Implantation of a left ventricular (LV) lead fails in 5% to 10% of patients in whom cardiac resynchronization therapy (CRT) is attempted. Alternatives for delivery of CRT are surgical epicardial and ...endocardial transvenous leads. Endocardial transseptal LV lead delivery is challenging because of the absence of dedicated equipment designed for this procedure.
The purpose of this study was to describe a new technique for delivery of a transseptal LV lead.
This dual approach from the right femoral vein and left subclavian vein involves use of an Endrys transseptal needle and Mullins sheath to deliver a gooseneck snare from the left subclavian vein into the right atrium that can then be used to deliver a deflectable sheath into the left atrium. An active fixation lead is advanced into the LV through the sheath and screwed into the lateral wall.
The procedure was performed successfully in 12 patients in whom transvenous LV lead implantation had previously failed. The Endrys transseptal needle, ideally suited for this technique, facilitated passage of the gooseneck snare into the left atrium with no difficulty. Median procedure time was 148 minutes (interquartile range IQR 113-176 minutes), and median fluoroscopy time was 16 minutes (IQR 10-19 minutes). There was no need for repeat procedures after median follow-up of 97 days (IQR 36-313 days).
This approach using an Endrys needle and a gooseneck snare provides a reliable and effective alternative technique for delivery of an endocardial LV lead that is delivered easily through a deflectable sheath inserted transseptally into the LV.
Background
Infections are a common complication following kidney transplantation, but are reported inconsistently in clinical trials. This study aimed to identify the infection outcomes of highest ...priority for patients/caregivers and health professionals to inform a core outcome set to be reported in all kidney transplant clinical trials.
Methods
In an international online survey, participants rated the absolute importance of 16 infections and eight severity dimensions on 9‐point Likert Scales, with 7–9 being critically important. Relative importance was determined using a best–worst scale. Means and proportions of the Likert‐scale ratings and best–worst preference scores were calculated.
Results
353 healthcare professionals (19 who identified as both patients/caregiver and healthcare professionals) and 220 patients/caregivers (190 patients, 22 caregivers, eight who identified as both) from 55 countries completed the survey. Both healthcare professionals and patients/caregivers rated bloodstream (mean 8.4 and 8.5, respectively; aggregate 8.5), kidney/bladder (mean 7.9 and 8.4; aggregate 8.1), and BK virus (mean 8.1 and 8.6; aggregate 8.3) as the top three most critically important infection outcomes, whilst infectious death (mean 8.8 and 8.6; aggregate 8.7), impaired graft function (mean 8.4 and 8.7; aggregate 8.5) and admission to the intensive care unit (mean 8.2 and 8.3; aggregate 8.2) were the top three severity dimensions. Relative importance (best–worst) scores were consistent.
Conclusions
Healthcare professionals and patients/caregivers consistently identified bloodstream infection, kidney/bladder infections, and BK virus as the three most important infection outcomes, and infectious death, admission to intensive care unit and infection impairing graft function as the three most important infection severity outcomes.
Introduction In this study, we experimentally evaluated whether complex, mature sutures can be separated using skeletal anchorage and light, continuous forces. Methods Twelve adult, 8- to 9-month-old ...female New Zealand white rabbits were randomly assigned to 1 control group and 2 experimental groups. Open-coil nickel-titanium springs delivered constant forces of 100 g across the sagittal suture to miniscrew implants placed bilaterally in the frontal bone. Sutural separation was measured biweekly. Separation was also measured with microcomputed tomography. Bone formation (mineral apposition) was measured with fluorescent labels. Qualitative histologic analyses of the suture tissues were performed using hematoxylin and eosin staining; osteoclasts were evaluated with tartrate resistant acid phosphatase staining. Results All 24 miniscrew implants remained stable throughout the experiment. There was no statistically significant sutural separation in the control group. In the experimental groups, sutural separation was significant ( P <0.05) at all time points after the initial records were taken. The rate of separation was linear during the first 42 days. There were moderate correlations ( R = 0.59-0.89; P <0.05) between miniscrew implant separation and bone marker separation. Mineral apposition rate, which was not measureable in the control group, was significant in the experimental group. The mineral apposition rate was greater between 14 and 28 days than between 28 and 38 days, and it was greater on the ectocranial than on the endocranial surface. Based on the microcomputed tomography analysis, 3-dimensional sutural volume of the experimental group increased significantly ( P = 0.02), but surface area did not ( P = 0.26). Conclusions It is possible to separate the sagittal suture of mature rabbits. Sutural separation is limited, indicating involvement of other articulations.
To assess the association between evidence-based decision making, including implementation of evidence-based interventions (EBIs), with accreditation of state health departments through the Public ...Health Accreditation Board (PHAB).
This was a cross-sectional, electronic survey of state health department practitioners. We utilized a survey instrument focused on evidence-based public health, de-implementation, and sustainability of public health programs. Survey questions were organized into 6 domains: (1) demographic information; (2) individual-level skills; (3) decision making on programs ending; (4) decision making on programs continuing; (5) organization/agency capacity; and (6) external influences.
The targeted practitioners were randomly selected from the 3000-person membership of National Association of Chronic Disease Directors and program manager lists from key Centers for Disease Control and Prevention-supported programs in cancer and cancer risk factors. The final target audience for the survey totaled 1329 practitioners, representing all 50 states.
The main outcome measures included the strength of association between a state's PHAB accreditation status and variables related to evidence-based public health and use of EBIs that fell within the individual participant skills, organization/agency capacity, and external influences domains.
We received 643 valid responses (response rate = 48.4%), representing all 50 states, with 35 states being PHAB accredited. There was a statistically significant association between PHAB accreditation and state health department use of quality improvement processes (P = .002), leadership plans to implement EBIs (P = .009), and leadership reactions to EBI implementation issues (P = .004). Respondents from PHAB-accredited states were significantly more likely than participants from nonaccredited states to report greater engagement with legislators and governors regarding EBIs and 14% less likely to report the inappropriate termination of programs in their work unit (P = .05).
The importance of accreditation relates to both internally focused functions and externally focused activities, especially regarding policy-related impact.
Objectives: Three experiments tested the utility of minimal versus extended voir dire questions in predicting mock jurors' verdicts and damage awards, and whether the biasing impact of their ...preexisting attitudes on case judgments could be reduced by judicial rehabilitation. Hypotheses: We hypothesized that extended voir dire questions would be more predictive of case judgments than minimal voir dire questions. We hypothesized that judicial rehabilitation would not reduce this impact of preexisting attitudes on case judgments. Method: Across three experiments, each focusing on a different civil case (insurance bad faith, wrongful birth, medical malpractice misdiagnosis), online participants (N = 2,041; 62% female; 77% White, 9% African American, 6% Asian/Pacific Islander, 6% Hispanic or Latino/a; Mage = 40) were paid MTurk workers. They were randomly assigned to experience (a) no voir dire, minimal voir dire focusing on previous legal experience and self-identification of biases, or extended voir dire focusing on specific attitudes about civil litigation, parties, and laws, and (b) no judicial rehabilitation, or judicial rehabilitation, before judging the case. Participants read a civil case, made case judgments, and completed bias awareness measures. Results: Demographic information and minimal voir dire questions did not predict case judgments, but the majority of extended voir dire responses predicted verdicts and damage awards. Judicial rehabilitation did not reduce the biasing impact of their preexisting attitudes on case judgments-but did result in mock jurors reporting that they were less biased, despite judicial rehabilitation not actually reducing their bias. Conclusions: Attorneys need the opportunity during voir dire to ask jurors about specific attitudes that might bias their decisions because relying on jurors' self-identification of their own biases has little utility. Further, although judicial rehabilitation might make jurors think that they are less biased, it may not actually reduce the impact of their preexisting attitudes on their case decisions.
Public Significance StatementContrary to popular belief, juror biases are not likely to be cured by judicial rehabilitation, which might backfire by creating the illusion in jurors that they are unbiased. Although very few mock jurors were able to self-identify things that might bias them when asked general questions in voir dire, they were willing to admit specific attitudes that biased their verdicts and damage awards when asked. Thus, we suggest reducing bias on juries by allowing attorneys to ask specific, detailed voir dire questions crafted by the parties to streamline the jury selection process and remove jurors for cause or via peremptory challenges, rather than relying on "quick fixes," such as general questions that ask jurors to self-identify their own bias or judicial rehabilitation.
In low-incidence countries, tuberculosis mainly affects migrants, mostly resulting from reactivation of latent tuberculosis infection (LTBI) acquired in high-incidence countries before migration. A ...nationwide primary care-based LTBI testing and treatment programme for migrants from high-incidence countries was therefore established in high tuberculosis incidence areas in England. We aimed to assess the effectiveness of this programme.
We did a retrospective, population-based cohort study of migrants who registered in primary care between Jan 1, 2011, and Dec 31, 2018, in 55 high-burden areas with programmatic LTBI testing and treatment. Eligible individuals were aged 16–35 years, born in a high-incidence country, and had entered England in the past 5 years. Individuals who tested interferon-γ release assay (IGRA)-negative were advised about symptoms of tuberculosis, whereas those who tested IGRA-positive were clinically assessed to rule out active tuberculosis and offered preventive therapy. The primary outcome was incident tuberculosis notified to the national Enhanced Tuberculosis Surveillance system.
Our cohort comprised 368 097 eligible individuals who had registered in primary care, of whom 37 268 (10·1%) were tested by the programme. 1446 incident cases of tuberculosis were identified: 166 cases in individuals who had IGRA testing (incidence 204 cases 95% CI 176–238 per 100 000 person-years) and 1280 in individuals without IGRA testing (82 cases 77–86 per 100 000 person-years). Overall, in our primary analysis including all diagnosed tuberculosis cases, a time-varying association was identified between LTBI testing and treatment and lower risk of incident tuberculosis (hazard ratio HR 0·76 95% CI 0·63–0·91) when compared with no testing. In stratified analysis by follow-up period, the intervention was associated with higher risk of tuberculosis diagnosis during the first 6 months of follow-up (9·93 7·63–12·9) and a lower risk after 6 months (0·57 0·41–0·79). IGRA-positive individuals had higher risk of tuberculosis diagnosis than IGRA-negative individuals (31·9 20·4–49·8). Of 37 268 migrants who were tested, 6640 (17·8%) were IGRA-positive, of whom 1740 (26·2%) started preventive treatment. LTBI treatment lowered the risk of tuberculosis: of 135 incident cases in the IGRA-positive cohort, seven cases were diagnosed in the treated group (1·87 cases 95% CI 0·89–3·93 per 1000 person-years) and 128 cases were diagnosed in the untreated group (10·9 cases 9·16–12·9 per 1000 person-years; HR 0·14 95% CI 0·06–0·32).
A low proportion of eligible migrants were tested by the programme and a small proportion of those testing positive started treatment. Despite this, programmatic LTBI testing and treatment of individuals migrating to a low-incidence region is effective at diagnosing active tuberculosis earlier and lowers the long-term risk of progression to tuberculosis. Increasing programme participation and treatment rates for those testing positive could substantially impact national tuberculosis incidence.
National Institute for Health Research Health Protection Research Unit in Respiratory Infections.
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