Safety and outcome of very high-power short-duration ablation using 70 W for pulmonary vein isolation in patients with paroxysmal atrial fibrillation

Aims

Pulmonary vein isolation (PVI) using radiofrequency ablation (RFA) in patients with paroxysmal atrial fibrillation (PAF) is effective but hampered by pulmonary vein reconnection due to insufficient ablation lesions. High-power delivery over a short period of time (HPSD) in RFA is stated to create more efficient lesions. The aim of this study was to compare intraprocedural safety and outcome of HPSD ablation to conventional power settings in patients undergoing PVI for PAF.

Methods and results

We included 197 patients with PAF that were scheduled for PVI. An ablation protocol with 70 W and a duration cut-off of 7 s at the anterior left atrium (LA) and 5 s at the posterior LA (HPSD group; n = 97) was compared to a conventional power protocol with 30–40 W for 20–40 s (standard group; n = 100) in terms of periprocedural complications and a 1-year outcome. The HPSD group showed significantly less arrhythmia recurrence during 1-year follow-up with 83.1% of patients free from atrial fibrillation compared to 65.1% in the standard group (P < 0.013). No pericardial tamponade, periprocedural thromboembolic complications, or atrio-oesophageal fistula occurred in either group. Mean radiofrequency time (12.4 ± 3.4 min vs. 35.6 ± 12.1 min) and procedural time (89.5 ± 23.9 min vs. 111.15 ± 27.9 min) were significantly shorter in the HPSD group compared to the standard group (both P < 0.001).

Conclusion

High-power short-duration ablation demonstrated a comparable safety profile to conventional ablation. High-power short-duration ablation using 70 W for 5–7 s leads to significantly less arrhythmia recurrences after 1 year. Radiofrequency and procedural time were significantly shortened.

Multisystemic Therapy for social, emotional, and behavioral problems in youth aged 10-17

BACKGROUND

Multisystemic Therapy (MST) is an intensive, home-based intervention for families of youth with social, emotional, and behavioral problems. Masters-level therapists engage family members in identifying and changing individual, family, and environmental factors thought to contribute to problem behavior. Intervention may include efforts to improve communication, parenting skills, peer relations, school performance, and social networks. Most MST trials were conducted by program developers in the USA; results of one independent trial are available and others are in progress.

OBJECTIVES

To provide unbiased estimates of the impacts of MST on restrictive out-of-home living arrangements, crime and delinquency, and other behavioral and psychosocial outcomes for youth and families.

SEARCH STRATEGY

Electronic searches were made of bibliographic databases (including the Cochrane Library, C2-SPECTR, PsycINFO, Science Direct and Sociological Abstracts) as well as government and professional websites, from 1985 to January 2003. Reference lists of articles were examined, and experts were contacted.

SELECTION CRITERIA

Studies where youth (age 10-17) with social, emotional, and/or behavioral problems were randomised to licensed MST programs or other conditions (usual services or alternative treatments).

DATA COLLECTION AND ANALYSIS

Two reviewers independently reviewed 266 titles and abstracts; 95 full-text reports were retrieved, and 35 unique studies were identified. Two reviewers independently read all study reports for inclusion. Eight studies were eligible for inclusion. Two reviewers independently assessed study quality and extracted data from these studies. Significant heterogeneity among studies was identified (assessed using Chi-square and I(2)), hence random effects models were used to pool data across studies. Odds ratios were used in analyses of dichotomous outcomes; standardised mean differences were used with continuous outcomes. Adjustments were made for small sample sizes (using Hedges g). Pooled estimates were weighted with inverse variance methods, and 95% confidence intervals were used.

MAIN RESULTS

The most rigorous (intent-to-treat) analysis found no significant differences between MST and usual services in restrictive out-of-home placements and arrests or convictions. Pooled results that include studies with data of varying quality tend to favor MST, but these relative effects are not significantly different from zero. The study sample size is small and effects are not consistent across studies; hence, it is not clear whether MST has clinically significant advantages over other services.

AUTHORS' CONCLUSIONS

There is inconclusive evidence of the effectiveness of MST compared with other interventions with youth. There is no evidence that MST has harmful effects.

REM sleep induction in prepubertal boys by vasotocin: evidence for the involvement of serotonin containing neurons

The pineal nonapeptide hormone arginine vasotocin (AVT) (100 ng/kg) administered intra-nasally (IN) to healthy prepubertal boys, dramatically increased the amount of REM sleep, decreased REM sleep latency, and induced REM periods at sleep onset. Neither arginine vasopressin (AVP) nor oxytocin administered IN at the dose of 100 ng/kg was able to reproduce the effects of AVT, demonstrating its high specificity. Methergoline, a selective central 5-hydroxytryptamine (5-HT) receptor blocker, administered IN at the dose of 100 ng/kg, completely prevented AVT induction of REM sleep. Fluoxetine, a specific 5-HT uptake inhibitor, administered IN at the dose of 25 microgram/kg, 10 min after AVT, greatly potentiated the effects of AVT in inducing REM periods at sleep onset and in increasing the amount of REM sleep and the percentage of dream reports. It is suggested that AVT induces REM sleep in prepubertal boys by interfering with 5-HT neurotransmission and that the high sensitivity of prepubertal boys to AVT reflects an immaturity of REM triggering centers.

The occurrence and antimicrobial susceptibility of salmonellae isolated from commercially available canine raw food diets in three Canadian cities

The purpose of the present study was to evaluate the prevalence and antimicrobial resistance patterns of Salmonella isolated from commercially available canine raw food diets in Canada. A total of 166 commercial frozen raw food diet samples were purchased from randomly selected local pet stores in three Canadian cities for a period of 8 months. All samples were evaluated for the presence of Salmonella, serotyped and tested for antimicrobial susceptibility. There was an overall Salmonella prevalence of 21%; chicken was an ingredient for 67% of the Salmonella-positive diets. Eighteen different Salmonella serotypes were recovered, and resistance was observed to 12 of the 16 antimicrobials tested, with the majority of Ontario isolates exhibiting resistance to ampicillin and Calgary isolates to tetracycline. This study demonstrates the potential risk of raw food diets, especially for immunocompromised individuals, and stresses the need for implementing regulatory guidelines for the production of these diets in order to help control and ideally eliminate the bacterial risks associated with their use and consumption.

Treatment of Cubital Tunnel Syndrome by Frontal Partial Medial Epicondylectomy. A Retrospective Series of 55 Cases

The outcomes of 55 cases of cubital tunnel syndrome treated by a partial frontal epicondylectomy are presented at a mean follow-up of 38 months follow-up. According to McGowan classification, 25 cases were grade I (45%), 12 grade II (22%) and 18 grade III (33%). The results (Wilson and Krout classification) were excellent or good in 41 patients (75%), fair in nine patients and unchanged in five, without any worsening or recurrence. Total relief was reported in 80% of grade I, 75% of grade II and 66% of grade III patients. Seven painful scars and one persistent 15° elbow extension deficit were the only complications. The satisfaction rate was 93%. This technique preserves bony protection, the blood supply and gliding tissues for the nerve and nerve recovery were comparable to other surgical procedures. Residual pain at the osteotomy site was not a serious problem.

Phases in the temporal multiscale evolution of the drug release mechanism in IPN-type chitosan based hydrogels

Different release mechanisms are identified in the temporal evolution of drug release from IPN-type hydrogels, conducted over longer timescales.

Multisystemic Therapy for social, emotional, and behavioral problems in youth aged 10-17

BACKGROUND

Multisystemic Therapy (MST) is an intensive, home-based intervention for families of youth with social, emotional, and behavioral problems. Masters-level therapists engage family members in identifying and changing individual, family, and environmental factors thought to contribute to problem behavior. Intervention may include efforts to improve communication, parenting skills, peer relations, school performance, and social networks. Most MST trials were conducted by program developers in the USA; results of one independent trial are available and others are in progress.

OBJECTIVES

To provide unbiased estimates of the impacts of MST on restrictive out-of-home living placements, crime and delinquency, and other behavioral and psychosocial outcomes for youth and families.

SEARCH STRATEGY

Electronic searches were made of bibliographic databases including the Cochrane Library, C2-SPECTR, PsycINFO, Science Direct and Sociological Abstracts) as well as government and professional websites, from 1985 to January 2003. Reference lists of articles were examined, and experts were contacted.

SELECTION CRITERIA

Studies where youth (age 10-17) with social, emotional, and/or behavioral problems were randomised to licensed MST programs or other conditions (usual services or alternative treatments).

DATA COLLECTION AND ANALYSIS

Two reviewers independently reviewed 266 titles and abstracts; 95 full-text reports were retrieved, and 35 unique studies were identified. Two reviewers independently read all study reports for inclusion. Eight studies were eligible for inclusion. Two reviewers independently assessed study quality and extracted data from these studies.Significant heterogeneity among studies was identified (assessed using Chi-square and I(2)), hence random effects models were used to pool data across studies. Odds ratios were used in analyses of dichotomous outcomes; standardised mean differences were used with continuous outcomes. Adjustments were made for small sample sizes (using Hedges g). Pooled estimates were weighted with inverse variance methods, and 95% confidence intervals were used.

MAIN RESULTS

Pooled results show no significant effects of MST on the likelihood or duration of restrictive out-of-home placements, proportion of youth who were arrested or convicted, or numbers of arrests/convictions within one-year post-intervention. There were no significant differences on drug tests or self-reported drug use at a 6-month follow-up. In analyses of post-treatment data for program completers, there were no significant between-group differences on self-reported delinquency, peer relations, youth behavior problems, youth psychiatric symptoms, parent psychiatric symptoms, or family functioning.

AUTHORS' CONCLUSIONS

There is little evidence of the superiority of MST over other interventions with youth. There is also no evidence that MST has harmful effects.

RF electrode-tissue coverage significantly influences steam pop incidence and lesion size

BACKGROUND

Steam pops are a rare complication associated with radiofrequency (RF) ablation and are hard to predict. The aim of this study was to assess the influence of coverage between the RF ablation electrode and cardiac tissue on steam pop incidence and lesion size.

METHODS AND RESULTS

An ex vivo model using porcine cardiac preparations and contact force sensing catheters was designed to perform RF ablations at different coverage levels between the RF electrode and cardiac tissue. During coverage level I, only the distal part of the ablation electrode was in contact with tissue. During coverage level II half of the ablation electrode, and during coverage level III the entire ablation electrode was embedded in tissue. RF applications (n = 60) at different coverage levels I-III were systematically performed using the same standardized ablation protocol. Ablations during coverage level III resulted in a significantly higher rate of steam pops (100%) when compared to ablations during coverage level II (10%) and coverage level I (0%), log rank p < .001. Coverage level I ablations resulted in significantly smaller lesion depths, diameters, and impedance drops when compared to higher coverage level ablations, p < .001. In the controlled ex vivo model, there was no difference in applied contact force or energy between different coverage levels.

CONCLUSIONS

The level of coverage between RF electrode, cardiac tissue, and the surrounding fluid significantly influenced the incidence of steam pops in an ex vivo setup. Larger coverage between RF electrode and tissue resulted in significantly larger lesion dimensions.

Mechanism and functional impact of CD40 ligand-induced von Willebrand factor release from endothelial cells

Co-stimulation via CD154 binding to CD40, pivotal for both innate and adaptive immunity, may also link haemostasis to vascular remodelling. Here we demonstrate that human platelet-bound or recombinant soluble CD154 (sCD154) elicit the release from and tethering of ultra-large (UL) von Willebrand factor (vWF) multimers to the surface of human cultured endothelial cells (ECs) exposed to shear stress. This CD40-mediated ULVWF multimer release from the Weibel-Palade bodies was triggered by consecutive activation of TRAF6, the tyrosine kinase c-Src and phospholipase Cγ1 followed by inositol-1,4,5 trisphosphate-mediated calcium mobilisation. Subsequent exposure to human washed platelets caused ULVWF multimer-platelet string formation on the EC surface in a shear stress-dependent manner. Platelets tethered to these ULVWF multimers exhibited P-selectin on their surface and captured labelled monocytes from the superfusate. When exposed to shear stress and sCD154, native ECs from wild-type but not CD40 or vWF-deficient mice revealed a comparable release of ULVWF multimers to which murine washed platelets rapidly adhered, turning P-selectin-positive and subsequently capturing monocytes from the perfusate. This novel CD154-provoked ULVWF multimer-platelet string formation at normal to fast flow may contribute to vascular remodelling processes requiring the perivascular or intravascular accumulation of pro-inflammatory macrophages such as arteriogenesis or atherosclerosis.

Early re-feeding in the management of acute diarrhoea in infants of 0-1 year of age

We compared early versus late re-feeding in the management of acute diarrhoea in the first year of life. In the study group (73 groups) breast feeding was resumed or early re-feeding was performed in non-breast-fed infants, so that the feeding regimen used prior to the onset of the disease was reached within 2-3 days. In the control group (49 patients) late re-feeding was performed so that the infants returned to their original feeding pattern after 4-6 days. there were no significant differences between the two groups in the number of stools and stool output per day, or in the duration of the disease. No weight gain or loss during the diet was noted more frequently in the late re-feeding group (67.2% versus 2.3.4%). This study confirms the favourable effect on body weight of early re-feeding in the management of acute diarrhoea.

BJS commission on surgery and perioperative care post-COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence.

METHODS

In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them.

RESULTS

BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training.

CONCLUSION

The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.

Microwave-dried or air-dried? Consumers' stated preferences and attitudes for organic dried strawberries. A multi-country investigation in Europe

Non-thermal food processing technologies are becoming more important in the organic food sector because, beyond preserving the organic feature, they could offer organic products with additional benefits in terms of enhanced nutritional content and healthiness as well as better sensory properties that could satisfy the more complex demands of organic consumers. Berries have a well-known health benefits and show increasing market shares in European markets while dehydration can increase the food convenience in terms of extended shelf-life. This study investigates for the first time organic consumers' stated preferences, attitudes and individual differences for a non-thermal organic processing technology. Specifically, we investigated consumers' preferences for organic dried strawberries varying in drying technology used, such as the most conventional (i.e. thermal) air drying and the most innovative (i.e. non-thermal) microwave drying, origin, price levels, and nutrient contents in three European countries: Norway, Romania and Turkey. Data from a total of 614 consumers were collected through an online choice experiment. Results show that on average consumers prefer organic dried strawberries produced with air drying technology that have national origin, with natural nutrient content and at low price, but country and individual differences are identified. Consumers who showed least rejection for microwave dried products are young, mostly from Norway and have higher positive attitudes towards new food technologies. Consumers who showed most rejection for microwave dried products are older, mostly from Turkey and have higher positive attitudes for organic, natural and ecological products. Organic producers who adopt microwave drying might better inform consumers about the characteristics, the process and highlight the nutritional benefits of such technology. Finally, this research informs policy makers about the need to define and regulate more clearly microwave drying as an organic technology, as well as to regulate labelling to ensure that consumers are not misled and correctly informed about the new technology.

Microparticles based on natural and synthetic polymers for ophthalmic applications

Sodium salt of carboxymethylcellulose/poly(vinyl alcohol) particles suitable for application in ocular drug administration were prepared by crosslinking with epichlorohydrin in an alkaline medium, in reverse emulsion. The influence of parameters related with the particles elaboration process (ratio between polymer mixture and crosslinking agent, concentration of polymer solution, duration of crosslinking reaction, stirring intensity, etc.) based on their composition, size, and swelling ability was studied. Obtained microparticles fulfill the requirements for biomaterials-they are formed from biocompatible polymers; the acute toxicity value (LD(50)) is high enough to consider these materials as weakly toxic (hence able to introduce within the organism); they are able to include and release drugs in a controlled way. The in vivo adrenalin ocular delivery from the microparticles was tested on voluntary human patient. The particles showed good adhesion properties without irritation to the patient and proved the capability to treat the ocular congestion.

Early recurrence after pulmonary vein isolation is associated with inferior long-term outcomes: Insights from a retrospective cohort study

AIMS

The aim of this retrospective cohort study was to assess the influence of early recurrence (ER) after pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) on long-term outcomes and to identify clinical variables associated with ER.

METHODS

We retrospectively collected clinical and procedural data from 1285 patients with paroxysmal AF who underwent PVI from 2011 to 2016. Kaplan-Meier, receiver operating characteristic (ROC) curve, logistic and Cox regression analyses were performed to analyze the influence of ER on long-term outcomes.

RESULTS

ER was observed in 13% of patients. Kaplan-Meier analyses showed significantly different outcomes in 1285 patients with and without ER (49% vs 74%, log rank P < .01) and in 286 patients in the subgroup that underwent reablation (44% vs 79%, log rank P < .01). The hazard ratio (HR) of ER was 1.7 within 48 hours (5% of patients), 2.7 within 1 month (5%), 3.0 within 2 months (2%), and 6.4 within 3 months (1%) for late recurrence (LR), P < .01. ROC analysis (area under the curve [AUC] = 0.79) resulted in 70.3% sensitivity and 74.2% specificity for a 14-day blanking period, and 53.1% sensitivity and 85.5% specificity for a 30-day blanking period. Female patients (odds ratio [OR] 1.69, P < .01) and those with diabetes (OR 1.95, P = .01) were at higher risk for ER.

CONCLUSIONS

ER is observed in a substantial number of patients with paroxysmal AF after PVI and has a continuous direct effect on LR according to the timing of ER. Randomized trials are required to assess the safety and effects of reablations in a shortened blanking period on long-term outcomes.

New radiopaque acrylic bone cement. II. Acrylic bone cement with bromine-containing monomer

Bromine-containing methacrylate, 2-(2-bromopropionyloxy) ethyl methacrylate (BPEM), had been used in the formulation of acrylic radiopaque cements. The effect of this monomer incorporated into the liquid phase of acrylic bone cement, on the curing parameters, thermal properties, water absorption, density, compression tests and radiopacity was studied. A decrease of maximum temperature and an increase of the setting time were observed with the addition of the bromine-containing monomer in the radiolucent cement composition. Adding BPEM in radiolucent acrylic bone cements composition results in the decrease of glass transition temperature and increase of its thermal stability. Acrylic bone cements modified with bromine-containing comonomer are characterized by polymerization shrinkage lower than the radiolucent cement. Addition of bromine-containing comonomer in radiolucent acrylic bone cement composition determines the increase of compressive strength. Acrylic bone cements modified with bromine-containing comonomer proved to be radiopaque.