Gradually increasing impedance in patients with pacemakers and implantable defibrillators: a watchful waiting strategy

Funding Acknowledgements Type of funding sources: None. Introduction Pacing impedance measurements are important in the surveillance of pacemaker and implantable cardioverter/defibrillator (ICD) devices. Whereas sudden changes in impedances can reflect lead fracture or isolation defects, gradually increasing impedances are thought to occur because of calcifications at the endomyocardial interface. In many cases, these leads are replaced prophylactically but this has not been studied systematically. Purpose We aimed to identify the outcome of right ventricular (RV) electrodes with high impedances that were left active in this single center study. Methods All patients in the electronic patient database were screened for impedances >1200Ohms. 41,201 individual recordings led to 207 individual patients. 161 patients were excluded from the analysis due to sudden impedance increase, temporarily high impedances or wrong entry. Of the remaining 46 patients, baseline characteristics as well as pacing impedance, sensing values, pacing thresholds, and shock impedance in case of ICDs were recorded. Results There were 17 pacemaker and 29 ICD patients, 68 ± 15 years old, 70% were male. Glomerular filtration rate at baseline was 81 ± 22 ml/min/1.73m2. Baseline RV impedance was 597 ± 123Ohms. During follow-up impedances increased to 1875 ± 682Ohms (p < 0,001). Pacing thresholds increased from 0,6 ± 0,4V to 3,0 ± 1,9V (p < 0,001). Sensing remained stable. The median time from implant to impedance rise >1000Ohms was 5,5 (3,4-7)years and median follow-up thereafter 2,4 years (1,2-4,2). During follow-up, no intervention was performed for 33 leads (72%). No events occurred. 13 leads (28%) were replaced , 9 prophylactically (mostly because of ICD advisory leads), 3 because of high pacing thresholds and high percentage pacing and one lead because of noise oversensing, probably unrelated as it occurred 7 years after impedance increase. Conclusions A watchful waiting strategy appears to be a safe option for patients with ICDs and pacemakers with low percentage pacing. As impedance increase cannot be used for surveillance for imminent lead fracture, other means such as short interval counts and non-sustained oversensing have to be employed and should be combined with remote monitoring.

Prevalence and time course of elevated serum levels of liver enzymes in otherwise healthy Thai infants with breast milk jaundice: a cohort study

BackgroundNeonatal jaundice and elevated levels of liver enzymes are found in infants with breast milk jaundice (BMJ).ObjectivesTo determine the prevalence and duration of elevated serum levels of liver enzymes in Thai infants with BMJ.MethodsWe conducted a prospective study of Thai infants with BMJ, excluding those with pathological causes of jaundice. We measured the serum levels of total bilirubin (TB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and γ-glutamyl transferase (GGT); followed infants with elevated levels; and estimated the time for levels to become normal using Kaplan–Meier analysis.ResultsWe included 42 infants (median age: 17.5 days) with BMJ, and elevated serum levels of at least 1 enzyme were found in 27 (64%) infants. We excluded 4 (10%) infants because they did not continue to be exclusively breastfed, 17 (40%) were lost to follow-up, and 21 (50%) completed the study. We found that 19 (45%) of the 42 infants had elevated GGT, 11 (26%) had elevated ALT, and 9 (21%) each had elevated AST and ALP levels. The median time for enzyme levels to normalize was 291 days (95% confidence interval [CI], 109.8 to 472.2) for ALT, 240 days (95% CI, 139.0 to 340.9) for AST, 184 days (95% CI, 4.4 to 363.6) for ALP, 120 days (95% CI, 74.6 to 164.5) for TB, and 63 days (95% CI, 61.44 to 64.6) for GGT. Infants were otherwise healthy during the follow-up.ConclusionThe prevalence of elevated serum levels of liver enzymes in Thai infants was unexpectedly high, but the levels became normal spontaneously despite continued breastfeeding, which endorses a “watchful waiting” strategy in managing asymptomatic infants with BMJ.

Neck and supraclavicular lymphadenopathy secondary to 9-valent human papillomavirus vaccination

We present two clinical cases of lymphadenopathy after vaccination with the human papillomavirus (HPV) 9-valent vaccine: an asymptomatic 11-year-old boy with inferior cervical and supraclavicular lymphadenopathy, and a 13-year-old girl who presented with lymphadenopathy. In both cases, medical history was unremarkable and there was no recent infection, or other clinical findings. Both adolescents had received the HPV 9-valent vaccine in the previous week. In the first case, blood tests, ultrasonography and biopsy were performed, while in the second, a watchful waiting strategy was adopted. In both cases, the lymphadenopathy resolved spontaneously. The boy received the second dose of the vaccine 6 months later and lymphadenopathy reappeared. The Naranjo scale was applied, classifying the events as definite (in the case of the boy) and probable (girl) adverse drug reactions. The vaccine is safe, but recognising this minor adverse event is important to prevent unnecessary investigation and reduce patient and parental anxiety.

Laxative co-medication and changes in defecation patterns during opioid use

Introduction Opioid-induced constipation is a clinically relevant side effect and a cause of potentially avoidable drug-related hospital admissions. Objectives To describe the presence of laxative co-medication, the reasons for not starting laxatives and to evaluate changes in stool patterns of opioid initiators. Methods In this observational study community pharmacists evaluated the availability of laxative co-medication in starting opioid users and registered reasons for non-use. Two opioid initiators per pharmacy were invited to complete questionnaires (‘Bristol stool form scale’ and ‘Rome III Diagnostic Questionnaire for the Adult Functional Gastrointestinal Disorders’) on their defecation prior to and during opioid use. Descriptive statistics and Chi square tests were used to analyse reasons for non-use of laxatives and changes in defecation patterns. Results Eighty-one pharmacists collected data from 460 opioid initiators. Of those, 344 (74.8%) used laxatives concomitantly. Main reason not to use laxatives was that either prescribers or patients did not consider them necessary. Sixty-seven (89.3%) of the 75 opioid starters with two questionnaires completed were not constipated at opioid start. Eleven of them (16%) developed constipation during opioid use (Chi square p=0.003). At follow-up within laxative users 10.6% were constipated compared to 20.7% in subjects without laxatives. Conclusion One in four opioid starters did not dispose of laxative co-medication, mainly because they were not considered necessary by either the prescriber or the patient. The prevalence of constipation doubled during opioid use. A watchful waiting strategy for the use of laxative co-medication might include a monitoring of defecation patterns with validated questionnaires.

Postoperative Longitudinal Outcomes in Patients with Residual Disc Fragments after Percutaneous Endoscopic Lumbar Discectomy

Background: Residual disc fragments are observed on immediate postoperative magnetic resonance imaging (MRI) in 2.8–15% of patients after percutaneous endoscopic lumbar discectomy (PELD). Considering the known postoperative longitudinal outcomes in patients with residual disc tissue, a ‘watchful waiting’ strategy may be preferable to immediate re-operation in patients with asymptomatic residual disc material. Objectives: The aim of the present study was to compare the longitudinal clinical outcomes between PELD patients in whom the complete removal of disc fragments was achieved (complete group) and those in whom residual disc fragments were observed on postoperative MRI (residual group). Study Design: Retrospective nested case-control study. Methods: A total of 225 patients were included (complete group, n=187 and residual group, n=38). Clinical assessments were performed using the visual analog pain score for the leg (VAS-L, x/10) and back (VAS-B, x/10) and the Korean version of the Oswestry Disability Index (K-ODI, x/45). A linear mixed-effects model was used to analyze changes during the first 24 postoperative months. Results: One month after surgery, significant improvements in the VAS-L, VAS-B and K-ODI values were observed and were maintained during the first 24 postoperative months. No differences in these changes were noted between the groups. Early reoperation (during the first 3 postoperative months) was performed in 3 patients in the residual group (7.9%) and in 4 patients in the complete group (2.1%) (P = 0.10). Limitations: First, the study design was retrospective. Moreover, the number of patients was relatively small and therefore insufficient to achieve robust statistical power. Second, we did not explore the radiological outcomes in patients with asymptomatic residual disc material because follow-up MRI was only obtained to document symptom recurrence. Conclusion: When residual disc tissue is observed in asymptomatic patients, a ‘watchful waiting’ strategy may be preferable to immediate re-operation. However, an increased early re-operation rate is expected for patients with residual disc tissue. Key words: Discectomy, endoscopes, longitudinal studies, patient-reported outcome, percutaneous, reoperation, spine, residual disc

A Case of Secondary Epiretinal Membrane Spontaneous Release

Purpose. To report a rare case of secondary epiretinal membrane (ERM) spontaneous separation with subsequent visual restoration. Case Summary. We are reporting a case with the history of branch retinal vein occlusion, peripheral retinal neovascularization, and retinal photocoagulation. Our examination revealed secondary ERM associated with relatively high visual acuity (0.6), and a watchful waiting strategy was chosen. During the follow-up, slight visual deterioration, progressive deformation of the retinal profile, and an increase in diffuse retinal edema were observed. No surgical or laser treatment was performed. On the next visit, the spontaneous ERM separation with residual parapapillary fixation, the increase in visual acuity (0.9), and the decrease in retinal thickness were revealed. Conclusion. Such cases present additional evidence to a deferral surgical strategy for the management of patients with ERM and relatively high visual acuity.