Multicountry research on comprehensive abortion policy implementation in Latin America: a mixed-methods study protocol.

INTRODUCTION: Access to comprehensive abortion care could prevent the death of between 13 865 and 38 940 women and the associated morbidity of 5 million women worldwide. There have been some important improvements in Latin America in terms of laws and policies on abortion. However, the predominant environment is still restrictive, and many women, adolescents and girls still face multiple barriers to exercise their reproductive rights. This research will systematically assess comprehensive abortion policies in five Latin American countries (Argentina, Colombia, Honduras, Mexico and Uruguay). The aim is to identify barriers, facilitators and strategies to the implementation of abortion policies, looking at four key dimensions-regulatory framework, abortion policy dynamics, abortion service delivery and health system and health outcomes indicators-to draw cross-cutting lessons learnt to improve current implementation and inform future safe abortion policy development. METHODS AND ANALYSIS: A mixed-method design will be used in the five countries to address the four dimensions through the Availability, Accessibility, Acceptability and Quality of Care model. The data collection tools include desk reviews and semi-structured interviews with key actors. Analysis will be performed using thematic analysis and stakeholder analysis. A regional synthesis exercise will be conducted to draw lessons on barriers, facilitators and the strategies. ETHICS AND DISSEMINATION: The project has been approved by the WHO Research Ethics Review Committee (ID: A66023) and by the local research ethics committees. Informed consent will be obtained from participants. Data will be treated with careful attention to protecting privacy and confidentiality. Findings from the study will be disseminated through a multipurpose strategy to target diverse audiences to foster the use of the study findings to inform the public debate agenda and policy implementation at national level. The strategy will include academic, advocacy and policy arenas and actors, including peer-reviewed publication and national and regional dissemination workshops.

Implementing the QUALI-DEC project in Argentina, Burkina Faso, Thailand and Viet Nam: a process delineation and theory-driven process evaluation protocol.

The project 'Quality Decision-making by women and providers' (QUALI-DEC) combines four non-clinical interventions to promote informed decision-making surrounding mode of birth, improve women's birth experiences, and reduce caesarean sections among low-risk women. QUALI-DEC is currently being implemented in 32 healthcare facilities across Argentina, Burkina Faso, Thailand, and Viet Nam. In this paper, we detail implementation processes and the planned process evaluation, which aims to assess how and for whom QUALI-DEC worked, the mechanisms of change and their interactions with context and setting; adaptations to intervention and implementation strategies, feasibility of scaling-up, and cost-effectiveness of the intervention. We developed a project theory of change illustrating how QUALI-DEC might lead to impact. The theory of change, together with on the ground observations of implementation processes, guided the process evaluation strategy including what research questions and perspectives to prioritise. Main data sources will include: 1) regular monitoring visits in healthcare facilities, 2) quantitative process and output indicators, 3) a before and after cross-sectional survey among post-partum women, 4) qualitative interviews with all opinion leaders, and 5) qualitative interviews with postpartum women and health workers in two healthcare facilities per country, as part of a case study approach. We foresee that the QUALI-DEC process evaluation will generate valuable information that will improve interpretation of the effectiveness evaluation. At the policy level, we anticipate that important lessons and methodological insights will be drawn, with application to other settings and stakeholders looking to implement complex interventions aiming to improve maternal and newborn health and wellbeing.Trial registration: ISRCTN67214403.

Effect on nutritional status and biomarkers of inflammation and oxidation of an oral nutritional supplement (with or without probiotics) in malnourished hemodialysis patients. A multicenter randomized clinical trial "Renacare Trial".

Background: Malnutrition in patients undergoing hemodialysis is frequent and associated with a reduction in muscular mass and strength, with an increment in biomarkers of inflammation and oxidation. Materials and methods: Randomized, multicenter, parallel-group trial in malnourished hemodialysis patients with three groups [(1) control (C) individualized diet, (2) oral nutritional supplement-ONS- + placebo-SU- PL-, and (3) ONS + probiotics-SU-PR]; the trial was open regarding the intake of ONS or individualized diet recommendations, but double-blind for the intake of probiotics. We obtained, at baseline and after 3 and 6 months, anthropometric measurements, handgrip strength, bioelectrical impedance analysis (BIA), dietary records, and routine biochemical parameters. Inflammation and oxidation were determined using ELISA techniques (Versamax and ProcartaPlex multiplex Immunoassay). Results were analyzed by intention to treat. Results: A total of 31 patients (11 corresponding to group C, 10 to SU-PL, and 10 to SU-PR) completed the 6-months trial. The two groups that took supplements significantly increased their protein calorie, fat (total and n-3), and fiber intake. Weight and fat-free mass (FFM) also increased significantly in the groups on supplements, both at 3 and 6 months, and dynamometry did so in the SU-PL group. At month 3, prealbumin and vitamin D were significantly increased in the SU-TOT (SU-PL + SU-PR) group. No changes were observed regarding levels of phosphorus and potassium in any of the groups. Urea increased significantly at 6 months in the SU-PL group. There were significant changes in some inflammation biomarkers in the groups on supplements during the intervention (brain-derived neurotrophic factor, bone morphogenetic protein-2, MCP-1, IL-1-beta, IL-10, IL-4, and IL-8). The total antioxidant capacity (TAC) increased significantly in the supplemented patients, with no significant changes observed in isoprostanes. Conclusion: The specific ONS improved protein-calorie intake, nutritional status (mainly FFM), and some biomarkers of inflammation/oxidation. The addition of probiotics could have a synergistic effect with ONS in such biomarkers. Clinical trail registration: https://clinicaltrials.gov/ct2/show/, identifier NCT03924089.

[Barriers in access to legal abortion in the public health system in two Argentine jurisdictions: Rosario and Autonomous City of Buenos Aires, 2019-2020]. / Barreras de acceso al aborto legal en el sistema público de salud de dos jurisdicciones de Argentina: Rosario y Ciudad Autónoma de Buenos Aires, 2019-2020.

In recent decades, decisive events shaping the political and social context surrounding abortion in Argentina culminated in the passing of the Voluntary Termination of Pregnancy (IVE in Spanish) Law in December 2020. The objective of this article is to explore the main barriers to accessing legal abortions in the public health system faced by women during 2019 and 2020 in two Argentine jurisdictions, Rosario and the Autonomous City of Buenos Aires. Based on an adaptation of the "three phases of delay" framework, surveys and semi-structured interviews with 117 women were conducted. Study participants reported difficulties in accessing information about the places and people to turn to for abortions, and most stated that pregnant individuals lack information regarding their legality. Although the majority of interviewees reported positive experiences with health services, they also identified some administrative and institutional barriers.

En las últimas décadas, en la Argentina sucedieron hechos determinantes en el contexto político y social con respecto al aborto, que culminaron con la aprobación de la Ley de Interrupción Voluntaria del Embarazo (IVE) en diciembre de 2020. El objetivo de este artículo es explorar las principales barreras que enfrentaron las mujeres en el acceso al aborto legal en el sistema público de salud de dos jurisdicciones de Argentina, Rosario y Ciudad Autónoma de Buenos Aires, en los años 2019 y 2020. A partir de una adaptación del modelo de las tres demoras, se realizaron encuestas y entrevistas semiestructuradas a 117 mujeres. Las participantes reportaron dificultades para acceder a información sobre lugares y personas donde recurrir para acceder un aborto. La mayoría de las participantes respondió que las personas gestantes no cuentan con información sobre la legalidad del aborto. Si bien la mayoría reportó haber tenido una buena experiencia con los servicios de salud, también identificaron algunas barreras administrativas e institucionales.

The presence of a large patent foramen ovale reduces acute and chronic success in atrial fibrillation ablation.

PURPOSE: In this study, we analyzed PFO implications in atrial fibrillation (AF) ablation. METHODS: Six hundred and twenty-five consecutive patients with AF undergoing PV isolation were included. We considered that a large and/or compliant PFO was present if the catheters advanced gently into the LA without puncturing the septum. Atrial tachyarrhythmias after the 3-month blanking period were classified as a recurrence. RESULTS: Out of the 625 patients included, 36 (5.8%) were found to have PFO. No significant differences were observed in the clinical characteristics of patients with PFO compared with patients without PFO. Nevertheless, patients with PFO had lower acute success in PV isolation compared with patients without PFO (98.2% vs. 88.5%; p = 0.006) even after adjusting for age, sex, type of AF, LA area, cardiomyopathy, time from AF diagnosis to the ablation, and ablation technique (odds ratio: 0.1; 95% confidence interval (CI): 0.02-0.9; p = 0.039). In 546 patients followed more than 6 months, the recurrence rate of any atrial tachyarrhythmia after 18.6 ± 11.9 months was significantly higher in patients with PFO compared with patients without PFO (41.9 vs. 70%; p = 0.012). This difference remained significant after adjusting for age, sex, type of AF, LA area, cardiomyopathy, time from AF diagnosis to the ablation, and ablation technique (hazard ratio: 1.9; 95% CI: 1.1-3.3; p = 0.015). CONCLUSIONS: The presence of a large and/or compliant PFO is an independent factor for PV isolation failure and arrhythmia recurrence rate after the ablation.

Stakeholder-Generated Implementation Strategies to Promote Evidence-Based ADHD Treatment in Community Mental Health.

Community implementation of evidence-based practices (EBPs) for Attention Deficit/Hyperactivity Disorder (ADHD) is greatly lacking. A recent randomized community-based trial of an EBP for ADHD (Supporting Teens' Autonomy Daily; STAND) demonstrated suboptimal implementation and effectiveness outcomes. In the present study, we conducted an Innovation Tournament (IT) with agency staff stakeholders (N = 26) to identify barriers to successful implementation of STAND and implementation strategies for a revised service delivery model. We conducted member-checking of agency staff-generated ideas with parents (N = 226) and subsequent querying of additional parent (N = 226) and youth-generated (N = 205) strategies to improve care. Go-Zone plots were utilized to identify strategies with the highest feasibility and importance. Practical barriers (i.e., transportation, scheduling difficulties) and parent/youth engagement were the most commonly cited obstacles to successful implementation of STAND in community contexts. Eighteen "winning" implementation strategies were identified that survived member checking. These were classified as train and educate stakeholders (n = 5; e.g., train agency supervisors to deliver supervision, digitize treatment materials and trainings), engage consumers (n = 9; e.g., begin treatment with rapport building sessions, increase psychoeducation), provide interactive assistance (n = 2; e.g., add group supervision, increase roleplay in supervision), and use of evaluative/iterative strategies (n = 2; e.g., perform fidelity checks, supervisor review of session recordings). Parents and youth desired longer duration of treatment and increased focus on maintenance. Strategies will be developed and tested as part of a pilot effectiveness trial designed to refine STAND's service delivery model.Trial Registration NCT02694939 www.clinicaltrials.gov.

Impact of COVID-19 in nutritional and functional status of survivors admitted in intensive care units during the first outbreak. Preliminary results of the NUTRICOVID study.

BACKGROUND & AIMS: COVID-19 patients present a high hospitalization rate with a high mortality risk for those requiring intensive care. When these patients have other comorbid conditions and older age, the risk for severe disease and poor outcomes after ICU admission are increased. The present work aims to describe the preliminary results of the ongoing NUTRICOVID study about the nutritional and functional status and the quality of life of adult COVID-19 survivors after ICU discharge, emphasizing the in-hospital and discharge situation of this population. METHODS: A multicenter, ambispective, observational cohort study was conducted in 16 public hospitals of the Community of Madrid with COVID-19 survivors who were admitted to the ICU during the first outbreak. Preliminary results of this study include data retrospectively collected. Malnutrition and sarcopenia were screened at discharge using MUST and SARC-F; the use of healthcare resources was measured as the length of hospital stay and requirement of respiratory support and tracheostomy during hospitalization; other study variables were the need for medical nutrition therapy (MNT); and patients' functional status (Barthel index) and health-related quality of life (EQ-5D-5L). RESULTS: A total of 176 patients were included in this preliminary analysis. Most patients were male and older than 60 years, who suffered an average (SD) weight loss of 16.6% (8.3%) during the hospital stay, with a median length of stay of 53 (27-89.5) days and a median ICU stay of 24.5 (11-43.5) days. At discharge, 83.5% and 86.9% of the patients were at risk of malnutrition and sarcopenia, respectively, but only 38% were prescribed MNT. In addition, more than 70% of patients had significant impairment of their mobility and to conduct their usual activities at hospital discharge. CONCLUSIONS: This preliminary analysis evidences the high nutritional and functional impairment of COVID-19 survivors at hospital discharge and highlights the need for guidelines and systematic protocols, together with appropriate rehabilitation programs, to optimize the nutritional management of these patients after discharge.

Fostering Resilience in Adolescents at Risk: Study protocol for a cluster randomized controlled trial within the resilience school-based intervention.

Introduction: Resilience is considered of high relevance when developing interventions to cope with stressful situations. Schools are one of the key settings to promote resilience among adolescents. The purpose of this cluster randomized controlled trial is to assess the effectiveness of an intervention in adolescents at risk, aged 12-to-15 years old, to increase resilience and emotional regulation strategies. Methods: The recruitment period started in January 2022. Schools will be randomly allocated to control and intervention groups by an external researcher using computer-generated random numbers. The minimum sample size was estimated to be 70 participants per group. Primary health care nurses will carry out the intervention during the school period (January to June 2022). Students will follow a specific training consisting of six 55-min sessions, for 6 weeks. Each session will consist of 5 min of mindfulness, followed by 45 min of the corresponding activity: introducing resilience, self-esteem, emotional regulation strategies, social skills, problem-solving, community resources, social and peer support, and 5 min to explain the activity to do at home. Data will be collected at baseline, 6 weeks, and 24 weeks after the intervention. The child youth resilience measure-32 (CYRM-32) scale will be used to assess the effectiveness of the intervention. This study received a grant in June 2021. Discussion: The intervention is intended to improve mental health through resilience. Different factors related to resilience will be promoted, such as self-esteem, emotional regulation, social and communication skills, problem-solving and peer support, among others. As it has been designed as a cluster-randomized school-based intervention, we will directly ameliorate the participation and engagement of the target population. With the present intervention, we expect to improve coping skills in adolescents by enhancing resilience capacities.

Barreras de acceso al aborto legal en el sistema público de salud de dos jurisdicciones de Argentina: Rosario y Ciudad Autónoma de Buenos Aires, 2019-2020 / Barriers in access to legal abortion in the public health system in two Argentine jurisdictions: Rosario and Autonomous City of Buenos Aires, 2019-2020

RESUMEN En las últimas décadas, en la Argentina sucedieron hechos determinantes en el contexto político y social con respecto al aborto, que culminaron con la aprobación de la Ley de Interrupción Voluntaria del Embarazo (IVE) en diciembre de 2020. El objetivo de este artículo es explorar las principales barreras que enfrentaron las mujeres en el acceso al aborto legal en el sistema público de salud de dos jurisdicciones de Argentina, Rosario y Ciudad Autónoma de Buenos Aires, en los años 2019 y 2020. A partir de una adaptación del modelo de las tres demoras, se realizaron encuestas y entrevistas semiestructuradas a 117 mujeres. Las participantes reportaron dificultades para acceder a información sobre lugares y personas donde recurrir para acceder un aborto. La mayoría de las participantes respondió que las personas gestantes no cuentan con información sobre la legalidad del aborto. Si bien la mayoría reportó haber tenido una buena experiencia con los servicios de salud, también identificaron algunas barreras administrativas e institucionales.

ABSTRACT In recent decades, decisive events shaping the political and social context surrounding abortion in Argentina culminated in the passing of the Voluntary Termination of Pregnancy (IVE in Spanish) Law in December 2020. The objective of this article is to explore the main barriers to accessing legal abortions in the public health system faced by women during 2019 and 2020 in two Argentine jurisdictions: Rosario and the Autonomous City of Buenos Aires. Based on an adaptation of the "three phases of delay" framework, surveys and semi-structured interviews with 117 women were conducted. Study participants reported difficulties in accessing information about the places and people to turn to for abortions, and most stated that pregnant individuals lack information regarding their legality. Although the majority of interviewees reported positive experiences with health services, they also identified some administrative and institutional barriers.

Study protocol of a randomised trial of Summer STRIPES: a peer-delivered high school preparatory intervention for students with ADHD.

INTRODUCTION: High schoolers with attention-deficit/hyperactivity disorder (ADHD) experience substantial impairments, particularly in the school setting. However, very few high school students with ADHD receive evidence-based interventions for their difficulties. We aim to improve access to care by adapting evidence-based psychosocial intervention components to a low-resource and novel school-based intervention model, Summer STRIPES (Students Taking Responsibility and Initiative through Peer Enhanced Support). Summer STRIPES is a brief peer-delivered summer orientation to high school with continued peer-delivered sessions during ninth grade. METHODS AND ANALYSIS: Participants will be 72 rising ninth grade students with ADHD who are randomised to receive either Summer STRIPES or school services as usual. Summer STRIPES will be delivered by 12 peer interventionists in a school setting. Outcomes will be measured at baseline, start of ninth grade, mid-ninth grade and end-of-ninth grade. At each assessment, self, parent and teacher measures will be obtained. We will test the effect of Summer STRIPES (compared with school services as usual) on ADHD symptoms and key mechanisms (intrinsic motivation, extrinsic motivation, executive functions) as well as key academic outcomes during the ninth-grade year (Grade Point Average (GPA), class attendance). ETHICS AND DISSEMINATION: Findings will contribute to our understanding of how to improve access and utilisation of care for adolescents with ADHD. The protocol is approved by the institutional review board at Seattle Children's Research Institute. The study results will be disseminated through publications in peer-reviewed journals and presentations at scientific conferences. TRIALS REGISTRATION NUMBER: NCT04571320; pre-results.

Top problems of adolescents and young adults with ADHD during the COVID-19 pandemic.

OBJECTIVE: ADHD symptom severity appears to be exacerbated during the COVID-19 pandemic. The present study surveyed top problems experienced by adolescents and young adults (A/YAs) with ADHD during the COVID-19 pandemic to identify possible reasons for symptom escalation and potential targets for intervention. We also explored perceived benefits of the pandemic for A/YAs with ADHD. METHOD: At the outbreak of the COVID-19 pandemic (April-June 2020), we administered self and parent ratings about current and pre-pandemic top problem severity and benefits of the pandemic to a sample of convenience (N = 134 A/YAs with ADHD participating in a prospective longitudinal study). RESULTS: The most common top problems reported in the sample were social isolation (parent-report: 26.7%; self-report: 41.5%), difficulties engaging in online learning (parent-report: 23.3%, self-report: 20.3%), motivation problems (parent-report: 27.9%), and boredom (self-report: 21.3%). According to parent (d = 0.98) and self-report (d = 1.33), these top problems were more severe during the pandemic than in prior months. Contrary to previous speculation, there was no evidence that pandemic-related changes mitigated ADHD severity. Multi-level models indicated that A/YAs with higher IQs experienced severer top problems exacerbations at the transition to the COVID-19 pandemic. CONCLUSIONS: For A/YAs with ADHD, several risk factors for depression and school dropout were incurred during the early months of the COVID-19 pandemic. A/YAs with ADHD should be monitored for school disengagement and depressive symptoms during the COVID-19 pandemic. Recommended interventions attend to reducing risk factors such as increasing social interaction, academic motivation, and behavioral activation among A/YAs with ADHD.

Implementing Parent-Teen Motivational Interviewing + Behavior Therapy for ADHD in Community Mental Health.

Despite the promise of psychosocial interventions for adolescent Attention Deficit Hyperactivity Disorder (ADHD), there are no studies that examine their implementation in community mental health contexts. In this study, we evaluate the implementation of community-based Supporting Teens' Autonomy Daily (STAND), a parent-teen Motivational Interviewing + Behavior Therapy intervention for adolescents with ADHD. Adolescents with ADHD (N = 225), who were clients at four community mental health agencies, received treatment from 82 therapists. There was double randomization of adolescents and therapists to STAND or Usual Care (UC). Nearly all therapists randomized to STAND completed the training and regularly attended supervision, rating STAND as acceptable and lower burden than UC practices. In the STAND group, MI competence and implementation were lower than in university trials (benchmark range, 19.5% for reflection to question ratio to 83.1% for technical globals). MI integrity in the STAND group was significantly higher than UC across most MITI indices. Content fidelity was adequate in STAND's engagement and skills phases (76.4-85.0%), but not its planning phase (24.4%). Therapists commonly neglected weekly review of goals and home practice and deviated from manualized pace and sequencing of therapy tasks. Learning MI was more challenging for bilingual therapists and therapists with more years of experience. STAND was delivered with higher integrity in earlier sessions and office-based sessions. Discussion identifies future directions for exporting adolescent ADHD interventions to community settings. Patient outcome data for this trial is presented elsewhere. Trial Registration: NCT02694939 www.clinicaltrials.gov .

Epicardial Connections Involving Pulmonary Veins: The Prevalence, Predictors, and Implications for Ablation Outcome.

BACKGROUND: The presence of epicardial connections (ECs) between pulmonary veins (PVs) and other anatomic structures may hinder PV isolation. In this study, we analyzed their prevalence, location, associated factors, and clinical implications. METHODS: Five hundred thirty-four consecutive patients with atrial fibrillation undergoing radiofrequency ablation were included. We considered that an EC was present if: (1) the first pass around the PV antrum did not produce PV isolation and (2) subsequent atrial activation during PV pacing showed that the earliest site was located away from the ablation line and later activation sites were observed near the ablation line. Clinical and electrophysiological variables were collected from all patients. Patients were followed during 12.9±9.4 months, and any documented atrial tachyarrhythmia after the 3-month blanking period was classified as a recurrence. RESULTS: Out of the 534 patients included, 72 (13.5%) were found to have 81 ECs. There was a significant association between the presence of ECs and structural heart disease (15.3% in patients without ECs versus 36.5% in patient with ECs; P<0.001) and patent foramen ovale (4.6% versus 13.5%; P=0.002). The presence of a left common trunk was significantly associated with the absence of ECs (29.6% in patients without ECs versus 16.2% in patients with ECs; P=0.014). Patients with ECs had lower acute success in PV isolation compared with patients without ECs (99.1% versus 86.1%; P<0.001). After adjusting for age, sex, type of atrial fibrillation, left atrium area, hypertension, structural heart disease, presence of left common trunk, patent foramen ovale, and time for atrial fibrillation diagnosis to the ablation, we found a significantly higher risk of atrial tachyarrhythmia recurrences in patients with ECs compared with patients without ECs (hazard ratio, 1.7 [95% CI, 1.1-2.9]; P=0.04). CONCLUSIONS: ECs between PVs and other adjacent structures are frequent in patient with atrial fibrillation (prevalence: 13.5%). Structural heart disease and a patent foramen ovale are strongly associated with the presence of ECs. ECs reduce the acute and chronic success of PV isolation.

Lessons learned in attempting catheter-based interatrial electrical disconnection for nonpharmacologic rate control of atrial fibrillation or flutter.

PURPOSE: Ablation of atrioventricular (AV) conduction and pacemaker implantation is the therapy of last resort for symptomatic atrial tachyarrythmias when rhythm and rate control fail, but is far from ideal. To evaluate whether interatrial electrical disconnection as a result of catheter ablation is feasible and of potential clinical utility as a means of non-pharmacological heart rate control. METHODS: Eleven patients with medically refractory atrial fibrillation or left atrial flutter and symptomatic rapid ventricular response were included. The ablation strategy consisted primarily of right atrial ablation of the interatrial electrical connections, which were located by electroanatomical activation maps performed during coronary sinus stimulation. Successive activation maps were performed as each connection was blocked. If the procedure was considered unsuccessful AV nodal ablation was performed. RESULTS: The coronary sinus ostium was earliest in 10/11 and could be ablated in 5/10 patients. Interatrial conduction block was only achieved in one patient (9.1%). An unexpected AV nodal modulation with an increase in the Wenckebach cycle length (> 50 ms) occurred in 8/11 patients. These patients remained without pacemaker implantation and only 1/8 required AV nodal ablation during the 1-year follow-up. Quality of life questionnaires indicated significant improvement in patients with AV nodal modulation. CONCLUSION: Interatrial electrical disconnection by right atrial catheter ablation is a not feasible with present day technology. The extensive right atrial septal ablation performed resulted in significant AV nodal modulation in most patients, which persisted and resulted in improvement in quality of life.

Electrogram voltage and pacing threshold before ablation, measured by mini-electrodes, predict parameters indicative of transmural lesions in the human atrium.

PURPOSE: An important attenuation of the atrial signal recorded with mini-electrodes (ME) embedded in an 8-mm tip was associated with a transmural radiofrequency lesion. Our aim was to assess if parameters obtained from ME or conventional bipoles before applications predict successful atrial lesions. METHODS: We prospectively included 33 consecutive patients undergoing cavotricuspid isthmus (CTI) ablation. Electrogram voltages and pacing thresholds were measured with ME and conventional bipoles before and after radiofrequency (RF) applications. The time before the loss of capture during applications was recorded. Lesions were considered successful, in accordance with preclinical data, if ME voltage decreased > 54%. RESULTS: Of 207 applications, 107 could be analyzed. During applications, voltages decreased more in the ME than in the conventional bipoles (66.8 ± 26.1% vs 37.5 ± 42.5%, P = 0.001). Likewise, pacing threshold increased significantly more using the ME (86.3 ± 22.9% ME, 52.6 ± 35.6% conventional, P = 0.001). ME pre-ablation voltages were significantly higher and pacing thresholds significantly lower in successful lesions (voltage 0.88 ± 0.71 vs 0.26 ± 0.18 mV, P = 0.0001; threshold 1.6 ± 1.7 vs 2.8 ± 3.0, P = 0.04). Neither of these parameters with conventional bipoles nor time to loss of capture showed differences. A ME voltage > 0.33 mV and a pacing threshold < 1.5 mA predicted a successful lesion with 0.78 and 0.6 sensitivity and 0.78 and 0.59 specificity. CONCLUSIONS: Certain pre-ablation parameters derived from ME such as electrogram voltage and pacing threshold differ from those obtained by a conventional configuration and can predict a successful atrial lesion.

Metacognitive and motivation deficits, exposure to trauma, and high parental demands characterize adolescents with late-onset ADHD.

The objective of this study is to evaluate support for three hypotheses about the etiology of adolescent-onset ADHD symptoms: (1) a "cool" cognitive load hypothesis, (2) a "hot" rewards processing hypothesis, and (3) a trauma exposure hypothesis. Participants (N = 50) were drawn from two public high schools in a culturally diverse metropolitan area. A detailed procedure for identifying and confirming late-onset ADHD cases is described. Adolescents with late-onset ADHD (n = 15) were identified and compared to childhood-onset (n = 17) and non-ADHD classmates (n = 18). Adolescents and parents completed measures of neurocognition, rewards' processing, clinical profile, and environmental demands. Late-onset cases were clinically and neurocognitively indistinguishable from childhood-onset cases; however, they experienced higher demands from parents (d = 1.09). Compared to the non-ADHD group, late-onset cases showed significant deficits in metacognition (d = 1.25) and academic motivation (d = 0.80), as well as a pronounced history of multiple trauma exposure (OR 11.82). At 1-year follow-up, ADHD persisted in 67.7% of late-onset cases. Late-onset cases (26.7%) were more likely than childhood-onset cases (0.0%) to transfer to alternative schools by 1-year follow-up. Multiple factors may contribute to adolescent-onset ADHD. Adolescents with metacognition and motivation deficits may be at greatest risk for the late-onset ADHD phenotype, particularly in highly demanding environments. Exposure to traumatic stress may play a key role in the exacerbation of existing deficits or onset of new symptoms. Late-onset ADHD was persistent in most cases and associated with higher risk for school disengagement than childhood-onset ADHD. Further work is needed to better understand the etiologies of late-onset ADHD symptoms.

Academic impairment among high school students with ADHD: The role of motivation and goal-directed executive functions.

Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with academic failure in high school; however the underpinnings of these difficulties are insufficiently understood. This study examined deficits in self-regulated learning in a sample of high school students with ADHD (n = 32) compared to demographically similar classmates without ADHD (n = 18). A multimethod battery of self and parent rating scales and cognitive tasks measured aspects of intrinsic motivation, extrinsic motivation, and goal-directed executive functions. A multiple regression modeled predictors of current Grade Point Average (GPA). Results indicated that high school students with ADHD placed lower value on academics (d = .99), were less likely to use goal-setting strategies (d = .95), possessed lower levels of metacognition (d = 1.86), and showed significant deficits in task-based cognitive flexibility (d = .80). After controlling for covariates, the set of self-regulated learning variables explained 23% of the variance in GPA, with metacognition (6% of variance explained) and cognitive flexibility (7% of variance explained) serving as significant predictors of outcome. Findings suggest that higher-order executive function deficits play a critical role in the academic functioning of high school students and students with ADHD show large deficits in these areas. Thus, interventions that target metacognition and cognitive flexibility (i.e., the ability to think through decisions before acting, inhibit automatic responses, and make effective decisions for a desired goal) may be particularly promising to remediate ADHD-related academic problems in high school.

A constant postpacing interval in response to overdrive pacing with variable number of beats: An aid in the identification of entrainment for a particular pacing train during macroreentrant atrial tachycardias.

BACKGROUND: When pacing trains with a constant cycle length (CL) but increasing number of beats are introduced during a macroreentrant atrial tachycardia (MAT), the postpacing interval (PPI) is expected to increase if entrainment does not occur but could be stable if entrainment occurs. We tested the ability of PPI analysis to detect entrainment. METHODS: Synchronized pacing trains with increasing number of beats (1-20) were delivered from the coronary sinus (CS) and lateral right atrium (RA) at a CL 20 ms shorter than the MAT CL. Pacing trains were grouped in pairs differing by one-paced beat, and the ∆PPI measured. RESULTS: In an initial prospective cohort of 21 patients (48% had left atrial flutter) the mean ∆PPI was 21.3 ± 5.6 ms for pairs of pacing trains in which neither entrained the MAT and 2.8 ± 1.4 ms for those in which both entrained the MAT (P < .0001). Results were similar for common vs atypical flutter, PPI-TCL ≤30 ms vs PPI-TCL >30 ms, presence vs absence of antiarrhythmic drugs and faster vs slower MAT. When an index pacing train was compared to one with two-paced beats less, a PPI difference of <19 ms identified entrainment with 95% sensitivity and 98% specificity. In a validation cohort of 16 patients, this cut-off value resulted in sensitivity and specificity of 90% and 94%. CONCLUSIONS: A relatively constant ∆PPI in response to overdrive pacing with identical CL but different number of beats allows accurate discrimination between trains that entrained vs those which did not entrain a MAT.