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Gupta U, Paluru N, Nankani D, Kulkarni K, Awasthi N. A comprehensive review on efficient artificial intelligence models for classification of abnormal cardiac rhythms using electrocardiograms. Heliyon 2024; 10:e26787. [PMID: 38562492 PMCID: PMC10982903 DOI: 10.1016/j.heliyon.2024.e26787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/20/2024] [Indexed: 04/04/2024] Open
Abstract
Deep learning has made many advances in data classification using electrocardiogram (ECG) waveforms. Over the past decade, data science research has focused on developing artificial intelligence (AI) based models that can analyze ECG waveforms to identify and classify abnormal cardiac rhythms accurately. However, the primary drawback of the current AI models is that most of these models are heavy, computationally intensive, and inefficient in terms of cost for real-time implementation. In this review, we first discuss the current state-of-the-art AI models utilized for ECG-based cardiac rhythm classification. Next, we present some of the upcoming modeling methodologies which have the potential to perform real-time implementation of AI-based heart rhythm diagnosis. These models hold significant promise in being lightweight and computationally efficient without compromising the accuracy. Contemporary models predominantly utilize 12-lead ECG for cardiac rhythm classification and cardiovascular status prediction, increasing the computational burden and making real-time implementation challenging. We also summarize research studies evaluating the potential of efficient data setups to reduce the number of ECG leads without affecting classification accuracy. Lastly, we present future perspectives on AI's utility in precision medicine by providing opportunities for accurate prediction and diagnostics of cardiovascular status in patients.
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Affiliation(s)
- Utkarsh Gupta
- Department of Computational and Data Sciences, Indian Institute of Science, Bengaluru, 560012, India
| | - Naveen Paluru
- Department of Computational and Data Sciences, Indian Institute of Science, Bengaluru, 560012, India
| | - Deepankar Nankani
- Department of Computer Science and Engineering, Indian Institute of Technology, Guwahati, Assam, 781039, India
| | - Kanchan Kulkarni
- IHU-LIRYC, Heart Rhythm Disease Institute, Fondation Bordeaux Université, Pessac, Bordeaux, F-33000, France
- University of Bordeaux, INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, F-33000, France
| | - Navchetan Awasthi
- Faculty of Science, Mathematics and Computer Science, Informatics Institute, University of Amsterdam, Amsterdam, 1090 GH, the Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Amsterdam, 1081 HV, the Netherlands
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Roberts JD, Walton RD, Loyer V, Bernus O, Kulkarni K. Open-source software for respiratory rate estimation using single-lead electrocardiograms. Sci Rep 2024; 14:167. [PMID: 38168512 PMCID: PMC10762020 DOI: 10.1038/s41598-023-50470-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024] Open
Abstract
Respiratory rate (RR) is a critical vital sign used to assess pulmonary function. Currently, RR estimating instrumentation is specialized and bulky, therefore unsuitable for remote health monitoring. Previously, RR was estimated using proprietary software that extract surface electrocardiogram (ECG) waveform features obtained at several thoracic locations. However, developing a non-proprietary method that uses minimal ECG leads, generally available from mobile cardiac monitors is highly desirable. Here, we introduce an open-source and well-documented Python-based algorithm that estimates RR requiring only single-stream ECG signals. The algorithm was first developed using ECGs from awake, spontaneously breathing adult human subjects. The algorithm-estimated RRs exhibited close linear correlation to the subjects' true RR values demonstrating an R2 of 0.9092 and root mean square error of 2.2 bpm. The algorithm robustness was then tested using ECGs generated by the ischemic hearts of anesthetized, mechanically ventilated sheep. Although the ECG waveforms during ischemia exhibited severe morphologic changes, the algorithm-determined RRs exhibited high fidelity with a resolution of 1 bpm, an absolute error of 0.07 ± 0.07 bpm, and a relative error of 0.67 ± 0.64%. This optimized Python-based RR estimation technique will likely be widely adapted for remote lung function assessment in patients with cardiopulmonary disease.
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Affiliation(s)
- Jesse D Roberts
- Departments of Anesthesia, Pediatrics, and Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Richard D Walton
- IHU-LIRYC, Heart Rhythm Disease Institute, Fondation Bordeaux Université, 33600, Pessac, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, University of Bordeaux, 33000, Bordeaux, France
| | - Virginie Loyer
- IHU-LIRYC, Heart Rhythm Disease Institute, Fondation Bordeaux Université, 33600, Pessac, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, University of Bordeaux, 33000, Bordeaux, France
| | - Olivier Bernus
- IHU-LIRYC, Heart Rhythm Disease Institute, Fondation Bordeaux Université, 33600, Pessac, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, University of Bordeaux, 33000, Bordeaux, France
| | - Kanchan Kulkarni
- IHU-LIRYC, Heart Rhythm Disease Institute, Fondation Bordeaux Université, 33600, Pessac, Bordeaux, France.
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, University of Bordeaux, 33000, Bordeaux, France.
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Chong HH, See A, Kulkarni K. National trends in the initial diagnosis and management of carpal tunnel syndrome: results from the ELECTS (ELEctrophysiology in Carpal Tunnel Syndrome) study. Ann R Coll Surg Engl 2024; 106:64-69. [PMID: 36448937 PMCID: PMC10757874 DOI: 10.1308/rcsann.2022.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2022] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION The optimal role of nerve conduction studies (NCS) in management of carpal tunnel syndrome (CTS) is unclear, with no standardised guidance. This study aimed to identify variation in practice in the initial diagnosis of patients with suspected CTS, alongside evaluating how NCS findings influence clinical decision making. METHODS A national multicentre collaborative survey was conducted in 2021. All centres providing surgery for CTS were invited to participate, primarily via social media. All middle-senior grade orthopaedic/plastic surgeons and advanced care practitioners that regularly manage new referrals for suspected CTS were eligible to respond. Local representatives at each participating site submitted their responses to a central team who collated and analysed the results. RESULTS A total of 137 healthcare professionals responded from 18 UK NHS Trusts. Of these 137, 124 (91%) reported not employing any validated clinical questionnaires in their routine practice, preferring to rely on clinical diagnosis and/or NCS if available, whereas 84 (61%) utilised NCS to aid diagnosis, with significant differences among professionals with differing experience (p < 0.01). The most common methods for determining the severity of CTS were history, examination and NCS. In symptomatic CTS with confirmatory NCS, over 50% of clinicians would choose surgical decompression as their first-line intervention. In cases of either negative NCS or atypical presentation, 37% and 51%, respectively, would consider conservative management (e.g. splintage) or steroid injection first line. CONCLUSIONS With growing waiting lists for NCS and surgery, national consensus guidelines should be developed to support decision making, while maximising efficient utilisation of increasingly constrained resources.
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Affiliation(s)
- HH Chong
- University Hospital of Leicester NHS Trust, UK
| | - A See
- Kettering General Hospital NHS Foundation Trust, UK
| | - K Kulkarni
- Pulvertaft Hand Centre, University Hospitals of Derby and Burton NHS Foundation Trust, UK
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Scotcher M, Chong HH, Asif A, Kulkarni K. Radiological Criteria for Acceptable Alignment in Paediatric Mid-Shaft Forearm Fractures: A Systematic Review. Malays Orthop J 2023; 17:26-32. [PMID: 38107363 PMCID: PMC10722999 DOI: 10.5704/moj.2311.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/16/2022] [Indexed: 12/19/2023] Open
Abstract
Introduction Forearm fractures are common in children. The remodelling capacity of growing long bones in children makes these potentially forgiving injuries, recovering with good outcomes despite minimal intervention. Clinicians rely on radiological characteristics that vary with age to guide treatment decisions and minimise adverse sequelae. The purpose of this review was to consolidate the evidence base of radiological indications for intervention in paediatric mid-shaft forearm fractures. Materials and methods The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed for this review. Citable research output reporting radiological criteria for mid-shaft forearm fractures in paediatric patients (age ≤16 years) was screened and analysed to ascertain acceptable radiological criteria for non-operative management. Results A total of 2,059 papers were initially identified; 14 were selected following screening. Sagittal angulation >15°, coronal angulation >10°, and/or >50% (or >1cm) translation were the most common radiological indications for intervention in children aged 0 to 10 years. For children over 10 years of age, the most common radiological indication for intervention was sagittal angulation >10°, coronal angulation >10°, and/or >50% (or >1cm) translation. Conclusion This study revealed a scarcity of high-quality evidence to guide management and significant variation in outcome reporting throughout the published literature. Since Noonan and Price's 1998 recommendations, there has been no significant evolution in the evidence-base guided threshold for intervention in paediatric mid-shaft forearm fractures. There remains a pressing need for a robust multicentre observational study using the patient-reported outcome measurement information system (PROMIS) to address this complex and controversial area of uncertainty in paediatric trauma management.
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Affiliation(s)
- M Scotcher
- Department of Plastic Surgery, Addenbrooke's Hospital Cambridge University, Cambridge, United Kingdom
| | - H H Chong
- Department of Orthopaedic and Trauma, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - A Asif
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - K Kulkarni
- Department of Plastic Surgery, Addenbrooke's Hospital Cambridge University, Cambridge, United Kingdom
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Senapati SG, Bhanushali AK, Lahori S, Naagendran MS, Sriram S, Ganguly A, Pusa M, Damani DN, Kulkarni K, Arunachalam SP. Mapping of Neuro-Cardiac Electrophysiology: Interlinking Epilepsy and Arrhythmia. J Cardiovasc Dev Dis 2023; 10:433. [PMID: 37887880 PMCID: PMC10607576 DOI: 10.3390/jcdd10100433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/10/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
The interplay between neurology and cardiology has gained significant attention in recent years, particularly regarding the shared pathophysiological mechanisms and clinical comorbidities observed in epilepsy and arrhythmias. Neuro-cardiac electrophysiology mapping involves the comprehensive assessment of both neural and cardiac electrical activity, aiming to unravel the intricate connections and potential cross-talk between the brain and the heart. The emergence of artificial intelligence (AI) has revolutionized the field by enabling the analysis of large-scale data sets, complex signal processing, and predictive modeling. AI algorithms have been applied to neuroimaging, electroencephalography (EEG), electrocardiography (ECG), and other diagnostic modalities to identify subtle patterns, classify disease subtypes, predict outcomes, and guide personalized treatment strategies. In this review, we highlight the potential clinical implications of neuro-cardiac mapping and AI in the management of epilepsy and arrhythmias. We address the challenges and limitations associated with these approaches, including data quality, interpretability, and ethical considerations. Further research and collaboration between neurologists, cardiologists, and AI experts are needed to fully unlock the potential of this interdisciplinary field.
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Affiliation(s)
- Sidhartha G. Senapati
- Department of Internal Medicine, Texas Tech University Health and Sciences Center, El Paso, TX 79905, USA; (S.G.S.); (D.N.D.)
| | - Aditi K. Bhanushali
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (A.K.B.); (S.L.)
| | - Simmy Lahori
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (A.K.B.); (S.L.)
| | | | - Shreya Sriram
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN 55905, USA;
| | - Arghyadeep Ganguly
- Department of Internal Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI 49007, USA;
| | - Mounika Pusa
- Mamata Medical College, Khammam 507002, Telangana, India;
| | - Devanshi N. Damani
- Department of Internal Medicine, Texas Tech University Health and Sciences Center, El Paso, TX 79905, USA; (S.G.S.); (D.N.D.)
- Department of Cardiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Kanchan Kulkarni
- IHU-LIRYC, Heart Rhythm Disease Institute, Fondation Bordeaux Université, Pessac, 33600 Bordeaux, France;
- INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, U1045, 33000 Bordeaux, France
| | - Shivaram P. Arunachalam
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (A.K.B.); (S.L.)
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Singh M, Anvekar P, Baraskar B, Pallipamu N, Gadam S, Cherukuri ASS, Damani DN, Kulkarni K, Arunachalam SP. Prospective of Pancreatic Cancer Diagnosis Using Cardiac Sensing. J Imaging 2023; 9:149. [PMID: 37623681 PMCID: PMC10455647 DOI: 10.3390/jimaging9080149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Pancreatic carcinoma (Ca Pancreas) is the third leading cause of cancer-related deaths in the world. The malignancies of the pancreas can be diagnosed with the help of various imaging modalities. An endoscopic ultrasound with a tissue biopsy is so far considered to be the gold standard in terms of the detection of Ca Pancreas, especially for lesions <2 mm. However, other methods, like computed tomography (CT), ultrasound, and magnetic resonance imaging (MRI), are also conventionally used. Moreover, newer techniques, like proteomics, radiomics, metabolomics, and artificial intelligence (AI), are slowly being introduced for diagnosing pancreatic cancer. Regardless, it is still a challenge to diagnose pancreatic carcinoma non-invasively at an early stage due to its delayed presentation. Similarly, this also makes it difficult to demonstrate an association between Ca Pancreas and other vital organs of the body, such as the heart. A number of studies have proven a correlation between the heart and pancreatic cancer. The tumor of the pancreas affects the heart at the physiological, as well as the molecular, level. An overexpression of the SMAD4 gene; a disruption in biomolecules, such as IGF, MAPK, and ApoE; and increased CA19-9 markers are a few of the many factors that are noted to affect cardiovascular systems with pancreatic malignancies. A comprehensive review of this correlation will aid researchers in conducting studies to help establish a definite relation between the two organs and discover ways to use it for the early detection of Ca Pancreas.
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Affiliation(s)
- Mansunderbir Singh
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (M.S.); (B.B.); (N.P.)
| | - Priyanka Anvekar
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55905, USA;
| | - Bhavana Baraskar
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (M.S.); (B.B.); (N.P.)
| | - Namratha Pallipamu
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (M.S.); (B.B.); (N.P.)
| | - Srikanth Gadam
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (M.S.); (B.B.); (N.P.)
| | - Akhila Sai Sree Cherukuri
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Devanshi N. Damani
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Internal Medicine, Texas Tech University Health Science Center, El Paso, TX 79995, USA
| | - Kanchan Kulkarni
- Centre de Recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, INSERM, U1045, 33000 Bordeaux, France;
- IHU Liryc, Heart Rhythm Disease Institute, Fondation Bordeaux Université, 33600 Bordeaux, France
| | - Shivaram P. Arunachalam
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (M.S.); (B.B.); (N.P.)
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Kulkarni K, Pallares-Lupon N, Bernus O, Walton RD. Can Stochastic Pacing Restore Heart Rate Variability in Diseased Hearts? An In-vivo Ovine Case Study. Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-5. [PMID: 38083585 DOI: 10.1109/embc40787.2023.10340585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Heart rate variability (HRV) is an important clinical parameter that depicts the autonomic balance. Diminished HRV has been associated with diseased hearts and incorporating stochasticity in pacing has been investigated as a potential mechanism for restoring the altered autonomic balance and preventing cardiac arrhythmias. We studied the change in HRV with the development of chronic myocardial infarction (MI) in adult sheep (n=16). Next, we investigated the utility of stochastic pacing in modulating HRV in-vivo in both sham and MI hearts. The propensity of the heart to the development of cardiac alternans, a known precursor to tachyarrhythmias, was studied under three different pacing techniques, namely periodic pacing, stochastic pacing and constant diastolic interval (DI) pacing in one sham and one MI sheep. Autonomic balance was observed to be altered after 6 weeks of chronic MI. Increased heart rate, QTc interval, standard deviation of the R-R intervals and LF/HF ratio was observed in MI hearts. Stochastic pacing was found to be proarrhythmic and increased T-wave alternans burden was observed with increase in stochasticity. Maintaining a constant DI on every beat demonstrated reduced alternans levels compared to both periodic and stochastic pacing.Clinical Relevance-Our results demonstrate that precise control of the diastolic interval may be more beneficial in inhibiting arrhythmias than stochastic pacing.
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Manga S, Muthavarapu N, Redij R, Baraskar B, Kaur A, Gaddam S, Gopalakrishnan K, Shinde R, Rajagopal A, Samaddar P, Damani DN, Shivaram S, Dey S, Mitra D, Roy S, Kulkarni K, Arunachalam SP. Estimation of Physiologic Pressures: Invasive and Non-Invasive Techniques, AI Models, and Future Perspectives. Sensors (Basel) 2023; 23:5744. [PMID: 37420919 DOI: 10.3390/s23125744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/25/2023] [Accepted: 06/12/2023] [Indexed: 07/09/2023]
Abstract
The measurement of physiologic pressure helps diagnose and prevent associated health complications. From typical conventional methods to more complicated modalities, such as the estimation of intracranial pressures, numerous invasive and noninvasive tools that provide us with insight into daily physiology and aid in understanding pathology are within our grasp. Currently, our standards for estimating vital pressures, including continuous BP measurements, pulmonary capillary wedge pressures, and hepatic portal gradients, involve the use of invasive modalities. As an emerging field in medical technology, artificial intelligence (AI) has been incorporated into analyzing and predicting patterns of physiologic pressures. AI has been used to construct models that have clinical applicability both in hospital settings and at-home settings for ease of use for patients. Studies applying AI to each of these compartmental pressures were searched and shortlisted for thorough assessment and review. There are several AI-based innovations in noninvasive blood pressure estimation based on imaging, auscultation, oscillometry and wearable technology employing biosignals. The purpose of this review is to provide an in-depth assessment of the involved physiologies, prevailing methodologies and emerging technologies incorporating AI in clinical practice for each type of compartmental pressure measurement. We also bring to the forefront AI-based noninvasive estimation techniques for physiologic pressure based on microwave systems that have promising potential for clinical practice.
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Affiliation(s)
- Sharanya Manga
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Neha Muthavarapu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Renisha Redij
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Avneet Kaur
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Sunil Gaddam
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Keerthy Gopalakrishnan
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Rutuja Shinde
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Poulami Samaddar
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Devanshi N Damani
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Internal Medicine, Texas Tech University Health Science Center, El Paso, TX 79995, USA
| | - Suganti Shivaram
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Shuvashis Dey
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Electrical and Computer Engineering, North Dakota State University, Fargo, ND 58105, USA
| | - Dipankar Mitra
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Computer Science, University of Wisconsin-La Crosse, La Crosse, WI 54601, USA
| | - Sayan Roy
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Electrical Engineering and Computer Science, South Dakota Mines, Rapid City, SD 57701, USA
| | - Kanchan Kulkarni
- Centre de Recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, INSERM, U1045, 33000 Bordeaux, France
- IHU Liryc, Heart Rhythm Disease Institute, Fondation Bordeaux Université, Bordeaux, 33600 Pessac, France
| | - Shivaram P Arunachalam
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Sethi AK, Muddaloor P, Anvekar P, Agarwal J, Mohan A, Singh M, Gopalakrishnan K, Yadav A, Adhikari A, Damani D, Kulkarni K, Aakre CA, Ryu AJ, Iyer VN, Arunachalam SP. Digital Pulmonology Practice with Phonopulmography Leveraging Artificial Intelligence: Future Perspectives Using Dual Microwave Acoustic Sensing and Imaging. Sensors (Basel) 2023; 23:5514. [PMID: 37420680 DOI: 10.3390/s23125514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 07/09/2023]
Abstract
Respiratory disorders, being one of the leading causes of disability worldwide, account for constant evolution in management technologies, resulting in the incorporation of artificial intelligence (AI) in the recording and analysis of lung sounds to aid diagnosis in clinical pulmonology practice. Although lung sound auscultation is a common clinical practice, its use in diagnosis is limited due to its high variability and subjectivity. We review the origin of lung sounds, various auscultation and processing methods over the years and their clinical applications to understand the potential for a lung sound auscultation and analysis device. Respiratory sounds result from the intra-pulmonary collision of molecules contained in the air, leading to turbulent flow and subsequent sound production. These sounds have been recorded via an electronic stethoscope and analyzed using back-propagation neural networks, wavelet transform models, Gaussian mixture models and recently with machine learning and deep learning models with possible use in asthma, COVID-19, asbestosis and interstitial lung disease. The purpose of this review was to summarize lung sound physiology, recording technologies and diagnostics methods using AI for digital pulmonology practice. Future research and development in recording and analyzing respiratory sounds in real time could revolutionize clinical practice for both the patients and the healthcare personnel.
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Affiliation(s)
- Arshia K Sethi
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Pratyusha Muddaloor
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Joshika Agarwal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Anmol Mohan
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Keerthy Gopalakrishnan
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology & Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Ashima Yadav
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Aakriti Adhikari
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Devanshi Damani
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Internal Medicine, Texas Tech University Health Science Center, El Paso, TX 79995, USA
| | - Kanchan Kulkarni
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, U1045, F-33000 Bordeaux, France
- IHU Liryc, Heart Rhythm Disease Institute, Fondation Bordeaux Université, F-33600 Pessac, France
| | | | - Alexander J Ryu
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Shivaram P Arunachalam
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology & Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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10
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Van Nostrand D, Veytsman I, Kulkarni K, Heimlich L, Burman KD. Redifferentiation of Differentiated Thyroid Cancer: Clinical Insights from a Narrative Review of Literature. Thyroid 2023. [PMID: 36792922 DOI: 10.1089/thy.2022.0632] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Background: Patients who have metastatic differentiated thyroid cancer (mDTC) frequently have negative diagnostic and/or post-therapy radioiodine scans. As a result, 131I therapy is frequently no longer considered a therapeutic option for these patients. However, with the knowledge of genomic alterations of patients with mDTC, the use of selected agents in specific patient groups may be used with the intention to re-establish 131I uptake (i.e., redifferentiation) and additional 131I therapy. The objectives of this narrative review are to present definitions of related terminology, a brief overview of the molecular mechanisms of redifferentiating agents, and a narrative review of the literature for redifferentiation in patients who have radioiodine refractory mDTC. Summary: We searched multiple electronic databases and reviewed the relevant English-language literature reported after 2010. Fourteen articles were included in this narrative review. Conclusions: Preliminary data suggest that select agents may offer potential for re-establishing 131I uptake in selected patients with radioiodine refractory mDTC (e.g., negative diagnostic and/or post-therapy radioiodine scans). These agents may also enhance uptake (e.g., uptake enhancement) in patients who have 131I uptake in mDTC on a diagnostic and/or post-therapy radioiodine scan. As a result, this may facilitate higher absorbed dose delivered (Gy (rad]) per 131I activity administered [GBq (mCi)]. This in turn may increase the likelihood of a better therapeutic effect for the planned administered 131I activity or a reduction in the originally planned administered 131I activity, while achieving the same intended therapeutic effect with potentially less untoward effects. Further studies are warranted to confirm these preliminary observations and to confirm acceptable subsequent 131I therapy responses after redifferentiation and/or uptake enhancement.
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Affiliation(s)
- Douglas Van Nostrand
- MedStar Health Research Institute, Washington, District of Columbia, USA
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Irina Veytsman
- MedStar Cancer Institute, Washington, District of Columbia, USA
| | - Kanchan Kulkarni
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Layla Heimlich
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Kenneth D Burman
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
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11
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Attlassy Y, Ahmed H, Slutsky R, Kulkarni K, Rajpurohit V, Taslakian B, Mabud T. Abstract No. 522 The Impact of Virtual Residency Interviews on the Geographic Distribution of Integrated Interventional and Diagnostic Radiology Residency Matches. J Vasc Interv Radiol 2023. [PMCID: PMC9950328 DOI: 10.1016/j.jvir.2022.12.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
Affiliation(s)
- Y. Attlassy
- New York University Grossman School of Medicine
| | - H. Ahmed
- New York University Grossman School of Medicine
| | - R. Slutsky
- New York University Grossman School of Medicine
| | - K. Kulkarni
- Department of Radiology at New York University Grossman School of Medicine
| | | | | | - T. Mabud
- New York University Grossman School of Medicine
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12
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Manduca S, Mabud T, Liu S, Taslakian B, Morris E, Kulkarni K. Abstract No. 146 Effect of Embolic Particle Size on Outcomes of Uterine Artery Embolization for Mixed Adenomyosis/Fibroids: Are Smaller Particles Needed? J Vasc Interv Radiol 2023. [DOI: 10.1016/j.jvir.2022.12.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
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13
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Ramlugun GS, Kulkarni K, Pallares-Lupon N, Boukens BJ, Efimov IR, Vigmond EJ, Bernus O, Walton RD. A comprehensive framework for evaluation of high pacing frequency and arrhythmic optical mapping signals. Front Physiol 2023; 14:734356. [PMID: 36755791 PMCID: PMC9901579 DOI: 10.3389/fphys.2023.734356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 01/09/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction: High pacing frequency or irregular activity due to arrhythmia produces complex optical mapping signals and challenges for processing. The objective is to establish an automated activation time-based analytical framework applicable to optical mapping images of complex electrical behavior. Methods: Optical mapping signals with varying complexity from sheep (N = 7) ventricular preparations were examined. Windows of activation centered on each action potential upstroke were derived using Hilbert transform phase. Upstroke morphology was evaluated for potential multiple activation components and peaks of upstroke signal derivatives defined activation time. Spatially and temporally clustered activation time points were grouped in to wave fronts for individual processing. Each activation time point was evaluated for corresponding repolarization times. Each wave front was subsequently classified based on repetitive or non-repetitive events. Wave fronts were evaluated for activation time minima defining sites of wave front origin. A visualization tool was further developed to probe dynamically the ensemble activation sequence. Results: Our framework facilitated activation time mapping during complex dynamic events including transitions to rotor-like reentry and ventricular fibrillation. We showed that using fixed AT windows to extract AT maps can impair interpretation of the activation sequence. However, the phase windowing of action potential upstrokes enabled accurate recapitulation of repetitive behavior, providing spatially coherent activation patterns. We further demonstrate that grouping the spatio-temporal distribution of AT points in to coherent wave fronts, facilitated interpretation of isolated conduction events, such as conduction slowing, and to derive dynamic changes in repolarization properties. Focal origins precisely detected sites of stimulation origin and breakthrough for individual wave fronts. Furthermore, a visualization tool to dynamically probe activation time windows during reentry revealed a critical single static line of conduction slowing associated with the rotation core. Conclusion: This comprehensive analytical framework enables detailed quantitative assessment and visualization of complex electrical behavior.
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Affiliation(s)
- Girish S. Ramlugun
- IHU-Liryc, Fondation Bordeaux Université, Pessac-Bordeaux, France,Univ. Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique, Bordeaux, France
| | - Kanchan Kulkarni
- IHU-Liryc, Fondation Bordeaux Université, Pessac-Bordeaux, France,Univ. Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique, Bordeaux, France
| | - Nestor Pallares-Lupon
- IHU-Liryc, Fondation Bordeaux Université, Pessac-Bordeaux, France,Univ. Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique, Bordeaux, France
| | - Bastiaan J. Boukens
- Department of Physiology, Cardiovascular Research Institute Maastricht, University Maastricht, Maastricht, Netherlands,Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Igor R. Efimov
- Department of Biomedical Engineering, The George Washington University, Washington, DC, United States,Department of Biomedical Engineering, Northwestern University, Chicago, IL, United States,Department of Medicine, Northwestern University, Chicago, IL, United States
| | - Edward J. Vigmond
- IHU-Liryc, Fondation Bordeaux Université, Pessac-Bordeaux, France,Univ. Bordeaux, Centre National de la Recherche Scientifique (CNRS), Institut de Mathématiques de Bordeaux, UMR5251, Bordeaux, France
| | - Olivier Bernus
- IHU-Liryc, Fondation Bordeaux Université, Pessac-Bordeaux, France,Univ. Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique, Bordeaux, France
| | - Richard D. Walton
- IHU-Liryc, Fondation Bordeaux Université, Pessac-Bordeaux, France,Univ. Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique, Bordeaux, France,*Correspondence: Richard D. Walton,
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14
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Kulkarni K, Nichols JH, Armoundas AA, Roberts Jr. JD. RespiCo: A novel, flexible, and stand-alone electronic respiratory coaching device. HardwareX 2022; 12:e00335. [PMID: 35873736 PMCID: PMC9304670 DOI: 10.1016/j.ohx.2022.e00335] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 06/15/2023]
Abstract
Conscious respiratory pattern and rate control is desired by patients with some forms of pulmonary disease that are undergoing respiratory muscle conditioning and rehabilitation, by practitioners of meditation hoping to improve mindfulness and wellbeing, by athletes striving to obtain breathing control in order to increase competitiveness, and by engineers and scientists that wish to use the data from breathing subjects to test hypotheses and develop physiological monitoring systems. Although prerecorded audio sources and computer applications are available that guide breathing exercises, they often suffer from being inflexible and allow only limited customization of the breathing cues. Here we describe a small, lightweight, battery-powered, microprocessor-based respiratory coaching device (RespiCo), which through wireless or wired connections, can be easily customized to precisely guide subjects to breathe at desired respiratory rates using specific breathing patterns through visual, auditory, or haptic cues. Digital signals can also be captured from the device to document the breathing cues provided by the device for research purposes. It is anticipated that this device will have important utility for those who wish to be guided to breathe in a precise manner or in research and development of physiologic monitoring systems.
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Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - John H. Nichols
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Harvard University, Cambridge, MA, United States
| | - Antonis A. Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Harvard University, Cambridge, MA, United States
| | - Jesse D. Roberts Jr.
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Harvard University, Cambridge, MA, United States
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15
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Kulkarni K, Pallares-Lupon N, Armoundas AA, Pasdois P, Bernus O, Walton RD. Investigating Electrophysiological Markers of Arrhythmogenesis in a Chronic Myocardial Infarction Ovine Model. Annu Int Conf IEEE Eng Med Biol Soc 2022; 2022:657-661. [PMID: 36086483 DOI: 10.1109/embc48229.2022.9871496] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Cardiac alternans has been associated with an increased propensity to lethal tachyarrhythmias such as ventricular tachycardia and fibrillation (VT/VF). Myocardial infarction (MI), resulting from restricted oxygen supply to the heart, is a known substrate for VT/VF. Here, we investigate the utility of cardiac alternans as a predictor of tachyarrhythmias in a chronic MI ovine model. In-vivo electrophysiological studies were performed to assess the change in microvolt T-wave alternans (TWA) with induction of acute ischemia following coronary artery occlusion. 24-hour telemetry was performed in an ambulatory animal for 6 weeks to monitor the progression of TWA with chronic MI. At 6 weeks, ex-vivo optical mapping experiments were performed to assess the spatiotemporal evolution of alternans in sham (n=5) and chronic MI hearts (n=8). Our results demonstrate that chronic MI leads to significant electrophysiological changes in the cardiac substrate. Significant increase in TWA is observed post occlusion and a steady rise in alternans is seen with progression of chronic MI. Compared to sham, chronic MI hearts show significant presence of localized action potential amplitude alternans, which spatially evolve with an increase in pacing frequency. Clinical Relevance - Our results demonstrate that localized alternans underlie arrhythmogenesis in chronic MI hearts and microvolt TWA can serve as a biomarker of disease progression during chronic MI.
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16
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Tria N, Kulkarni K. Abstract No. 507 Safety and feasibility of adjuvant liposomal bupivacaine in superior hypogastric nerve block performed during uterine fibroid embolization. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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17
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Kulkarni K, Lupon NP, Armoundas AA, Pasdois P, Bernus O, Walton RD. PO-645-05 CARDIAC ALTERNANS AS A BIOMARKER OF DYNAMIC ELECTROPHYSIOLOGICAL CHANGES IN ARRHYTHMOGENIC ISCHEMIC SUBSTRATES. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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18
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Kulkarni K, Salavatian S, Stavrakis S. Editorial: Advances in Cardiac Pacing and Neural Control Strategies: Basic, Translational and Clinical Research. Front Physiol 2022; 13:866991. [PMID: 35295569 PMCID: PMC8918658 DOI: 10.3389/fphys.2022.866991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Kanchan Kulkarni
- University of Bordeaux, INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, France
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
- *Correspondence: Kanchan Kulkarni
| | - Siamak Salavatian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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19
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Pallares-Lupon N, Bayer JD, Guillot B, Caluori G, Ramlugun GS, Kulkarni K, Loyer V, Bloquet S, El Hamrani D, Naulin J, Constantin M, Dos Santos P, Bernus O, Jaïs P, Pasdois P, Walton RD. Tissue Preparation Techniques for Contrast-Enhanced Micro Computed Tomography Imaging of Large Mammalian Cardiac Models with Chronic Disease. J Vis Exp 2022. [DOI: 10.3791/62909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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20
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Patel MH, Sampath S, Kapoor A, Damani DN, Chellapuram N, Challa AB, Kaur MP, Walton RD, Stavrakis S, Arunachalam SP, Kulkarni K. Advances in Cardiac Pacing: Arrhythmia Prediction, Prevention and Control Strategies. Front Physiol 2021; 12:783241. [PMID: 34925071 PMCID: PMC8674736 DOI: 10.3389/fphys.2021.783241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/08/2021] [Indexed: 02/01/2023] Open
Abstract
Cardiac arrhythmias constitute a tremendous burden on healthcare and are the leading cause of mortality worldwide. An alarming number of people have been reported to manifest sudden cardiac death as the first symptom of cardiac arrhythmias, accounting for about 20% of all deaths annually. Furthermore, patients prone to atrial tachyarrhythmias such as atrial flutter and fibrillation often have associated comorbidities including hypertension, ischemic heart disease, valvular cardiomyopathy and increased risk of stroke. Technological advances in electrical stimulation and sensing modalities have led to the proliferation of medical devices including pacemakers and implantable defibrillators, aiming to restore normal cardiac rhythm. However, given the complex spatiotemporal dynamics and non-linearity of the human heart, predicting the onset of arrhythmias and preventing the transition from steady state to unstable rhythms has been an extremely challenging task. Defibrillatory shocks still remain the primary clinical intervention for lethal ventricular arrhythmias, yet patients with implantable cardioverter defibrillators often suffer from inappropriate shocks due to false positives and reduced quality of life. Here, we aim to present a comprehensive review of the current advances in cardiac arrhythmia prediction, prevention and control strategies. We provide an overview of traditional clinical arrhythmia management methods and describe promising potential pacing techniques for predicting the onset of abnormal rhythms and effectively suppressing cardiac arrhythmias. We also offer a clinical perspective on bridging the gap between basic and clinical science that would aid in the assimilation of promising anti-arrhythmic pacing strategies.
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Affiliation(s)
- Mehrie Harshad Patel
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Shrikanth Sampath
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Anoushka Kapoor
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | | | - Nikitha Chellapuram
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | | | - Manmeet Pal Kaur
- Department of Medicine, GAIL, Mayo Clinic, Rochester, MN, United States
| | - Richard D. Walton
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Shivaram P. Arunachalam
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
- Department of Medicine, GAIL, Mayo Clinic, Rochester, MN, United States
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Kanchan Kulkarni
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
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21
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Stavrakis S, Kulkarni K, Singh JP, Katritsis DG, Armoundas AA. Autonomic Modulation of Cardiac Arrhythmias: Methods to Assess Treatment and Outcomes. JACC Clin Electrophysiol 2021; 6:467-483. [PMID: 32439031 DOI: 10.1016/j.jacep.2020.02.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/06/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
The autonomic nervous system plays a central role in the pathogenesis of multiple cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. As such, autonomic modulation represents an attractive therapeutic approach in these conditions. Notably, autonomic modulation exploits the plasticity of the neural tissue to induce neural remodeling and thus obtain therapeutic benefit. Different forms of autonomic modulation include vagus nerve stimulation, tragus stimulation, renal denervation, baroreceptor activation therapy, and cardiac sympathetic denervation. This review seeks to highlight these autonomic modulation therapeutic modalities, which have shown promise in early preclinical and clinical trials and represent exciting alternatives to standard arrhythmia treatment. We also present an overview of the various methods used to assess autonomic tone, including heart rate variability, skin sympathetic nerve activity, and alternans, which can be used as surrogate markers and predictors of the treatment effect. Although the use of autonomic modulation to treat cardiac arrhythmias is supported by strong preclinical data and preliminary studies in humans, in light of the disappointing results of a number of recent randomized clinical trials of autonomic modulation therapies in heart failure, the need for optimization of the stimulation parameters and rigorous patient selection based on appropriate biomarkers cannot be overemphasized.
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Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
| | - Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
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22
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Kulkarni K, Pallares-Lupon N, Loyer V, Bloquet S, El Hamrani D, Naulin J, Bernus O, Walton RD. B-PO02-026 LOCALIZED CARDIAC ALTERNANS PRESAGE VENTRICULAR TACHYARRHYTHMIAS IN OVINE CHRONIC MYOCARDIAL INFARCTION MODEL. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Kulkarni K, Stavrakis S, Elkholey K, Singh JP, Parks KA, Armoundas AA. Microvolt T-Wave Alternans Is Modulated by Acute Low-Level Tragus Stimulation in Patients With Ischemic Cardiomyopathy and Heart Failure. Front Physiol 2021; 12:707724. [PMID: 34366894 PMCID: PMC8343129 DOI: 10.3389/fphys.2021.707724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/30/2021] [Indexed: 12/15/2022] Open
Abstract
Aims: Microvolt T-wave alternans (TWA), an oscillation in T-wave morphology of the electrocardiogram (ECG), has been associated with increased susceptibility to ventricular tachy-arrhythmias, while vagus nerve stimulation has shown promising anti-arrhythmic effects in in vivo and ex vivo animal studies. We aimed to examine the effect of non-invasive, acute low-level tragus stimulation (LLTS) on TWA in patients with ischemic cardiomyopathy and heart failure. Methods: 26 patients with ischemic cardiomyopathy (left ventricular ejection fraction <35%) and chronic stable heart failure, previously implanted with an automatic implantable cardioverter defibrillator (ICD) device with an atrial lead (dual chamber ICD or cardiac resynchronization therapy defibrillator), were enrolled in the study. Each patient sequentially received, (1) Sham LLTS (electrode on tragus, but no stimulation delivered) for 5 min; (2) Active LLTS at two different frequencies (5 and 20 Hz, 15 min each); and (3) Active LLTS, during concomitant atrial pacing at 100 bpm at two different frequencies (5 and 20 Hz, 15 min each). LLTS was delivered through a transcutaneous electrical nerve stimulation device (pulse width 200 μs, frequency 5/20 Hz, amplitude 1 mA lower than the discomfort threshold). TWA burden was assessed using continuous ECG monitoring during sham and active LLTS in sinus rhythm, as well as during atrial pacing. Results: Right atrial pacing at 100 bpm led to significantly heightened TWA burden compared to sinus rhythm, with or without LLTS. Acute LLTS at both 5 and 20 Hz, during sinus rhythm led to a significant rise in TWA burden in the precordial leads (p < 0.05). Conclusion: Acute LLTS results in a heart-rate dependent increase in TWA burden.
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Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - Stavros Stavrakis
- Heart Rhythm Institute, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Khaled Elkholey
- Heart Rhythm Institute, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, United States
| | - Kimberly A Parks
- Cardiology Division, Brigham and Women's Hospital, Boston, MA, United States
| | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, United States
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24
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Kulkarni K, Sevakula RK, Kassab MB, Nichols J, Roberts JD, Isselbacher EM, Armoundas AA. Ambulatory monitoring promises equitable personalized healthcare delivery in underrepresented patients. Eur Heart J Digit Health 2021; 2:494-510. [PMID: 34604759 PMCID: PMC8482046 DOI: 10.1093/ehjdh/ztab047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/28/2021] [Indexed: 01/30/2023]
Abstract
The pandemic has brought to everybody's attention the apparent need of remote monitoring, highlighting hitherto unseen challenges in healthcare. Today, mobile monitoring and real-time data collection, processing and decision-making, can drastically improve the cardiorespiratory-haemodynamic health diagnosis and care, not only in the rural communities, but urban ones with limited healthcare access as well. Disparities in socioeconomic status and geographic variances resulting in regional inequity in access to healthcare delivery, and significant differences in mortality rates between rural and urban communities have been a growing concern. Evolution of wireless devices and smartphones has initiated a new era in medicine. Mobile health technologies have a promising role in equitable delivery of personalized medicine and are becoming essential components in the delivery of healthcare to patients with limited access to in-hospital services. Yet, the utility of portable health monitoring devices has been suboptimal due to the lack of user-friendly and computationally efficient physiological data collection and analysis platforms. We present a comprehensive review of the current cardiac, pulmonary, and haemodynamic telemonitoring technologies. We also propose a novel low-cost smartphone-based system capable of providing complete cardiorespiratory assessment using a single platform for arrhythmia prediction along with detection of underlying ischaemia and sleep apnoea; we believe this system holds significant potential in aiding the diagnosis and treatment of cardiorespiratory diseases, particularly in underserved populations.
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Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Boston, MA 02129, USA
| | - Rahul Kumar Sevakula
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Boston, MA 02129, USA
| | - Mohamad B Kassab
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Boston, MA 02129, USA
| | - John Nichols
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Jesse D. Roberts
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Boston, MA 02129, USA,Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Eric M Isselbacher
- Healthcare Transformation Lab, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Boston, MA 02129, USA,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA,Corresponding author. Tel: +617-726-0930,
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25
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Crepeau PK, Kulkarni K, Martucci J, Lai V. Comparing surgical thoroughness and recurrence in thyroid cancer patients across race/ethnicity. Surgery 2021; 170:1099-1104. [PMID: 34127303 DOI: 10.1016/j.surg.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/05/2021] [Accepted: 05/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND For patients with differentiated thyroid cancer who will receive postoperative radioactive iodine, thyroid remnant uptake can be calculated and may point to the thoroughness of the surgical resection. In the United States, outcome disparities exist among ethnic/racial minorities with differentiated thyroid cancer. Data about surgical thoroughness and recurrence rates across races/ethnicities do not exist. This study compared the amount of thyroid remnant uptake and cancer recurrence rates across race/ethnicity. METHODS This was a retrospective analysis of adult patients with differentiated thyroid cancer who had postoperative radioactive iodine in 2017 and 2018 and were followed to 2020. We collected thyroid bed remnant uptake from postoperative radioactive iodine scans and analyzed it as a ratio of percent of uptake to dose of radioactive iodine received to control for varying radioactive iodine doses. Thyroid remnant, uptake to dose of radioactive iodine received, and recurrence were evaluated across race/ethnicity. RESULTS Of 218 patients: 61% were White, 21% Black, 11% Asian, and 7% Hispanic; 72% were female. Seventy-one percent of patients had their surgery done by a high-volume surgeon, although volume data were not available for all. In White, Black, Asian, and Hispanic patients, median uptake was 0.68%, 0.44%, 1.5%, and 0.8%, respectively (P = .13). We did not observe differences in median uptake to dose of radioactive iodine received across groups (P = .41). Recurrence rate was 17.0% among White patients, 16.7% among Black patients, 17.6% among Asian patients, and 16.7% among Hispanic patients (P = 1.00). CONCLUSION We did not observe differences across race/ethnicity in surgical thoroughness or rate of recurrence. These findings suggest that disparities may be mitigated when ethnic/racial minorities have similar access to quality surgical care.
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Affiliation(s)
- Philip K Crepeau
- Department of Surgery, MedStar Georgetown University/Washington Hospital Center, Washington, DC
| | - Kanchan Kulkarni
- Department of Nuclear Medicine, MedStar Washington Hospital Center, Washington, DC
| | | | - Victoria Lai
- Department of Surgery, MedStar Georgetown University/Washington Hospital Center, Washington, DC.
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Kulkarni K, Singh JP, Parks KA, Katritsis DG, Stavrakis S, Armoundas AA. Low-Level Tragus Stimulation Modulates Atrial Alternans and Fibrillation Burden in Patients With Paroxysmal Atrial Fibrillation. J Am Heart Assoc 2021; 10:e020865. [PMID: 34075778 PMCID: PMC8477868 DOI: 10.1161/jaha.120.020865] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Low‐level tragus stimulation (LLTS) has been shown to significantly reduce atrial fibrillation (AF) burden in patients with paroxysmal AF. P‐wave alternans (PWA) is believed to be generated by the same substrate responsible for AF. Hence, PWA may serve as a marker in guiding LLTS therapy. We investigated the utility of PWA in guiding LLTS therapy in patients with AF. Methods and Results Twenty‐eight patients with AF were randomized to either active LLTS or sham (earlobe stimulation). LLTS was delivered through a transcutaneous electrical nerve stimulation device (pulse width 200 μs, frequency 20 Hz, amplitude 10–50 mA), for 1 hour daily over a 6‐month period. AF burden over 2‐week periods was assessed by noninvasive continuous ECG monitoring at baseline, 3 months, and 6 months. A 5‐minute control ECG for PWA analysis was recorded during all 3 follow‐up visits. Following the control ECG, an additional 5‐minute ECG was recorded during active LLTS in all patients. At baseline, acute LLTS led to a significant rise in PWA burden. However, active patients receiving chronic LLTS demonstrated a significant reduction in both PWA and AF burden after 6 months (P<0.05). Active patients who demonstrated an increase in PWA burden with acute LLTS showed a significant drop in AF burden after 6 months of chronic LLTS. Conclusions Chronic, intermittent LLTS resulted in lower PWA and AF burden than did sham control stimulation. Our results support the use of PWA as a potential marker for guiding LLTS treatment of paroxysmal AF.
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Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research Center Massachusetts General Hospital Boston MA
| | - Jagmeet P Singh
- Cardiology Division Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | | | | | - Stavros Stavrakis
- Heart Rhythm Institute University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Antonis A Armoundas
- Cardiovascular Research Center Massachusetts General Hospital Boston MA.,Institute for Medical Engineering and Science Massachusetts Institute of TechnologyCambridge MA
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Abstract
Life‐threatening ventricular arrhythmias and sudden cardiac death are often preceded by cardiac alternans, a beat‐to‐beat oscillation in the T‐wave morphology or duration. However, given the spatiotemporal and structural complexity of the human heart, designing algorithms to effectively suppress alternans and prevent fatal rhythms is challenging. Recently, an antiarrhythmic constant diastolic interval pacing protocol was proposed and shown to be effective in suppressing alternans in 0‐, 1‐, and 2‐dimensional in silico studies as well as in ex vivo whole heart experiments. Herein, we provide a systematic review of the electrophysiological conditions and mechanisms that enable constant diastolic interval pacing to be an effective antiarrhythmic pacing strategy. We also demonstrate a successful translation of the constant diastolic interval pacing protocol into an ECG‐based real‐time control system capable of modulating beat‐to‐beat cardiac electrical activity and preventing alternans. Furthermore, we present evidence of the clinical utility of real‐time alternans suppression in reducing arrhythmia susceptibility in vivo. We provide a comprehensive overview of this promising pacing technique, which can potentially be translated into a clinically viable device that could radically improve the quality of life of patients experiencing abnormal cardiac rhythms.
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Affiliation(s)
- Kanchan Kulkarni
- IHU-LIRYC, Electrophysiology and Heart Modeling InstituteFondation Bordeaux Université Pessac, Bordeaux France.,Centre de Recherche Cardio-Thoracique de Bordeaux University of Bordeaux France.,Centre de Recherche Cardio-Thoracique de Bordeaux INSERM Bordeaux France
| | - Richard D Walton
- IHU-LIRYC, Electrophysiology and Heart Modeling InstituteFondation Bordeaux Université Pessac, Bordeaux France.,Centre de Recherche Cardio-Thoracique de Bordeaux University of Bordeaux France.,Centre de Recherche Cardio-Thoracique de Bordeaux INSERM Bordeaux France
| | - Antonis A Armoundas
- Cardiovascular Research Center Massachusetts General Hospital Boston MA.,Institute for Medical Engineering and Science Massachusetts Institute of Technology Cambridge MA
| | - Elena G Tolkacheva
- Department of Biomedical Engineering University of Minnesota-Twin Cities Minneapolis MN
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Wu D, Plyku D, Kulkarni K, Garcia C, Atkins F, Tefera E, Burman KD, Wartofsky L, Van Nostrand D. Optimal Time for 124I PET/CT Imaging in Metastatic Differentiated Thyroid Cancer. Clin Nucl Med 2021; 46:283-288. [PMID: 33492859 DOI: 10.1097/rlu.0000000000003505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of this study was to determine the optimal time for 124I PET/CT imaging to maximize the detection of locoregional and/or distant metastases of differentiated thyroid cancer. METHODS Differentiated thyroid cancer patients suspected of having metastatic disease were prepared with low-iodine diet and appropriate thyroid-stimulating hormone stimulation. 124I PET and low-dose localization CT were performed over 4 days after oral administration of 31.5 or 62.9 MBq (0.85 or 1.7 mCi) of 124I. Each scan was independently reviewed by 2 nuclear medicine physicians. All foci of activity were categorized, and the visual intensity of uptake was scored by a semiquantitative 3-point grading system (1: mild uptake, 2: moderate uptake, 3: intense uptake). Lesion volumes were determined on the CT image or on the PET images. Background (bkg) was also measured for each lesion and on each individual PET image. For each lesion, the mean activity concentration rate per unit administered activity (ACRmean/AA) and lesion-to-bkg ratios were compared across the 5 different time points. The semiquantitative grade and the quantitative measurements were compared. RESULTS A total of 45 124I PET/CT scans were reviewed for 9 patients. In the visual assessment, a total of 31 foci suggestive for or highly suggestive of metastasis were identified on 124I PET/CT. Of these, 6 were seen on the 2-h, 18 on the 24-h, 27 on the 48-h, 24 on the 72-h, and 20 on the 96-h scan. There was a significant difference between the 24- and 48-h scans in the total number of foci (ie, locoregional and distant metastasis) (P < 0.05) and in the number of distant metastases (P < 0.05). The 24-, 48-, and 72-h scans identified the same number of locoregional foci. The 48-h scan visualized more of the distant metastases than any other time point. 124I PET/CT with dual-time-point imaging was superior to single-time-point imaging (97% vs 87%). In the quantitative analysis, the median ACRmean/AA was highest at 24 and 48 h, and the median lesion-to-bkg ratio was variable for different lesion locations. For lung metastases, the highest median lesion-to-bkg ratio was at 72 and 96 h. CONCLUSIONS 124I PET/CT with dual-time-point imaging was superior to any single-time-point imaging (P < 0.10). Based on the visual assessment, dual time points at 48 + 72 h or 48 + 96 h yielded the highest lesion detection rate, whereas for single-time-point imaging, the 48-h images had the highest lesion detection rate. If the 48-h scan is completely negative or has negative 124I uptake in the region of interest, then a 72- or 96-h scan may be valuable. If lung metastases are suspected, then one should consider additional imaging at 72 or 96 h.
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Affiliation(s)
| | | | - Kanchan Kulkarni
- Division of Nuclear Medicine, MedStar Health Washington Hospital Center, Washington, DC
| | - Carlos Garcia
- Division of Nuclear Medicine, MedStar Health Washington Hospital Center, Washington, DC
| | | | - Eshetu Tefera
- Department of Biostatistics and Biomedical informatics, MedStar Health Research Institute, Hyattsville, MD
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Kulkarni K, Awasthi N, Roberts JD, Armoundas AA. Utility of a Smartphone-Based System (cvrPhone) in Estimating Minute Ventilation from Electrocardiographic Signals. Telemed J E Health 2021; 27:1433-1439. [PMID: 33729001 DOI: 10.1089/tmj.2020.0507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: We investigated the ability of a novel stand-alone, smartphone-based system, the cvrPhone, in estimating the minute ventilation (MV) from body surface electrocardiographic (ECG) signals. Methods: Twelve lead ECG signals were collected from anesthetized and mechanically ventilated swine (n = 9) using standard surface electrodes and the cvrPhone. The tidal volume delivered to the animals was varied between 0, 250, 500, and 750 mL at respiration rates of 6 and 14 breaths/min. MV estimates were determined by the cvrPhone and were compared with the delivered ones. Results: The median relative estimation errors were 17%, -4%, 35%, -3%, -9%, and 1%, for true MVs of 1,500, 3,000, 3,500, 4,500, 7,000, and 10,500 breaths*mL/min, respectively. The MV estimates at each of the settings were significantly different from each other (p < 0.05). Conclusions: We have demonstrated that accurate MV estimations can be derived from standard body surface ECG signals, using a smartphone.
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Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research Center, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Navchetan Awasthi
- Cardiovascular Research Center, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jesse D Roberts
- Cardiovascular Research Center, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Antonis A Armoundas
- Cardiovascular Research Center, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology Cambridge, Massachusetts, USA
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Peterknecht E, Agerbak E, Mohamedahmed AYY, Stonelake S, Kulkarni K, Peravali R, Zaman S. Aggressive angiomyxoma of the ischioanal fossa in a post-menopausal woman. Ann R Coll Surg Engl 2021; 103:e59-e64. [PMID: 33559550 PMCID: PMC9773864 DOI: 10.1308/rcsann.2020.7008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Aggressive angiomyxoma is a rare mesenchymal tumour, primarily arising in the soft tissue of the pelvis and perineum in women of reproductive age. There is a paucity of evidence on optimal management because of the rarity of these tumours, but the consensus has been for surgical excision. We present the case of a 65-year-old woman who was admitted with left-sided buttock pain and initially diagnosed with a perianal abscess. She underwent examination under anaesthesia rectum with surgical excision of the lesion, subsequent histopathological and immunochemical analysis was suggestive of aggressive angiomyxoma. To complement our case report, we also present a literature review focusing on aggressive angiomyxoma in the ischioanal fossa (also known as the ischiorectal fossa) with only eight cases of primary aggressive angiomyxoma involving the ischioanal fossa documented to date. The primary aims of this case report and literature review are to familiarise clinicians with the clinical, histopathological and immunochemical features of these tumours, and to increase appreciation that despite the rarity of aggressive angiomyxoma, it might be considered in the differential diagnosis of ischioanal lesions.
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Affiliation(s)
- E Peterknecht
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - E Agerbak
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - AYY Mohamedahmed
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - S Stonelake
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - K Kulkarni
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - R Peravali
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - S Zaman
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
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Baral N, Bansal R, Basyal B, Lee W, Kulkarni K, Kantorovich V, Sharma M. Nonseminomatous Germ-Cell Tumor Presenting as Bilateral Adrenal Masses. AACE Clin Case Rep 2020; 7:43-46. [PMID: 33851019 PMCID: PMC7924156 DOI: 10.1016/j.aace.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective Many tumors can metastasize to the adrenal glands, making the diagnosis of adrenal masses challenging. Awareness that rare primary tumors can metastasize to the adrenals and consideration of biopsy for their diagnosis, sometimes at extra-adrenal sites, is essential to prevent unnecessary adrenalectomies and facilitate the right treatment. We report a rare case of bilateral adrenal masses due to metastasis from a nonseminomatous germ-cell tumor of a retroperitoneal lymph node origin. Methods The diagnosis of the adrenal masses from the nonseminomatous germ-cell tumor of a retroperitoneal lymph node origin was based on a retroperitoneal lymph node core biopsy. An initial core biopsy of the adrenal gland revealed necrotic tissue and inflammatory cells without evidence of malignancy. Due to nondiagnostic findings, the core biopsy was repeated, which showed degenerating cells with a high mitotic index and immunohistochemical staining positive for vimentin, suggesting the possibility of a high-grade sarcoma. A retroperitoneal lymph node biopsy was performed. The patient was started on chemotherapy. Results A 34-year-old man presented with acute left upper-abdominal pain of 2 weeks and tenderness on the left upper quadrant of the abdomen, and he was found to have bilateral adrenal masses. Laboratory results showed the following: adrenocorticotropic hormone 41 pg/mL (7-69 pg/mL), metanephrine <0.1 nmol/L (0-0.49 nmol/L), normetanephrine 0.99 nmol/L (0-0.89 nmol/L), and morning cortisol 3.1 μg/dL after a 1-mg dexamethasone-suppression test. His dehydroepiandrosterone sulfate level was 62 μg/dL (120-520 μg/dL), and 17OH progesterone level was 36 ng/dL (<138 ng/dL); androstenedione and serum estradiol levels were normal. Laboratory tests for tumor markers revealed the following: testosterone 21 ng/dL (241-827 ng/dL), prostate-specific antigen 0.57 ng/mL (0-4 ng/mL), alpha-fetoprotein 1.9 IU/mL (0.6-6 IU/ml), and beta-human chorionic gonadotropin 134 mIU/mL (0-1 mIU/mL). Conclusion We report a rare case of rapidly progressing adrenal masses in a young man, found to have metastasized from nonseminomatous germ-cell tumors. Histopathologic confirmation of the metastatic tumor was done, which prevented unnecessary adrenalectomy. The patient received appropriate chemotherapy.
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Affiliation(s)
- Neelam Baral
- Department of Endocrinology, Georgetown University, Washington, District of Columbia
| | - Rashika Bansal
- Department of Endocrinology, National Institutes of Health, Bethesda, Maryland
- Address correspondence and reprint requests to Dr Rashika Bansal, Adult Endocrine Fellow, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bldg 10 CRC, Rm 7C-432A, 10 Center Drive, Bethesda, MD 20892.
| | - Binaya Basyal
- Department of Cardiology, Georgetown University, Washington, District of Columbia
| | - Wen Lee
- Department of Pathology, Medstar Georgetown University, Washington, District of Columbia
| | - Kanchan Kulkarni
- Department of Nuclear Medicine, Medstar Washington Hospital Center, Washington, District of Columbia
| | | | - Meeta Sharma
- Department of Endocrinology, Medstar Washington Hospital Center, Washington, District of Columbia
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Wu D, Gomes-Lima CJ, Kulkarni K, Burman KD, Wartofsky L, Van Nostrand D. 30 mCi exploratory scan for two-step dosimetric 131I therapy in differentiated thyroid cancer patients: A novel approach and case report. World J Nucl Med 2020; 19:266-270. [PMID: 33354183 PMCID: PMC7745862 DOI: 10.4103/wjnm.wjnm_35_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 09/17/2019] [Indexed: 11/04/2022] Open
Abstract
Differentiated thyroid cancer patients with significantly elevated or rapidly rising serum thyroglobulin (Tg) levels and negative diagnostic radioiodine scans (DxScan) often present a therapeutic dilemma in deciding whether or not to administer an 131I treatment. In this report, we describe a novel two-step approach of a 30 mCi 131I exploratory scan before a dosimetric 131I therapy to help “un-blind” the treating physician of the benefit/risk ratio of a further “blind” 131I treatment. A 51-year-old man presented with rising Tg levels, a negative DxScan, and a history of widely metastatic follicular thyroid cancer. He had undergone total thyroidectomy, remnant ablation with 3.8 GBq (103.5 mCi) of 131I, Gammaknife®, and treatment with 12.1 GBq (326 mCi) of 131I for multiple metastases. However, at 19 months after the treatments, his Tg levels continued to rise, and scans demonstrated no evidence of radioiodine-avid metastatic disease. In anticipation of a “blind” 131I treatment, the medical team and the patient opted for a 30 mCi exploratory scan. The total dosimetrically guided prescribed activity (DGPA) was decided based on the whole-body dosimetry. The patient was first given 30 mCi of 131I, and the exploratory scan was performed 22 h later, which demonstrated 131I uptake in the left lung, left humeral head, T10, and right proximal thigh muscle. Based on the positive exploratory scan, the remainder of the DGPA was administered within several hours after the scan. On the post-DGPA treatment scan performed at 5–7 days, the lesions seen on the ~ 22 h exploratory scan were confirmed, and an additional lesion was observed in the left kidney. The 30 mCi exploratory scan suggested the potential for a response in the radioiodine-avid lesions despite a negative diagnostic scan. This method allows 131I treatment to be administered to patients who may have a greater potential for a therapeutic response while avoiding unwarranted side effects in those patients with nonavid disease.
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Affiliation(s)
- Di Wu
- Medstar Health Research Institute, Hyattsville, MD, USA.,Department of Nuclear Medicine Research, Medstar Washington Hospital Center, Washington, DC, USA
| | - Cristiane Jeyce Gomes-Lima
- Medstar Health Research Institute, Hyattsville, MD, USA.,Division of Endocrinology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Kanchan Kulkarni
- Division of Nuclear Medicine, Medstar Washington Hospital Center, Washington, DC, USA
| | - Kenneth D Burman
- Division of Endocrinology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Leonard Wartofsky
- Medstar Health Research Institute, Hyattsville, MD, USA.,Division of Endocrinology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Douglas Van Nostrand
- Medstar Health Research Institute, Hyattsville, MD, USA.,Department of Nuclear Medicine Research, Medstar Washington Hospital Center, Washington, DC, USA
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Scotcher M, Asif A, Kulkarni K. Are UK and Ireland trauma and orthopaedic surgeons maintaining their research output? Ann R Coll Surg Engl 2020; 102:625-631. [PMID: 32777931 DOI: 10.1308/rcsann.2020.0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Healthcare faces growing challenges. With reports of diminishing research output from the UK and Ireland in the leading surgical journals, this study aimed to ascertain whether this trend had been echoed in the trauma and orthopaedic literature. MATERIALS AND METHODS Citable research output from the 10 globally leading trauma and orthopaedic journals was analysed from five individual years, over a 20-year period, to ascertain trends in absolute output, geographical mix, and level of evidence. RESULTS The overall number of published articles fell by 14.5%. North America saw the greatest decline (-8.0%), followed by Japan (-5.6%) and Europe (-3.3%). The UK and Ireland (+2.9%) and the rest of the world (+13.9%) saw rising output. A decline in lower (levels IV and V) and a rise in higher (levels I, II and III) quality evidence was observed. The UK and Ireland had a greater proportion of higher-quality studies than North America and Japan, but lower than Europe and the rest of the world. The impact factor of the leading journal rose from 4.47 to 7.01. DISCUSSION The research landscape has evolved, with leading journals placing greater emphasis on higher-quality evidence. UK and Irish research output remains stable, contributing 14% of the most highly cited publications in 2018, and challenging North America's dominance with a greater proportion of level I and II evidence in the leading journals. CONCLUSION With the growing emergence of Europe and the rest of the world, UK and Irish authors must build upon the region's output despite political challenges such as Brexit. Increasing international collaboration will continue to play an important role.
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Affiliation(s)
| | - A Asif
- University of Leicester, Leicester, UK
| | - K Kulkarni
- University Hospitals of Leicester NHS Trust, Leicester, UK
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Mann J, Wernham A, Kulkarni K, Varma S. An unexpected lesion on the scalp. Clin Exp Dermatol 2020; 45:922-924. [PMID: 32449175 DOI: 10.1111/ced.14268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2020] [Indexed: 11/29/2022]
Affiliation(s)
- J Mann
- Departments of Dermatology, Nottingham Treatment Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Wernham
- Departments of Dermatology, Nottingham Treatment Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - K Kulkarni
- Department of Histopathology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Varma
- Departments of Dermatology, Nottingham Treatment Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Merchant FM, Sayadi O, Sohn K, Weiss EH, Puppala D, Doddamani R, Singh JP, Heist EK, Owen C, Kulkarni K, Armoundas AA. Real-Time Closed-Loop Suppression of Repolarization Alternans Reduces Arrhythmia Susceptibility In Vivo. Circ Arrhythm Electrophysiol 2020; 13:e008186. [PMID: 32434448 DOI: 10.1161/circep.119.008186] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Repolarization alternans (RA) has been implicated in the pathogenesis of ventricular arrhythmias and sudden cardiac death. METHODS We have developed a real-time, closed-loop system to record and analyze RA from multiple intracardiac leads, and deliver dynamically R-wave triggered pacing stimuli during the absolute refractory period. We have evaluated the ability of this system to control RA and reduce arrhythmia susceptibility, in vivo. RESULTS R-wave triggered pacing can induce RA, the magnitude of which can be modulated by varying the amplitude, pulse width, and size of the pacing vector. Using a swine model (n=9), we demonstrate that to induce a 1 µV change in the alternans voltage on the body surface, coronary sinus and left ventricle leads, requires a delivered charge of 0.04±0.02, 0.05±0.025, and 0.06±0.033 µC, respectively, while to induce a one unit change of the Kscore, requires a delivered charge of 0.93±0.73, 0.32±0.29, and 0.33±0.37 µC, respectively. For all body surface and intracardiac leads, both Δ(alternans voltage) and ΔKscore between baseline and R-wave triggered paced beats increases consistently with an increase in the pacing pulse amplitude, pulse width, and vector spacing. Additionally, we show that the proposed method can be used to suppress spontaneously occurring alternans (n=7), in the presence of myocardial ischemia. Suppression of RA by pacing during the absolute refractory period results in a significant reduction in arrhythmia susceptibility, evidenced by a lower Srank score during programmed ventricular stimulation compared with baseline before ischemia. CONCLUSIONS We have developed and evaluated a novel closed-loop method to dynamically modulate RA in a swine model. Our data suggest that suppression of RA directly reduces arrhythmia susceptibility and reinforces the concept that RA plays a critical role in the pathophysiology of arrhythmogenesis.
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Affiliation(s)
- Faisal M Merchant
- Cardiology Division, Emory University School of Medicine, Atlanta, GA (F.M.M.).,Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Omid Sayadi
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Kwanghyun Sohn
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Eric H Weiss
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology Cambridge (E.H.W., A.A.A.)
| | - Dheeraj Puppala
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Rajiv Doddamani
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service (J.P.S., E.K.H.), Massachusetts General Hospital, Boston
| | - E Kevin Heist
- Cardiology Division, Cardiac Arrhythmia Service (J.P.S., E.K.H.), Massachusetts General Hospital, Boston
| | - Chris Owen
- Neurosurgery Division (C.O.), Massachusetts General Hospital, Boston
| | - Kanchan Kulkarni
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Antonis A Armoundas
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology Cambridge (E.H.W., A.A.A.)
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Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | | | - Mohamad B. Kassab
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Furrukh Sana
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Kasra Moazzami
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Omid Sayadi
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Jagmeet P. Singh
- Cardiology DivisionCardiac Arrhythmia ServiceMassachusetts General HospitalBostonMA
| | - E. Kevin Heist
- Cardiology DivisionCardiac Arrhythmia ServiceMassachusetts General HospitalBostonMA
| | - Antonis A. Armoundas
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Institute for Medical Engineering and ScienceMassachusetts Institute of TechnologyCambridgeMA
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Sohn K, Dalvin SP, Merchant FM, Kulkarni K, Sana F, Abohashem S, Singh JP, Heist EK, Owen C, Isselbacher EM, Armoundas AA. Utility of a Smartphone Based System (cvrPhone) to Predict Short-term Arrhythmia Susceptibility. Sci Rep 2019; 9:14497. [PMID: 31601824 PMCID: PMC6787075 DOI: 10.1038/s41598-019-50487-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 09/10/2019] [Indexed: 01/27/2023] Open
Abstract
Repolarization alternans (RA) has been implicated in the pathogenesis of ventricular arrhythmias and sudden cardiac death. We developed a 12-lead, blue-tooth/Smart-Phone (Android) based electrocardiogram (ECG) acquisition and monitoring system (cvrPhone), and an application to estimate RA, in real-time. In in-vivo swine studies (N = 17), 12-lead ECG signals were recorded at baseline and following coronary artery occlusion. RA was estimated using the Fast Fourier Transform (FFT) method using a custom developed algorithm in JAVA. Underlying ischemia was detected using a custom developed ischemic index. RA from each lead showed a significant (p < 0.05) increase within 1 min of occlusion compared to baseline (n = 29). Following myocardial infarction, spontaneous ventricular tachycardia episodes (n = 4) were preceded by significant (p < 0.05) increase of RA prior to the onset of the tachy-arrhythmias. Similarly, the ischemic index exhibited a significant increase following myocardial infarction (p < 0.05) and preceding a tachy-arrhythmic event. In conclusion, RA can be effectively estimated using surface lead electrocardiograms by analyzing beat-to-beat variability in ECG morphology using a smartphone based platform. cvrPhone can be used to detect myocardial ischemia and arrhythmia susceptibility using a user-friendly, clinically acceptable, mobile platform.
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Affiliation(s)
- Kwanghyun Sohn
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Steven P Dalvin
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Faisal M Merchant
- Cardiology Division, Emory, University School of Medicine, Atlanta, GA, USA
| | - Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Furrukh Sana
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Shady Abohashem
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA
| | - E Kevin Heist
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA
| | - Chris Owen
- Neurosurgery Division, Massachusetts General Hospital, Boston, MA, USA
| | - Eric M Isselbacher
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA
| | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA. .,Institute for Medical Engineering and Science, Massachusetts Institute of Technology Cambridge, MA, USA.
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Sathiaraj E, Chakraborthy S, Priya K, Kulkarni K. SUN-PO091: Nutritionist Delivered Quality Improvement Program Results in Significant Reduction in Unplanned Hospital Admissions Among Cancer Patients Undergoing Chemotherapy and/or Radiotherapy. Clin Nutr 2019. [DOI: 10.1016/s0261-5614(19)32725-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Wu D, Gomes Lima CJ, Moreau SL, Kulkarni K, Zeymo A, Burman KD, Wartofsky L, Van Nostrand D. Improved Survival After Multimodal Approach with 131I Treatment in Patients with Bone Metastases Secondary to Differentiated Thyroid Cancer. Thyroid 2019; 29:971-978. [PMID: 31017051 DOI: 10.1089/thy.2018.0582] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: The objective of this study was to evaluate the overall survival (OS) of radioiodine (131I) treatments alone or combined with non-131I treatments in patients with bone metastases (BM) of differentiated thyroid cancer (DTC). Methods: This was a retrospective study of patients who were evaluated between 2001 and 2018 at MedStar Washington Hospital Center and who had DTC, BM, and at least one 131I treatment after the diagnosis of BM. The OS was analyzed by Kaplan-Meier survival curves and was compared by log-rank test between two groups: patients who received 131I treatments alone and those who received treatments combining 131I with non-131I treatments (CombTx). Non-131I treatments include surgery, radiofrequency ablation, cryotherapy, arterial embolization, external beam radiation, Cyberknife, systemic targeted therapy, and anti-resorptive medication. Results: A total of 77 patients met the above criteria and were followed up to 41 years. Thirty percent (23/77) of patients received 131I treatment alone, and 70% (54/77) received CombTx. For 131I treatment alone, the median survival was 3.9 years, and the 1-, 2-, 3-, 5-, and 10-year OS rates were 86%, 81%, 61%, 35%, and 23%, respectively. For CombTx, the median survival was 7.7 years, and the 1-, 2-, 3-, 5-, and 10-year OS rates were 96%, 92%, 86%, 69%, and 30%, respectively. Patients who had undergone initial 131I therapy within six months post thyroidectomy demonstrated a better median survival after BM diagnosis than those whose initial 131I therapy was six months or more after thyroidectomy (6.5 vs. 0.5 years; p < 0.001). Patients who received external beam radiation therapy demonstrated a better median survival than those who did not (7.8 vs. 4.4 years; p = 0.016). Patients who received denosumab demonstrated a better median survival than those who did not (7.7 vs. 5.2 years; p = 0.03). Patients who were <55 years of age at the initial diagnosis of DTC or at the initial diagnosis of BM had a better median OS than those diagnosed at ≥55 years of age (both p = 0.01). In the multivariate analysis, only age at initial diagnosis of DTC and initial 131I therapy within six months post thyroidectomy, and multiple 131I treatments were independent prognostic factors. Conclusions: In patients with DTC with BM, 131I treatment in combination with one or more non-131I direct and systemic treatments was associated with a significant increase in OS compared with those patients who were treated by 131I treatment alone.
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Affiliation(s)
- Di Wu
- 1MedStar Clinical Research Center, MedStar Health Research Institute, Hyattsville, Maryland
- 2Nuclear Medicine Research, MedStar Washington Hospital Center, Washington, DC
| | - Cristiane J Gomes Lima
- 1MedStar Clinical Research Center, MedStar Health Research Institute, Hyattsville, Maryland
- 3Division of Endocrinology, MedStar Washington Hospital Center, Washington, DC
| | - Shari L Moreau
- 4Division of Nuclear Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Kanchan Kulkarni
- 4Division of Nuclear Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Alexander Zeymo
- 5Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Hyattsville, Maryland
| | - Kenneth D Burman
- 3Division of Endocrinology, MedStar Washington Hospital Center, Washington, DC
| | - Leonard Wartofsky
- 3Division of Endocrinology, MedStar Washington Hospital Center, Washington, DC
| | - Douglas Van Nostrand
- 1MedStar Clinical Research Center, MedStar Health Research Institute, Hyattsville, Maryland
- 2Nuclear Medicine Research, MedStar Washington Hospital Center, Washington, DC
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Sohn K, Merchant FM, Abohashem S, Kulkarni K, Singh JP, Heist EK, Owen C, Roberts JD, Isselbacher EM, Sana F, Armoundas AA. Utility of a smartphone based system (cvrphone) to accurately determine apneic events from electrocardiographic signals. PLoS One 2019; 14:e0217217. [PMID: 31206522 PMCID: PMC6576766 DOI: 10.1371/journal.pone.0217217] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/07/2019] [Indexed: 11/20/2022] Open
Abstract
Background Sleep disordered breathing manifested as sleep apnea (SA) is prevalent in the general population, and while it is associated with increased morbidity and mortality risk in some patient populations, it remains under-diagnosed. The objective of this study was to assess the accuracy of respiration-rate (RR) and tidal-volume (TV) estimation algorithms, from body-surface ECG signals, using a smartphone based ambulatory respiration monitoring system (cvrPhone). Methods Twelve lead ECG signals were collected using the cvrPhone from anesthetized and mechanically ventilated swine (n = 9). During ECG data acquisition, the mechanical ventilator tidal-volume (TV) was varied from 250 to 0 to 750 to 0 to 500 to 0 to 750 ml at respiratory rates (RR) of 6 and 14 breaths/min, respectively, and the RR and TV values were estimated from the ECG signals using custom algorithms. Results TV estimations from any two different TV settings showed statistically significant difference (p < 0.01) regardless of the RR. RRs were estimated to be 6.1±1.1 and 14.0±0.2 breaths/min at 6 and 14 breaths/min, respectively (when 250, 500 and 750 ml TV settings were combined). During apnea, the estimated TV and RR values were 11.7±54.9 ml and 0.0±3.5 breaths/min, which were significantly different (p<0.05) than TV and RR values during non-apnea breathing. In addition, the time delay from the apnea onset to the first apnea detection was 8.6±6.7 and 7.0±3.2 seconds for TV and RR respectively. Conclusions We have demonstrated that apnea can reliably be detected using ECG-derived RR and TV algorithms. These results support the concept that our algorithms can be utilized to detect SA in conjunction with ECG monitoring.
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Affiliation(s)
- Kwanghyun Sohn
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States of America
| | - Faisal M. Merchant
- Cardiology Division, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Shady Abohashem
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States of America
| | - Jagmeet P. Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, United States of America
| | - E. Kevin Heist
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, United States of America
| | - Chris Owen
- Neurosurgery Division, Massachusetts General Hospital, Boston, MA, United States of America
| | - Jesse D. Roberts
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Eric M. Isselbacher
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, United States of America
| | - Furrukh Sana
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States of America
| | - Antonis A. Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States of America
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology Cambridge, MA, United States of America
- * E-mail:
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Delatour V, Clouet-Foraison N, Gaie-Levrel N, Marcovina S, Hoofnagle A, Kuklenyik Z, Caulfield M, Otvos J, Contois J, Krauss R, Kulkarni K, Remaley A, Vesper H, Cobbaert C, Gillery P. Standardization of advanced lipoprotein testing: The BioSITrace project. Clin Chim Acta 2019. [DOI: 10.1016/j.cca.2019.03.1479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kushchayeva YS, Tella SH, Kushchayev SV, Van Nostrand D, Kulkarni K. Comparison of hyperparathyroidism types and utility of dual radiopharmaceutical acquisition with Tc99m sestamibi and 123I for localization of rapid washout parathyroid adenomas. Osteoporos Int 2019; 30:1051-1057. [PMID: 30706095 DOI: 10.1007/s00198-019-04846-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 01/06/2019] [Indexed: 11/29/2022]
Abstract
UNLABELLED Tc99m-sestamibi dual-time imaging is a standard tool for localization of adenomas/hyperplasia in hyperparathyroidism. We investigated the degree and causes of localization failure among different types of hyperparathyroidism. Pre-operative parathyroid hormone levels and size of the gland were major determinants of Tc99m-sestamibi positivity; 123I scan may be helpful in localization failures. INTRODUCTION Tc99m-sestamibi dual-time imaging is a standard tool for localization of adenomas/hyperplasia in hyperparathyroidism. However, parathyroid adenomas/hyperplasia has been reported to washout as fast as normal thyroid tissue ("rapid washout") which may lead to diagnostic failure. We aimed to evaluate the determinants of rapid washout and to determine the role of subtraction imaging for detection of parathyroid adenomas/hyperplasia with rapid washout. METHODS Retrospective analysis of patients with hyperparathyroidism who have undergone Tc99m-sestamibi dual-time imaging and parathyroid surgery. Rapid washout was correlated to the type of hyperparathyroidism in surgically confirmed cases. Biochemical and pathological data were reviewed. RESULTS A total of 135 hyperparathyroidism patients met the inclusion criteria. Ninety-six (72%), 29 (21%), and 10 (7%) had primary, secondary, and tertiary hyperparathyroidisms, respectively. Rapid washout was identified in 28/87 glands (32%), 14/53 glands (26%), and 1/16 glands (6%) with primary, secondary, and tertiary hyperparathyroidisms, respectively. Glands that were positive on late-phase Tc99m-sestamibi scans were significantly large being 1.7 (IQR 1.4-2.3) vs. 1.45 (IQR 1-2) cm (p = 0.003). High parathyroid hormone levels (PTH) were associated with early-phase Tc99m-sestamibi positivity in both primary (p = 0.01) and secondary hyperparathyroidism (p = 0.03) but not with last phase (p = 0.11, p = 0.37, respectively). Correlative imaging with subtraction scintigraphy was positive in 14/16 (87.5%) parathyroid adenomas. CONCLUSION Pre-operative PTH levels and size of the gland were major determinants of Tc99m-sestamibi positivity on early-phase Tc99m-sestamibi scans, whereas size is an independent predictor of late-phase Tc99m-sestamibi positivity. Subtraction scintigraphy might be a useful tool in suspected cases of rapid washout adenomas/hyperplasia.
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Affiliation(s)
- Y S Kushchayeva
- Diabetes, Endocrinology, and Obesity Branch, NIDDK, NIH, Bethesda, MD, USA
| | - S H Tella
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - S V Kushchayev
- Department of Radiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - D Van Nostrand
- Division of Nuclear Medicine, MedStar Washington Hospital Center, 110 Irving Street, NW, Suite GB1, Washington, DC, 20010, USA
| | - K Kulkarni
- Division of Nuclear Medicine, MedStar Washington Hospital Center, 110 Irving Street, NW, Suite GB1, Washington, DC, 20010, USA.
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Keller S, Gorantla V, Aaltonen E, Kulkarni K, McDermott M. 03:27 PM Abstract No. 134 Superior hypogastric nerve block for post-procedure pain control after uterine artery embolization. J Vasc Interv Radiol 2019. [DOI: 10.1016/j.jvir.2018.12.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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McDermott M, Kulkarni K. 03:00 PM Abstract No. 421 Treatment of enhanced myometrial vascularity with transarterial embolization. J Vasc Interv Radiol 2019. [DOI: 10.1016/j.jvir.2018.12.500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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45
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Wu D, Khorjekar G, Kharazi P, Moreau S, Kulkarni K, Burman KD, Wartofsky L, Van Nostrand D. Poor patient compliance with instructions for continuous sialogogues after 131 I therapy. Oral Dis 2018; 25:158-163. [PMID: 30169900 DOI: 10.1111/odi.12969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/05/2018] [Accepted: 08/22/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To analyze the role of patient compliance as a factor in evaluating the effectiveness of continuous sialogogues to prevent salivary side effects from 131 I therapy in differentiated thyroid cancer patients. METHODS Differentiated thyroid cancer patients who were clinically scheduled for an 131 I therapy at MedStar Washington Hospital Center between 2012 and 2013 were given instructions for continuous sialogogues per standard clinical protocol. The prospective survey was given at multiple time points. RESULTS Ninety-nine patients consented to participate of whom 94 participants had complete data. The mean prescribed 131 I activity was 121 ± 50 mCi (4.5 ± 1.9 GBq), range 27.5-288 mCi (1.0-10.7 GBq ). Overall, only 10% (9/94) of patients were compliant with continuous sialogogues. Even though all patients took sialogogues on the first day of post-therapy, 17% of participants did not continuously take sialogogues during the first day, 60% during the first night, and 72% on the second day despite rigorous instructions to continue for two days. CONCLUSION Despite repetitive instructions to use sialogogues continuously, most patients (90%) were not compliant. In future studies, strict monitoring and evaluation of patient compliance will be crucial when assessing the effect of continuous versus intermittent or delayed initiation of sialogogues.
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Affiliation(s)
- Di Wu
- MedStar Clinical Research Center, MedStar Health Research Institute, Hyattsville, Maryland.,Nuclear Medicine Research, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Gauri Khorjekar
- Department of Radiology and Nuclear Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Shari Moreau
- Division of Nuclear Medicine, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Kanchan Kulkarni
- Division of Nuclear Medicine, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Kenneth D Burman
- Division of Endocrinology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Leonard Wartofsky
- Division of Endocrinology, MedStar Washington Hospital Center, Washington, District of Columbia.,MedStar Health Research Institute, Hyattsville, Maryland
| | - Douglas Van Nostrand
- Division of Nuclear Medicine, MedStar Washington Hospital Center, Washington, District of Columbia.,MedStar Health Research Institute, Hyattsville, Maryland
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Kulkarni K, Xie X, Fernandez de Velasco EM, Anderson A, Martemyanov KA, Wickman K, Tolkacheva EG. The influences of the M2R-GIRK4-RGS6 dependent parasympathetic pathway on electrophysiological properties of the mouse heart. PLoS One 2018; 13:e0193798. [PMID: 29668674 PMCID: PMC5905881 DOI: 10.1371/journal.pone.0193798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 02/20/2018] [Indexed: 02/07/2023] Open
Abstract
A large body of work has established the prominent roles of the atrial M2R-IKACh signaling pathway, and the negative regulatory protein RGS6, in modulating critical aspects of parasympathetic influence on cardiac function, including pace-making, heart rate (HR) variability (HRV), and atrial arrhythmogenesis. Despite increasing evidence of its innervation of the ventricles, and the expression of M2R, IKACh channel subunits, and RGS6 in ventricle, the effects of parasympathetic modulation on ventricular electrophysiology are less clear. The main objective of our study was to investigate the contribution of M2R-IKACh signaling pathway elements in murine ventricular electrophysiology, using in-vivo ECG measurements, isolated whole-heart optical mapping and constitutive knockout mice lacking IKACh (Girk4–/–) or RGS6 (Rgs6-/-). Consistent with previous findings, mice lacking GIRK4 exhibited diminished HR and HRV responses to the cholinergic agonist carbachol (CCh), and resistance to CCh-induced arrhythmic episodes. In line with its role as a negative regulator of atrial M2R-IKACh signaling, loss of RGS6 correlated with a mild resting bradycardia, enhanced HR and HRV responses to CCh, and increased propensity for arrhythmic episodes. Interestingly, ventricles from mice lacking GIRK4 or RGS6 both exhibited increased action potential duration (APD) at baseline, and APD was prolonged by CCh across all genotypes. Similarly, CCh significantly increased the slope of APD restitution in all genotypes. There was no impact of genotype or CCh on either conduction velocity or heterogeneity. Our data suggests that altered parasympathetic signaling through the M2R-IKACh pathway can affect ventricular electrophysiological properties distinct from its influence on atrial physiology.
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Affiliation(s)
- Kanchan Kulkarni
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Xueyi Xie
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota, United States of America
| | | | - Allison Anderson
- Department of Pharmacology, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Kirill A. Martemyanov
- Department of Neuroscience, The Scripps Research Institute, Jupiter, Florida, United States of America
| | - Kevin Wickman
- Department of Pharmacology, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Elena G. Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota, United States of America
- * E-mail:
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Lee SW, Kulkarni K, Annoni EM, Libbus I, KenKnight BH, Tolkacheva EG. Stochastic vagus nerve stimulation affects acute heart rate dynamics in rats. PLoS One 2018; 13:e0194910. [PMID: 29590213 PMCID: PMC5874066 DOI: 10.1371/journal.pone.0194910] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 03/13/2018] [Indexed: 01/09/2023] Open
Abstract
Vagus nerve stimulation (VNS) is an approved therapy for treatment of epilepsy and depression. While also shown to be promising in several preclinical and clinical studies to treat cardiovascular diseases, optimal therapeutic stimulation paradigms are still under investigation. Traditionally, parameters such as frequency, current, and duty cycle are used to adjust the efficacy of VNS therapy. This study explored the effect of novel stochastic VNS (S-VNS) on acute heart rate (HR) dynamics. The effect of S-VNS was evaluated in Sprague Dawley rats by comparing the acute HR and HR variability (HRV) responses to standard, periodic VNS (P-VNS) across different frequencies (FREQs, 10-30 Hz). Our results demonstrate that both S-VNS and P-VNS produced negative chronotropic effects in a FREQ-dependent manner with S-VNS inducing a significantly smaller drop in HR at 10 Hz and 20 Hz compared to P-VNS (p<0.05). S-VNS demonstrated a FREQ-dependent drop in the SD1/SD2 ratio, a measure of HRV, which was absent in P-VNS, suggesting that S-VNS may acutely modulate the nonlinear relationship between short- and long-term HRV. In conclusion, S-VNS is a novel stimulation procedure that may provide different physiological outcomes from standard P-VNS, as indicated by our analysis of HR dynamics. Our study provides a rationale for further detailed investigations into the therapeutic potential of S-VNS as a novel neuromodulation technique.
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Affiliation(s)
- Steven W Lee
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, United States of America
| | - Kanchan Kulkarni
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, United States of America
| | - Elizabeth M Annoni
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, United States of America
| | - Imad Libbus
- LivaNova, PLC (Cyberonics, Inc.), Houston, TX, United States of America
| | - Bruce H KenKnight
- LivaNova, PLC (Cyberonics, Inc.), Houston, TX, United States of America
| | - Elena G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, United States of America
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Tolkacheva EG, Kluck R, Kulkarni K. P883Heart rhythm control using novel anti-arrhythmic pacing protocol. Europace 2018. [DOI: 10.1093/europace/euy015.485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- E G Tolkacheva
- University of Minnesota, Biomedical Engineering, Minneapolis, United States of America
| | - R Kluck
- University of Minnesota, Biomedical Engineering, Minneapolis, United States of America
| | - K Kulkarni
- University of Minnesota, Biomedical Engineering, Minneapolis, United States of America
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Amico AL, Fang R, Raoul A, Wroblewski K, Nielsen S, Weipert C, Abe H, Sheth D, Romero I, Kulkarni K, Schacht D, Patrick-Miller L, Verp M, Bradbury AR, Hlubocky F, Olopade OI. Abstract P5-19-04: Psychosocial impact of a multi-modality surveillance program for women at high-risk for breast cancer. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p5-19-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose: To evaluate the psychosocial impact of semi-annual dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) screening in women at high-risk for breast cancer.
Background: For women with BRCA1 and BRCA2 mutations and/or a personal or family history of breast cancer, annual breast MRI has shown improved sensitivity and cancer detection compared to mammography. However, MRI's heightened sensitivity may lead to increased: false positives requiring additional follow-up biopsy/imaging; iatrogenic risk; and psychosocial distress, which all may negatively impact women's overall health-related quality of life.
Methods: Between 2004 and 2016, we assembled a prospective cohort of high-risk women undergoing semi-annual DCE-MRI and annual mammography. We reviewed a subset of this group. Participants completed psychosocial assessments at baseline and 6-month visits using the following measures: coping (MBSS); state/trait anxiety (STAI-S/T); depression (BDI-II); risk perception; and mental health (SF-36). Participants were classified according to Monitor or Blunter coping style. Mixed-effects logistic regressions models examined effects of demographics on psychosocial changes over time.
Results: 295 women were recruited to the study; 44% of the study participants had pathogenic mutations in BRCA1 or BRCA2 genes. 232 of 295 enrolled participants (78.6%) completed psychosocial assessments. For the total population: median age 44y (range: 21-73), 71% ≥college/post-graduate education; 84% Caucasian; 8% African American; 2% Latino; 99% with health insurance; 72% annual income of >$60,000. One third of women had a personal cancer history. Participants were evenly split between baseline Monitoring and Blunting coping style (49% and 51%, respectively). No significant differences were found between demographics (age, race, income, mutation, cancer type, cancer history) or psychosocial factors (baseline trait anxiety (p =0.64), depression (p =0.65), SF36 global health (p=0.66). After adjusting for education, race, cancer history and coping, women with ≥$60,000 income had lower trait anxiety (p<0.000) and greater mental health (p<0.001) than those with <$60,000 income. Over time, change in trait anxiety varied by coping (p=0.0006): Blunters did not experience significant changes in trait anxiety (p=0.072) while Monitors had significant diminished trait anxiety over time (p<0.001). For depression, women with ≥$60,000 income and college educated had lower BDI-II depression (p<0.000). Yet, women with a cancer history had significantly greater BDH-II depression (p= 0.048). Mental health over time varied by race as non-whites had greater gains in mental health (p=0.001) over time than whites (p=0.03).
Conclusion: Semi-annual DCE-MRI did not cause a significantly elevated state anxiety or depression, nor was there a significant decline in mental health over time for groups regardless of cancer history and genetic mutation status. Coping style may have an impact on psychosocial outcomes for those undergoing heightened surveillance over time.
Citation Format: Amico AL, Fang R, Raoul A, Wroblewski K, Nielsen S, Weipert C, Abe H, Sheth D, Romero I, Kulkarni K, Schacht D, Patrick-Miller L, Verp M, Bradbury AR, Hlubocky F, Olopade OI. Psychosocial impact of a multi-modality surveillance program for women at high-risk for breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-19-04.
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Affiliation(s)
- AL Amico
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - R Fang
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - A Raoul
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - K Wroblewski
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - S Nielsen
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - C Weipert
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - H Abe
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - D Sheth
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - I Romero
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - K Kulkarni
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - D Schacht
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - L Patrick-Miller
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - M Verp
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - AR Bradbury
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - F Hlubocky
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
| | - OI Olopade
- The University of Chicago, Chicago, IL; University of Pennsylvania, Philadelphia, PA; Independent Contractor
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Parker S, Nagra NS, Kulkarni K, Pegrum J, Barry S, Hughes R, Ghani Y. Inadequate pelvic radiographs: implications of not getting it right the first time. Ann R Coll Surg Engl 2017; 99:534-539. [PMID: 28682132 DOI: 10.1308/rcsann.2017.0095] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Pelvic radiography is a frequent investigation. European guidelines aim to ensure appropriate use and adequate quality. When initial images are inadequate, repeat radiographs are often required, which may have significant patient safety and economic implications. Objectives The study aimed to assess the adequacy of pelvic imaging across three orthopaedic centres, to identify causes for inadequate imaging and to establish the cost of inadequate imaging from financial and patient safety perspectives. Methods Pelvic radiographs were identified on Picture Archiving and Communication System software at three UK hospitals. Radiographs were assessed against European guidelines and indications for repeat imaging were analysed. Results A total of 1,531 sequential pelvic radiographs were reviewed. The mean age of patients was 60 years (range 5 months to 101 years). Of this total, 51.9% of images were suboptimal, with no significant difference across the three hospitals (P > 0.05). Hospital 3 repeated radiographs in 6.3% of cases, compare with 18.1% and 19.7% at hospitals 1 and 2, respectively (P > 0.05). Hospital 3 identified pathology missed on the initial radiograph in 1% of cases, compared with 5.4% and 5.5% at hospitals 1 and 2, respectively (P > 0.05). Out-of-hours imaging is associated with a higher rate of suboptimal quality (69.1%) compared with normal working hours (51.3%; P = 0.006). Adequacy rates vary with age (χ 2 = 43.62, P < 0.001). Risk of having a suboptimal radiograph increases above the age of 60-years (χ 2 = 4.45, P < 0.05). The annual cost of repeat radiographs was £56,200 per hospital. Discussion and conclusion High rates of pelvic radiograph inadequacy can lead to missed pathology and the requirement for repeat imaging, which has significant patient safety and financial implications. Risk factors for inadequate radiographs include older patients and those having out-of-hours imaging.
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Affiliation(s)
- S Parker
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital , Reading , UK
| | - N S Nagra
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital , Oxford , UK
| | - K Kulkarni
- Department of Trauma and Orthopaedics, East and North Herts NHS Trust, Lister Hospital , Stevenage , UK
| | - J Pegrum
- Department of Orthopaedics, Nuffield Orthopaedic Centre, Headington , Oxford , UK
| | - S Barry
- Department of Radiology, John Radcliffe Hospital , Oxford , UK
| | - R Hughes
- Department of Radiology, Stoke Mandeville Hospital , Aylesbury , UK
| | - Y Ghani
- Department of Trauma and Orthopaedic Surgery, Stoke Mandeville Hospital , Aylesbury , UK
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