Transient complete heart block following catheter ablation of a left lateral accessory pathway.

A 16-year-old female with symptomatic Wolff-Parkinson-White (WPW) syndrome underwent catheter ablation of a left-sided lateral accessory pathway. The accessory pathway was eliminated with the first ablation lesion; however, the patient immediately developed complete heart block (CHB). At first, complete heart block was thought to be due to ablation of left atrial extension of the AV node, and pacemaker therapy was considered. However, careful ECG analysis revealed that the development of CHB was in fact due to bump injury to the AV node during transseptal catheterization. Conservative management allowed resolution of AV nodal conduction without need for a permanent pacemaker

Ventricular Arrhythmia Discriminator Programming and the Impact on the Incidence of Inappropriate Therapy in Patients with Implantable Cardiac Defibrillators

Background: The incidence of inappropriate therapy from implantable cardioverter defibrillators (ICDs) has been reduced by programming ventricular arrhythmia discriminators (VAD) on at the time of implant. Objective: To determine which VAD is most effective in preventing inappropriate therapy.Methods and Results: Dual chamber ICD (n=48) or cardiac resynchronization therapy defibrillator (CRT-D) (n=55) implantation was performed in 103 patients (M=94, F=9). Patients were followed prospectively for therapy events (shock or anti-tachycardia pacing) for a mean 362±289 days. Events were correlated with clinical characteristics and VAD programming. Of the 103 pts followed, 11 received inappropriate therapy (IT), 15 received appropriate therapy (AT), and 77 received no therapy (NT). In the AT and IT groups, a total of 207 events (ATP=171, shock=36) were observed. A total of sixty-four electrograms (EGMs) were analyzed. Programming VADs "ON" versus "OFF" reduced the incidence of IT events compared to those receiving AT or NT events (p<.01), with a trend in fewer patients receiving IT (31.3% "ON" vs 55.6% "OFF", p = 0.131). Programming atrial fibrillation (AF) detection ON resulted in fewer patients receiving IT compared to those receiving AT or NT (3.6% vs 19%, p<.05). Furthermore, programming AF or AFL algorithms "ON", resulted in overall fewer episodes of IT therapy (p<.01). Conclusions: AF or AFL discriminators significantly reduced the incidence of IT, and were predominantly responsible for the benefits from VAD programming observed in this study. Activating these features as part of routine ICD or CRT-D programming may provide a simple and effective alternative to the use of more complex and multiple VAD strategies

'How to know what you need to do': a cross-country comparison of maternal health guidelines in Burkina Faso, Ghana and Tanzania

Initiatives to raise the quality of care provided to mothers need to be given priority in Sub Saharan Africa (SSA). The promotion of clinical practice guidelines (CPGs) is a common strategy, but their implementation is often challenging, limiting their potential impact. Through a cross-country perspective, this study explored CPGs for maternal health in Burkina Faso, Ghana, and Tanzania. The objectives were to compare factors related to CPG use including their content compared with World Health Organization (WHO) guidelines, their format, and their development processes. Perceptions of their availability and use in practice were also explored. The overall purpose was to further the understanding of how to increase CPGs' potential to improve quality of care for mothers in SSA. The study was a multiple case study design consisting of cross-country comparisons using document review and key informant interviews. A conceptual framework to aid analysis and discussion of results was developed, including selected domains related to guidelines' implementability and use by health workers in practice in terms of usability, applicability, and adaptability. The study revealed few significant differences in content between the national guidelines for maternal health and WHO recommendations. There were, however, marked variations in the format of CPGs between the three countries. Apart from the Ghanaian and one of the Tanzanian CPGs, the levels of both usability and applicability were assessed as low or medium. In all three countries, the use of CPGs by health workers in practice was perceived to be limited. Our cross-country study suggests that it is not poor quality of content or lack of evidence base that constitute the major barrier for CPGs to positively impact on quality improvement in maternal care in SSA. It rather emphasises the need to prioritise the format of guidelines to increase their usability and applicability and to consider these attributes together with implementation strategies as integral to their development processes

Assessment of Metabolic Phenotypes in Patients with Non-ischemic Dilated Cardiomyopathy Undergoing Cardiac Resynchronization Therapy

Studies of myocardial metabolism have reported that contractile performance at a given myocardial oxygen consumption (MVO2) can be lower when the heart is oxidizing fatty acids rather than glucose or lactate. The objective of this study is to assess the prognostic value of myocardial metabolic phenotypes in identifying non-responders among non-ischemic dilated cardiomyopathy (NIDCM) patients undergoing cardiac resynchronization therapy (CRT). Arterial and coronary sinus plasma concentrations of oxygen, glucose, lactate, pyruvate, free fatty acids (FFA), and 22 amino acids were obtained from 19 male and 2 female patients (mean age 56 ± 16) with NIDCM undergoing CRT. Metabolite fluxes/MVO2 and extraction fractions were calculated. Flux balance analysis (FBA) was performed with MetaFluxNet 1.8 on a metabolic network of the cardiac mitochondria (189 reactions, 230 metabolites) reconstructed from mitochondrial proteomic data (615 proteins) from human heart tissue. Non-responders based on left ventricular ejection fraction (LVEF) demonstrated a greater mean FFA extraction fraction (35% ± 17%) than responders [18 ± 10%, p = 0.0098, area under the estimated ROC curve (AUC) was 0.8238, S.E. 0.1115]. Calculated adenosine triphosphate (ATP)/MVO2 using FBA correlated with change in New York Heart Association (NYHA) class (rho = 0.63, p = 0.0298; AUC = 0.8381, S.E. 0.1316). Non-responders based on both LVEF and NYHA demonstrated a greater mean FFA uptake/MVO2 (0.115 ± 0.112) than responders (0.034 ± 0.030, p = 0.0171; AUC = 0.8593, S.E. 0.0965). Myocardial FFA flux and calculated maximal ATP synthesis flux using FBA may be helpful as biomarkers in identifying non-responders among NIDCM patients undergoing CRT

Monitoring and evaluation of malaria in pregnancy – developing a rational basis for control

Monitoring and evaluation of malaria control in pregnancy is essential for assessing the efficacy and effectiveness of health interventions aimed at reducing the major burden of this disease on women living in endemic areas. Yet there is no currently integrated strategic approach on how this should be achieved. Malaria control in pregnancy is formulated in relation to epidemiological patterns of exposure. Current emphasis is on intermittent preventive treatment (IPTp) during pregnancy with sulphadoxine-pyrimethamine in higher transmission areas, combined with insecticide treated bed nets (ITNs) and case management. Emphasis in lower transmission areas is primarily on case management. This paper discusses a rational basis for monitoring and evaluation based on: assessments of therapeutic and prophylactic drug efficacy; proportional reductions in parasite prevalence; seasonal effects; rapid assessment methodologies; birthweight and/or anaemia nomograms; case-coverage methods; maternal mortality indices; operational and programmatic indicators; and safety and pharmacovigilance of antimalarials in pregnancy. These approaches should be incorporated more effectively within National Programmes in order to facilitate surveillance and improve identification of high-risk women. Systems for utilizing routinely collected data should be strengthened, with greater attention to safety and pharmacovigilance with the advent of artemisinin combination therapies, and prospects of inadvertent exposures to artemisinins in the first trimester. Integrating monitoring activities within malaria control, reproductive health and adolescent-friendly services will be critical for implementation. Large-scale operational research is required to further evaluate the validity of currently proposed indicators, and in order to clarify the breadth and scale of implementation to be deployed

Imaging and Modeling of Myocardial Metabolism

Current imaging methods have focused on evaluation of myocardial anatomy and function. However, since myocardial metabolism and function are interrelated, metabolic myocardial imaging techniques, such as positron emission tomography, single photon emission tomography, and magnetic resonance spectroscopy present novel opportunities for probing myocardial pathology and developing new therapeutic approaches. Potential clinical applications of metabolic imaging include hypertensive and ischemic heart disease, heart failure, cardiac transplantation, as well as cardiomyopathies. Furthermore, response to therapeutic intervention can be monitored using metabolic imaging. Analysis of metabolic data in the past has been limited, focusing primarily on isolated metabolites. Models of myocardial metabolism, however, such as the oxygen transport and cellular energetics model and constraint-based metabolic network modeling, offer opportunities for evaluation interactions between greater numbers of metabolites in the heart. In this review, the roles of metabolic myocardial imaging and analysis of metabolic data using modeling methods for expanding our understanding of cardiac pathology are discussed

Nyutexaminerade specialistsjuksköterskors upplevelse av introduktionen på intensivvårdsavdelning

Syftet med studien var att undersöka hur nyutbildade intensivvårdssjuksköterskor upplevde introduktionen på intensivvårdsavdelningen (IVA). Data samlades in genom semistrukturerade intervjuer av tio nyutbildade intensivvårdssjuksköterskor. Data analyserades med kvalitativ innehållsanalys. I huvudresultatet framkom två teman. Första temat ”Yttre faktorer som påverkar upplevelsen av introduktionen både positivt och negativt” innehöll kategorierna bemötande, checklista/introduktionsprogram, handledning, mentorskap, psykosociala miljön och organisatoriska faktorer. Dessa yttre faktorer påverkade upplevelsen av introduktionen och den enskilda sjuksköterskan hade själv svårt att påverka dessa. Andra temat ”Individfaktorer som påverkar upplevelsen av introduktionen både positivt och negativt” med kategorierna sammanhållning mellan de nyutbildade, att klara sig själv som ny samt känsla av att kunna påverka. För att tillfredsställa nyutexaminerade intensivvårdssjuksköterskors behov av god introduktion måste hänsyn tas till både yttre faktorer och individfaktorer.The purpose of the study was to investigate how newly graduated intensive care nurses experienced their introduction at the intensive care unit. The data were collected by semi-structured interviews with ten new graduates further analysed using a qualitative content analysis method. The main result is presented in two themes. The first theme “External factors influencing the experience of introduction both negatively and positively”, included the categories: response, checklist/introduction program, supervision, mentorship, psychosocial environment and organisational factors. These external factors had an impact on the experience of the introduction, and the nurse herself/himself had difficult to influence those factors. The second theme “Individual factors influencing the experience of introduction both negatively and positively”, included the categories: social bonding among the graduates, to cope by herself/himself as a new graduate and sense of opportunity to influence. To be able to satisfy the needs of good quality introduction for newly graduate intensive care nurses, both external and individual factors must be considered.