Objectives
To determine the feasibility of pragmatic implementation strategies for three good questions (in Dutch: Drie Goede Vragen; 3GV. What are my options; what are the risks and benefits related ...to these options; and what does this mean for my situation?) to increase shared decision‐making (SDM) efforts in Dutch secondary care, and identify barriers and facilitators of implementation.
Methods
Convergent mixed‐method design: pre‐post surveys with patients attending one of six clinical departments in a Dutch Hospital, post‐intervention interviews with patients and health‐care professionals. Primary outcomes: feasibility (reach, use of 3GV). Secondary outcomes: SDM, experiences with 3GV and decision making. Interviews focused on barriers and facilitators of 3GV use. Interviews were content coded and categorized into determinants of behaviour change.
Results
35% of the respondents who had heard of 3GV (52%) used all three questions. 3GV use did not lead to more SDM (SDMQ9 M = Δ0.3;SE = 2.2) but patients felt empowered to decide (88%) and to SDM (86%). Barriers were as follows: time investment, other SDM projects and perception that the need to use 3GV differs per patient/consultation. Respondents preferred to use 3GV as they saw fit for the consultation, instead of literally asking them. Facilitators: easy, accessible information materials that can be flexibly used.
Conclusion
Implementation of 3GV seemed feasible, although influenced by contextual characteristics (eg type of decisions, patients, on‐going interventions). 3GV contributed to important elements of SDM, and respondents were willing to apply them in a way that suited their situation.
Practice implications
We recommend continuation of current and new implementation strategies to enable 3GV implementation in secondary care.
Substernal Pacing in Humans
Introduction
The objective of this study was to assess feasibility of ventricular pacing and thresholds from within the substernal space to examine a new extravascular ICD ...configuration with pacing capabilities.
Methods
In patients undergoing midline sternotomy, a duodecapolar diagnostic pacing catheter was positioned in the substernal space anterior to the pericardium, and a cutaneous patch in left lateral position. Different unipolar and bipolar pacing configurations were assessed. Strength‐duration curves were performed to identify the optimal output, starting at 25 mA with a pulse width of 10 milliseconds.
Results
Eight patients with mean age 69 ± 9 years were included. In 5, ventricular capture was achieved in ≥1 configuration. The mean bipolar pacing thresholds at PW 10, 5, 3, 1 milliseconds were 12.4 ± 3.7 mA (5 patients), 13.3 ± 5.8 mA (3 patients), 18.3 ± 5.7 mA (3 patients), and 25 ± 0 mA (2 patients), respectively. The 60‐mm electrode spacing was the most successful bipolar configuration. Unipolar pacing was successful in 3 out of 4 patients with mean thresholds of 10 ± 0 mA at 10 milliseconds (3 patients), 15 ± 0 mA at 5 milliseconds (3 patients), 16.7 ± 2.9 mA at 3 milliseconds (3 patients), and 20 ± 7.1 mA at 1 milliseconds (2 patients).
Conclusion
Ventricular pacing from the substernal space in patients with midline sternotomy is feasible. Closed sternum studies are needed to determine pacing thresholds more accurately.
Aims
Despite longstanding recognition of significant age‐dependent differences in drug disposition during childhood, the exact course and the underlying mechanisms are not known. Our aim was to ...determine the course and determinants of individual relative dose requirements, during long‐term follow‐up in children on tacrolimus.
Methods
This was a cohort study in a tertiary hospital with standardized annual pharmacokinetic (PK) follow‐up (AUC0–12hr) in recipients of a renal allograft (≤19 years), between 1998 and 2015. In addition, the presence of relevant pharmacogenetic variants was determined. The evolution of dose‐corrected exposure was evaluated using mixed models.
Results
A total of 184 PK visits by 43 children were included in the study (median age: 14.6). AUC0–12h corrected for dose per kg demonstrated a biphasic course: annual increase 4.4% (CI: 0.3–8.7%) until ±14 years of age, followed by 13.4% increase (CI 8.7–18.3%). Moreover, exposure corrected for dose per m2 proved stable until 14 years (+0.8% annually; CI: −3.0 to +4.8%), followed by a steep increase ≥14 years (+11%; CI: 7.0–16.0%). Analysis according to bone maturation instead of age demonstrated a similar course with a distinct divergence at TW2: 800 (P = 0.01). Genetic variation in CYP3A4, CYP3A5, and CYP3A7 was associated with altered dose requirements, independent of age.
Conclusions
Children exhibit a biphasic course in tacrolimus disposition characterized by a high and stable drug clearance until a specific phase in pubertal development (TW2: 800 at age: ±14 years), followed by an important decline in relative dose requirements thereafter. Pharmacogenetic variation demonstrated an age/puberty independent effect. We suggest a critical reappraisal of current paediatric dosing algorithms for tacrolimus and drugs with a similar disposition.
Based on regional-scale studies, aboveground production and litter decomposition are thought to positively covary, because they are driven by shared biotic and climatic factors. Until now we have ...been unable to test whether production and decomposition are generally coupled across climatically dissimilar regions, because we lacked replicated data collected within a single vegetation type across multiple regions, obfuscating the drivers and generality of the association between production and decomposition. Furthermore, our understanding of the relationships between production and decomposition rests heavily on separate meta-analyses of each response, because no studies have simultaneously measured production and the accumulation or decomposition of litter using consistent methods at globally relevant scales. Here, we use a multi-country grassland dataset collected using a standardized protocol to show that live plant biomass (an estimate of aboveground net primary production) and litter disappearance (represented by mass loss of aboveground litter) do not strongly covary. Live biomass and litter disappearance varied at different spatial scales. There was substantial variation in live biomass among continents, sites and plots whereas among continent differences accounted for most of the variation in litter disappearance rates. Although there were strong associations among aboveground biomass, litter disappearance and climatic factors in some regions (e.g. U.S. Great Plains), these relationships were inconsistent within and among the regions represented by this study. These results highlight the importance of replication among regions and continents when characterizing the correlations between ecosystem processes and interpreting their global-scale implications for carbon flux. We must exercise caution in parameterizing litter decomposition and aboveground production in future regional and global carbon models as their relationship is complex.
How sex affects the sinus rhythm heartbeat Veen, Danny; Schram-Serban, Corina; van Schie, Mathijs ...
International journal of cardiology. Heart & vasculature,
December 2023, 2023-Dec, 2023-12-00, 20231201, 2023-12-01, Letnik:
49
Journal Article
Recenzirano
Odprti dostop
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There is increasing awareness of sex-specific differences in epidemiology and pathophysiology of atrial fibrillation (AF). It is, however, unknown whether males and females differ in ...atrial electrophysiological properties during sinus rhythm (SR). The aim of this study was therefore to investigate sex-based (regional) differences in electrophysiological properties during SR of the right (RA) and left (LA) atrium including Bachmanns Bundle (BB) and pulmonary vein region (PVA).
Intra-operative, high resolution mapping during SR was performed in 53 matched females with males (without a history of AF), to measure lines of conduction block (CB), continuous conduction delay and block (cCDCB), conduction velocities (CV), total atrial activation times (TAT), unipolar potential voltages and percentage of low voltage areas (LVA).
Compared to males, females have significantly 1) lower unipolar potential voltages and slower CV at both RA and BB, 2) more LVAs, CB and cCDCB lines and longer CB and cCDCB lines at the RA only (all P < 0.05).
Electrophysiological properties of the atria during SR differ between males and females. These sex-based differences are particularly present at the RA and to a lesser degree at BB. In females, both the RA and BB contained more areas of conduction disorders and low voltage potentials. Future studies are required to investigate whether these areas play a role in sex-based differences in vulnerability to arrhythmias such as atrial fibrillation.
Background
C‐terminal Agrin Fragment (CAF) has been proposed as a novel biomarker for sarcopenia originating from the degeneration of the neuromuscular junctions. In patients with stroke muscle ...wasting is a common observation that predicts functional outcome. We aimed to evaluate agrin sub‐fragment CAF22 as a marker of decreased muscle mass and physical performance in the early phase after acute stroke.
Methods
Patients with acute ischaemic or haemorrhagic stroke (n = 123, mean age 70 ± 11 y, body mass index BMI 27.0 ± 4.9 kg/m2) admitted to inpatient rehabilitation were studied in comparison to 26 healthy controls of similar age and BMI. Functional assessments were performed at begin (23 ± 17 days post stroke) and at the end of the structured rehabilitation programme (49 ± 18 days post stroke) that included physical assessment, maximum hand grip strength, Rivermead motor assessment, and Barthel index. Body composition was assessed by bioelectrical impedance analysis (BIA). Serum levels of CAF22 were measured by ELISA.
Results
CAF22 levels were elevated in stroke patients at admission (134.3 ± 52.3 pM) and showed incomplete recovery until discharge (118.2 ± 42.7 pM) compared to healthy controls (95.7 ± 31.8 pM, p < 0.001). Simple regression analyses revealed an association between CAF22 levels and parameters of physical performance, hand grip strength, and phase angle, a BIA derived measure of the muscle cellular integrity. Improvement of the handgrip strength of the paretic arm during rehabilitation was independently related to the recovery of CAF22 serum levels only in those patients who showed increased lean mass during the rehabilitation.
Conclusions
CAF22 serum profiles showed a dynamic elevation and recovery in the subacute phase after acute stroke. Further studies are needed to explore the potential of CAF22 as a serum marker to monitor the muscle status in patients after stroke.
We present an extension of the Individual Brain Charting dataset -a high spatial-resolution, multi-task, functional Magnetic Resonance Imaging dataset, intended to support the investigation on the ...functional principles governing cognition in the human brain. The concomitant data acquisition from the same 12 participants, in the same environment, allows to obtain in the long run finer cognitive topographies, free from inter-subject and inter-site variability. This second release provides more data from psychological domains present in the first release, and also yields data featuring new ones. It includes tasks on e.g. mental time travel, reward, theory-of-mind, pain, numerosity, self-reference effect and speech recognition. In total, 13 tasks with 86 contrasts were added to the dataset and 63 new components were included in the cognitive description of the ensuing contrasts. As the dataset becomes larger, the collection of the corresponding topographies becomes more comprehensive, leading to better brain-atlasing frameworks. This dataset is an open-access facility; raw data and derivatives are publicly available in neuroimaging repositories.
Abstract
Funding Acknowledgements
Prof. Dr. NMS de Groot is supported by funding grants from CVON-AFFIP (914728), NWO-Vidi (91717339), Biosense Webster USA (ICD 783454) and Medical Del
Introduction
...Treatment of atrial fibrillation (AF) is still suboptimal as mechanisms underlying AF initiation and persistence are incompletely understood. Endo-Epicardial asynchrony (EEA) plays an important role in AF persistence and has so far only been demonstrated in the right atrium (RA).
Purpose
To investigate whether EEA also exists in the thin walled left atrium (LA) and to measure the maximal degree of EEA between the endo- and epicardial layers during sinus rhythm (SR).
Methods
Simultaneous endo-epicardial mapping of the LA was performed during SR in 3 male patients (73 ± 1.5 years) with history of paroxysmal AF undergoing cardiac surgery including rhythm surgery and LA appendage amputation. Simultaneous endo-epicardial mapping was performed with a mapping clamp containing two electrode arrays of 8x16 electrodes (diameters: 0.4mm, interelectrode distance: 2mm) positioned exactly opposite to each other. The mapping clamp was introduced through the LA appendage with its tip towards the superior pulmonary vein. Local endo-epicardial activation time differences were determined by selecting the median time delay within the exact opposite electrode and its 8 surrounding electrodes. The asynchrony map consisted of the maximum of 2 medians from direct opposite electrodes. EEA was defined as time differences ≥15ms. Conduction delay (CD) and conduction block (CB) were defined as differences in local activation times between neighboring electrodes of respectively ≥7 and ≥12ms.
Results
A total of 35 SR beats were analyzed. Mean total activation time of the whole endo-epicardial LA tissue was 42.4 ± 9.5ms and did not differ between both layers (epicardium: 31.2 ± 9.9ms; endocardium: 37.8 ± 10.3ms; P= 0.62). CD and CB were observed in respectively 3.2% and 6.3% at the epicardium and 3.3% and 3.0% at the endocardium. The lowest amount of CD (5.2%) and CB (0.3%) was observed in the patient who had his first AF episode only 11 days prior to surgery. Also, no EEA was present in this patient. In two patients with paroxysmal AF >6 months, the prevalence of EEA was respectively 2.7% and 41.4% and the degree of EEA ranged from 15 to 44ms. Interestingly, the patient with the highest degree of EEA was diagnosed with paroxysmal AF for almost 5 years (Figure 1).
Conclusion
Our data provides evidence for the existence of EEA in the human left atrium which appears to be already present during SR. Knowledge of EEA and the ability to stage AF based on the degree of EEA is essential for individualized and staged future therapy for AF.
Abstract Figure 1. The maximal degree of endo-epi
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