Search

This study sought to determine what medical emergency resources and training are provided in U.S. public and academic libraries, how public versus academic preparedness compares, and what reasons may contribute to decisions against adoption. Survey responses from 65 libraries were analyzed regarding availability of, plans to acquire, or reasons for not acquiring five interventions—automatic electronic defibrillators (AEDs), naloxone, epinephrine, cardiopulmonary resuscitation (CPR) training, and mental health crisis training. Findings showed that these interventions were not necessarily common—41.5% of respondents offered zero of the five interventions, while the most common, AED, was available in 52.3% of libraries. AEDs and epinephrine were somewhat more common in academic libraries, but naloxone, CPR training, and mental health crisis training were more common in public libraries. Primary reasons for not adopting medical interventions included alternative emergency response options, cost, concerns regarding legal liability, and the sense that this is outside the scope of a library's duties. Implications and considerations for library planning are discussed. [ABSTRACT FROM AUTHOR]

This survey evaluated hypnosis practice in French centres in June 2020. The survey was sent via email to different rhythmology centres in France and responses from cardiologists and nurses were obtained. We present here the preliminary results of this survey. Hypnosis was used on a regular basis in 7.5% of the centres and 13% of the participants received education on hypnosis. 75% of the participants were interested to have an education of hypnosis. The survey points the different possibilities of improvement of management of patients while having the different procedures. [ABSTRACT FROM AUTHOR]

Home monitoring follow-up is part of the routine follow-up of the majority of implantable cardiac defibrillators, and is increasing regarding pacemakers follow-up. This article reviews history, guidelines and legislation for home monitoring follow-up of implantable cardiac devices, and discusses its evolution after ETAPES program. [ABSTRACT FROM AUTHOR]

Aims Patients are restricted from driving following implantable cardioverter defibrillator (ICD) implantation or shock. We sought to investigate how many patients are aware of, and adhere to, the driving restrictions, and what proportion experience an ICD shock or other cardiac symptoms while driving. Methods and results We performed a nationwide survey of all living Danish residents 18 years or older who received a first-time ICD between 2013 and 2016 (n  = 3913) and linked their responses with nationwide registers. Of 2741 respondents (47% primary prevention, 83% male, median age 67 years), 2513 (92%) held a valid driver's license at ICD implantation, 175 (7%) of whom had a license for professional driving. Many drivers were unaware of driving restrictions: primary prevention 58%; secondary prevention 36%; post-appropriate shock 28%; professional drivers 55%. Almost all (94%) resumed non-professional driving after ICD implantation, more than one-third during the restricted period; 35% resumed professional driving. During a median follow-up of 2.3 years, 5 (0.2%) reported receiving an ICD shock while driving, one of which resulted in a traffic accident. The estimated risk of harm was 0.0002% per person-year. Conclusion In this nationwide study, many ICD patients were unaware of driving restrictions, and more than one third resumed driving during a driving restriction period. However, the rate of reported ICD shocks while driving was very low. [ABSTRACT FROM AUTHOR]

The introduction of wearable cardioverter defibrillators (WCD) provides a novel means of protection in select patients at high risk for sudden cardiac death. The WCD can safely record and terminate life-threatening arrhythmias. In this review, we explore the data behind indications for WCD use and discuss its limitations. We searched PubMed, Google Scholar and Cochrane Central Register of controlled trials for relevant studies. The VEST trial, the first randomised controlled trial on WCD use, did not show statistical significance in utility of the WCD in post-myocardial infarction patients with low ejection fraction. While the use of WCD in this select patient population showed no benefit, the findings of the trial merit closer inspection. Various other indications of WCD use still exist and others require exploration. Select subsets of patients who stand to benefit for other indications include severely decreased left ventricular function post-revascularization with high arrhythmic burden, severe non-ischaemic cardiomyopathy, patients awaiting heart transplant and patients who have had their implantable cardioverter device temporarily removed. The role of the WCD is also being explored in children, peripartum cardiomyopathy, haemodialysis patients, and in syncope secondary to high-risk arrhythmias. [ABSTRACT FROM AUTHOR]

Since the publication of the SIMPLE and NORDIC trials, defibrillation testing (DFT) is rarely performed during routine implantation of transvenous implantable cardioverter-defibrillators (ICD). However, the results of these trials cannot be extrapolated to the later introduced subcutaneous ICD (S-ICD) and a class I recommendation to perform DFT during the implantation of these devices remains in the current guidelines. Due to the high conversion success rate of DFT on one hand, and the risk of complications on the other, a significant number of physicians omit DFT in S‑ICD recipients. Several retrospective analyses have assessed the safety of the omission of DFT and report contradicting results and recommendations. It is known that implant position, as well as device factors and patient characteristics, influence defibrillation success. A better comprehension of these factors and their relationship could lead to more reliable and safer alternatives to DFT. An ongoing randomised clinical trial, which is expected to end in 2023, is the first study to implement a method that assesses implant position to identify patients who are likely to fail their DFT. [ABSTRACT FROM AUTHOR]

Abstract Background Cardiac resynchronization therapy (CRT) is an established option for patients with heart failure. Limited data exists on indications and outcome of CRT in contemporary congenital heart disease (CHD) patients. Methods and results All patients with CRT registered in the German National Register for Congenital Heart Defects were systematically identified. We analysed data on demographics, type of congenital defect as well as repair, associated conditions, indication for CRT, heart failure medication, combination with a defibrillator or pacemaker and outcome. Overall, 65 patients with CRT were identified. The most common congenital diagnoses were Tetralogy of Fallot (n = 11), congenitally corrected transposition of the great arteries (ccTGA) (n = 9) and double outlet right ventricle (n = 6). The majority of patients (n = 48, 87%) had conventional antibradycardia pacing or ICD indications. Of these, the majority (n = 44) underwent an upgrade to a CRT system to avoid the detrimental consequences of longstanding conventional ventricular single-site pacing, whereas four patients required an ICD due to heart failure and a history of malignant ventricular tachycardia. During a median follow-up of 6.9 years 19 patients developed complications: 16 patients experienced pacemaker lead dysfunction and 3 patients pacemaker infection. Conclusions The current study based on a large national register for CHD shows that CRT is feasible and can be used as an adjunct in the heart failure treatment of selected CHD patients. Uptake of this therapy proved to be low in this nationwide study and CRT implantation was largely used in patients with a pre-existing pacing indication or those requiring an ICD. Highlights • Heart failure remains a major issue in congenital heart disease (CHD). • Reporting results of a nationwide CHD registry on cardiac resynchronisation (CRT). • CRT therapy can improve symptoms in selected patients. • Uptake of CRT therapy has been slow in our study. • Most patients have concomitant anti-bradycardia indications for CRT. [ABSTRACT FROM AUTHOR]

Résumé Le nombre de patients porteurs de stimulateurs et de défibrillateurs automatiques implantables (dispositifs rythmologiques implantables) traités par irradiation est de plus en plus important, justifiant une prise en charge standardisée, en collaboration avec les cardiologues. Les interactions entre les champs électromagnétiques, les particules secondaires des accélérateurs et les appareils implantés peuvent être responsables de dysfonctionnements généralement transitoires et réversibles dont les conséquences cliniques peuvent varier selon la pathologie cardiaque et le rythme sous-jacents. Il existe de nombreuses recommandations internationales sur la prise en charge de ces patients traités par irradiation ; les points clés identifiés sont la dose totale cumulée au boîtier maximale tolérée de 5 Gy et la nécessité d’une évaluation préalable, puis d’une surveillance régulière du dispositif rythmologique implantable jusqu’à six mois après le traitement. L’analyse des données publiées montre une incidence relativement faible d’évènements indésirables, de faible gravité. Les recommandations internationales les plus récentes soulignent la faisabilité et l’intérêt de l’application de protocoles adaptés par tous les centres de radiothérapie. Abstract An increasing number of patients with cardiac implantable electronic devices benefit from radiotherapy, warranting specific collaborative management between both radiation oncologists and cardiologists. Interactions between electromagnetic fields, secondary particles and cardiac implantable electronic devices may result in transient and reversible malfunctions with significant consequences depending on the underlying cardiac pathology and the level of patient's cardiac implantable electronic devices dependency. Numerous international guidelines on patients’ management have been proposed and all agree on a total cumulated dose limit at the battery of 5 Gy and on the need for an initial as well as repeated evaluation over time, up to 6 months after the last radiation. The analysis of the published data revealed relatively rare incidence of significant adverse events. The most recent international guidelines underline the feasibility and safety of radiotherapy for cardiac implantable electronic devices holders, with the need for systematic local protocol in all radiotherapy centers. [ABSTRACT FROM AUTHOR]

Introduction: Public access defibrillation doubles the chances of neurologically intact survival following out-of-hospital cardiac arrest (OHCA). Although there are increasing numbers of defibrillators (automated external defibrillator (AEDs)) available in the community, they are used infrequently, despite often being available. We aimed to match OHCAs with known AED locations in order to understand AED availability, the effects of reduced AED availability at night and the operational radius at which they can be effectively retrieved.Methods: All emergency calls to South Central Ambulance Service from April 2014 to April 2016 were screened to identify cardiac arrests. Each was mapped to the nearest AED, according to the time of day. Mapping software was used to calculate the actual walking distance for a bystander between each OHCA and respective AED, when travelling at a brisk walking speed (4 mph).Results: 4012 cardiac arrests were identified and mapped to one of 2076 AEDs. All AEDs were available during daytime hours, but only 713 at night (34.3%). 5.91% of cardiac arrests were within a retrieval (walking) radius of 100 m during the day, falling to 1.59% out-of-hours. Distances to rural AEDs were greater than in urban areas (P<0.0001). An AED could potentially have been retrieved prior to actual ambulance arrival in 25.3% cases.Conclusion: Existing AEDs are underused; 36.4% of OHCAs are located within 500 m of an AED. Although more AEDs will improve availability, greater use can be made of existing AEDs, particularly by ensuring they are all available on a 24/7 basis. [ABSTRACT FROM AUTHOR]

Cardiovascular devices and hemodynamic monitoring systems continue to evolve with the goal of allowing for rapid clinical intervention and management. Cardiovascular devices including the CardioMicroelectromechanical (CardioMEMS) device, implantable loop recorder, and right ventricular (RV) leadless pacemaker are now widely used for treatment and monitoring of advanced cardiac conditions, as many of these devices have been shown to significantly improve patient outcomes. Additionally, hemodynamic monitoring devices have shown utility in monitoring patients with aortic aneurysms after endovascular aortic repair (EVAR) for early detection of Type I and Type II endoleaks. There is limited published data regarding the imaging features of these devices. As these devices become more widely used, it is important for radiologists to become familiar with the normal imaging features and potential complications. The goal of this review is to summarize the data regarding the use of leadless cardiovascular devices including the CardioMEMS device, implantable loop recorder, and RV leadless pacemaker, and to present cases demonstrating their utility and normal imaging features. [ABSTRACT FROM AUTHOR]

Background: Internal cardioverter defibrillator (ICD) therapy reduced all-cause mortality. Conversely, few studies reported that ICDs' shocks may reduce survival. Recently authors suggested that, multiple inflammatory and molecular pathways were related to worse prognosis in metabolic syndrome (MS) patients treated by ICDs. Therefore, it may be relevant to find new biomarkers to predict ICDs' shock and worse prognosis in treated patients. Methods: In 99 MS vs. 107 no MS patients treated by ICD for primary prevention, we evaluated all-cause mortality, cardiac deaths, hospitalization for heart failure, appropriate and inappropriate therapy, and survival after appropriate ICD therapy. Results: MS vs. no MS patients had higher levels of failing heart stress biomarkers. The highest values of ST2 were related to worse prognosis. Patients who had better survival after appropriate ICD therapy were those associated with lowest ST2 values. At multivariate Cox regression analysis, C reactive protein (CRP) (0.110 [0.027–0.446], p-value 0.002), troponine I (TnI) protein (0.010 [0.001–0.051], p-value 0.010), and B type natriuretic peptide (BNP) (1.151 [1.010–1.510], p-value 0.001), predicted all cause of deaths. BNP predicted cardiac deaths (1.010 [1.001–1.206], p-value 0.033). MS, and BNP predicted hospitalization for heart failure events (2.902 [1.345–4.795], p-value 0.001; 1.005 [1.000–1.016], p-value 0.007). ST2 predicted appropriate therapy (1.012 [1.007–1.260], p-value 0.001), as BNP (1.005 [1.001–1.160], p-value 0.028), LVEF (1.902 [1.857–1.950], p-value 0.001), and CRP (1.833 [1.878–1.993], p-value 0.028). ST2, and BNP predicted survival after ICD appropriate therapy (4.297 [1.985–9.302], p-value 0.001; 1.210 [1.072–1.685], p-value 0.024). Conclusions: ST2 values may differentiate MS patients with a higher risk of ICDs' therapy, and worse prognosis. Therefore, ST2 protein may be used as valid monitoring biomarker, and as a predictive biomarker in failing heart ICDs' patients affected by MS. [ABSTRACT FROM AUTHOR]

Infection is an important complication of cardiac implantable electronic device procedures. To further study the factors associated with infection, we retrospectively reviewed the records of 3,205 consecutive patients who had undergone de novo or revision cardiac electronic device implantation at our institution from March 2011 through March 2015. We recorded all infections and specified whether they were related to the characteristics of the patient, device, or procedure. To identify predictors of infection, we performed multivariate analysis. Device infections were identified in 85 patients (2.7%), at a mean follow-up time of 27 ± 11 months. The main predictors of device infection were use of an implantable cardioverter-defibrillator or a cardiac resynchronization therapy defibrillator device (odds ratio [OR]=16; 95% CI, 4.14–61.85; P=0.0001), stage 3 chronic kidney disease (OR=9.41; 95% CI, 1.77–50.04; P=0.009), a revision procedure (OR=8.8; 95% CI, 3.37–23.2; P=0.0001), or postoperative hematoma (OR=6.9; 95% CI, 1.58–30.2; P=0.01). We also identified 2 novel predictors of infection: a low body mass index of <20 kg/m2 (OR=1.03; 95% CI, 1.01–1.06; P=0.005), and use of povidone-iodine rather than chlorhexidine-alcohol for topical antisepsis (OR=4.4; 95% CI, 2.01–9.4; P=0.03). We conclude that comorbidities, device characteristics, procedure types, and postoperative noninfective complications all increase the risk of device infection after a cardiac implantable electronic device procedure. [ABSTRACT FROM AUTHOR]

Objective: To determine the incremental value of implantable cardioverter defibrillators (ICD) in contemporary optimally treated patients with heart failure (HF) undergoing cardiac resynchronisation therapy (CRT).Methods: Consecutive patients with HF undergoing CRT-pacemaker (CRT-P) or CRT-defibrillator (CRT-D) implantation in a single tertiary care centre between October 2008 and August 2015 were retrospectively evaluated. For patients with a primary prevention indication of the CRT-D, no benefit of the ICD was defined as absence of appropriate therapy (device analysis) or lethal ventricular tachyarrhythmias (mode of death analysis) during follow-up.Results: 687 patients (CRT-P/CRT-D; n=361/326) were followed for 38±22 months. CRT-P recipients were older (75.7±9.1 vs 71.8±9.3 years; p<0.001) and had a higher comorbidity burden. Five patients with CRT-P (1%) experienced episodes of sustained ventricular-tachycardia vs 64 (20%) patients with CRT-D (p<0.001). Remote tele-monitoring detected the episodes of sustained ventricular tachycardia in four patients with CRT-P, allowing for elective upgrade to CRT-D. All-cause mortality was higher in patients with CRT-P versus CRT-D (21% vs 12%, p=0.003), even after adjusting for baseline characteristics (HR 2.5; 95% CI 1.36 to 4.60; p=0.003). However, mode of death analysis revealed a predominant non-cardiac mode of death in CRT-P recipients (n=47 (71%) vs n=13 (38%) in CRT-D, p=0.002). Multivariate analysis revealed that age >80 years, New York Heart Association class IV, intolerance to beta-blockers and underlying non-ischaemic cardiomyopathy were independently associated with little incremental value of a primary prevention ICD on top of CRT.Conclusions: The majority of patients with contemporary HF as currently selected for CRT-P exhibit mainly non-cardiac-driven mortality. Weighing risk of ventricular-tachyarrhythmic death versus risk of all-cause mortality helps to address the incremental value of an ICD to CRT-P. [ABSTRACT FROM AUTHOR]

Background: We aimed to investigate the effect of automated external defibrillator (AED) feedback mechanisms on survival in out-of-hospital cardiac arrest (OHCA) victims. In addition, we investigated converting rates in patients with shockable rhythms according to AED shock waveforms and energy levels.Methods: We collected data on OHCA occurring between 2011 and 2014 in the Capital Region of Denmark where an AED was applied prior to ambulance arrival. Patient data were obtained from the Danish Cardiac Arrest Registry and medical records. AED data were retrieved from the Emergency Medical Dispatch Centre (EMDC) and information on feedback mechanisms, energy waveform and energy level was downloaded from the applied AEDs.Results: A total of 196 OHCAs had an AED applied prior to ambulance arrival; 62 of these (32%) provided audio visual (AV) feedback while no feedback was provided in 134 (68%). We found no difference in return of spontaneous circulation (ROSC) at hospital arrival according to AV-feedback; 34 (55%, 95% confidence interval (CI) [13-67]) vs. 72 (54%, 95% CI [45-62]), P = 1 (odds ratio (OR) 1.1, 95% CI [0.6-1.9]) or 30-day survival; 24 (39%, 95% CI [28-51]) vs. 53 (40%, 95% CI [32-49]), P = 0.88 (OR 1.1 (95% CI [0.6-2.0])). Moreover, we found no difference in converting rates among patients with initial shockable rhythm receiving one or more shocks according to AED energy waveform and energy level.Conclusions: No difference in survival after OHCA according to AED feedback mechanisms, nor any difference in converting rates according to AED waveform or energy levels was detected. [ABSTRACT FROM AUTHOR]

BACKGROUND: Lead management is an increasingly important aspect of care in patients with cardiac implantable electronic devices; however, relatively little is known about long-term outcomes after capping and abandoning leads. METHODS: Using the 5% Medicare sample, we identified patients with de novo cardiac implantable electronic device implantations between January 1, 2000, and December 31, 2013, and with a subsequent lead addition or extraction ≥12 months after the de novo implantation. Patients who underwent extraction for infection were excluded. Using multivariable Cox proportional hazards models, we compared cumulative incidence of all-cause mortality, device-related infection, device revision, and lead extraction at 1 and 5 years for the extraction versus the cap and abandon group. RESULTS: Among 6859 patients, 1113 (16.2%) underwent extraction, whereas 5746 (83.8%) underwent capping and abandonment. Extraction patients tended to be younger (median, 78 versus 79 years; P<0.0001), were less likely to be male (65% versus 68%; P=0.05), and had shorter lead dwell time (median, 3.0 versus 4.0 years; P<0.0001) and fewer comorbidities. Over a median follow-up of 2.4 years (25th, 75th percentiles, 1.0, 4.3 years), the overall 1-year and 5-year cumulative incidence of mortality was 13.5% (95% confidence interval [CI], 12.7–14.4) and 54.3% (95% CI, 52.8–55.8), respectively. Extraction was associated with a lower risk of device infection at 5 years relative to capping (adjusted hazard ratio, 0.78; 95% CI, 0.62–0.97; P=0.027). There was no association between extraction and mortality, lead revision, or lead extraction at 5 years. CONCLUSIONS: Elective lead extraction for noninfectious indications had similar long-term survival to that for capping and abandoning leads in a Medicare population. However, extraction was associated with lower risk of device infections at 5 years. [ABSTRACT FROM AUTHOR]

Background: Despite recent advances, the average survival after out-of-hospital cardiac arrest (OHCA) remains <10%. Early defibrillation by an automated external defibrillator is the most important intervention for patients with OHCA, showing survival proportions >50%. Accordingly, placement of automated external defibrillators in the community as part of a public access defibrillation program (PAD) is recommended by international guidelines. However, different strategies have been proposed on how exactly to increase and make use of publicly available automated external defibrillators. This systematic review aimed to evaluate the effect of PAD and the different PAD strategies on survival after OHCA.Methods: PubMed, Embase, and the Cochrane Library were systematically searched on August 31, 2015 for observational studies reporting survival to hospital discharge in OHCA patients where an automated external defibrillator had been used by nonemergency medical services. PAD was divided into 3 groups according to who applied the defibrillator: nondispatched lay first responders, professional first responders (firefighters/police) dispatched by the Emergency Medical Dispatch Center (EMDC), or lay first responders dispatched by the EMDC.Results: A total of 41 studies were included; 18 reported PAD by nondispatched lay first responders, 20 reported PAD by EMDC-dispatched professional first responders (firefighters/police), and 3 reported both. We identified no qualified studies reporting survival after PAD by EMDC-dispatched lay first responders. The overall survival to hospital discharge after OHCA treated with PAD showed a median survival of 40.0% (range, 9.1-83.3). Defibrillation by nondispatched lay first responders was associated with the highest survival with a median survival of 53.0% (range, 26.0-72.0), whereas defibrillation by EMDC-dispatched professional first responders (firefighters/police) was associated with a median survival of 28.6% (range, 9.0-76.0). A meta-analysis of the different survival outcomes could not be performed because of the large heterogeneity of the included studies.Conclusions: This systematic review showed a median overall survival of 40% for patients with OHCA treated by PAD. Defibrillation by nondispatched lay first responders was found to correlate with the highest impact on survival in comparison with EMDC-dispatched professional first responders. PAD by EMDC-dispatched lay first responders could be a promising strategy, but evidence is lacking. [ABSTRACT FROM AUTHOR]

With advances in cardiology and cardiothoracic surgery, several newer implantable cardiac devices have become common in the surgical population. Multichamber pacemakers, implanted cardiac defibrillators and ventricular assist devices are frequent in current day practice. Many of the newer implantable cardiac electronic devices are targeted at managing heart failure. While managing such patients for non-cardiac surgeries, specific issues related to equipment characteristics and troubleshooting should be a priority for the anaesthesiologists. There is a possibility of malfunction of the devices resulting in catastrophic outcomes. Therefore, it is imperative to understand the pathophysiology, device characteristics and troubleshooting before embarking on anaesthetising patients with implantable cardiac electronic devices. [ABSTRACT FROM AUTHOR]

Aim: An increasing number of failing automated external defibrillators (AEDs) is reported: AEDs not giving a shock or other malfunction. We assessed to what extent AEDs are 'failing' and whether this had a device-related or operator-related cause.Methods: We studied analysis periods from AEDs used between January 2012 and December 2014. For each analysis period we assessed the correctness of the (no)-shock advice (sensitivity/specificity) and reasons for an incorrect (no)-shock advice. If no shock was delivered after a shock advice, we assessed the reason for no-shock delivery.Results: We analyzed 1114 AED recordings with 3310 analysis periods (1091 shock advices; 2219 no-shock advices). Sensitivity for coarse ventricular fibrillation was 99% and specificity for non-shockable rhythm detection 98%. The AED gave an incorrect shock advice in 4% (44/1091) of all shock advices, due to device-related (n=15) and operator-related errors (n=28) (one unknown). Of these 44 shock advices, only 2 shocks caused a rhythm change. One percent (26/2219) of all no-shock advices was incorrect due to device-related (n=20) and operator-related errors (n=6). In 5% (59/1091) of all shock advices, no shock was delivered: operator failed to deliver shock (n=33), AED was removed (n=17), operator pushed 'off' button (n=8) and other (n=1). Of the 1073 analysis periods with a shockable rhythm, 67 (6%) did not receive an AED shock.Conclusion: Errors associated with AED use are rare (4%) and when occurring are in 72% caused by the operator or circumstances of use. Fully automatic AEDs may prevent the majority of these errors. [ABSTRACT FROM AUTHOR]

Background: Public Access Defibrillation (PAD) programs have emerged since mid-1990s with the aim of improving survival from Out-of-Hospital Cardiac Arrest (OHCA). The extent to which their implementation in the community differs among different areas has not been evaluated.Methods: We carried out a 5-year prospective national evaluation of PAD programs in 51 French districts (29.3 million inhabitants), through the cumulative density of Automated External Defibrillator (AEDs) and the proportion of persons educated in Basic Life Support (BLS).Results: Major regional discrepancies were observed with AED density from 5 to 3399 per 100,000 inhabitants per 1000km2, and BLS-educated inhabitants varying from 6955 to 36,636 per 100,000 inhabitants. Only 18 districts (35.3%) achieved both AED density and educational rate above median (>13,988 and >22, respectively). Extrapolating the data from the French national registry on sports OHCA, mean survival rate was two-folds higher with AED density above the median (7.9% vs. 17.8%, P<0.001) and four-fold higher with BLS-education above the median (5.0% vs. 20.9%, P<0.001). In the group with both AED density and BLS-education level above the median, the survival rate reached up to 22.5%. Only the rate of population BLS education remained independently associated with survival (OR 1.64, 95% Confidence Interval 1.17-2.31; P=0.0045).Conclusions: Major heterogeneities in PAD programs exist, with significant room for better coordination in implementation. Population education in BLS provides an important benefit, regardless of the density of AEDs deployed, which should be taken into account in planning public health policies for improving OHCA survival. [ABSTRACT FROM AUTHOR]

Introduction: The aim of the study was to evaluate the impact of individual training on the level of physical capacity and echocardiographic parameters in patients with systolic heart failure (SHF), NYHA III and an implantable cardioverter-defibrillator (ICD).Material and Methods: The study included 84 patients with SHF, randomly assigned to one of two groups: with regular training (ICD-Ex) and a control group (ICD-control). The ICD-Ex group participated in a hospital rehabilitation program which after discharge was individually continued for 6 months in an outpatient setting. The ICD-control group participated in a training program during hospitalization, but after discharge did not perform any controlled activities. Prior to discharge, at 6 and 18 months cardiopulmonary exercise testing (CPX), standard echocardiographic examination and the 6-minute walk test (6-MWT) were performed in all patients.Results: After 18 months in the ICD-Ex group most of the CPX parameters improved significantly (VO2 peak, ml/kg/min: 13.0 ±4.1 vs. 15.9 ±6.1, p < 0.0017; VCO2 peak, l/min: 1.14 ±0.34 vs. 1.58 ±0.65, p < 0.0008; Watt: 74.5 ±29.7 vs. 92.6 ±39.1, p < 0.0006; METs 3.72 ±1.81 vs. 4.35 ±1.46, p < 0.0131). In the ICD-control group no significant improvement of any parameter was observed. Left ventricular systolic dimensions remained significantly lower at 18 months only in the ICD-Ex group (49.5 ±11.0 vs. 43.4 ±10.0, p < 0.011). Left ventricular ejection fraction in both groups significantly increased at 6 and 18 months compared to baseline (ICD-Ex: 25.07 ±5.4 vs. 31.4 ±9.2, p < 0.001, vs. 30.9 ±8.9, p < 0.002, ICD-C: 25.1 ±8.3 vs. 29.2 ±7.7, p < 0.012 vs. 30.1 ±9.1, p < 0.005). Distance of the 6-MWT was significantly improved after 6 and 18 months in the ICD-Ex group and was overall longer than in the ICD-control group (491 ±127 vs. 423 ±114 m, p < 0.04).Conclusions: An individual, 6-month training program, properly controlled in patients with SHF and an implanted ICD, was safe and resulted in a significant improvement of exercise tolerance and capacity and echocardiographic parameters. [ABSTRACT FROM AUTHOR]

Introduction: For a cloud-based telecardiology solution to be established in any scenario, it is necessary to ensure optimum levels of security, as patient's data will not be in the same place from where access is gained. The main objective of this article is to present a secure, cloud-based solution for a telecardiology service in different scenarios: a hospital, a health center in a city, and a group of health centers in a rural area. Methods: iCanCloud software is used to simulate the scenarios. The first scenario will be a city hospital with over 220,000 patients at its emergency services, and ∼1 million outpatient consultations. For the health center in a city, it serves ∼107,000 medical consultations and 16,700 pediatric consultations/year. In the last scenario, a group of health centers in a rural area serve an average 437.08 consultations/month and around 15.6 a day. Results: Each one of the solutions proposed shares common features including the following: secure authentication through smart cards, the use of StorageGRID technology, and load balancers. For all cases, the cloud is private and the estimated price of the solution would cost around 450 €/month. Conclusions: Thanks to the research conducted in this work, it has been possible to provide an adapted solution in the form of a telecardiology service for a hospital, city health center, and rural health centers that offer security, privacy, and robustness, and is also optimum for a large number of cloud requests. [ABSTRACT FROM AUTHOR]

A review of several articles on cardiology published in 2016 is presented including "Defibrillator Implantation in Patients With Nonischemic Systolic Heart Failure" by J. J. Thune et al published in the "New England Journal of Medicine (NEJM)," "Coronary-Artery Bypass Surgery in Patients With Ischemic Cardiomyopathy" by K. L. Lee et al published in NEJM, and "Blood-Pressure Lowering in Intermediate-Risk Persons Without Cardiovascular Disease" by J. Bosch et al published in NEJM.

Background The role of implantable cardioverter defibrillator (ICD) in reducing mortality in patients with left ventricular assisted devices (LVADs) listed for heart transplant remains unclear. We therefore, sought to interrogate whether ICDs are associated with reduced mortality in patients with LVADs listed for heart transplantation. Methods We searched the United Network for Organ Sharing (UNOS) Registry for LVAD patients (age ≥ 18 years) with dilated cardiomyopathies listed for heart transplantation (2008-2015). The group was matched by propensity scores with respect to presence of ICD at listing. The primary end-point was waitlist mortality, while secondary endpoints were waitlist mortality, delisting, or cardiovascular cause-specific mortality in patients with and without ICD. Results A total of 1444 LVAD patients were included in this analysis (722 with ICD, 722 without ICD). No statistically-significant differences were present between the two groups in demographics, device type, listing status, or hemodynamics. The presence of an ICD was not associated with decreased wait-list mortality (Hazard Ratio 1.19 [0.75-1.88], p = 0.46), waitlist mortality/delisting (Hazard Ratio 1.20 [0.86-1.67], p = 0.28), or cardiovascular wait-list mortality (HR 1.24 [0.45-3.43], p = 0.67) over a median of 5.6 months. Only 7 deaths occurred due to arrhythmia/cardiac arrest (2 in the ICD group and 5 in the non-ICD group). Conclusion Presence of ICDs at listing in heart failure patients bridged to transplantation with durable LVADs is not associated with lower waitlist mortality, cardiovascular wait-list mortality or wait-list mortality or delisting; however, there were numerically fewer arrhythmic deaths in the ICD group. Additional prospective studies should be undertaken to confirm these findings. [ABSTRACT FROM AUTHOR]

Automated external defibrillators (AEDs) are portable devices that defibrillate and diagnose sudden-cardiac-arrest patients. Therefore, AEDs are widely installed in public places such as airports, schools, sport complexes, etc., and the installation of AEDs is required by law in these places. However, despite their usefulness, AEDs are mostly installed indoors with limited coverage outdoors. Hence, this study conducts research in the placement of AEDs in outdoor locations. This study considers a complicated urban environment using a pedestrian network dataset and network barriers. We draw on the Teitz and Bart's (1968) heuristic method that was built in the location-allocation solver in ArcMap. The results of this study found that a total of 455 AEDs, including 227 pre-installed AEDs, could be placed in the study area, thus providing an additional 228 devices. Compared with 10 different installation methods that were set as experimental groups, our test results found that additional installations were able to cover 10% to 30% more actual out-of-hospital cardiac-arrest cases. The main contribution of this study is the proposal of a new method in locating AEDs in optimal areas while considering complicated urban environments. We predict that the cardiac-arrest-related mortality rate would be reduced through implementing the findings of this study. [ABSTRACT FROM AUTHOR]

The increase in mortality associated with arrhythmia is an inevitable problem of modern society such as westernized eating habits and an increase in stress due to industrialization, and the related social costs are increasing. In this regard, the supply of automatic external defibrillator (AED) used outside hospitals is increasing mainly in public institutions, and AED is a medical practice performed by non-medical personnel. Therefore, studies on arrhythmia detection algorithm to make accurate clinical judgment for proper use are increasing. In this paper, we propose a time domain analysis method to detect arrhythmia in real time and implement AED by porting it to programmable gate array and digital signal processor. The analysis of the phase domain improves the detection rate of R-peak using the differentiated electrocardiogram (ECG) waveform rather than the existing ECG waveform and makes it easy to distinguish the normal ECG from the arrhythmia signal in the phase domain. The proposed algorithm was verified by simulation using Labview and ModelSim, and it was verified that the proposed algorithm works effectively by performing animal experiments using the implemented AED. [ABSTRACT FROM PUBLISHER]

Objectives: Arrhythmogenic right ventricular cardiomyopathy caused by a TMEM43 p.S358L mutation is a fully penetrant autosomal dominant cause of sudden cardiac death where prophylactic implantable cardioverter defibrillator therapy significantly reduces mortality by returning lethal cardiac rhythms to normal. This qualitative study assessed the psychological ramifications of the implantable cardioverter defibrillator on recipients, their spouses and their mutation negative siblings. Design: Qualitative interview study. Participants: Twenty-one individuals (nine mutation positive, eight mutation negative and four spouses) from 15 families completed semi-structured interviews. Results: No theoretical assumptions about the data were made: inductive sub-coding was accomplished with the constant comparison method and cohesive themes across all respondent interviews were determined. All interviewees had a family history of sudden cardiac death and appropriate implantable cardioverter defibrillator therapy in themselves or family members. Average length of time with an implantable cardioverter defibrillator was 10 years. Major themes included: (1) acceptance and gratitude, (2) grudging acceptance, (3) psychological effects (on emotional and psychological well-being; functioning of the broader family unit; and relationships), and (4) practical concerns (on clothes, travel, loss of driving licence and the effects of an implantable cardioverter defibrillator discharge). These affected all family members, regardless of mutation status. Conclusions: Despite the survival advantage of implantable cardioverter defibrillator therapy, the intervention carries psychological and practical burdens for family members from kindreds manifesting p.S358L TMEM43 ARVC that does not appear to dissipate with time. A move towards integrating psychology services with the cardiac genetics clinic for the extended family may provide benefit. [ABSTRACT FROM AUTHOR]

Cardiac implantable electronic devices (CIED) are utilized in increasing number and in heterogeneous populations. With excellent training, checklists, and "muscle memory," the implantation procedure is generally very safe and efficient. Nevertheless, significant and potentially life‐threatening complications can occur. [ABSTRACT FROM AUTHOR]

Advances in the field of defibrillation have brought to practice different types of devices that include the transvenous implantable cardioverter-defibrillator (ICD) with or without cardiac resynchronization therapy, the subcutaneous ICD (S-ICD), and the wearable cardioverter-defibrillator. To ensure optimal use of these devices and to achieve best patient outcomes, clinicians need to understand how these devices work, learn the characteristics of patients who qualify them for one type of device versus another, and recognize the remaining gaps in knowledge surrounding these devices. The transvenous ICD has been shown in several randomized clinical trials to improve the survival of patients resuscitated from near-fatal ventricular fibrillation and those with sustained ventricular tachycardia with syncope or systolic heart failure as a result of ischemic or nonischemic cardiomyopathy despite receiving guideline-directed medical therapy. Important gaps in knowledge regarding the transvenous ICD involve the role of the ICD in patient subgroups not included, or not well represented, in clinical trials and the need to refine the selection criteria for the ICD in patients who are indicated for it. S-ICDs were recently introduced into the clinical arena as another option for many patients who have an approved indication for a transvenous ICD. The main advantage of the S-ICD is a lower risk of infection and lead-related complications; however, the S-ICD does not offer bradycardia or antitachycardia pacing. The S-ICD may be ideal for patients with limited vascular access, high infection risk, or some congenital heart diseases. However, more data are needed regarding the efficacy and effectiveness of the S-ICD in comparison to transvenous ICDs, the extent of defibrillation testing required, and the use of the S-ICD with other novel technologies, including leadless pacemakers. Cardiac resynchronization therapy- defibrillators are indicated in patients with a left ventricular ejection fraction ≤35%, QRS width ≥130 ms, and New York Heart Association class II, III, or ambulatory IV symptoms despite treatment with guideline-directed medical therapy. Multiple randomized controlled trials have shown that the cardiac resynchronization therapy-defibrillator improves survival, quality of life, and several echocardiographic measures. One main challenge related to cardiac resynchronization therapy-defibrillators is the 30% nonresponse rate. Many initiatives are underway to address this challenge including improved cardiac resynchronization therapy and imaging technologies and enhanced selection of patients and device programming. [ABSTRACT FROM AUTHOR]

BACKGROUND: To popularize the wide-spread use of automated external defibrillator (AED) to save life in sudden cardiac arrest, we compared the strength and weakness of different types of AEDs to enable a sound selection based on regional requirement. METHODS: This was a retrospective descriptive study. Different types of AEDs were compared according to the information of AEDs from manuals and brochures provided by the manufacturers. Fifteen types of AEDs were divided into 3 groups, basic, intermediate and advanced. RESULTS: Lifeline? AUTO AED had the best performance in price, portability and user-friendly among AEDs of basic level. It required less time for shock charging. Samaritan PAD defibrillator was superior in price, portability, durability and characteristic among AEDs of intermediate level. It had the longest warranty and highest protection against water and dust. Lifeline? PRO AED had the best performance in most of the criteria among AEDs of advanced level and offered CPR video and manual mode for laypersons and clinicians respectively. CONCLUSION: Lifeline? AUTO AED, Samaritan PAD defibrillator, Lifeline? PRO AED are superior in AEDs of basic, intermediate and advanced levels, respectively. A feasible AED may be chosen by users according to the regional requirement and the current information about the best available products. [ABSTRACT FROM AUTHOR]

Background: The occurrence of out-of-hospital cardiac arrest (OHCA) is a critical life-threatening event which frequently warrants early defibrillation with an automated external defibrillator (AED). The optimization of allocating a limited number of AEDs in various types of communities is challenging. We aimed to propose a two-stage modeling framework including spatial accessibility evaluation and priority ranking to identify the highest gaps between demand and supply for allocating AEDs. Methods: In this study, a total of 6135 OHCA patients were defined as demand, and the existing 476 publicly available AEDs locations and 51 emergency medical service (EMS) stations were defined as supply. To identify the demand for AEDs, Bayesian spatial analysis with the integrated nested Laplace approximation (INLA) method is applied to estimate the composite spatial risks from multiple factors. The population density, proportion of elderly people, and land use classifications are identified as risk factors. Then, the multi-criterion two-step floating catchment area (MC2SFCA) method is used to measure spatial accessibility of AEDs between the spatial risks and the supply of AEDs. Priority ranking is utilized for prioritizing deployment of AEDs among communities because of limited resources. Results: Among 6135 OHCA patients, 56.85 % were older than 65 years old, and 79.04 % were in a residential area. The spatial distribution of OHCA incidents was found to be concentrated in the metropolitan area of Kaohsiung City, Taiwan. According to the posterior mean estimated by INLA, the spatial effects including population density and proportion of elderly people, and land use classifications are positively associated with the OHCA incidence. Utilizing the MC2SFCA for spatial accessibility, we found that supply of AEDs is less than demand in most areas, especially in rural areas. Under limited resources, we identify priority places for deploying AEDs based on transportation time to the nearest hospital and population size of the communities. Conclusion: The proposed method will be beneficial for optimizing resource allocation while considering multiple local risks. The optimized deployment of AEDs can broaden EMS coverage and minimize the problems of the disparity in urban areas and the deficiency in rural areas. [ABSTRACT FROM AUTHOR]

Background: The use of an implantable cardioverter defibrillator (ICD) is a widely used and effective therapy, which reduces the risk of cardiac death in many cardiac diseases, both implanted for secondary and primary prevention. However, recurrent arrhythmias and ICD discharges have adverse prognostic significance. Additional parameters that would identify patients who are at increased risk of arrhythmias and appropriate ICD interventions would be of clinical value. Modern ICDs are relatively complex devices with a number of functions, including the possibility to perform noninvasive programmed stimulation (NIPS) with an implanted electrode located in the right ventricle.Methods/design: The aim of the study is to evaluate the usefulness of NIPS in determining the likelihood of life-threatening arrhythmic events in patients with ICD. The study will include 150 consecutive patients with an ICD implanted both for primary and secondary prevention, regardless of etiology, who are followed in the outpatient clinic of our center and do not meet the exclusion criteria. A 12-step St. George's Hospital NIPS protocol using ICD will be performed. The endpoint is to induce sustained ventricular arrhythmia (VT lasting more than 30 seconds or hemodynamically unstable VT/VF) or the end of the protocol. In case of serious and/or hemodynamically unstable heart rhythm disorders resistant to treatment with a low-energy antiarrhythmic pacing (ATP), the patient receives a short-term intravenous general anesthesia, and internal or external defibrillation is performed. Outpatient follow-up will be conducted during the pre-scheduled ICD control visits. An analysis of records of a registered memory device will be collected, a patient will be interviewed, and physical examination will be carried out. The follow-ups will be held every 3 months for 1 year. The primary endpoint of the follow-up will be appropriate intervention of ICD or sudden cardiac (arrhythmic) death; the secondary, appropriate ICD intervention, or death from cardiovascular causes; and the tertiary, appropriate ICD intervention, death or hospitalization for cardiovascular causes.Discussion: It is expected that appropriate ICD interventions during follow-up will occur more often in patients who had sustained ventricular arrhythmias induced during NIPS.Clinical Trials Registry: ClinicalTrials.gov, NCT02373306 , date of registration: 26 February 2015. [ABSTRACT FROM AUTHOR]

Key clinical message Short QT syndrome carries the risk for inappropriate therapies using transvenous ICD because of overdetection of the ample T wave. SQT syndrome may also benefit from subcutaneous ICD, although additional cases are needed to affirm the safety of such device in this setting. [ABSTRACT FROM AUTHOR]

An optimal control approach to a simplified reaction-diffusion system describing cardiac defibrillation is proposed that allows for joint optimization of shape and duration of defibrillation pulses. Within the framework, optimized multi-phasic pulses with low energy, short duration and/or low amplitude can be designed according to specific needs. The approach is based on a novel time optimal control formulation for the monodomain model, which takes into consideration the dynamical system properties of the uncontrolled equation. The highly complex dynamics requires a consistent discretization of first- and second-order information to guarantee effective optimization schemes leading to successful defibrillation. Numerical examples underline the efficiency of the proposed method. [ABSTRACT FROM AUTHOR]

Several well-designed and conducted randomized clinical trials (RCTs) have proven the survival benefit of implantable cardioverter defibrillators (ICDs). This benefit has been demonstrated in patients who survive a cardiac arrest due to a ventricular tachyarrhythmia or have sustained ventricular tachycardia not due to a transient or a reversible cause. The survival benefit of ICDs has also been shown in patients with significant systolic dysfunction (left ventricular ejection fraction (LVEF) ≤35%) due to ischemic or non-ischemic cardiomyopathy. The compelling evidence on the benefits of ICDs led the Centers for Medicare and Medicaid services (CMS) to cover secondary and primary prevention ICDs in Medicare beneficiaries. However, for primary prevention ICDs, CMS provides coverage with evidence development that requires clinicians to enter data on primary prevention ICD implants in Medicare beneficiaries into the National Cardiovascular Data Registry (NCDR) ICD Registry. [ABSTRACT FROM AUTHOR]

Key Clinical Message Patients with reversible cardiac impairment may be, at least temporarily, at high risk of SCD and may go unprotected for considerable time. A less-invasive definitive or bridge solution is the implantation of a subcutaneous cardioverter-defibrillator (S- ICD). The less invasiveness of this procedure ensures easy removal of the system without exposing the patient to the risk of complications. [ABSTRACT FROM AUTHOR]

The aim of this work is to develop a BPX preconditioner for the Bidomain model of electrocardiology. This model describes the bioelectrical activity of the cardiac tissue and consists of a system of a non-linear parabolic reaction–diffusion partial differential equation (PDE) and an elliptic linear PDE, modeling at macroscopic level the evolution of the transmembrane and extracellular electric potentials of the anisotropic cardiac tissue. The evolution equation is coupled through the non-linear reaction term with a stiff system of ordinary differential equations, the so-called membrane model, describing the ionic currents through the cellular membrane. The discretization of the coupled system by finite elements in space and semi-implicit finite differences in time yields at each time step the solution of an ill-conditioned linear system. The goal of the present study is to construct, analyze and numerically test a BPX preconditioner for the linear system arising from the discretization of the Bidomain model. Optimal convergence rate estimates are established and verified by two- and three-dimensional numerical tests on both structured and unstructured meshes. Moreover, in a full heartbeat simulation on a three-dimensional wedge of ventricular tissue, the BPX preconditioner is about 35% faster in terms of CPU times than ILU(0) and an Algebraic Multigrid preconditioner. [ABSTRACT FROM AUTHOR]

Recently, left ventricular assist devices (LVADs) have become a viable therapeutic approach as a bridge to cardiac transplantation, as well as destination therapy or as part of the bridge to recovery. In Japan, paracorporeal pneumatic devices are the only choice for such therapy, as implantable LVADs are not yet generally available due to device lag, which represents a serious problem in this field. Clinical trials of four different continuous-flow pumps, both axial and centrifugal flow types, were completed at about the same time, and two of those devices, DuraHeart and EVAHEART, have already been approved for use in Japan. Thus, reports of advanced treatment for severe heart failure with these devices are expected. The DuraHeart (Terumo Heart, Ann Arbor, MI, USA) and another device named the HeartWare (HeartWare Inc, Miami Lakes, FL, USA) are so-called third-generation devices, as they have achieved miniaturization and improvements in performance from the use of magnetic levitation. Based on our experiences from both clinical research and experimental use, we herein discuss the DuraHeart and HeartWare devices, with a focus on the clinical outcomes and management strategies. Because of the long waiting period for heart transplantation in Japan, these two devices are considered to have important roles in the near future for the treatment of severe heart failure, and a comprehensive strategy for LVAD therapy including such third-generation implantable devices is expected. [ABSTRACT FROM AUTHOR]

The benefit of implantable cardioverter-defibrillators (ICDs) remains controversial in elderly patients and may be attenuated by a greater risk of nonarrhythmic death. We examined the effect of age on outcomes after prophylactic ICD implantation. All patients with coronary artery disease or dilated cardiomyopathy implanted with an ICD for primary prevention of sudden cardiac death in 12 French medical centers were included in a retrospective observational study. The 5,534 ICD recipients were divided according to age: 18 to 59 years (n = 2,139), 60 to 74 years (n = 2,693), and ≥75 years (n = 702). Greater prevalences of coronary artery disease and atrial fibrillation at the time of implant were observed with increasing age (both p <0.0001). During a mean follow-up of 3.1 ± 2.0 years, the annual mortality rate increased with age: 3.1%per year for age 18 to 59 years, 5.7%per year for age 60 to 74 years, and 7.5% per year for age ≥75 years (p <0.001). Older age was independently associated with a greater risk of death (adjusted odds ratio 1.43, 95% confidence interval 1.14 to 1.80 for age 60 to 74 years; and adjusted odds ratio 1.65, 95% confidence interval 1.22 to 2.22 for age >75 years). Proportions of cardiac deaths (55.2%, 57.6%, and 57.0%, p = 0.84), including ICD-unresponsive sudden death (9.9%, 6.0%, and 10.6%, p = 0.08), and rates of appropriate ICD therapies were similar in the 3 age groups. Older age was independently associated with a higher rate of early complications and a lower rate of inappropriate therapies. In conclusion, older patients exhibited higher global mortality after ICD implantation for primary prevention, whereas rates of sudden deaths and of appropriate device therapies were similar across age groups. [ABSTRACT FROM AUTHOR]

The patient population benefitting from cardiac implantable electronic devices (CIEDs) is increasing. This study introduces a device annotation method that supports the consistent description of the functional attributes of cardiac devices and evaluates how this method can detect device changes from a CIED registry. We designed the Cardiac Device Ontology, an ontology of CIEDs and device functions. We annotated 146 cardiac devices with this ontology and used it to detect therapy changes with respect to atrioventricular pacing, cardiac resynchronization therapy, and defibrillation capability in a French national registry of patients with implants (STIDEFIX). We then analyzed a set of 6905 device replacements from the STIDEFIX registry. Ontology-based identification of therapy changes (upgraded, downgraded, or similar) was accurate (6905 cases) and performed better than straightforward analysis of the registry codes (F-measure 1.00 versus 0.75 to 0.97). This study demonstrates the feasibility and effectiveness of ontology-based functional annotation of devices in the cardiac domain. Such annotation allowed a better description and in-depth analysis of STIDEFIX. This method was useful for the automatic detection of therapy changes and may be reused for analyzing data from other device registries. [ABSTRACT FROM PUBLISHER]

A 56-year-old man with ischemic cardiomyopathy, a biventricular implantable cardioverter-defibrillator (ICD), and a left ventricular assist device (LVAD) developed a pocket hematoma and infection after an ICD generator change. The biventricular ICD was extracted, and the patient was given a full course of antibiotics. Because he had no indications for bradycardia pacing or biventricular pacing, he was implanted with a subcutaneous ICD under full anticoagulation. There was no interference in sensing or shock delivery from the ICD. The LVAD readings were unchanged during and after the procedure. The patient had an uneventful postoperative course, and both devices were functioning normally. To our knowledge, this is the first reported case of the implantation of a subcutaneous ICD in the presence of an LVAD. This report illustrates that both devices can be implanted successfully in the same patient. In addition, the subcutaneous ICD minimizes the risk of bloodstream infections, which can be fatal in patients who have life-supporting devices such as an LVAD. [ABSTRACT FROM AUTHOR]