rest and exercise in patients with nonischemic cardiomyopathy treated with cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) can improve global left ventricular (LV) function. However, limited data are available on regional LV contractility at rest and during exercise. The aim of the present study was to prospectively investigate the effects of CRT on regional LV ejection fraction (EF), global LVEF, and dyssynchrony, during rest and exercise, using radionuclide angiography. A total of 32 consecutive patients with heart failure and nonischemic cardiomyopathy underwent technetium-99m radionuclide angiography with bicycle exercise immediately after CRT implantation (during spontaneous rhythm and after CRT activation) and 3 months later. The regional EF was assessed in the interventricular septum and the lateral wall (LW). Intraventricular dyssynchrony was evaluated using Fourier phase analysis. During spontaneous rhythm, the EF was severely depressed in the septum compared to in the LW. CRT improved septal EF at rest and during exercise both at baseline (p <0.001) and after 3 months (p <0.05). The basal LW EF decreased during CRT (p <0.05, both at rest and during exercise). LV dyssynchrony decreased both at baseline and during follow-up, and the global LVEF showed improvement only at 3 months (p <0.001). In conclusion, in patients with nonischemic cardiomyopathy, CRT affects regional LV function by increasing the septal EF and reducing LW contractility, both at rest and during exercise. This was associated with an improvement in global LVEF and dyssynchrony.

Atrial fibrillation: adverse effects of "pill-in-the-pocket" treatment and propafenone-carvedilol interaction

Propafenone and carvedilol share a common hepatic metabolism involving the oxidative pathway (CYP2D6). Therefore, oral loading with propafenone (as "pill-in-the-pocket" treatment of recent-onset atrial fibrillation) in a patient on concurrent carvedilol treatment may lead to a pharmacokinetic interaction, with high plasma levels of propafenone and potential drug-related adverse effects. In clinical practice, in order to improve the safety of "pill-in-the-pocket" treatment, use of propafenone loading should, in our view, be discouraged in patients on concurrent treatment with carvedilol.

Is cardiac resynchronization therapy cost-effective?

Cardiac resynchronization therapy (CRT) is a treatment of proven efficacy for selected patients with heart failure and associated conduction disturbances. The increasing financial burden that healthcare systems face has increased the interest in cost-effectiveness and cost-utility estimates, focused on devices with defibrillation capabilities (CRT-D), with a high upfront cost, as well as on simpler devices providing only biventricular pacing (CRT-P). Available economic estimates are largely dependent on data source, assumptions, modelling technique, time horizon, and perspective, leading to some variability in cost-effectiveness and cost-utility estimates. As a whole, cost-effectiveness and cost-utility estimates of both CRT-P and CRT-D improve as the time horizon examined is lengthened and appear to be below US$50,000 per quality-adjusted life-year, a threshold value commonly adopted for coverage of healthcare interventions in the USA and quite comparable with similar thresholds used within Europe. Limited data are available on the comparative cost-effectiveness or cost-utility of CRT-P and CRT-D devices. Moreover, more data on the effectiveness and long-term benefits of CRT-D and CRT-P are needed in order to estimate better the value of these treatments in the 'real world, as well as for attempts to improve cost-effectiveness through improved patient selection.

Phrenic Stimulation

Background— Phrenic stimulation (PS) may hinder left ventricular (LV) pacing. We prospectively observed its prevalence in consecutive patients with cardiac resynchronization therapy (CRT) devices.

Methods and Results— In the years 2003 to 2006, 197 patients received a CRT device. PS and LV threshold measurements were carried out at implantation and at 6-month follow-up. LV reverse remodeling was assessed by echocardiography before implantation and at follow-up. LV lead placement was lateral/posterolateral in 86% of patients. Both PS and LV reverse remodeling occurred most frequently at the lateral/posterolateral LV pacing sites ( P <0.001). PS was detected in 73 (37%) of patients and was clinically relevant in 41 (22%). The detection of PS at implantation had a poor sensitivity, as it occurred only in left lateral or sitting position in 27 patients. Ten patients (5%) underwent repeated surgery and 4 (2%) had their CRT turned off because of PS. At follow-up, we could manage PS noninvasively in 32 patients with a small PS-LV threshold difference: in 20 by cathode programmability (3 also thanks to automatic management of LV output) and in 12 (without cathode programmability) by programming the LV output as threshold +1 V.

Conclusions— PS may seriously hinder CRT. A bipolar LV lead and cathode programmability are mandatory to avoid PS by changing the LV pacing vector at target sites for CRT. LV stability at target sites despite PS should also be pursued by these means. The automatic adjustment of LV pacing output is complementary in patients with a small PS-LV threshold difference.

Troponin I rise after pacemaker implantation at the time of "universal definition of myocardial infarction"

We assessed incidence, magnitude, and time course of cardiac troponin I (cTnI) increase after pacemaker implantation in patients without acute coronary syndromes (ACSs). Seventy patients (mean age 71 years, interquartile range 44 to 92, 38 men) undergoing elective implantation of a single-/dual-chamber pacemaker with active/passive fixation leads were enrolled, excluding subjects with clinical suspicion of ACS, abnormal basal cTnI level, or presenting conditions predisposing to abnormal cTnI. Cardiac TnI concentrations were determined in basal conditions, at the end of the procedure, and after 8, 12, and 24 hours. Single-/dual-chamber devices were implanted in 31 of 39 patients. Cardiac TnI peak concentration occurred within the 12-hour assay in 69 of 70 patients; 26 of 70 had a cTnI above the normal cut-off range. All patients presented normal cTnI at 24-hour assay. In conclusion, pacemaker implantation is associated with increases of cTnI levels in up to 37% of patients. This can affect the specificity of cTnI assessment for ruling out ACS, especially within 12 hours after the procedure. These data deserve consideration in a contemporary setting, in which troponin has gathered a pivotal role in the diagnosis and therapy of ACS, and in particular clinical presentations in which electrocardiogram loses its diagnostic capabilities (due to paced rhythms) and symptoms may be lacking or confusing.