Preduodenal mechanisms in initiating gallbladder emptying in man

The existence of preduodenal phases of gallbladder emptying in normal volunteers was investigated by evaluating the effect of sham feeding a sandwich (chew and spit) (n = 15), the sight and smell of food followed by sham feeding a cooked meal (n = 15), and gastric distension (intragastric balloon tube) (n = 9) on gallbladder emptying and comparing these responses with those after ingestion of a standard meal (n = 14). A control group given no intestinal stimuli were studied to determine the frequency of spontaneous emptying during fasting (n = 18). 99mTc-EHIDA (2,6 diethylphenylcarbamoylmethyliminodiacetic acid) was used as the biliary tracer. The frequency of gallbladder emptying during fasting was 0.0045/min. Thus, in any 20 min period emptying occurred spontaneously in only about 1 in 11 volunteers. Significant emptying (greater than 5 per cent over 20 min) occurred in 8 out of 15 volunteers after sham feeding a sandwich (P less than 0.001 versus control), in 8 out of 15 volunteers after sham feeding a cooked meal (P = 1.0 versus sandwich sham feed, n.s.), in 6 out of 9 volunteers after gastric distension (P less than 0.001 versus control) and in 14 out of 14 volunteers after meal ingestion. The rate of emptying was significantly greater in the gastric distension and meal ingestion groups compared with other groups (P less than 0.05). However, the emptying rate after sham feeding was not significantly different from spontaneous gallbladder emptying (P greater than 0.05, n.s.). There was no significant difference in time to onset of emptying between the four stimulus groups (P greater than 0.05, n.s.). These results suggest that pre-duodenal stimuli can evoke gallbladder emptying in man, although the precise physiological significance of this phenomenon remains to be established.     

Recurrence of left atrium-pulmonary vein conduction following successful disconnection in asymptomatic patients.

BACKGROUND: The clinical significance of conduction recurrences in isolated pulmonary veins of patients with atrial fibrillation is not established. METHODS: Twenty-two patients with paoxysmal atrial fibrillation underwent successful pulmonary vein isolation. Six months after the procedure, 14 patients were free of atrial fibrillation. Two of these patients were subjected to repeat mapping of the left superior pulmonary vein. RESULTS: There was recurrence of pulmonary vein to left atrium conduction despite complete lack of symptoms or evidence of recurrent atrial fibrillation. CONCLUSION: Successful pulmonary vein isolation with abolition of paroxysmal atrial fibrillation does not confer permanent disconnection of the pulmonary vein musculature from the left atrium.     

Avoiding visual tipoffs to face lift surgery. A troubleshooting guide.

As aesthetic surgeons we should look more closely at our finished products. A visible scar, distorted ear lobe or tragus, or unnatural hairline says "face lift" to a patient's friends and creates a self-conscious, unhappy patient. The modifications I have adopted of accepted techniques give a more natural look and less conspicuous scarring. They avoid the most dreaded question a patient's associates may ask: "Have you had a face lift?" The text outlines the areas where tipoffs are most prevalent and makes suggestions to minimize them. It is impossible to do inconspicuous surgery all the time, but it is possible by careful observation to minimize visual tipoffs. An unnatural tragus or bad scar should be considered as severe a complication as nerve damage. We should use as proficient avoidance techniques for one as for the other.     

Grover disease and bullous pemphigoid: a clinicopathological study of six cases

Grover disease (GD) is an idiopathic dermatosis that typically manifests as itchy papules over the trunk in middle‐aged men. Bullous pemphigoid (BP) is an autoimmune bullous disease that affects older people. Not only are the two diseases easily distinguishable on clinical grounds, they are also characterized by differences in histopathology, pathogenesis and response to treatment Thus, the co‐occurrence of these two conditions in the same patient is usually considered coincidental. In this report, we present a multicentre retrospective analysis of six patients who developed both GD and BP over a short period of time, and in all cases but one, GD preceded BP. We discuss the clinical and histopathological features of these patients, and the suggested mechanisms of the diseases. We conclude that GD might predispose to the development of BP.     

Comparison of right ventricular impedance, pulse pressure and maximal dP/dt for determination of hemodynamic stability of ventricular arrhythmias associated with coronary artery disease

By monitoring hemodynamic parameters, a future generation of automatic implantable defibrillators will provide tiered therapy of ventricular arrhythmias according to the associated hemodynamic compromise. Changes in intracardiac impedance permit beat-to-beat assessment of ventricular volumes and make this parameter attractive as a rapid discriminator of hemodynamic compromise during arrhythmias. Beat-to-beat changes in right ventricular (RV) impedance were measured before, during and after 27 episodes of ventricular tachyarrhythmias induced in 17 men (64 +/- 7 years, mean +/- standard deviation; left ventricular ejection fraction 41 +/- 11%). Impedance was measured using a tripolar lead system and was compared to ventricular tachycardia cycle length, RV pulse pressure and maximum systolic RV dP/dt as indicators of systemic hemodynamic compromise. The average decreases in systolic blood pressure and mean arterial pressure during ventricular tachycardia were 48 +/- 23% and 46 +/- 26%, respectively (mean +/- standard deviation; p less than 0.001 for each). Right ventricular impedance decreased an average 39 +/- 22% from its baseline value (p less than 0.001) during ventricular tachycardia. The percent change in impedance from baseline during ventricular tachycardia correlated significantly with the percent decrease in systolic and mean arterial pressure (r = 0.45 and 0.42, respectively; both p less than 0.05). Right ventricular dP/dt correlated the most poorly of all parameters with changes in blood pressure while impedance X RV pulse pressure correlated best with changes in mean and systolic pressure (r greater than or equal to 0.82, p less than 0.001).     

Response of Pulmonary Vein Potentials to Burst Pacing

BACKGROUND: Pulmonary vein potentials recorded at the ostia of pulmonary veins (PV) are a useful guide for segmental isolation of the PV in patients with atrial fibrillation (AF). Even during coronary sinus pacing at 600 ms, atrial (A) and PV potentials can overlap in 50-60% of patients making the accurate identification of PV potentials very difficult. METHODS: Nineteen patients (M:F 15:4) with paroxysmal AF underwent segmental isolation of one or more PV. Coronary sinus (CS) pacing was performed at cycle lengths of 600/550/500/450/400/350/300 ms and bipolar electrograms were recorded from the 10 or 20 pole Lasso catheter placed at the atrial-PV junction in 27 pulmonary veins. Stimulus (S) to A, S-PVP and A-PVP intervals were measured during CS pacing at the different cycle lengths at sweep speed of 200 mm/sec. RESULTS: During CS pacing at 600 ms the A and PV potentials were significantly overlapped (A-PVP < or = 25 ms) in 15 of 27 (55%) veins. During pacing at 300 ms, the A and PV potentials were significantly separated (A-PVP > or = 25 ms) in 9 of the 15 veins where A and PV potentials overlapped and 21 of all 27 (78%) veins. In two patients pacing at 300 ms was associated with 2:1 conduction block from atrial to PV fascicle. CONCLUSIONS: Coronary sinus pacing at cycle length of 300 ms demonstrated better separation of A and PV potentials compared to pacing at 600 ms. This strategy is easier and less time consuming compared to extrastimuli testing. It also confirms that the electrophysiological properties of PV fascicles are different from that of the adjacent atrial musculature.     

The rationale and design of the SMART CRT trial

Aims

The SMART CRT study will assess the efficacy of an atrioventricular optimization algorithm to improve reverse remodeling among patients undergoing cardiac resynchronization therapy (CRT) in the presence of interventricular electrical delay.

Methods and results

The SMART CRT study is a global, multicenter, prospective, randomized study of patients undergoing CRT implantation. The primary endpoint of this trial is response rate to CRT, defined as decrease in left ventricular end‐systolic volume (LVESV) ≥15% at 6 months compared to preimplant baseline. Additional prespecified analyses are: (1) clinical composite endpoint combining all‐cause mortality, heart failure events, New York Heart Association class, and Quality of Life (using a patient global assessment instrument); (2) the individual components of the clinical composite endpoint; (3) 6‐minute walk distance; (4) Kansas City Cardiomyopathy Questionnaire; (5) LVESV as a continuous variable; and (6) absolute left‐ventricular ejection fraction. Subjects with intraventricular delay ≥ 70 ms measured between the right ventricular and left ventricular pacing leads will be randomized in a 1:1 ratio to have either an AV Delay and pacing chamber determined by SmartDelay? or a Fixed AV Delay of 120 ms with biventricular pacing. Enrollment of an estimated 726 of subjects from up to 100 centers worldwide is planned to achieve 436 randomized subjects and 370 complete data sets required to power the primary endpoint.

Conclusions

This trial will provide important data regarding the importance of AV Delay programming in patients with prolonged interventricular delay at the pacing sites.