Electromagnetic interference of an implantable loop recorder by commonly encountered electronic devices.

Electromagnetic interference of pacemaker systems has been well established and can lead to an inappropriate function of these devices. Recently, an implantable loop recorder (ILR) (REVEAL, Medtronic Inc.) has been introduced to evaluate the possible arrhythmic etiology of patients with recurrent syncope. We evaluated the interference of this device in two patients with implantable ILR and in three nonimplanted ILRs with four electromagnetic sources: cellular phones (GSMs), electronic article surveillance systems (EASs), metal detector gates (MDGs), and magnetic resonance imaging (MRI). The GSM did not affect appropriate function of the ILR whereas radiofrequency (RF) EAS could interfere with normal function in implanted and nonimplanted systems. The MDG had no influence on ILR function. The magnetic field induced by the MRI resulted in an irreversible error in one nonimplanted ILR. Therefore, although interference between electromagnetic sources and ILRs appears to be rare in our study, physicians should be aware of possible malfunctioning of these devices.

Usefulness of echocardiography to predict inappropriate atrial sensing in single-lead VDD pacing.

Reliable atrial sensing is the prerequisite for restoration of atrioventricular synchrony in patients with single-lead VDD pacing systems. To determine echocardiographic variables associated with inappropriate atrial sensing, 21 consecutive patients with symptomatic second- or third-degree AV block and normal sinus node function were studied. Prior to implantation echocardiographic measurements of end-systolic and end-diastolic dimensions and volumes of the right atrium and right ventricle were performed. All patients underwent implantation of a Medtronic Thera VDD(d) pacemaker with a bipolar Medtronic Capsure electrode. A minimal amplitude of the unfiltered atrial electrocardiogram of > or =0.5 mV was required for permanent lead position and the atrial sensitivity was programmed below the lowest recorded value. Appropriate atrial sensing (atrial triggered ventricular paced complexes/total number of ventricular paced complexes) was assessed during 24-hour Holter monitoring and treadmill exercise testing 3 to 6 weeks after implantation. Inappropriate atrial sensing (<95% correct atrial synchronization during Holter registration and/or <97.5% during exercise testing) was present in nine patients. Right atrial volumes and the right ventricular end-diastolic volume was significantly higher, as compared to patients without inappropriate sensing (12 patients). The right atrial and diastolic volumes had the highest correlation with correct atrial sensing r = 0.83, P<0.0001). Using a postdefined cut-off value of > or =80 mL for the end-diastolic right atrial volume, sensitivity and specificity for inappropriate sensing was 100% and 92%, respectively. These findings show that preimplant echocardiography can identify patients with inappropriate sensing during VDD pacing, in whom DDD pacing should be considered.

One-year vestibular and balance outcomes of Oklahoma City bombing survivors.

This multisite investigation assessed subjective, behavioral, and objective balance function in 30 blast survivors. Subjects with vertigo, dizziness, or imbalance were screened (n = 6) or evaluated (n = 27) during 1 year. Tests included a questionnaire, electronystagmography (ENG), and computerized dynamic posturography (CDP). Ninety-seven percent of subjects were located inside a building during the blast, and 63 percent of subjects experienced dysequilibrium within 48 hours. Forty-three percent of symptoms could not be attributed to head injury. Sixty percent of subjects had abnormal ENG and/or CDP; ENG abnormalities mostly were peripheral or nonlocalizing, whereas CDP patterns were "vestibular," "surface dependent," and "physiologically inconsistent." At 1-year postblast, 55 percent of initially abnormal CDP results were normal, and 72 percent of subjects said symptoms were unchanged or occurred intermittently. A serial, test battery approach is recommended to assess symptoms. Blast-related dysequilibrium had clinically significant manifestations and should be considered a valid component of aural blast injury.

One-year audiologic monitoring of individuals exposed to the 1995 Oklahoma City bombing.

This longitudinal study evaluated subjective, behavioral, and objective auditory function in 83 explosion survivors. Subjects were evaluated quarterly for 1 year with conventional pure-tone and extended high-frequencies audiometry, otoscopic inspections, immittance and speech audiometry, and questionnaires. There was no obvious relationship between subject location and symptoms or test results. Tinnitus, distorted hearing, loudness sensitivity, and otalgia were common symptoms. On average, 76 percent of subjects had predominantly sensorineural hearing loss at one or more frequencies. Twenty-four percent of subjects required amplification. Extended high frequencies showed evidence of acoustic trauma even when conventional frequencies fell within the normal range. Males had significantly poorer responses than females across frequencies. Auditory status of the group was significantly compromised and unchanged at the end of 1-year postblast.

Pediatric eighth cranial nerve schwannoma without evidence of neurofibromatosis.

Schwannomas of the eighth cranial nerve are rare in children. We report a 4 10/12 - year-old girl with no evidence of neurofibromatosis who presented with facial droop. Radiographic studies revealed a large cerebellopontine angle tumor. At surgery, the tumor was attached to the eighth cranial nerve and histologically was a schwannoma. This is the youngest reported case of unilateral eighth cranial nerve schwannoma in a patient without the stigmata of neurofibromatosis.

Pacing-induced left ventricular dysfunction. Relationship with coronary perfusion.

In a patient admitted with symptomatic complete heart block, a DDD pacemaker was implanted. Prior to implantation, echocardiography showed normal left ventricular function. Shortly after implantation, acute congestive heart failure developed with extensive regional hypo- and akinetic segments in the anteroseptal, anterolateral and apical region. Subsequent perfusion imaging with methoxyisobuticeisonitrite (MIBI) at rest demonstrated hypoperfusion in the same regions while coronary angiography showed normal epicardial coronary vessels. Thus, impaired regional coronary flow can be associated with cardiac stimulation, inducing marked deterioration of left ventricular function.

Ejection fraction improvement by beta-blocker treatment in patients with heart failure: an analysis of studies published in the literature.

Because ejection fraction (EF) is one of the most important predictors of survival in patients with left ventricular (LV) dysfunction and because Packer showed a large reduction in mortality figures with carvedilol, in contrast to former studies with bisoprolol and metoprolol, we investigated if this difference in survival may be related to a difference in improvement of LV function by different beta-blockers. We searched the MEDLINE database and all reference lists of articles obtained through the search for the relation between beta-blocker treatment and improvement in EF. Forty-one studies met the criteria and we added two of our own studies. Four hundred and fifty-eight patients were treated with metoprolol with a mean follow-up of 9.5 months and a mean increase in EF of 7.4 EF units. One thousand thirty patients were treated with carvedilol with a mean follow up of 7 months and a mean increase in EF of 5.7 EF units. One hundred ninety-nine patients were treated with bucindolol with a mean follow-up of 4 months and a mean increase in EF of 4.6 EF units. Several small studies with nebivolol, atenolol, and propranolol were also studied and, when combined, the mean increase in EF was 8.6 EF units. When patients with idiopathic and ischemic cardiomyopathies were compared, the average increase in EF units was 8.5 vs. 6.0, respectively. The use of beta-blocker treatment in heart failure patients, irrespective of the etiology, improved LV function in almost all studies and it appears that the differences among beta-blockers and among etiologies is small and probably insignificant. However, there is a difference in survival rate when the various beta-blockers are compared, suggesting that mechanisms other than improvement of LV function by beta-blockers are responsible for the difference in survival.

Human offset auditory brainstem response: effects of stimulus acoustic ringing and rise-fall time.

Offset auditory brainstem response (ABR) traditionally has been thought to be an artifactual response elicited by stimulus acoustic ringing. Additionally, offset ABR's sensitivity to stimulus rise-fall time has been associated with concurrent changes in acoustic ringing. The present study tested the validity of offset ABR by recording the response in 40 young, normal-hearing adults using tone burst stimuli with varying degrees of acoustic ringing and various rise-fall times. Stimuli were computer-generated 10-ms tone bursts of 500 and 2000 Hz. In Experiment 1, offset ABR was recorded using stimuli with no acoustic ringing, normal ringing, and excessive ringing. Rise-fall time was held constant at 0.5 ms. In Experiment 2, rise-fall time was manipulated in a stimulus with no ringing. In Experiment 3, only rise time was manipulated in a no-ringing stimulus, while fall time was held constant at 0.5 ms. Reliable offset ABRs were recorded for all degrees of acoustic ringing, including the "no-ringing' condition. Offset ABR was sensitive to rise and fall times, and was elicited best with a 500-Hz stimulus. The results indicate that offset ABR is a real response and not an artifact produced by acoustic ringing.

Motivation and methods for manipulating acoustic ringing of earphones.

Transient acoustic stimuli are used for generating auditory evoked responses (AERs). Common transducers do not accurately reproduce transient stimuli, since the transducer diaphragm oscillates at its resonant frequency at the abrupt initiation or termination of a stimulus. These oscillations are called "acoustic ringing." This paper discusses methods for reducing and canceling acoustic ringing, and describes one method, a systems approach, in detail. It also delineates one method for enhancing acoustic ringing. The methods described provide effective techniques for empirical study of the effects of acoustic ringing on AERs or for any application requiring accurate transduction of a transient stimulus.

Value and limitations of exercise stress testing to predict the functional results of coronary artery bypass grafting.

To assess the value of exercise stress testing to predict the functional result of revascularization, 90 patients were evaluated by coronary angiography and exercise testing pre and postoperatively. Patients were classified on the basis of the postoperative angiogram in a group with successful surgery and a group with unsuccessful surgery. The predictive accuracy positive of ST segment depression to detect unsuccessful surgery was 67% The predictive accuracy negative was 61%. The best predictor of unsuccessful surgery was residual angina pectoris after revascularization with predictive value positive and negative of 85% and 60%, respectively. Thus exercise stress testing has limited value to accurately predict the degree of revascularization.

Comparison of Etymotic insert and TDH supra-aural earphones in auditory brainstem response measurement.

There are few systematic comparisons of Etymotic ER-3A insert earphones versus supra-aural earphones in auditory brainstem response (ABR) measurement. We compared ER-3A insert earphones and two types of supra-aural earphones (TDH-39P and TDH-49P) in a group of normal hearing adults. Acoustic analyses revealed spectral and temporal differences among earphones. Behavioral and ABR thresholds to click stimuli were slightly elevated with the ER-3A compared to the TDH earphones. The ER-3A earphones produced a latency delay, relative to the TDH earphones, that varied from about 0.8 to 1.0 msec, and increased at lower stimulus intensity levels. In addition, ABR wave I amplitude was significantly reduced with the ER-3A earphone. Based on these data, we recommend collection of normative data with the ER-3A earphones prior to their use in ABR measurement.

Issues surrounding MDI formulation development with non-CFC propellants.

Reformulation of metered-dose inhalers (MDIs) without the use of chlorofluorocarbon (CFC) propellants presents numerous obstacles because there are no alternative propellants that can serve as immediate replacements for pharmaceutical use. Hydrofluorocarbons (HFCs), hydrochlorofluorocarbons (HCFCs) and hydrocarbons (HCs) are all under consideration as possible alternatives for CFC propellants. However, no single propellant or combination of propellants has been identified with all of the physical-chemical properties of CFCs. Based on their zero ozone depletion potentials, relatively low global warming potentials, non-flammabilities, densities, and vapor pressures, HFA-134a and HFA-227 are the most attractive replacement propellants identified to date. Yet, their use in MDIs will still require: (1) identification of a metering valve with propellant and formulation-compatible gaskets, (2) use of current suspending agents at levels much lower than in present MDIs or identification (and characterization) of new suspending agents, and (3) modification of existing manufacturing technologies. Demonstration of acceptable final product stability, safety and efficacy will be necessary prior to submission to worldwide registration authorities.

Interaural attenuation using etymotic ER-3A insert earphones in auditory brain stem response testing.

Click interaural attenuation (IA) was measured behaviorally and with the auditory brain stem response (ABR) in two unilaterally deaf adults with Etymotic ER-3A insert earphones, and TDH-39P and TDH-49P supraaural earphones. Stimulus crossover for each set of earphones was also determined with pure-tone audiometry. Pure-tone results agreed with previous research, showing that the ER-3A provided substantially greater IA than the supraaural earphones, particularly for low frequencies. For click stimuli, behavioral and ABR results revealed only modest, if any, improvement in IA with the ER-3A relative to the supraaural earphones. The results of this study suggest that while the ER-3A earphones provide a clear IA advantage for behavioral pure-tone audiometry, they do not eliminate the need for contralateral masking of click stimuli in ABR testing.

Moisture sorption kinetics for water-soluble substances. I: Theoretical considerations of heat transport control.

A model based on heat transport control was developed to describe the uptake of water on a deliquescent solid in an atmosphere of pure water vapor. The model assumes the presence of a saturated liquid film on the surface of the solid. The decrease in the vapor pressure of water over the surface, brought about by the colligative effect of solid dissolved in the liquid film, is effectively offset by the increase in temperature of the film (and the solid) caused by the heat released on condensation of the water vapor. The thermal transients die out quickly and a steady-state analysis is valid. At steady state the temperature of the liquid film (and solid) is that temperature at which the vapor pressure of water above the saturated solution is equal to the chamber pressure. Consequently, water uptake occurs at a rate that depends on the heat flux away from the surface. The water uptake rate, W'h, is constant at a given relative humidity and is described by an equation of the form W'h = (C + F) . ln (RHi/RHo), where C and F are conductive and radiative coefficients, RHi the chamber relative humidity, and RHo the relative humidity at and above which continuous water uptake (deliquescence) occurs. The model contains no adjustable parameters and can thus be directly tested against experimental results.

Moisture sorption kinetics for water-soluble substances. II: Experimental verification of heat transport control.

The rates of water sorption as a function of relative humidity for water-soluble substances exhibiting deliquescence have been measured in an atmosphere of pure water vapor. The substances studied included a series of alkali halides, choline halides, and sugars. The results were compared with a theoretical model, previously described, which relates the rate of water uptake to the transport of heat produced during the process away from the surface. Taking into account the heat of water vapor condensation, heat of solution, and heat of hydration, when hydration occurs, the model allows excellent a priori prediction of water uptake rates as a function of relative humidity.

Moisture sorption kinetics for water-soluble substances. III: Theoretical and experimental studies in air.

As an extension of the model of heat transport control developed for the kinetics of water sorption by water-soluble substances from an atmosphere of pure water vapor, equations have been developed to account for limitations of diffusion on mass transport of water vapor when air is present. Although the inability to determine the vapor diffusion layer thickness prevents using these equations to predict sorption behavior a priori, minimum water sorption rates can be calculated by assuming a diffusion layer thickness equal to the sample chamber radius. Combining heat transport and mass transport produces equations which describe very well the observed sorption by three water-soluble salts in one atmosphere of air. As in the absence of air, sorption rates are predicted and observed to be constant at a given atmospheric relative humidity.