Search

Background: Caspofungin is an echinocandin agent with fungicidal activity against candida species. We performed a double-blind trial to compare caspofungin with amphotericin B deoxycholate for the primary treatment of invasive candidiasis.Methods: We enrolled patients who had clinical evidence of infection and a positive culture for candida species from blood or another site. Patients were stratified according to the severity of disease, as indicated by the Acute Physiology and Chronic Health Evaluation (APACHE II) score, and the presence or absence of neutropenia and were randomly assigned to receive either caspofungin or amphotericin B. The study was designed to compare the efficacy of caspofungin with that of amphotericin B in patients with invasive candidiasis and in a subgroup with candidemia.Results: Of the 239 patients enrolled, 224 were included in the modified intention-to-treat analysis. Base-line characteristics, including the percentage of patients with neutropenia and the mean APACHE II score, were similar in the two treatment groups. A modified intention-to-treat analysis showed that the efficacy of caspofungin was similar to that of amphotericin B, with successful outcomes in 73.4 percent of the patients treated with caspofungin and in 61.7 percent of those treated with amphotericin B (difference after adjustment for APACHE II score and neutropenic status, 12.7 percentage points; 95.6 percent confidence interval, -0.7 to 26.0). An analysis of patients who met prespecified criteria for evaluation showed that caspofungin was superior, with a favorable response in 80.7 percent of patients, as compared with 64.9 percent of those who received amphotericin B (difference, 15.4 percentage points; 95.6 percent confidence interval, 1.1 to 29.7). Caspofungin was as effective as amphotericin B in patients who had candidemia, with a favorable response in 71.7 percent and 62.8 percent of patients, respectively (difference, 10.0 percentage points; 95.0 percent confidence interval, -4.5 to 24.5). There were significantly fewer drug-related adverse events in the caspofungin group than in the amphotericin B group.Conclusions: Caspofungin is at least as effective as amphotericin B for the treatment of invasive candidiasis and, more specifically, candidemia. [ABSTRACT FROM AUTHOR]

Background: Cardiac implantable electronic device (CIED) procedures can cause significant post-operative pain. Opioid use for post-operative pain is associated with risk of persistent use. The benefits of pectoral nerve blocks (PECs) have been established for other chest wall surgeries but adoption in electrophysiology has been limited., Objectives: To evaluate the efficacy of intraoperative ultrasound guided PECs performed at the time of CIED procedures by the implanting physician from within the device pocket., Methods: Patients undergoing a pectoral CIED procedure at 7 centers from 2022-2023 were included. Patients underwent intraoperative PECs and subcutaneous local anesthetic vs subcutaneous local anesthetic only at the discretion of the operator. Patients were prospectively evaluated for post-operative pain., Results: 610 patients (67±15 years old, 63% male) were enrolled and half (n=305) underwent PECs. Patients who underwent PECs were more likely to have a history of chronic pain (32 vs 11%, p<0.001). PECs was associated with lower pain scores in the 4 hours after the procedure (1.5±2.1 vs 4.5±2.5, p<0.001). Pain scores were not different after 24-hours (2.8±1.7 vs 3.1±2.2) and 2-weeks (0.9±1.4 vs 0.9±1.2). PECs patients were less likely to receive inpatient opioids (10 vs 48%, p<0.001) and to be discharged with an opioid prescription (15 vs 59%, p<0.001). In multivariable linear regression, PECs (p<0.001), age (p=0.002) and absence of chronic pain (p=0.009) were associated with lower acute post-operative pain., Conclusions: Intraoperative PECs can reduce post operative pain and opioid use. This procedure can be readily performed by the implanting physician from within the device pocket., (Copyright © 2024. Published by Elsevier Inc.)

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is an appealing alternative to transvenous ICD systems. However, data on indications for S-ICD explantations are sparse. The objective of this study was to assess the incidence and indications for S-ICD explantation at a large tertiary referral center. We conducted a retrospective study of all S-ICD explantations performed from 2014-2020. Data on demographics, comorbidities, implantation characteristics, and indications for explantation were collected. A total of 64 patients underwent S-ICD explantation during the study period. During that time, there were 410 S-ICD implantations at our institution, of which 53 (12.9%) were explanted with a mean duration from implant to explant of 19.7 ± 20.1 months. The mean age of the patients at explantation was 44.8 ± 15.3 years, and 42% (n = 27) were women. The indication for S-ICD implantation was primary prevention in 58% and secondary prevention in 42% of patients, respectively. The most common reason for explantation was infection (32.8%), followed by abnormal sensing (25%) and the need for pacing (18.8%). Those who underwent S-ICD explantation for pacing indications were significantly older (55.7 ± 13.6 vs. 42.3 ± 14.6 years, P = 0.005) with a wider QRS duration (111 ± 19 vs. 98 ± 19 ms, P = 0.03) at device implantation compared to patients who underwent explantation for other indications. The incidence of S-ICD explantation in a large tertiary practice was 12.9%. While infection was the indication for one-third of the explantations, a significant number of explantations were due to sensing abnormalities and the need for pacing. These data may have implications for patient selection for S-ICD implantation., Competing Interests: The authors report no conflicts of interest for the published content. This study was funded in part by the Mark Marchlinski EP Research & Education Fund., (Copyright: © 2022 Innovations in Cardiac Rhythm Management.)

Importance: Autonomic neuromodulation provides therapeutic benefit in ventricular tachycardia (VT) storm. Transcutaneous magnetic stimulation (TcMS) can noninvasively and nondestructively modulate a patient's nervous system activity and may reduce VT burden in patients with VT storm., Objective: To evaluate the safety and efficacy of TcMS of the left stellate ganglion for patients with VT storm., Design, Setting, and Participants: This double-blind, sham-controlled randomized clinical trial took place at a single tertiary referral center between August 2019 and July 2021. The study included 26 adult patients with 3 or more episodes of VT in 24 hours., Interventions: Patients were randomly assigned to receive a single session of either TcMS that targeted the left stellate ganglion (n = 14) or sham stimulation (n = 12)., Main Outcomes and Measures: The primary outcome was freedom from VT in the 24-hour period following randomization. Key secondary outcomes included safety of TcMS on cardiac implantable electronic devices, as well as burden of VT in the 72-hour period following randomization., Results: Among 26 patients (mean [SD] age, 64 [13] years; 20 [77%] male), a mean (SD) of 12.7 (10.3) episodes of VT occurred within the 24 hours preceding randomization. Patients had recurrent VT despite taking a mean (SD) of 2.0 (0.6) antiarrhythmic drugs (AADs), and 11 patients (42%) required mechanical hemodynamic support at the time of randomization. In the 24-hour period after randomization, VT recurred in 4 of 14 patients (29% [SD 47%]) in the TcMS group vs 7 of 12 patients (58% [SD 51%]) in the sham group (P = .20). In the 72-hour period after randomization, patients in the TcMS group had a mean (SD) of 4.5 (7.2) episodes of VT vs 10.7 (13.8) in the sham group (incidence rate ratio, 0.42; P < .001). Patients in the TcMS group were taking fewer AADs 24 hours after randomization compared with baseline (mean [SD], 0.9 [0.8] vs 1.8 [0.4]; P = .001), whereas there was no difference in the number of AADs taken for the sham group (mean [SD], 2.3 [0.8] vs 1.9 [0.5]; P = .20). None of the 7 patients in the TcMS group with a cardiac implantable electronic device had clinically significant effects on device function., Conclusions and Relevance: In this randomized clinical trial, findings support the potential for TcMS to safely reduce the burden of VT in the setting of VT storm in patients with and without cardiac implantable electronic devices and inform the design of future trials to further investigate this novel treatment approach., Trial Registration: ClinicalTrials.gov Identifier: NCT04043312.

Left ventricular assist devices (LVAD) produce electromagnetic interference (EMI) which can have implications when patients require cardiac implantable electronic devices. Leadless pacemakers have been successfully implanted in patients with Heartmate 2 and Heartmate 3 LVADs without evidence of EMI or device-to-device interaction. Here we report a case of a Heartmate 3 LVAD and Micra VR transcatheter pacing system interaction requiring device repositioning., (© 2021 Wiley Periodicals LLC.)

[Figure: see text].

Traditional rules of arrhythmia mechanisms may not apply in altered anatomical states such as heart transplantation. We present a case of a young man presenting with incessant tachycardia that violates routine electrocardiographic criteria for rhythm analysis. Meticulous attention to surgical techniques and anastomotic sites is crucial when approaching post-operative arrhythmias., (Copyright © 2021 Elsevier Inc. All rights reserved.)

A 12-lead electrocardiogram of a regular narrow complex tachycardia with electrocardiographic characteristics used to help elucidate the arrhythmia mechanism. ( Level of Difficulty: Intermediate. )., Competing Interests: This work was supported by the Mark Marchlinski EP Research and Education Fund. The author has reported he has no relationships relevant to the contents of this paper to disclose., (© 2021 The Authors.)

A 58-year-old man asymptomatic from the cardiovascular point of view and with no known relevant family history was found by transthoracic echocardiography to have apical hypertrophic cardiomyopathy (AHCM). His electrocardiogram (ECG) revealed prominent precordial R-waves, particularly in V3-V4 leads, and "giant" (>1.0 mV), inverted T-waves, previously associated with AHCM. ECGs recorded 17 and 13 years previously, did not disclose such abnormalities, as the ones of his current ECG. The presented case illustrates a potential role of serial ECGs (along with serial imaging testing) in detecting the development and progression of regional left ventricular hypertrophy in patients with AHCM, and probably in other hypertrophic cardiomyopathy phenotypes., (Copyright © 2018. Published by Elsevier Inc.)

Atrial fibrillation (AF) is associated with thrombus formation in the left atrial appendage and systemic embolic events including ischemic stroke. Cardiogenic thromboembolism can also occur in the absence of clinical AF as a result of various pathological conditions affecting the endocardium. The inconsistent temporal relation between AF and ischemic events has stimulated exploration for factors other than clinical AF that contribute to thromboembolism. These include subclinical AF, a thrombogenic atrial cardiomyopathy, and left atrial appendage dysfunction and embolism from other sources. In conclusion, thromboembolism during normal sinus rhythm is likely multifactorial, involving intertwined pathologic processes. Patients at risk, if accurately identified, could theoretically benefit from anticoagulation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: During ablation of the posterior wall (PW), luminal oesophageal temperature elevation (OTE) prompts attenuation of radiofrequency (RF) energy delivery to minimize oesophageal injury. This strategy on lesion efficacy is unknown. The goal of this study was to analyse the relationship between OTE and pulmonary vein reconnection (PVR)., Methods and Results: During the index antral pulmonary vein (PV) isolation procedure with an irrigated RF ablation catheter, OTE was detected with a multisensor oesophageal temperature probe. Posterior wall ablation did not exceed 25 W and was terminated when the temperature was ≥38.5°C. Patients undergoing redo procedures (n = 142) were studied for PW sites of PVR along 4 segments: left and right superior, and left and right inferior. Pulmonary vein reconnections had occurred in 51 of the 142 patients (36%), in 58 of 284 PV pairs (20%). Among these 58 reconnected pairs, 83% (n = 48) were along the PW. Oesophageal temperature elevation had occurred in 30 patients (59%). No difference in characteristics was seen between the patients with OTE (n = 30) and those without (n = 21). For superior segments, there was no interaction between the presence or absence of OTE and PVR. For inferior segments, there were more PVRs in the group with OTE: for the right-inferior segment, the PVR rate was 72% for OTE cases vs. 42% without (P = 0.04), and for the left-inferior segment, the PVR rate was 44% for OTE cases vs. 22.9% without (P = 0.12)., Conclusion: Pulmonary vein reconnections are predominantly posteriorly located. Along the right- and left-inferior PW segments, there was an association with elevated oesophageal temperature during the index procedure., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions please email: journals.permissions@oup.com.)

Background: The management of impalement penetrating brain injuries (IPBI) from non-missile objects is extremely challenging, especially when vascular structures are involved. Cerebral angiography is a crucial tool in initial evaluation to assess for vascular injury as standard non-invasive imaging modalities are limited by foreign body artifact, especially for metallic objects., Case Study: This study reports a case of an IPBI caused by a segment of steel rebar resulting in injury to the left jugular bulb and posterior temporal lobe. It describes the initial presentation, radiology, management and outcome in this patient and reviews the literature of similar injuries.

Object: The use of an intracranial stent requires dual antiplatelet therapy to avoid in-stent thrombosis. In this study, the authors sought to investigate whether the use of dual antiplatelet therapy is a risk factor for hemorrhagic complications in patients undergoing permanent ventriculoperitoneal (VP) shunt for hydrocephalus following aneurysmal subarachnoid hemorrhage (aSAH)., Methods: Patients were given 325 mg acetylsalicylic acid and 600 mg clopidogrel during the coil/stent procedure, and they were maintained on dual antiplatelet therapy with acetylsalicylic acid 325 mg daily and clopidogrel 75 mg daily during hospitalization and for 6 weeks posttreatment. Patients underwent placement of VP shunt at a later time during initial hospitalization, usually between 7 and 21 days following aSAH. Postoperative CT scans obtained in each study patient were reviewed for hemorrhages related to placement of the VP shunt., Results: A total of 206 patients were admitted to the University of Iowa Hospitals and Clinics with aSAH between July 2009 and October 2010. Thirty-seven of these patients were treated with a VP shunt for persistent hydrocephalus. Twelve patients (32%) had previously undergone stent-assisted coiling and were on dual antiplatelet therapy with acetylsalicylic acid and clopidogrel. The remaining 25 patients (68%) had undergone surgical clipping or aneurysm coiling and were not receiving antiplatelet therapy at the time of surgery. Four cases (10.8%) of new intracranial hemorrhages associated with VP shunt placement were observed. All 4 hemorrhages (33%) occurred in patients on dual antiplatelet therapy for stent-assisted coiling. No new intracranial hemorrhages were observed in patients not receiving dual antiplatelet therapy. The difference in hemorrhagic complications between the 2 groups was statistically significant (4 [33%] of 12 vs 0 of 25, p = 0.0075]). All 4 hemorrhages occurred along the tract of the ventricular catheter. Only 1 hemorrhage (1 [8.3%] of 12) was clinically significant as it resulted in occlusion of the proximal shunt catheter and required revision of the VP shunt. The patient did not suffer any permanent morbidity related to the hemorrhage. The remaining 3 hemorrhages were not clinically significant., Conclusions: This small clinical series suggests that placement of a VP shunt in patients on dual antiplatelet therapy may be associated with an increased, but low, rate of symptomatic intracranial hemorrhage. It appears that in patients who are poor candidates for open surgical clipping and have aneurysms amenable to stent-assisted coiling, the risk of symptomatic hemorrhage may be an acceptable trade-off for avoiding risks associated with discontinuation of antiplatelet therapy. The authors' results are preliminary, however, and require confirmation in larger studies.

The O-antigenic polysaccharide of Salmonella Mara O:39 (formerly Q) was investigated by sugar and methylation analyses, absolute configuration assignment, mass spectrometry and NMR spectroscopy. The experiments revealed an O-polysaccharide chain composed of the following linear tetrasaccharide repeating units with the structure: -->2)-alpha-L-Quip3NAc-(1-->3)-alpha-D-Manp-(1-->3)-alpha-L-Fucp-(1-->3)-alpha-D-GalpNAc-(1--> where alpha-L-Quip3NAc is the residue of 3-acetamido-3,6-dideoxy-alpha-L-glucopyranose. This repeating unit is the first published structure of the O-polysaccharide from 27 serotypes of Salmonella bacteria belonging to serogroup O:39 in the Kauffmann-White classification system.

We present a case of a 47-year-old woman suffering from Bourneville-Pringle disease and uterus cancer undergoing radical operation. Surgery was performed under general anaesthesia and went uneventfully.

Members of three classes of pyridinylimidazoles bind with varying affinities to CSBP (p38) kinase which is a member of a stress-induced signal transduction pathway. Based upon SAR and protein homology modeling, the pharmacophore and three potential modes of binding to the enzyme are presented. For a subset of pyridinylimidazoles, binding is shown to correlate with inhibition of CSBP kinase activity, whereas no significant inhibition of PKA, PKC alpha and ERK kinase activity is observed.