Convergence of Epicardial and Endocardial RF Ablation for the Treatment of Symptomatic Persistent AF (CONVERGE Trial): Rationale and design.

Atrial fibrillation is the most common sustained arrhythmia affecting over 33 million people worldwide. Approximately 70% of AF patients have non-paroxysmal AF. As AF progresses from paroxysmal to non-paroxysmal forms, the prevalence of comorbidities increases. The efficacy of catheter ablation for persistent and long standing persistent (LSP) AF is <40%, often requiring multiple ablation procedures with greater cost and potentially more complications. There is an unmet need to effectively treat such patients. METHODS: CONVERGE is an investigational device exempt, prospective, multi-center, open label 2:1 randomized controlled pivotal study to evaluate the overall success of the Convergent hybrid procedure compared to endocardial catheter ablation for the treatment of symptomatic persistent AF refractory or intolerant to at least one Class I and /or III anti-arrhythmic drug (AAD). A total of 153 subjects at 27 centers are treated in the study. The CONVERGE study is differentiated from other studies currently being conducted on the persistent AF population, because a) there is no time restriction on the duration of diagnosed AF in the patients being studied and b) the trial allows patients with left atrial sizes up to 6 centimeters. The ongoing trials are limited to either 6 months, 12 months or 3-years of continuous AF making CONVERGE the only ablation trial thus far to include a substantial portion of patients with longstanding persistent AF. The convergent procedure involves combination of minimally invasive pericardioscopic epicardial ablation with endocardial left atrial ablation. The primary endpoint is freedom from AF/AFL/AF absent class I/III AAD, except for a previously failed class I/ III AAD with no increase in dosage following 3-months through 12-months. The primary safety endpoint is the incidence of major adverse events from the procedure through 30-days post procedure. CONCLUSION: CONVERGE AF compares the overall success of the Convergent hybrid procedure to endocardial catheter ablation for the treatment of persistent and longstanding persistent AF. By providing objective comparative data, the study aims to provide guidance on the treatment of such patients.

Development of a chute to facilitate transvaginal ultrasound guided oocyte aspiration (TUGA) in the sow.

A procedure developed for nonsurgical transvaginal ultrasound-guided oocyte aspiration in the mature sow was dependent upon development of a special chute. This chute was designed to immobilize and protect the sow. The floor of the chute possessed a metal bar that was elevated via a hydraulic lift until the weight of the sow rested on the bar, while her hooves were still in contact with the floor. This exact positioning of the female prevented her from resisting procedure and allowed for a comfortable setting for technician to manipulate the ovaries (per rectum) and perform transvaginal ultrasound guided oocyte aspiration (TUGA). Oocyte collection was performed in six sows, and none experienced detrimental health effects from the procedure.

Depression among emergency medicine residents over an academic year.

OBJECTIVES: To describe the frequency of depression among emergency medicine (EM) residents by month, gender, rotation type, postgraduate year (PGY), and number of hours worked. METHODS: This was a prospective, nonblinded, cohort study of consenting EM residents in a four-year, 51-resident EM residency program from July 2003 to June 2004. Participants received an anonymous monthly survey via Web site that consisted of the Center for Epidemiologic Studies Depression Scale (CESD) and the resident's gender, PGY, number of hours worked in the previous week (< or =40, 41-60, 61-80 and >80), and rotation type (EM, intensive care unit, non-EM clinical, or other). Residents were excluded from analysis if they did not complete at least one survey during each season. For each resident, the peak score for each three-month period was recorded and analyzed with a mixed-model analysis of variance to account for a repeated-measures effect. RESULTS: Fifty of 51 (98.0%) residents consented for participation. Nineteen (38%) were excluded because of incomplete data. The prevalence of depression was 12.1% (95% confidence interval [95% CI] = 7.5% to 19.0%; 15 of 124 scores). The women had numerically, but not statistically, significantly lower mean +/- standard deviation CESD scores than the men (6.4 +/- 6.8 vs. 8.7 +/- 8.6, p = 1.0). There was no significant difference in mean CESD score by month, PGY, rotation type, or number of hours worked. CONCLUSIONS: Season, number of hours worked, rotation type, PGY, and gender all failed to predict depression among EM residents in this single-center trial. The prevalence of depression was comparable to that of the general population.

Identifying inaccuracies on emergency medicine residency applications.

BACKGROUND: Previous trials have showed a 10-30% rate of inaccuracies on applications to individual residency programs. No studies have attempted to corroborate this on a national level. Attempts by residency programs to diminish the frequency of inaccuracies on applications have not been reported. We seek to clarify the national incidence of inaccuracies on applications to emergency medicine residency programs. METHODS: This is a multi-center, single-blinded, randomized, cohort study of all applicants from LCME accredited schools to involved EM residency programs. Applications were randomly selected to investigate claims of AOA election, advanced degrees and publications. Errors were reported to applicants' deans and the NRMP. RESULTS: Nine residencies reviewed 493 applications (28.6% of all applicants who applied to any EM program). 56 applications (11.4%, 95%CI 8.6-14.2%) contained at least one error. Excluding "benign" errors, 9.8% (95% CI 7.2-12.4%), contained at least one error. 41% (95% CI 35.0-47.0%) of all publications contained an error. All AOA membership claims were verified, but 13.7% (95%CI 4.4-23.1%) of claimed advanced degrees were inaccurate. Inter-rater reliability of evaluations was good. Investigators were reluctant to notify applicants' dean's offices and the NRMP. CONCLUSION: This is the largest study to date of accuracy on application for residency and the first such multi-centered trial. High rates of incorrect data were found on applications. This data will serve as a baseline for future years of the project, with emphasis on reporting inaccuracies and warning applicants of the project's goals.

Surgical versus nonsurgical treatment of empyema thoracis: an outcomes analysis.

BACKGROUND: Empyema thoracis (ET) is associated with substantial morbidity and mortality. The optimal means for draining the pleural space remains controversial but there may be increasing bias for less invasive strategies. This study compared outcome after a nonsurgical versus a surgical approach to ET. METHODS: Patients with ET over a 10-year period (n = 93) were reviewed and stratified into nonsurgical (thoracentesis and/or closed tube thoracostomy) and surgical (thoracotomy, decortication, and/or open window thoracostomy) groups based on pleural drainage techniques. Hospital course was analyzed except when altered by death (n = 12), noncompliance (n = 3), or severe comorbidities (n = 3). RESULTS: Seventy-five patients were stratified into nonsurgical (n = 32) and surgical (n = 43) groups. Demographics, comorbidities, signs and symptoms, and causative organisms were similar between groups. Mortality did not significantly differ in nonsurgical (16%) versus surgical (10%) groups (P = 0.7). Although delay in diagnosis and number of therapeutic interventions were nearly identical, the time to definitive therapy was longer in the surgical versus the nonsurgical group (18 +/- 3.8 versus 8.5 +/- 3.8 days, P = 0.023). The time to discharge after definitive therapy (20.0 +/- 3.5 versus 35.6 +/- 14.0 days, P < 0.001), and overall hospital stay (40.6 +/- 5.3 versus 47.4 +/- 15 days, P = 0.01) was significantly decreased in the surgical versus nonsurgical treatment groups, respectively. CONCLUSION: The treatment of ET is complex. Failure to adequately evacuate the pleural space and/or persistent signs of infection should prompt surgical intervention. Surgical therapy is preferred for advanced stages of ET. Delaying definitive surgical treatment is largely responsible for prolonging hospital course.

Fluxo coronário desregulado durante reperfusäo pós cardioplegia / Coronary flow response is impaired during post-cardioplegia

Estudaram-se a demanda metabólica e a distribuiçäo do fluxo coronariano na presneça de fibrilaçäo ventricular (FV), durante a reperfusäo pós-cardioplegia. Foram colocados 15 suínos em circulaçäo extracorpórea e submetidos a parada cardíaca cardioplégica sangüínea anterógrada hipotérmica intermitente, durante uma hora, seguida por reperfusäo miocárdica controlada. Os animais foram divididos em três grupos (n=5), conforme estivessem em assistolia (Grupo 1) ou em FV de curta (grupo 2) ou longa duraçäo (Grupo 3), durante os dez primeiros minutos de reperfusäo. Os valores do consumo miocárdico de oxigênio (MVO2), em ml O2/min/g (média + erro padräo) durante a reperfusäo foram de 1,325 + 0,144 (grupo 1); 2,472 + 0,208 (Grupo 2) e 2,469 + 0,228 (Grupo 3). A diferença entre o MVO2 dos coraçöes em assistolia e o dos coraçöes em FV, quer de curta ou longa duraçäo, foi significante (p<0,001). A relaçäo entre os fluxos sangüíneos endo e epicárdico, bem como o fluxo sangüíneo coronário global (ml/mim/100g) foram semelhantes nos 3 grupos. Os valores dessa última variável, em ml/mim/100g, corresponderam a, respectivamente, 169,3 + 11,7; 185,0 + 15,7 e 179,9 + 13,2. Os resultados demonstram que a auto-regulaçäo coronária está alterada durante a fase inicial de reperfusäo pós criocardioplegia, pois a perfusäo miocárdica näo aumentou em resposta à elevaçäo do consumo de oxigênio imposta pela FV. Essa constataçäo, de grande interesse clínico, sugere que a ocorrência de FV durante a fase inicial da reperfusäo possa contribuir para o desenvolvimento de lesöes teciduais em coraçöes cujo fluxo coronário já esteja previamente comprometido, por obstruçäo coronária, distensäo ou hipertrofia ventricular.

Emprego de uma nova emulsäo de perfluorocarbonos (Oxygent MR) em circulaçäo extracorpórea: estudo experimental em cäes / Use of a new fluorocarbon emulsion (Oxygent MR) in extracorporeal circulation: experimental study in dogs

Testou-se uma nova emulsao de perfluorocarbonos (OxygentMR, Alliance Pharmaceutical, San Diego, CA 92121, EUA) em circulaçao extracorpórea (CEC) com hipotermia de 32 graus Celsius e hematócrito de 12 por cento. Estudaram-se 42 caes, 12 dos quais nao receberam a droga e serviram de controle (Grupo 1), enquanto os demais constituíram 3 grupos de lO animais cada, tratados com doses de Oxygent de 1,5 ml/kg (Grupo 2), 3 ml/kg (Grupo 3) e 6 ml/kg (Grupo 4) as quais geraram fluorocritos de, respectivamente, 1 por cento, 2 por cento e 3 por cento. Foram analisadas variáveis do metabolismo do oxigênio (O2) em 6 diferentes fluxos de perfusao (Q), ordenados ao acaso. Reaqueceram-se os caes, interrompeu-se a CEC e acompanharam-se os animais por l hora. Diferenças intergrupos foram analisadas pelo teste das médias dos quadrados mínimos e pelo teste de Duncan, considerando-se significantes os valores de p