Left Bundle Branch Area Pacing From a Femoral Approach in a Patient Without Superior Access.

Limited venous access and lateral left ventricular scar are impediments to traditional cardiac resynchronization therapy. We present a case where placement of an implantable cardioverter-defibrillator from a femoral approach while using left bundle branch area pacing led to clinical improvement. (Level of Difficulty: Intermediate.).

Low lateral thoracic site for cardiac implantable electronic device implantation: A viable alternative in patients with limited access options after infected device extraction.

BACKGROUND: Device reimplantation after extraction because of cardiac implantable electronic device (CIED) infection in pacemaker-dependent patients can be challenging in individuals with limited access options. OBJECTIVE: The purpose of this study was to describe a straightforward, low lateral thoracic implantation technique for patients with a patent axillary vein but unavailable bilateral pectoral sites. METHODS: Nine pacemaker-dependent patients (mean age 70 ± 13 years, 7 male) who underwent CIED extraction and low lateral thoracic reimplantation in whom bilateral pectoral sites were unavailable were included in the study. RESULTS: Extraction was performed a median of 10 (interquartile range [IQR] 8-13) days before CIED reimplantation (4 dual-chamber, 3 single-chamber, 2 cardiac resynchronization therapy). The new generator was implanted in the low lateral thoracic region ipsilateral to the extracted generator in 7 patients (78%) and contralateral in 2 patients (22%), via a subcutaneous pocket in 6 (67%) and submuscular pocket in 3 (33%). Median procedure duration was 85 (IQR 61-116) minutes, median fluoroscopy time was 7.2 (IQR 5.7-10.9), minutes and median fluoroscopy exposure was 26.0 (IQR 10.0-110.5) mGy. No acute complications occurred. Over median follow-up of 92 (IQR 31-131) days, 1 patient experienced right atrial lead dislodgment (122 days postimplantation) requiring lead revision. No patients experienced recurrent device infection. CONCLUSION: In pacemaker-dependent patients with limited prepectoral and vascular access options, a low lateral thoracic implantation site is a viable alternative to surgical epicardial or femoral pacing systems. This simple implantation technique is a safe and effective option in selected patients who require a single-chamber, dual-chamber, or biventricular pacemaker or implantable cardioverter-defibrillator.

Patient knowledge and perception of upper respiratory infections, antibiotic indications and resistance.

BACKGROUND AND OBJECTIVE: The misuse of antibiotics is not a harmless practice; rather, it can render future antibiotic treatments ineffective. This study looked to determine patient knowledge and perception of upper respiratory infections and indicated treatment. METHODS: The authors developed and administered a questionnaire to 98 patients visiting affiliated family medicine clinical sites. Participants were selected randomly, either while sitting in the waiting room, or after being seen by the clinician. RESULTS: While more than half the respondents recognized that treatment for colds did not require antibiotics, 70% erroneously indicated that viruses require antibiotic treatment. Additionally, almost 90% of respondents thought that yellow nasal discharge or coughing up yellow mucous requires antibiotic treatment. It was interesting to note that 95% of patients reported satisfaction when advised by their physician that antibiotic treatment wasn't necessary, even if they initially thought they needed antibiotics. CONCLUSIONS: Primary care providers have the greatest opportunity to curb inappropriate antibiotic use by both prescribing appropriately and educating their patients about proper antibiotic use when indicated.

Co-processing of organic fraction of municipal solid waste and primary sludge--stabilization and disinfection.

Batch mesophilic digesters were fed a mixture of the organic fraction of municipal solid waste (OF-MSW) and primary sludge (PS), and operated under non-mixing condition at a 30-day influent mass retention time. The reactors were started in a slurry mode and brought to the target level of 26-30% total solids in about 3 months from start. Two feed characteristics, the level of PS solids in the feed, and the particle size of the OF-MSW, were the variables used to determine their effect on methane production during digester operation. Higher biodegradable volatile solid reductions and methane yields matched increased fractions of primary sludge in the feed (5%, 10%, and 15% as dry solids). Incomplete digestion, limited to fermentation, took place in reactors that did not receive primary sludge. The particle size did not have any effect on specific weight of the feed but the amount of primary sludge did. Addition of vitamins and micronutrients to the inhibited reactors did not stimulate methane production, which narrowed the range of possible causes to the lack of available macronutrients, namely nitrogen. On the other hand, possible un-ionized ammonia (NH3) inhibition of reactors fed with the highest primary sludge-amended feed hindered organic conversion rates. Elimination of pathogenic microorganisms from the high-solids residue via long-term storage, followed by low-dose lime disinfection, was also investigated. Storage alone reduced fecal coliform and Salmonella sp. bacteria to below detection, but bacterial spores of anaerobic Clostridium perfringens survived. Subsequent liming of the residue caused irreversible inactivation of the spores because of high pH and, possibly, free ammonia (NH3) inherent to sludge.

The effect of the menstrual cycle on acne.

Acne is a common disease with an underlying hormonal basis; however, there has never been a study to determine the ways in which the different stages of the menstrual cycle affect acne in women. Four hundred female participants, aged 12 to 52 years, were questioned whether their acne got worse before, during, or after their menstrual period and also asked whether it was unrelated to the menstrual period. Their age, severity of acne, ethnicity, and oral contraceptive use were also recorded. Overall 177 of 400 (44%) of those interviewed experienced premenstrual flares of their acne. Severity of acne, ethnicity, and oral contraceptive use did not affect the premenstrual flare rate. Women older than 33 years had a higher rate of premenstrual flares relative to women aged 20 to 33 years (P =.03 by chi(2) analysis). We concluded that almost half of all women experience premenstrual flares of their acne. Premenstrual flares may be more common in older women.

Epidermal growth factor disrupts gap-junctional communication and induces phosphorylation of connexin43 on serine.

Growth factors regulate cellular proliferation and differentiation by activating plasma membrane tyrosine kinase receptors and triggering a cascade of events mediated by intracellular signaling proteins. The mechanism underlying growth factor modification of cellular functions, such as gap-junctional communication (gjc), has not been established clearly. Addition of epidermal growth factor (EGF) to T51B rat liver epithelial cells resulted in the rapid activation of EGF receptor tyrosine kinase activity followed by a transient dose-dependent disruption of gjc. This change did not result from the gross disturbance of membrane gap junction plaques as measured by immunofluorescence microscopy, but instead correlated with markedly elevated phosphorylation of the connexin43 (cx43) gap junction protein, a profound shift to predominantly phosphorylated forms of cx43, and the appearance of a novel phosphorylated cx43 protein. These changes in cx43 phosphorylation involved only serine residues. On restoration of gjc, these alterations in cx43 phosphorylation reverted to the pre-EGF treatment state. Both events were inhibited by the serine/threonine protein phosphatase inhibitor, okadaic acid. Therefore, unlike the case for pp60v-src, EGF-induced disruption of gjc is not associated with tyrosine phosphorylation of cx43, but instead may result from phosphorylation of cx43 by activated intracellular signaling serine protein kinase(s).

Effects of central administration of morphine on renal function in conscious rats.

Systemic administration of morphine in rats produces an anti-natriuretic effect that is at least partially dependent on renal nerves. The present studies were carried out in order to assess the renal response to central administration of morphine. Male Sprague-Dawley rats were surgically prepared with arterial, venous and bladder cannulas. In addition, a guide cannula was placed into the lateral ventrical and secured to the surface of the skull. Experiments were carried out at least 3 days after surgery. Renal clearance measurements were 30 min each. After a basal period, morphine sulfate (4 micrograms/4 microliters) or vehicle was injected into the lateral cerebral ventricle. Two clearance measurements were obtained, followed by central administration of naloxone HCl (4 micrograms/4 microliters) or vehicle and two more clearance periods. Morphine administration had no effect on blood pressure or heart rate but caused a sharp reduction in sodium excretion (3200 +/- 958 vs 970 +/- 158 nEq/100 g/min in period 5; P less than .05). This response was reversed by the addition of naloxone (3280 +/- 583 nEq/100 g/min in period 5; P less than .05). Furthermore, morphine had no effect on renal plasma flow and glomerular filtration rate. Naloxone increased the renal plasma flow and glomerular filtration rate in morphine-treated rats, whereas it had no effect in controls. It is concluded that central administration of morphine in conscious rats enhances renal tubular sodium reabsorption by an opiate receptor-dependent mechanism.

Abdominal angina and mesenteric insufficiency.

Chronic bowel ischemia is not uncommon. If it is considered in the differential diagnosis of gastrointestinal disorders, it can be corrected surgically. In selected cases symptomatic relief can be achieved, and thus high mortality and morbidity can be prevented.