Complications in Device Therapy: Spectrum, Prevalence, and Management

PURPOSE OF REVIEW

Cardiac implantable electronic device implant numbers are continually increasing due to the expanding indications and ageing population. This review explores the complications associated with device therapy and discusses ways to minimise and manage such complications.

RECENT FINDINGS

Complications related to device therapy contribute to mortality and morbidity. Recent publications have detailed clear guidelines for appropriate cardiac device selection, as well as consensus documents discussing care quality and optimal implantation techniques. There have also been advances in device technologies that may offer alternative options to patients at high risk of/or already having encountered a complication. Adherence to guidelines, appropriate training, and selection of device, in addition to good surgical technique are key in reducing the burden of complications and improving acceptability of device therapy.

Identifying the best predictive diagnostic criteria for psoriasis in children (< 18 years): a UK multicentre case-control diagnostic accuracy study (DIPSOC study)

BACKGROUND

In children, psoriasis can be challenging to diagnose. Difficulties arise from differences in the clinical presentation compared with adults.

OBJECTIVES

To test the diagnostic accuracy of previously agreed consensus criteria and to develop a shortlist of the best predictive diagnostic criteria for childhood psoriasis.

METHODS

A case-control diagnostic accuracy study in 12 UK dermatology departments (2017-2019) assessed 18 clinical criteria using blinded trained investigators. Children (< 18 years) with dermatologist-diagnosed psoriasis (cases, N = 170) or a different scaly inflammatory rash (controls, N = 160) were recruited. The best predictive criteria were identified using backward logistic regression, and internal validation was conducted using bootstrapping.

RESULTS

The sensitivity of the consensus-agreed criteria and consensus scoring algorithm was 84·6%, the specificity was 65·1% and the area under the curve (AUC) was 0·75. The seven diagnostic criteria that performed best were: (i) scale and erythema in the scalp involving the hairline, (ii) scaly erythema inside the external auditory meatus, (iii) persistent well-demarcated erythematous rash anywhere on the body, (iv) persistent erythema in the umbilicus, (v) scaly erythematous plaques on the extensor surfaces of the elbows and/or knees, (vi) well-demarcated erythematous rash in the napkin area involving the crural fold and (vii) family history of psoriasis. The sensitivity of the best predictive model was 76·8%, with specificity 72·7% and AUC 0·84. The c-statistic optimism-adjusted shrinkage factor was 0·012.

CONCLUSIONS

This study provides examination- and history-based data on the clinical features of psoriasis in children and proposes seven diagnostic criteria with good discriminatory ability in secondary-care patients. External validation is now needed.

A self-report questionnaire to detect hand dermatitis in nurses

BACKGROUND

Hand dermatitis is highly prevalent among nurses due to their frequent exposure to wet work. Providing cost-effective dermatological health surveillance for this occupational group presents a challenge to health service providers.

AIMS

To ascertain the predictive value of nurses' self-assessment of whether they had current hand dermatitis using a screening questionnaire when compared with the assessment made by a dermatologist of the nurses' hand photographs.

METHODS

We conducted a cross-sectional study comparing the self-report decision made by student and intensive care nurses using a single hand dermatitis screening question with the clinical assessment of their hand photographs made by dermatologists using a standardized photographic guide.

RESULTS

We analysed data collected at study baseline (n = 1599). The results showed that the screening question had a high negative predictive value (91%; 95% CI 89-93), but a low positive predictive value (39%; 95% CI 34-45). It demonstrated acceptable accuracy in distinguishing those with and without the disease (area under the receiver operator curve = 0.7) and had a high specificity (86%; 95% CI 84-88) but a sensitivity of only 52% (95% CI 46-59) in identifying hand dermatitis.

CONCLUSIONS

We found that nurses were able to accurately self-assess themselves as not having any signs of hand dermatitis. By contrast, they were less able to accurately self-assess positive cases suggesting under-recognition of early disease. We propose that a questionnaire containing a single hand dermatitis screening question should be considered as a tool for screening out clear cases as part of a workplace health surveillance programme for detecting hand dermatitis.

Submuscular reburial as an alternative to lead extraction in high risk patients

Funding Acknowledgements

Type of funding sources: None.

Background

The Heart Rhythm Society (HRS) and European Heart Rhythm Association (EHRA) consensus states complete extraction is recommended for all patients with definite cardiac implantable electronic device (CIED) infection. Although complete removal of hardware is the best way to manage infections, lead extraction is a complex procedure with significant risk. As age and complexity of patients increase so too does extraction risk. In very high risk cases conservative management is cited, though little is known on outcomes.

Purpose

We are a high volume tertiary centre which serves a population of 2 million. 2 experienced operators perform 65 extraction procedures per year for the past 10 years. We report our experience of device reburial as initial management of CIED pre-erosion and erosion in cases deemed too high risk for extraction.

Method

We retrospectively reviewed all reburial procedures undertaken over 9 years. Patient and lead factors influencing decisions were assessed. Information on number of leads, dwell time, prior procedure, infective status and comorbidity was collated. The outcomes included morbidity, defined by repeat procedure (revision and/or extraction) and mortality. 

Results

86 patients underwent 96 procedures from March 2013 until August 2020. All patients undergoing device reburial were included. 55.8% of patients were male, mean age was 73. 21 patients died, 7 of these deaths occurred within 12 months of the index reburial procedure. The mean follow up period was 39 months (range 5–90). 65.1% of patients had a procedure (de novo implant, upgrade or replacement) within 12 months prior to revision.

We reviewed patients in 2 subgroups based on revision indication – erosion and pre-erosion. Erosion was defined as externalised lead/device. Pre-erosion was defined as superficial device with skin tethering but no exposure. The former is a definite indication for lead extraction, the latter a relative indication. All in the pre-erosion group were systemically well with no infection evident. One patient with erosion had a positive blood culture.

The mean age in the erosion group was 85 years with a Clinical Frailty Score (CFS) 4.98 and lead dwell time 17.87 years compared to age 68 years, CFS 3.98 and dwell time 8.14 years in the pre-erosion group. Patients in this cohort with an eroded device were deemed too high risk to undergo transvenous lead extraction.

A higher proportion of patients presenting with erosion died within 12 months of the index reburial procedure (16.67% vs 4.84%). 21% with an eroded device and 11% with a pre-eroding device undergoing reburial as first line management required future extraction.

Conclusion

Our 9 year data suggests less invasive intervention is a valid option in high risk groups such as older age, frailty, long lead dwell time, with an acceptable incidence of reintervention and/or extraction. This data can help guide informed consent in the future.

CIED guided HF management : a prospective cohort study

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Liverpool Clinical Commissioning Group

Background

Heart failure (HF) is associated with significant morbidity and mortality. (1) Cardiac Implantable Electronic Devices (CIED) generated Heart Failure Risk Score (HFRS) alerts may guide management in this complex cohort and help direct resources to appropriate patients. (2)

Aim 

To develop and evaluate an integrated, multidisciplinary approach to HF management for patients with CIED by sharing HFRS alerts directly with the HF teams.

Methods

We undertook a prospective, single centre cohort study of patients who generated high risk HFRS alerts. These alerts were shared with community HF teams responsible for routine care of patient, prompting patient contact and appropriate intervention by the team. Impact of the pathway was evaluated by review of outcomes including hospitalisation and clinical intervention within 4- 6 weeks of the alert and mortality during the follow up period. Ongoing education was provided to help teams deal with alerts. A validated user questionnaire was completed by the stake holders to obtain user feedback.

Results

365 "High risk" alerts were noted in 188 patients in a 2 year period (November 2018 - November 2020). The mean number of alerts per patients was 1.9 and 44 (23%) of patients had &gt;3 "high risk" alerts in the follow up period. Having three or more alerts significantly increased the risk of hospitalisation for heart failure (HR 2.5, CI 1.1–5.6 p = 0.03) but not mortality (HR 2.1 CI 0.6-7.2 p = 0.23). Overall 75 (39%) of patients were hospitalised in the 4-6 week period of the alert – 53 (28%) of these were unplanned of which 24(13%) were for decompensated HF. A further 24(13%) had planned admissions for care to improve therapy (AV node ablation, device and lead replacement) and reduce morbidity (LA appendage occlude, IV Iron therapy). 33(18%) of patients died in the follow up period.  15(8%) received therapy from the device. 18(10%) of patient underwent deactivation of ICD therapy.

Contact was established in 176 (94%) of patients, and alerts actioned appropriately. 55 patients reported being asymptomatic, and in 45 the trends were improving so no further clinical action was taken. 76 patients had an onward referral made for further management including; 32 to a Cardiologist, 20 to primary care, 13 referrals to community HF teams and 11 referrals to palliative care. 23 patients had medications changes instituted. The feedback on the pathway was positive. 

Conclusions 

An integrated approach to HF for patients with CIEDs in situ can facilitate timely risk stratification and intervention in this cohort of patients and potentially reduce unplanned health care utilisation. Intervention in these patients is not limited to HF alone and provides the opportunity for holistic management of this complex cohort Abstract Figure.

The use of telemetric oximetry in the clinical setting

The reliability and ease of use of a combined functions-cardiac telemetry and telemetric pulse oximetry system was evaluated in a four phase investigation. This technology was assessed favorably for use in the care of patients on continuous epidural and patient-controlled analgesia.

Increasing compliance with breast self-examination

The number of women who actually perform breast self-examination (BSE) monthly is less than desired. This is unfortunate since BSE is critical to the early detection of breast cancers. Common motivators and barriers to performance, and nursing strategies to increase the effectiveness of BSE, are explored in this review.

A multicenter study of costs and nursing impact of cartridge-needle units

A multicenter study of the overall costs and impact on medication administration of sterile cartridge-needle units (Carpuject) and conventional disposable syringes with multiple- and single-dose vials was conducted in six hospitals in the Voluntary Hospitals of America (VHA) system. Data collection involved a time and motion phase measuring procurement, preparation, and disposal of both systems and a 6-month prospective global cost analysis of component costs, waste disposal, nursing time, needlestick injuries, and subsequent treatment. Nonacquisition costs were substantially lower with the use of the cartridge-needle units. When all costs are considered, sterile cartridge-needle units are a cost-effective alternative to conventional disposable syringes and multidose vials.

Adherence to risk-factor instructions one year following coronary artery bypass surgery

A convenience sample (n = 60) of two comparable groups of cardiac bypass patients was studied to assess the effectiveness of a structured teaching guide used by nurses in educating patients and families about normal postoperative recovery and risk-factor modification. One group was educated by an unstructured method, and the other group received structured teaching with the use of a written guide developed by nurses experienced in open-heart recovery. Both groups had higher total knowledge scores postoperatively than preoperatively. To assess whether the type of teaching had affected changes in behavior, a six-week postoperative health interview was conducted, and a follow-up questionnaire was mailed at one year.

The cost-effectiveness of same-day admission surgery

The move toward outpatient and same-day surgical services has been phenomenal in recent years. In this study comparing same-day and traditional surgery patients in a Midwest tertiary care center, hospital charges and costs were significantly lower for same-day surgery patients. These differences reflected decreased lengths of stay and reduced ancillary services.

Personal health records: an evaluation

A cohort of mothers whose babies were born over one calendar month were followed up eight to 11 months after being given a personal health record for their newborn babies. Eight per cent of mothers lost the records and three more said they had not been given a record while in hospital; a total of 10% of mothers had either lost or misplaced the record. There were no particular demographic characteristics which identified the mothers who were more likely to lose the record. Most parents liked personal health records and used them frequently, as did the community health staff. Most private doctors, however, did not find them useful. Before wider distribution of such records is contemplated health workers should be adequately prepared, especially doctors in the private sector.

Structured postoperative teaching and knowledge and compliance of patients who had coronary artery bypass surgery

A convenience sample of two comparable groups of patients who had coronary artery bypass surgery was studied to assess the effectiveness of a structured teaching guide used by nurses in educating the patient and his family about normal postoperative recovery. Preoperative health assessments were performed on 64 patients, and risk factors for heart disease were identified for each individual. One group was educated by an unstructured method; the other group received structured teaching with the use of a guide developed by nurses experienced in recovery after open heart surgery. Knowledge was assessed before instituting teaching and on discharge from the hospital. All patients were again assessed 6 weeks after discharge for postoperative health and compliance with their health risk factors identified earlier. An analysis of variance with repeated measures revealed that both groups had higher total knowledge scores after surgery. Most postoperative health behaviors (angina, smoking, hypertension, and diet) were comparable between groups. However, those patients who had structured postoperative teaching walked more blocks after surgery (mean = 15.61) than those patients who received routine teaching (mean = 7.00) (p less than 0.005), although these two groups were not equivalent before surgery. In addition, the patients who had structured teaching had higher total compliance scores (mean = 86.8) than those who had unstructured teaching (mean = 79.5) (p less than 0.05). Therefore although structured teaching may not have initially affected patient's knowledge, it may have had an impact on their compliance with postoperative health behaviors.

A comparison of the anxiety-reducing potential of two techniques of bathing

This study compared the effects of the towel bath and the conventional bed bath on patient anxiety. The sample of 105 patients were divided into two groups--those who would be having invasive procedures and those with unrelieved pain. Anxiety was measured using the State-Trait Anxiety Inventory (STAI), the Palmar Sweat Index (PSI), and the Behavioral Cues Index (BCI). The scores from the STAI A-State subscale supported the hypothesis that the towel bath resulted in a significant decrease in anxiety for the sample as a whole and for the invasive procedure subsample. The hypothesis was rejected for the unrelieved pain subsample. Scores from the Palmar Sweat Index and the Behavioral Cues Index did not support any of the hypotheses. Based on the findings of this study, bathing is recommended for its anxiety-reducing effects.

A Comparison of Speciation in Diclidophorinean Monogenean Gill Parasites and in Their Fish Hosts

Twelve species of monogenean gill parasites belonging to the subfamily Diclidophorinae and species-specific to mainly gadid fish hosts have been compared with each other, and their taxonomic interrelationships assessed. A comparison of the resulting classification with that of Svetovidov's of the hosts has shown a considerable degree of correspondence between, and hence of mutual support for, the two independently derived classifications. However, since a very substantial majority of gadid species do not have monogenean gill parasites, the usefulness of a classification of these parasites in elucidating taxonomic problems of the hosts is correspondingly limited.