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Background Ebstein’s anomaly is a rare condition due to incomplete delamination of the tricuspid valve (TV) leaflets with downward displacement of the proximal leaflet attachments. It is associated with a smaller functional right ventricle (RV) and tricuspid regurgitation (TR) that is typically treated with TV replacement or repair. However, future re-intervention poses challenges. We describe a multidisciplinary team approach to re-intervention in a pacing-dependant Ebstein patient with severe bioprosthetic TV regurgitation. Case summary A 49-year-old female patient underwent bioprosthetic TV replacement for severe TR in Ebstein’s. Post-operatively, she developed complete atrioventricular (AV) block necessitating the implantation of a permanent pacemaker which included a coronary sinus (CS) lead as the ventricular lead. Five years later, she presented with syncope due to a failing ventricular pacing lead, and a new RV lead was positioned across the TV bioprosthesis due to the lack of CS options. Two years later, she presented with breathlessness and lethargy with severe TR identified on transthoracic echocardiography. She successfully underwent a percutaneous leadless pacemaker implant, extraction of existing pacing system, and implantation of valve-in-valve TV. Discussion Patients with Ebstein’s anomaly typically undergo TV repair or replacement. Following surgical intervention, owing to the anatomical location, patients can develop AV block requiring a pacemaker. Pacemaker implantation may involve a CS lead to avoid placing a lead across the new TV in efforts to avoid lead induced TR. Over time, these patients not uncommonly require re-intervention that can be challenging especially in pacing-dependant patients with leads across the TV.

A current limitation of single chamber implantable cardioverter defibrillators (ICDs) is the lack of an atrial lead to reliably detect atrial fibrillation (AF) episodes. A novel ventricular based atrial fibrillation (VBAF) detection algorithm was created for single chamber ICDs to assess R-R variability for detection of AF.Patients implanted with Visia AF™ ICDs were prospectively enrolled in the Medtronic Product Surveillance Registry from December 15, 2015 to January 23, 2019 and followed with at least 30 days of monitoring with the algorithm. Time to device-detected daily burden of AF ≥ 6 min, ≥6 h, and ≥23 h were reported. Clinical actions after device-detected AF were recorded.A total of 291 patients were enrolled with a mean follow-up of 22.5 ± 7.9 months. Of these, 212 (73%) had no prior history of AF at device implant. However, 38% of these individuals had AF detected with the VBAF algorithm with daily burden of ≥6 min within two years of implant. In these 80 patients with newly detected AF by their ICD, 23 (29%) had a confirmed clinical diagnosis of AF by their provider. Of patients with a clinical diagnosis of AF, nine (39%) were newly placed on anticoagulation, including five of five (100%) patients having a burden23 h.Continuous AF monitoring with the new VBAF algorithm permits early identification and actionable treatment for patients with undiagnosed AF that may improve patient outcomes.

Introduction: Catheter-associated urinary tract infections (CAUTI), remains the commonest hospital-acquired infection (HAI). This emphasizes the need to implement and monitor effective infection control programs to reduce the risk of CAUTI. Objectives: Aim of the present study was to determine the etiology with antibiotic susceptibility and also to calculate CAUTI rate. Materials and Methods: The Patients admitted in intensive care unit (ICU), Rajarajeshwari Medical College and Hospital who were on urinary catheter insertion for >48 hours from 1 August, 2019 to 30 September, 2019 were included in the study. Under aseptic conditions urine samples were collected from clinically suspected cases of CAUTI, the samples were processed in the department of Microbiology, as per standard protocols. Uropathogens were isolated, identified and subjected to antibiotic sensitivity test. CAUTI rate was calculated and results were noted. Results: Among 460 patients on catheter in ICU, 28(6%) patients developed clinical signs or symptoms of UTI. Of 28 urine samples cultured, 4(14%) yielded growth of single organis [Escherichia coli (3), Klebsiella (1)] and 24(86%) showed no evidence of growth. 2300 catheter days were obtained of 460 patients on indwelling catheter in ICU. Thus CAUTI rate was 1.74 per 1000 catheter days over a 2 month period. Discussion and Conclusion: CAUTI remained a great burden to patient safety and a challenge to the infection control team. Implementation of proper care bundles and continuous education to health care workers plays a key role in reducing the CAUTI rates, thereby decreasing the morbidity and hospital stay to the patients. Keywords: CAUTI, Devise associated, Hospital acquired, UTI, CAUTI rate.

Background: HIV/AIDS poses a significant and one of the most genuine general well-being challenges. For HIV anticipation in the Indian scenario, the main plausible and financially savvy approach that can be adapted is proper training about HIV/AIDS and its various aspects. The present study was embraced to survey the degree of information and awareness about HIV/AIDS among clients attending ICTC facility in our hospital. Materials and Methods: A total of 200 clients, of age >18yrs, attending the ICTC for HIV testing were studied over a period of 3 months. A questionnaire was prepared in regards to the methods of transmission, preventive techniques, mentality towards patient living with HIV/ AIDS and the source of HIV/ AIDS. The response of clients to the questionnaire was recorded. Results: Among 200 participants, 97% were aware that unprotected sex is a mode of HIV transmission and 64% were aware that infected blood transfusion, use of unsterile needles and syringes contribute to other modes of HIV transmission. It was also noted that uneducated clients had a false perception that HIV can be transmitted by drinking water from same glass and by mosquito bite and this was statistically significant compared to educated individuals. The main source of acquiring positive information among the clients regarding HIV was observed to be television (32.5%). Conclusion: Stigma among the general public was mostly due to fear of contracting the illness. There is a requirement for more noteworthy endeavours toward making data with respect to HIV/AIDS accessible to all. The level of awareness regarding HIV/AIDS needs to be elevated among the public. Keywords : HIV, AIDS, Awareness, Education.

AimsHeart 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.MethodsPatients 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.Results334 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; pConclusionHF multispecialty virtual MDT model provides integrated, holistic care across all healthcare tiers for management of HF and associated comorbidities. This approach is associated with reduced clinic attendances and all-cause hospitalisations, leading to significant cost savings.

The transition to consultant practice represents an important transition from the role of trainee to trainer. We used the theoretical framework of Threshold Concepts to better understand this transition by analysing data from a broader qualitative study examining the experience of early career Certified Gynaecological Oncologists (CGOs) in Australia and New Zealand.Semi-structured interviews were conducted with CGOs of5 years consultant experience. Transcripts were analysed using reflexive thematic analysis, sensitised by the theoretical framework of Threshold Concepts.Seven early career CGOs were interviewed. Analysis resulted in the construction of five main themes related to the trainer role, each demonstrating characteristics of Threshold Concepts: 'Part of becoming and being a consultant'; 'Managing complex work environments and training responsibilities'; 'Optimising near peer relationships'; 'Recency informing evolution of training'; and "'Being responsible and letting go…' - the next transition."The themes offer insights into the areas of the transition to trainer that are troublesome, the impact of negotiating these challenges on professional identity formation, and the strategies used by CGOs to negotiate them. Using the lens of Threshold Concepts, these experiences can be normalised, and supported through efforts to facilitate the development of skills in reflection, feedback, coaching and mentorship.

Effects of the COVID-19 pandemic on cardiac rhythm management (CRM) services remain poorly quantified.To describe the impact of COVID-19 on specialist CRM centers in the United Kingdom (UK).Two-center study involving the Liverpool Heart and Chest Hospital NHS Foundation Trust and Royal Papworth Hospital NHS Foundation Trust. The first nationwide lockdown lasted from April to July 2020 and the second from December 2020 to March 2021.Compared to the pre-pandemic period,During the COVID-19 pandemic, specialist centers in the UK were affected such that the number of procedures performed was greatly reduced in the initial period with latter improvements as better coping strategies were developed.

Introduction: Infections due to Gram-positive bacteria are on a rise, of which those due to Enterococcus spp. form a major part. The shifting pattern of infections caused by Enterococci from novel urinary tract infections to soft tissue and wound infections are increasingly reported. Objective: The aim of the present study is to isolate, speciate Enterococci, determine the antibiotic resistance pattern and to detect vancomycin resistance by E- test. Materials and Methods: All wound swabs, pus samples sent for bacterial culture, irrespective of the diagnosis of the patients which were received to the department of microbiology for a period of one year were included in the study. The samples were processed for isolation, identification and speciation of Enterococci. Antimicrobial susceptibility testing was done by Kirby-Bauer disk diffusion method. Vancomycin resistance was determined by E-test. Results: A total of 3000 pus samples were received over a period of one year. Out of which 43 isolates were detected as Enterococcus species. Among 43 isolates, 26 were E.faecalis, 17 were E.faecium. In present study, ampicillin resistance was seen in 88% followed by resistance to erythromycin (86%) and clindamycin (72%). High level gentamycin resistance was seen in 28% cases. Vancomycin resistance was not detected in any of the samples. Conclusion: The shifting spectrum of infections due to Enterococcus is gaining inquisitiveness among health care workers especially in the trauma care units. Thus there is a prerequisite to isolate speciate and determine the resistance that helps in holistic health care. Keywords: Enterococci, Soft tissue infection, Antibiotic resistance, Vancomycin resistance, E test.

Introduction: Carriage of Staphylococcus aureus in the web spaces and anterior nares among the health care workers is a substantial source of human infections. Screening, detection and treatment of such carriers is an important modality in prevention of infections. Colonized health workers especially in teaching hospitals may subsequently develop clinical infections and act as reservoirs for infection among vulnerable individuals. Objectives: Screening of the nursing staff from various departments including critical and non critical areas, identification and speciation of staphylococcus and determining its resistance to cefoxitin and Mupirocin. Materials and Methods: The study was done in the department of Microbiology, Rajarajeswari medical college and hospital, Bangalore, Karnataka. Two swabs were collected from each health care personnel, one swab from anterior nares and other from the web spaces. Swabs were streaked on to blood agar and MacConkey agar plate and incubated at 37?C for 48hours. Identification done by standard protocols. Susceptibility to cefoxitin and mupirocin was done by Kirby- baeur disc diffusion method. MIC of mupirocin was done E-test method. Results: A total of 200 nursing staff was screened during the study period. Majority of the cultures yielded Coagulase negative staphylococcus followed by no growth from the anterior nares. From the web spaces majority yielded no growth. Out of 78 CONS that were isolated 72 were sensitive to cefoxitin and 8 were resistant. Out of 24 isolated Staphylococcus aureus isolates 20 isolates were sensitive and 4 were resistant to cefoxitin. The MIC values of the four methicillin resistant Staphylococc us aureus were 0.38, 0.25, 0.25, 0.19 which were reported as sensitive strains. Keywords: MRSA, Staphylococcus aureus, Mupirocin, Nasal carriers, Webspaces, Screening nursing staff.

AimsHeart failure (HF) is associated with multiple co-morbidities which independently influence response to treatment as well as outcomes. This retrospective observational study (January 2020-June 2021) analysed the impact of monthly virtual HF multi-specialty multi-disciplinary team (MDT) meetings to address the management of associated comorbidities and thereby upon provision, cost of care and HF outcomes.MethodsPatients acted as their own controls, with outcomes compared for equal periods (for each patient) pre versus post-MDT meeting. The MDT comprised of HF cardiologists (primary, secondary, tertiary care), HF specialist nurses (hospital, community), nephrologist, endocrinologist, palliative care specialist, chest physician, pharmacist, clinical pharmacologist and geriatrician. Outcome measures were 1) all-cause hospitalisations, 2) outpatient clinic attendances, and 3) cost.Results334 patients (mean age 72.5±11 years) were discussed virtually through MDT meetings and follow-up duration was 13.9 ± 4 months. The mean age-adjusted Charlson Co-morbidity Index was 7.6 ± 2.1 and Rockwood Frailty Score was 5.5 ± 1.6. The mean number of clinic attendances prevented was 1.6 ± 0.4. The total cost of funding monthly meetings for the duration of the study was £32400 and the 64 clinic appointments generated cost £9600. The MDT meetings prevented 534 clinic appointments (cost saving £80,100) and reduced all-cause hospitalisations (pre-MDT meeting 1.1±0.4 vs. 0.6±0.1 post-MDT meeting; pConclusionThe HF multispecialty virtual MDT model provides integration of care across all tiers of healthcare for HF management and a holistic approach addressing associated co-morbidities. This approach can reduce the need for out-patient attendances and all-cause hospitalisations, leading to significant cost-savings.Key questionsWhat is already known about this subject?Heart failure is associated with several co-morbid health conditions (multi-morbidity) which independently influence outcomes as well as response to treatment.What does this study add?This study assesses the impact of multispecialty multi-morbidity input into the management of co-morbidities and thereby the effect upon all-cause outcomes.How might this impact on clinical practice?Results of this study illustrate that multi-speciality management of comorbidities associated with heart failure, may not only improve all-cause outcomes but could also prove to be cost-beneficial.

Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model. This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings. A total of 189 patients were discussed from January-December 2020. This was uninterrupted during the COVID-19 pandemic. The mean age was 70.3±18.1 years and median follow-up 6 months (range 1–13 months). The mean Charlson Co-morbidity score was 5.3±1.2 and Rockwood Frailty Score was 4.9±1. The mean number of outpatient clinic attendances avoided was 1.7±0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system. Funding Acknowledgement Type of funding sources: None.

Introduction: Ventilator-associated pneumonia (VAP) is a serious health care-associated infection. It prolongs hospital stay and drives up hospital costs reporting high morbidity and mortality. VAP is defined as pneumonia that occurs 48h or more after endotracheal intubation or tracheostomy, caused by infectious agents not present or incubating at the time mechanical ventilation.VAP requires rapid diagnosis and initiation of the appropriate antibiotics. Materials and Methods: The present study was done in the department of Microbiology, Rajarajeswari Medical college, Bangalore. All the clinically suspected cases of VAP from intensive care units over a period of one year were included in the study. Endotracheal aspirate (ETA) and bronchoalveolar lavage (BAL) samples were collected from all patients and processed . Identification was carried out according to standard biochemical tests. Sensitivity pattern was determined using Kirby-bauer disc diffusion according to CLSI guidelines. Results: Out of 160 patients, who were on mechanical ventilation, 7 patients fulfilled the clinical and microbiological criteria. Incidence of VAP in our study is 4.4 and incidence density is 10.5 for 1000 ventilator days.57% of bacterial isolates were found to be Acinetobacter spp. followed by Pseudomonas aeruginosa 29% and Klebsiella pneumoniae 14%. Among 7 cases, 3(43%) were Early onset, 4(57%) were late onset VAP. Discussion and Conclusion: Even in the era of advanced medical care VAP remains a major challenge. The risk of developing VAP can be reduced by VAP prevention care bundles. Timely diagnosis is a major step to initiate appropriate antibiotics for better outcomes. Both patients and units are at risk of developing multidrug–resistant organisms and therefore appropriate antibiotic stewardship is essential. Better knowledge of local patterns of pathogens causing VAP can help facilitate treatment choice, in turn reducing the ventilator days and hospital stay.

Frontal fibrosing alopecia (FFA) is a recently described inflammatory and scarring type of hair loss affecting almost exclusively women. Despite a dramatic recent increase in incidence the aetiopathogenesis of FFA remains unknown. We undertake genome-wide association studies in females from a UK cohort, comprising 844 cases and 3,760 controls, a Spanish cohort of 172 cases and 385 controls, and perform statistical meta-analysis. We observe genome-wide significant association with FFA at four genomic loci: 2p22.2, 6p21.1, 8q24.22 and 15q2.1. Within the 6p21.1 locus, fine-mapping indicates that the association is driven by the HLA-B*07:02 allele. At 2p22.1, we implicate a putative causal missense variant in CYP1B1, encoding the homonymous xenobiotic- and hormone-processing enzyme. Transcriptomic analysis of affected scalp tissue highlights overrepresentation of transcripts encoding components of innate and adaptive immune response pathways. These findings provide insight into disease pathogenesis and characterise FFA as a genetically predisposed immuno-inflammatory disorder driven by HLA-B*07:02., Frontal fibrosing alopecia (FFA) features lichenoid cutaneous inflammation and scarring hair loss. Here, Tziotzios et al. identify four genetic loci associated with FFA by GWAS followed by Bayesian fine-mapping, co-localisation and HLA imputation which highlights HLA-B*07:02 as a risk factor.

Background/Introduction Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model. Methods This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings. Results A total of 189 patients were discussed from January- December 2020. This was uninterrupted during the COVID- 19 pandemic. The mean age was 70.3 ± 18.1 years and median follow-up 6 months (range 1-13 months). The mean Charlson Co-morbidity score was 5.3 ± 1.2 and Rockwood Frailty Score was 4.9 ± 1. The mean number of outpatient clinic attendances avoided was 1.7 ± 0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p

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.

The essence of appropriate nutritional intake on a regular basis has a great impact in maintaining fundamental physiological functions and the body metabolism. Considering how pivotal maintaining a nourishing fat diet is to human health, Omega-3 fatty acids have gained a lot of attention in recent times. Omega-3 fatty acids (n-3 FAs) such as eicosapentaenoic acid (EPA) and DHA are considered as essential fatty acids (EFAs) offering enormous nutritional benefits: from playing a major role in the prevention and treatment of a number of human diseases, such as cardiovascular disorders and neurological disorders, to having anti-inflammatory properties, to providing joint support, etc. Hence, their incorporation into our daily diet is of great importance. Also, both EPA and DHA have been shown to be therapeutically significant in treating several infectious diseases. EFAs were initially thought to be marine in origin, produced by fishes. Consequentially, this led to the increase in the industrial extraction of fish oils for meeting the commercial need for of n-3-rich dietary supplements. Although fish oil supplementation met almost all of the dietary demand for EFAs, they did come with a fair share of drawbacks such as undesirable odour and flavour, heavy metal contamination, extinction of fish species, etc. Oleaginous micro-organisms are a promising alternative for the production of a more sustainable, consistent and quality production of n-3 FAs. Thus, the entire review focuses on understanding the eco-friendlier production of n-3 FAs by micro-organisms.

As the number of patients with cardiac implantable electronic devices (CIEDs) grows, they are likely to present with issues to diverse groups of physicians. Guideline-adherent management is associated with improved prognosis in patients with CIED infection or lead problems but is insufficiently implemented in practice. The European Heart Rhythm Association (EHRA) with the support of the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery, performed a multinational educational needs assessment study in ESC member countries, directed at physicians who might be confronted with CIED patients with complications. A total of 336 physicians from 43 countries, reached through the ESC mailing list, participated. They included a mix of electrophysiologists, cardiologists general physicians and cardiac surgeons .One hundred and twenty-nine (38%) of the respondents performed lead extraction. The survey included eight clinical cases and a self-evaluation question of knowledge and skills to apply that knowledge. The survey looked at 14 areas of care across five stages of the patient journey. Of the non-extracting physicians over 50% felt they lacked the knowledge and skills to make the diagnosis and refer for lead extraction and over 75% felt they lacked knowledge and skills to manage aspects of extraction and post-extraction care. Barriers to correct referral were logistic and attitudinal. Extracting physicians reported significantly higher rates of adequate skills and knowledge across all five stages of the patient journey (P

Aims Pacing and Cardiac Resynchronization Therapy (CRT) procedural training for novice operators usually takes place in-vivo and methods vary across countries/institutions. No common system exists to objectively assess trainee ability to perform required tasks at predetermined performance levels prior to in-vivo practice. We sought to characterize and validate with experts a reference approach to pacing/CRT implants based on objective and explicit performance quality metrics, for the development of a reproducible, simulation-based, training curriculum aiming to operator proficiency. Methods Three experienced CRT implanters, a behavioural scientist and two engineers performed a detailed task deconstruction of the pacing/CRT procedure and identified the performance metrics (phases, steps, errors, critical errors) that constitute an optimal CRT implant for training purposes. The metrics were stress tested to determine reliability and score-ability and then subjected to detailed systematic review by an international panel of 15 expert implanters in a modified Delphi process. Results Thirteen procedure phases were identified, consisting of 196 steps, 122 errors, 50 critical errors. The expert panel deliberation added 16 metrics, deleted 12, and modified 43. Unanimous panel consensus on the resulting CRT procedure metrics was obtained, which verified face and content validity. Conclusion A reference pacing/CRT procedure and metrics created by a core group of experts accurately characterize the essential components of performance and were endorsed by an international panel of experienced peers. The metrics will underpin quality-assured novice implanter training.

Aims Transvenous lead extraction is challenging, often requiring specialist equipment and prolonged hospital admission. A single tariff or itemized costs may be available for reimbursement. Due to limited data relating to the costs of transvenous extraction, it is unclear whether either form of reimbursement is adequate. We aim to describe accurately the total real-world costs of managing patients undergoing transvenous extraction at a single, large centre. We further aim to consider the additional costs of device reimplantation. Methods and results At a single UK extraction centre, a retrospective, patient level service line analysis was undertaken, during a complete financial year. Seventy-four patients required transvenous extraction (47 infected and 27 non-infected; 156 leads). Sixty-nine procedures (93%) were performed under general anaesthesia, with a median time in theatre of 95 min [interquartile range (IQR) 71-120]. Specialist extraction tools were required for 130 leads (83%). The median hospitalization duration was 3 days (IQR 1-8). The mean cost of extraction was £9228 (±4099); infected £10 727 (±4178) and non-infected £6619 (±2269). With the additional costs of device reimplantation, the overall mean cost rose to £17 574 (±12 882); infected £22 615 (±13 343) and non-infected £8801 (±5007). At the time of this study, the UK NHS tariff was £2530 for elective and £4764 for non-elective extraction, covering barely half of the real costs. Conclusion We demonstrated a substantial difference between the real-world cost of extraction and the UK NHS tariff. Extracting centres should scrutinize their practice, including the timing of reimplantation.

The number of cardiac implantable electronic device (CIED) implantations has increased over recent years. Transvenous lead extraction (TLE), as a part of an overall lead management strategy, has also been increasing, not only as a consequence of this growth, but also because of increasing rates of infection, lead failure, awareness of indications for lead management, and development of extraction tools. Clinical research is essential for understanding efficacy and risks of TLE.

This article was migrated. The article was marked as recommended. A national survey (questionnaire) on Cardiology trainees undertaken on behalf of the author by the British Junior Cardiologists Association (BJCA) on training opportunities, needs, attitudes and perceived barriers that exist within "current training" in cardiac devices suggests lack of opportunity for hands on training and poor attitude to training resulting in a perceived lack of competence. The conflict between service commitment and training was a recurring theme.

We describe the case of a 75-year-old woman with permanent atrial fibrillation and advanced chronic kidney disease who was referred with worsening dyspnoea. She previously underwent surgical mitral and aortic mechanical valve replacements in 1989 for severe mitral and aortic stenoses secondary to

BACKGROUND: Extra pulmonary tuberculosis (EPTB) is a major health problem due to its destructive nature. The term EPTB, which encompasses all forms of TB other than pulmonary TB (PTB), has a broad spectrum of clinical manifestations, hence a real diagnostic challenge. AIM: The primary objective of this study was to describe the basic demographic, clinical characteristics, trends of various types of tuberculosis and to detect the incidence of EPTB in Mysore over a period of two years. MATERIALS AND METHODS: This is an observational study of patients of all types of Extrapulmonary tuberculosis from January 2011 to December 2013 in all age groups, evaluated at Mysore Medical College and Research institute, Mysore, Karnataka, India. RESULTS: Among 4500 cases registered for treatment of all forms of tuberculosis, 710(15.77%) had EPTB. More than half of the cases of EPTB (n = 472, 66%) were among adult age groups. Pleural TB was the commonest type of EPTB (n = 268, 37.03%), followed by lymph node TB (n = 210, 29.81%). Involvement of lymph nodes was the commonest manifestation in less than 14 years of age group, while involvement of pleura was more common among > 65 years. CONCLUSION: The burden of EPTB is more among the productive age group. Increase in the trend of EPTB cases, and other rare forms of EPTB are a point of concern highlighting the importance of strengthening the services towards this group.

Background: The use of pacemakers in the treatment of cardioinhibitory vasovagal syncope is controversial with a mixed message from the limited evidence base. Single chamber leadless pacemakers have been shown to be an effective alternative option to conventional pacemakers. Objective: This study examines the use of leadless pacemakers in a cardioinhibitory vasovagal population in the United Kingdom. Methods: Observational data on 32 patients implanted with the Micra Transcatheter Pacemaker System for vasovagal syncope are presented. Data was collected on implant indications, implant procedure and follow up data from 12 centres across the United Kingdom that had elected to use a Micra leadless pacemaker in this patient population. Results: 32 patients aged 37 ± 14 years (range 18 to 64 years) with 62% of the patients being female were recruited to the study. Vasovagal syncope was diagnosed clinically and with the support of Holter monitoring, tilt table testing and implantable loop recorders. The duration of symptoms was 8 ± 8 yrs. with an average frequency of syncope being 4 ± 6 times/year. The Micra pacemaker was successfully implanted in all patients with a major complication rate of 3.1%. Patients were followed up for 404 ± 237 days (range 63–928 days). At follow up 28 (87%) patients were free from symptoms. Conclusions: This observational study suggests that the use of a single chamber leadless pacemaker in the treatment of cardioinhibitory vasovagal syncope might be a reasonable clinical option. Keywords: Vasovagal, Cardioinhibitory, Syncope, Pacemaker, Leadless pacemaker, Micra

Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by loss of dopamine in the substantia nigra. It is predominantly a motor disorder but has shown to present with psychosis in few cases. Psychotic symptoms result from chronic treatment with few anti- Parkinson’s medications, ranging from depression, delusions to visual hallucinations, eventually progressing to auditory hallucinations in a few cases. Presence of psychotic symptoms with loss of insight is indicative of late stage of Parkinson’s disease and has poor prognosis. Accurate diagnosis of symptoms can be difficult due to significant overlapping clinical presentations which can be an admixture of underlying disease, exacerbation of pre-existing psychiatric illness or iatrogenic. The article below portrays the complex interplay between Parkinson’s disease psychosis, medications and underlying disease process which heralds early identification of the symptoms using diagnostic tools and imaging techniques to improve the health of individuals and the community by “translating” findings into diagnostic tools and medicines. It also highlights the dire need to develop neuroprotective drugs as a mode of primary prevention of psychosis. We cannot underemphasize the need to educate the patient and caregiver to seek medical attention at earliest for prompt identification and application of disease modifying therapies to reduce disability and morbidity associated with it and limit nursing home placements

Background The management of patients with recurrent gynecological malignancy is complex, and often contentious. While historically, patients with metastases in the lungs, liver or brain have been treated with palliative intent, surgery is proving to have an increasing role in the management of such patients. Methods In this review article, the surgical management of lung, liver and brain metastases from gynecological cancers is examined. A search of the English language literature over the last 25 years was conducted using the Medline and PubMed databases. Results The results for management of metastases from the endometrium, ovary and cervix to the lung, brain and liver show that surprisingly good long-term survival results can be achieved for resection of metastases from all three organs. Patient selection is critical, and surgery is often used in conjunction with other treatment modalities. Conclusions From this review, it is apparent that surgery should play an increasing role in the management of patients with parenchymal metastases from gynecological cancers. The surgery should ideally be performed in high volume, tertiary centers where there is a committed multi-disciplinary team with the necessary infrastructure to achieve the best possible outcomes in terms of both survival and morbidity.

Purpose: To review the two main approaches of intraperitoneal (IP) chemotherapy delivery in ovarian cancer: postoperative adjuvant IP chemotherapy after cytoreductive surgery (CRS) and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Methods: A literature search was conducted to identify studies that employed postoperative adjuvant IP chemotherapy after CRS or combined CRS and intraoperative HIPEC in patients with ovarian cancer. Data of interest included chemotherapy protocol, morbidity and mortality, and survival data. Results: Three large randomized controlled trials comprising 707 patients with advanced ovarian cancer who received postoperative adjuvant IP chemotherapy were reviewed. Morbidity rate ranged from 56% to 94% in IP chemotherapy, and mortality rate ranged from 1% to 2%. Median disease-free survival ranged from 24 to 28 months, and overall survival ranged from 49 to 66 months. Planned chemotherapy completion rates ranged from 42% to 71%. Twentyfour nonrandomized studies that reported HIPEC comprised 1167 patients with both advanced and recurrent ovarian cancer. In patients with advanced ovarian cancer, mortality ranged from 0% to 5%, minor morbidity ranged from 16% to 90%, and major morbidity ranged from 0% to 40%. Median disease-free survival ranged from 13 to 56 months, and overall survival ranged from 14 to 64 months. Survival at 5 years ranged from 35% to 70%. In patients with recurrent ovarian cancer, the mortality rate ranged from 0% to 10%, minor morbidity ranged from 7% to 90%, and major morbidity ranged from 0% to 49%. Median disease-free survival ranged from 13 to 24 months and overall survival from 23 to 49 months. Survival at 5 years ranged from 12% to 54%. Conclusion: There is level-one evidence suggesting the benefit of postoperative adjuvant intraperitoneal chemotherapy for patients with advanced ovarian cancer after cytoreductive surgery, albeit catheter-related complications resulted after treatment discontinuation. Studies report the use of HIPEC predominantly in the setting of recurrent disease and have demonstrated encouraging results, which merits further investigation in future clinical trials.

Key Clinical Message We report a case of incidentally diagnosed chronic lymphocytic leukemia (CLL) in a patient with glioblastoma, which responded completely following standard treatment of the glioblastoma with temozolomide and cranial irradiation. The patient remained without an evidence of CLL until his death from recurrent glioblastoma. Further study of temozolomide for the treatment of CLL is indicated.

The severe health hazards of respirable suspended particulate matter (RSPM or PM10) are well known, and control of RSPM is an integral part of any effective air quality management plan. The proposed study addresses the implementation of an air quality model for exposure assessment subsequent to its validation for the particulate matter in a megacity in India, namely Delhi, where RSPM concentrations most often exceed the ambient air quality standards. The model validation has been accomplished here for the total suspended particulate matter (TSPM) for which an extensive source inventory is available along with the requisite air quality data. A regulatory air dispersion model of US Environmental Protection Agency, AERMOD (Aermic Dispersion Model version 07026), which is a steady-state Gaussian Plume Model with improved atmospheric boundary layer physics, has been utilized for this purpose. Model validation shows a satisfactory model performance based on various statistical indicators. Subsequently, RSPM values are obtained from TSPM estimates and applied for exposure assessment for predefined emission control scenarios. The results from the model have been used to analyse mortality change associated with two hypothetical scenarios, namely, (1) reduction of vehicular traffic emissions by a fixed amount due to introduction of metro rail and compressed natural gas based buses in the city and (2) shift to a cleaner fuel in all the thermal power plants. The results from the exposure assessment study showed the importance of control of vehicular emission in improving the air quality and accrued health benefits. Copyright © 2010 Curtin University of Technology and John Wiley & Sons, Ltd.