Procedural and Intermediate-term Results of the Electroanatomical-guided Cardioneuroablation for the Treatment of Supra-Hisian Second- or Advanced-degree Atrioventricular Block: the PIRECNA multicentre registry.

AIMS: Prior case series showed promising results for cardioneuroablation in patients with vagally induced atrioventricular blocks (VAVBs). We aimed to examine the acute procedural characteristics and intermediate-term outcomes of electroanatomical-guided cardioneuroablation (EACNA) in patients with VAVB. METHODS AND RESULTS: This international multicentre retrospective registry included data collected from 20 centres. Patients presenting with symptomatic paroxysmal or persistent VAVB were included in the study. All patients underwent EACNA. Procedural success was defined by the acute reversal of atrioventricular blocks (AVBs) and complete abolition of atropine response. The primary outcome was occurrence of syncope and daytime second- or advanced-degree AVB on serial prolonged electrocardiogram monitoring during follow-up. A total of 130 patients underwent EACNA. Acute procedural success was achieved in 96.2% of the cases. During a median follow-up of 300 days (150, 496), the primary outcome occurred in 17/125 (14%) cases with acute procedural success (recurrence of AVB in 9 and new syncope in 8 cases). Operator experience and use of extracardiac vagal stimulation were similar for patients with and without primary outcomes. A history of atrial fibrillation, hypertension, and coronary artery disease was associated with a higher primary outcome occurrence. Only four patients with primary outcome required pacemaker placement during follow-up. CONCLUSION: This is the largest multicentre study demonstrating the feasibility of EACNA with encouraging intermediate-term outcomes in selected patients with VAVB. Studies investigating the effect on burden of daytime symptoms caused by the AVB are required to confirm these findings.

A Systematic Study of the Temperature Dependence of the Dielectric Function of GaSe Uniaxial Crystals from 27 to 300 K.

We report the temperature dependences of the dielectric function ε = ε1 + iε2 and critical point (CP) energies of the uniaxial crystal GaSe in the spectral energy region from 0.74 to 6.42 eV and at temperatures from 27 to 300 K using spectroscopic ellipsometry. The fundamental bandgap and strong exciton effect near 2.1 eV are detected only in the c-direction, which is perpendicular to the cleavage plane of the crystal. The temperature dependences of the CP energies were determined by fitting the data to the phenomenological expression that incorporates the Bose-Einstein statistical factor and the temperature coefficient to describe the electron-phonon interaction. To determine the origin of this anisotropy, we perform first-principles calculations using the mBJ method for bandgap correction. The results clearly demonstrate that the anisotropic dielectric characteristics can be directly attributed to the inherent anisotropy of p orbitals. More specifically, this prominent excitonic feature and fundamental bandgap are derived from the band-to-band transition between s and pz orbitals at the Γ-point.

Cardioneuroablation for the management of patients with recurrent vasovagal syncope and symptomatic bradyarrhythmias: the CNA-FWRD Registry.

BACKGROUND: Cardioneuroablation has been emerging as a potential treatment alternative in appropriately selected patients with cardioinhibitory vasovagal syncope (VVS) and functional AV block (AVB). However the majority of available evidence has been derived from retrospective cohort studies performed by experienced operators. METHODS: The Cardioneuroablation for the Management of Patients with Recurrent Vasovagal Syncope and Symptomatic Bradyarrhythmias (CNA-FWRD) Registry is a multicenter prospective registry with cross-over design evaluating acute and long-term outcomes of VVS and AVB patients treated by conservative therapy and CNA. RESULTS: The study is a prospective observational registry with cross-over design for analysis of outcomes between a control group (i.e., behavioral and medical therapy only) and intervention group (Cardioneuroablation). Primary and secondary outcomes will only be assessed after enrollment in the registry. The follow-up period will be 3 years after enrollment. CONCLUSIONS: There remains a lack of prospective multicentered data for long-term outcomes comparing conservative therapy to radiofrequency CNA procedures particularly for key outcomes including recurrence of syncope, AV block, durable impact of disruption of the autonomic nervous system, and long-term complications after CNA. The CNA-FWRD registry has the potential to help fill this information gap.

Small bowel perforation due to ingested frog bone: a case report.

Perforation of the gastrointestinal tract by ingested foreign body is an uncommon surgical emergency, most typically associated with the consumption of fish and chicken bones. We present an unusual case of a gentleman presenting emergently with an acute abdomen following ingestion of a meal containing frog meat. Emergent computed tomography (CT) revealed findings suggestive of jejunal perforation due to a foreign body. At laparotomy, a mid-jejunal site of perforation was noted due to a protruding piece of fractured frog bone. Washout and primary repair of the small bowel enterotomy were performed, and the patient made an excellent post-operative recovery.

Learning From Alarms: A Robust Learning Approach for Accurate Photoplethysmography-Based Atrial Fibrillation Detection Using Eight Million Samples Labeled With Imprecise Arrhythmia Alarms.

Atrial fibrillation (AF) is a common cardiac arrhythmia with serious health consequences if not detected and treated early. Detecting AF using wearable devices with photoplethysmography (PPG) sensors and deep neural networks has demonstrated some success using proprietary algorithms in commercial solutions. However, to improve continuous AF detection in ambulatory settings towards a population-wide screening use case, we face several challenges, one of which is the lack of large-scale labeled training data. To address this challenge, we propose to leverage AF alarms from bedside patient monitors to label concurrent PPG signals, resulting in the largest PPG-AF dataset so far (8.5 M 30-second records from 24,100 patients) and demonstrating a practical approach to build large labeled PPG datasets. Furthermore, we recognize that the AF labels thus obtained contain errors because of false AF alarms generated from imperfect built-in algorithms from bedside monitors. Dealing with label noise with unknown distribution characteristics in this case requires advanced algorithms. We, therefore, introduce and open-source a novel loss design, the cluster membership consistency (CMC) loss, to mitigate label errors. By comparing CMC with state-of-the-art methods selected from a noisy label competition, we demonstrate its superiority in handling label noise in PPG data, resilience to poor-quality signals, and computational efficiency.

Mental health impact on patients with COVID-19 in the community under a long period of full lockdown in Vietnam.

OBJECTIVE: We aimed to investigate the impact on the mental health of patients with COVID-19 in a centralized isolation facility in the community who experienced a long period of full lockdown during the fourth wave of the COVID-19 pandemic in Vietnam. METHODS: We performed a retrospective cross-sectional study among 125 patients with COVID-19 in a centralized isolation facility in the community of Ho Chi Minh City from September to November 2021. We collected data on depression, anxiety, and stress symptoms, as indicated by scores on the Depression Anxiety Stress Scale-21, as well as sociodemographic characteristics. RESULTS: The prevalence of depression, anxiety, and stress among patients with COVID-19 was 14.4%, 20.8%, and 20.0%, respectively. Depression scores were significantly and positively correlated with body mass index whereas stress scores were significantly and positively correlated with age. CONCLUSION: Our findings indicated an increased prevalence of depression, anxiety, and stress among patients with COVID-19 who were in a centralized isolation facility during the fourth COVID-19 wave in Vietnam. Overweight and older age were identified as risk factors for adverse mental health in patients with COVID-19. Psychological intervention programs should be implemented in isolation facilities for individuals with COVID-19 infection.

A multi-detector comparison to determine convergence of measured relative output factors for small field dosimetry.

The TRS-483 Code of Practice (CoP) provides generic relative output correction factors, [Formula: see text], for a range of detectors and beam energies as used in small field dosimetry. In this work, the convergence of the relative output factors (ROFs) for 6 MV X-ray beams with and without flattening filters was investigated under different combinations of beam collimation and published detector correction factors. The SFD, PFD and CC04 (IBA) were used to measure ROFs of a TrueBeam STx linear accelerator with small fields collimated by the high-definition MLC, which has 2.5 and 5.0 mm projected leaves. Two configurations were used for the collimators: (1) fixed jaws at 10 × 10 cm2 and (2) with a 2 mm offset from the MLC edge, in line with the recommended geometry from IROC-H as part of their auditing program and published dataset. The [Formula: see text] factors for the three detectors were taken from the TRS483 CoP and other published works. The average differences of ROFs measured by detectors under MLC fields with fixed jaws and with 2 mm jaws offset for the 6 MV-WFF beam are 1.4% and 1.9%, respectively. Similarly, they are 2.3% and 2.4% for the 6MV-FFF beam. The relative differences between the detector-average ROFs and the corresponding IROC-H dataset are 2.0% and 3.1% for the 6 MV-WFF beam, while they are 2.4% and 3.2% for the 6MV-FFF beam at the smallest available field size of 2 × 2 cm2. For smaller field sizes, the average ROFs of the three detectors and corresponding results from Akino and Dufreneix showed the largest difference to be 6.6% and 6.2% under the 6 MV-WFF beam, while they are 3.4% and 3.6% under the 6 MV-WFF beam at the smallest field size of 0.5 × 0.5 cm2. Some well-published specific output correction factors for different small field detector types give better convergence in the calculation of the relative output factor in comparison with the generic data provided by the TRS-483 CoP. Relative output factor measurements should be performed as close as possible to the clinical settings including a combination of collimation systems, beam types and using at least three different types of small field detector for more accurate computation of the treatment planning system. The IROC-H dataset is not available for field size smaller than 2 × 2 cm2 for double checks and so that user should carefully check with other publications with the same setting.

Cryothermal energy demonstrates shorter ablation time and lower complication rates compared with radiofrequency in surgical hybrid ablation for recurrent ventricular tachycardia.

BACKGROUND: Recurrent ventricular tachycardia (VT) after prior endocardial catheter ablation(s) presents challenges in the setting of prior cardiac surgery where percutaneous epicardial access may not be feasible. OBJECTIVE: The purpose of this study was to compare the outcomes of cryothermal vs radiofrequency ablation in direct surgical epicardial access procedures. METHODS: We performed a retrospective study of consecutive surgical epicardial VT ablation cases. Surgical cases using cryothermal vs radiofrequency ablation were analyzed and outcomes were compared. RESULTS: Between 2009 and 2022, 43 patients underwent either a cryothermal (n = 17) or a radiofrequency (n = 26) hybrid epicardial ablation procedure with direct surgical access. Both groups were similarly matched for age, sex, etiology of VT, and comorbidities with a high burden of refractory VT despite previous endocardial and/or percutaneous epicardial ablation procedures. The surgical access site was lateral thoracotomy (76.5%) in the cryothermal ablation group compared with lateral thoracotomy (42.3%) and subxiphoid approach (38.5%) in the radiofrequency group, with the remainder in both groups performed via median sternotomy. The ablation time was significantly shorter in those undergoing cryothermal ablation vs radiofrequency ablation (11.54 ± 15.5 minutes vs 48.48 ± 23.6 minutes; P < .001). There were no complications in the cryothermal ablation group compared with 6 patients with complications in the radiofrequency group. Recurrent VT episodes and all-cause mortality were similar in both groups. CONCLUSION: Hybrid surgical VT ablation with cryothermal or radiofrequency energy demonstrated similar efficacy outcomes. Cryothermal ablation was more efficient and safer than radiofrequency in a surgical setting and should be considered when surgical access is required.

Understanding Cardiac Anatomy and Imaging to Improve Safety of Procedures: The Right Ventricle.

Right ventricular perforation is a catastrophic complication of catheter-based intracardiac interventions. In this context, appreciation of 5 attachments of the right ventricle to the aortoventricular unit is essential to recognize extent of right ventricular free wall. We herein present progressive dissection and virtual and photographic endoscopic images of the hearts without distortion. Real dissection images show us how and where to avoid this complication by indicating the true muscular component of the ventricular septum. Both virtual and photographic endoscopic images, when combined with transillumination, beautifully shows the thin wall regions and trabeculations with unprecedented clarity. We believe recognition of these anatomical nuances can reduce the likelihood of right ventricular perforation.

Transcatheter Aortic Valve Replacement Guided by Preprocedural Simulation of Fluoroscopic Location of the Membranous Septum.

We show the virtual simulation of the fluoroscopic location of the membranous septum using preprocedural cardiac computed tomographic data sets. Recognizing the risk distance before the procedure can help individualize implantation strategy to reduce the risk of atrioventricular conduction axis damage during transcatheter aortic valve replacement. (Level of Difficulty: Advanced.).

Ventricular Parasystole in Cardiomyopathy Patients: A Link Between His-Purkinje System Damage and Ventricular Fibrillation.

BACKGROUND: The clinical relevance and prognostic implications of ventricular parasystole are unknown. OBJECTIVES: This study sought to assess the prevalence of ventricular parasystole in patients with implantable cardioverter-defibrillators (ICDs) and ventricular parasystole's association with ventricular arrhythmias and conduction system abnormalities. METHODS: This study retrospectively evaluated patients who underwent ICD interrogation at a single center between June 1, 2019, and August 31, 2020, and reviewed all available ICD and electrocardiogram data. This study identified patients with ventricular parasystole and compared the prevalence of ventricular fibrillation (VF), ventricular tachycardia (VT), and new conduction system abnormalities in those with ≥5 years of intrinsic QRS-complex electrocardiograms to those without parasystole. RESULTS: This study included 374 patients (age 57 ± 21 years, 72% male, 45% nonischemic, 32% ischemic cardiomyopathy), of which, 104 (28%) had VT only, 39 (10%) VF only, and 10 (3%) both VT/VF. Ventricular parasystole was identified in 33 patients (9%); parasystolic foci were predominantly from the His-Purkinje system. Compared with those without parasystole, patients with parasystole had a significantly higher rate of VF (36% vs 11%; P < 0.01), but not VT (42% vs 29%; P = 0.12). Patients with parasystole, compared with those without parasystole, had a higher prevalence of new conduction abnormalities, particularly progressive intraventricular conduction delay (11 of 18 [61%] vs 12 of 83 [14%]; P < 0.01) and new right bundle branch block (4 of 18 [22%] vs 1 of 83 [1%]; P < 0.01). CONCLUSIONS: Ventricular parasystole was strongly associated with new conduction system abnormalities and VF in patients who have cardiomyopathy with ICDs, suggesting a potential link between VF and His-Purkinje damage in this patient population.

Envisioning the Future of Student Success: Report of the 2022-2023 AACP Student Affairs Standing Committee.

Over the past several years, traditional metrics have indicated declining student success within colleges and schools of pharmacy. Though students may be less well-prepared for professional school than in years past, once candidates are admitted to our institutions, we have a responsibility to effectively support their progression through the program. The 2022-2023 Student Affairs Committee was convened to evaluate and advance the construct of student success within Doctor of Pharmacy programs. The Student Affairs Committee was charged with identifying environmental factors affecting the ability of pharmacy students to be successful; determining how colleges and schools of pharmacy are currently meeting needs related to student progress; conducting a literature review to determine what academic support measures minimize attrition; and developing innovative suggestions and recommendations that better support student success. To accomplish this work, we conducted an extensive literature review and synthesis of evidence, engaged in professional networking across the Academy, and administered a wide-ranging student success survey to all colleges and schools of pharmacy. In this report, we explore the complex and interacting systems that affect learning behavior and academic success and offer a novel, comprehensive description of how the Academy is currently responding to challenges of academic and student success. Additionally, we envision the future of student success, offering 7 recommendations to the American Association of Colleges of Pharmacy and 5 suggestions to members of the Academy to advance this vision.

Magnetic resonance imaging is safe in patients with left bundle branch pacing.

BACKGROUND: The use of left bundle branch pacing (LBBP) has dramatically increased since it was first described in 2016, but to date there are no published data on the safety of performing magnetic resonance imaging (MRI) in these patients. METHODS: Patients with LBBP who underwent MRI between January 2016 and October 2022 were retrospectively studied in our clinical center, which has a special program for imaging patients with cardiac devices. All patients underwent close cardiac monitoring throughout the MRI scans. Occurrence of arrhythmias or other adverse effects during MRI were assessed. LBBP lead parameters immediately pre- and post-MRI and at an outpatient follow-up were compared. RESULTS: Fifteen patients with LBBP underwent a total of 19 MRI sessions during the study period. Lead parameters did not significantly change after the MRI or on follow-up, which took place at a median of 91 days after the MRI. No patient developed arrhythmias during the MRI sessions, and no adverse effects such as lead dislodgement were reported. CONCLUSION: Although larger studies are necessary to verify our findings, MRI in patients with LBBP appears safe based on this initial case series.

Status of udder health performance indicators and implementation of on farm monitoring on German dairy cow farms: results from a large scale cross-sectional study.

Regional benchmarking data enables farmers to compare their animal health situation to that of other herds and identify areas with improvement potential. For the udder health status of German dairy cow farms, such data were incomplete. Therefore, the aim of this study was (1) to describe the incidence of clinical mastitis (CM), (2) to describe cell count based udder health indicators [annual mean test day average of the proportion of animals without indication of mastitis (aWIM), new infection risk during lactation (aNIR), and proportion of cows with low chance of cure (aLCC); heifer mastitis rate (HM)] and their seasonal variation, and (3) to evaluate the level of implementation of selected measures of mastitis monitoring. Herds in three German regions (North: n = 253; East: n = 252, South: n = 260) with different production conditions were visited. Data on CM incidence and measures of mastitis monitoring were collected via structured questionnaire-based interviews. Additionally, dairy herd improvement (DHI) test day data from the 365 days preceding the interview were obtained. The median (Q0.1, Q0.9) farmer reported incidence of mild CM was 14.8% (3.5, 30.8%) in North, 16.2% (1.9, 50.4%) in East, and 11.8% (0.0, 30.7%) in South. For severe CM the reported incidence was 4.0% (0.0, 12.2%), 2.0% (0.0, 10.8%), and 2.6% (0.0, 11.0%) for North, East, and South, respectively. The median aWIM was 60.7% (53.4, 68.1%), 59.0% (49.7, 65.4%), and 60.2% (51.5, 67.8%), whereas the median aNIR was 17.1% (13.6, 21.6%), 19.9% (16.2, 24.9%), and 18.3% (14.4, 22.0%) in North, East, and South, respectively with large seasonal variations. Median aLCC was ≤1.1% (≤ 0.7%, ≤ 1.8%) in all regions and HM was 28.4% (19.7, 37.2%), 35.7% (26.7, 44.2%), and 23.5% (13.1, 35.9%), in North, East and South, respectively. Participation in a DHI testing program (N: 95.7%, E: 98.8%, S: 89.2%) and premilking (N: 91.1%, E: 93.7%, S: 90.2%) were widely used. Several aspects of udder health monitoring, including exact documentation of CM cases, regular microbiological analysis of milk samples and the use of a veterinary herd health consultancy service were not applied on many farms. The results of this study can be used by dairy farmers and their advisors as benchmarks for the assessment of the udder health situation in their herds.

The evaluation of decorated camera housings - A driving simulator study.

Traffic enforcement cameras can lead to unwanted side-effects. For instance, red-light cameras at intersections can increase the chance at rear-end collisions, probably caused by slowing down abruptly. Additionally, on the highways, speed cameras could lead to kangaroo-jumps in driving speed. Warning drivers about cameras is a possible solution. Cameras that are uncommonly decorated (e.g. colored in pink or in yellow) may provide better conspicuity compared to those in standard colors like gray. However, besides warning drivers about their presence, more conspicuity of cameras could also distract drivers from the primary driving task. Therefore, the impact of such decoration on safety is unclear. This study evaluates different decorated designs of the camera housing and how such decoration may influence camera's conspicuity and induce distraction while driving. Three camera colored-designs were evaluated (gray, pink, and a mixture of yellow and black) using a driving simulator. Fifty-four participants drove nine different conditions, i.e. three camera-designs in three roadway-settings (basic highway segments, intersections operating during the amber-phase, and intersections with a bicycle-lane). Subjective and objective measures allowed to assess if: 1) decorated camera housings increased conspicuity, 2) signs of distraction could be found, and 3) driving was influenced. In addition to the detection success rate, other eye-tracking parameters were: time-to-first-fixation, fixation count, and average and total fixation duration. Driving measures, i.e. speed, acceleration or deceleration rate, lane-keeping behavior, and minimum time-to-collision, were included to assess if the tested camera-designs impacted driving behavior. Moreover, a post-drive questionnaire assessed the participants' opinions. Using camera colored-designs improved the camera's conspicuity. However, driving measures remained comparable across the three camera-designs. Although the subjective data indicated some distraction from the decorated cameras, clear indications for an effect on traffic safety were lacking. Meanwhile, a little over half of the respondents supported camera decoration. The current study does not allow firm conclusions, and additional research is recommended.

Outcomes in orthotopic heart transplantation following pacemaker implantation.

BACKGROUND: Bradyarrhythmias including sinus node dysfunction (SND) and atrioventricular block (AVB) can necessitate pacemaker (PPM) implantation in orthotopic heart transplant (OHT) recipients. Prior studies have shown conflicting findings regarding the effect of PPM implantation on survival. We evaluated the effect of PPM indication on long-term re-transplant-free survival in OHT patients. METHODS: We conducted a retrospective cohort study of OHT patients at UCLA Medical Center from 1985 to 2018. Indication for PPM (SND, AVB) was identified. Cox proportional hazards model with pacemaker implantation as a time-varying covariate was used to evaluate its effect on the primary endpoint of retransplant or death. We included 1609 OHTs in 1511 adult patients with median follow-up of 12 years. RESULTS: At transplant, patients were aged 53 ± 13 years and 1125 (74.5%) were male. Pacemakers were implanted in 109 (7.2%) patients; 65 for SND (4.3%) and 43 for AVB (2.8%). Repeat OHT was performed in 103 (6.4%) cases and 798 (52.8%) patients died during the follow-up period. The risk of the primary endpoint was significantly higher in patients requiring PPM for AVB (HR 3.0, 95% CI 2.1-4.2, p < .01) after controlling for age at OHT, gender, hypertension, diabetes, renal disease, history of repeat OHT, acute rejection, transplant coronary vasculopathy, and atrial fibrillation, but not PPM for SND (HR 1.0, 95% CI 0.70-1.4, p = 1.0). CONCLUSIONS: Patients who required PPM for AVB, but not SND, were at significantly higher risk of death or retransplant compared to patients who did not require PPM.