Anesthetic Management for Ventricular Tachycardia Ablation: A National Anesthesia Clinical Outcomes Registry Analysis

OBJECTIVES

The authors analyzed anesthetic management trends during ventricular tachycardia (VT) ablation, hypothesizing that (1) monitored anesthesia care (MAC) is more commonly used than general anesthesia (GA); (2) MAC uses significantly increased after release of the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias; and (3) anesthetic approach varies based on patient and hospital characteristics.

DESIGN

Retrospective study.

SETTING

National Anesthesia Clinical Outcomes Registry data.

PARTICIPANTS

Patients 18 years or older who underwent elective VT ablation between 2013 and 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Covariates were selected a priori within multivariate models, and interrupted time-series analysis was performed. Of the 15,505 patients who underwent VT ablation between 2013 and 2021, 9,790 (63.1%) received GA. After the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias supported avoidance of GA in idiopathic VT, no statistically significant increase in MAC was evident (immediate change in intercept post-consensus statement release adjusted odds ratio 1.41, p = 0.1629; change in slope post-consensus statement release adjusted odds ratio 1.06 per quarter, p = 0.1591). Multivariate analysis demonstrated that sex, American Society of Anesthesiologists physical status, age, and geographic location were statistically significantly associated with the anesthetic approach.

CONCLUSIONS

GA has remained the primary anesthetic type for VT ablation despite the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias suggested its avoidance in idiopathic VT. Achieving widespread clinical practice change is an ongoing challenge in medicine, emphasizing the importance of developing effective implementation strategies to facilitate awareness of guideline release and subsequent adherence to and adoption of recommendations.

A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults

STUDY OBJECTIVES

The treatment of obstructive sleep apnea is often impeded by intolerance of positive airway pressure therapy, which is frequently attributed to the inability to breathe through the nose. Providers caring for patients with sleep apnea need a working knowledge of nasal passage disease and available treatments to better manage this common comorbidity.

METHODS

This review examines the literature connecting rhinosinusitis to adverse sleep and sleep apnea outcomes. It explores the different types of nasal and sinus diseases a sleep apnea provider might encounter, focusing on the medications used to treat them and indications for referral to otolaryngology.

RESULTS

Chronic rhinosinusitis can be either allergic or nonallergic. Both types can interfere with sleep and sleep apnea therapy. The successful management of chronic rhinosinusitis can improve positive airway pressure tolerance and adherence. A wide range of over-the-counter and prescription pharmacotherapy is available, with data supporting intranasal over oral treatment. Surgical treatment for chronic rhinosinusitis in obstructive sleep apnea addresses nasal obstruction, often with inferior turbinate reduction and septoplasty.

CONCLUSIONS

Sleep specialists should have a working knowledge of the available options to treat chronic rhinosinusitis. These options are often safe, effective, and readily accessible. Otolaryngologists and allergists/immunologists provide additional treatment options for more complicated patients. Providing treatment for chronic rhinosinusitis should be included as part of comprehensive sleep apnea care.

CITATION

Ali MM, Ellison M, Iweala OI, Spector AR. A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults. J Clin Sleep Med. 2023;19(8):1545-1552.

Anesthetic choice for arteriovenous access creation: A National Anesthesia Clinical Outcomes Registry analysis

BACKGROUND

We sought to evaluate differences in primary anesthetic type used in arteriovenous access creation with the hypothesis that administration of regional anesthesia and monitored anesthesia care (MAC) with local anesthesia as the primary anesthetic has increased over time.

METHODS

National Anesthesia Clinical Outcomes Registry data were retrospectively evaluated. Covariates were selected a priori within multivariate models to determine predictors of anesthetic type in adults who underwent elective arteriovenous access creation between 2010 and 2018.

RESULTS

A total of 144,392 patients met criteria; 90,741 (62.8%) received general anesthesia. The use of regional anesthesia and MAC decreased over time (8.0%-6.8%, 36.8%-27.8%, respectively; both p < 0.0001). Patients who underwent regional anesthesia were more likely to have ASA physical status >III and to reside in rural areas (52.3% and 12.9%, respectively; both p < 0.0001). Patients who underwent MAC were more likely to be older, male, receive care outside the South, and reside in urban areas (median age 65, 56.8%, 68.1%, and 70.8%, respectively; all p < 0.0001). Multivariate analysis revealed that being male, having an ASA physical status >III, and each 5-year increase in age resulted in increased odds of receiving alternatives to general anesthesia (regional anesthesia adjusted odds ratios (AORs) 1.06, 1.12, and 1.26, MAC AORs 1.09, 1.2, and 1.1, respectively; all p < 0.0001). Treatment in the Midwest, South, or West was associated with decreased odds of receiving alternatives to general anesthesia compared to the Northeast (regional anesthesia AORs 0.28, 0.38, and 0.03, all p < 0.0001; MAC 0.76, 0.13, and 0.43, respectively; all p < 0.05).

CONCLUSIONS

Use of regional anesthesia and MAC with local anesthesia for arteriovenous access creation has decreased over time with general anesthesia remaining the primary anesthetic type. Anesthetic choice, however, varies with patient characteristics and geography.

Immunologic risk stratification of pediatric heart transplant patients by combining HLA-EMMA and PIRCHE-II

Human leukocyte antigen (HLA) molecular mismatch is a powerful biomarker of rejection. Few studies have explored its use in assessing rejection risk in heart transplant recipients. We tested the hypothesis that a combination of HLA Epitope Mismatch Algorithm (HLA-EMMA) and Predicted Indirectly Recognizable HLA Epitopes (PIRCHE-II) algorithms can improve risk stratification of pediatric heart transplant recipients. Class I and II HLA genotyping were performed by next-generation sequencing on 274 recipient/donor pairs enrolled in the Clinical Trials in Organ Transplantation in Children (CTOTC). Using high-resolution genotypes, we performed HLA molecular mismatch analysis with HLA-EMMA and PIRCHE-II, and correlated these findings with clinical outcomes. Patients without pre-formed donor specific antibody (DSA) (n=100) were used for correlations with post-transplant DSA and antibody mediated rejection (ABMR). Risk cut-offs were determined for DSA and ABMR using both algorithms. HLA-EMMA cut-offs alone predict the risk of DSA and ABMR; however, if used in combination with PIRCHE-II, the population could be further stratified into low-, intermediate-, and high-risk groups. The combination of HLA-EMMA and PIRCHE-II enables more granular immunological risk stratification. Intermediate-risk cases, like low-risk cases, are at a lower risk of DSA and ABMR. This new way of risk evaluation may facilitate individualized immunosuppression and surveillance.

Results from a blind comparison of chloride measurements by accredited laboratories and the implications for enforcing increasingly stringent HCl emission limits in EU legislation

We report results from a blind comparison of six analytical laboratories ISO/IEC 17025 accredited for the implementation of the analytical element of EN 1911, which involves the quantification of chloride in deionized water collected from HCl emitting industrial processes regulated under the EU's Industrial Emissions Directive (IED). Both "synthetic" (sodium chloride dissolved in deionized water) and "real" (extracted and collected from a stack simulator facility) samples were prepared across ranges which were equivalent to concentrations in the stack of 0-10 mg·m^-3 and 0-60 mg·m^-3, respectively. Laboratory measurements of the real samples showed significantly poorer performance than the synthetic, implying that the use of synthetic samples in national proficiency testing schemes may be leading to an overly optimistic view of the uncertainties that can routinely be achieved in measurements of real industrial processes. In addition, at the applicable emission limits (10 mg·m^-3 and 3 mg·m^-3) and measurement ranges (0-15 mg·m^-3 and 0-4.5 mg·m^-3) under the IED and more recent BAT Conclusions legislation it was found that of the real samples 22 out of 102 (21.6%) and 28 out of 51 (54.9%), respectively, of the measurements would not comply with the overall uncertainty that at least one national regulator considers as necessary for EN 1911 to be an "effective tool" for the calibration of automated measuring systems (AMSs - process plant operator analyzers providing continuous monitoring of emissions). Hence, it is proposed that at the next revision of EN 1911 the standard should be revised to give the same degree of consideration to the analytical element of the method as the sampling element. Key analytical laboratory uncertainty sources should be identified, numerical uncertainty requirements should be placed on key analytical uncertainty sources, and there should be an overall uncertainty requirement for the analytical element.Implications: The deviations observed between laboratories ISO/IEC 17025 accredited for chloride analysis bring into question the ability of the current version of EN 1911 (the CEN Standard Reference Method for monitoring HCl industrial emissions) to meet the uncertainty requirements associated with emission limits under both the EU's Industrial Emissions Directive and the increasingly stringent industrial sub-sectors BAT Conclusions legislation. It is proposed that at the next revision of EN 1911 that uncertainty guidance and requirements for the analytical element are added if this measurement method is to continue to be mandated across Europe for ensuring emissions data meet legislative quality requirements.

Healthcare Leadership in the COVID-19 Pandemic: From Innovative Preparation to Evolutionary Transformation

Purpose

In pandemics, centralized healthcare leadership is a critical requirement. The objective of this study was to analyze the early development, operation, and effectiveness of a COVID-19 organizational leadership team and transformation of healthcare services at West Virginia University Hospitals and Health System (WVUHS). The analysis focused on how Kotter’s Leading Change eight-stage paradigm could contribute to an understanding of the determinants of successful organizational change in response to the COVID-19 pandemic.

Methods

The fifteen core leaders of WVUHS COVID-19 strategic system were interviewed. A qualitative thematic analysis of the interviews was used to evaluate key aspects of leadership dynamics and system-wide changes in healthcare policies and protocols to contain the pandemic. Outcome measures included the degree to which WVUHS could handle and contain COVID-19 cases as well as COVID-19 death and vaccination rates in West Virginia compared with other states.

Results

The leadership team radically and rapidly revamped nearly all healthcare policies, procedures, and protocols for WVUHS hospitals and clinics, and launched a Hospital Incident Command System. As a result of this effective leadership team and strategic plan, WVUHS surge capacity was adequate for COVID-19 cases. In addition, West Virginia was an early frontrunner in COVID-19 vaccination rates as well as lower death rates.

Conclusion

WVUHS’s leadership response to the COVID-19 pandemic followed Kotter’s eight-stage paradigm for Leading Change in organizations, including the establishment of a sense of urgency, formation of a powerful guiding coalition, creation of a vision, communication of the vision, empowerment of others to act on the vision, plan for and creation of short-term wins, consolidation of improvements and production of more changes, and institutionalization of new approaches. This approach was effective in limiting the spread and impact of COVID-19 within the hospital network and across the state, with many lessons learned along the way.

Quadricuspid Aortic Valve Repair Facilitated by Geometric Ring Annuloplasty

Quadricuspid aortic valve (QAV) is a rare congenital anomaly often associated with aortic insufficiency. The exact anatomy of QAV is variable, and most cases have undergone aortic valve replacement. With the recognition that aortic valve repair achieves superior patient outcomes as compared to replacement, a systematic approach to autologous reconstruction of QAV is needed. This article reports 2 cases having successful repair utilizing geometric aortic annuloplasty rings, and describes a proposed scheme for repairing most QAV defects, based on relative leaflet and commissural characteristics. Using either tri-leaflet or bicuspid ring annuloplasty, the normal sub-commissural triangles can be remodeled into a 120° or 180° configuration, respectively, and then the leaflets can be sutured and plicated to fit annular geometry. With this approach, most quadricuspid valves potentially could undergo autologous reconstruction.

Incidence, Prevalence, and Outcomes of Pediatric Trauma in Rural Appalachia (West Virginia) From 2017 to 2019

Background Appalachian rural pediatric trauma has its unique incidence, presentation, and distribution due to the mechanisms of injury, geographic location, access to care, and social issues.  Purpose To review, analyze, and understand pediatric trauma in West Virginia during the period 2017-2019. Materials and methods After institutional review board approval, the statewide trauma database was queried and analyzed in a retrospective cohort study for all pediatric trauma ages zero to 18 from 2017-2019 in the Appalachian regions one through four in West Virginia. The following were analyzed: gender, injury mechanism, Glasgow Coma Scale Score (GCS) at admission, injury severity score (ISS), toxicology screen results, hospital length of stay, duration of ventilatory support, number of procedures performed during admission, presence of non-accidental trauma, cardiac arrest, patient discharge disposition, and mortality. Results One-thousand eighty-two (1182) patients between the ages of zero to 18 were admitted to the trauma center. An average of 37% was female and 63% male. In the 11-18 age group, 24% were female and 76% were male. Most injuries were due to blunt force (89%), followed by penetrating injuries (7.2%) and burns (1.4%). The majority had minor or moderate injuries with 95% receiving a Glasgow Coma Scale (GCS) >13 and 72% listed as minor on the injury severity score (ISS). Children in ages 0-2 years had the highest proportion of poor (0-8) GCS scores, high ISS (>14) scores, most hospital admission days, most days on a ventilator, highest mortality, most pre-hospital cardiac arrests, child abuse, burns, and placement with child protective services. An average of 31% of children tested, and 17% in the age group of 0-2 had a positive toxicology screen. There were 3670 procedures done in total and the most common procedure performed was an ultrasound of the abdomen. Procedures were performed in 90% of the patients. Conclusions and relevance Based on our study, the zero to two-year-old pediatric trauma patients are most vulnerable to poor outcomes and may need targeted preventative interventions. Toxicology screens may need to be more widely implemented in pediatric trauma in the Appalachian region. Rural trauma in Appalachia has endemic issues related to substance abuse, poverty, and a lower degree of social support as compared to urban areas. Although the distribution of injury may follow a national distribution, mechanism, management, and outcomes can vary.

A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery

Patient: Male, 34-year-old

Final Diagnosis: Infective endocarditis of the tricuspid valve

Symptoms: Lethargy • weakness

Medication: —

Clinical Procedure: Tricuspid valve repair • tricuspid valve replacement

Specialty: Anesthesiology • Cardiac Surgery • Infectious Diseases • Psychiatry

Will Protective Innovations Like the "Airway Box" Become Routine Practice After the Pandemic?: An Opinion Survey

Background

Tracheal intubation carries an elevated risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the generation of aerosols containing high concentrations of the virus. An airway box was designed to mitigate the exposure of healthcare professionals performing intubations.

Aim

We evaluated usability and sustainability in the routine practice of the "airway box" as a protective device during high-risk airway procedures. 

Materials and methods

After institutional review board approval, clinicians were educated on using the device through simulation, intranet learning modules, and emailed resources. The airway box was made available in the emergency department, critical care units, perioperative area, and operating rooms. QR codes affixed to the box, emailed, and displayed in common areas provided easy access to complete a REDcap survey (Vanderbilt University Nashville, USA) eliciting providers’ experience. Data was collected and analyzed between April 1 and July 31, 2020, on REDcap, and the results were analyzed.

Results

687 emergent intubations took place. 232 were performed by anesthesiologists, 315 by emergency department providers, and 140 by critical care specialists. 39 surveys were completed, 29 from intubations in the operating room, three from the critical care units, five from interventional radiology suites, and two perioperatively. Providers found the device to be readily available, with a score of 4.51/5, and the majority of providers, 60%, found the device easy to use, rating it either a 4 or 5 out of 5. Providers acquired a mean Mallampati score of 1.75 and 1.40 mean laryngoscopic grade view.

Conclusion

Intubation boxes may effectively mitigate high-risk viral exposure during airway procedures. Survey responses show that devices were easy to use and did not significantly affect visualization of the airway. Similar to mask use, enclosure devices in clinical practice could become a vital part of medical protective equipment even after the SARS-CoV-2 pandemic if they are effectively implemented. 

Anesthetic Choice for Atrial Fibrillation Ablation: A National Anesthesia Clinical Outcomes Registry Analysis

OBJECTIVE

The authors evaluated the type of anesthesia administered in atrial fibrillation ablation, hypothesizing that monitored anesthesia care is used less frequently than general anesthesia.

DESIGN

A retrospective study.

SETTING

National Anesthesia Clinical Outcomes Registry data, which are multi-institutional from across the United States.

PARTICIPANTS

Adult patients who underwent elective atrial fibrillation ablation between 2013 and 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

National Anesthesia Clinical Outcomes Registry data were evaluated, and covariates were selected a priori within multivariate models to assess for predictors of anesthetic type. A total of 54,321 patients underwent atrial fibrillation ablation; 3,251 (6.0%) received monitored anesthesia care. Patients who received monitored anesthesia care were more likely to be >80 years old (12.4% v 4.9%; p < 0.0001), female (36.1% v 34.3%; p < 0.0001), have American Society of Anesthesiologists physical status >III (17.28% v 10.48%; p < 0.0001), and reside in urban areas (62.23% v 53.37%; p < 0.0001). They received care in the Northeast (17.6% v 10.1%; p < 0.0001) at low-volume centers (median 224 v 284 procedures; p < 0.0001). Multivariate analysis revealed that each five-year increase in age, being female, and having an American Society of Anesthesiologists physical status >III resulted in a 7% (p < 0.0001), 9% (p = 0.032), and 200% (p < 0.0001) increased odds of receiving monitored anesthesia care, respectively. Requiring additional ablation of atria or of a second arrhythmia and residing outside the Northeast resulted in a decreased odds of monitored anesthesia care (adjusted odds ratio 0.24 [p=0.002] and < 0.5 [p < 0.03], respectively). For each 50 cases performed annually at a center, the odds decreased by 5% (p = 0.005).

CONCLUSIONS

General anesthesia is the most common type of anesthesia administered for atrial fibrillation ablation. The type of anesthesia administered, however, varies with patient, procedural, and hospital characteristics.

Aortic Cannulation around Grade 5 Aortic Arch Atheroma Utilizing Transesophageal Echocardiography

A 61-year-old male with severe aortic valve stenosis was scheduled for a minimally invasive bioprosthetic aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) showed a unicuspid aortic valve and extensive aortic atheromatous disease. A large atheroma with mobile components existed near the distal aortic arch. A 17-French aortic cannula was successfully placed using TEE guidance with the tip proximal to the mobile atheroma to avoid inadvertent disruption and subsequent embolic sequelae. The patient had no evidence of perioperative stroke or other complications postoperatively. This case demonstrates one strategy to manage severe atheromatous disease intraoperatively. We also review additional management options.

Uncertainty requirements of the European Union's Industrial Emissions Directive for monitoring sulfur dioxide emissions: Implications from a blind comparison of sulfate measurements by accredited laboratories

We report results from a blind comparison of five analytical laboratories ISO/IEC 17025 (International Organization for Standardization/International Electrotechnical Commission) accredited for the analysis of sulfate collected in H₂O_2(aq) from industrial stacks in accordance with the European Standard Reference Method (SRM) for sulfur dioxide (SO₂) (EN 14791): the method produced under European Commission mandate to support the enforcement of the Industrial Emissions Directive (IED). Both "synthetic" (sodium sulfate dissolved in aqueous hydrogen peroxide [H₂O_2(aq)]) and "real" (extracted and collected from a stack simulator facility in accordance with EN 14791) samples were prepared across 2-10 and 10-290 mg·m₀^-3 emission equivalent concentration ranges, respectively. From the measurements returned by the laboratories, it was found that in 35% of the former and 28% of the latter the stated expanded uncertainty limits did not intersect with the mean. It was also found with the real samples that in 30% of the 46 different concentration test levels the stated expanded uncertainty of at least two of the laboratories did not intersect. With respect to compliance monitoring, it was found that EN 14791 was capable of enforcing emission limits under the IED associated with waste incinerators (i.e., 50 mg·m₀^-3), as only 3% of the deviations were in excess of the required uncertainty (commensurate with a 95% level of confidence). However, with respect to the use of EN 14791 for calibration of automated measuring systems (AMSs), it was found that 38.5% of the deviations were in excess of the uncertainty recommended by at least one national regulator as being necessary for EN 14791 to be an "effective tool" for the calibration of AMSs. With emission limits under the IED and the Best Available Technique Reference (BREF) documents it adopts becoming increasingly stringent, it is clear that more work is needed to determine the capability of the SRM and also alternative methods based on portable instruments. Implications: The deviations observed between laboratories ISO/IEC 17025 accredited for sulfate analysis bring into question the monitoring communities' ability to routinely meet the uncertainty requirements associated with increasingly stringent SO₂ emission limits under the European Union's Industrial Emissions Directive. Furthermore, with even further reductions in the near future due to legislative adoption of BREF documents, such issues are only likely to be exacerbated. If the European monitoring community is to have confidence in the capability of the existing Standard Reference Method described in EN 14791 for enforcing increasingly stringent limits, work is needed to validate this method at these lower emission levels.

The impact of Huntington disease on young people

This chapter covers the challenges young people impacted by Huntington's disease (HD) experience on a daily basis. Research suggests young people in HD families are twice as likely to struggle with issues such as self-harm, depression, anxiety etc. Yet support for young people in HD families is generally lacking. Young people in HD families have to face their own genetic risk for HD, caregiving responsibilities, social isolation, financial woes, educational impact on top of witnessing their family member progressing with HD and gradually losing one ability after another until they are unable to do anything. There are plenty of challenges when you're a young person impacted by HD. This chapter covers most.

Prolonged Paralysis Following Emergent Cesarean Section with Succinylcholine Despite Normal Dibucaine Number

Prolonged paralysis due to a quantitative or qualitative deficiency of pseudocholinesterase activity is an uncommon but known side effect of succinylcholine. We describe a patient who experienced prolonged paralysis following administration of succinylcholine for general anesthesia and endotracheal intubation for an emergent cesarean section despite laboratory evidence of normal enzyme function. The patient required mechanical ventilation in the intensive care unit for several hours following surgery. The patient was extubated following return of full muscle strength and had a good outcome. The enzyme responsible for the metabolism of succinylcholine, pseudocholinesterase, was determined to be low in quantity in this patient but was functionally normal. This low level, by itself, was unlikely to be solely responsible for the prolonged paralysis. The patient likely had an abnormal pseudocholinesterase enzyme variant that is undetectable by standard laboratory tests.

Effect of Head Position on Intraocular Pressure During Lumbar Spine Fusion: A Randomized, Prospective Study

BACKGROUND

Ischemic optic neuropathy resulting in visual loss is a rare but devastating complication of spine surgery. Elevated intraocular pressure (IOP) results in decreased perfusion and possibly ischemic optic neuropathy. We performed a randomized, prospective trial to evaluate the effect of head positioning on IOP during lumbar spine fusion.

METHODS

The study included fifty-two patients treated at one institution. Inclusion criteria were a lumbar spine fusion and an age of eighteen to eighty years. Exclusion criteria were a diagnosis of tumor, infection, or traumatic injury or a history of eye disease, ocular surgery, cervical spine surgery, chronic neck pain, or cervical stenosis. The control group underwent the surgery with the head in neutral and the face parallel to the level operating room table whereas, in the experimental group, the neck was extended so that the face had a 10° angle of inclination in relation to the table. IOP measurements were recorded along with the corresponding blood pressure and PCO2 values at the same time points. The primary outcome measure was the change in intraocular pressure (ΔIOP, defined as the maximum IOP minus the initial IOP).

RESULTS

Analysis of covariance (ANCOVA) was used for categorical risk factors, and regression analysis was used for continuous risk factors. The mean ΔIOP, corrected for duration of surgery, was significantly (p = 0.0074) lower in the group treated with the head elevated than it was in the group treated with the head in neutral (difference between the two groups, 4.53 mm Hg [95% confidence interval, 1.29 to 7.79 mm Hg]). No patient sustained visual loss or any cervical-spine-related complications.

CONCLUSIONS

Head elevation for adult lumbar spine fusion performed with the patient prone resulted in significantly lower IOP measurements than those seen when the operation was done with the patient's head in neutral. As lower IOP correlates with increased optic nerve perfusion, this intervention could mitigate the risk of perioperative blindness after spine surgery done with the patient prone.

Developing an intervention to facilitate family communication about inherited genetic conditions, and training genetic counsellors in its delivery

Many families experience difficulty in talking about an inherited genetic condition that affects one or more of them. There have now been a number of studies identifying the issues in detail, however few have developed interventions to assist families. The SPRinG collaborative have used the UK Medical Research Council's guidance on Developing and Evaluating Complex Interventions, to work with families and genetic counsellors (GCs) to co-design a psycho-educational intervention to facilitate family communication and promote better coping and adaptation to living with an inherited genetic condition for parents and their children (<18 years). The intervention is modelled on multi-family discussion groups (MFDGs) used in psychiatric settings. The MFDG was developed and tested over three phases. First focus groups with parents, young people, children and health professionals discussed whether MFDG was acceptable and proposed a suitable design. Using evidence and focus group data, the intervention and a training manual were developed and three GCs were trained in its delivery. Finally, a prototype MFDG was led by a family therapist and co-facilitated by the three GCs. Data analysis showed that families attending the focus groups and intervention thought MFDG highly beneficial, and the pilot sessions had a significant impact on their family' functioning. We also demonstrated that it is possible to train GCs to deliver the MFDG intervention. Further studies are now required to test the feasibility of undertaking a definitive randomised controlled trial to evaluate its effectiveness in improving family outcomes before implementing into genetic counselling practice.

Proteomic analysis of the supernatant of red blood cell units: the effects of storage and leucoreduction

BACKGROUND

Red blood cell (RBC) transfusion is a life-saving intervention for critically ill patients; however, it has been linked to increased morbidity and mortality. We hypothesize that a number of important proteins accumulate during routine storage of RBCs, which may explain some of the adverse effects seen in transfused patients.

STUDY DESIGN

Five RBC units were drawn and divided (half prestorage leucoreduced (LR-RBC) and half left as an unmodified control (RBC). The supernatant was separated on days 1 and 42 of storage and proteomic analyses completed with in-gel tryptic digestion and nano-liquid chromatography tandem mass spectrometry.

RESULTS

In RBC supernatants, 401 proteins were identified: 203 increased with storage, 114 decreased, and 84 were unchanged. In LR-RBC supernatant, 231 proteins were identified: 84 increased with storage, 30 decreased, and 117 were unchanged. Prestorage leucoreduction removed many platelet- and leucocyte-derived structural proteins; however, a number of intracellular proteins accumulated including peroxiredoxins (Prdx) 6 and latexin. The increases were confirmed by immunoblotting, including the T-phosphorylation of Prdx-6, indicating that it may be functioning as an active phospholipase. Active matrix metalloproteinase-9 also increased with a coinciding decrease in the metalloproteinase inhibitor 1 and cystatin C.

CONCLUSION

We conclude that a number of proteins increase with RBC storage, which is partially ameliorated with leucoreduction, and transfusion of stored RBCs may introduce mediators that result in adverse events in the transfused host.

Silicon optical fiber

Described herein are initial experimental details and properties of a silicon core, silica glass-clad optical fiber fabricated using conventional optical fiber draw methods. Such semiconductor core fibers have potential to greatly influence the fields of nonlinear fiber optics, infrared and THz power delivery. More specifically, x-ray diffraction and Raman spectroscopy showed the core to be highly crystalline silicon. The measured propagation losses were 4.3 dB/m at 2.936 microm, which likely are caused by either microcracks in the core arising from the large thermal expansion mismatch with the cladding or to SiO(2) precipitates formed from oxygen dissolved in the silicon melt. Suggestions for enhancing the performance of these semiconductor core fibers are provided. Here we show that lengths of an optical fiber containing a highly crystalline semiconducting core can be produced using scalable fiber fabrication techniques.

Effects of overlapping parametric resonances on the particle diffusion process

The evolution of the beam distribution in a double-rf system with a phase modulation on either the primary or secondary rf cavity was measured. We find that the particle diffusion process obeys the Einstein relation if the phase space becomes globally chaotic. When dominant parametric resonances still exist in the phase space, particles stream along the separatrices of the dominant resonance, and the beam width exhibits characteristic oscillatory structure. The particle-tracking simulations for the double-rf system are employed to reveal the essential diffusion mechanism. Coherent octupolar motion has been observed in the bunch beam excitation. The evolution of the longitudinal phase space in the octupole mode is displayed.

Differential targeting of nicotinic acetylcholine receptors by novel alphaA-conotoxins

We describe the isolation and characterization of two peptide toxins from Conus ermineus venom targeted to nicotinic acetylcholine receptors (nAChRs). The peptide structures have been confirmed by mass spectrometry and chemical synthesis. In contrast to the 12-18 residue, 4 Cys-containing alpha-conotoxins, the new toxins have 30 residues and 6 Cys residues. The toxins, named alphaA-conotoxins EIVA and EIVB, block both Torpedo and mouse alpha1-containing muscle subtype nAChRs expressed in Xenopus oocytes at low nanomolar concentrations. In contrast to alpha-bungarotoxin, alphaA-EIVA is inactive at alpha7-containing nAChRs even at micromolar concentrations. In this regard, alphaA-EIVA is similar to the previously described alpha-conotoxins (e.g. alpha-MI and alpha-GI) which also selectively target alpha1- versus alpha7-containing nAChRs. However, alpha-MI and alpha-GI discriminate between the alpha/delta versus alpha/gamma subunit interfaces of the mouse muscle nAChR with 10,000-fold selectivity. In contrast, alphaA-conotoxin EIVA blocks both the alpha/gamma site and alpha/delta site with equally high affinity but with distinct kinetics. The alphaA-conotoxins thus represent novel probes for the alpha/gamma as well as the alpha/delta binding sites of the nAChR.

Who gets a heart? Rationing and rationalizing in heart transplantation

National policy on organ transplantation is made by the United Network for Organ Sharing (UNOS), a representative body composed of health care professionals and patients. Standardized criteria for determining when a patient should be placed on the waiting list for heart transplantation are now in effect nationwide. Current and future directions to maximize the utilization of available donated organs are explored.

Molecular activation-deactivation of xanthine oxidase in human milk

Enzymic activity and protein levels of xanthine oxidase were measured in serial samples of breast milk donated by each of 14 mothers, starting, in all but two cases, within 7 days following parturition. Enzyme activity varied widely, usually reaching peak values during the first 15 days and falling thereafter, by as much as 98%, to basal levels that were subsequently largely maintained. Corresponding changes in xanthine oxidase protein levels were not observed and, consequently, the specific activity of xanthine oxidase followed the above pattern. The capacity of human xanthine oxidase to undergo activation-deactivation cycles at the molecular level has important implications, not only for its role in breast milk, but also for its potential as a source of reactive oxygen species in other human tissues.