[Pacemaker, implanted cardiac defibrillator and irradiation: Management proposal in 2010 depending on the type of cardiac stimulator and prognosis and location of cancer]

Ionizing radiation may interfere with electric components of pacemakers or implantable cardioverter-defibrillators. The type, severity and extent of radiation damage to pacemakers, have previously been shown to depend on the total dose and dose rate. Over 300,000 new cancer cases are treated yearly in France, among which 60% are irradiated in the course of their disease. One among 400 of these patients has an implanted pacemaker or defibrillator. The incidence of pacemaker and implanted cardioverter defribillator increases in an ageing population. The oncologic prognosis must be weighted against the cardiologic prognosis in a multidisciplinary and transversal setting. Innovative irradiation techniques and technological sophistications of pacemakers and implantable cardioverter-defibrillators (with the introduction of more radiosensitive complementary metal-oxide-semiconductors since 1970) have potentially changed the tolerance profiles. This review of the literature studied the geometric, dosimetric and radiobiological characteristics of the radiation beams for high energy photons, stereotactic irradiation, protontherapy. Standardized protocols and radiotherapy optimization (particle, treatment fields, energy) are advisable in order to improve patient management during radiotherapy and prolonged monitoring is necessary following radiation therapy. The dose received at the pacemaker/heart should be calculated. The threshold for the cumulated dose to the pacemaker/implantable cardioverter-defibrillator (2 to 5 Gy depending on the brand), the necessity to remove/displace the device based on the dose-volume histogram on dosimetry, as well as the use of lead shielding and magnet are discussed.

Publication bias in blood and marrow transplantation

Only a small proportion of abstracts lead to full publication. Abstracts with "positive" results are more likely to be published than other abstracts, leading to publication bias. To date, this issue has not been examined in the blood and marrow transplantation (BMT) literature. We hypothesized that because BMT centers are often based at academic centers, the proportion of abstracts leading to publication will be high. All abstracts presented at the Canadian Blood and Marrow Transplant Group biannual meetings in 2002, 2004, and 2006 were reviewed and categorized by study type, funding source, single-center or multicenter study, form of presentation, and positive or negative results, using the authors' definitions. To determine publication, each reference was searched on multiple databases (MEDLINE, EMBASE, Web of Science, and CINAHL) by first, second, and final author names. Two authors performed abstract categorization and searching, and disagreements were resolved by consensus. Of the 141 abstracts reviewed, only 43 were published (30.4%). Twenty-one studies were published from 2002 (36.8%), compared with 12 from 2004 (24.0%) and 10 from 2006 (29.4%) (P = .35). Neither positive results nor the number of involved centers were associated with the likelihood of publication. Clinical studies (retrospective or prospective) were more likely to be published than nonclinical studies (P = .014). Funded studies and oral presentations were more likely to be published (P = .009 and .004, respectively). A low rate of publication is seen in the field of BMT. Studies with clinical outcomes, externally funded studies, and studies presented orally were more likely to be published. However, there was no publication bias in favor of studies with positive results. Publication bias should be evaluated further at larger BMT meetings, and efforts should be made to encourage full publication of scientific abstracts.

'Speaking valve' aspiration in a laryngectomy patient

Tracheo-oesophageal speech using a one-way speaking valve is a common mode of speech rehabilitation for laryngectomy patients. Aspiration of this device can cause significant airway obstruction and pose anaesthetic and surgical challenges during its retrieval. In this case report, we describe our management of a patient who had had a laryngectomy who aspirated his speaking valve through his stoma. Emergency retrieval of the valve was performed, during which difficulties were encountered, first in obtaining an adequate seal for pre-oxygenation, and second in maintaining adequate oxygen saturation. We discuss some innovative techniques that could be used to address these issues.

Prediction of hemodynamic changes towards PEEP titrations at different volemic levels using a minimal cardiovascular model

A cardiovascular system model and parameter identification method have previously been validated for porcine experiments of induced pulmonary embolism and positive end-expiratory pressure (PEEP) titrations, accurately tracking all the main hemodynamic trends. In this research, the model and parameter identification process are further validated by predicting the effect of intervention. An overall population-specific rule linking specific model parameters to increases in PEEP is formulated to predict the hemodynamic effects on arterial pressure, pulmonary artery pressure and stroke volume. Hemodynamic changes are predicted for an increase from 0 to 10 cm H(2)O with median absolute percentage errors less than 7% (systolic pressures) and 13% (stroke volume). For an increase from 10 to 20 cm H(2)O median absolute percentage errors are less than 11% (systolic pressures) and 17% (stroke volume). These results validate the general applicability of such a rule, which is not pig-specific, but holds over for all analyzed pigs. This rule enables physiological simulation and prediction of patient response. Overall, the prediction accuracy achieved represents a further clinical validation of these models, methods and overall approach to cardiovascular diagnosis and therapy guidance.

Model-based identification of PEEP titrations during different volemic levels

A cardiovascular system (CVS) model has previously been validated in simulated cardiac and circulatory disease states. It has also been shown to accurately capture all main hemodynamic trends in a porcine model of pulmonary embolism. In this research, a slightly extended CVS model and parameter identification process are presented and validated in a porcine experiment of positive end-expiratory pressure (PEEP) titrations at different volemic levels. The model is extended to more physiologically represent the separation of venous and arterial circulation. Errors for the identified model are within 5% when re-simulated and compared to clinical data. All identified parameter trends match clinically expected changes. This work represents another clinical validation of the underlying fundamental CVS model, and the methods and approach of using them for cardiovascular diagnosis in critical care.

Set up of a serum-free culture system for bovine embryos: embryo development and quality before and after transient transfer

It is well known that serum in culture medium negatively affects blastocyst quality. The objective of this work was to develop and test a serum-free culture medium which could improve embryo quality, measured by the resistance to freezing, lipid and glutathione content of the resulting blastocysts, as well as the ability of the blastocysts to elongate after transient transfer to recipient cows. In a first experiment we showed that adding a mixture of insulin, transferrin and selenium to serum-free Synthetic Oviduct Fluid medium (SOF-ITS) improved embryo development and quality. In the second experiment, the addition of BSA to SOF-ITS further improved blastocyst development. Moreover, a reduction in lipid content of morulae was observed in SOF-ITS-BSA by comparison with morulae cultured with serum (SOF-FCS). The resistance to freezing measured by hatching rates 24h post-thawing was also improved for blastocysts with a diameter between 160 and 180 microm cultured in SOF-ITS-BSA by comparison to those produced with serum. In order to evaluate the redox potential of the embryos, reduced glutathione content (GSH) was evaluated both before and after cryopreservation. A significant decrease in glutathione was observed after freezing, whatever the culture medium, but no difference was observed between culture conditions. Transient transfers were performed and elongated D-13 embryos were recovered. Elongation was more pronounced and the embryonic disk more often visible in embryos cultured in SOF-ITS-BSA than in embryos cultured with FCS. In conclusion, the serum-free system we developed to produce in vitro bovine embryos meets the developmental and qualitative requirements for a large-scale use.

Dental plaque control effect of a zinc citrate dentifrice

OBJECTIVE

This research evaluated the antiplaque efficacy of a new 2% zinc citrate fluoride dentifrice versus a non-zinc matching placebo or a commercial fluoride dentifrice, also used as the washout product in two crossover studies.

METHODS

Healthy human subjects meeting inclusion criteria entered two respective randomized crossover clinical studies. Study 1 had 24 subjects, and compared the zinc dentifrice to the commercial fluoride dentifrice over a 24-hour period. Study 2 had 19 subjects, and compared the zinc dentifrice to the matching placebo over a 24-hour period. After one week of washout using the commercial fluoride dentifrice, the subjects used the test product for one week prior to the test period. Both studies employed the Modified Gingival Margin Plaque Index (MGMPI) for the assessments.

RESULTS

In Study 1, the mean differences in the MGMPI score, representing post-treatment plaque regrowth along the gingival margin for the zinc prototype as compared to the commercial fluoride dentifrice, were 13.87 (+/- 8.27) and 21.23 (+/- 11.08), respectively. Study 2 demonstrated the mean differences in MGMPI scores for the zinc dentifrice and a matching placebo of 14.99 (+/- 13.32) and 24.38 (+/- 7.69), respectively. In both studies, the zinc dentifrice demonstrated a significant 35% and 39% inhibition of dental plaque formation compared to those of their respective control dentifrices.

CONCLUSION

Two clinical studies demonstrated plaque control efficacy for a new zinc citrate-containing dentifrice, suggesting a new antiplaque and possible multi-benefit dentifrice for oral hygiene.

Energy and migratory behavior in glass eels (Anguilla anguilla)

The influence of energy content of glass eels (Anguilla anguilla) on their migratory behavior was investigated in November 2004 and February 2005 under laboratory conditions. Fish were sorted according to their response to a decrease in light intensity: Glass eels becoming active at dusk and using water flow to move with the current were considered as "active", whereas those remaining in the substratum throughout the catching period (24 h) were categorized as "inactive". "Active" glass eels exhibited higher energy content than "inactive" ones, whatever the catching month, and were more pigmented. Differences in percentage dry weight between "active" and "inactive" fish were already significant in the first pigmentary stages, suggesting that energy content plays a causal role in the estuarine migration of glass eels. The possible impact of energy state on the development of different migratory tactics in glass eels is discussed.

Comparison between Principal Component Analysis and Independent Component Analysis in Electroencephalograms Modelling

Principal Component Analysis (PCA) is a classical technique in statistical data analysis, feature extraction and data reduction, aiming at explaining observed signals as a linear combination of orthogonal principal components. Independent Component Analysis (ICA) is a technique of array processing and data analysis, aiming at recovering unobserved signals or 'sources' from observed mixtures, exploiting only the assumption of mutual independence between the signals. The separation of the sources by ICA has great potential in applications such as the separation of sound signals (like voices mixed in simultaneous multiple records, for example), in telecommunication or in the treatment of medical signals. However, ICA is not yet often used by statisticians. In this paper, we shall present ICA in a statistical framework and compare this method with PCA for electroencephalograms (EEG) analysis. We shall see that ICA provides a more useful data representation than PCA, for instance, for the representation of a particular characteristic of the EEG named event-related potential (ERP).

Does a positive end-expiratory pressure-induced reduction in stroke volume indicate preload responsiveness? An experimental study

BACKGROUND

Increases in positive end-expiratory pressure (PEEP) are often associated with cardiovascular depression, responding to fluid loading. Therefore, we hypothesized that if stroke volume (SV) is reduced by an increase in PEEP this reduction is an indicator of hypovolemia or preload responsiveness, i.e. that SV would increase by fluid administration at zero end-expiratory pressure (ZEEP). The relationship between the cardiovascular response to different PEEP levels and fluid load as well as the relation between change in SV as a result of change in preload (Frank-Starling relationship) were evaluated in a porcine model. In addition, other measures of fluid status were assessed.

METHODS

Eight, 20-22 kg, anesthetized, mechanically ventilated pigs were subjected to 0, 10, and 20 cm H(2)O PEEP at 10% (of estimated blood volume) hypovolemia, normo- and 10% hypervolemia, and to ZEEP at 20% hypervolemia. SV, cardiac output, intrathoracic blood volume and airway, esophageal, vascular pressures, stroke volume variations, left ventricular end-diastolic and end-systolic areas and respiratory variations in the diameter of the inferior vena cava were obtained.

RESULTS

At hypovolemia and normovolemia, 10 cm H(2)O PEEP induced a significant decrease in SV, while no change occurred at 10% hypervolemia. SV measured at ZEEP increased from hypovolemia to normovolemia and 10% hypervolemia, while no change was found between 10% and 20% hypervolemia. The sensitivity and specificity decrease in SV by PEEP indicating an increase in SV by fluids was 60-88% and 67%, respectively, depending on the volemic (preload) levels.

CONCLUSION

Although the overall results suggest that a change in SV by PEEP might predict preload responsiveness, the individual response of SV by 10 cm H(2)O PEEP and of the successive fluid administration seemed to be dependent on where on the Frank-Starling curve the heart function was located.

Epidemiology, clinical and laboratory characteristics of Staphylococcus aureus bacteraemia in a university hospital in UK

There has been a persistent increase in the number of meticillin-resistant Staphylococcus aureus (MRSA) and meticillin-susceptible Staphylococcus aureus (MSSA) bacteraemia in the UK. This prospective study included 147 episodes of S. aureus bacteraemia in 139 patients over a 14 month period, from 1 November 2001 to 31 December 2002. Eighty-seven (59%) episodes in 84 patients and 60 (41%) in 56 patients were due to MRSA and MSSA, respectively. An intra-vascular device (29, 33%) and a soft-tissue (15, 25%) source were the commonest identifiable foci for bacteraemia in the MRSA and MSSA groups, respectively. Attributable mortality in the MRSA group was higher than the MSSA group (33% vs 16%; P=0.03) but there was no statistical difference for either attributable (P=0.35) or crude (P=0.39) mortality between the two groups, when adjusted for age, respiratory focus and inappropriate antibiotic therapy. A respiratory source (P=0.02) and inappropriate antibiotic therapy (P=0.02) were associated with attributable mortality in the MRSA group whereas advanced age was the only risk factor (P=0.02) in the MSSA group. The present study shows that S. aureus bacteraemia continues to be a serious infection mostly affecting the elderly and emphasizes the need for improved strategy in the control and management of this condition.

Identification, characterization and quantitation of pyrogenic polycylic aromatic hydrocarbons and other organic compounds in tire fire products

On 15 August 2001, a tire fire took place at the Pneu Lavoie Facility in Gatineau, Quebec, in which 4000 to 6000 new and recycled tires were stored along with other potentially hazardous materials. Comprehensive gas chromatography-mass spectrometry (GC-MS) analyses were performed on the tire fire samples to facilitate detailed chemical composition characterization of toxic polycyclic aromatic hydrocarbons (PAHs) and other organic compounds in samples. It is found that significant amounts of PAHs, particularly the high-ring-number PAHs, were generated during the fire. In total, 165 PAH compounds including 13 isomers of molecular weight (MW) 302, 10 isomers of MW 278, 10 isomers of MW 276, 7 isomers of MW 252, 7 isomers of MW 228, and 8 isomers of MW 216 PAHs were positively identified in the tire fire wipe samples for the first time. Numerous S-, O-, and N-containing PAH compounds were also detected. The identification and characterization of the PAH isomers was mainly based on: (1) a positive match of mass spectral data of the PAH isomers with the NIST authentic mass spectra database; (2) a positive match of the GC retention indices (I) of PAHs with authentic standards and with those reported in the literature; (3) agreement of the PAH elution order with the NIST (US National Institute of Standards and Technology) Standard Reference Material 1597 for complex mixture of PAHs from coal tar; (4) a positive match of the distribution patterns of PAH isomers in the SIM mode between the tire fire samples and the NIST Standard Reference Materials and well-characterized reference oils. Quantitation of target PAHs was done on the GC-MS in the selected ion monitoring (SIM) mode using the internal standard method. The relative response factors (RRF) for target PAHs were obtained from analyses of authentic PAH standard compounds. Alkylated PAH homologues were quantitated using straight baseline integration of each level of alkylation.

An outbreak of Serratia marcescens on the neonatal unit: a tale of two clones

Serratia spp. are an important cause of hospital-acquired infections and outbreaks in high-risk settings. Twenty-one patients were infected or colonized over a nine-month period during 2001-2002 on a neonatal unit. Twenty-two isolates collected were examined for antibiotic susceptibility, beta-lactamase production and genotype. Random-amplified polymorphic DNA polymerase chain reaction and pulsed-field gel electrophoresis revealed that two clones were present. The first clone caused invasive clinical infection in four babies, and was subsequently replaced by a non-invasive clone that affected 14 babies. Phenotypically, the two strains also differed in their prodigiosin production; the first strain was non-pigmented whereas the second strain displayed pink-red pigmentation. Clinical features suggested a difference in their pathogenicity. No environmental source was found. The outbreak terminated following enhanced compliance with infection control measures and a change of antibiotic policy. Although S. marcescens continued to be isolated occasionally for another five months of follow-up, these were sporadic isolates with distinct molecular typing patterns.

Infection risk associated with a closed luer access device

The potential for microbial contamination associated with a recently developed needleless closed luer access device (CLAD) (Q-Syte; Becton Dickinson, Sandy, UT, USA) was evaluated in vitro. Compression seals of 50 multiply activated Q-Syte devices were inoculated with Staphylococcus epidermidis NCTC 9865 in 25% (v/v) human blood and then disinfected with 70% (v/v) isopropyl alcohol followed by flushing with 0.9% (w/v) sterile saline. Forty-eight of 50 (96%) saline flushes passed through devices that had been activated up to a maximum of 70 times remained sterile. A further 25 Q-Syte CLADs that had undergone multiple activations were challenged with prefilled 0.9% (w/v) sterile saline syringes, the external luer tips of which had been inoculated with S. epidermidis NCTC 9865 prior to accessing the devices. None of the devices that had been accessed up to 70 times allowed passage of micro-organisms, despite challenge micro-organisms being detected on both the syringe tip after activation and the compression seals before decontamination. These findings suggest that the Q-Syte CLAD may be activated up to 70 times with no increased risk of microbial contamination within the fluid pathway. The device may also offer protection from the external surface of syringe tips contaminated with micro-organisms.