Search

Aims: Cardiac resynchronization therapy via the coronary sinus (CS) is not always possible. Left ventricular (LV) endocardial lead placement is a potential alternative. The purpose of this study was to assess the feasibility of endocardial LV pacing using a steerable lead introducer and active fixation polyurethane lead. Methods and Results: Endocardial LV lead placement was attempted in nine patients (seven males, age 48-77 years) in whom transvenous CS lead placement had failed. Trans-septal puncture and septal dilatation were performed via the femoral route. A steerable introducer catheter was advanced across the septal puncture site from the right or left subclavian vein into the LV. An active fixation polyurethane lead was then implanted into the high postero-lateral aspect of the LV endocardial wall. All patients were anticoagulated following implant. Successful LV lead placement was achieved in eight patients. There were no acute complications and no embolic events during follow-up (1-32 months). All implanted patients responded well with either improvement in New York Heart Association class or maintenance of symptomatic improvement that had previously been conferred by LV epicardial pacing. Conclusion: Targeted LV endocardial pacing is a potential alternative to CS pacing and warrants a trial to characterize long-term benefits and risks. [ABSTRACT FROM AUTHOR]

Context: Ventilator-associated pneumonia (VAP) causes substantial morbidity. A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation.Objective: To determine whether a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP.Design, Setting, and Participants: Prospective, randomized, single-blind, controlled study conducted in 54 centers in North America. A total of 9417 adult patients (> or = 18 years) were screened between 2002 and 2006. A total of 2003 patients expected to require mechanical ventilation for 24 hours or longer were randomized.Intervention: Patients were assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes, similar except for a silver coating on the experimental tube.Main Outcome Measures: Primary outcome was VAP incidence based on quantitative bronchoalveolar lavage fluid culture with 10(4) colony-forming units/mL or greater in patients intubated for 24 hours or longer. Other outcomes were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality, and adverse events.Results: Among patients intubated for 24 hours or longer, rates of microbiologically confirmed VAP were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4%-6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7%-9.7%) (P = .03) in the group receiving the uncoated tube (all intubated patients, 3.8% [37/968; 95% CI, 2.7%-5.2%] and 5.8% [56/964; 95% CI, 4.4%-7.5%] [P = .04]), with a relative risk reduction of 35.9% (95% CI, 3.6%-69.0%; all intubated patients, 34.2% [95% CI, 1.2%-67.9%]). The silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005). No statistically significant between-group differences were observed in durations of intubation, intensive care unit stay, and hospital stay; mortality; and frequency and severity of adverse events.Conclusion: Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube.Trial Registration: clinicaltrials.gov Identifier: NCT00148642. [ABSTRACT FROM AUTHOR]

Aims: The determination of dynamic changes in ventricular repolarization may provide insight into arrhythmogenic mechanisms as a consequence of pacing site. This study investigated acute pacing site effects on global characteristics of electrical restitution using high resolution, non-contact mapping (NCM). [ABSTRACT FROM PUBLISHER]

PURPOSE OF REVIEW: This review will summarize recent clinical and experimental data on the use of immune-modulating nutrients in critical illness. It will present the concept of these nutrients as pharmacologic agents or 'nutraceuticals' administered in addition to protein, calorie, vitamin, and trace element sources. RECENT FINDINGS: Studies have defined the physiologic roles of arginine in critical illness, such as its role as a precursor for the production of nitric oxide. Investigations have determined that, in critical illness, glutamine levels decrease and severe glutamine deficiency is associated with increased mortality. Experimental studies have revealed that glutamine attenuates proinflammatory cytokine responses, improves gut barrier and immune cell functions, increases the ability to mount a stress response, and decreases mortality. Clinical trials and meta-analyses of studies testing immune-modulating nutritional formulations have reported numerous benefits but also some conflicting results. Dose and route of administration are key factors that influence the benefit, or lack thereof, of these nutraceuticals. SUMMARY: Cumulative studies of enteral immune-modulating nutritional formulations report benefits in surgical critically ill patients such as burn, trauma, or gastrointestinal surgery populations. Conflicting data in patients with sepsis warrant concern and further evaluation; in particular, controversy seems to stem around the use of arginine. Glutamine is beneficial when given in high doses or via the parenteral route (>0.20-0.30 g/kg per day or >or=30 g/day). Providing both omega-3 and omega-6 polyunsaturated fatty acids is important in immune modulation. The best doses and combinations of immune-modulating components remain unclear. [ABSTRACT FROM AUTHOR]