Regional left atrial voltage in patients with atrial fibrillation

BACKGROUND: Regional differences in fibrosis, particularly related to the posterior wall and septum, may be important in atrial fibrillation (AF). Using electroanatomic mapping, voltage can be used as a measure of fibrosis. OBJECTIVES: The purpose of this study was to determine if patients with AF have disproportionately lower voltage in the septal and posterior walls of the left atrium. METHODS: Sinus rhythm left atrial electroanatomic maps were used in serial patients presenting for left atrial ablation of AF (8-mm tip). Patients undergoing left atrial mapping for focal atrial tachycardia (AT) were used as a comparison group (4-mm tip). Animal experiments were performed to assess the influence of ablation catheter tip size on voltage amplitude. RESULTS: The posterior and septal walls exhibited the lowest voltages in both groups. Compared with the anterior wall, there was a 3.78-fold greater odds of finding a low-voltage point (<0.5 mV) in the septum (P <.001) and a 3.37-fold greater odds of finding a low-voltage point in the posterior wall (P <.001) in the AF patients; the proportion of low-voltage points by region were not significantly different in the AT group. In the animal model, the mean voltage obtained from an 8-mm ablation catheter was significantly higher (0.30 +/- 0.17 mV) than that obtained from the same points using a 4-mm catheter (0.22 +/- 0.17, P = .05). CONCLUSION: Regional differences in voltage are present in patients with atrial arrhythmias, with AF patients exhibiting significantly more low-voltage areas in the septum and posterior walls.     

Psychiatric considerations in pulmonary disease.

Lung disease is a prominent cause of morbidity and mortality worldwide. When a patient has a common lung disease, such as asthma, or a less prevalent one, such as idiopathic pulmonary fibrosis, psychiatric issues should be considered as an integral part of the care plan for each patient. There have been many studies of psychologic factors and psychiatric syndromes in various lung diseases and their treatment. In this article, the authors focus on an evidence-based approach to reviewing this clinical literature.     

Seizure freedom off antiepileptic drugs after temporal lobe epilepsy surgery.

Data are limited on seizure recurrence after antiepileptic drug (AED) discontinuation in operated seizure-free patients. We reviewed seizure outcome in patients who came off AEDs after being seizure-free for 2 years following temporal lobe surgery in our center. Thirty-nine (68%) of 57 patients who discontinued AED therapy remained seizure-free. They had a younger age at surgery than the group with seizure recurrence (p=0.01). Earlier surgery may be a favorable predictor for seizure freedom after AED discontinuation.     

Respiratory problems in children with neurological impairment.

Children with severe neurological impairment have a high incidence of respiratory problems which are multifactorial and may be related to or dependent on the underlying disability. In addition, common respiratory conditions such as asthma will be represented in this group as in the general paediatric population. In order to maximise quality of life and reduce morbidity and mortality, each child should be carefully assessed and treated, making adjustments where necessary in the treatment regime to take account of the disability.     

Glatiramer acetate in the treatment of multiple sclerosis

Glatiramer acetate is an immunomodulating drug used in the treatment of multiple sclerosis. It consists of a copolymer of amino acid residues in the same stoichiometric proportions as in myelin basic protein. Its mechanism of action is not entirely known and is probably multifaceted, with deletion of some immune cell populations and stimulation of others in these patients. Some mechanisms involve neuroprotectant effects. There is ample evidence of its efficacy in relapsing-remitting disease, using both clinical and imaging measures of disease activity, and in this paper we review the clinical and basic studies of this drug. Finally we discuss how some of its neuroprotectant effects may be useful in neurodegeneration such as is seen in more advanced cases of multiple sclerosis and other diseases such as amyotrophic lateral sclerosis and Parkinson’s disease.     

Deep dermal burn injury results in scarless wound healing in the ovine fetus

Early to mid-term fetuses heal cutaneous incisional wounds without scars; however, fetal response to burn injury has not been ascertained. We present a fetal model of thermal injury and subsequent analysis of fetal and lamb response to burn injury. A reproducible deep dermal burn injury was created in the fetus by application of water at 66 degrees C for 7 seconds, and at 82 degrees C for 10 seconds to the lamb. Macroscopically, the area of fetal scald was undetectable from day 7 post injury, while all lamb scalds were readily identified and eventually healed with scarring. Using a five-point histopathology scoring system for alteration in tissue morphology, differences were detected between control and scalded skin at all stages in lamb postburn, but no difference was detected in the fetal model after day 7. There were also large differences in content of alpha-smooth muscle actin and transforming growth factor-beta1 between control and scalded lamb and these differences were statistically significant at day 14 (P < 0.01). This novel model of fetal and lamb response to deep dermal injury indicates that the fetus heals a deep burn injury in a scarless fashion. Further elucidation of this specific fetal process of burn injury repair may lead to improved outcome for patients with burn injury.     

Suicide risk and symptom reduction in patients assigned to placebo in duloxetine and escitalopram clinical trials: analysis of the FDA summary basis of approval reports.

BACKGROUND: We assessed suicide and suicide attempt risk as well as symptom reduction among 3,282 depressed patients participating in duloxetine and escitalopram clinical trials assigned to either an antidepressant or placebo. METHODS: We reviewed the FDA Summary Basis of Approval reports for data regarding safety and efficacy for duloxetine and escitalopram. Furthermore, we compared suicide risk among antidepressant clinical trials in this study with our two previous analyses on seven antidepressant clinical trials. RESULTS: Suicide and suicide attempt risk varied considerably among the three analyses, showing up to ten fold differences. Interestingly, the variability exists across the three reports, rather than between treatments (antidepressants versus placebo). CONCLUSIONS: These findings suggest caution in generalizing suicide risk even from a relatively large number of participants and thus, firm conclusions can only be drawn if the number of participants is overwhelmingly large (approximately two million patients). We also noted similar magnitude of response to placebo and antidepressants among the three studies.     

Spilled Gallstones: the Source of an Enigma

Spillage of gallstones may occur in the course of laparoscopic cholecystectomy. The incidence of this mishap and its consequences are variable. Ignored by many surgeons, stone spillage may be the source of significant morbidity many years after surgery. In this report, we describe the clinical course of a patient who presented with upper abdominal pain and swelling. The past history was positive for laparoscopic cholecystectomy 15 years earlier. After excision, the swelling was found to be a pseudocyst formed around spilled gallstones during a previous cholecystectomy. Apart from postoperative wound infection, the patient recovered well and remains so. Here, we discuss the problem and provide suggestions for spillage prevention and stone retrieval once spillage occurs.     

Extracorporeal membrane oxygenation for postcardiotomy mechanical cardiovascular support in children with congenital heart disease

Extracorporeal membrane oxygenation (ECMO) is increasingly used to support postcardiotomy cardiorespiratory failure in children with congenital heart disease. We report on survival outcomes and factors associated with survival for postcardiotomy ECMO patients.