The Year in Electrophysiology: Selected Highlights From 2023.

This special article is a continuation of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia, highlighting the latest developments in the field of electrophysiology, particularly concerning cardiac anesthesiologists. The selected topics in the specialty for 2023 include consensus statements on left atrial appendage closure, outcomes in patients with atrial fibrillation and heart failure after ablation, further developments in the field of pulse field ablation, alternate defibrillation strategies for refractory ventricular fibrillation, updates on conduction system pacing, new devices such as the Aurora EV system and AVEIR leadless pacemaker system, artificial intelligence and its use in electrocardiogram-based diagnosis and latest evidence regarding the impact of anesthetic techniques on patient outcomes undergoing electrophysiology procedures.

Faculty as Teachers: Career Development for the Clinician-Educator.

Clinician-Educators are the primary faculty in academic anesthesiology departments. These individuals assist with the departmental mission of clinical care and of education. Despite the critical role of the clinician-educator, academic advancement for these individuals has been difficult with the criteria for promotion continuing to evolve. The problem lies in the documentation of clinical and educational excellence in a means that a promotion committee may understand. Faculty development and advanced degrees in education have been helpful with the success of programs remaining unclear.

Best shot: A motivational interviewing approach to address vaccine hesitancy in pediatric outpatient settings.

BACKGROUND: Vaccine hesitancy in parents and childhood vaccine refusal is increasing. A standard of care to address this problem has not been identified. PURPOSE: To identify if the use of motivational interviewing by pediatric providers during routine well child visits, when compared to standard of care, would increase vaccine rates in children 0-12 months of age. Factors associated with vaccine hesitancy were also investigated. METHODS: A quasi-experimental study was completed on a convenience sample of pediatric providers (N = 6) and caregivers of children 0-12 months of age (N = 66). Four providers were trained to use motivational interviewing. During the well child visit the Parent Attitudes About Childhood Vaccines survey was completed, and the motivational interviewing intervention was implemented. Clinic's data were compared with other clinic data of non-trained providers. FINDINGS: Vaccine refusal/delays rate was 11.4% among caregivers. Vaccine refusal rate decreased after the intervention (9.00% pre-intervention and 6.40% post-intervention). An ordinal regression identified caregivers with higher vaccine hesitancy scores and more children were more likely to delay or refuse vaccines, while caregivers ≥30 years or with high income were less likely to delay/refuse vaccines. A difference in difference analysis identified that an additional 2.6% of children received vaccines when seen by trained providers compared to non-trained (ß = -0.330, OR = 0.719, p = 0.470). DISCUSSION: Findings indicate a condensed motivational interviewing education session may be clinically significant in decreasing vaccine hesitancy among this population. APPLICATIONS TO PRACTICE: A more robust study to confirm these findings is recommended prior to practice implementation.

Neurodevelopmental and neurobehavioral characteristics in males and females with CDKL5 duplications.

Point mutations and genomic deletions of the CDKL5 (STK9) gene on chromosome Xp22 have been reported in patients with severe neurodevelopmental abnormalities, including Rett-like disorders. To date, only larger-sized (8-21 Mb) duplications harboring CDKL5 have been described. We report seven females and four males from seven unrelated families with CDKL5 duplications 540-935 kb in size. Three families of different ethnicities had identical 667kb duplications containing only the shorter CDKL5 isoform. Four affected boys, 8-14 years of age, and three affected girls, 6-8 years of age, manifested autistic behavior, developmental delay, language impairment, and hyperactivity. Of note, two boys and one girl had macrocephaly. Two carrier mothers of the affected boys reported a history of problems with learning and mathematics while at school. None of the patients had epilepsy. Similarly to CDKL5 mutations and deletions, the X-inactivation pattern in all six studied females was random. We hypothesize that the increased dosage of CDKL5 might have affected interactions of this kinase with its substrates, leading to perturbation of synaptic plasticity and learning, and resulting in autistic behavior, developmental and speech delay, hyperactivity, and macrocephaly.

Force variations in the distal radius and ulna: effect of ulnar variance and forearm motion.

PURPOSE: To better define normal wrist joint forces during wrist motion and forearm motion at specific wrist and forearm positions and to see if there is a relationship between these forces and the amount of ulnar variance. A secondary purpose was to determine the relationship between the thickness of the articular disk of the triangular fibrocartilage complex and the amount of force transmitted through the distal ulna. METHODS: Multi-axis load cells were attached to the distal radius and ulna of 9 fresh cadaver forearms. The axial radial and ulnar compressive forces were recorded while each wrist was moved through wrist and forearm motions using a modified wrist joint simulator. During each motion, the tendon forces required to cause each motion were recorded. The ulnar variance and triangular fibrocartilage complex articular disc thickness were measured. RESULTS: The axial force through the distal ulna and the wrist extensor forces were greatest with the forearm in pronation. No relationship was found between the amount of force through the distal ulna and the amount of ulnar variance. A strong inverse relationship was found between the triangular fibrocartilage complex thickness and the ulnar variance. CONCLUSIONS: Wrists with positive ulnar variance have generally been thought to transmit greater loads across the distal ulna, which has been felt to predispose these wrists to the development of ulnar impaction. The results of this study appear to show that all wrists have similar loading across the distal ulna regardless of ulnar variance. By comparison, pronation relatively increases loading across the distal ulna. CLINICAL RELEVANCE: Because these results suggest that within reasonable ranges of ulnar variance loading across the distal ulna is independent of ulnar variance, the clinically observed incidence of ulnar impaction is more likely the result of increased wear on a thinner and less durable triangular fibrocartilage complex than due to increased distal ulna loading in ulnar positive variant wrists.

Transvascular and intravascular fluid transport in the rainbow trout: revisiting Starling's forces, the secondary circulation and interstitial compliance.

The kinetics of transvascular fluid transport across fish capillaries and redistribution of fluids between intravascular compartments in intact fish are unknown. Cannulae were placed in the dorsal aorta (DA) and caudal vein (CV) of rainbow trout Oncorhynchus mykiss (mass 0.45-0.85 kg) and the fish spleenectomized. The following day a peristaltic pump was fitted to complete the extracorporeal arterio-venous circulation. Hematocrit (Hct) was monitored in unanesthetized fish either manually, by collecting blood from the extracorporeal loop at 5 min intervals for a period of 1 h (groups 1 and 2), or continuously (instantaneously) with an impedance flow-cell inserted in the aortic cannula (group 3). Fish in group 1 were volume expanded by injecting a volume of saline (0.9 g% NaCl; SI) or trout plasma (PI) equivalent to 40% of the plasma volume. In group 2, 20% or 35% of the blood volume was removed, and in group 3, 35% of the blood volume was removed. Plasma volume (Vp) was calculated from an assumed blood volume of 35 ml kg(-1) and the Hct. Vp declined mono-exponentially after SI with a half-time of 6.8 min and Vp reached a new steady state at 28.1 ml kg(-1); 30% of the injected volume remained in the vasculature. Volume recovery after PI was also mono-exponential, but slower (half-time=15.4 min) than SI, whereas the steady-state Vp (27.3 ml kg(-1)) was similar and 30% of the injected volume remained in the vasculature. Thus the presence of plasma proteins delayed fluid efflux from the vasculature, but did not affect the volume lost. Transvascular fluid filtration coefficients calculated from this data were 5.5 (SI) and 4.5 ml mmHg(-1) kg(-1) min(-1) (PI), and interstitial compliance was 11.8 (SI) and 9.7 ml mmHg(-1) kg(-1) (PI). The rate of volume recovery after 20% or 35% hemorrhage was independent of the hemorrhage volume (half-time=13.3 and 15.1 min, respectively) and similar to the half-time of PI, indicating that protein-rich interstitial fluid is returned to the vasculature. There is a nearly instantaneous change in Hct that occurs during the hemorrhage period; it is dependent on hemorrhage duration and volume and not associated with the subsequent mono-exponential recovery. This initial response is best explained by a rapid fluid shift from a large-volume (approximately 40% of total blood volume), low-hematocrit (less than half of systemic Hct) microcirculation into the higher-hematocrit macrocirculation. These studies are consistent with transcapillary fluid flux across a barrier that is highly permeable to protein, and cannot be explained by fluid shift between primary and secondary circulations, or by transcapilllary flux across a capillary bed that is impermeable to plasma proteins. The results support the hypothesis that whole-body reflection coefficients in trout are very low and that plasma oncotic pressure is not a determinant of transcapillary fluid balance. They also show that both transvascular and intravascular fluid movements are important effectors of central volume homeostasis.