Advanced interatrial block predicts ineffective cardioversion of atrial fibrillation: a FinCV2 cohort study

AimsRhythm control using electrical cardioversion (CV) is a common treatment strategy for patients with symptomatic atrial fibrillation (AF). To guide clinical decision making, we sought to assess if electrocardiographic interatrial blocks could predict CV failure or AF recurrence as the phenomenon is strongly associated with atrial arrhythmias.MethodsThis study included 715 patients who underwent a CV for persistent AF lasting >48 h. P-wave duration and morphology were analyzed in post-procedure or the most recent sinus rhythm electrocardiograms and compared with rates of CV failure and AF recurrence within 30 days after CV as well as their combination (ineffective CV).ResultsCV was unsuccessful in 63 out of 715 patients (8.8%) and AF recurred in 209 out of 652 (29.2%) patients within 30 days after CV. Overall, 272 (38.0%) CVs turned out ineffective. Advanced interatrial block (AIAB) defined as P-wave duration ≥120 ms and biphasic morphology in inferior leads (II, III and aVF) was diagnosed in 72 (10.1%) cases. AIAB was an independent predictor for CV failure (OR 4.51, 95%CI 1.76–11.56, p = .002), AF recurrence (OR 2.93, 95%CI 1.43–5.99, p = .003) and ineffective CV (OR 3.87, 95%CI 2.04–7.36, p < .001).ConclusionAIAB predicted CV failure, AF recurrence as well as their composite. This study presents an easy electrocardiographic tool for the identification of patients with persistent AF who might not benefit from an elective CV in the future.

KEY MESSAGES

• Interatrial blocks are very common in patients with atrial fibrillation.
• Advanced interatrial block predicts ineffective cardioversion.

     

Lumbar spinal stenosis patients are satisfied with short-term results of surgery - younger age, symptom severity, disability and depression decrease satisfaction

Purpose. To study the lumbar spinal stenosis (LSS) patients' (n = 98) satisfaction with surgery outcome and associated factors at three months post-operative stage.

Method. LSS-related physical functioning and pain were assessed with Oswestry disability index, Stucki questionnaire, Visual Analogue Scale and pain drawings. Depression was assessed with 21-item Beck Depression Inventory. Psychological well-being was assessed with the Life satisfaction scale, Toronto Alexithymia Scale and Sense of Coherence Scale. All questionnaires were administered before and 3 months after surgical treatment of LSS. Satisfaction with surgery outcome was assessed with a separate scale.

Results. Considerable improvement was evident in all the functional and pain-related variables. Two-thirds (66%) of the patients were at least clearly satisfied with the surgery outcome. Younger age, symptom severity, disability and depression were independently associated with dissatisfaction with surgery outcome.

Conclusion. The lack of physical, functional and emotional well-being is associated with the patients' dissatisfaction with the surgery outcome. Patient satisfaction is a valid outcome to be measured in LSS patients undergoing surgery. It is recommended that patients should be provided with realistic pre-operative patient information and that depression be assessed pre-operatively.     

The clinical utility of serum anti‐Müllerian hormone in the follow‐up of ovarian adult‐type granulosa cell tumors—A comparative study with inhibin B

Ovarian adult‐type granulosa cell tumors (AGCTs) require prolonged follow‐up, but evidence regarding the optimal follow‐up marker is lacking. The objective of our study was to validate the clinical usefulness of serum anti‐Müllerian hormone (AMH) and the current marker inhibin B as single and combined markers of AGCTs. We conducted a longitudinal, partially prospective cohort study of 123 premenopausal and postmenopausal AGCT patients with a median follow‐up time of 10.5 years (range 0.3–50.0 years). Serum AMH and inhibin B levels were measured from 560 pretreatment and follow‐up serum samples by using immunoenzymometric assays. We found that serum AMH and inhibin B levels were significantly elevated in patients with primary or recurrent AGCTs. The levels of both markers positively correlated to tumor size (p < 0.05). AMH and inhibin B performed similarly in receiving operator characteristic analyses; area under the curve (AUC) values were 0.92 [95% confidence interval (CI) 0.88–0.95] for AMH, and 0.94 (95% CI 0.90–0.96) for inhibin B. AMH was highly sensitive (92%) and specific (81%) in detecting a macroscopic AGCT. However, in AUC comparison analyses, the combination of the markers was superior to inhibin B alone. In conclusion, serum AMH is a sensitive and specific marker of AGCT, and either AMH or inhibin B can be monitored during follow‐up. However, combining AMH and inhibin B in AGCT patient follow‐up improves the detection of recurrent disease.     

Monitoring cerebral oxygenation during balloon occlusion with multichannel NIRS

We report on oxygenation changes noninvasively recorded by multichannel continuous-wave near infrared spectroscopy (CW-NIRS) during endovascular neuroradiologic interventions requiring temporary balloon occlusion of arteries supplying the cerebral circulation. Digital subtraction angiography (DSA) provides reference data on the site, timing, and effectiveness of the flow stagnation as well as on the amount and direction of collateral circulation. This setting allows us to relate CW-NIRS findings to brain specific perfusion changes. We focused our analysis on the transition from normal perfusion to vessel occlusion, i.e., before hypoxia becomes clinically apparent. The localization of the maximal response correlated either with the core (occlusion of the middle cerebral artery) or with the watershed areas (occlusion of the internal carotid artery) of the respective vascular territories. In one patient with clinically and angiographically confirmed insufficient collateral flow during carotid artery occlusion, the total hemoglobin concentration became significantly asymmetric, with decreased values in the ipsilateral watershed area and contralaterally increased values. Multichannel CW-NIRS monitoring might serve as an objective and early predictive marker of critical perfusion changes during interventions—to prevent hypoxic damage of the brain. It also might provide valuable human reference data on oxygenation changes as they typically occur during acute stroke.     

Self-limited thrombotic microangiopathy associated with perianal abscess

A 43-year-old female with Staphyloccocus-induced perianal abscess, was admitted to hospital because of a clinical picture of acute renal failure and thrombotic microangiopathy. Schistocytes, thrombopenia, a negative Coombs test and no detectable plasma haptoglobin were diagnostic for thrombotic microangiopathy. Antibiotics, surgical drainage, plasmapheresis and fresh frozen plasma were given with a favourable evolution. We review the prognostic factors determining recovery of renal function and hematological abnormalities.     

Challenges of Using In Vitro Data for Modeling P-Glycoprotein Efflux in the Blood-Brain Barrier

The efficacy of central nervous system (CNS) drugs may be limited by their poor ability to cross the blood-brain barrier (BBB). Transporters, such as p-glycoprotein, may affect the distribution of many drugs into the CNS in conjunction with the restricted paracellular pathway of the BBB. It is therefore important to gain information on unbound drug concentrations in the brain in drug development to ensure sufficient drug exposure from plasma at the target site in the CNS. In vitro methods are routinely used in drug development to study passive permeability and p-glycoprotein efflux of new drugs. This review discusses the challenges in the use of in vitro data as input parameters in physiologically based pharmacokinetic (PBPK) models of CNS drug disposition of p-glycoprotein substrates. Experience with quinidine demonstrates the variability in in vitro parameters of passive permeability and active p-glycoprotein efflux. Further work is needed to generate parameter values that are independent of the model and assay. This is a prerequisite for reliable predictions of drug concentrations in the brain in vivo.     

Design and synthesis of lipid-mimetic cationic iridium complexes and their liposomal formulation for in vitro and in vivo application in luminescent bioimaging

Two iridium [Ir(N^C)₂(N^N)]⁺ complexes with the diimine N^N ligand containing a long polymethylene hydrophobic chain were synthesized and characterized by using NMR and ESI mass-spectrometry: N^N – 2-(1-hexadecyl-1H-imidazol-2-yl)pyridine, N^C – methyl-2-phenylquinoline-4-carboxylate (Ir1) and 2-phenylquinoline-4-carboxylic acid (Ir2). These complexes were used to prepare the luminescent PEGylated DPPC liposomes (DPPC/DSPE-PEG2000/Ir-complex = 95/4.5/1 mol%) using a thin film hydration method. The narrowly dispersed liposomes had diameters of about 110 nm. The photophysics of the complexes and labeled liposomes were carefully studied. Ir1 and Ir2 give red emission (λ_em = 667 and 605 nm) with a lifetime in the microsecond domain and quantum yields of 4.8% and 10.0% in degassed solution. Incorporation of the complexes into the liposome lipid bilayer results in shielding of the emitters from interaction with molecular oxygen and partial suppression of excited state nonradiative relaxation due to the effect of the relatively rigid bilayer matrix. Delivery of labeled liposomes to the cultured ARPE-19 cells demonstrated the usefulness of Ir1 and Ir2 in cellular imaging. Labeled liposomes were then injected intravitreally into rat eyes and imaged successfully with optical coherence tomography and funduscopy. In conclusion, iridium complexes enabled the successful labeling and imaging of liposomes in cells and animals.

Novel lipoidal Ir(iii) phosphorescent labels were embedded into liposomes and used for imaging in cells and animals.     

Long-term results of surgery for lumbar spinal stenosis: a randomised controlled trial

We randomised a total of 94 patients with long-standing moderate lumbar spinal stenosis (LSS) into a surgical group and a non-operative group, with 50 and 44 patients, respectively. The operative treatment comprised undercutting laminectomy of stenotic segments, augmented with transpedicular-instrumented fusion in suspected lumbar instability. The primary outcome was the Oswestry disability index (ODI), and the other main outcomes included assessments of leg and back pain and self-reported walking ability, all based on questionnaire data from 85 patients at the 6-year follow-up. At the 6-year follow-up, the mean difference in ODI in favour of surgery was 9.5 (95% confidence interval 0.9–18.1, P-value for global difference 0.006), whereas the intensity of leg or back pain did not differ between the two treatment groups any longer. Walking ability did not differ between the treatment groups at any time. Decompressive surgery of LSS provided modest but consistent improvement in functional ability, surpassing that obtained after non-operative measures.