Protocol modifications reduce risk of delayed pericardial effusions after vein of Marshall ethanol infusion: follow-up from the Maine experience.

BACKGROUND: While ethanol infusion into the vein of Marshall (VOM) as an adjunct to atrial fibrillation ablation has shown promise, adoption has been limited by the technical expertise required, unclear antiarrhythmic mechanism, and complication risk. Delayed pericardial effusions have been associated with ethanol infusion into the VOM in prior studies. Very little is known about how the procedural approach itself can impact the risk of delayed effusions. We sought to understand the incidence and influence of procedural technique on complications including delayed pericardial effusions from VOM ethanol infusion at a large single medical center. METHODS: A total of 275 atrial ablation cases wherein VOM ethanol infusion was attempted were identified from the time of the program's inception in 2019 at Maine Medical Center (Portland, ME) until October of 2023. Cases were classified into phase I cases (early experience) and phase II cases (later experience) based upon temporal programmatic changes in the ethanol dose and infusion rate as well as the use of routine VOM venography. Procedural details and complications were adjudicated from the medical record. RESULTS: The overall VOM ethanol infusion success was 91.4%. Nine complications (3.3%) occurred in eight patients (2.9% of patients). These were more frequent in phase I (5.8%) compared to phase II (1.3%, p = 0.047). This difference was driven by a difference in delayed presentations of tamponade, which occurred in four patients in phase I (3.3%) and in no patients in phase II (0%, p = 0.037). Twelve-month estimated atrial arrhythmia freedom did not differ between groups (73.8% phase I vs 70.4% phase II, p = 0.24). CONCLUSION: In our single-center experience, adjustments to the procedural approach with lower ethanol infusion rate and dosage, combined with utilizing selective VOM venography, associated with a lowering of complication rates and in particular, delayed pericardial tamponade.

Musculoskeletal injury or Sports-Related Concussion (SRC) in a season of rugby union does not affect performance on concussion battery testing in university-aged student-athletes.

BACKGROUND: Sub-concussive and concussive impacts sustained during contact sports such as rugby may affect neurocognitive performance, vestibular-ocular-motor function, symptom burden and academic ability. METHOD: Student-athletes (n = 146) participating in rugby union British Universities or domestic competitions were assessed on the Immediate Post-Concussion and Cognitive Test, Post-Concussion Symptom Scale, vestibular-oculo-motor screening tool and revised perceived academic impact tool. Individual change from pre-season (July-September 2021) to 2-weeks following last exposure to contact (April-July 2022) was analysed. RESULTS: Symptom burden significantly worsened (p=0.016) over the season. Significant improvements on verbal memory (p=0.016), visual memory (p=0.008) and motor processing speed (p=0.001) suggest a possible learning effect. Surprisingly, the number of days lost to concussion significantly and positively affected performance on verbal memory (p = 0.018) and reaction time (p = 0.027). Previous concussive events significantly predicted a worsening in symptom burden (p < 0.028), as did in-season concussive events, predicting improved verbal memory (p = 0.033) and symptom burden change (p = 0.047). Baseline performance significantly affected change on several neurocognitive tests, with low-scorers showing more improvement over the season. CONCLUSION: Participation in rugby union was not associated with deleterious effects on brain function. Previous concussive events and in-season factors, possibly related to learning effects, may explain improvement in cognitive function across the season.

Use of intracardiac echocardiography in vein of Marshall ethanol infusion for ablation of persistent atrial fibrillation.

BACKGROUND: Few methods have been reported to demonstrate real-time effects during vein of Marshall (VOM) ethanol infusion in persistent atrial fibrillation (PeAF). OBJECTIVE: This study was to evaluate the impact of left atrial (LA) monitoring using intracardiac echocardiography (ICE) during VOM ethanol infusion. METHODS: Seventy-four consecutive patients with PeAF who underwent VOM ethanol infusion followed by radiofrequency (RF) ablation were included. Patients with findings on ICE consistent with echogenic streaming in the LA and with increased myocardial local echogenicity along the VOM area were placed into one group (group A) and those without into the other group (group B). Outcomes between the 2 groups were compared. RESULTS: Forty-six patients (62%) were placed into group A. A new ethanol-induced low-voltage area in group A was larger than that in group B (8.5 cm2 [5.5-10.2 cm2] and 4.0 cm2 (2.4-6.3 cm2]; P < .001). The RF ablation time required to achieve MI block was reduced in group A patients (263.0 seconds [196.0-351.0 seconds] vs 417.0 seconds [315.0-709.5 seconds] in group B patients; P < .001). MI block was achieved in 46 patients (100%) via an endocardial approach in group A and 27 patients (96.4%) in group B (extra coronary sinus ablation in 4 patients). One patient developed clinically significant pericardial effusions and required pericardiocentesis in group B. CONCLUSION: Presence of increased myocardial local echogenicity at the ridge and consistent echogenic streaming in the LA detected by ICE-based imaging during VOM ethanol infusion suggests increased ablated tissue in that region and lower RF ablation time during ablation for PeAF.

Impact of Vein of Marshall Ethanol Infusion Combined with Anatomical Ablation for the Treatment of Persistent Atrial Fibrillation: A Long-Term Follow-Up Based on Implantable Loop Recorders.

BACKGROUND: The best ablation treatment for persistent atrial fibrillation (PeAF) patients is still debated. The vein of Marshall (VOM) seems to be a promising target for ablation and could be combined with a linear set of ablation lesions. The aim of our study is to evaluate the incidence of AF recurrences in a PeAF population treated with a comprehensive ablation approach consisting of VOM ethanol infusion (EI), pulmonary vein isolation (PVI), a left atrial (LA) roofline, a mitral line (guided by the newly formed lesion after alcohol infusion into the VOM and validated by pacing), and a cavotricuspid isthmus line. METHODS: Consecutive patients undergoing the first ablation procedure of catheter ablation (CA) for PeAF were enrolled. All patients underwent VOM-EI, PVI, and ablation lines along the roof of the LA, mitral, and cavotricuspid isthmus. LA voltage mapping before and after VOM-EI was also performed. An implantable loop recorder (ILR) was implanted at the end of the ablation in each patient. RESULTS: Thirty-one consecutive patients (66 ± 8 years and 71% male) affected by PeAF were included in this study. The VOM-EI procedural phase lasted 21.4 ± 10.1 min. PV isolation and lines were validated in all subjects. The ML block was achieved within 10.8 ± 8.7 min. At a mean follow-up of 12 ± 7 months, 27 out of 31 (87%) patients remained free from AT/AF recurrences. Among the patients with recurrences, two (50%) had incomplete ablation lesions and three (75%) had "suboptimal" VOM-EI. In 23/31 patients (74%), antiarrhythmic drugs (AADs) were discontinued after 1 month of follow-up. No significant complications were reported during the follow-up. CONCLUSIONS: this single-center experience demonstrates that VOM-EI systematically combined with an anatomical ablation set in patients with PeAF resulted in feasible, safe, and effective freedom from AF/AT recurrences in 87% of the population after a 1-year follow-up period according to an ILR.

Balloon dilation and transient stenting of unilateral membranous choanal atresia in a British Shorthair cat with chronic purulent rhinitis and ascending meningoencephalitis.

INTRODUCTION: Choanal atresia is a rare congenital anomaly in humans and animals, characterized by the absence of communication of one or both nasal cavities with the nasopharynx. The severity of clinical signs depends on the presence of unilateral versus bilateral stenosis as well as comorbidities. With bilateral atresia, respiration may be severely compromised particularly during sleep, as airflow can only occur when breathing through the open mouth. Various therapeutic modalities have been described in people and adopted for animals. All treatments may be associated with complications, the most important being post-therapeutic scar formation with re-stenosis. This report describes a 10-month-old British Shorthair cat with chronic unilateral serosal nasal discharge that changed to mucopurulent discharge. When acute neurological signs developed, the cat was presented to the veterinary hospital. A diagnosis of primary, membranous right sided choanal atresia was achieved via computed tomography (CT) and nasopharyngeal (posterior) rhinoscopy. Secondary changes included destructive rhinitis with progression to the CNS with a subdural empyema and meningoencephalitis. Retinal changes and aspiration bronchopneumonia were suspected additional complications. After recovery from the secondary infections, the membranous obstruction was perforated and dilated using a valvuloplasty balloon by an orthograde transnasal approach under endoscopic guidance from a retroflexed nasopharyngeal view. To prevent re-stenosis, a foley catheter was placed as a transient stent for 6 days. The cat recovered uneventfully and was asymptomatic after the stent removal. Endoscopic re-examination after 5 months confirmed a persistent opening and patency of the generated right choanal passage. The cat remains asymptomatic 10 months after the procedure. Transnasal endoscopic balloon dilation and transient stenting of choanal atresia is a minimally invasive and relatively simple procedure with potentially sustained success.

INTRODUCTION: L'atrésie des choanes est une anomalie congénitale rare chez l'homme et l'animal, caractérisée par l'absence de communication d'une ou des deux cavités nasales avec le nasopharynx. La gravité des signes cliniques dépend de la présence d'une sténose unilatérale ou bilatérale, ainsi que des comorbidités. En cas d'atrésie bilatérale, la respiration peut être gravement compromise, en particulier pendant le sommeil, car l'air ne peut circuler que par la bouche ouverte. Diverses modalités thérapeutiques ont été décrites chez l'homme et adaptées pour les animaux. Tous les traitements peuvent être associés à des complications, la plus importante étant la formation de cicatrices post-thérapeutiques avec resténose. Ce rapport décrit un chat British Shorthair de 10 mois présentant un écoulement nasal séreux unilatéral chronique qui s'est finalement transformé en un écoulement muco-purulent. Lorsque des signes neurologiques aigus sont apparus, le chat a été présenté à l'hôpital vétérinaire. La tomodensitométrie (CT) et la rhinoscopie nasopharyngée (postérieure) ont permis de diagnostiquer une atrésie choanale primaire membraneuse du côté droit. Les altératiins secondaires comprenaient une rhinite destructrice avec une progression vers le SNC avec empyème sous-dural et méningo-encéphalite. Des altérations de la rétine et une bronchopneumonie par aspiration étaient des complications supplémentaires présumées. Après guérison des infections secondaires, l'obstruction membraneuse a été perforée et dilatée à l'aide d'un ballonnet de valvuloplastie par une approche transnasale orthograde sous guidage endoscopique à partir d'une vue nasopharyngée rétrofléchie. Pour éviter une nouvelle sténose, une sonde de Foley a été placée comme stent transitoire pendant 6 jours. Le chat s'est rétabli sans incident et était asymptomatique après le retrait du stent. Le réexamen endoscopique effectué 5 mois plus tard a confirmé la persistance de l'ouverture et de la perméabilité de la voie choanale droite générée. Le chat reste asymptomatique 10 mois après l'intervention. La dilatation endoscopique transnasale par ballonnet et la pose d'une endoprothèse transitoire dans le cas d'une atrésie des choanes est une procédure peu invasive et relativement simple dont le succès peut être durable.

The Maine vein of Marshall ethanol experience: learning curve and safety.

BACKGROUND: The marginal benefit of ethanol infusion into the vein of Marshall (VOM) as an adjunct to atrial fibrillation ablation has shown promise in a single randomized study and case series from very experienced centers. However, adoption has not been widespread and the impact on real-world outcomes outside of leading centers is not established. The objective in this study is to understand the learning curve, and explore procedural outcomes and safety with VOM ethanol infusion from a large single medical center. METHODS: One hundred twenty nine atrial ablation cases wherein VOM ethanol infusion was attempted were identified from the time of the program's inception in 2019 at Maine Medical Center (Portland, ME). Our technical approach, procedural success, and complications were adjudicated from the medical record. RESULTS: The overall VOM ethanol infusion success was 90%. Infusion success rates improved and fluoroscopy utilization decreased with experience. Arrhythmia recurrence was 14% after a mean follow-up of 9.5 months. Complications occurred in 5.4% of patients, including a 3.1% risk of delayed tamponade. CONCLUSION: In our single center experience, VOM ethanol infusion was feasible with a high technical success rate. These positive results are balanced against a concerning rate of delayed tamponade.

Angiographic Characteristics of the Vein of Marshall in Patients with and without Atrial Fibrillation.

BACKGROUND: Ethanol infusion into the vein of Marshall (Et-VOM) is a novel therapeutic treatment for atrial fibrillation (AF). However, few studies have focused on the difference between AF and non-AF patients (presented other types of arrhythmias) regarding the characteristics of the vein of Marshall (VOM). OBJECTIVE: This study sought to investigate the incidence, morphology, and angiographic characteristics of the VOM. METHODS: Coronary sinus (CS) angiography was performed in all patients. The baseline, angiographic characteristics and measurements of VOM dimensions were compared between the AF and non-AF group. RESULTS: CS angiography was performed in 290 patients. The VOM detection rate was higher in the AF group than in the non-AF group (91.8% vs. 84.1%, p = 0.044). In the right anterior oblique (RAO) projection, AF patients had significant larger VOM ostium, CS ostium, and CS diameter at VOM ostium than non-AF patients (1.9 ± 0.9 vs. 1.7 ± 0.7 mm, p = 0.015; 12.8 ± 4.1 vs. 11.4 ± 3.7 mm, p = 0.016; 9.1 ± 3.1 vs. 8.2 ± 2.9 mm, p = 0.028, respectively). There was a slight linear correlation between the VOM ostium and the CS ostium diameter as well as left atrial volume (LAV). CONCLUSION: AF patients seem to have a higher incidence of the VOM, larger VOM ostium, CS ostium, and CS lumen in RAO view. Meanwhile, the VOM ostium may correlate with the CS ostium and LAV.

Owner reported clinical signs and -treatment decisions in equine pastern dermatitis.

INTRODUCTION: Equine pastern dermatitis has a high prevalence in the equine population, especially in draft breeds. This skin condition is difficult to treat, and it is suspected that owners often decide on a treatment without consulting a veterinarian. The objectives of this study were to describe owner-reported clinical signs, severity, and reasons to consult a veterinarian. Moreover, we inquired about preventive measures and treatments, both instituted by owners without previous consultation or prescribed by their veterinarians. A total of 123 horses (owners recruited over social media) were included in the study. All horses suffered from equine pastern dermatitis at least once in the two years preceding the study. Standardized questionnaires collecting information on management, housing conditions, clinical signs as well as preventive measures and treatments were filled out by participants. The data was recorded, and descriptive statistics were performed. Most horses (71 out of 115 available answers, 62 %) had shown clinical signs of equine pastern dermatitis at least four times in their lives. A total of 113 horses (92 % of all included horses) were affected by equine pastern dermatitis at the time of the interview. For 37 horses (32 %) out of 114 available answers the owners consulted their veterinarian only after the horse showed signs of pain or lameness. Usually, treatments that did not require a medical prescription were applied without consulting their veterinarian (e. g. only 9 % (14 out of 150 prescriptions) of topical creams promoting wound healing were prescribed by a veterinarian). A total of 31 treatment decisions (55 %) with creams containing anti-bacterial, anti-mycotic and/or anti-inflammatory agents and 100 % of systemic medications containing anti-bacterial, anti-parasitic or anti-inflammatory agents were prescribed by veterinarians. Overall, 69 % of treatment decisions were made without consulting a veterinarian, making it then more difficult to determine underlying causes for the pastern dermatitis and rendering the treatment often longer and more onerous. To raise owner awareness of possible consequences if a veterinarian is consulted too late in the disease process, specific information campaigns to improve animal welfare should be considered.

INTRODUCTION: La dermatite du paturon a une prévalence élevée dans la population équine, en particulier chez les races de trait. Cette affection cutanée est difficile à traiter et on soupçonne que les propriétaires décident souvent d'un traitement sans consulter un vétérinaire. Les objectifs de cette étude étaient de décrire les signes cliniques rapportés par les propriétaires, la sévérité et les raisons de consulter un vétérinaire. De plus, nous nous sommes renseignés sur les mesures préventives et les traitements, qu'ils soient mis en place par les propriétaires sans consultation préalable ou prescrits par leurs vétérinaires. Un total de 123 chevaux (propriétaires recrutés via les médias sociaux) ont été inclus dans l'étude. Tous les chevaux ont souffert de dermatite du paturon au moins une fois au cours des deux années précédant l'étude. Des questionnaires standardisés, recueillant des informations sur la gestion, les conditions de logement, les signes cliniques ainsi que les mesures préventives et les traitements, ont été remplis par les participants. Les données ont été enregistrées et des statistiques descriptives ont été réalisées. La plupart des chevaux (71 sur 115 réponses disponibles, 62 %) avaient présenté des signes cliniques de dermatite du paturon au moins quatre fois dans leur vie. Au total, 113 chevaux (92 % de tous les chevaux inclus) étaient atteints de dermatite du paturon équin au moment de l'entretien. Pour 37 chevaux (32%) sur les 114 réponses disponibles, les propriétaires ont consulté leur vétérinaire uniquement après que le cheval a eu montré des signes de douleur ou de boiterie. En général, les traitements qui ne nécessitaient pas de prescription médicale étaient appliqués sans consulter leur vétérinaire (par exemple, seuls 9 % [14 sur 150 prescriptions] des crèmes topiques favorisant la cicatrisation des plaies étaient prescrites par un vétérinaire). Au total, 31 décisions de traitement (55%) avec des crèmes contenant des agents antibactériens, antimycosiques et/ou anti-inflammatoires et 100% des médicaments systémiques contenant des agents antibactériens, antiparasitaires ou anti-inflammatoires ont été prescrits par des vétérinaires. Dans l'ensemble, 69 % des décisions de traitement ont été prises sans consulter un vétérinaire, ce qui rend plus difficile la détermination des causes sous-jacentes de la dermatite du paturon et rend le traitement souvent plus long et plus onéreux. Pour sensibiliser les propriétaires aux conséquences possibles d'une consultation trop tardive d'un vétérinaire dans le processus de la maladie, des campagnes d'information spécifiques visant à améliorer le bien-être des animaux devraient être envisagées.

A case report of ethanol infusion in the vein of Marshall using the right jugular vein approach.

BACKGROUND: Ethanol infusion has recently been described as a curative strategy for certain peri-mitral flutters by blocking electrical conduction across the mitral isthmus along with the Marshall bundle. The present case showed that a right jugular vein approach, less described, may be a good choice when performing an ethanol infusion in the vein of Marshall (VOM). CASE SUMMARY: A 45-year-old man was admitted to our unit for dyspnoea associated with an atypical atrial flutter with a cycle length of 320 ms. The left atrial activation map showed a peri-mitral counter-clockwise circuit. The atrial flutter cycle length went up to 345 ms once an endocardial and epicardial point-by point-ablation of the mitral line was completed. At this stage, a new activation map showed that the mitral line was still permeable with an epicardial conduction bridge through the VOM. We decided to use an ethanol infusion for the ablation of the VOM. The coronary sinus could not be thoroughly catheterized due to a winding and angular shape so we decided to try a right jugular vein approach. A total of 9 mL of ethanol was injected into the VOM. A final venogram showed the diffusion of ethanol around the VOM. Sinus rhythm was restored during the last ethanol infusion. A new voltage map confirmed the completion of the mitral line, and we confirmed the bidirectional block. DISCUSSION: The present case showed that a right jugular vein approach may be a good choice when catheterizing and performing an ethanol infusion in the VOM.

Coronary Arterial Vasospasm: A Rare Complication of Vein of Marshall Ethanol Infusion for Atrial Fibrillation.

A 75-year-old man was admitted for repeat ablation of atrial fibrillation. At 30 min after infusion of 3.5 ml of ethanol into the vein of Marshall, inferior ST-segment elevation with coronary arterial vasospasm was observed. This is the first report of coronary vasospasm after chemical ablation of the vein of Marshall. (Level of Difficulty: Intermediate.).

The volatilome - investigation of volatile organic metabolites (VOM) as potential tumor markers in patients with head and neck squamous cell carcinoma (HNSCC).

BACKGROUND: Different organisms such as bacteria, molds and humans produce and release a relative unknown class of metabolites which are responsible for the individual olfactory pattern. These volatile organic metabolites (VOM) represent a kind of biosignature that reflects the sum of all multifactorial influences, including genetics, environmental factors, nutritional and disease status. As a result of pathological processes the individual body odor can be influenced by newly produced or altered compositions of the VOM. Until now, human VOM have been detected in various body media, such as on the skin, in the exhaled air as well as in body fluids such as saliva, mother's milk, sweat, blood and urine. METHODS: In this retrospective case-control study urinary VOM of 53 therapy-naive patients with head and neck squamous cell carcinoma (HNSCC) and 82 healthy controls were semi-quantified by headspace solid-phase micro extraction (SPME) gas chromatography (GC) mass spectrometry (MS). At first, the procedure was optimized in respect to the extraction parameters. By using Student's t-test significant differences in the VOM pattern with the corresponding p-values were obtained. For multivariate metabolite pattern recognition the hierarchical cluster analysis by Ward was applied, followed by the supervised partial least squares-discriminant analysis (PLS-DA). RESULTS: In total 81 VOMs could identified in the urine samples of all study participants, of which 25 were significantly increased and of which were 10 significantly reduced in HNSCC-patients compared to the controls. In addition, the multivariate statistics confirmed that on the basis of the renal excreted pattern of the volatile metabolites a high discrimination can be carried out between patients with a tumor in the head and neck region and controls. The substance group of the saturated, unbranched aldehydes makes a substantial contribution in this context. CONCLUSIONS: The systematic pattern analysis of urinary VOMs appears to have potential clinical application as a diagnostic tool for cancer, especially HNSCC.

A lemma science of mind: the potential of the Kegon (Flower Ornament) Sutra.

The paper argues for a new perspective on the relationship between Buddhism and European psychology, or sciences of the mind, based in the Kegon Sutra, a text that emerged in the early stages of Mahayana Buddhism (3rd - 5th century CE). The basis of European science is logos intellection, formalized by Aristotle as following three laws: the law of identity, the law of contradiction and the law of the excluded middle. Logic in the Buddhist tradition, by contrast, is based in lemma (meaning to understand as a whole not with language, but with intuition). Lemma-based science born in the Buddhist tradition shows that rational perception is possible even without the three laws of logos. The Kegon Sutra, which explains what Buddha preached only a week after he attained enlightenment, is unified under the logic of lemma and can be seen as an effort to create a 'lemma science of the mind'. The fundamental teaching of the Kegon Sutra is explored, and its principles are compared with primary process thinking and the unconscious as outlined by Freud and Jung. Jung's research of Eastern texts led him to create a science of the mind that went further than Freud: his concept of synchronicity is given by way of example and can be seen anew within the idea of a lemma-based science.