Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 64
Filtrar
1.
Syst Rev ; 11(1): 42, 2022 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-35264212

RESUMO

BACKGROUND: People with severe mental illnesses (SMI) such as schizophrenia die on average 15 to 20 years earlier than everyone else. Two thirds of these deaths are from preventable physical illnesses such as hypertension, cardiovascular disease, and diabetes, which are worsened by weight gain. Antipsychotics are associated with significant weight gain. In REalist Synthesis Of non-pharmacologicaL interVEntions (RESOLVE), a realist synthesis, combining primary and secondary data, will be used to understand and explain how, why, for whom, and in what contexts non-pharmacological interventions can help service users to manage antipsychotic-induced weight gain. METHODS: A five-step approach will be used to develop guidance: 1. Developing the initial programme theory An initial (candidate) programme theory, which sets out how and why outcomes occur within an intervention, will be developed. 2. Developing the search The initial programme theory will be refined using academic and grey literature. The proposed initial sampling frame are as follows: Context: people living with SMI, taking antipsychotics, different types of SMI. INTERVENTION: non-pharmacological interventions. MECHANISMS: triggered by the intervention. Outcomes e.g. weight, metabolic adverse events, quality of life, adherence, burden, economic. Searching for relevant documents will continue until sufficient data is found to conclude that the refined programme theory is coherent and plausible. Lived experience (service users) and stakeholder (practitioners) groups will provide feedback. 3. Selection, appraisal and data extraction Documents will be screened against inclusion and exclusion criteria. The text extracted from these documents will be coded as contexts, mechanisms and their relationships to outcomes. 4. Primary data collection Realist interviews with up to 30 service users and informal carers, and 20 practitioners will gather data to support, refute or refine the programme theory. 5. Data analysis A realist logic of analysis will be used to develop and refine the programme theory from secondary and primary data. The analysis will aim to identify practical intervention strategies to change contexts so that key mechanisms are triggered to produce desired outcomes. Guidance will be produced based on these strategies. DISCUSSION: This realist synthesis aims to develop guidance for service users and practitioners on the most appropriate interventional strategies to manage and limit antipsychotic weight gain. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42021268697.


Assuntos
Antipsicóticos , Transtornos Mentais , Antipsicóticos/efeitos adversos , Atenção à Saúde , Humanos , Transtornos Mentais/terapia , Guias de Prática Clínica como Assunto , Qualidade de Vida , Revisões Sistemáticas como Assunto , Ganho de Peso/efeitos dos fármacos
2.
HPB (Oxford) ; 2022 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-35093297

RESUMO

BACKGROUND: The Genetic And Morphologic Evaluation (GAME) score and modified clinical score (m-CS) are two novel prognostic models that incorporate KRAS mutation status to predict survival after resection of colorectal liver metastases (CRLM). This retrospective cohort study evaluated the performance of these two models. METHODS: A total of 103 patients who underwent resection of CRLM between 2007 and 2017 and had known KRAS mutation status were included, 39 (37.9%) of whom had KRAS mutated tumours. Complete case analysis of the patients was performed according to the Clinical Risk Score (CRS), m-CS, and GAME score. The primary outcome was overall survival stratified according to low-risk and high-risk scores. Harrell's C-index and Akaike information criterion (AIC) were used to compare the discrimination of the evaluated prognostic models. RESULTS: The GAME score demonstrated the largest difference in overall survival for patients stratified according to low-risk and high-risk groups. Harrell's C-index values for the CRS, m-CS, and GAME models were 0.583, 0.600, and 0.668, respectively. AIC values for the CRS, m-CS, and GAME models were 441, 439, and 427, respectively. CONCLUSION: The GAME score outperforms the CRS and m-CS in predicting overall survival after resection of CRLM in patients with known KRAS mutation status.

3.
Neuropsychologia ; 164: 108093, 2022 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-34822860

RESUMO

The human brain constantly monitors the environment for unexpected changes. Under the prediction violation account, the Inferior Frontal Cortex (IFC) is involved in prediction-related processes for deviance detection processes in the Superior Temporal Cortex (STC). Consistent with this account, previous studies revealed an IFC-to-STC-followed-by-IFC mismatch response pattern to physical changes using event-related optical signals (EROS). However, detecting physical changes can be achieved by direct comparison of physical features between stimuli without making predictions, thus direct evidence supporting the prediction nature of the IFC-STC network in pre-attentive change detection was lacking. To address this issue, this study examined the EROS mismatch responses of the IFC-STC network when detecting the violation of an abstract rule. The rule "the higher the frequency of a tone, the stronger the intensity" established by standards was violated by deviants of 12 deviance levels. When deviants were preceded by a short train of standards, early IFC, STC, and late IFC EROS mismatch responses linearly increased with the deviance levels. When deviants were preceded by a longer train of standards, the STC but not the early or late IFC EROS mismatch responses were elicited by all the deviants without modulation by deviance levels. These results demonstrate a functional role of the IFC in the abstract change detection when insufficient rule-conforming information could be extracted from the preceding standards and are consistent with the predictive violation account of pre-attentive change detection.


Assuntos
Atenção , Lobo Frontal , Estimulação Acústica , Atenção/fisiologia , Encéfalo , Mapeamento Encefálico , Eletroencefalografia , Potenciais Evocados Auditivos , Lobo Frontal/diagnóstico por imagem , Lobo Frontal/fisiologia , Humanos , Lobo Temporal/diagnóstico por imagem , Lobo Temporal/fisiologia
4.
Health Soc Care Community ; 30(2): e325-e346, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34337817

RESUMO

Volunteering for an organisation, charity or group enables people to make connections with others and to be involved in interesting, worthwhile and/or enjoyable pursuits. Engaging in volunteering can form part of a social prescribing action plan developed between a patient and link worker. Greater understanding of the processes through which volunteering can improve people's well-being as part of social prescribing will help to support link workers in their role. We conducted a best-fit framework synthesis of qualitative literature on volunteering and well-being. Our search of eight electronic databases, complemented by a Google search, conducted in June 2020, resulted in the location of 2210 potentially relevant references. After screening, 335 papers were read in full and 54 drawn upon within the review. They were published between 1993 and 2020. We used the New Economics Foundation's Five Ways to Well-Being model to guide data extraction and synthesis. From this, we developed a conceptual framework that highlights how volunteering can contribute to identity validation and modification leading to the establishment of an acceptable sense of self. Our findings have implications for: (a) the use of volunteering as part of a link worker's toolkit as they seek to support people with varying psychosocial needs and (b) requirements of organisations accepting referrals to volunteering as part of social prescribing.


Assuntos
Voluntários , Humanos , Pesquisa Qualitativa , Voluntários/psicologia
5.
Circ Arrhythm Electrophysiol ; 15(1): e009925, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34937397

RESUMO

BACKGROUND: Population studies have demonstrated a range of sex differences including a higher prevalence of atrial fibrillation (AF) in men and a higher risk of AF recurrence in women. However, the underlying reasons for this higher recurrence are unknown. This study evaluated whether sex-based electrophysiological substrate differences exist to account for worse AF ablation outcomes in women. METHODS: High-density electroanatomic mapping of the left atrium was performed in 116 consecutive patients with AF. Regional analysis was performed across 6 left atrium segments. High-density maps were created using a multipolar catheter (Biosense Webster) during distal coronary sinus pacing at 600 and 300 ms. Mean voltage and conduction velocity was determined. Complex fractionated signals and double potentials were manually annotated. RESULTS: Overall, 42 (36%) were female, mean age was 61±8 years and AF was persistent in 52%. Global mean voltage was significantly lower in females compared with males at 600 ms (1.46±0.17 versus 1.84±0.15 mV, P<0.001) and 300 ms (1.27±0.18 versus 1.57±0.18 mV, P=0.013) pacing. These differences were seen uniformly across the left atrium. Females demonstrated significant conduction velocity slowing (34.9±6.1 versus 44.1±6.9 cm/s, P=0.002) and greater proportion of complex fractionated signals (9.9±1.7% versus 6.0±1.7%, P=0.014). After a median follow-up of 22 months (Q1-Q3: 15-29), females had significantly lower single-procedure (22 [54%] versus 54 [75%], P=0.029) and multiprocedure (24 [59%] versus 60 [83%], P=0.005) arrhythmia-free survival. Female sex and persistent AF were independent predictors of single and multiprocedure arrhythmia recurrence. CONCLUSIONS: Female patients demonstrated more advanced atrial remodeling on high-density electroanatomic mapping and greater post-AF ablation arrhythmia recurrence compared with males. These changes may contribute to sex-based differences in the clinical course of females with AF and in part explain the higher risk of recurrence. Graphic Abstract: A graphic abstract is available for this article.


Assuntos
Fibrilação Atrial/fisiopatologia , Remodelamento Atrial , Frequência Cardíaca , Potenciais de Ação , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Ablação por Cateter , Técnicas Eletrofisiológicas Cardíacas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento
6.
Artigo em Inglês | MEDLINE | ID: mdl-34651327

RESUMO

OBJECTIVE: To understand why, how and under what circumstances interventions lead to improved access of young adults with experience of homelessness (YAEH) to primary care dental services in the UK. METHODS: We followed a realist, theory-driven methodology. It involved locating existing theories, searching for evidence, document selection, data extraction/appraisal and evidence synthesis. We searched scientific databases and grey literature sources. We used these data and relevant substantive theories to develop explanations of how, why and under what circumstances interventions lead to desired outcomes. We presented these explanations in the form of context-mechanism-outcome configurations (CMOCs). The CMOCs were incorporated in an overarching programme theory, which was iteratively developed and refined throughout the realist synthesis. RESULTS: We used 106 scientific and 18 grey literature records to synthesize 61 CMOCs. Our revised programme theory highlights the importance of four main considerations: 'preparing a service', 'producing and disseminating information', 'outreach activities' and 'facilitating interactions'. When designing dental programmes for YAEH, we recommend considering the importance of prior service planning (including resourcing of emergency dental care, training staff and incorporating safety measures), creating positive experiences, flexibility, patient-centeredness, being informative and reassuring, creating an enabling environment (including strong communication, building rapport and avoiding negative judgements), having realistic expectations and designing services that empower patients. CONCLUSIONS: Improving dental access of YAEH requires attention to multiple levels. Services can achieve positive outcomes by understanding the complexity of YAEH lives, and creating contextual circumstances that encourage their attendance.

8.
Wound Manag Prev ; 67(4): 16-22, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-34283799

RESUMO

BACKGROUND: Chronic wounds require frequent assessment, minor procedures, and dressing changes. Discomfort, anxiety, and stress are commonly reported during treatment procedures. PURPOSE: To examine the effect of music during treatment on post-wound care treatment anxiety levels and blood pressure measurements in patients with chronic wounds. METHODS: This randomized controlled trial was conducted in a wound care center within a nonprofit academic medical center with a before-and-after intervention measurement. A total of 222 consecutive patients were randomly allocated to either an intervention group (n = 112; classical music was played during treatment) or a control group (n = 110; no music was played during treatment) at their scheduled routine outpatient visits. The State-Trait Anxiety Inventory (STAI) was administered and blood pressure measurements were obtained automatically by machine before and after the intervention. Pretreatment and posttreatment scores were compared using the paired t-test in SPSS 25. RESULTS: Patient age and sex did not differ between the intervention and control groups and pretreatment and posttreatment STAI scores; blood pressure measurements were almost identitical in the control group. In the intervention group, statistically significant differences between the pretreatment and posttreatment STAI scores (M = 45.94 and 40.83), systolic blood pressure measurements (M = 141.94 and 135.72), and diastolic blood pressure measurements (M = 70.93 and 66.23) were observed (P < .001). CONCLUSION: In this study, playing classical music in the treatment room during wound care interventions resulted in a significant decrease in patient anxiety scores and blood pressure measurements.


Assuntos
Musicoterapia , Música , Ansiedade/terapia , Transtornos de Ansiedade , Pressão Sanguínea , Humanos
9.
Herzschrittmacherther Elektrophysiol ; 32(2): 214-220, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33970332

RESUMO

The number of patients of reproductive age with inherited and congenital heart disease receiving implantable cardiac defibrillators (ICD) is steadily increasing. Safely and effectively coordinating pregnancy in this high-risk cohort is important to optimise maternal-foetal outcomes. As members of the multidisciplinary team caring for pregnant patients with indications for ICD, cardiologists and electrophysiologists should be aware of the considerations and nuances involved in managing these patients. This article reviews the pathophysiology of arrhythmias, ICD implantation considerations, novel minimal fluoroscopy techniques and subcutaneous ICD. In addition, antenatal and device management during pregnancy and delivery are discussed.


Assuntos
Desfibriladores Implantáveis , Cardiopatias Congênitas , Arritmias Cardíacas , Morte Súbita Cardíaca/prevenção & controle , Feminino , Humanos , Gravidez
10.
Int J Cardiol ; 331: 100-105, 2021 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-33548379

RESUMO

BACKGROUND: Binge drinking is a common atrial fibrillation (AF) trigger, however the mechanisms are poorly understood. OBJECTIVE: To investigate the effects of alcohol intoxication and hangover with rhythm monitoring and cardiac MRI. METHODS: Patients underwent serial cardiac MRI pre- and post-binge with continuous Holter monitoring. Time periods analyzed: baseline (24 h pre-binge), consumption, hangover (0- 24 h post-consumption) and post-hangover (24-48 h post-consumption). RESULTS: 50 patients (age 49 ± 15 years, 40% paroxysmal AF) completed the study (intake 8.4 ± 3.1 standard drinks). Mean heart rate increased from 72 ± 10 to 80 ± 13 beats per minute (bpm) during consumption (p < 0.001). The hangover period was characterised by higher daily atrial ectopic count (50, IQR 10-132 vs baseline 43, IQR 10-113; p = 0.04) and reduced heart rate variability (SDNN 55 ms, IQR 40-65 versus 62 ms, IQR 51-66; p = 0.007). There was evidence of heightened parasympathetic activity post-hangover with heart rate slowing (mean HR 54 ± 6 bpm; p = 0.03) and increased activity in the High frequency band when separating the complex heart rate variability waveform into its component rhythms (291 ms2, 97-538 versus baseline 237 ms2, IQR 104-332; p = 0.04). Three patients developed AF 11, 29 and 34 h post-binge. Cardiac MRI (2.7 ± 0.7 days post-binge) demonstrated a decrease in left atrial (LA) emptying fraction (57.9 ± 8.5 to 53.5 ± 6.7%; p = 0.003) but no change in LA volume, left ventricular ejection fraction or markers of ventricular inflammation. CONCLUSION: Binge drinking is associated with sympathetic activation followed by a 'rebound' parasympathetic response and atrial mechanical dysfunction which may explain the propensity and temporal association between binge drinking and AF.


Assuntos
Fibrilação Atrial , Consumo Excessivo de Bebidas Alcoólicas , Adulto , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/epidemiologia , Consumo Excessivo de Bebidas Alcoólicas/diagnóstico por imagem , Consumo Excessivo de Bebidas Alcoólicas/epidemiologia , Frequência Cardíaca , Férias e Feriados , Humanos , Pessoa de Meia-Idade , Volume Sistólico , Função Ventricular Esquerda
11.
Europace ; 23(5): 691-700, 2021 05 21.
Artigo em Inglês | MEDLINE | ID: mdl-33447844

RESUMO

AIMS: Obstructive sleep apnoea (OSA) associates with atrial fibrillation (AF), but the relationship of OSA severity and AF phenotype with the atrial substrate remains poorly defined. We sought to define the atrial substrate across the spectrum of OSA severity utilizing high-density mapping. METHODS AND RESULTS: Sixty-six consecutive patients (male 71%, age 61 ± 9) having AF ablation (paroxysmal AF 36, persistent AF 30) were recruited. All patents underwent formal overnight polysomnography and high-density left atrial (LA) mapping (mean 2351 ± 1244 points) in paced rhythm. Apnoea-hypopnoea index (AHI) (mean 21 ± 18) associated with lower voltage (-0.34, P = 0.005), increased complex points (r = 0.43, P < 0.001), more low-voltage areas (r = 0.42, P < 0.001), and greater voltage heterogeneity (r = 0.39, P = 0.001), and persisted after multivariable adjustment. Atrial conduction heterogeneity (r = 0.24, P = 0.025) but not conduction velocity (r = -0.09, P = 0.50) associated with AHI. Patchy regions of low voltage that co-localized with slowed conduction defined the atrial substrate in paroxysmal AF, while a diffuse atrial substrate predominated in persistent AF. The association of AHI with remodelling was most apparent among paroxysmal AF [LA voltage: paroxysmal AF -0.015 (-0.025, -0.005), P = 0.004 vs. persistent AF -0.006 (-0.017, 0.005), P = 0.30]. Furthermore, in paroxysmal AF an AHI ≥ 30 defined a threshold at which atrial remodelling became most evident (nil-mild vs. moderate vs. severe: 1.92 ± 0.42 mV vs. 1.84 ± 0.28 mV vs. 1.34 ± 0.41 mV, P = 0.006). In contrast, significant remodelling was observed across all OSA categories in persistent AF (1.67 ± 0.55 mV vs. 1.50 ± 0.66 mV vs. 1.55 ± 0.67 mV, P = 0.82). CONCLUSION: High-density mapping observed that OSA associates with marked atrial remodelling, predominantly among paroxysmal AF cohorts with severe OSA. This may facilitate the identification of AF patients that stand to derive the greatest benefit from OSA management.


Assuntos
Fibrilação Atrial , Remodelamento Atrial , Ablação por Cateter , Apneia Obstrutiva do Sono , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Apneia Obstrutiva do Sono/diagnóstico
12.
JACC Clin Electrophysiol ; 6(13): 1721-1731, 2020 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-33334453

RESUMO

OBJECTIVES: This study sought to determine the long-term outcomes of restoring sinus rhythm with catheter ablation (CA). BACKGROUND: The CAMERA-MRI (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Heart Failure-An MRI-Guided Multicenter Randomized Controlled Trial) study demonstrated that restoration of sinus rhythm with CA significantly improved left ventricular ejection fraction (LVEF) compared with medical rate control (MRC) at 6 months in persistent atrial fibrillation and otherwise unexplained systolic heart failure. However, the long-term outcomes have not been reported. METHODS: Patients enrolled in the CAMERA-MRI study were followed for 4 years with echocardiogram and cardiac magnetic resonance. CA involved pulmonary vein isolation and posterior left atrial wall isolation in 94%. Patients crossed over to CA after 6-month study duration. Arrhythmia burden was determined with implanted cardiac monitors or cardiac devices. RESULTS: Sixty-six patients (age 62 ± 10 years, atrial fibrillation duration of 22 ± 16 months, and LVEF 33 ± 9%) were randomized 1:1 to CA versus MRC. Eighteen of 33 patients crossed over from MRC group to CA group. At 4.0 ± 0.9 years, atrial fibrillation recurred in 27 patients (57%) in the CA group with a mean burden of 10.6 ± 21.2% after 1.4 ± 0.6 procedures. There was an absolute increase in LVEF with CA of 16.4 ± 13.3% compared with 8.6 ± 7.6% in MRC (p = 0.001). In the CA group, the absence of ventricular late gadolinium enhancement was associated with a greater improvement in absolute LVEF (19 ± 13% vs. 10 ± 11% in the late gadolinium enhancement-positive group; p = 0.04) and LVEF normalization in 19 patients (58%) versus 4 patients (18%) in the late gadolinium enhancement-positive group (p = 0.008) at 4.0 ± 0.9 years follow-up. CONCLUSIONS: CA is superior to MRC in improving LVEF in the long term in patients with atrial fibrillation and systolic heart failure. The greatest recovery in systolic function was demonstrated in the absence of ventricular fibrosis on cardiac magnetic resonance.


Assuntos
Fibrilação Atrial , Ablação por Cateter , Disfunção Ventricular Esquerda , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/cirurgia , Meios de Contraste , Gadolínio , Átrios do Coração , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Volume Sistólico , Disfunção Ventricular Esquerda/diagnóstico por imagem , Função Ventricular Esquerda
13.
JACC Clin Electrophysiol ; 6(12): 1509-1521, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33213811

RESUMO

OBJECTIVES: This study sought to assess the atrial electrophysiological properties and post-ablation outcomes in patients with atrial fibrillation (AF) with and without the rs2200733 single nucleotide variant. BACKGROUND: The phenotype associated with chromosome 4q25 of the AF-susceptibility locus remains unknown. METHODS: In this study, 102 consecutive patients (ages 61 ± 9 years, 64% male) with paroxysmal or persistent AF were prospectively recruited prior to ablation. Patients were genotyped for rs2200733 and high-density left atrial (LA) electroanatomic maps were created using a multipolar catheter during distal coronary sinus (CS) pacing at 600 ms. Voltage, conduction velocity (CV), CV heterogeneity, and fractionated signals of 6 LA segments were determined. Arrhythmia recurrence was assessed by continuous device (51%) and Holter monitoring. RESULTS: Overall, 41 patients (40%) were single nucleotide variant carriers (38 heterozygous, 3 homozygous). A mean of 2,239 ± 852 points per patient were collected. Carriers had relatively increased CV heterogeneity (45.7 ± 7.5% vs. 35.9 ± 2.3%; p < 0.001), complex signals (9.4 ± 2.9% vs 6.0 ± 1.2%; p = 0.008), regional LA slowing, or conduction block (31.7 ± 8.2% vs. 17.9 ± 1.9%; p = 0.013) particularly in the posterior and lateral walls. There were no differences in CV, voltage, atrial refractoriness, or sinus node function. At follow-up (median: 27 months; range 19 to 31 months), carriers had lower arrhythmia-free survival (51% vs. 80%; p = 0.003). On multivariable analysis, carrier status was independently associated with CV heterogeneity (p = 0.001), complex signals (p = 0.002), and arrhythmia recurrence (p = 0.019). CONCLUSIONS: These data provide the first evidence that the rs2200733-tagged haplotype alters LA electrical remodeling and is a determinant of long-term outcome following AF ablation. The molecular mechanisms underpinning these changes warrant further investigation.


Assuntos
Fibrilação Atrial , Remodelamento Atrial , Ablação por Cateter , Fibrilação Atrial/genética , Fibrilação Atrial/cirurgia , Feminino , Predisposição Genética para Doença , Átrios do Coração , Humanos , Masculino , Pessoa de Meia-Idade
14.
Healthc Q ; 23(2): 50-57, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32762821

RESUMO

To provide effective, comprehensive care to increasingly complex patients in Canadian communities, healthcare providers are shifting from solo providers of primary care to interprofessional, team-based primary healthcare services. Team-based care is considered one of the most effective means of caring for complex patients, including frail elders and individuals with chronic illness, mental health issues and addictions. Team-based care relies on effective team processes, the social or relational processes that enhance team collaboration and decision making. This realist review will highlight the team processes associated with high-performing teams and provide team development and sustainment strategies for providers and healthcare decision makers.


Assuntos
Relações Interprofissionais , Equipe de Assistência ao Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Canadá , Comportamento Cooperativo , Tomada de Decisões , Processos Grupais , Humanos
15.
Circ Arrhythm Electrophysiol ; 13(8): e008512, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32634027

RESUMO

BACKGROUND: Endocardial-epicardial dissociation and focal breakthroughs in humans with atrial fibrillation (AF) have been recently demonstrated using activation mapping of short 10-second AF segments. In the current study, we used simultaneous endo-epi phase mapping to characterize endo-epi activation patterns on long segments of human persistent AF. METHODS: Simultaneous intraoperative mapping of endo- and epicardial lateral right atrium wall was performed in patients with persistent AF using 2 high-density grid catheters (16 electrodes, 3 mm spacing). Filtered unipolar and bipolar electrograms of continuous 2-minute AF recordings and electrodes locations were exported for phase analyses. We defined endocardial-epicardial dissociation as phase difference of ≥20 ms between paired endo-epi electrodes. Wavefronts were classified as rotations, single wavefronts, focal waves, or disorganized activity as per standard criteria. Endo-Epi wavefront patterns were simultaneously compared on dynamic phase maps. Complex fractionated electrograms were defined as bipolar electrograms with ≥5 directional changes occupying at least 70% of sample duration. RESULTS: Fourteen patients with persistent AF undergoing cardiac surgery were included. Endocardial-epicardial dissociation was seen in 50.3% of phase maps with significant temporal heterogeneity. Disorganized activity (Endo: 41.3% versus Epi: 46.8%, P=0.0194) and single wavefronts (Endo: 31.3% versus Epi: 28.1%, P=0.129) were the dominant patterns. Transient rotations (Endo: 22% versus Epi: 19.2%, P=0.169; mean duration: 590±140 ms) and nonsustained focal waves (Endo: 1.2% versus Epi: 1.6%, P=0.669) were also observed. Apparent transmural migration of rotational activations (n=6) from the epi- to the endocardium was seen in 2 patients. Electrogram fractionation was significantly higher in the epicardium than endocardium (61.2% versus 51.6%, P<0.0001). CONCLUSIONS: Simultaneous endo-epi phase mapping of prolonged human persistent AF recordings shows significant Endocardial-epicardial dissociation marked temporal heterogeneity, discordant and transitioning wavefronts patterns and complex fractionations. No sustained focal activity was observed. Such complex 3-dimensional interactions provide insight into why endocardial mapping alone may not fully characterize the AF mechanism and why endocardial ablation may not be sufficient. Graphic Abstract: A graphic abstract is available for this article.


Assuntos
Potenciais de Ação , Fibrilação Atrial/diagnóstico , Cateterismo Cardíaco , Endocárdio/fisiopatologia , Mapeamento Epicárdico , Frequência Cardíaca , Pericárdio/fisiopatologia , Idoso , Fibrilação Atrial/fisiopatologia , Cateterismo Cardíaco/instrumentação , Cateteres Cardíacos , Mapeamento Epicárdico/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores de Tempo
16.
Heart Rhythm ; 17(12): 2154-2163, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32622994

RESUMO

BACKGROUND: The 3-dimensional (3D) nature of sinoatrial node (SAN) function has not been characterized in the intact human heart. OBJECTIVE: The purpose of this study was to characterize the 3D nature of SAN function in patients with structural heart disease (SHD) using simultaneous endocardial-epicardial (endo-epi) phase mapping. METHODS: Simultaneous intraoperative endo-epi SAN mapping was performed during sinus rhythm at baseline (SRbaseline) and postoverdrive suppression at 600 ms (SRpost-pace600) and 400 ms (SRpost-pace400) using 2 Abbott Advisor HD Grid Mapping Catheters. Unipolar and bipolar electrograms (EGMs) were exported for phase analysis to determine (1) activation exits; (2) wavefront propagation sequence; (3) endo-epi dissociation; and (4) fractionation. Comparison of these variables was made among the 3 rhythms from an endo-epi perspective. RESULTS: Sixteen patients with SHD were included. SRbaseline activations were unicentric and predominantly exited cranially (87.5%) with endo-epi synchrony. However, with overdrive suppression, a tendency for caudal exit shift and endo-epi asynchrony was observed: SRpost-pace600 vs SRbaseline: cranial endo 75% vs 87.5% (P = .046); cranial epi 68.8% vs 87.5% (P = 0.002); caudal endo 12.5% vs 6.2% (P = 0.215); caudal epi 25% vs 6.2% (P = .0003); and SRpost-pace400 vs SRbaseline: cranial endo 81.3% vs 87.5% (P = 0.335); cranial epi 68.7% vs 87.5% (P = 0.0034; caudal endo 12.5% vs 6.2% (P = .148); caudal epi 31.2% vs 6.2% (P = 0.0017), consistent with multicentricity. EGM fractionation was more prevalent with overdrive suppression. CONCLUSION: During mapping of the intact human heart, SAN demonstrated redundancy of sinoatrial exits with postoverdrive shift in sites of earliest activation and epi-endo dissociation of sinoatrial exits.


Assuntos
Mapeamento Epicárdico/métodos , Cardiopatias/fisiopatologia , Frequência Cardíaca/fisiologia , Nó Sinoatrial/fisiopatologia , Feminino , Seguimentos , Cardiopatias/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade
17.
N Engl J Med ; 382(1): 20-28, 2020 01 02.
Artigo em Inglês | MEDLINE | ID: mdl-31893513

RESUMO

BACKGROUND: Excessive alcohol consumption is associated with incident atrial fibrillation and adverse atrial remodeling; however, the effect of abstinence from alcohol on secondary prevention of atrial fibrillation is unclear. METHODS: We conducted a multicenter, prospective, open-label, randomized, controlled trial at six hospitals in Australia. Adults who consumed 10 or more standard drinks (with 1 standard drink containing approximately 12 g of pure alcohol) per week and who had paroxysmal or persistent atrial fibrillation in sinus rhythm at baseline were randomly assigned in a 1:1 ratio to either abstain from alcohol or continue their usual alcohol consumption. The two primary end points were freedom from recurrence of atrial fibrillation (after a 2-week "blanking period") and total atrial fibrillation burden (proportion of time in atrial fibrillation) during 6 months of follow-up. RESULTS: Of 140 patients who underwent randomization (85% men; mean [±SD] age, 62±9 years), 70 were assigned to the abstinence group and 70 to the control group. Patients in the abstinence group reduced their alcohol intake from 16.8±7.7 to 2.1±3.7 standard drinks per week (a reduction of 87.5%), and patients in the control group reduced their alcohol intake from 16.4±6.9 to 13.2±6.5 drinks per week (a reduction of 19.5%). After a 2-week blanking period, atrial fibrillation recurred in 37 of 70 patients (53%) in the abstinence group and in 51 of 70 patients (73%) in the control group. The abstinence group had a longer period before recurrence of atrial fibrillation than the control group (hazard ratio, 0.55; 95% confidence interval, 0.36 to 0.84; P = 0.005). The atrial fibrillation burden over 6 months of follow-up was significantly lower in the abstinence group than in the control group (median percentage of time in atrial fibrillation, 0.5% [interquartile range, 0.0 to 3.0] vs. 1.2% [interquartile range, 0.0 to 10.3]; P = 0.01). CONCLUSIONS: Abstinence from alcohol reduced arrhythmia recurrences in regular drinkers with atrial fibrillation. (Funded by the Government of Victoria Operational Infrastructure Support Program and others; Australian New Zealand Clinical Trials Registry number, ACTRN12616000256471.).


Assuntos
Abstinência de Álcool , Consumo de Bebidas Alcoólicas/efeitos adversos , Fibrilação Atrial/prevenção & controle , Idoso , Fibrilação Atrial/etiologia , Austrália , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Prevenção Secundária
18.
Wellcome Open Res ; 5: 265, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33274301

RESUMO

In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes.  Our programme theory is an expression of our assumptions about what actions will be both useful and feasible.  It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.

19.
Heart Rhythm ; 17(5 Pt A): 692-698, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31866381

RESUMO

BACKGROUND: Female gender is associated with an increased recurrence of atrial fibrillation (AF) after catheter ablation (CA). Although AF is more common in men, women constitute a significant proportion with persistent atrial fibrillation (PsAF). OBJECTIVE: The purpose of this study was to determine whether multiple ablation procedures improves arrhythmia outcomes in females with PsAF compared to men. METHODS: We performed a multicenter observational study to determine long-term arrhythmia outcomes in patients undergoing >1 CA for PsAF. CA involved pulmonary vein (PV) isolation with additional ablation including linear, posterior wall isolation, electrogram-guided, or a combination of these. RESULTS: A total of 281 patients had >1 ablation procedure for PsAF and were included in this analysis (mean age 58.7 ± 9.3 years; 86 [30.6%] female; left atrial [LA] area 27.0 ± 5.3 cm2; PsAF duration 1.7 ± 1.7 years). At mean follow-up of 45.5 ± 31.8 months, freedom from recurrent AF was present in 148 patients(52.7%) after 2.2 ± 0.5 procedures. After multivariate analysis, female gender (hazard ratio [HR] 2.10; P <.001) and enduring PV isolation (HR 1.64; P = .01) were independently associated with AF recurrence. Enduring PV isolation was significantly higher in women than in men (33.7% vs 19.5%; P = .01). CONCLUSION: Female gender was independently and strongly associated with arrhythmia recurrence in patients undergoing multiple procedures for PsAF. PV reconnection was less likely, and fewer reconnected PVs occurred in women. Further studies are required to better understand the mechanisms responsible for AF in females to assist in closing the gender gap in the success of CA.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Veias Pulmonares/cirurgia , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Austrália/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Recidiva , Distribuição por Sexo , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento
20.
JACC Clin Electrophysiol ; 5(11): 1265-1277, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31753431

RESUMO

OBJECTIVES: This study sought to determine the impact of rate and direction on left atrial (LA) substrate. BACKGROUND: The extent to which substrate mapped in sinus rhythm varies according to cycle length and direction of wave front propagation is unknown. METHODS: A total of 73 consecutive patients with atrial fibrillation (AF) underwent electroanatomic LA mapping before pulmonary vein isolation using multipolar catheter during distal coronary sinus (CS) pacing at 600 ms and 300 ms. Additional maps were created during left superior pulmonary vein pacing at 300 ms. Bipolar voltage, conduction velocity (CV), and complex signals were determined. RESULTS: Mean age was 61 ± 9 years, 67% were men, and 53% had persistent AF. Global mean voltage was lower with CS pacing at 300 ms compared with 600 ms (1.56 ± 0.47 mV vs. 1.74 ± 0.48 mV; p < 0.001). This was seen in all LA segments. Global CV was reduced (30.4 ± 13.0 cm/s vs. 38.6 ± 14.0 cm/s; p < 0.001) with greater complex signals at 300 ms (8.9% vs. 5.3%; p < 0.005). Compared with CS pacing, left superior pulmonary vein pacing demonstrated highly regional changes with decreased voltage (1.04 ± 0.43 mV vs. 1.47 ± 0.53 mV; p = 0.01) and CV (24.4 ± 13.0 cm/s vs. 39.9 ± 16.6 cm/s; p = 0.008), and greater complex signals posteriorly. Longer AF duration in paroxysmal AF (p = 0.02) and shorter duration in persistent AF (p = 0.015) and left ventricular ejection fraction (p = 0.016) were independent predictors of voltage change. CONCLUSIONS: In patients with AF, variation in cycle length and direction of wave front activation produce both generalized and regional changes in voltage, CV, and complex fractionation, resulting in significant changes in substrate maps. This study highlights the potential limitations of static low-voltage maps to identify the AF ablation target zone.


Assuntos
Fibrilação Atrial/fisiopatologia , Técnicas Eletrofisiológicas Cardíacas/métodos , Átrios do Coração/fisiopatologia , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Estimulação Cardíaca Artificial , Ablação por Cateter , Seio Coronário , Feminino , Sistema de Condução Cardíaco/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Veias Pulmonares/cirurgia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...