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Abstract Background Patients who have recurrent atrial fibrillation (AF) following redo catheter ablation may eventually be managed with a pace‐and‐ablate approach, involving pacemaker implant followed by atrioventricular nodal ablation (AVNA). We sought to determine which factors would predict subsequent AVNA in patients undergoing redo AF ablation. Methods We analyzed patients undergoing redo AF ablations between 2013 and 2019 at our institution. Follow‐up was censored on December 31, 2021. Patients with no available follow‐up data were excluded. Time‐to‐event analysis with Cox proportional hazard regression was used to compare those who underwent AVNA to those who did not. Results A total of 467 patients were included, of whom 39 (8.4%) underwent AVNA. After multivariable adjustment, female sex (aHR 4.68 [95% CI 2.30–9.50]; p

Background & Aims: Non-Fermenting Gram-Negative Bacilli [NFGNB] which are considered as environmental contaminants have emerged as multidrug-resistant bacteria and are of serious concern to the treating physician. The aim of this study was to determine the proportion of metallo-beta-lactamase producing Pseudomonas aeruginosa and Acinetobacter species in clinical samples received in the Microbiology Laboratory and to study the antibiotic sensitivity pattern of metallo-beta-lactamase (MBL) producing strains. Materials & Methods: Various samples (pus, sputum, urine, blood and body fluids, etc.) were processed according to standard protocols. P.aeruginosa and Acinetobacter spp were isolated and identified with the help of various culture media, staining methods and biochemical reactions. Antibiotic susceptibility test was done by using Kirby-bauer disc diffusion method. MBL producers were identified using CLSI guidelines. Results: Out of 600 positive culture isolates from various samples, 65 (10.8%) were non-fermenting gram-negative bacilli, 40 (61.53%) were Pseudomonas aeruginosa, and 25 (38.47%) were Acinetobacter species. The overall incidence of MBL positive isolates in our study was 12.3% (8 of 65). All the isolates of Pseudomonas aeruginosa and Acinetobacterspecies were 100% sensitive to Colistin and Tigecycline. Conclusion: The study helps in understanding the antibiotic resistance pattern of isolates causing nosocomial infections, helping clinicians in making appropriate antibiotic choices as an empirical therapy and the policy-makers to bring out the measures in controlling the superbugs.

BACKGROUND: Advanced surgical techniques, such as total laparoscopic hysterectomy, are often challenging to acquire beyond fellowship training programs for practicing obstetrician-gynecologists. A lack of formative data currently exist for continuing medical education programs, limiting our understanding of how improvement in surgical skills and training programs occur. OBJECTIVE: This study aimed to investigate how practicing obstetrician-gynecologists acting as trainees experience a program that aims to teach them total laparoscopic hysterectomy, and to assess whether their surgical skills improve according to data from formative assessment tools and qualitative data from open-ended survey questions and in-depth interviews. STUDY DESIGN: We report a process analysis of formative data collected during a pilot implementation trial of a surgical training program targeting practicing obstetrician-gynecologists. Eleven consultant obstetrician-gynecologists and 4 experienced surgical mentors participated in 4 hospitals in Queensland, Australia. Total laparoscopic hysterectomy was performed in 700 patients over the course of the study. A total laparoscopic hysterectomy surgical mentorship training program of 10 training days with up to 3 total laparoscopic hysterectomy procedures per day was performed. Both the obstetrician-gynecologists and the surgical mentor completed a formative assessment questionnaire analyzing the trainee's performance after each surgical procedure. Mentors were formatively assessed by the Structured Training Trainer Assessment Report (STTAR) and at the completion of the study by the mini-STTAR, a summative assessment of quality of mentorship. Obstetrician-gynecologists, mentors, hospital leaders, and surgical administrative staff participated in qualitative interviews about the training program. RESULTS: Over time, there was a demonstrated improvement in trainee performance reported by both mentors and trainees in all competency assessment tool domains as the case number increased, with mentors consistently rating trainees’ performance higher than the trainees themselves. Most trainees were satisfied with their mentor in all 31 areas during formative assessment, and at the end of the training, structure, attributes, and role modeling were all rated high (average score >4.5; range, 3.79–5.00), whereas training behavior was rated slightly lower at 4.1 (range, 3.79–4.45). Qualitative interviews demonstrated that the trainees found the training to be a beneficial, hands-on experience. CONCLUSION: Formative assessment clearly documented improvement in surgical skills during a total laparoscopic hysterectomy training program for consultant obstetrician-gynecologists.

Guidelines help clinicians to deliver high-quality care with therapies based on up-to-date evidence. There has been significant progress in the management of heart failure with regards to both medication and cardiac device therapy. These advances have been incorporated into national and international guidelines with varying degrees of success. This article reviews current guidance from the National Institute of Health and Care Excellence in the UK and compares this with European Society of Cardiology guidelines, and evaluates how differences between them may impact on clinical practice.

Introduction: Cervical nodes form one of the major groups of Lymph Nodes (LN) that are frequently involved in inflammatory and neoplastic diseases. Metastasis causes the most apparent change in consistency of the node among the various nodal pathologies. Ultrasound elastography provides an estimate of tissue consistency by measuring the degree of distortion under the application of an external force. Aim: To estimate the diagnostic accuracy of sonoelastography in the differentiation of malignant and benign cervical LN with Fine Needle Aspiration Cytology (FNAC)/biopsy considered as a gold standard. Materials and Methods: A cross-sectional study was carried out from March 2020 to January 2021 in a tertiary care hospital in south India, a total of 50 patients with cervical lymphadenopathy underwent ultrasonography followed by elastography of superficial neck LN using high frequency linear transducer by freehand technique. The ultrasound characteristics of selected LN were determined and colour elastogram pattern was assessed using colour mapping elastography. The Chi-square test was performed. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were obtained. The results were then compared to the fine needle aspiration cytology. Results: A total of 50 subjects (median age of 40.5±18.71 years; 19 (38%) males and 31 (62%) females). The grayscale and colour Doppler features of cervical LN which helped predict malignancy were short axis ≥8 mm, Short:Long axis diameter ratio (S:L) ≥0.5, absence of normal central fatty hilum, abnormal echogenicity, lobulated border, presence of calcification and peripheral/mixed vascularity. With reference to the above variables of cervical LN characterisation on grayscale, colour doppler ultrasound and sonoelastography findings, elastography pattern was the most promising variable to differentiate malignant from benign cervical LN with 95.2% sensitivity, 75.0% specificity, 95.2% PPV, 75.0% NPV and 92.0% accuracy. Conclusion: Sonoelastography is useful in the assessment of elastic properties of cervical LN with short examination time required, real-time display, immediate interpretation and limited cost. Sonoelastography had higher diagnostic accuracy than gray scale and doppler ultrasound in differentiating benign from malignant cervical LN. Sonoelastography is an effective supplement to conventional gray scale and colour doppler ultrasound and that the combination is clinically recommended for a more accurate diagnosis of metastatic LN.

Cardiac implantable electronic device (CIED) implants are rising in an older, more co-morbid population. The prevalence of CIED infection ranges from 1–4%. Whilst complete extraction of all transvenous hardware is recommended for infected, eroded, or pre-eroding CIEDs, this approach is not without risk and may be unacceptable to some patients. Long-term data on a more conservative strategy is lacking. We report on our experience of conservative management with pocket revision as a primary strategy in carefully selected patients. Method: A retrospective review of all CIED revision procedures was undertaken at a large tertiary center, over a 7-year period, with a mean follow-up timeframe of 39 months. Results: A total of 86 patients underwent 96 revision procedures; 7 patients required further revisions and 13 went on to undergo CIED extraction by the end of the follow-up period. The overall rate of mortality at 12 months was 8.1%, increasing to 24.4% at the end of the follow-up period. Conclusion: Our data provide important outcome information on an alternative strategy to lead extraction in carefully selected patients where the risk of extraction is perceived to be unacceptable. The absence of systemic infection appears to predict better outcomes than previously reported, and over two-thirds of patients remained complication-free at 12 months.

Pacemakers are a key technology in the treatment of bradyarrhythmias. Leadless pacemakers (LP) were introduced to address limitations of transvenous devices. However, guidelines and other restrictions have led to LPs becoming niche products. The aim of this consensus statement was to determine the strength of opinion of UK implantation experts as to how LPs can be more optimally used. Using a modified Delphi approach, a panel of LP experts developed 36 statements that were used to form a survey that was distributed to LP implanters in the UK. Stopping criteria included a 3-month window for response, a minimum 25% response rate and at least 75% of statements achieving the threshold for consensus (agreed at 66%). In all, 31 of 36 statements reached consensus, and 23 of these achieved ≥90% agreement. Five statements did not achieve consensus. On the basis of these results, seven recommendations were proposed. The implementation of these recommendations may increase the use of LPs, with the aim of improving patient outcomes. ,1 ,1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 9

Objective: To review the relevant literature on the use of atrioventricular node ablation and pacing in patients with heart failure and atrial fibrillation. Methods: APubMed/MEDLINE and SCOPUS search was performed in order to assess the clinical outcomes of atrioventricular node ablation and pacemaker implantation, as well as the complications that may occur. Results: Several clinical trials, observational analyses and meta-analyses have shown that the “pace and ablate” strategy not only improves symptoms but also can enhance cardiac performance in patients with heart failure and atrial fibrillation. Although this procedure is effective and safe, some complications may occur including worsening of heart failure, permanent fibrillation, arrhythmias and sudden death. Regarding pacemaker implantation, cardiac resynchronization therapy is shown to be the optimal choice compared to right ventricle apical pacing. His bundle pacing is a promising alternative to cardiac resynchronization therapy and has shown beneficial effects, while left bundle branch pacing is an innovative modality. Conclusions: Atrioventricular node ablation and pacemaker implantation is shown to have beneficial effects on clinical outcomes of patients with atrial fibrillation ± heart failure who do not respond or are intolerant to medical treatment. Cardiac resynchronization therapy is the treatment of choice and His bundle pacing seems to be an effective alternative way of pacing in these patients.

Aims Heart failure (HF) is associated with comorbidities which independently influence treatment response and outcomes. This retrospective observational study (January 2020–June 2021) analysed the impact of monthly HF multispecialty multidisciplinary team (MDT) meetings to address management of HF comorbidities and thereby on provision, cost of care and HF outcomes.Methods Patients acted as their own controls, with outcomes compared for equal periods (for each patient) pre (HF MDT) versus post-MDT (multispecialty) meeting. The multispecialty MDT comprised HF cardiologists (primary, secondary, tertiary care), HF nurses, nephrologist, endocrinologist, palliative care, chest physician, pharmacist, clinical pharmacologist and geriatrician. Outcome measures were (1) all-cause hospitalisations, (2) outpatient clinic attendances and (3) cost.Results 334 patients (mean age 72.5±11 years) were discussed virtually through MDT meetings and follow-up duration was 13.9±4 months. Mean age-adjusted Charlson Comorbidity Index was 7.6±2.1 and Rockwood Frailty Score 5.5±1.6. Multispecialty interventions included optimising diabetes therapy (haemoglobin A1c-HbA1c pre-MDT 68±11 mmol/mol vs post-MDT 61±9 mmol/mol; p

Aim: To evaluate use of CIED-generated Heart Failure Risk Score (HFRS) alerts in an integrated, multi-disciplinary approach to HF management. Methods: We undertook a prospective, single centre outcome study of patients implanted with an HFRS-enabled Medtronic CIED, generating a “high risk” alert between November 2018 and November 2020. All patients generating a “high risk” HFRS alert were managed within an integrated HF pathway. Alerts were shared with local HF teams, prompting patient contact and appropriate intervention. Outcome data on health care utilisation (HCU) and mortality were collected. A validated questionnaire was completed by the HF teams to obtain feedback. Results: 367 “High risk” alerts were noted in 188 patients. The mean patient age was 70 and 49% had a Charlson Comorbidity Score of >6. Mean number of alerts per patients was 1.95 and 44 (23%) of patients had >3 “high risk” alerts in the follow up period. Overall, 75 (39%) patients were hospitalised in the 4–6-week period of the alert; 53 (28%) were unplanned of which 24 (13%) were for decompensated HF. A total of 33 (18%) patients died in the study 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). The feedback on the pathway was positive. Conclusions: Patients with “high risk” alerts are co-morbid and have significant HCU. An integrated approach can facilitate timely risk stratification and intervention. Intervention in these patients is not limited to HF alone and provides the opportunity for holistic management of this complex cohort.

Introduction: Infections from gram negative bacilli is a challenge for clinicians and laboratory personnel. Treatment of these infections remained as an area of concern. Both fluroquinolones and cephalosporins are most common choice of antibiotics. Despite Cephalosporins, being drug of choice they are expensive also showed many adverse reactions. This study, compares and reevaluates the susceptibility of gram negative bacteria to fluroquinolones (ciprofloxacin) compared to cephalosporins. Method: Various samples(pus, sputum, urine, blood and bodyfluids) were processed according to standard protocols. Antibiotic done susceptibility by using Kirby-baur disc diffusion method. ESBL and Amp C producers were identified using CLSI guidelines. Result: Among 400 isolates, majority were from pus followed by urine, sputum. The most common organism isolated was Klebsiella spp, (33.25%) Escherichia coli (29.5%), Pseudomonas spp (27.25%), Enterobacter spp (6.25%), Citrobacter 5 (1.25%), and Acinetobacter spp (2.5%). Isolates showed 20-80% susceptibility to ciprofloxacin, 30-60% to third and fourth generation cephalosporins. Klebsiella and Pseudomonas showed 64% and 31% susceptibility to ciprofloxacin. Acinetobacter spp showed 30% susceptibility to cefipime and 20% to ciprofloxacin. 34 isolates were ESBL 18 were AmpC producers, of which 15(44%) ESBL and 7(38%) of AmpC producers were ciprofloxacin susceptible. Conclusion: Ciprofloxacin was found to be more effective than the fourth generation cephalosporin (cefepime) against gram negative bacilli. Ciprofloxacin can be considered for treatment as it is more active and cost effective when compared to cephalosporins. Keywords: Fluroquinolones, Cephalosporins, Multidrug resistant, ESBL, Amp C

Introduction: Among vector borne diseases, malaria remained a major threat to public health from decades because of its course and complications. Being the endemic region, malaria poses a great threat because it causes multiorgan failure. Though continuous monitoring, effective implementation of control measures are in place still India contributes to majority of cases in sub Asian region. Aim: To estimate the prevalence of malaria, to determine the seasonality and to analyse the trend of the disease over the period. Materials and Methods: This was a retrospective study conducted at Chikamagalur a district in Karnataka, India, in the year 2022 over a period of six months. The study was done by collecting the data of patient details from the laboratory register. The results were analysed, positive results were calculated for disease burden by Plasmodium vivax (P. vivax) and Plasmodium falciparum (P. falciparum). Results: Out of 27,474 samples, 94 were found positive for malaria parasite of which P. vivax cases were 90 (95%) and 4 (5%) was P. falciparum cases. Prevalence rate was 0.34%. There is 24% drop in malaria cases from 2019-2021 when compared to 2015-2018. Conclusion: The present study shows decline in the number of malaria cases from 2015 to 2021. The cases showed seasonal variation with maximum cases being reported in September. As India is in the decline phase of cases, with the collective efforts of clinicians, laboratory personnel and community health workers, elimination of malaria could be a possibility.