Improving Postdischarge Outcomes in Acute Heart Failure

The global burden that acute heart failure (AHF) carries has remained unchanged over the past several decades (1). European registries (2–5) showed that 1-year outcome rates remain unacceptably high (Table 1) and confirm that hospitalization for AHF represents a change in the natural history of the disease process(6). As patients hospitalized for HF have a bad prognosis, it is crucial to utilize hospitalization as an opportunity to: 1) assess the individual components of the cardiac substrate; 2) identify and treat comorbidities; 3) identify early, safe endpoints of therapy to facilitate timely hospital discharge and outpatient follow-up; and 4) implement and begin optimization guideline-directed medical therapies (GDMTs). As outcomes are influenced by many factors, many of which are incompletely understood, a systematic approach is proposed that should start with admission and continues through post-discharge (7)

Cryogenic Ion Trapping Systems with Surface-Electrode Traps

We present two simple cryogenic RF ion trap systems in which cryogenic temperatures and ultra high vacuum pressures can be reached in as little as 12 hours. The ion traps are operated either in a liquid helium bath cryostat or in a low vibration closed cycle cryostat. The fast turn around time and availability of buffer gas cooling made the systems ideal for testing surface-electrode ion traps. The vibration amplitude of the closed cycled cryostat was found to be below 106 nm. We evaluated the systems by loading surface-electrode ion traps with $^{88}$Sr$^+$ ions using laser ablation, which is compatible with the cryogenic environment. Using Doppler cooling we observed small ion crystals in which optically resolved ions have a trapped lifetime over 2500 minutes.Comment: 10 pages, 13 EPS figure

Time-separated entangled light pulses from a single-atom emitter

The controlled interaction between a single, trapped, laser-driven atom and the mode of a high-finesse optical cavity allows for the generation of temporally separated, entangled light pulses. Entanglement between the photon-number fluctuations of the pulses is created and mediated via the atomic center-of-mass motion, which is interfaced with light through the mechanical effect of atom-photon interaction. By means of a quantum noise analysis we determine the correlation matrix which characterizes the entanglement, as a function of the system parameters. The scheme is feasible in experimentally accessible parameter regimes. It may be easily extended to the generation of entangled pulses at different frequencies, even at vastly different wavelengths.Comment: 17 pages, 5 figures. Modified version, to appear in the New Journal of Physic

On the importance of grain size in luminescence dating using quartz

There are two major problems commonly encountered when applying Optically Stimulated Luminescence (OSL) dating in the high dose range: (i) age discrepancy between different grain sizes, and (ii) age underestimation. A marked and systematic discrepancy between fine-grain (4–11 μm) and coarse-grain (63–90 μm) quartz single aliquot regeneration protocol (SAR) ages has been reported previously for Romanian and Serbian loess >40 ka (De of ∼100 Gy), generally with fine-grain ages underestimating the depositional age. In this paper, we show a similar age pattern for two grain size fractions from Chinese loess, thus pointing to a potential worldwide phenomenon. While age underestimation is often attributed to signal saturation problems, this is not the case for fine grain material, which saturates at higher doses than coarse grains, yet begins to underestimate true ages earlier. Here we examine the dose response curves of quartz from different sedimentary contexts around the world, using a range of grain sizes (diameters of 4–11 μm, 11–30 μm, 35–50 μm, 63–90 μm, 90–125 μm, 125–180 μm, and 180–250 μm). All dose response curves can be adequately described by a sum of two saturating exponential functions, whose saturation characteristics (D0 values) are clearly anticorrelated with grain diameter (φ) through an inverse square root relationship, D0 = A/√φ, where A is a scaling factor. While the mechanism behind this grain-size dependency of saturation characteristics still needs to be understood, our results show that the observation of an extended SAR laboratory dose response curve does not necessarily enable high doses to be recorded accurately, or provide a corresponding extended age range

Trapped electron coupled to superconducting devices

We propose to couple a trapped single electron to superconducting structures located at a variable distance from the electron. The electron is captured in a cryogenic Penning trap using electric fields and a static magnetic field in the Tesla range. Measurements on the electron will allow investigating the properties of the superconductor such as vortex structure, damping and decoherence. We propose to couple a superconducting microwave resonator to the electron in order to realize a circuit QED-like experiment, as well as to couple superconducting Josephson junctions or superconducting quantum interferometers (SQUIDs) to the electron. The electron may also be coupled to a vortex which is situated in a double well potential, realized by nearby pinning centers in the superconductor, acting as a quantum mechanical two level system that can be controlled by a transport current tilting the double well potential. When the vortex is trapped in the interferometer arms of a SQUID, this would allow its detection both by the SQUID and by the electron.Comment: 13 pages, 5 figure

Therapeutic Advances in the Management of Cardiogenic Shock

Background: Cardiogenic shock (CS) is a life-threatening state of tissue hypoperfusion, associated with a very high risk of mortality, despite intensive monitoring and modern treatment modalities. The present review aimed at describing the therapeutic advances in the management of CS. Areas of uncertainty: Many uncertainties about CS management remain in clinical practice, and these relate to the intensity of invasive monitoring, the type and timing of vasoactive therapies, the risk-benefit ratio of mechanical circulatory support (MCS) therapy, and optimal ventilation mode. Furthermore, most of the data are obtained from CS in the setting of acute myocardial infarction (AMI), although for non-AMI-CS patients, there are very few evidences for etiological or MCS therapies. Data sources: The prospective multicentric acute heart failure registries that specifically presented characteristics of patients with CS, distinct to other phenotypes, were included in the present review. Relevant clinical trials investigating therapeutic strategies in post-AMI-CS patients were added as source information. Several trials investigating vasoactive medications and meta-analysis providing information about benefits and risks of MCS devices were reviewed in this study. Therapeutic advances: Early revascularization remains the most important intervention for CS in settings of AMI, and in patients with multivessel disease, recent trial data recommend revascularization on a "culprit-lesion-only" strategy. Although diverse types of MCS devices improve hemodynamics and organ perfusion in patients with CS, results from almost all randomized trials incorporating clinical end points were inconclusive. However, development of new algorithms for utilization of MCS devices and progresses in technology showed benefit in selected patients. A major advance in the management of CS is development of concept of regional CS centers based on the level of facilities and expertise. The modern systems of care with CS centers used as hubs integrated with emergency medical systems and other referee hospitals have the potential to improve patient outcomes. Conclusions: Additional research is needed to establish new triage algorithms and to clarify intensity and timing of pharmacological and mechanical therapies

The role of social innovation in criminal justice reform and the risk posed by proposed reforms in England and Wales

© The Author(s) 2013.The UK government has called for a rehabilitation revolution in England and Wales and put its faith in market testing. It hopes this will lead to greater innovation, resulting in reductions in re-offending while also driving down costs. However, many of the most innovative developments in criminal justice over recent decades have come through social innovation. Examples include restorative justice and justice reinvestment. In this article we argue that while social innovation will respond to some extent to conventional economic policy levers such as market testing, de-regulation and the intelligent use of public sector purchasing power it is not simply an extension of the neo-liberal model into the social realm. Social innovation, based on solidarity and reciprocity, is an alternative to the logic of the neo-liberal paradigm. In policy terms, the promotion of social innovation will need to take account of the interplay between government policy, social and cultural norms and individual and social capacity. Current proposals for reforming the criminal justice system may not leave sufficient scope to develop the conditions for effective social innovation

Therapeutic Advances in the Management of Acute Decompensated Heart Failure.

Background: Acute decompensated heart failure (ADHF) is the most common presenting phenotype of acute heart failure (AHF). The main goal of this article was to review the contemporary management strategies in these patients and to describe how future clinical trials may address unmet clinical needs. Areas of uncertainty: The current pathophysiologic understanding of AHF is incomplete. The guideline recommendations for the management of ADHF are based only on algorithms provided by expert consensus guided by blood pressure and/or clinical signs of congestion or hypoperfusion. The lack of adequately conducted trials to address the unmet need for evidence therapy in AHF has not yet been surpassed, and at this time, there is no evidence-based strategy for targeted decongestive therapy to improve outcomes. The precise time point for initiation of guideline-directed medical therapies (GDMTs), as respect to moment of decompensation, is also unknown. Data sources: The available data informing current management of patients with ADHF are based on randomized controlled trials, observational studies, and administrative databases. Therapeutic advances: A major step-forward in the management of ADHF patients is recognizing congestion, either clinical or hemodynamic, as a major trigger for heart failure (HF) hospitalization and most important target for therapy. However, a strategy based exclusively on congestion is not sufficient, and at present, comprehensive assessment during hospitalization of cardiac and noncardiovascular substrate with identification of potential therapeutic targets represents "the corner-stone" of ADHF management. In the last years, substantial data have emerged to support the continuation of GDMTs during hospitalization for HF decompensation. Recently, several clinical trials raised hypothesis of "moving to the left" concept that argues for very early implementation of GDMTs as potential strategy to improve outcomes. Conclusions: The management of ADHF is still based on expert consensus documents. Further research is required to identify novel therapeutic targets, to establish the precise time point to initiate GDMTs, and to identify patients at risk of recurrent hospitalization

Predictors of Post-discharge Mortality Among Patients Hospitalized for Acute Heart Failure

Acute Heart Failure (AHF) is a " multi-event disease" and hospitalisation is a critical event in the clinical course of HF. Despite relatively rapid relief of symptoms, hospitalisation for AHF is followed by an increased risk of death and re-hospitalisation. In AHF, risk stratification from clinically available data is increasingly important in evaluating long-term prognosis. From the perspective of patients, information on the risk of mortality and re-hospitalisation would be helpful in providing patients with insight into their disease. From the perspective of care providers, it may facilitate management decisions, such as who needs to be admitted and to what level of care (i.e. floor, step-down, ICU). Furthermore, risk-stratification may help identify patients who need to be evaluated for advanced HF therapies (i.e. left-ventricle assistance device or transplant or palliative care), and patients who need early a post-discharge follow-up plan. Finally, risk stratification will allow for more robust efforts to identify among risk markers the true targets for therapies that may direct treatment strategies to selected high-risk patients. Further clinical research will be needed to evaluate if appropriate risk stratification of patients could improve clinical outcome and resources allocation

Rationale and Design of a Prospective, Multicenter, Observational Study Evaluating Iron Deficiency in Patients Hospitalized for Heart Failure (FERIC-RO)

Introduction: Several landmark studies, which enrolled heart failure (HF) patients who were ambulatory at the time of inclusion, identified iron deficiency (ID) as an important therapeutic target: intravenous iron administration with ferric carboxymaltose (FCM) improves morbidity, exercise capacity, and quality of life in patients with HF and reduced EF (HFrEF). However, there is still limited knowledge about ID prevalence during hospitalization for Worsening Chronic HF (WCHF) and about the relationship between ID during hospitalization and post-discharge outcomes. Although previous studies documented ID as an independent risk factor for poor outcomes in HFrEF, its prognostic significance in HF patients with EF>40% remains unclear