Acute hemodynamic response of epicardial and endocardial cardiac resynchronization therapy, His bundle pacing and left bundle branch pacing

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Medtronic

Background / Introduction

Endocardial pacing and conduction system pacing are emerging as alternative methods to deliver cardiac resynchronization therapy (CRT) and have been shown to achieve superior acute hemodynamic response (AHR) compared to conventional epicardial pacing. However, a direct comparison of all the methods of delivering CRT has not yet been performed.

Purpose

To directly compare the AHR of conventional CRT (BiV Epi), endocardial pacing (BiV Endo), His bundle pacing (HBP) and left bundle branch pacing (LBBP) during a temporary CRT study.

Methods

4 patients underwent a temporary CRT and hemodynamic study. Temporary pacing was achieved using quadripolar catheters in the right atrium and coronary sinus, and roving decapolar catheters in the right ventricle (RV) and left ventricle (LV) via retrograde aortic access. Hemodynamic assessment was performed with a PressureWire X (Abbott, CA, USA) in the LV cavity. AHR was calculated as the percentage improvement in LV dP/dtmax from baseline AAI or RV pacing (if underlying complete heart block).

Results

The patients had a mean age of 67.5 ±5.8 years and all had non-ischemic cardiomyopathy with severe LV impairment (mean ejection fraction 22.5 ±7.4%). 3 patients had left bundle branch block and 1 patient had complete heart block with an RV paced rhythm (mean QRS duration 157 ±24 ms). All methods of delivering CRT achieved a mean AHR of >10%, which is considered clinically significant and is predictive of LV remodelling at 6 months. Mean AHR during BiV Epi pacing was 12.6 ±5.0%. There was a trend towards higher AHR for BiV Endo pacing (23.6 ±7.6%), HBP (17.4 ± 9.5%) and LBBP (16.1 ±7.8%) as shown in figure 1, however there was no significant difference between groups on one-way analysis of variance (p = 0.348).

Conclusions

All methods of delivering CRT achieved an AHR >10%. The AHR during BiV Endo pacing, HBP and LBBP was higher than for BiV Epi pacing, but this did not reach statistical significance. Further investigation with larger studies is required to determine which method of delivering CRT achieves the best hemodynamic response.

Figure 1. Box plot of acute hemodynamic response (AHR) for conventional cardiac resynchronization therapy (BiV Epi), endocardial pacing (BiV Endo), His bundle pacing (HBP) and left bundle branch pacing (LBBP). Data displayed as median (solid line), mean (+), 1st and 3rd quartiles (box) and minimum and maximum values (whiskers). Abstract Figure 1

Assessing survival and re-hospitalisation following transvenous lead extraction in cardiac resynchronisation therapy devices depending on reimplantation timing: a propensity score matched analysis

Funding Acknowledgements

Type of funding sources: None.

Background

 Among patients undergoing transvenous lead extraction (TLE), differences in complication rate and 1-year mortality has been explored in patients with cardiac resynchronisation therapy (CRT) devices.  Longer term outcomes and the influence of timing of reimplantation of device, with respect to rehospitalisation and longer-term mortality is poorly understood. 

Purpose

 The purpose of this study was to evaluate whether early reimplantation following TLE in patients with CRT devices influenced survival and rehospitalisation.

Methods

 Clinical data from consecutive patients undergoing TLE in the reference centre between the years 2000 to 2019 were prospectively collected.  Patients surviving to discharge who were re-implanted with the same device were included. The cohort was split depending on whether or not they had a CRT device at time of explant.  The association between TLE in CRT patients and all-cause mortality and re-hospitalisation was assessed by Kaplan Meier estimates in a 1:1 propensity-score matched cohort, with a calliper of 0.10.  Early reimplantation was defined as reimplantation within 7 days of TLE, and late reimplantation as reimplantation after greater than 7 days of TLE.

Results

 Of 1005 patients included in the analysis, 285 (25%) had a CRT device.  After matching, 192 CRT patients were compared with 192 non-CRT patients.  Propensity scores were calculated using 39 baseline characteristics, including age, gender, co-morbidities, TLE indication, left ventricular ejection fraction, baseline creatinine and technical extraction data.  Mean follow up was 53.5 ± 38.3 months, mean age at explant was 67.7 ± 12.1 years, 83.3% were male and 54.4% had an infective indication for TLE.  In the matched cohort, there was no significant difference between the CRT and non-CRT group with respect to long-term mortality (hazard ratio [HR] = 1.01, 95% confidence interval [CI] [0.74-1.39], p = 0.093) or rehospitalisation (HR = 1.2 [0.87-1.66], p = 0.265).  A similar proportion of patients were reimplanted within 7 days in the CRT and non-CRT groups (59.4% vs 61.5%, p = 0.754).  In the matched non-CRT group, late reimplantation was associated with similar mortality to early reimplantation (HR = 1.33 [0.86-2.05], p = 0.208) and rehospitalisation (HR = 0.88 [0.53-1.45], p = 0.603).  In the matched CRT group, late reimplantation was associated with higher mortality (HR = 1.64 [1.04-2.57], p = 0.032) and rehospitalisation (HR = 1.57 [1.00-2.46], p = 0.049] (see figure).

Conclusion

  In this closely matched population, TLE in CRT patients resulted in similar long-term outcomes compared with non-CRT patients.  Early reimplantation post CRT explant was associated with reduced long-term mortality and rehospitalisation.  This suggests a longer duration without biventricular pacing post TLE may induce negative reverse-remodelling and should be avoided in a CRT population. Abstract Figure. Kaplan-Meier survival curves

Long-term survival following transvenous lead extraction: importance of indication and comorbidities

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: 

The significant rise in cardiac implantable electronic devices (CIED) has been paralleled by an increase in the number of procedures required for the removal of such devices and their associated leads.  High procedural success rates with low rates of major in hospital complications is well recognised.  Longer term mortality following transvenous lead extraction (TLE) is less well characterised. Long term outcomes are important as they should inform the decision making and consent process, especially in non-infected cases where there may not be a class I indication for lead removal. 

Purpose

 The purpose of this study was to evaluate the factors influencing survival in patients undergoing TLE depending on extraction indication.

Methods

 Clinical data from consecutive patients undergoing TLE in the reference centre between the years 2000 to 2019 were prospectively collected.  Only patients surviving to discharge were included. The total cohort was divided into groups depending on whether there was an infective or non-infective indication for TLE.  We evaluated the association of demographic, clinical, device related and procedure-related factors on mortality.

Results

 A total of 1151 patients were included in the analysis.  632 (54.9%) and 519 patients (45.1%) were for infective and non-infective indications respectively. Analysis of long-term outcomes on the total cohort (mean 66-month follow-up) revealed a mortality of 34.1% (392 deaths).  A higher proportion of patients died in the infection vs the non-infection group (38.6% vs 28.5%, p < 0.001).  Local infection (hazard ratio [HR] = 1.4, 95% confidence interval [CI] [1.12-1.75]) was associated with similar long-term mortality risk as systemic infection (HR = 1.3, CI[0.99-1.72]). Multivariate analysis demonstrated increased risk of mortality with higher age (HR = 1.05, CI[1.04-1.07]), eGFR < 60ml/min/1.73m2 (HR = 1.55, CI[11.22-1.97]), higher cumulative co-morbidity burden (HR = 1.15, CI [1.06-1.23], and reduced risk per percentage increase in LVEF (HR = 0.98, CI[0.96-1.00]). Kaplan-Meier survival analysis demonstrated statistically worse prognosis in patients with a higher number of leads extracted and increasing co-morbidities.

Conclusion

  Long-term mortality for patients undergoing TLE remains high. Consensus guidelines recommend evaluating risk for major complications when determining whether to proceed with TLE. This study suggests assessing longer-term outcomes when considering TLE, particularly for non-infective indications. Abstract Figure.

Lactation Induction in a Transgender Woman Wanting to Breastfeed: Case Report

CONTEXT

Breastfeeding is known to have many health and wellness benefits to the mother and infant; however, breastfeeding in trans women has been greatly under-researched.

OBJECTIVE

To review potential methods of lactation induction in trans women wishing to breastfeed and to review the embryological basis for breastfeeding in trans women.

DESIGN

This article summarizes a case of successful lactation in a trans woman, in which milk production was achieved in just over 1 month.

SETTING

This patient was followed in an outpatient endocrinology clinic.

PARTICIPANT

A single trans woman was followed in our endocrinology clinic for a period of 9 months while she took hormone therapy to help with lactation.

INTERVENTIONS

Readily available lactation induction protocols for nonpuerpural mothers were reviewed and used to guide hormone therapy selection. Daily dose of progesterone was increased from 100 mg to 200 mg daily. The galactogogue domperidone was started at 10 mg 3 times daily and titrated up to effect. She was encouraged to use an electric pump and to increase her frequency of pumping.

MAIN OUTCOME MEASURE

Lactation induction.

RESULTS

At one month, she had noticed a significant increase in her breast size and fullness. Her milk supply had increased rapidly, and she was producing up to 3 to 5 ounces of milk per day with manual expression alone.

CONCLUSIONS

We report the second case in the medical literature to demonstrate successful breastfeeding in a trans woman through use of hormonal augmentation.

A rule-based method for predicting the electrical activation of the heart with cardiac resynchronization therapy from non-invasive clinical data

Background

Cardiac Resynchronization Therapy (CRT) is one of the few effective treatments for heart failure patients with ventricular dyssynchrony. The pacing location of the left ventricle is indicated as a determinant of CRT outcome.

Objective

Patient specific computational models allow the activation pattern following CRT implant to be predicted and this may be used to optimize CRT lead placement.

Methods

In this study, the effects of heterogeneous cardiac substrate (scar, fast endocardial conduction, slow septal conduction, functional block) on accurately predicting the electrical activation of the LV epicardium were tested to determine the minimal detail required to create a rule based model of cardiac electrophysiology. Non-invasive clinical data (CT or CMR images and 12 lead ECG) from eighteen patients from two centers were used to investigate the models.

Results

Validation with invasive electro-anatomical mapping data identified that computer models with fast endocardial conduction were able to predict the electrical activation with a mean distance errors of 9.2 ± 0.5 mm (CMR data) or (CT data) 7.5 ± 0.7 mm.

Conclusion

This study identified a simple rule-based fast endocardial conduction model, built using non-invasive clinical data that can be used to rapidly and robustly predict the electrical activation of the heart. Pre-procedural prediction of the latest electrically activating region to identify the optimal LV pacing site could potentially be a useful clinical planning tool for CRT procedures.

Epidemiology of dependence on illicit substances, with a special focus on opioid dependence, in the State of Punjab, India: Results from two different yet complementary survey methods

BACKGROUND

We used two different yet complementary methods to capture the 'hidden population' of illicit substance users in the state of Punjab, India: Rapid Assessment Survey (RAS) and Punjab Drug Use Monitoring Survey (P-DUMS).

METHODOLOGY

For the RAS component, following a pilot study, Respondent Driven Sampling was used to recruit 6600 community-dwelling substance dependent persons aged 11-60 years from all the 22 districts of Punjab. Size was estimated using benchmark-multiplier method, and prevalence was calculated by projecting these data to the source population. For the P-DUMS component, data were collected on 7421 inpatients from 75 government de-addiction centres from 19 districts of Punjab.

RESULTS

Subjects In both RAS and P-DUMS were primarily opioid dependent (88% in RAS and 83% in P-DUMS). Heroin (inhaled/injected) emerged as the commonest opioid in both RAS (46%) and P-DUMS (52%), though 30.5% of the RAS sample also used the prescription opioid tramadol. Using the benchmark-multiplier method, 0.27 million (2.5% of the source population) were estimated to be opioid dependent, of which nearly 78,000 (0.7% of the source population) were injecting opioid users (IDUs), predominantly heroin (62%) but also buprenorphine (32.5%). High-risk behaviour was reported by nearly 60% of IDUs. Only 14% of the RAS sample had ever visited any de-addiction centre, and only 2.8% individuals had been admitted to a de-addiction centre in the past year.

CONCLUSION

There is a substantive problem of opioid dependence in this difficult-to-reach population of Punjab, with low treatment access. Misuse of prescription opioids along with IDU also raises concern.

Epidemiology of substance use and dependence in the state of Punjab, India: Results of a household survey on a statewide representative sample

BACKGROUND

Despite its political sensitivity, little scientifically valid evidence on the prevalence, pattern and treatment need of substance use in the northern border state of Punjab, India is available till date.

METHODOLOGY

The 'universe' for the survey was the entire house-dwelling population of Punjab, of both genders, aged 11-60 years. Stratified multistage sampling technique was used. Following a pilot study, data were collected by trained research workers by face-to-face interview using pre-tested survey instruments.

RESULTS

From 6398 households, 13,925 respondents were interviewed. Prevalence of lifetime and current (12 month) dependence on any substance were 15.8% (95% confidence interval [CI] 15.1-16.4%) and 14.7% (95% CI 14.1-15.3%) respectively. Of the specific substances, current dependence was the highest on alcohol (10.9%; 95% CI 10.3-11.4%), followed by tobacco (8.1%; 95% CI 7.7-8.6%). Regarding opioids, lifetime use was 1.9% (95% CI 1.6-2.1%) and current dependence 0.8% (95%CI 0.7-1.0%). Use of and dependence on natural opioids was the highest. After projecting these figures to the entire source population of the state, number of currently dependent alcohol, tobacco and opioid users were 2.2, 1.6, and 0.17 million, respectively. Overall, substance use was predominant in men and significantly more common in rural areas. Majority (81%) of the tobacco users, and 51% each of alcohol and opioid users needed intervention. However, merely one in six subjects sought any professional help.

CONCLUSION

Punjab has a substantive problem related to substance use. Though alcohol and tobacco are by far the major substances of use and dependence, the large number of opioid users also raises concern. Treatment services need scaling-up.

Diagnosis of frontal meningioma presenting with psychiatric symptoms

The frontal lobes of the brain are notoriously "silent": Benign tumors such as meningiomas that compress the frontal lobes from the outside may not produce any symptoms other than progressive change of personality and intellect until they are large. We present two cases with symptoms suggestive of depressive episodes, which on further investigations showed space occupying lesions suggestive of frontal meningiomas.

Comprehensive Evaluation of Drug De-addiction Centres (DDCs) in Punjab (Northern India)

BACKGROUND

Drug addiction is on the rise in Punjab,India. There are 15 DDCs which are supported by the Indian Red Cross Society. There is alleged mushrooming of private Drug De-addiction Centres (DDCs) in the smaller towns, villages and cities of Punjab.

OBJECTIVE

This study aimed to evaluate DDCs in Punjab.

MATERIALS AND METHODS

A total of 10 DDCs were included in the study and scheduled visits were made to collect data by using a pre-tested questionnaire.

RESULTS

The duration of treatment was 1 month at the Red Cross DDCs and it was approximately 6 months at private DDCs. The staff at the private DDCs were inadequate. The major drugs which were abused by patients were Propoxyphene, Alcohol, Bhukki and Cannabis. Patients were usually referred to the DDCs either by family members (35.3%) or social workers (29.8%). About 72.5% of patients were married, 36.3% had passed 10th standard and 54.4% were employed. A majority dropped out of the DDCs due to personal reasons and lack of family support. On comparison, more patients were found to be treated at Red Cross centres (75.3%) than at private centres (65.8%). All DDCs had conducted regular sessions of individual, group and family counseling for patients. Red Cross DDCs ensured that ex-clients received follow-ups and home visits. More patients were satisfied with the services which were provided by the Red Cross DDCs. On the contrary, more patients at the private DDCs complained about harassment fromstaff personnel (p>0.05).

CONCLUSION

It is recommended that all DDCs should be checked regularly, and that the private centres should be provided with additional support from the government, to help run them more efficiently.

Methane emission from rice fields in relation to management of irrigation water

A field experiment was conducted for two years to find out best water management practice to mitigate methane emission from the rice-fields. Continuously flooded conditions yielded two major flushes of methane emission and on an average resulted in relatively higher rate of methane emission (2.20 and 1.30 mg m(-2) hr(-1), respectively in 2005 and 2006) during the kharif season. The methane flux was reduced to half (1.02 and 0.47 mg m(-2) hr(-1), respectively in 2005 and 2006) when rice fields were irrigated 2-3 days after infiltration of flood water into the soil. Irrigating the field at 0.15 bar matric potential reduced seasonal methane flux by 60% (0.99 and 0.41 mg m(-2) hr(-1), respectively in 2005 and 2006) as compared to completely flooded conditions, without any decline in grain yield (60 q ha(-1)).

Suitability of village pond waters for irrigation-a case study from district Ludhiana, India

The village ponds were used for storing rainwater for animals and recharging of underground water. Recent developments like public water supply for household purpose, provision of household wastewater concrete channels, and toilet septic tanks have polluted the village ponds. The infiltration of water has decreased due to non-cleaning of silt from the pond beds. Increased discharge of wastewater from households, coupled with a low infiltration rate, has inundated these ponds. People have abandoned the use of this water for animals. An effort has been made to assess the suitability of this water for irrigation in the vicinity so as to clean these ponds. Seventy-eight water samples were collected from the village ponds in the Ludhiana district of Punjab. The samples were analyzed for total solids (TS), total dissolved solids (TDS), total suspended solids (TSS), biological oxygen demand (BOD), chemical oxygen demand (COD), electrical conductivity (EC), residual sodium carbonate (RSC), nitrogen, water soluble P and K, as well as micronutrients and pollutant elements. The total solids content of these waters were on the higher side. Considering TSS, BOD, and COD, some of these waters are unsafe for their disposal in river or water bodies. Electrical conductivity ranged from 693 to 5050 μmhos/cm, and RSC varied between -1.9 and 22.8 meq/l. The inorganic N (NH+₄+ NO-₃-N) and total Kjeldahl N ranged from 3 to 30 and 8 to 41 mg/l, respectively. The amount of micronutrients (Zn, Cu, Fe, and Mn) present in pond water indicated its high nutrient value. The content of the pollutant elements such as nickel, cadmium, and lead was below the maximum permissible limits, thereby indicating its suitability for irrigation. According to the EC and RSC criteria, 18% of the samples were fit, 31% were marginal, and 51% were unfit for irrigation. The data indicate that these waters are a good source of nutrients for agriculture.

Effect of organic materials and rice cultivars on methane emission from rice field

A field experiment was conducted for two years on a sandy loam (Typic Ustochrept) soil of Punjab to study the effect of organic materials and rice cultivars on methane emission from rice fields. The methane flux varied between 0.04 and 0.93 mg m(-2) hr(-1) in bare soil and transplanting of rice crop doubled the methane flux (0.07 to 2.06 mg m(-2) hr(-1)). Among rice cultivars, significantly (p < 0.05) higher amount of methane was emitted from Pusa 44 compared to PR 118 and PR 111. Application of organic materials enhanced methane emission from rice fields and resulted in increased soil organic carbon content. The greatest seasonal methane flux was observed in wheat straw amended plots (229.6 kg ha(-1)) followed by farmyard manure (111.6 kg ha(-1)), green manure (85.4 kg ha(-1)) and the least from rice straw compost amended plots (36.9 kg ha(-1)) as compared to control (21.5 kg ha(-1)). The differential effect of organic materials in enhancing methane flux was related to total carbon or C:N ratio of the material. The results showed that incorporation of humified organic matter such as rice straw compost could minimize methane emission from rice fields with co-benefits of increased soil fertility and crop productivity.

Tension-free open mesh repair of ventral hernias--Stoppa's technique

Tension-free prosthetic mesh repair of giant, complex, or recurrent ventral hernias in the form of a modified Stoppa technique has been used in 60 cases. Complication rate has been comparable with other such studies. In obese patients with a pendulous anterior abdominal wall, limited panniculectomy was carried out while repairing the hernia through a low transverse abdominal incision. None of the patients required a progressive preoperative pneumoperitoneum. The incidence of wound infection was 5%. One patient had a wound hematoma that required evacuation; minor wound complications occurred in 11% cases. The hospital stay ranged from 1 to 6 weeks (mean, 10.3 days). One case required readmission for resuturing of the wound. None of the cases required removal of the mesh. There was no recurrence at follow-up (mean, 26 months) in 80% of the cases. This technique is an excellent but somewhat tedious procedure.

Isolated tubercular splenic abscess

Splenic abscess due to tuberculosis is extremely rare in immunocompetent individuals. We report a case of tubercular splenic abscess (TSA) in an immunocompetent individual for its rarity.

Chemotherapeutic evaluation of N-(4-hydroxyphenyl) retinamide-O-glucuronide in the rat mammary tumor model

The growth inhibitory effects of N-(4- Hydroxyphenyl) retinamide (4-HPR) and its glucuronide derivative, N-(4-Hydroxyphenyl) retinamide-O-glucuronide (4-HPROG) on established DMBA induced rat mammary tumors were compared. The results indicate that the glucuronide analog had a greater antitumor potency than equimolar concentration of the free retinoid. Tumor regression occurred in 75% of the rats fed 2 mmol/Kg diet of 4-HPROG. In a 6-week study, the maximum tolerated dietary dose (MTD) was found to be 3.5 mmol/Kg diet for 4-HPR and 5 mmol/Kg diet in the case of 4-HPROG. The higher potency and lower toxicity of the glucuronide suggests that this conjugate may have an in vivo chemotherapeutic advantage over the parent free retinoid.

Perforation of small intestine caused by Churg-Strauss syndrome

In Churug-Strauss Syndrome (CSS), gastrointestinal tract (GIT) is an uncommon site of involvement. In addition to review of recent literature, we herein report a case of CSS with unusual involvement of GIT. The patient was being treated for idiopathic hypereosinophilic syndrome for 2 years; he later developed acute peritonitis and an emergency laparotomy revealed 3-cm-diameter perforation in the small intestine. In order to establish a correlation between the clinical features and the histopathological findings, we highlight the importance of adequate sampling and examination of mesenteric vessels in the attached mesentry in the resected specimen.

Comparative evaluation of intramuscular buprenorphine, pentazocine and nefopam in post-operative pain relief

In immediate postoperative period, many injectable analgesics are being used with diverse side effects. The present study was conducted on 75 patients of both sexes, who underwent various types of surgery, to evaluate pain relief in immediate postoperative period. The drugs used for producing postoperative analgesia are buprenorphine, pentazocine and nefopam, all by intramuscular route.

Sperm motility, velocity and migration

Four different methods for evaluating sperm motility were analysed for experimental error: subjective assessment of a wet film preparation, sperm velocity measured by time-lapse photography, sperm velocity measured by computer analysis and sperm migration across a nucleopore membrane. Subjective assessment of motility was found to be inaccurate, within single observer and between 2 observers. Both methods of measuring mean sperm velocity were accurate, particularly that using the computer analysis system; a high technical failure rate was found using time-lapse photography. Sperm migration across a nucleopore membrane was found to be highly inaccurate. Two groups were then analysed for the predictive value of these tests (excluding sperm migration): 104 proven fertile men and 53 infertile men. Although subjective motility was able to predict from which group the sample came at optimum cut-off with 78% accuracy, computer analysed sperm velocity could predict with overall 91% accuracy at optimum cut-off. Computer analysis of sperm velocity offers a rapid, objective and predictive assessment of sperm function.

An epidemiological study of psychiatric disorders in rural faridkot (punjab)

Epidemiological study of priority psychiatric disorders in a rural area of Faridkot it described. Prevalence is found to be 22.12 per thousand and this is comparable to figures reported by other studies. The prevalence is highest in age group of 35-44, males are more affected than females, and prevalence it more in widows and divorced. Psychiatric morbidity is found to be more in nuclear families as compared to joint families. Among various diagnostic categories prevalence of Manic depressive psychoses (13.08 per thousand) is found to be most common. The implications of the above observations are discussed and compared with the previous reported studies.

Prevalence of psychiatric morbidity among medical in-patients

One hundred patients admitted in medical wards of G. G. S. Medical College, Faridkot, were examined for presence of Psychiatric illness. 31 cases were found to be suffering from some sort of psychiatric illness. Out of 31, 16 patients were found to be suffering from primary affective disorders and physical symptoms in them appeared to be direct consequences of depression. Other psychiatric morbidity was constituted by hysteria (6), organic bran syndrome (5), anxiety neuroses (3) and schizophrenia (l). Psychiatric cases were found to be maximum in age group of 31-60 years and more patients belonged to middle class. Relationship of psychiatric illness with duration and type of medical illness is also discussed.

Hemangioendothelioma of the mandible: report of case

A case of hemangioendothelioma of the mandible, the third of its kind to involve the jawbone is reported. The radiological appearance of new bone formation is a unique feature in this case. The vascular malignant tumor has a poor prognosis.