High power, short duration ablation: at least for the right pulmonary vein carina, maybe not so fastGustavo S. Guandalini, MD a and Francis E. Marchlinski, MD aa Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PACorresponding author: Dr. Francis E. Marchlinski, Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, Pennsylvania 19104. E-mail: Francis.Marchlinski@pennmedicine.upenn.edu.The authors have no conflicts to disclose.Word count: 1,170.This research was supported by the Richard T and Angela Clark Innovation Fund in Cardiovascular Medicine.
Letter to the Editor, BJOG Title: ESMiE confidential enquiry: Broader view besides focus on errors by birth-attendants.Re: Rowe R, Draper ES, Kenyon S, Bevan C, Dickens J, Forrester M, Scanlan R, Tuffnell D, Kurinczuk JJ. Intrapartum-related perinatal deaths in births planned in midwifery-led settings in Great Britain: findings and recommendations from the ESMiE confidential enquiry. BJOG 2020;127:1665–1675.Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKShort running title: ESMiE enquiry: broader viewEmail: email@example.com Tel: 07906620662Word count: 500Corresponding Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKStatement of interest: The author has no conflict of interest or funding to declare.
Re: Training in the use of intrapartum electronic fetal monitoring with cardiotocography: systematic review and meta‐analysis. Cardiotocography training is a complex intervention and requires complex evaluations: a letter to editor.Lightly K, Weeks AD, Scott HCorrespondence to Dr Kate Lightly – firstname.lastname@example.orgClinical Research Fellow, Sanyu Research Unit, University of Liverpool and Liverpool Women’s NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS.Professor Andrew D WeeksProfessor of International Maternal Health, Sanyu Research Unit, University of Liverpool and Liverpool Women’s NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS.Professor Hazel ScottDean of School of Medicine, School of Medicine, University of Liverpool, Cedar House, Liverpool, L69 3GE.Running title - CTG training requires complex evaluationsWe congratulate Kelly et al on their review on the effects of training in cardiotocography (CTG).i It is a critical step towards understanding how to correctly implement CTG training. However, we query the relevance of some of the included studies and whether using Kirkpatrick’s model adequately captures all of the relevant complexities. We believe that further work is needed to understand how such training will impact on practice.Some of the CTG research projects reviewed were poorly representative of the needs of clinicians tasked with improving fetal monitoring in their hospitals. For clinicians, their population of interest is practising clinicians who work on labour wards (sometimes infrequently); studies involving undergraduates alone may not be generalisable. Training in intermittent auscultation is also relevant. Considerable detail on the training intervention is required, including not only the format of teaching, but the duration, curriculum and proportion of relevant staff trained. Detail is also required of supporting interventions and context, as training alone is unlikely to impact change. Many would consider ‘no training’ unethical and therefore not a relevant comparator . In the UK, CTG training and competency is now required for all maternity staff.ii The ultimate aim of CTG (and therefore CTG training) is to detect the hypoxic fetus, so that timely intervention can be undertaken to avoid perinatal harm, without unnecessary intervention. Therefore, the outcomes of interest have to include intrapartum stillbirths, hypoxic ischaemic encephalopathy and mode of delivery.Kirkpatrick’s model was used in this review to evaluate training at four levels (reaction, knowledge, behaviour change and organisational performance). However, it does not attempt to understand why interventions work, or the context, or the causal pathways between training and change in practice.iii Whether participants like training (‘reaction’) is of little relevance, and knowledge acquisition (‘knowledge’) is a proxy which does not equate with improved on the job performance and outcomes. Maternal and perinatal outcomes (‘performance’) were only collected in a small number of studies.CTG training is a complex intervention which aims to create change, not simply knowledge acquisition. We therefore believe that a formal Realist Evaluation is needed. This emerging methodology has been used successfully to understand healthcare change processes and supplement traditional Cochrane style reviews. It aims to understand why complex interventions work, how, for whom, in what context and to what extentiv. Collaboration with the relevant authors to gain detailed intervention descriptions, with a realist approach, may add some much needed explanatory power to this critical subject.Training alone is unlikely to impact change. Even the best educational package will fail without the necessary support - it needs an educational and working culture which supports learning and change, aligned and clear policies, and motivated, well supported drivers and leaders.How doctors learn and what supports them to put new knowledge into practice are key research questions. High quality, methodologically appropriate, properly funded studies are needed to address these questions. Not answering them means many research findings are redundant, as they simply will not be implemented.ReferencesI Kelly S, Redmond P, King S, Oliver‐Williams C, Lamé G, Liberati E et al. Training in the use of intrapartum electronic fetal monitoring with cardiotocography: systematic review and meta‐analysis. BJOG. 2021; 00: 1–12. https://doi.org/10.1111/1471-0528.16619ii NHS England. Saving Babies’ Lives Version Two. A care bundle for reducing perinatal mortality. London: NHS England 2019. [cited 2021 Feb 3]. Available from: www.england.nhs.ukiii Moreau KA. Has the new Kirkpatrick generation built a better hammer for our evaluation toolbox? Med Teach. 2017 Sep; 39(9): 999-1001. https://doi.org/10.1080/0142159X.2017.1337874iv Wong G, Westhorp G, Greenhalgh J, Manzano A, Jagosh J, Greenhalgh T. Quality and reporting standards, resources, training materials and information for realist evaluation: the RAMESES II project. Health Services and Delivery Research. 2017 5 (28): 1–108. https://doi.org/10.3310/hsdr05280.Acknowledgements – NilDisclosure of interests - NilContribution to authorshipKL wrote the first draft of this letter and then it was revised by AW and HS.Details of ethics approval – N/AFunding – Dr Lightly’s PhD entitled “Improving intrapartum fetal monitoring in India: A mixed methods approach” is funded by MRC/DfID/Wellcome Trust Joint Global Health Trials Fund. MR/R006/1801
Atmospheric and climate change will expose tropical forests to conditions they have not experienced in millions of years. To better understand the consequences of this change we studied photosynthetic acclimation of the neotropical tree species Tabebuia rosea to combined 4°C warming and twice-ambient (800 ppm) CO2. We measured temperature responses of the maximum rates of ribulose 1,5-bisphosphate carboxylation (VCMax), photosynthetic electron transport (JMax), net photosynthesis (PNet), and stomatal conductance (gs), and fitted the data using a probabilistic Bayesian approach. To evaluate short-term acclimation plants were then switched between treatment and control conditions and re-measured after 1–2 weeks. Consistent with acclimation, the optimum temperatures (TOpt) for VCMax, JMax and PNet were 1–5°C higher in treatment than in control plants, while photosynthetic capacity (VCMax, JMax, and PNet at TOpt) was 8–25% lower. Likewise, moving control plants to treatment conditions moderately increased temperature optima and decreased photosynthetic capacity. Stomatal density and sensitivity to leaf-to-air vapor pressure deficit were not affected by growth conditions, and treatment plants did not exhibit stronger stomatal limitations. Collectively, these results illustrate the strong photosynthetic plasticity of this tropical tree species as even fully-developed leaves of saplings transferred to extreme conditions partially acclimated.
Abstract: Objectives: Our work assessed the prevalence of co-infections in patients with SARS-CoV-2. Methods: All patients hospitalized in a Parisian hospital during the first wave of COVID-19 were tested by mPCR if they presented ILI symptoms. Results: A total of 806 patients (21%) were positive for SARS-CoV-2, 755 (20%) were positive for other respiratory viruses. Among the SARS-CoV-2 positive patients, 49 (6%) had viral co-infections. They presented similar age, symptoms, except for fever (p=0.013) and headaches (p=0.048), than single SARS-CoV-2 infections. Conclusions: SARS-CoV-2 infected patients presenting viral co-infections had similar clinical characteristics and prognosis than patients solely infected with SARS-CoV-2.
We congratulate Kar et al. on their elegant study evaluating ex-vivo temperature profiles and the resulting thermal injury formation on the epiesophageal surface during radiofrequency (RF) ablation. In addition to being the first study to detail temperature profiles inclusive of the epiesophageal surface during RF ablation, we believe that the results add further concern to the use of temperature sensing technology in the quest to reduce esophageal injury. Three recent clinical trials have evaluated the efficacy of luminal esophageal temperature (LET) monitoring and found either no benefits, or signals of harm. On the other hand, two pilot RCTs suggest benefits of active cooling, and a large RCT, the IMPACT study, further confirms this benefit by finding an 83% reduction in esophageal lesion formation using an active cooling device. With no degradation in ablation efficacy, as well as a reduction/elimination of the need for fluoroscopy and reports of shortened procedure time with active cooling technology, the data of Kar et al., combined with growing clinical data, suggest that continued use of LET monitoring may be unjustified.
Quantifying how multiple ecosystem services and functions are affected by different drivers of Global Change is challenging. Particularly in African savanna regions, highly integrated land-use activities created a landscape mosaic with flows of multiple resources between land use types. A framework is needed that quantifies the effects of climate change, management and policy interventions on ecosystem services that are most relevant for rural communities, such as provision of food, feed, carbon sequestration, nutrient cycling and natural pest control. In spite of progress made in ecosystem modelling, data availability and stakeholder interactions, these elements have neither been brought together in an integrated framework, nor evaluated in the context of real-world problems. Here, we propose and outline such framework as developed by a multi-disciplinary research network, the Southern African Limpopo Landscapes network (SALLnet). Components of the framework such as the crop model APSIM and the vegetation model aDGVM2 had already been parameterized and evaluated using data sets from savanna regions of eastern, western and southern Africa, and were fine-tuned using novel data sets from Limpopo. A prototype of an agent-based farm household model was developed using comprehensive farm survey information from the Limpopo Province of South Africa. A first test of the functionality of the integrated framework has been performed for alternative policy interventions on smallholder crop-livestock systems. We discuss the versatile applicability of the framework, with a focus on smallholder landscapes in the savanna regions of southern Africa that are considered hotspots of global change impacts.
Background Aortic Aneurysm (AA) is a common atherosclerotic condition, accounting for nearly 6,000 deaths in England and up to 175,000 deaths globally each year. The pathological outward bulging of the aorta typically results from atherosclerosis or hereditary connective tissue disorders. AAs are usually asymptomatic until spontaneous rupture or detected on incidental screening. 8 in 10 patients do not survive the rupture and die either before reaching hospital or from complications following surgery. Similar to other cardiovascular pathologies (CVPs), AA is thought to be subject to chronobiological patterns of varying incidence. Methods We performed a literature review of the current literature to evaluate the association between circadian rhythms, seasonal variations, and genetic factors and the pathogenesis of AA, reviewing the impact of chronobiology. Results The incidence of AA is found to peak in the early morning (6 AM – 11 AM) and colder months, and conversely troughs towards the evening and warmer months, exhibiting a similar pattern of chronobiological rhythm as other CVPs such as myocardial infarcts, or cerebrovascular strokes. Conclusion Literature suggests there exists a clear relationship between chronobiology and the incidence and pathogenesis of ruptured AA; incidence increases in the morning (6am - 11am), and during colder months (December – January). This is more pronounced in patients with Marfan Syndrome, or vitamin D deficiency. The underlying pathophysiology and implications this has for chronotherapeutics, are also discussed. Our review shows a clear need for further research into the chronotherapeutic approach to preventing ruptured AA in the journey towards precision medicine.
1. Trait differences among plant species can favor species coexistence. The role that such differences play in the assembly of diverse plant communities maintained by frequent fires remains unresolved. This lack of resolution results in part from the possibility that species with similar traits may coexist because none has a significant fitness advantage and in part from the difficulty of experimental manipulation of highly diverse assemblages dominated by perennial species. 2. We examined a 65-year chronosequence of losses of herbaceous species following fire suppression (and subsequent encroachment by Pinus elliottii) in three wet longleaf pine savannas. We used cluster analysis, similarity profile permutation tests and k-R cluster analysis to identify statistically significant functional groups. We then used randomization tests to determine if the absence of functional groups near pines was greater (or less) than expected by chance. We also tested whether tolerant and sensitive species were less (or more) likely to co-occur by chance in areas in savannas away from pines in accordance with predictions of modern coexistence theory. 3. Functional group richness near pines was lower than expected from random species extirpations. Wetland perennials with thick rhizomes and high leaf water content, spring-flowering wetland forbs (including Drosera tracyi), orchids, Polygala spp., and club mosses were more likely to be absent near pines than expected by chance. C3 grasses and sedges with seed banks and tall, fall-flowering C4 grasses were less likely to be absent near pines than expected by chance. Species sensitive to pine encroachment were more likely to co-occur with other such species away from pines at two of the three sites. 4. Results suggest that herb species diversity in frequently-burned wet savannas is maintained in part by a weak fitness (e.g., competitive) hierarchy among herbs, and not as a result of trait differences among co-occurring species.
Accurate assessment of right ventricular (RV) function is drawing a growing attention. Pressure-volume (PV) loop analysis is the gold standard method for evaluating RV function; however, it is not widely employed due to its invasive nature and complexity. The present report is the first to have drawn a RV PV loop in a patient with pulmonary hypertension, with a simultaneous recording of RV pressure and volume using high fidelity micromanometry and 3D echocardiography. This allows for less invasive and simple assessment of RV function, potentially promoting better understanding and management of pulmonary hypertension and other cardiovascular diseases.
Arrhythmia Induced Cardiomyopathy: What are Predictors of Myocardial Recovery?Acile Nahlawi BS, Marwan M. Refaat MDDepartment of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, LebanonRunning Title: AIC and Predictors of Myocardial RecoveryDisclosures: NoneFunding: NoneKeywords: Cardiac Arrhythmias, Cardiovascular Diseases, Heart Diseases, Congestive Heart Failure, CardiomyopathyWords: 958 (excluding references)Correspondence:Marwan M. Refaat, MD, FACC, FAHA, FHRS, FASE, FESC, FACP, FRCPAssociate Professor of MedicineDirector, Cardiovascular Fellowship ProgramDepartment of Internal Medicine, Cardiovascular Medicine/Cardiac ElectrophysiologyDepartment of Biochemistry and Molecular GeneticsAmerican University of Beirut Faculty of Medicine and Medical CenterPO Box 11-0236, Riad El-Solh 1107 2020- Beirut, LebanonFax: +961-1-370814Clinic: +961-1-759616 or +961-1-355500 or +961-1-350000/+961-1-374374 Extension 5800Office: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366 (Direct)Email: email@example.comCardiomyopathies cause a significant public health burden and improvement in sudden cardiac death risk stratification helped in decreasing mortality by improved pharmacotherapy as well as device implantations including implantable cardiac defibrillators and cardiac resynchronization therapy [1-4]. Arrhythmia induced cardiomyopathy (AIC) is a major cause of non-ischemic cardiomyopathy and heart failure (HF) worldwide . It is characterized by an impairment of left ventricular systolic function secondary to high heart rate (tachycardia-induced), asynchrony (frequent premature ventricular contractions-induced or right ventricular pacing-induced) or an irregular rhythm (such as atrial fibrillation-induced) that serves as the trigger of AIC and this is mediated by calcium mishandling. The distinctive feature of AIC is the substantial improvement in left ventricular systolic function following arrhythmia suppression or elimination . Atrial Fibrillation (AF) is concomitantly present with and potentially the cause of 10 to 50% of HF cases . AIC is an important, commonly encountered and potentially reversible entity that is often under-recognized. The exact incidence and prevalence of AIC remains poorly defined in the literature . In some studies, it was present in as high as 50% of patients with AF undergoing ablation, while it was reported to be present in 10% of patients with focal atrial tachycardia undergoing ablation . In addition, very little attention, if any, is given to AIC in major trials on AF and HF, despite its significant implications on morbidity and mortality and the promising benefits of treatment . Many aspects of AIC are yet to be understood. In fact, few studies limited by small sample size constitute our main source of knowledge on extent and predictors of ventricular recovery after treatment initiation in patients with AIC [9,10].In their multicenter retrospective study, Gopinathannair et al. aimed to assess the degree of recovery of the left ventricular systolic function after suppression/elimination of the underlying arrythmia and to evaluate factors influencing this response such as baseline patient and arrhythmia characteristics. The study sample comprised 243 patients from 3 different institutions whose charts were reviewed retrospectively (no recruitment timeframe was indicated). The patient characteristics studied included baseline left ventricular ejection fraction (LVEF), presence of structural heart disease (SHD) [ defined as significant coronary artery disease, prior myocardial infarction, hemodynamically significant valvular heart disease, or other structural cardiomyopathies] and medications used. As for the arrhythmia characteristics, they included arrhythmia duration and arrhythmia type. The authors used echocardiography as the imaging modality to determine extent of ventricular function recovery by comparing myocardial function before and after treatment of the culprit arrhythmia. The echocardiographic parameters that were assessed included LVEF, LV end-diastolic and end-systolic diameters, left atrial dimension, valvular abnormalities, right ventricular systolic pressures, and pulmonary arterial pressures.In contrast to reported literature on the topic, Gopinathannair et al. found that none of the studied patient and arrhythmia characteristics had a significant effect on the recovery of ventricular function. Their results showed that initiation of aggressive arrhythmia treatment is warranted in patients with suspected AIC, regardless of arrhythmia duration, arrhythmia type, severity of baseline LVEF, and underlying structural heart disease. This was concluded based on the consistent substantial improvement in LVEF after arrhythmia suppression/elimination, mainly through rhythm control, across all different subgroups. In fact, the extent of LVEF improvement was similar whether comparing the group with known arrhythmia duration [KN] to that with unknown arrhythmia duration [UKN] (21.2±9 % vs 19.4±11 %, p-value =0.16) or comparing the group with longest arrhythmia duration to the rest (21.5±7.5 % vs 21.0 ± 9.2%, p-value=0.77). On the other hand, greatest improvement was seen in the group with lowest initial LVEF (24±17 vs 19±7%; p-value <0.0001), making low index LVEF the only predictor of LVEF recovery after arrhythmia treatment in patients with AIC. However, the LVEF in these patients did not reach complete normalization; they had lower post-treatment LVEF compared to other groups (45±14 vs 54±8%; p<0.0001), a finding consistent with the available literature. Also similar to previous studies, the authors found that patients with PVCs experienced smaller extent of recovery compared to other arrhythmia types. The authors concluded by stressing the importance of suspecting AIC in patients having cardiomyopathy with a persistent arrhythmia and initiating aggressive arrhythmia treatment regardless of initial patient and arrhythmia characteristics.As for the limitations of the study by Gopinathannair et al., there are few to mention. First, the study had a retrospective design and therefore findings only serve to generate hypotheses that need further testing and validation. Second, there is a lack of a control group to exclude interference of confounding factors. Although the use of Angiotensin-Converting Enzyme inhibitors (ACEi)/ Angiotension receptor blockers (ARB) did not independently predict LVEF improvement in multivariate analysis, it could still be a confounder given the lower rates of ACEi/ARB use in the cohort. Third, the timeframe of the study and the period of follow-up were not clearly defined. Fourth, there is lack of blinding of echocardiographic analyses which can potentially lead to inter- and intra-observer variability. Finally, the sample population was not diverse as it consisted in its majority of Caucasians.The Gopinathannair et al. study demonstrated several points of strength. Among these are its multicenter nature and its relatively larger sample size compared to similar studies, giving its findings more weight. Moreover, the authors appropriately and clearly defined their inclusion and exclusion criteria. Furthermore, no funding was needed for the study which potentially frees it from direct or indirect influences on its design, execution and interpretation. Finally, the study has successfully improved our understanding of predictors of ventricular recovery in patients with AIC and showed that patients with AIC who had the longest duration of arrhythmia still had LV systolic function improvement with arrhythmia suppression/elimination. This study paves the way for prospective studies and randomized clinical trials to validate the generated hypotheses and corroborate the observational findings.
This systematic review evaluates the efficacy and safety of biologicals for chronic rhinosinusitis with nasal polyps (CRSwNP) compared to the standard of care. Pubmed, EMBASE and Cochrane Library were searched for RCTs. Critical and important CRSwNP-related outcomes were considered. The risk of bias and the certainty of the evidence were assessed using GRADE. RCTs evaluated (dupilumab-2, omalizumab-4, mepolizumab-2, reslizumab-1) included 1236 adults, with follow-up 20-64 weeks. Dupilumab reduces the need for surgery (NFS) and oral corticosteroid (OCS) use (RR 0.28; 95%CI 0.20-0.39, moderate certainty) and improves with high certainty smell (mean difference (MD) +10.54; 95%CI +9.24 to +11.84) and quality of life (QoL) (MD -19.14; 95%CI 95%CI -22.80 to -15.47), with fewer treatment-related adverse events (TAEs) (RR 0.95; 95%CI 0.89-1.02, moderate certainty). Omalizumab reduces NFS (RR 0.85; 95%CI 0.78 to 0.92, high certainty), decreases OCS use (RR 0.38; 95%CI 0.10-1.38, moderate certainty), improves with high certainty smell (MD +3.84; 95%CI +3.64 to +4.04) and QoL (MD -15.65; 95%CI -16.16 to -15.13), with increased TAE (RR 1.73; 95%CI 0.60-5.03, moderate certainty). There is low certainty for mepolizumab reducing NFS (RR 0.78; 95%CI 0.64 to 0.94) and improving QoL (MD -13.3; 95% CI -23.93 to -2.67) and smell (MD +0.7; 95%CI -0.48 to +1.88), with increased TAEs (RR 1.64; 95%CI 0.41-6.50). The evidence for reslizumab is very uncertain.
Surgical treatment of type A dissections is based on best evidence practice for the lack of controlled randomized studies providing definitive scientific evidence. Despite its widespread use, axillary cannulation still remains a debated topic as the preferred method of cannulation and perfusion strategy in the treatment of this complex condition.