Laser assisted extraction of pacemaker and implantable defibrillator leads

OBJECTIVE: To analyze the results of laser-assisted extraction of permanent pacemaker and defibrillator leads. METHODS: We operated upon 36 patients, whose mean age was 54.2 years, and extracted 56 leads. The reasons for extracting the leads were as follows: infection in 19 patients, elective replacement in 13, and other causes in 4 patients. The mean time of catheter placement was 7.5±5.5 years. Forty-seven leads were from pacemakers, and 9 were from defibrillators. Thirty-eight leads were in use, 14 had been abandoned in the pacemaker pocket, and 4 had been abandoned inside the venous system. RESULTS: We successfully extracted 54 catheters, obtaining a 96.4% rate of success and an 82.1% rate for complete extraction. The 2 unsuccessful cases were due to the presence of calcium in the trajectory of the lead. The mean duration of laser light application was 123.0±104.5 s, using 5,215.2±4,924.0 pulses, in a total of 24.4±24.2 cycles of application. Thirty-four leads were extracted from the myocardium with countertraction after complete progression of the laser sheath, 12 leads came loose during the progression of the laser sheath, and the remaining 10 were extracted with other maneuvers. One patient experienced cardiac tamponade after extraction of the defibrillator lead, requiring open emergency surgery. CONCLUSION: The use of the excimer laser allowed extraction of the leads with a 96% rate of success; it was not effective in 2 patients who had calcification on the lead. One patient (2.8%) had a complication that required cardiac surgery on an emergency basis.

Predictors of Arrhythmic Events Detected by Implantable Loop Recorders in Renal Transplant Candidates

AbstractBackground:The recording of arrhythmic events (AE) in renal transplant candidates (RTCs) undergoing dialysis is limited by conventional electrocardiography. However, continuous cardiac rhythm monitoring seems to be more appropriate due to automatic detection of arrhythmia, but this method has not been used.Objective:We aimed to investigate the incidence and predictors of AE in RTCs using an implantable loop recorder (ILR).Methods:A prospective observational study conducted from June 2009 to January 2011 included 100 consecutive ambulatory RTCs who underwent ILR and were followed-up for at least 1 year. Multivariate logistic regression was applied to define predictors of AE.Results:During a mean follow-up of 424 ± 127 days, AE could be detected in 98% of patients, and 92% had more than one type of arrhythmia, with most considered potentially not serious. Sustained atrial tachycardia and atrial fibrillation occurred in 7% and 13% of patients, respectively, and bradyarrhythmia and non-sustained or sustained ventricular tachycardia (VT) occurred in 25% and 57%, respectively. There were 18 deaths, of which 7 were sudden cardiac events: 3 bradyarrhythmias, 1 ventricular fibrillation, 1 myocardial infarction, and 2 undetermined. The presence of a long QTc (odds ratio [OR] = 7.28; 95% confidence interval [CI], 2.01–26.35; p = 0.002), and the duration of the PR interval (OR = 1.05; 95% CI, 1.02–1.08; p < 0.001) were independently associated with bradyarrhythmias. Left ventricular dilatation (LVD) was independently associated with non-sustained VT (OR = 2.83; 95% CI, 1.01–7.96; p = 0.041).Conclusions:In medium-term follow-up of RTCs, ILR helped detect a high incidence of AE, most of which did not have clinical relevance. The PR interval and presence of long QTc were predictive of bradyarrhythmias, whereas LVD was predictive of non-sustained VT.

A and B mode ultrasonography in preoperative evaluation of lens and posterior segment of dogs eyes with cataract

Ultrasonography of the lens and posterior segment is an indispensable step in the preoperative evaluation of dogs with cataracts, since ophthalmoscopy is not feasible when there is opacification of the lens. This study evaluated the echographic conditions of cataractous lens and fundus of the eye in dogs affected by cataracts. The study was conducted in 30 dogs (56 eyes), 10 males and 20 females, with different types of cataracts at different stages of development. Echography in A and B modes, simultaneously, was carried out for the examination of the lens and posterior segment. The examinations revealed anterior cortical, posterior cortical and nuclear cataract in 12 eyes (21.4%), anterior cortical, posterior cortical, nuclear and posterior capsular in 23 eyes (41%), anterior cortical, posterior cortical and posterior capsular cataract in one eye (1.7%), anterior cortical and nuclear cataract in one eye (1.7%), anterior cortical, nuclear and posterior capsular cataract in five eyes (8.9%), and anterior cortical cataract in seven eyes (12.5%). Abnormal ultrasonographic alterations were observed in the posterior segment in 26 eyes evaluated (46.4%). Vitreal degeneration was detected in 12 eyes (21.4%), images of vitreal exudate or hemorrhage in seven eyes (12.5%), persistence of hyaloid artery in four eyes (7.1%) and lens subluxation in three eyes (5.3%). The results obtained reiterate the importance of ultrasonography in canine patients presented for cataract surgery given that alterations of the posterior segment are difficult to identify in a clinical examination when the lens is opacified.

Antioxidant status of dog aqueous humor after extracapsular lens extraction

We determined the antioxidant status of the aqueous humor after extracapsular lens extraction in 14 mongrel dogs weighing about 10 kg. The animals were examined by slit lamp biomicroscopy, applanation tonometry and indirect ophthalmoscopy. One eye was submitted to conventional extracapsular lens extraction and the other was used as control. Samples of aqueous humor were obtained by anterior chamber paracentesis before and at days 1, 2, 3, 7 and 15 after surgery. Total antioxidant status was determined as the capacity of aqueous humor to inhibit free radical generation by 2,2-azobis(2-amidopropane) chlorine. Ascorbic acid concentration was measured by HPLC with UV detection. Protein content was determined with the biuret reagent. Statistical analysis was performed by ANOVA followed by the Tukey-Kramer test. Protein concentration increased from 0.61 to 22 mg/ml 24 h after surgery. These levels were maintained and returned to normal at day 7. Total antioxidant capacity was reduced from 50 to about 30 min until day 3 and at day 7 it was equal to control. Ascorbic acid levels were reduced from 252 to about 110 µM and then returned to control values at day 15. Considering the importance of ascorbic acid concentration in aqueous humor for the maintenance of the antioxidant status of the anterior segment of the eye, the decrease of antioxidant defenses suggests that the surgical procedures promote an oxidative stress condition in the eye.

Efficacy of cognitive behavioral therapy in reducing psychiatric symptoms in patients with implantable cardioverter defibrillator: an integrative review

This article is a systematic review of the available literature on the benefits that cognitive behavioral therapy (CBT) offers patients with implanted cardioverter defibrillators (ICDs) and confirms its effectiveness. After receiving the device, some patients fear that it will malfunction, or they remain in a constant state of tension due to sudden electrical discharges and develop symptoms of anxiety and depression. A search with the key words “anxiety”, “depression”, “implantable cardioverter”, “cognitive behavioral therapy” and “psychotherapy” was carried out. The search was conducted in early January 2013. Sources for the search were ISI Web of Knowledge, PubMed, and PsycINFO. A total of 224 articles were retrieved: 155 from PubMed, 69 from ISI Web of Knowledge. Of these, 16 were written in a foreign language and 47 were duplicates, leaving 161 references for analysis of the abstracts. A total of 19 articles were eliminated after analysis of the abstracts, 13 were eliminated after full-text reading, and 11 articles were selected for the review. The collection of articles for literature review covered studies conducted over a period of 13 years (1998-2011), and, according to methodological design, there were 1 cross-sectional study, 1 prospective observational study, 2 clinical trials, 4 case-control studies, and 3 case studies. The criterion used for selection of the 11 articles was the effectiveness of the intervention of CBT to decrease anxiety and depression in patients with ICD, expressed as a ratio. The research indicated that CBT has been effective in the treatment of ICD patients with depressive and anxiety symptoms. Research also showed that young women represented a risk group, for which further study is needed. Because the number of references on this theme was small, further studies should be carried out.

Lectins for the detection of IgM antibodies to T. gondii in the diagnosis of acute toxoplasmosis by immunofluorescence test

Lectins were labeled with fluorescein and tried as conjugates in the immunofluorescence (IP) test for the detection of IgM antibodies to T. gondii, in the diagnosis of acute toxoplasmosis. This approach was an attempt to find alternative reagents for anti-human IgM fluorescent conjugates (AHIgMFC), which contain quite frequently anaibcdies to toxoplasma, as contaminants, due to natural T. gondii infections among animals used for imunization. Lentil (Lens culinaris) lectin fluorescence conjugates (LcFC) provided most satisfactory results. The evaluation of LcFC carried out in a total of 179 sera from patients with acute and chronic toxoplasmosis, with non-related infections or healthy subjects, gave high values of relative efficiency, co-positivity and co-negativity indices, respectively 0.989, 0.969 and 1.000, in reference to the conventional AHIgMFC. Moreover, three batches of LcFC successively prepared gave reproducible test results. The advantage of LcFC as an alternative reagent for the serodiagnosis of acute toxoplasmosis is supported by practical aspects of its preparation.

Ventricular arrhythmias in Chagas disease

Sudden death is one of the most characteristic phenomena of Chagas disease, and approximately one-third of infected patients develop life-threatening heart disease, including malignant ventricular arrhythmias. Fibrotic lesions secondary to chronic cardiomyopathy produce arrhythmogenic substrates that lead to the appearance and maintenance of ventricular arrhythmias. The objective of this study is to discuss the main clinical and epidemiological aspects of ventricular arrhythmias in Chagas disease, the specific workups and treatments for these abnormalities, and the breakthroughs needed to determine a more effective approach to these arrhythmias. A literature review was performed via a search of the PubMed database from 1965 to May 31, 2014 for studies of patients with Chagas disease. Clinical management of patients with chronic Chagas disease begins with proper clinical stratification and the identification of individuals at a higher risk of sudden cardiac death. Once a patient develops malignant ventricular arrhythmia, the therapeutic approach aims to prevent the recurrence of arrhythmias and sudden cardiac death by the use of implantable cardioverter defibrillators, antiarrhythmic drugs, or both. In select cases, invasive ablation of the reentrant circuit causing tachycardia may be useful. Ventricular arrhythmias are important manifestations of Chagas cardiomyopathy. This review highlights the absence of high-quality evidence regarding the treatment of ventricular arrhythmias in Chagas disease. Recognizing high-risk patients who require specific therapies, especially invasive procedures such as the implantation of cardioverter defibrillators and ablative approaches, is a major challenge in clinical practice.

Taxonomic relevance of seed and seedling morphology in two Amazonian species of Entada (Leguminosae)

We carried out a comparative morphological study to evaluate the taxonomic value of seed and seedling traits of Entada polystachya and E. simplicata (Leguminosae, Mimosoideae, Mimoseae). Seeds of both species were collected from wild populations in Roraima State, Brazil. Our results show consistent quantitative and qualitative differences between these species regarding their seeds and seedlings. Testa fracture lines, funiculus impression, lens characters, radicle shape and length, and cotyledon lobes length, seedling morphology group, number of pinnae at first node, and hypocotyl length permit a straightforward distinction of E. polystachya from E. simplicata, supporting a recent treatment of the latter taxon as a distinct species, endemic to Roraima State, northern Amazonia, Brazil.

Cardiopulmonary resuscitation: update, controversies and new advances

Cardiopulmonary arrest is a medical emergency in which the lapse of time between event onset and the initiation of measures of basic and advanced support, as well as the correct care based on specific protocols for each clinical situation, constitute decisive factors for a successful therapy. Cardiopulmonary arrest care cannot be restricted to the hospital setting because of its fulminant nature. This necessitates the creation of new concepts, strategies and structures, such as the concept of life chain, cardio-pulmonary resuscitation courses for professionals who work in emergency medical services, the automated external defibrillator, the implantable cardioverter-defibrillator, and mobile intensive care units, among others. New concepts, strategies and structures motivated by new advances have also modified the treatment and improved the results of cardiopulmonary resuscitation in the hospital setting. Among them, we can cite the concept of cerebral resuscitation, the application of the life chain, the creation of the universal life support algorithm, the adjustment of drug doses, new techniques - measure of the end-tidal carbon dioxide levels and of the coronary perfusion pressure - and new drugs under research.

Correlations Between the Collagen Content of the Human Left Ventricular Myocardium, Measured by Biochemical and Morphometric Methods

OBJECTIVE: To assess, in myocardium specimens obtained from necropsies, the correlation between the concentration of hydroxyproline, measured with the photocolorimetric method, and the intensity of fibrosis, determined with the morphometric method. METHODS: Left ventricle myocardium samples were obtained from 45 patients who had undergone necropsy, some of them with a variety of cardiopathies and others without any heart disease. The concentrations of hydroxyproline were determined with the photocolorimetric method. In the histologic sections from each heart, the myocardial fibrosis was quantified by using a light microscope with an integrating ocular lens. RESULTS: A median of, respectively, 4.5 and 4.3 mug of hydroxyproline/mg of dry weight was found in fixed and nonfixed left ventricle myocardium fragments. A positive correlation occurred between the hydroxyproline concentrations and the intensity of fibrosis, both in the fixed (Sr=+0.25; p=0.099) and in the nonfixed (Sr=+0.32; p=0.03) specimens. CONCLUSION: The biochemical methodology was proven to be adequate, and manual morphometry was shown to have limitations that may interfere with the statistical significance of correlations for the estimate of fibrosis intensity in the human myocardium.

Stratification of the Risk of Sudden Death in Nonischemic Heart Failure

Despite significant therapeutic advancements, heart failure remains a highly prevalent clinical condition associated with significant morbidity and mortality. In 30%-40% patients, the etiology of heart failure is nonischemic. The implantable cardioverter-defibrillator (ICD) is capable of preventing sudden death and decreasing total mortality in patients with nonischemic heart failure. However, a significant number of patients receiving ICD do not receive any kind of therapy during follow-up. Moreover, considering the situation in Brazil and several other countries, ICD cannot be implanted in all patients with nonischemic heart failure. Therefore, there is an urgent need to identify patients at an increased risk of sudden death because these would benefit more than patients at a lower risk, despite the presence of heart failure in both risk groups. In this study, the authors review the primary available methods for the stratification of the risk of sudden death in patients with nonischemic heart failure.

Autologous Transplantation of Bone Marrow Adult Stem Cells for the Treatment of Idiopathic Dilated Cardiomyopathy

Background:Morbimortality in patients with dilated idiopathic cardiomyopathy is high, even under optimal medical treatment. Autologous infusion of bone marrow adult stem cells has shown promising preliminary results in these patients.Objective:Determine the effectiveness of autologous transplantation of bone marrow adult stem cells on systolic and diastolic left ventricular function, and on the degree of mitral regurgitation in patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III.Methods:We administered 4,54 x 108 ± 0,89 x 108 bone marrow adult stem cells into the coronary arteries of 24 patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III. Changes in functional class, systolic and diastolic left ventricular function and degree of mitral regurgitation were assessed after 3 months, 6 months and 1 year.Results:During follow-up, six patients (25%) improved functional class and eight (33.3%) kept stable. Left ventricular ejection fraction improved 8.9%, 9.7% e 13.6%, after 3, 6 and 12 months (p = 0.024; 0.017 and 0.018), respectively. There were no significant changes neither in diastolic left ventricular function nor in mitral regurgitation degree. A combined cardiac resynchronization and implantable cardioversion defibrillation was implanted in two patients (8.3%). Four patients (16.6%) had sudden death and four patients died due to terminal cardiac failure. Average survival of these eight patients was 2.6 years.Conclusion:Intracoronary infusion of bone marrow adult stem cells was associated with an improvement or stabilization of functional class and an improvement in left ventricular ejection fraction, suggesting the efficacy of this intervention. There were no significant changes neither in left ventricular diastolic function nor in the degree of mitral regurgitation.

Teratoma do ovario com estruturas semelhando cristalino

Em uma mulher, brasileira, de côr parda, com 48 anos de idade, morta com tuberculose do peritoneo, tuberculose peribronquica do lóbo superior do pulmão esquerdo e tuberculose cronica fibrosa do apice de ambos os pulmões, a necropsía revelou a existencia de um teratoma no ovario esquerdo. O ovario, pouco aumentado de volume, é constituído por duas porções de tamanho sensivelmente egual, de consistencia firme, separadas, em sua superficie, por profundo sulco. Ao córte, tem a aparencia de tecido fibroso em cuja espessura existem numerosos pequenos cistos. Ao microscopio, os cistos são revestidos por epitelio descontinuo, despertando grande interesse o seu conteúdo. Este é formado por fibras e células com morfologia semelhante ás do cristalino. Sugerimos a possibilidade de que, no presente teratoma (Teratoma lentifer, de lens, lentis: cristalino, e ferre: produzir) haja participado, de modo dominante, o ectodérme, e mesmo uma região circumscrita do ectodérme, a qual corresponderia aquela emque se desenvolve, habitualmente, a placa do cristalino (« Linsenplatte »). A multiplicidade e a presença exclusiva de estruturas figurando saculos cristalinicos (« Linsensäckchen ») são argumentos a favor de uma origem de ponto restrito do ectodérme, destinado a desenvolvimento posterior especifico, qual o da formação do cristalino.

Aspectos parasitários observados no local inoculado com esporozoitos de Plasmodium Gallinaceum

The following is a summary of the studies made on the development of Plasmodium gallinaceum sporozoites inoculated into normal chicks. Initially large numbers of laboratory reared Aëdes aegypti were fed on pullets heavily infected with gametocytes. Following the infectious meal the mosquitoes were kept on a diet of sugar and water syrup until the appearance of the sporozoites in the salivary glands. Normal chicks kept in hematophagous arthropod proof cages were then inoculated either by bite of the infected mosquitoes or by subcutaneous inoculations of salivary gland suspensions. By the first method ten mosquitoes fed to engorgement on each normal chick and were then sacrificed immediately afterwards to determine the sporozoite count. By the second method five pairs of salivary glands were dissected out at room temperature, triturated in physiological saline and inoculated subcutaneously. The epidermis and dermis at the site of inoculation were excised from six hours after inoculation to forty eight hours after appearance of the parasites in the blood stream and stretched out on filter paper with the epithelial surface downward. The dermis was then curretted. Slides were made of the scrapings consisting of connective tissue and epithelial cells of the basal layers which were fixed by metyl alcohol and stained with Giemsa for examination under the oil immersion lens. Skin fragments removed from normal chicks and from regions other than the site of inoculation in the infected chicks were used as controls. In these, only the normal histological aspect was ever encountered. In the biopsy made at the earliest period following inoculation clearly defined elongated forms with eight or more chromatin granules arranged in rosary formation were found. The author believes these to be products of the sporozoite evolution. Search for transition stages between these forms and sporozoites is planned in biopsies to be taken immediately following inoculation and at given intervals up to the six hour period. 1.) 6 and 12 hour periods. The bodies referred to above found in the first period in great abundance, apparently in proportion to the large numbers of sporozoites inoculated, were perceptibly reduced in numbers in the second period. 2.) 18 hour period. Only one biopsy was examined. This presented a binuclear body shown in Fig. 1, having a more or less hyaline protoplasm staining an intense blue and a narrow vacuole delimiting the cell boundaries. The two chromatin grains were quite large presenting a clearly defined nuclear texture. 3.) 24 hour period. A similar body to that above (Fig. 2) was seen in the only preparation examined. 4.) 60 hour period. The exoerythrocytic schizonts were found more frequently from this period onward. Several such were found no longer to contain the previously described vacuoles (Fig. 3). 5.) 84 hour period. Cells bearing eight or more schizonts were frequently encountered here. That these are apparently not bodies in process of division may be seen in Fig. 4. From this time onward small violet granules similar to volutine grains appeared constantly in the schizont nucleus and protoplasm. These are definitely not hemozoin. The above observations fell within the incubation period as repeated examinations of the peripheral and visceral blood were negative. Exoery-throcytic parasites also were never encountered in the viscera at this time. Exoerythrocytic schizonts searched for at site of inoculation 1, 24 and 48 hours after the incubation period were present in large number at all three times with apparent tendency to diminish as the number within the blood stream increased. Many of them presented the violet granules mentioned above. The appearance of the chromatin and the intensity of staining of the protoplasm varied from body to body which doubtless corresponds to the evolutionary stage of each. This diversity of aspect may frequently be seen in the parasites of the same host cell (Fig. 5.). These findings lend substance to the theory that the exoerythrocytic forms are the link between the sporozoites and the pigmented parasites of the red blood corpuscles. The explanation of their continued presence in the organism after infection of the blood stream takes place and their presence in cases infected by the inoculation blood does not come within the scope of this work. Large scale observations shortly to be undertaken will be reported in more detail particularly observations on the first evolutionary phases of the sporozoite within the organism of the vertebrate host.

An ocellar "pupil" that does not change with light intensity, but with the insect age in Triatoma infestans

The simple eyes (ocelli) of recently emerged adult Triatoma infestans exhibit a narrow elongated "pupil", surrounded by a ring of brown-reddish pigment, the "iris". This pupil does not respond to changes in the illumination, but varies in size after the imaginal ecdysis. This change corresponds, internally, with the growth of the corneal lens and the associated retina up to an age of about 20 days. This has not been previously observed in an insect. The use of this characteristic for recognising young adults of this species is suggested.