Iron Deficiency Anemia Presenting With Pancytopenia: A Study From India.

INTRODUCTION: Iron deficiency anemia (IDA) is the most common cause of anemia worldwide. IDA is commonly associated with thrombocytosis and normal or slightly decreased leukocyte count. Sometimes it can present with thrombocytopenia, but rarely present with pancytopenia. Here we are presenting six cases of severe iron deficiency presenting with pancytopenia, which responded to iron replenishment. METHODS:  This 12-month observational study was conducted in the Department of General Medicine at a tertiary care Centre in India. All cases of pancytopenia (after exclusion of other causes) with IDA were included. IDA was established with the help of a complete blood count (CBC), peripheral smear examination, serum iron studies, and serum ferritin.  Results: In our study, CBC at four weeks later of iron transfusion without other supplementation showed significant improvement in hematological parameters. CONCLUSION:  Severe iron deficiency is a reversible etiology of pancytopenia. It should be kept as a differential diagnosis of pancytopenia if common causes of pancytopenia are ruled out.

Effect of liquiritigenin on chloroquine accumulation in digestive vacuole leading to apoptosis-like death of chloroquine-resistant P. falciparum.

BACKGROUND: Malaria remains one of the major health concerns, especially in tropical countries. Although drugs such as artemisinin-based combinations are efficient for treating Plasmodium falciparum, the growing threat from multi-drug resistance has become a major challenge. Thus, there is a constant need to identify and validate new combinations to sustain current disease control strategies to overcome the challenge of drug resistance in the malaria parasites. To meet this demand, liquiritigenin (LTG) has been found to positively interact in combination with the existing clinically used drug chloroquine (CQ), which has become unfunctional due to acquired drug resistance. PURPOSE: To evaluate the best interaction between LTG and CQ against CQ- resistant strain of P. falciparum. Furthermore, the in vivo antimalarial efficacy and possible mechanism of action of the best combination was also assessed. METHODS: The in vitro anti-plasmodial potential of LTG against CQ- resistant strain K1 of P. falciparum was tested using Giemsa staining method. The behaviour of the combinations was evaluated using the fix ratio method and evaluated the interaction of LTG and CQ by calculating the fractional inhibitory concentration index (FICI). Oral toxicity study was carried out in a mice model. In vivo antimalarial efficacy of LTG alone and in combination with CQ was evaluated using a four-day suppression test in a mouse model. The effect of LTG on CQ accumulation was measured using HPLC and the rate of alkalinization of the digestive vacuole. Cytosolic Ca2+ level, mitochondrial membrane potential, caspase-like activity, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay, and Annexin V Apoptosis assay to assess anti-plasmodial potential. Proteomics analysis was evaluated by LC-MS/MS analysis. RESULTS: LTG possesses anti-plasmodial activity on its own and it showed to be an adjuvant of CQ. In in vitro studies, LTG showed synergy with CQ only in the ratio (CQ: LTG-1:4) against CQ-resistant strain (K1) of P. falciparum. Interestingly, in vivo studies, LTG in combination with CQ showed higher chemo-suppression and enhanced mean survival time at much lower concentrations compared to individual doses of LTG and CQ against CQ- resistant strain (N67) of Plasmodium yoelli nigeriensis. LTG was found to increase the CQ accumulation into digestive vacuole, reducing the rate of alkalinization, in turn increasing cytosolic Ca2+ level, loss of mitochondrial potential, caspase-3 activity, DNA damage and externalization of phosphatidylserine of the membrane (in vitro). These observations indicate the involvement of apoptosis-like death of P. falciparum that might be due to the accumulation of CQ. CONCLUSION: LTG showed synergy with CQ in the ratio LTG: CQ, 4:1) in vitro and was able to curtail the IC50 of CQ and LTG. Interestingly, in vivo in combination with CQ, LTG showed higher chemo-suppression as well as enhanced mean survival time at a much lower concentrations of both the partners as compared to an individual dose of CQ and LTG. Thus, synergistic drug combination offers the possibility to enhance CQ efficacy in chemotherapy.

Retrospective Window of Interest Annotation Provides New Insights Into Functional Channels in Ventricular Tachycardia Substrate.

BACKGROUND: Accurate annotation of local activation time is crucial in the functional assessment of ventricular tachycardia (VT) substrate. A major limitation of modern mapping systems is the standard prospective window of interest (sWOI) is limited to 490 to 500 milliseconds, preventing annotation of very late potentials (LPs). A novel retrospective window of interest (rWOI), which allows annotation of all diastolic potentials, was used to assess the functional VT substrate. OBJECTIVES: This study sought to investigate the utility of a novel rWOI, which allows accurate visualization and annotation of all LPs during VT substrate mapping. METHODS: Patients with high-density VT substrate maps and a defined isthmus were included. All electrograms were manually annotated to latest activation using a novel rWOI. Reannotated substrate maps were correlated to critical sites, with areas of late activation examined. Propagation patterns were examined to assess the functional aspects of the VT substrate. RESULTS: Forty-eight cases were identified with 1,820 ± 826 points per map. Using the novel rWOI, 31 maps (65%) demonstrated LPs beyond the sWOI limit. Two distinct patterns of channel activation were seen during substrate mapping: 1) functional block with unidirectional conduction into the channel (76%); and 2) wave front collision within the channel (24%). In addition, a novel marker termed the zone of early and late crowding was studied in the rWOI substrate maps and found to have a higher positive predictive value (85%) than traditional deceleration zones (69%) for detecting critical sites of re-entry. CONCLUSIONS: The standard WOI of contemporary mapping systems is arbitrarily limited and results in important very late potentials being excluded from annotation. Future versions of electroanatomical mapping systems should provide longer WOIs for accurate local activation time annotation.

Quebrachitol from Putranjiva roxburghii Wall. (Putranjivaceae) a potent antimalarial: Pre-clinical efficacy and its interaction with PfLDH.

Researchers are exploring natural resources in search of a new and effective anti-malarial compound to address the challenges in malarial treatment due to emerging incidences of drug-resistant strains. Following background knowledge of traditional medicine, we evaluated the in-vitro and in-vivo anti-malarial efficacy of Putranjiva P. roxburghii (Putranjivaceae) twigs ethanol extracts and fraction (PRT). In-vitro parasite-specific lactate dehydrogenase (pLDH) assay was performed using a chloroquine-sensitive Plasmodium falciparum strain. The results of the in-vitro study were further validated by in-vivo anti-malarial studies on P. berghei Keyberg 173 (K173) infected mice. The crude ethanol extract of the PRT showed the most moderate antiparasitic activity (IC50 = 15.51 µg/mL). In contrast, its butanol fraction extract showed potent activity (IC50 = 5.14 µg/mL) with a selectivity index (SI) of 28.87. Two phytochemicals, viz. 2, 4 dihydroxy-5-(hydroxymethyl) benzoic acid (DHMBA), and quebrachitol (QBC), were identified with anti-parasitic activity (IC50 = 5.01 µg/mL and 0.87 µg/mL) and selectivity index (SI) of 45 and 158. The in-vivo studies confirmed the significant anti-malarial activity of QBC at the dose of 30 and 60 mg/kg body weight with chemo-suppression values of 73.26% and 61.88%, respectively. The present study demonstrates the bioactive marker-based standardization of P. roxburghii twig, the antiplasmodial potential of PRT, and the role of QBC in suppressing parasitemia. The findings of the study support QBC as a prospective lead for a natural product-based adjunct remedy to conventional antiparasitic agents for malarial infectious.

Patient-Led Mass Screening for Atrial Fibrillation in the Older Population Using Handheld Electrocardiographic Devices Integrated With a Clinician-Coordinated Remote Central Monitoring System: Protocol for a Randomized Controlled Trial and Process Evaluation.

BACKGROUND: Atrial fibrillation (AF) is common in older people and increases the risk of stroke. The feasibility and effectiveness of the implementation of a patient-led AF screening program for older people are unknown. OBJECTIVE: This study aims to examine the feasibility and effectiveness of an AF screening program comprising patient-led monitoring of single-lead electrocardiograms (ECGs) with clinician-coordinated central monitoring to diagnose AF among community-dwelling people aged ≥75 years in Australia. METHODS: This is a nationwide randomized controlled implementation trial conducted via the internet and remotely among 200 community-dwelling adults aged ≥75 years with no known AF. Randomization will be performed in a 1:1 allocation ratio for the intervention versus control. Intervention group participants will be enrolled in the monitoring program at randomization. They will receive a handheld single-lead ECG device and training on the self-recording of ECGs on weekdays and submit their ECGs via their smartphones. The control group participants will receive usual care from their general practitioners for the initial 6 months and then commence the 6-month monitoring program. The ECGs will be reviewed centrally by trained personnel. Participants and their general practitioners will be notified of AF and other clinically significant ECG abnormalities. RESULTS: This study will establish the feasibility and effectiveness of implementing the intervention in this patient population. The primary clinical outcome is the AF detection rate, and the primary feasibility outcome is the patient satisfaction score. Other outcomes include appropriate use of anticoagulant therapy, participant recruitment rate, program engagement (eg, frequency of ECG transmission), agreement in ECG interpretation between the device automatic algorithm and clinicians, the proportion of participants who complete the trial and number of dropouts, and the impact of frailty on feasibility and outcomes. We will conduct a qualitative evaluation to examine the barriers to and acceptability and enablers of implementation. Ethics approval was obtained from the human research ethics committee at the University of Sydney (project number 2020/680). The results will be disseminated via conventional scientific forums, including peer-reviewed publications and presentations at national and international conferences. CONCLUSIONS: By incorporating an integrated health care approach involving patient empowerment, centralized clinician-coordinated ECG monitoring, and facilitation of primary care and specialist services, it is possible to diagnose and treat AF early to reduce stroke risk. This study will provide new information on how to implement AF screening using digital health technology practicably and feasibly for older and frail populations residing in the community. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621000184875; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380877. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34778.

Inhibition of heme detoxification pathway in malaria parasite by 3-hydroxy-11-keto-ß-boswellic acid isolated from Boswellia serrata.

Malaria eradication is still a major global health problem in developing countries, which has been of more concern ever since the malaria parasite has developed resistance against frontline antimalarial drugs. Historical evidence proves that the plants possess a major resource for the development of novel anti-malarial drugs. In the present study, the bioactivity guided fractionation of the oleogum-resin of Boswellia serrata Roxb. yielded the optimum activity in the ethyl acetate fraction with an IC50 of 22 ± 3.9 µg/mL and 26.5 ± 4.5 µg/mL against chloroquine sensitive (NF54) and resistant (K1) strains of Plasmodium falciparum respectively. Further, upon fractionation, the ethyl acetate fraction yielded four major compounds, of which 3-Hydroxy-11-keto-ß-boswellic acid (KBA) was found to be the most potent with IC50 values 4.5 ± 0.60 µg/mL and 6.25 ± 1.02 µg/mL against sensitive and resistant strains respectively. KBA was found to inhibit heme detoxification pathways, one of the most common therapeutic targets, which probably lead to an increase in reactive oxygen species (ROS) and nitric oxide (NO) detrimental to P. falciparum. Further, the induced intracellular oxidative stress affected the macromolecules in terms of DNA damage, increased lipid peroxidation, protein carbonylation as well as loss of mitochondrial membrane potential. However, it did not exhibit any cytotoxic effect in VERO cells. Under in vivo conditions, KBA exhibited a significant reduction in parasitemia, retarding the development of anaemia, resulting in an enhancement of the mean survival time in Plasmodium yoelii nigeriensis (chloroquine-resistant) infected mice. Further, KBA did not exhibit any abnormality in serum biochemistry of animals that underwent acute oral toxicity studies at 2000 mg/kg body weight.

Intracardiac Echocardiography to Guide Mapping and Ablation of Arrhythmias in Patients with Congenital Heart Disease.

Catheter ablation of arrhythmias in congenital heart disease can be a challenging undertaking with often complicated anatomic considerations. Understanding this anatomy and the prior surgical repairs is key to procedural planning and a successful outcome. Intracardiac echocardiography (ICE) adds complimentary real-time visualization of anatomy and catheter positioning along with other imaging modalities. In addition, ICE can visualize suture lines, baffles, and conduits from repaired congenital heart disease and forms a useful part of the toolkit required to deal with these complex arrhythmias.

Novel bioactive compound from the bark of Putranjiva roxburghii Wall.

Putranjivah (Putranjiva roxburghii Wall, family - Putranjivaceae) is an Indian native medicinal plant used to treat many diseases such as treatment of mouth and stomach ulcers, hot swellings, smallpox, burning sensation and ophthalmopathy. The study of chemical constituents in the bark of P. roxburghii resulted in a new triterpene (6) along with five known triterpenoids (1-5). The chemical characterisation was based on 1H, 13C, 2D-NMR experimentation, and ESI-MS data. The anti-plasmodial activity was investigated by measuring parasite-specific lactate dehydrogenase (pLDH) based in vitro assay. The IC50 value results showed that friedlein (2.40 ± 0.70) and roxburghonol (4.10 ± 1.7 µg/ml) possess better anti-plasmodial activity than other isolated triterpenes (2-5) but not as potent as chloroquine (0.023 ± 0.002 µg/ml) against chloroquine-sensitive Plasmodium falciparum (3D7) strain.

Cross-sectional Study of Calcium Phosphate Product and Intact Parathyroid Hormone Levels in Predialysis and Postdialysis Patients with Stage 5 Chronic Kidney Disease.

Chronic kidney disease (CKD) gradually deteriorates the mineral homeostasis, with a disruption of normal serum phosphorus, calcium, and intact parathyroid hormone (iPTH). Hemodialysis is one of the replacement therapies used to treat CKD patients to achieve normal kidney function. The present study aimed to evaluate the impact of dialysis on serum levels of calcium, phosphorus, and iPTH in CKD patients. A cross-sectional observational study was conducted between May 2015 and April 2017 in patients with CKD stage 5. The demographic characteristics including age, sex, body weight, and estimated glomeruli filtration rate were recorded. Serum levels of calcium, phosphorus, and iPTH were measured. A total of 100 patients divided into predialysis (n = 50) and postdialysis group (n = 50) with the mean age 50.34 and 51.88 years were included in this study, respectively. Mean levels of serum calcium and iPTH in the postdialysis patients were significantly lower than predialysis patients (P = 0.0183 and P <0.001). The proportion of patients (74%) with serum phosphorus level >4.5 mg/dL was significantly higher in postdialysis group (0.003). The risk of having high level of iPTH was 3.20 times more among the patients with level of phosphorus between 2.5 and 4.5 mg/dL [odds ratio (OR), 3.20; 95% confidence interval (CI), 1.16-8.80; P = 0.02] and 2.82 times more among patients with level of calcium <8.5 mg/dL (OR, 2.82; 95% CI, 1.13-7.01; P = 0.02). Overall observations suggest a significant reduction in levels of serum calcium and iPTH after dialysis in patients with CKD stage 5.

Electroanatomical Voltage Mapping to Distinguish Right-Sided Cardiac Sarcoidosis From Arrhythmogenic Right Ventricular Cardiomyopathy.

OBJECTIVES: This study sought to investigate the value of electroanatomical voltage mapping (EAVM) to distinguish cardiac sarcoidosis (CS) from arrhythmogenic right ventricular cardiomyopathy (ARVC) in patients with ventricular tachycardia from the right ventricle (RV). BACKGROUND: CS can mimic ARVC. Because scar in ARVC is predominantly subepicardial, this study hypothesized that the relative sizes of endocardial low bipolar voltage (BV) to low unipolar voltage (UV) areas may distinguish CS from ARVC. METHODS: Patients with CS affecting the RV (n = 14), patients with gene-positive ARVC (n = 13), and a reference group of patients without structural heart disease (n = 9) who underwent RV endocardial EAVM were included. RV region-specific BV and UV cutoffs were derived from control subjects. In CS and ARVC, segmental involvement was determined and low-voltage areas were measured, using <1.5 mV for BV and <3.9 mV, <4.4 mV, and <5.5 mV for UV. The ratio between low BV and low UV area was calculated generating 3 parameters: Ratio3.9, Ratio4.4 and Ratio5.5, respectively. RESULTS: In control subjects, BV and UV varied significantly among RV regions. The basal septum was involved in 71% of CS patients and in none of ARVC patients. Ratio5.5 discriminated CS from ARVC the best. An algorithm including Ratio5.5 ≥0.45 and basal septal involvement identified CS with 93% sensitivity and 85% specificity. This was validated in a separate population (CS [n = 6], ARVC [n = 10]) with 100% sensitivity and 100% specificity. CONCLUSIONS: EAVM provides detailed information about scar characteristics and scar distribution in the RV. An algorithm combining Ratio5.5 (area BV <1.5 mV/area UV <5.5 mV) and bipolar basal septal involvement allows accurate diagnosis of (isolated) CS in patients presenting with monomorphic ventricular tachycardia from the RV.

Position Statement on the Management of Cardiac Electrophysiology and Cardiac Implantable Electronic Devices in Australia During the COVID-19 Pandemic: A Living Document.

The COVID-19 pandemic poses a significant stress on health resources in Australia. The Heart Rhythm Council of the Cardiac Society of Australia and New Zealand aims to provide a framework for efficient resource utilisation balanced with competing risks when appropriately treating patients with cardiac arrhythmias. This document provides practical recommendations for the electrophysiology (EP) and cardiac implantable electronic devices (CIED) services in Australia. The document will be updated regularly as new evidence and knowledge is gained with time.

Allium cepa exerts neuroprotective effect on retinal ganglion cells of pterygopalatine artery (PPA) ligated mice.

BACKGROUND: Repeated failure to rescue the damaged retinal ganglion cells (RGCs) by various drugs has warranted the need to screen common herbal compounds available in the form of various eye formulations for their efficacy. OBJECTIVE: We aimed to investigate the neuroprotective effect of pretreatment with aqueous extract of A. cepa in Ischemia/Reperfusion (I/R) induced retinal injury. METHODS: Ischemia was induced for 2 h by pterygopalatine artery (PPA) ligation in C57BL/6J mice, followed by reperfusion. The neuroprotective role of oral pretreatment with aqueous extract of A. cepa (300 mg/kg) was analyzed with respect to control and injury only group at 7, 14, and 28 day after the surgery for expression of different genes in the retina by Real-Time PCR. RESULTS: Molecular analysis at different time points showed increased expression of BCl-2, GDNF, GFAP, and Brn3b in the retina at 14 and 28 day after A. cepa treatment in comparison to the injury alone group. However, at shorter time point (7th day), the expression of these genes was pronounced in the injury only group in comparison to the injury and pretreated group. CONCLUSION: Pretreatment with aqueous extract of A. cepa may protect from the neuronal damage in I/R-induced retinal injury in mice by altering the expression of neurotrophic factor.

Effectiveness of Yoga as the Public Health Intervention Module in the Management of Diabetes and Diabetes Associated Dementia in South East Asia: A Narrative Review.

BACKGROUND: Diabetes mellitus (DM) is widely spread in South Asian (ASEAN) and Indian sub-continent. The increasing healthcare costs of DM can be prevented in the developing world by improved public healthcare interventions. Modifiable risk factors of DM like sedentary lifestyle, obesity, and stressful conditions are associated with its progression; however, the epidemiological data collected by Public Institutions are limited. SUMMARY: A review of published literature describing geographic distribution of DM and associated dementia in South Asian region, particularly India, was conducted with the purpose of assessing the feasibility and challenges associated with the Yoga-based risk reduction. PubMed and Google Scholar databases were searched for DM and dementia-related articles by using a combination of keywords: Diabetes, Diabetes related Dementia Southeast Asia, Pre-diabetes, Yoga, lifestyle modification, Dementia and Exercise. The epidemiological data generated from these diseases have not prompted to any major public health policies. Yoga can be a cost-effective intervention for the prevention of Type 2 DM (T2DM) and its associated cognitive decline when detected early. If nationwide intervention of Yoga is brought about by the state, its integration in health care will become more meaningful and acceptable. Key Message: Studies suggest that Yoga and change in lifestyle can modify the health risks associated with T2DM and associated dementia if it is mainstreamed with the public health initiative of Ayushman Bharat scheme.

Catheter ablation of ventricular arrhythmia guided by a high-density grid catheter.

INTRODUCTION: Minimal data exist on the Advisor HD Grid (HDG) catheter and the Precision electroanatomic mapping (EAM) system for ventricular arrhythmia (VA) procedures. Using the HDG catheter, the EAM uses the high-density (HD) wave mapping and best duplicate software to compare the maximum peak-to-peak bipolar voltages within a small zone independent of wavefront direction and catheter orientation. This study aimed to summarize the procedural experience for VAs using the HDG catheter. METHODS: Clinical and procedural characteristics of VA ablation procedures were retrospectively reviewed that used the HDG catheter and the Precision EAM over a 12-month period. RESULTS: A total of 22 patients, 18 with sustained ventricular tachycardia and 4 with premature ventricular contractions were included. Clinically indicated left and/or right ventricular (LV, RV, respectively), and aortic maps were created. LV substrate maps (n = 13) used a median 1700 points (interquartile range [IQR]25%-75% , 1427-2412) out of a median 18 573 (IQR25%-75% , 15 713-41 067) total points collected. RV substrate maps (n = 11) used a median 1435 points (IQR25%-75% , 1114-1871) out of a median 16 005 (IQR25%-75% , 11 063-21 405) total points collected. Total point utilization, used vs collected, was 9%. Mean mapping time was 43 ± 17 minutes (substrate, 34 ± 18 minutes; activation/pace mapping, 9 ± 13 minutes). Acute success was achieved in 56 (86%) and short-term success achieved in 16 patients (73%) at a median follow-up of 145 days (IQR25%-75% , 62-273 days). There were no procedural complications. CONCLUSION: HD wave mapping using the novel HDG catheter integrated with the Precision EAM is safe and feasible in VA procedures in the LV, RV, and aorta. Mapping times are consistent with other multielectrode mapping catheters.

Mastering the art of epicardial access in cardiac electrophysiology.

Access to the epicardial space is fundamental to several cardiac procedures. While traditional indications include catheter ablation of ventricular arrhythmias and accessory pathways, novel indications include left atrial appendage occlusion, esophageal protection, mapping and ablation during atrial fibrillation procedures, implantation of epicardial pacing leads, and phrenic nerve displacement to facilitate safe ablation of atrial and ventricular arrhythmias. Accessing the epicardial space safely is a major challenge requiring intimate knowledge of cardiac anatomy, extensive training, and expertise. Over the past years, multiple technological advances have led to significant improvements in epicardial access success and safety. Important examples of such advances include CO2 insufflation through the coronary sinus or the right atrial appendage, pressure sensor needle, computed tomography, cardiac magnetic resonance, and electroanatomic mapping-guided epicardial access. In addition, we provide special maneuvers to minimize inadvertent right ventricular perforation.

Satiety-induced enhanced neuronal activity in the frontal operculum relates to the desire for food in the obese female brain.

In the present pilot study, we questioned how eating to satiety affects cognitive influences on the desire for food and corresponding neuronal activity in the obese female brain. During EEG recording, lean (n = 10) and obese women (n = 10) self-rated the ability to reappraise visually presented food. All women were measured twice, when hungry and after eating to satiety. After eating to satiety, reappraisal of food was easier than when being hungry. Comparing the EEG data of the sated to the hungry state, we found that only in obese women the frontal operculum was involved not only in the reappraisal of food but also in admitting the desire for the same food. The right frontal operculum in the obese female brain, assumed to primarily host gustatory processes, may be involved in opposing cognitive influences on the desire for food. These findings may help to find potential brain targets for non-invasive brain stimulation or neurofeedback studies that aim at modulating the desire for food.

Early and long-term outcomes after manual and remote magnetic navigation-guided catheter ablation for ventricular tachycardia.

Aims: Remote magnetic navigation (RMN) is a safe and effective means of performing ventricular tachycardia (VT) ablation. It may have advantages over manual catheter ablation due to ease of manoeuvrability and catheter stability. We sought to compare the safety and efficacy of RMN vs. manual VT ablation. Methods and results: Retrospective study of procedural outcomes of 139 consecutive VT ablation procedures (69 RMN, 70 manual ablation) in 113 patients between 2009 and 2015 was performed. Remote magnetic navigation was associated with overall higher acute procedural success (80% vs. 60%, P = 0.01), with a trend to fewer major complications (3% vs. 9% P = 0.09). Seventy-nine patients were followed up for a median of 17.0 [interquartile range (IQR) 3.0-41.0] months for the RMN group and 15.5 (IQR 6.5-30.0) months for manual ablation group. In the ischaemic cardiomyopathy subgroup, RMN was associated with longer survival from the composite endpoint of VT recurrence leading to defibrillator shock, re-hospitalization or repeat catheter ablation and all-cause mortality; single-procedure adjusted hazard ratio (HR) 0.240 (95% CI 0.070-0.821) P = 0.023, multi-procedure HR 0.170 (95% CI 0.046-0.632) P = 0.002. In patients with implanted defibrillators, multi-procedure VT-free survival was superior with RMN, HR 0.199 (95% CI 0.060-0.657) P = 0.003. Conclusion: Remote magnetic navigation may improve clinical outcomes after catheter ablation of VT in patients with ischaemic cardiomyopathy. Further prospective clinical studies are required to confirm these findings.

Cathodal neuromodulation of dominant temporoparietal cortex with transcranial direct current stimulation for tinnitus: A case series.

There is scant literature on the effectiveness of using transcranial direct current stimulation (tDCS) as an intervention modality for managing tinnitus. The current case series reflects the use of tDCS as an effective intervention for tinnitus while inhibiting the dominant temporoparietal cortex and simultaneous stimulating the non-dominant dorsolateral prefrontal cortex.

Downstream overdrive pacing and intracardiac concealed fusion to guide rapid identification of atrial tachycardia after atrial fibrillation ablation.

Aims: Atrial tachycardia (AT) related to atrial fibrillation (AF) ablation frequently poses a diagnostic challenge. Downstream overdrive pacing (DOP) can be used to rapidly detect reentry and assess proximity of a pacing site to an AT circuit or focus. We hypothesized that systematic DOP using multielectrode catheters would facilitate AT mapping. Methods and results: DOP identified constant fusion when the post-pacing interval (PPI)-tachycardia cycle length (TCL) <40 ms and stimulus to adjacent upstream atrial electrogram interval >75% of TCL. Mapping was performed as follows: (i) CS DOP, (ii) DOP at left atrial (LA) roof, (iii) DOP at selected LA sites based on prior DOP attempts, and (iv) mapping and ablation at regions of fractionated electrograms in region of AT. Activation mapping was performed at operator discretion. AT diagnosis was confirmed by successful ablation or additional mapping when ablation was unsuccessful. Fifty consecutive patients with sustained AT underwent mapping of 68 ATs, of whom 42 (62%) were macroreentrant, 19 were locally reentrant (28%), and 7 (10%) were focal. AT was correctly identified with a median of three DOP attempts. All macroreentrant ATs were identified with ≤6 DOP attempts. One AT (1.6%) was terminated by DOP, and three ATs (4.8%) required activation mapping. Intracardiac concealed fusion was seen in 26 ATs (38%), each of which was successfully ablated. Conclusion: Reentry could be demonstrated in a substantial majority of AF ablation-related AT. A stepwise diagnostic approach using DOP and recognition of intracardiac concealed fusion can be used to rapidly identify and ablate reentrant AT.