Combined Radiofrequency Ablation-Cooling Catheter for Reversible Cryothermal Mapping and Ablation

Reversible cryothermal mapping of cardiac arrhythmias has beenperformed intraoperatively. However, a steerable cooling catheter forreversible mapping has not yet been developed. We therefore developed andtested a cooling system consisting of a +15°C hypertonic salinereservoir and a 7F steerable catheter also capable of radiofrequency (RF)ablation. Using excised ovine hearts placed in a 37°C circulating salinebath, we measured the temperatures at depths of 0 mm, 1 mm, and 2 mm. Thetemperature after 90 seconds of cooling was 16.5 ± 2.1°C at 0 mmcompared to 23.9 ± 4.1°C at 1 mm and 31.1 ± 3.9°C at 2mm depth (p < 0.01). These data suggest that a 7F steerable combined RFablation–cooling catheter may achieve temperatures suitable formapping arrhythmias such as atrial tachycardias and right ventricularoutflow tract tachycardias. Further enhancements to achieve lowertemperatures at depth may be needed to reversibly map other arrhythmiassuch as left ventricular tachycardias.     

Extraction of Buried P Waves from Printed Electrocardiograms

Background: Morphologic identification of ectopic P‐waves from surface ECGs can be challenging, particularly when the P‐wave is buried in the QRST wave complex. Because ECGs are often available on paper and not digitally, we developed a method of subtracting the T‐wave from the buried P‐wave complex on paper ECGs. Methods: To validate our system, an atrial extrastimulus was introduced during and following the T‐wave. The ECGs were scanned and then transformed from an image format to a digital format. A computer algorithm digitally subtracted a QRST with no buried P‐wave from one with a buried P‐wave, thus resulting in an extracted P‐wave. The extracted P‐waves were compared to the nonburied P‐wave by determining correlation coefficients and by visual grading by two independent reviewers. Results: Visual grading comparing the buried P‐wave with the exposed paced P‐wave was 94%. The median correlation coefficient was 85%. Conclusions: An ectopic atrial P‐wave obscured by a coincident QRST wave complex can be accurately derived from printed ECG using this PC‐based system. Addition of this technique to the existing methods may aid in the localization and ablation of ectopic atrial foci.     

Hormonal Replacement in Patients with Brain Injury-Induced Hypopituitarism: Who, When and How to Treat?

Traumatic brain injury is one of the main causes of death, as well as, physical and cognitive disabilities in young adults. Recent studies have demonstrated head injury (TBI and SAH) as a frequent cause of hypopituitarism. Since hormonal deficits may contribute to the outcome of the patient, it is important to establish guidelines of who, when, and how to treat. The probability of developing hypopituitarism has been based on the severity of the TBI. Yet discrepancies in recent studies display that minimal TBI can also result in hypopituitarism. Thus patients with moderate to severe TBI must be screened and those with minimal TBI monitored for hypopituitarism. The temporal relationship between TBI and occurrence of hypopituitarism is observed in 3 phases-acute, recovery, and chronic. Clear hormonal deficits should be treated, but the question arises concerning subtle abnormalities and their role in the outcome of TBI patients.     

A landscape effect in tenosynovial giant-cell tumor from activation of CSF1 expression by a translocation in a minority of tumor cells

Tenosynovial giant-cell tumor (TGCT) and pigmented villonodular synovitis (PVNS) are related conditions with features of both reactive inflammatory disorders and clonal neoplastic proliferations. Chromosomal translocations involving chromosome 1p13 have been reported in both TGCT and PVNS. We confirm that translocations involving 1p13 are present in a majority of cases of TGCT and PVNS and show that CSF1 is the gene at the chromosome 1p13 breakpoint. In some cases of both TGCT and PVNS, CSF1 is fused to COL6A3 (2q35). The CSF1 translocations result in overexpression of CSF1. In cases of TGCT and PVNS carrying this translocation, it is present in a minority of the intratumoral cells, leading to CSF1 expression only in these cells, whereas the majority of cells express CSF1R but not CSF1, suggesting a tumor-landscaping effect with aberrant CSF1 expression in the neoplastic cells, leading to the abnormal accumulation of nonneoplastic cells that form a tumorous mass.     

Beneficial effects of a switch to a Lopinavir/ritonavir-containing regimen for patients with partial or no immune reconstitution with highly active antiretroviral therapy despite complete viral suppression

The purpose of this study was to determine if switching to an Lopinavir/ritonavir (LPV/r)-containing regimen resulted in greater immune reconstitution in patients with immunologic failure despite complete viral suppression with highly active antiretroviral therapy (HAART). Twenty patients with partial or no immune response to HAART despite viral suppression were enrolled. Ten were randomized to stay on their current regimen and 10 were randomized to LPV/r plus their current NRTI backbone. T cell subsets, ex vivo apoptosis, and the percent of circulating cells with detectable intracellular HIV-1 RNA were measured. The mean increase in CD4(+) count at 6 months was 116/mm(3) (172-288) for the LPV/r-containing arm versus 32/mm(3) (264-296) for continuation regimens (p = 0.03). The number of patients with an increase ≥50 cells/mm(3) was also greater in the LPV/r arm (7/9 versus 2/10, p = 0.01). This paralleled a decrease in ex vivo apoptosis of naive CD4(+) T cells at 6 months (21.7-11.0% for the LPV/r arm versus 17.3-18.9% for the continuation arm, p = 0.04) and memory cells (21.1-14.1% for LPV/r versus 20.2-17.9% for continuation arm, NSS). Switching patients to an LPV/r-containing regimen improved CD4(+) counts in patients with prior immunologic failure, and this may be due to an effect of LPV/r on apoptosis.     

Practices to support co-design processes: A case-study of co-designing a program for children with parents with a mental health problem in the Austrian region of Tyrol

Forms of collaborative knowledge production, such as community-academic partnerships (CAP), have been increasingly used in health care. However, instructions on how to deliver such processes are lacking. We aim to identify practice ingredients for one element within a CAP, a 6-month co-design process, during which 26 community- and 13 research-partners collaboratively designed an intervention programme for children whose parent have a mental illness. Using 22 published facilitating and hindering factors for CAP as the analytical framework, eight community-partners reflected on the activities which took place during the co-design process. From a qualitative content analysis of the data, we distilled essential practices for each CAP factor. Ten community- and eight research-partners revised the results and co-authored this article. We identified 36 practices across the 22 CAP facilitating or hindering factors. Most practices address more than one factor. Many practices relate to workshop design, facilitation methods, and relationship building. Most practices were identified for facilitating ‘trust among partners’, ‘shared visions, goals and/or missions’, ‘effective/frequent communication’, and ‘well-structured meetings’. Fewer practices were observed for ‘effective conflict resolution’, ‘positive community impact’ and for avoiding ‘excessive funding pressure/control struggles’ and ‘high burden of activities’. Co-designing a programme for mental healthcare is a challenging process that requires skills in process management and communication. We provide practice steps for delivering co-design activities. However, practitioners may have to adapt them to different cultural contexts. Further research is needed to analyse whether co-writing with community-partners results in a better research output and benefits for participants.     

Dietetic practice in the management of gestational diabetes mellitus: A survey of Australian dietitians

Aim: To examine current Australian dietetic practice in the management of gestational diabetes, to identify models of dietetic care and to determine the need for national evidence‐based dietetic practice guidelines for gestational diabetes. Methods: A 55‐item cross‐sectional survey of Australian dietitians practicing in the area of gestational diabetes was undertaken. Participants were recruited via Dietitians Association of Australia interest group membership, public and private hospital maternity and diabetes services across Australia. The survey examined dietetic service provision, interventions, management recommendations, postnatal care, current guideline use and the perceived need for Australian evidence‐based dietetic management guidelines. Results: A total of 220 eligible dietitians participated in the survey. The majority (77%) reported that all women with gestational diabetes attending their service were referred to a dietitian. Group (33%) and individual consults (93%) were provided and 67% provided one to two dietetic consults per client. Fifty‐four per cent (54%) believed that their service currently offered adequate antenatal dietetic interventions and 8% adequate postnatal follow up for women with gestational diabetes. There were differences in the implementation of medical nutrition therapy by Australian dietitians in regards to nutrient recommendations. However, consistency was seen in key components of nutrition education. Dietitians perceived that there was a need for evidence‐based gestational diabetes dietetic practice guidelines (86%) and nutrition recommendations (87%). Conclusion: The survey results strongly indicate there is a need for evidence‐based gestational diabetes practice guidelines and nutritional recommendations and provide baseline data for future practice of Australian dietitians working in gestational diabetes.