Short-term and long-term success of electrical cardioversion in atrial fibrillation in managed care system

Abstract Background Initial success of electrical cardioversion (ECV) of atrial fibrillation (AF) has been reported in several studies as 50%-90%, of which only 50% patients remain in sinus rhythm (SR) at the end of one year. We conducted this study to see if outcomes of other trials are applicable in managed care setting. Methods We conducted a retrospective study in 370 consecutive patients who underwent ECV for AF. They were reviewed for initial outcome of ECV and recurrence of AF after a successful ECV, with and without prophylactic antiarrhythmic drugs. Results Initial success of ECV for AF was 65.7%. At one year, 47% remained in SR. AF for ≤ 3 months (p = 0.006) and pretreatment with antiarrhythmic drugs (p = 0.032) resulted in improved success. Predictors of recurrence were patients ≤ 65 years (p = 0.019), paroxysmal atrial fibrillation (PAF) (p = 0.0094) and alcohol consumption (p = 0.0074). Conclusion Shorter duration of AF, prophylactic antiarrhythmic drugs and serial ECVs improve outcome of ECV in AF. For younger patients with PAF and alcohol consumption, due to higher recurrence of AF, rate control or ablative therapy may be the preferred strategy

981-46 Impact of a Comprehensive Management Program on the Hospitalization Rate for Patients with Advanced Heart Failure

Patients with advanced heart failure have a course that is often characterized by frequent hospitalizations and progressive deterioration. These patients are commonly referred to specialized centers for consideration of heart transplantation (Tx). To assess the impact of the changes in therapy made in conjunction with heart transplantation evaluation on patient outcomes, we assessed the hospitalization rate and patient's functional status in the 6 months prior to referral compared to the 6 months after referral. Since 1/91, 214 patients were evaluated, accepted for Tx, and discharged having undergone adjustments in medical therapy and a comprehensive patient education program. At time of referral patients had mean LVEF 0.21, NYHA class 3.3, VO2 max 11.0ml/kg, and had undergone a total of 429 hospitalizations in the previous 6 months. During evaluation patients had their ACE inhibitor dose increased by a mean 91.5mg/day of captopril or the equivalent, were diuresed a mean 4.2 liters, were placed on a flexible regimen of loop diuretics, and were counseled on dietary management and home based progressive aerobic exercise. After 6 months of follow-up there were only 63 hospitalizations required (mean hospitalization rate per patient over the 6 months pre-evaluation 2.00±1.45 vs post-evaluation 0.29±0.53 p<0.00001). Patient's NYHA class improved to 2.4 (p<0.0001) and VO2 max increased to 15.2 (p<0.001). Excluding the 12 elective status Tx, 14 urgent status Tx, and 9 deaths within 6 months yielded similar results (344 pre vs 34 post-evaluation hospitalizations). 64 patients (30%) improved their functional status to the point that transplantation was deferred in favor of sustained medical therapy.Referral to a heart failure specialty program is associated with a dramatic occurred between day 10±1 and 3 month. 4 patients died after hospital discharge (no death directly related to thromboembolic disease). Thus no higher risk of PE can be seen in patients with free floating prox-DVT and anticoagulant therapy should be efficient to prevent recurrent PE in such patient

Improving survival for patients with advanced heart failure: A study of 737 consecutive patients

Objectives.This study sought to determine whether survival and risk of sudden death have improved for patients with advanced heart failure referred for consideration for heart transplantation as advances in medical therapy were systematically implemented over an 8-year period.Background.Recent survival trials in patients with mild to moderate heart failure and patients after a myocardial infarction have shown that angiotensin-converting enzyme inhibitors are beneficial, type I antiarrhythmic drugs can be detrimental, and amiodarone may be beneficial in some groups. The impact of advances in therapy may be enhanced or blunted when applied to severe heart failure.Methods.One-year mortality and sudden death were determined in relation to time, baseline variables and therapeutics for 737 consecutive patients referred for heart transplantation and discharged home on medical therapy from 1986 to 1988, 1989 to 1990 and 1991 to 1993. Medical care was directed by a single team of physicians with policies established by consensus. From 1986 to 1990, the hydralazine/isosorbide dinitrate combination or angiotensin-converting enzyme inhibitors were the initial vasodilators, and class I antiarrhythmic drugs were allowed. After 1990, captopril was the initial vasodilator, given to 86% of patients compared with 46% of patients before 1989. After mid-1989, class I agents were routinely withdrawn, and amiodarone was used for frequent ventricular ectopic beats or atrial fibrillation (53% of patients after 1990 vs. 10% before 1989).Results.The total 1-year mortality rate decreased from 33% before 1989 to 16% after 1990 (p = 0.0001), and sudden death decreased from 20% to 8% (p = 0.0006). Adjusted for clinical and hemodynamic variables in multivariate proportional hazards models, total mortality and sudden death were lower after 1990.Conclusions.The large reduction in mortality, particularly in sudden death, from advanced heart failure since 1990 may reflect an enhanced impact of therapeutic advances shown in large randomized trials when they are incorporated into a comprehensive approach in this population. This improved survival supports the growing practice of maintaining potential heart transplant candidates on optimal medical therapy until clinical decompensation mandates transplantation

Positive Darwinian Selection in the Piston That Powers Proton Pumps in Complex I of the Mitochondria of Pacific Salmon

The mechanism of oxidative phosphorylation is well understood, but evolution of the proteins involved is not. We combined phylogenetic, genomic, and structural biology analyses to examine the evolution of twelve mitochondrial encoded proteins of closely related, yet phenotypically diverse, Pacific salmon. Two separate analyses identified the same seven positively selected sites in ND5. A strong signal was also detected at three sites of ND2. An energetic coupling analysis revealed several structures in the ND5 protein that may have co-evolved with the selected sites. These data implicate Complex I, specifically the piston arm of ND5 where it connects the proton pumps, as important in the evolution of Pacific salmon. Lastly, the lineage to Chinook experienced rapid evolution at the piston arm

Macrophages in intestinal homeostasis and inflammation

The intestine contains the largest pool of macrophages in the body which are essential for maintaining mucosal homeostasis in the face of the microbiota and the constant need for epithelial renewal but are also important components of protective immunity and are involved in the pathology of inflammatory bowel disease (IBD). However, defining the biological roles of intestinal macrophages has been impeded by problems in defining the phenotype and origins of different populations of myeloid cells in the mucosa. Here, we discuss how multiple parameters can be used in combination to discriminate between functionally distinct myeloid cells and discuss the roles of macrophages during homeostasis and how these may change when inflammation ensues. We also discuss the evidence that intestinal macrophages do not fit the current paradigm that tissue-resident macrophages are derived from embryonic precursors that self-renew in situ, but require constant replenishment by blood monocytes. We describe our recent work demonstrating that classical monocytes constantly enter the intestinal mucosa and how the environment dictates their subsequent fate. We believe that understanding the factors that drive intestinal macrophage development in the steady state and how these may change in response to pathogens or inflammation could provide important insights into the treatment of IBD

ProjectorKit: Easing the Development of Interactive Applications for Mobile Projectors

Researchers have developed interaction concepts based on mobile projectors. Yet pursuing work in this area – particularly in applying projector-based techniques within an application – is cumbersome and time-consuming. To mitigate this problem, we generalize existing interaction techniques using mobile projectors. First, we identified five interaction primitives that serve as building blocks for a large set of applications. Second, these primitives were used to derive a set of principles that inform the design of a toolkit that ease and support software development for mobile projectors. Finally, we implemented these principles in a toolkit, called ProjectorKit, which we contribute to the community as a flexible open-source platform.N

From focus to context and back:combining mobile projectors and stationary displays

Focus plus context displays combine high-resolution detail and lower-resolution overview using displays of different pixel densities. Historically, they employed two fixed-size displays of different resolutions, one embedded within the other. In this paper, we explore focus plus context displays using one or more mobile projectors in combination with a stationary display. The portability of mobile projectors as applied to focus plus context displays contributes in three ways. First, the projector’s projection on the stationary display can transition dynamically from being the focus of one’s interest (i.e. providing a high resolution view when close to the display) to providing context around it (i.e. providing a low resolution view beyond the display’s borders when further away from it). Second, users can dynamically reposition and resize a focal area that matches their interest rather than repositioning all content into a fixed high-resolution area. Third, multiple users can manipulate multiple foci or context areas without interfering with one other. A proof-of-concept implementation illustrates these contributions