Farhan M. Asrar

Cardiac resynchronization therapy in patients with postero-lateral scar by cardiac magnetic resonance: A systematic review and meta-analysis

BACKGROUND Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected patients with heart failure, but up to one third of patients may not respond to CRT. A transmural postero-lateral (TMPL) wall scar in the left ventricle (LV) or over the LV pacing site may attenuate clinical and echocardiographic response to CRT. METHODS AND RESULTS We systematically searched PubMed, EMBASE, and Cochrane databases for studies examining the association between Cardiac magnetic resonance (CMR)-determined postero-lateral or LV pacing site scar and clinical and echocardiographic response to CRT. Eleven prospective studies were included. The presence of TMPL scar on pre-implant CMR was associated with a 75% lower chance of echocardiographic response to CRT, and a similarly lower chance of clinical response. Significant scar over LV pacing site on pre-implant CMR was also associated with a 46% lower chance of echocardiographic response to CRT, and a 67% lower chance of clinical response. CONCLUSIONS The presence of transmural postero-lateral scar or significant scar within the LV pacing site detected by pre-implant CMR is associated with a lower rate of clinical or echocardiographic response to CRT.

Help from above: outer space and the fight against Ebola

www.thelancet.com/infection Vol 15 August 2015 873 more parents are delaying and refusing vaccines through non-medical exemptions. As legislators, they are looking for a direct legislative fi x by proposing to eliminate nonmedical exemptions altogether. Unfortunately, despite the good intentions, this approach is imprudent. The problem of vaccine hesitancy is far more complex than can be addressed with a simple ban on non-medical exemptions. Parents no longer fear diseases such as measles, which have been largely controlled through vaccination. Instead, parental fear has shifted from the diseases to the vaccines. Despite a remarkable safety record, vaccines are not perfect and many parental safety concerns have remained unaddressed. Eff ective methods to address vaccine hesitancy at the level of the provider, community, and nation are scarce. Trust in the pharmaceutical companies that make vaccines and the governments that purchase and promote them are at an all-time low. A more draconian approach could result in more harm than good, and might even backfi re by driving hesitant parents to accept antivaccination arguments. This lesson was learned in the UK more than 150 years ago when the government made smallpox vaccination compulsory, initially without non-medical exemptions. Antivaccination groups were joined by libertarians, and 20 000 demonstrators took to the streets of Leicester. Parents who refused vaccines became martyrs. Ultimately, the UK resorted to the introduction of a non-medical (conscientious) exemption. Rather than repeating history, lessons need to be learned from it. In fact, the recent legislative eff orts have resulted in substantial backlash. This backlash has been a factor in the defeat of proposed laws in Washington and Oregon, which proposed to restrict exemptions. There is substantial value in making exemptions more stringent and including requirements for health education. However, getting rid of non-medical exemptions altogether and making mandatory vaccination truly compulsory risks substantial public backlash and could be counterproductive to the ultimate objective of reaching and sustaining high rates of immunisation coverage and disease control.

Contamination of Hair With 3,4-Methylene Dioxymethamphetamine (Ecstasy) in 2 Young Girls from a “Meth Lab”

In mid-2006, police raided a family house in the province of Ontario, Canada, and found evidence suggesting that it had been used to manufacture MDMA or methamphetamine, together with the chemicals butane and buthylamine, and packages containing MDMA, cocaine, and heroin. The family living in the house included 2 girls, each aged 14 months and 8 years, and their parents. We performed a pediatric examination after the girls were transferred to the care of CAS. They appeared in good health and were apparently well cared for. The older girl was a bright student, according to the report provided by her teacher. The younger girl was usually with her mother. Both girls regularly visited the doctor, and their vaccination status was up to date. Physical examination revealed no major health problems or concerns. Their development was normal for their age, and both showed excellent interaction with their mother, the pediatrician, and the social worker. As part of the consultation, a hair sample for drug testing was obtained from each girl, with written consent from the mother and the CAS representative in charge. Hair from both children was positive for either MDMA or methamphetamine (enzyme-linked immunosorbent assay cross-reactivity approaches 100% for these 2 drugs) at relatively high levels (8.63 and 1.35 ng/mg of hair, respectively; range The recent explosion in the number of “meth home labs” illegally producing methamphetamine has brought to the forefront the serious public health issues associated with this illegal practice. It is not uncommon to find children residing in these households, and their environmental exposure to illicit drugs produced in the premises has not been systematically evaluated. Two years ago, because of the increase in numbers of meth home labs detected by police, the Motherisk Program at the Hospital for Sick Children initiated, in collaboration with the Children’s Aid Society (CAS), a program to follow all children found to reside in homes where methamphetamine laboratories operated. A key question that arose is whether there is a risk of environmental exposure to amphetamines in this setting. We describe the use of hair test to detect 3,4-methylene dioxymethamphetamine (MDMA or ecstasy) exposure in 2 girls residing in a household where a meth lab operated.

Sleep apnea and severe bradyarrhythmia – an alternative treatment option: a case report

IntroductionSinus arrest, atrio-ventricular block, supraventricular, and ventricular arrhythmias have been reported in patients with sleep apnea syndrome. The arrhythmias usually occur during sleep and contribute to the cardiovascular morbidity and mortality, and the treatment of sleep apnea usually results in the resolution of the brady- arrhythmias. Weight loss, continuous positive airway pressure (CPAP), oral appliances, and upper airway surgery are the recommended treatments, however, compliance and efficacy are issues.Case presentationA 58-year-old Arab man presented with recurrent presyncope. He was subsequently diagnosed with sleep apnea associated with frequent and significant sinus pauses. He presented a treatment challenge because he refused continuous positive airway pressure and pacemaker, however, he was successfully treated with theophylline.ConclusionFrequent and significant sinus pause associated with sleep apnea was successfully treated with theophylline in our patient when the standard treatment of care was refused.