Inflammation, periodontitis, and coronary heart disease.
Explore the source record for details and available documents.
Coronary Disease↗
Biomedical subjects
J Ruskin
Publications and source records attributed to J Ruskin.
Long-term infection rates associated with the pectoral versus abdominal approach to cardioverter- defibrillator implants.
Infection is an uncommon (0% to 6.7%) but serious complication after implantable cardioverter-defibrillator (ICD) implantation. All ICD primary implants, replacements, or revisions performed at the Massachusetts General Hospital between April 1983 and May 1999 were reviewed. A total of 21 ICD-related infections (1.2%) were identified among 1,700 procedures affecting 1.8% of the 1,170 patients who underwent a primary implant, a generator change, or a revision of their systems. The mean follow-up time was 35 +/- 33 months. Of the 959 patients with long-term follow-up, 19 of the 584 patients (3.2%) with abdominal and 2 of the 375 patients (0.5%) with pectoral systems developed ICD-related infections (p = 0.03). There was no significant difference between the infection rate among the 959 primary ICD implants and the 447 replacements or system revisions. Only 5 of the patients (24%) had systemic signs of infection, including fever (T>100.5) and elevated white blood count >12,000. Cultures from the wound revealed staphylococcal species in 16 patients (76%). Nineteen patients were treated with removal of the entire ICD system in addition to intravenous antibiotics for 2 to 4 weeks. A decrease in the incidence of ICD-related infection has occurred since the advent of transvenous pectoral systems. The main organism responsible for ICD infection is Staphylococcus. The mainstay of ICD infection management consists of complete removal of the entire implanted system.
Antibiotic Prophylaxis↗
Diagnostic quiz #38. Case no. 1. Central giant cell granuloma.
Explore the source record for details and available documents.
Adolescent↗
Thromboembolic complications of cardiac radiofrequency catheter ablation: a review of the reported incidence, pathogenesis and current research directions.
INTRODUCTION: Radiofrequency catheter ablation (RFCA) has become established as an effective therapy for the treatment of many cardiac tachyarrhythmias. The principle limitation of conventional RFCA continues to be the risk of thromboembolism. This risk is of particular concern for the ongoing development of the catheter maze procedure for the treatment of atrial fibrillation, which currently involves the creation of extensive linear lesions in the left atrium. METHODS AND RESULTS: A Medline search of the literature over the last ten years was performed. Focused review of the reported thromboembolic complications of RFCA indicates an overall incidence of 0.6%. However, the risk is increased when ablation is performed in the left heart (1.8% to 2%) and for ventricular tachycardia (2.8%). It is of concern that intravenous heparin and the use of temperature feedback to control radiofrequency current do not eliminate the risk of thromboembolic events. CONCLUSION: The thromboembolic complications of RFCA are not eliminated by the treatment of intravenous herapin and mode of temperature control during ablation. Potential approaches to further reduce the risk of thromboembolism include the adjunctive administration of specific inhibitors of platelet activation and aggregation, intraprocedural intracardiac echocardiography, irrigated radiofrequency ablation, and cryoablation catheter systems.
Anticoagulants↗
Rate control and sinus rhythm maintenance in atrial fibrillation: national trends in medication use, 1980-1996.
BACKGROUND: Little is known about national patterns of pharmacological treatment of atrial fibrillation, in particular, use of medications for ventricular rate control and for restoration and maintenance of sinus rhythm. METHODS: We analyzed 1555 visits by patients with atrial fibrillation to randomly selected office-based US physicians included in National Ambulatory Medical Care surveys conducted in 1980, 1981, 1985, and 1989 through 1996. To determine national trends, we evaluated the proportion of atrial fibrillation visits with reported use of rate control medications (digoxin and antiarrhythmics in classes II and IV) and sinus rhythm medications (classes IA, IC, and III). RESULTS: The use of rate control agents decreased from 79% of atrial fibrillation visits in 1980-1981 to 62% in 1994-1996. Declining use was noted for both digoxin (76% in 1980-1981 to 53% in 1994-1996) and beta-blockers (19%-13%). After their introduction, the use of verapamil hydrochloride and diltiazem hydrochloride increased to 15% of atrial fibrillation visits in 1994-1996. Sinus rhythm agent use decreased from 18% of visits in 1980-1981 to 4% in 1992-1993 and then rose to 13% in 1994-1996. The use of class IA agents declined from 18% in 1980-1981 to 3.5% in 1992-1993 and then increased to 8% in 1994-1996. Quinidine remained the most widely used sinus rhythm medication, despite its declining share of this category. Newly available sotalol hydrochloride and amiodarone hydrochloride were used in 3.6% of visits in 1994-1996. CONCLUSIONS: Despite changes in the treatment of atrial fibrillation, digoxin remains the dominant rate control medication. Medications for sinus rhythm maintenance are not widely used. Quinidine use declined prominently in the 1980s, possibly because of concerns about proarrhythmic effects. The use of sinus rhythm agents, however, is now rising.
Adrenergic beta-Antagonists↗
Nonpharmacologic therapies for atrial fibrillation.
The limited efficacy and proarrhythmic risks of antiarrhythmic drug therapies for atrial fibrillation have led to the exploration of a wide spectrum of alternative therapeutic approaches. The diversity of the approaches is warranted by the current absence of a single procedure that can safely and effectively cure atrial fibrillation. The interventional therapies that are currently under most active development include implantable atrial defibrillator therapy, prophylactic atrial pacing in combination with drug therapy, multisite regional pace-entrainment of atrial fibrillation by rapid pacing, atrial surgery, and catheter ablation for atrial fibrillation. The current limitations of these procedures include: (1) for the implantable atrial defibrillator--patient tolerance of low energy shocks and early recurrence of atrial fibrillation; (2) for prophylactic pacing-limited efficacy in a small proportion of the total atrial fibrillation population; (3) for multisite regional pace-entrainment--lack of proved efficacy and difficulty in the expansion and merging of the entrained regions; (4) for atrial surgery--highly invasive as a stand-alone procedure; and (5) for catheter ablation-lack of proved long-term efficacy, shortcomings of currently available technology, and risk of thromboembolic stroke. It is evident that more basic and clinical research as well as technologic innovation are needed. However, it is likely that some of these new therapies, possibly in combination with antiarrhythmic drug therapy, will offer considerable clinical benefit to selected patients with symptomatic atrial fibrillation.
Atrial Fibrillation↗
The treatment of patients with infected implantable cardioverter-defibrillator systems.
OBJECTIVE: The purpose of this study was to evaluate the treatment of patients with infected implantable cardioverter-defibrillator systems. METHODS: Retrospective analysis was done of the cases of 21 patients treated for implantable cardioverter-defibrillator infection during an 11-year period. RESULTS: Of 723 cardioverter-defibrillator implantations (550 primary implants, 173 replacements), nine (1.2%) were complicated by early postoperative device-related infections. Late infections developed in two patients 19 and 22 months, respectively, after implantation. Ten other patients were transferred to our institution for treatment of cardioverter-defibrillator infection. The time from implantation to overt infection was 2.2 +/- 1.3 months, excluding the two late infections. The responsible organisms were Staphylococcus aureus (9), Staphylococcus epidermidis (6), Streptococcus hemolyticus (1), gram-negative bacteria (3), Candida albicans (1), and Corynebacterium (1). All patients were treated with intravenous antibiotic drugs. Total system removal was done in 15 patients and partial removal in 2; in 4, the cardioverter-defibrillator system was not explanted. There were no perioperative deaths. A new implantable cardioverter-defibrillator system was reimplanted in 7 patients after 2 to 6 weeks of antibiotic therapy. Ten patients were treated without reimplantation (2 arrhythmia operation, 8 antiarrhythmic drugs). Four patients (3 patients without explantation and 1 with partial system removal) were treated with maintenance long-term antibiotic therapy. During a mean follow-up of 21 +/- 2.8 months, no patient had clinical recurrence of infection. One patient treated with antiarrhythmic drugs without system reimplantation died suddenly. CONCLUSIONS: Infections that involve implantable cardioverter-defibrillator systems can be safely managed by removing the entire system with reimplantation after intravenous antibiotic therapy. In selected patients in whom the risk for system explantation is high and anticipated life expectancy is short, long-term antibiotic therapy to suppress low-virulence infections may represent an acceptable alternative.
Adult↗
Mucormycosis of the vulva following bone marrow transplantation.
Mucormycosis is uncommon in bone marrow transplant recipients. Primary cutaneous mucor in any setting is unusual. It may mimic necrotizing bacterial infection particularly in patients with severe neutropenia. We report a case of vulvar mucormycosis in a transplant recipient. Diagnosis depends on histological identification of fungal hyphae invading tissue and blood vessels.
Adult↗
Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals.
Antimicrobial resistance results in increased morbidity, mortality, and costs of health care. Prevention of the emergence of resistance and the dissemination of resistant microorganisms will reduce these adverse effects and their attendant costs. Appropriate antimicrobial stewardship that includes optimal selection, dose, and duration of treatment, as well as control of antibiotic use, will prevent or slow the emergence of resistance among microorganisms. A comprehensively applied infection control program will interdict the dissemination of resistant strains.
Anti-Bacterial Agents↗
Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals.
Antimicrobial resistance results in increased morbidity, mortality, and costs of health care. Prevention of the emergence of resistance and the dissemination of resistant microorganisms will reduce these adverse effects and their attendant costs. Appropriate antimicrobial stewardship that includes optimal selection, dose, and duration of treatment, as well as control of antibiotic use, will prevent or slow the emergence of resistance among microorganisms. A comprehensively applied infection control program will interdict the dissemination of resistant strains.
Anti-Bacterial Agents↗
Clarithromycin and ethambutol with or without clofazimine for the treatment of bacteremic Mycobacterium avium complex disease in patients with HIV infection.
OBJECTIVE: To compare the efficacy of two- and three-drug regimens for treating Mycobacterium avium complex (MAC) bacteremia in patients with AIDS. DESIGN: Randomized open-label clinical trial. SETTING: Outpatient HIV specialty centers' clinics. PATIENTS: A total of 106 adults with AIDS and MAC bacteremia. INTERVENTIONS: Patients were treated with clarithromycin 500 mg twice daily and ethambutol 800-1,000 mg daily and were randomized to receive clofazimine 100 mg daily or no clofazimine. MAIN OUTCOME MEASURES: Quantitative blood MAC cultures, symptoms, adverse reactions and survival. RESULTS: Patients randomly assigned to three drugs had significantly higher baseline colony counts of MAC in blood than patients receiving two drugs. The proportion of patients becoming culture-negative was 65% in the two-drug group and 54% in the three-drug group. The median time to negative culture was 58 days for patients in the two-drug and 63 days for the three-drug group. At the last visit during treatment, the mean reduction in colony forming units/ml of MAC in blood was 1.8 log10 for the two-drug group and 2.3 log10 for the three-drug group. Improvement in fever and night sweats was reported by 87 and 89% of the two-drug patients and 84 and 86% of the three-drug patients. During the study, 38% of two-drug patients and 61% of three-drug patients died (P = 0.032), and time to death was shorter in patients treated with three drugs (P = 0.012). In a multivariate analysis, both assignment to clofazimine and high baseline colony counts of MAC bacteremia were significantly associated with death (P < 0.05). CONCLUSION: The addition of clofazimine to a regimen of clarithromycin and ethambutol for MAC bacteremia in AIDS patients does not contribute to clinical response and is associated with higher mortality.
AIDS-Related Opportunistic Infections↗
A population pharmacokinetic model of trimethoprim in patients with pneumocystis pneumonia, made with parametric and nonparametric methods.
A population pharmacokinetic model of intravenously and orally administered trimethoprim in patients with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia has been made using a parametric iterative two-stage Bayesian and a nonparametric expectation maximization computer program. When good information was present in the serum level data, both methods obtained similar results. With the nonparametric expectation maximization program, the median apparent rate constant for absorption (Ka) was 1.602 hr-1, median slope (Ks) of the relationship between creatinine clearance and elimination was 0.001168 hr-1, median apparent volume of distribution (Vs) was 1.058 l/kg, and median fraction of oral dose absorbed (Fa) was 0.955. These results permit dosage individualization adjusted to body weight and renal function to achieve chosen serum level peak and trough goals. Peak goals of 9 ug/ml and trough goals of 5 ug/ml appear reasonable for most patients in this population, and should permit most to complete an effective course of therapy with a reduced risk for treatment-terminating hematologic toxicity. However, therapeutic goals should always be selected based on each patient's apparent need for the drug and the risk of toxicity that is justifiably acceptable to obtain the expected benefits of the drug.
AIDS-Related Opportunistic Infections↗
Catheter ablation for atrial fibrillation.
Catheter ablation for atrial fibrillation is based upon the critical mass of fibrillation hypothesis and aims to compartmentalize the atria by the creation of linear lesions, thereby reducing the amount of contiguous myocardium available for the propagation of multiple activation wavefronts. Early attempts at creating right atrial linear lesions with conventional catheter tip technology to treat patients with chronic and paroxysmal atrial fibrillation yielded disappointing results. Although more efficacious, the creation of extensive left atrial lesions has been associated with a high rate of thromboembolic stroke despite the administration of heparin and use of temperature feedback to control radiofrequency energy. Approaches to reduce the risk of stroke include: the creation of more continuous and effective right atrial lesions with linear array catheter technology and thereby reduce the requirement for left atrial ablation; the assessment of adjuvant pharmacological agents to inhibit platelet aggregation; guidance of radiofrequency energy delivery by intracardiac echo; assessment of transvenous cryotherapy as an alternative to radiofrequency energy in order to reduce endocardial disruption; and development of minimally invasive surgical approaches to left atrial epicardial ablation.
Animals↗
Dose-response relation between terfenadine (Seldane) and the QTc interval on the scalar electrocardiogram: distinguishing a drug effect from spontaneous variability.
The primary goal of this investigation was to describe the effect of terfenadine on the QT interval corrected for heart rate (QTc) of the scalar electrocardiogram (ECG). The design was double-blind, four-period crossover, dose escalation, which involved 28 normal healthy volunteers and 28 patients with stable cardiovascular disease. At baseline, the normal subjects had a mean QTc interval of 407 msec, whereas the patients with cardiovascular disease had a mean QTc interval of 417 msec (p<0.01). The largest increase in mean QTc on terfenadine was 24 msec in a normal subject and 28 msec in a patient with cardiovascular disease. The longest average QTc observed was 449 msec and 501 msec in any normal subject and patient with cardiovascular disease, respectively. Compared to baseline, terfenadine 60 mg twice daily is associated with a QTc increase of 6 msec in normal subjects and a 12 msec increase in patients with cardiovascular disease (p<0.01 vs baseline; p>0.05 when the two populations were compared). Although the QTc increase from baseline are statistically significant, the magnitude of the spontaneous variability in QTc in the same patients is much greater. Because 40 ECGs were obtained while taking placebo in each participant, the spontaneous variability in QTc interval with placebo was also described. Only one of the 28 normal subjects had a mean baseline QTc=440 msec, yet 14 of the 28 normal subjects had at lease one of the 40 placebo ECGs with a QTc=440 msec. The 28 patients with cardiovascular disease had a mean QTc at baseline of 417 msec; yet 20 of 28 had at lease one ECG on placebo with a QTc interval = 440 msec. On the average, the QTc fluctuated 56 msec in each patient during placebo administration. From the observed placebo variability, we calculated that an increase in QTc of=35 msec while receiving drug therapy is likely to represent a drug effect at the 95% confidence interval.
Aged↗
Rapid oral desensitization to trimethoprim-sulfamethoxazole (TMP-SMZ): use in prophylaxis for Pneumocystis carinii pneumonia in patients with AIDS who were previously intolerant to TMP-SMZ.
Trimethoprim-sulfamethoxazole (TMP-SMZ) is the drug of choice as prophylaxis for Pneumocystis carinii pneumonia in patients with AIDS. However, adverse reactions ascribed to TMP-SMZ are common in such patients. We previously described a rapid method of oral TMP-SMZ desensitization in patients with AIDS and varying degrees of intolerance to the drug. To assess the feasibility, safety, and long-term clinical utility of our desensitization protocol, we retrospectively studied 22 consecutive patients who underwent desensitization. Prior to the procedure each of the study subjects had exhibited moderate to severe reactions to TMP-SMZ. Desensitization was successfully completed in 19 (86%) of the patients. The three patients for whom desensitization failed experienced chills and/or vomiting that resolved promptly with symptomatic therapy. One of the 19 patients was unavailable for long-term follow-up. Of the remaining 18 patients, three discontinued taking TMP-SMZ within 2 weeks of desensitization because of macular rash and fever. The other 15 (71%) of the evaluable patients tolerated both desensitization and subsequent prophylaxis and took TMP-SMZ for a mean of 14 months (in some cases, for as long as 41 months). None had P. carinii pneumonia while receiving TMP-SMZ. These results indicate that most patients who are presumed to be TMP-SMZ-intolerant can be rapidly desensitized with oral TMP-SMZ and subsequently receive the drug for protracted periods as effective prophylaxis for P. carinii pneumonia.
Acquired Immunodeficiency Syndrome↗
Identifying Pneumocystis carinii in pleural effusions.
Explore the source record for details and available documents.
Humans↗
Data monitoring in the cardiac arrhythmia suppression trial.
OBJECTIVE: This report discusses practical aspects of data monitoring in a clinical trial which stopped ahead of schedule due to adverse findings. DESIGN: A review of the considerations and decisions made by the data-monitoring committee of the Cardiac Arrhythmia Suppression Trial (CAST), a randomized, double-blind clinical trial. PATIENTS: CAST consisted of men and women with a recent myocardial infarction, asymptomatic or minimally symptomatic ventricular arrhythmias, and reduced left ventricular ejection fraction. INTERVENTIONS: In CAST, 3 antiarrhythmic agents, encainide, flecainide, and moricizine, were compared against placebo. MAIN OUTCOME MEASURES: The main outcome measures in CAST were arrhythmic death and total mortality. RESULTS: CAST found the 3 agents to be harmful. Encainide and flecainide were stopped first. Subsequently, moricizine was discontinued ahead of schedule. CONCLUSIONS: The complexity of the study design and a midcourse protocol modification raise several data-monitoring issues not previously discussed. These include how to handle apparently dramatic yet unexpected results, the need for flexibility in modifying study design and goals, and the conflict between existing study data and both conventional wisdom and medical practice.
Anti-Arrhythmia Agents↗
Cardiac arrest.
Explore the source record for details and available documents.
Anti-Arrhythmia Agents↗