Mount Carmel East

Previous studies demonstrated that accelerometer-based, mechanically timed atrioventricular synchrony (AVS) is feasible using a leadless ventricular pacemaker. The purpose of this study was to determine the performance of a leadless ventricular pacemaker with accelerometer-based algorithms that provide AVS pacing. AccelAV was a prospective, single-arm study to characterize AVS in patients implanted with a Micra AV, which uses the device accelerometer to mechanically detect atrial contractions and promote VDD pacing. The primary objective was to characterize resting AVS at 1 month in patients with complete atrioventricular block (AVB) and normal sinus function. A total of 152 patients (age 77 ± 11 years; 48% female) from 20 centers were enrolled and implanted with a leadless pacemaker. Among patients with normal sinus function and complete AVB (n = 54), mean resting AVS was 85.4% at 1 month, and ambulatory AVS was 74.8%. In the subset of patients (n = 20) with programming optimization, mean ambulatory AVS was 82.6%, representing a 10.5% improvement (P <.001). Quality of life as measured by the EQ-5D-3L (EuroQol Five-Dimensions Three-Level questionnaire) improved significantly from preimplant to 3 months (P = .031). In 37 patients with AVB at both 1 and 3 months, mean AVS during rest did not differ (86.1% vs 84.1%; P = .43). There were no upgrades to dual-chamber devices or cardiac resynchronization therapy through 3 months. Accelerometer-based mechanical atrial sensing provided by a leadless pacemaker implanted in the right ventricle significantly improves quality of life in a select cohort of patients with AV block and normal sinus function. AVS remained stable through 3 months, and there were no system upgrades to dual-chamber pacemakers.

Histoplasmosis occurs primarily in the lungs but can disseminate in immunocompromised patients. Serology can be negative in patients with local infection, making the diagnosis challenging. Definite diagnosis is by microscopic examination of the tissue sample. We report a rare case of Histoplasma stomatitis whose lesions manifested after initiating antiretroviral therapy.

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Due to the high prevalence of obesity in adults, nutrition support clinicians are encountering greater numbers of obese patients who require nutrition support during hospitalization. The purpose of this clinical guideline is to serve as a framework for the nutrition support care of adult patients with obesity. A systematic review of the best available evidence to answer a series of questions regarding management of nutrition support in patients with obesity was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process, that includes consideration of the strength of the evidence together with the risks and benefits to the patient, was used to develop the clinical guideline recommendations prior to multiple levels of external and internal review and approval by the A.S.P.E.N. Board of Directors. (1) Do clinical outcomes vary across levels of obesity in critically ill or hospitalized non-intensive care unit (ICU) patients? (2) How should energy requirements be determined in obese critically ill or hospitalized non-ICU patients? (3) Are clinical outcomes improved with hypocaloric, high protein diets in hospitalized patients? (4) In obese patients who have had a malabsorptive or restrictive surgical procedure, what micronutrients should be evaluated?

The relationship between pulmonary disease and nutrition is significant. Nutrition support therapy is common in this patient population as a supportive and/or therapeutic measure. Historical reports of adverse respiratory function associated with high parenteral carbohydrate intakes have been the rationale for using high-fat enteral formulas in patients with chronic pulmonary dysfunction. Theoretically, providing a low-carbohydrate formula will reduce carbon dioxide production, result in a reduced respiratory quotient, and lead to associated improvement in pulmonary outcomes. In the patient with acute respiratory distress syndrome, an imbalance of mediators exists, with proinflammatory mediators being dominant, ultimately affecting the disease course. An enteral formula with modified lipids designed to modulate eicosanoid production, and therefore influence the inflammatory cascade, is available. This article reviews the rationale for use of modified enteral formulas in both chronic and acute pulmonary disease, reviews the available studies evaluating the efficacy of these formulas, and provides overall recommendations for the use of specialized enteral formulas in individuals with pulmonary disease.