ISE/ISHNE expert consensus statement on the ECG diagnosis of left ventricular hypertrophy: The change of the paradigm

The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria. The classical paradigm postulates that the increased left ventricular mass generates a stronger electrical field, increasing the leftward and posterior QRS forces, reflected in the augmented QRS amplitude. However, the low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm. The theoretical background for voltage measured at the body surface is defined by the solid angle theorem, which relates the measured voltage to spatial and non-spatial determinants. The spatial determinants are represented by the extent of the activation front and the distance of the recording electrodes. The non-spatial determinants comprise electrical characteristics of the myocardium, which are comparatively neglected in the interpretation of the QRS patterns. Various clinical conditions are associated with LVH. These conditions produce considerable diversity of electrical properties alterations thereby modifying the resultant QRS patterns. The spectrum of QRS patterns observed in LVH patients is quite broad, including also left axis deviation, left anterior fascicular block, incomplete and complete left bundle branch blocks, Q waves, and fragmented QRS. Importantly, the QRS complex can be within normal limits. The new paradigm stresses the electrophysiological background in interpreting QRS changes, i.e., the effect of the non-spatial determinants. This postulates that the role of ECG is not to estimate LV size in LVH, but to understand and decode the underlying electrical processes, which are crucial in relation to cardiovascular risk assessment.

Healthcare is not about health

Initiatives designed to reduce the disease burden and improve the health of the US population that focus on increasing access to health care have been disappointing. Progress requires multifaceted change. We must first acknowledge that the healthcare system is focused on reversing or modifying disease, not enhancing health. Our conceptualization of the development of ill health and disease must also change. Scientific advances are clarifying the complex interactions among the development of ill health and disease and an individual's behaviors, their microbiota, and their physical, social, and emotional environments. A person's genetic makeup predisposes them to a wide array of disease conditions but is rarely deterministic in and of itself. Factors extrinsic to the individual, including the social determinants of health, play a major role in disease development, often decades later. The complexity of health and disease requires a "team" accountable for the health of our populations, and these teams must be expanded beyond the medical professions. Governmental officials, architects, business leaders, civic organizations, social and neighborhood groups are among the key stakeholders on the health side of the equation. If and when disease does become manifest, then the care part of the healthcare system assumes the larger role. This has major implications for the education of our clinically focused health science students, but also of professional disciplines previously deemed peripheral to health. Simply redoubling our efforts and focusing on our current healthcare system is insufficient to make progress in the health of the populace. One example of a multipronged approach in Allentown, PA is explored in depth.

Contribution to the Personalized Management of the Nosocomial Infections: A New Paradigm Regarding the Influence of the Community Microbial Environment on the Incidence of the Healthcare-Associated Infections (HAI) in Emergency Hospital Surgical Departments

Background: The management of acute surgical pathology implies not only the diagnosis-treatment sequence but also an important preventive component. In the surgical hospital department, wound infection is one of the most frequent complications which must be managed both in a preventive and a personalized manner. To achieve this goal, several factors of negative local evolution, contributing to the slowdown of the healing processes, such as the colonization and contamination of the wounds, need to be emphasized and controlled from the first moment. In this context, knowing the bacteriological status at admission ensures the distinction between the colonization and infection processes and could help to manage in an efficient way the fight against bacterial pathogen infections from the beginning. Methods: A prospective study was performed for 21 months on 973 patients hospitalized as emergencies in the Plastic and Reconstructive Surgery Department within the Emergency University County Hospital of Brasov, Romania. We analyzed the bacteriological profile of the patients from admission to discharge and the bidirectional and cyclic microorganism dynamics both in the hospital and the community microbial environment. Results: Of the 973 samples collected at admission, 702 were positive, with 17 bacterial species and one fungal, with a predominance of Gram-positive cocci at 74,85%. The most frequently isolated strains were Staphylococcus species (86.51% of the Gram-positive/64.7% of the total isolated strains), while Klebsiella at 8.16% and Pseudomonas aeruginosa species at 5.63% were mainly emphasized in the case of Gram-negative bacilli. Two to seven pathogens were introduced after admission, suggesting that the community microbial environment is in a process of evolution and enrichment with hospital pathogens. Conclusions: The high level of positive bacteriological samples and the complex associations of the pathogens found at the admission bacteriological screening sustain the new idea that the pathogenic microorganisms existing in the community microbial environment have started to increasingly influence the hospital microbial environment, in contrast with the previous consideration, which emphasized only the unidirectional relationship between hospital infections and the changing bacteriological characteristics of the community environment. This modified paradigm must become the basis of a new personalized approach to the management of nosocomial infections.

Novel paradigms in the therapeutic management of heart failure with preserved ejection fraction: clinical perspectives

Heart failure with preserved ejection fraction (HFpEF) is a pathological complexity that decreases cardiac output and elevates the ventricular filling pressure. HFpEF is usually misdiagnosed and maltreated. HFpEF is usually correlated with excessive morbidity and mortality. The prevalence of HFpEF is growing, and there is a deficiency of evidence-based therapy, creating challenges for the physician with no effective management guidelines. Moreover, HFpEF is not equivalent to diastolic heart failure as previously thought, as diastolic dysfunction is not the only underlying mechanism related to HFpEF and sometimes may be absent. Several other mechanisms may work in concert to produce HFpEF syndrome, either cardiac related (chronotropic incompetence, a longitudinal left ventricular (LV) systolic dysfunction despite a normal ejection fraction) or extracardiac related (pulmonary hypertension, abnormal ventricular-arterial coupling, abnormal exercise-induced vasodilation, extracardiac volume overload). These complex pathophysiologic mechanisms indicate that HFpEF is heterogeneous and that this syndrome might be related to a vascular or an endothelial dysfunction or might be considered a cardiac manifestation of one or more systemic illnesses. The heterogeneity of HFpEF necessitates excluding many differential diagnoses. In addition, the multiple comorbidities that are inherent to this condition need to be controlled in order to achieve effective management. Taken together, these key mechanisms might contribute to the multiple difficulties in the management of HFpEF patients; these mechanisms also explain why medications used in patients with other heart conditions may or may not be successful in these patients. Novel therapies and clinical trials including paradigm shifts in therapeutic management are needed to effectively manage HFpEF. The current review article sheds light on novel paradigms related to pathologies, diagnoses, and strategies, along with some proposed recommendations and clinical options for effective management of HFpEF.

Utilitarian Moral Judgment Exclusively Coheres with Inference from Is to Ought

Faced with moral choice, people either judge according to pre-existing obligations (deontological judgment), or by taking into account the consequences of their actions (utilitarian judgment). We propose that the latter coheres with a more general cognitive mechanism – deontic introduction, the tendency to infer normative (‘deontic’) conclusions from descriptive premises (is-ought inference). Participants were presented with vignettes that allowed either deontological or utilitarian choice, and asked to draw a range of deontic conclusions, as well as judge the overall moral rightness of each choice separately. We predicted and found a selective defeasibility pattern, in which manipulations that suppressed deontic introduction also suppressed utilitarian moral judgment, but had little effect on deontological moral judgment. Thus, deontic introduction coheres with utilitarian moral judgment almost exclusively. We suggest a family of norm-generating informal inferences, in which normative conclusions are drawn from descriptive (although value-laden) premises. This family includes deontic introduction and utilitarian moral judgment as well as other informal inferences. We conclude with a call for greater integration of research in moral judgment and research into deontic reasoning and informal inference.

Emerging horizons for tick-borne pathogens: from the 'one pathogen-one disease' vision to the pathobiome paradigm

Ticks, as vectors of several notorious zoonotic pathogens, represent an important and increasing threat for human and animal health in Europe. Recent applications of new technology revealed the complexity of the tick microbiome, which may affect its vectorial capacity. Appreciation of these complex systems is expanding our understanding of tick-borne pathogens, leading us to evolve a more integrated view that embraces the 'pathobiome'; the pathogenic agent integrated within its abiotic and biotic environments. In this review, we will explore how this new vision will revolutionize our understanding of tick-borne diseases. We will discuss the implications in terms of future research approaches that will enable us to efficiently prevent and control the threat posed by ticks.

Ginseng pharmacology: a new paradigm based on gintonin-lysophosphatidic acid receptor interactions

Ginseng, the root of Panax ginseng, is used as a traditional medicine. Despite the long history of the use of ginseng, there is no specific scientific or clinical rationale for ginseng pharmacology besides its application as a general tonic. The ambiguous description of ginseng pharmacology might be due to the absence of a predominant active ingredient that represents ginseng pharmacology. Recent studies show that ginseng abundantly contains lysophosphatidic acids (LPAs), which are phospholipid-derived growth factor with diverse biological functions including those claimed to be exhibited by ginseng. LPAs in ginseng form a complex with ginseng proteins, which can bind and deliver LPA to its cognate receptors with a high affinity. As a first messenger, gintonin produces second messenger Ca²⁺ via G protein-coupled LPA receptors. Ca²⁺ is an intracellular mediator of gintonin and initiates a cascade of amplifications for further intercellular communications by activation of Ca²⁺-dependent kinases, receptors, gliotransmitter, and neurotransmitter release. Ginsenosides, which have been regarded as primary ingredients of ginseng, cannot elicit intracellular [Ca²⁺]_i transients, since they lack specific cell surface receptor. However, ginsenosides exhibit non-specific ion channel and receptor regulations. This is the key characteristic that distinguishes gintonin from ginsenosides. Although the current discourse on ginseng pharmacology is focused on ginsenosides, gintonin can definitely provide a mode of action for ginseng pharmacology that ginsenosides cannot. This review article introduces a novel concept of ginseng ligand-LPA receptor interaction and proposes to establish a paradigm that shifts the focus from ginsenosides to gintonin as a major ingredient representing ginseng pharmacology.

Imaging deductive reasoning and the new paradigm

There has been a great expansion of research into human reasoning at all of Marr’s explanatory levels. There is a tendency for this work to progress within a level largely ignoring the others which can lead to slippage between levels (Chater et al., 2003). It is argued that recent brain imaging research on deductive reasoning—implementational level—has largely ignored the new paradigm in reasoning—computational level (Over, 2009). Consequently, recent imaging results are reviewed with the focus on how they relate to the new paradigm. The imaging results are drawn primarily from a recent meta-analysis by Prado et al. (2011) but further imaging results are also reviewed where relevant. Three main observations are made. First, the main function of the core brain region identified is most likely elaborative, defeasible reasoning not deductive reasoning. Second, the subtraction methodology and the meta-analytic approach may remove all traces of content specific System 1 processes thought to underpin much human reasoning. Third, interpreting the function of the brain regions activated by a task depends on theories of the function that a task engages. When there are multiple interpretations of that function, interpreting what an active brain region is doing is not clear cut. It is concluded that there is a need to more tightly connect brain activation to function, which could be achieved using formalized computational level models and a parametric variation approach.

Cardiac autonomic functions and the emergence of violence in a highly realistic model of social conflict in humans

Among the multitude of factors that can transform human social interactions into violent conflicts, biological features received much attention in recent years as correlates of decision making and aggressiveness especially in critical situations. We present here a highly realistic new model of human aggression and violence, where genuine acts of aggression are readily performed and which at the same time allows the parallel recording of biological concomitants. Particularly, we studied police officers trained at the International Training Centre (Budapest, Hungary), who are prepared to perform operations under extreme conditions of stress. We found that aggressive arousal can transform a basically peaceful social encounter into a violent conflict. Autonomic recordings show that this change is accompanied by increased heart rates, which was associated earlier with reduced cognitive complexity of perceptions (“attentional myopia”) and promotes a bias toward hostile attributions and aggression. We also observed reduced heart rate variability in violent subjects, which is believed to signal a poor functioning of prefrontal-subcortical inhibitory circuits and reduces self-control. Importantly, these autonomic particularities were observed already at the beginning of social encounters i.e., before aggressive acts were initiated, suggesting that individual characteristics of the stress-response define the way in which social pressure affects social behavior, particularly the way in which this develops into violence. Taken together, these findings suggest that cardiac autonomic functions are valuable external symptoms of internal motivational states and decision making processes, and raise the possibility that behavior under social pressure can be predicted by the individual characteristics of stress responsiveness.

A new paradigm is needed for medical education in the mid-twenty-first century and beyond: are we ready?

The twentieth century witnessed profound changes in medical education. All these changes, however, took place within the existing framework, suggested by Flexner a century ago. The present paper suggests that we are approaching a singularity point, where we shall have to change the paradigm and be prepared for an entirely new genre of medical education. This suggestion is based upon analysis of existing and envisaged trends: first, in technology, such as availability of information and sophisticated simulations; second, in medical practice, such as far-reaching interventions in life and death that create an array of new moral dilemmas, as well as a change in patient mix in hospitals and a growing need of team work; third, in the societal attitude toward higher education. The structure of the future medical school is delineated in a rough sketch, and so are the roles of the future medical teacher. It is concluded that we are presently not prepared for the approaching changes, neither from practical nor from attitudinal points of view, and that it is now high time for both awareness of and preparation for these changes.

Low-risk papillary thyroid cancer: times are changing

The prevalence of papillary thyroid cancer (PTC), particularly of low-risk PTC (MACIS <6), is rising due to the increasingly use of neck imaging techniques, fine-needle aspiration and whole body PET scans. Observational cohort studies carried out in the last two decades suggest that low-risk PTC are being overtreated due to the current management paradigm being built on studies done in the 70s and 80s that still echo in some influential guidelines. With the progressive adoption of total thyroidectomy and central neck dissection as the mainstay of treatment for PTC, and suppressed basal thyroglobulin and neck ultrasound once a year as the essential tools for follow-up, the use of radioiodine ablation, body scans and stimulated thyroglobulin concentrations has become obsolete for the vast majority of patients with low-risk PTC. Future guidelines on the management of differentiated thyroid cancer should discuss separately three different diseases: low-risk PTC, high-risk PTC and follicular cancer.