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Effect of investigator disturbance in experimental forensic entomology: succession and community composition.

Carrion insect succession studies have historically used repeated sampling of single or a few carcasses to produce data, either weighing the carcasses, removing a qualitative subsample of the fauna present, or both, on every visit over the course of decomposition and succession. This study, conducted in a set of related experimental hypotheses with two trials in a single season, investigated the effect that repeated sampling has on insect succession, determined by the number of taxa collected on each visit and by community composition. Each trial lasted at least 21 days, with daily visits on the first 14 days. Rat carcasses used in this study were all placed in the field on the same day, but then either sampled qualitatively on every visit (similar to most succession studies) or ignored until a given day of succession, when they were sampled qualitatively (a subsample) and then destructively sampled in their entirety. Carcasses sampled on every visit were in two groups: those from which only a sample of the fauna was taken and those from which a sample of fauna was taken and the carcass was weighed for biomass determination. Of the carcasses visited only once, the number of taxa in subsamples was compared to the actual number of taxa present when the carcass was destructively sampled to determine if the subsamples adequately represented the total carcass fauna. Data from the qualitative subsamples of those carcasses visited only once were also compared to data collected from carcasses that were sampled on every visit to investigate the effect of the repeated sampling. A total of 39 taxa were collected from carcasses during the study and the component taxa are discussed individually in relation to their role in succession. Number of taxa differed on only one visit between the qualitative subsamples and the actual number of taxa present, primarily because the organisms missed by the qualitative sampling were cryptic (hidden deep within body cavities) or rare (only represented by very few specimens). There were no differences discovered between number of taxa in qualitative subsamples from carcasses sampled repeatedly (with or without biomass determinations) and those sampled only a single time. Community composition differed considerably in later stages of decomposition, with disparate communities due primarily to small numbers of rare taxa. These results indicate that the methods used historically for community composition determination in experimental forensic entomology are generally adequate.

Animals↗

High success rate and low incidence of headache and neurological symptoms with two spinal needle designs in children.

BACKGROUND: In children, only a few trials have evaluated the use of spinal needles with special tip designs. In this study, we compared the success rate and incidence of post-dural puncture complaints of two small-gauge spinal needle designs used in children undergoing spinal anaesthesia (SA). METHODS: Three hundred and three children aged 9 months to 17 years presenting for subumbilical surgery were randomly assigned to have a 26G Atraucan (n = 156) or 27G Whitacre (n = 147) spinal needle for SA. The number of attempts to obtain successful cerebrospinal fluid (CSF) return and the success rate of SA were recorded. The first week of recovery was recorded by a diary. RESULTS: Both groups had a similar one-attempt success rate: 80% in the Atraucan group and 81% in the Whitacre group. Failure to obtain CSF occurred in one patient in the Atraucan group and in two patients in the Whitacre group. Paraesthesia was observed more commonly in the Whitacre group (10%) than in the Atraucan group (2%) (P = 0.004). The success rate of SA was 96%, with no differences between the two needles; one child was given general anaesthesia and 11 children (3%) a single dose of supplemental analgesia for the skin incision. Forty-one children (15%) developed a headache, 13 of which were classified as post-dural puncture headache (PDPH), seven cases (5%) in the Atraucan group and six (4%) in the Whitacre group; none of the children required a blood patch. Fifteen children (10%) in the Atraucan group and nine (7%) in the Whitacre group developed low back pain. Two children (1%) in the Atraucan group and four (3%) in the Whitacre group developed transient neurological symptoms (TNSs). CONCLUSION: Both needles were associated with a high success rate and a low incidence of complaints.

Adolescent↗

Electrogram patterns predictive of successful radiofrequency catheter ablation of accessory pathways.

UNLABELLED: We assessed anterograde conduction electrogram parameters at successful ablation sites according to accessory pathway (AP) location and compared them to the most favorable electrograms at unsuccessful sites. A median of three radiofrequency energy impulses was applied to ablate 97% of 136 APs versus four impulses to ablate 90% of 65 concealed APs. Electrograms at successful sites showed variable A/V ratio (0.04-7), and a QS pattern of unipolar ventricular wave in 90%. Electrograms were different in right versus left AP: AV time 29 +/- 7 versus 38 +/- 10; and timing of ventricular deflection: 17 +/- 9 versus 2 +/- 9 msec, respectively. Analysis in each patient of the mapping parameters at successful versus "most favorable" unsuccessful sites showed an improvement in at least one parameter in 55%, no apparent change in all parameter values in 30%, and even less favorable parameters in 15% of patients. In patients with manifest AP, overall comparison of electrograms at successful versus unsuccessful sites showed no difference in A/V ratio (1.3 +/- 1.5 vs 1.2 +/- 1.6), unipolar pattern distribution, and AV time (34 +/- 10 vs 35 +/- 9), but earlier bipolar main ventricular potential (-4 +/- 12 vs -1.5 +/- 10 msec) and unipolar intrinsic deflection timings (-5.2 +/- 11 vs -1.8 +/- 10 msec). In patients with concealed AP, a retrograde continuous electrical activity was recorded in 72% of successful versus 38% of unsuccessful sites (P = 0.03). CONCLUSIONS: Electrogram characteristics at successful radiofrequency ablation are different in right and left manifest AP.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

Effect of shock timing on defibrillation success.

The goal of this study was to determine whether delivering transvenous defibrillation shocks, coordinated with the up/down-slope VF waveform patterns in the shocking lead, would improve the probability of successful defibrillation. Anesthetized swine (32-38 kg, n = 8) were implanted with an RV-->SVC + SQArray transvenous system to measure VF waveform patterns and to deliver shocks. The shocks were generated by a Cardiac Pacemakers Inc. biphasic waveform generator. Energy required for 50% success probability (E50) was determined using the multishock up-down protocol. VF was repeatedly induced and defibrillation shocks at E50 were given after 10 seconds. The defibrillation outcome, delivered energy (Ed), peak voltage (V), peak current (I), system impedance (Z) and VF waveform pattern at the time of shock were recorded and measured. Out of a total of 685 shocks, 324 (47%) succeeded and 361 (53%) failed. The Ed, V, I, and Z were similar for the two defibrillation outcome groups (success or failure). VF patterns were classified as high or low amplitude at the time of the shock based on the peak-to-peak amplitude of signals recorded between the shocking electrodes. Shocks that coincided with high amplitude VF patterns were further divided into shocks that occurred on the up-slope or on the down-slope. The probability of success when the E50 shocks were coincident with high or low amplitude fibrillation did not differ significantly (Student's t-test: 46% vs 48%. P = NS). However, during high amplitude fibrillation, shocks delivered on the up-slope were significantly more successful than those delivered on the down-slope (Chi-square: 67% vs 39%; P < 0.001). These results suggest that delivering defibrillation shocks during the up-slope of the high amplitude signal in the shocking lead may improve the probability of successful defibrillation of ICDs.

Animals↗

Predictors of permanence of successful radiofrequency lesions created with controlled catheter tip temperature.

Transient interruption of accessory pathway (AP) conduction is often encountered during creation of RF lesions, with return of conduction after seconds to weeks. Maximum catheter tip temperature (Tmax) has not been shown to be a good predictor of successful RF ablation. However, other indices related to catheter tip temperature (T) may predict permanent AP interruption. Ninety-one successful RF applications in 58 patients (mean age 11.9 +/- 5.5 years, 38 WPW syndrome, 18 concealed AP, 2 both) were reviewed retrospectively. Forty-two RF applications were transiently successful, with a median time of AP conduction recurrence of 120 seconds (sec; range, 1 sec to > 1 day). This group was compared with 49 permanently successful RF applications. T was measured and controlled using the Medtronic Atakr system (San Jose, CA, USA). RF lesion duration, power output, Tmax and time to Tmax (tmax) were not significantly different between the two groups. By univariate analysis, each of the following indices was able to discriminate between the transient and permanent lesions, and highly correlated with one another, T at the moment of AP interruption (Tsucc; transient 55.0 +/- 7.9 degrees C vs permanent 49.8 +/- 7.7 degrees C, P = 0.0025), time to success (tsucc; transient 4.0 +/- 3.0 sec vs permanent 1.8 +/- 1.3 sec, P = 0.0001), ratio of Tsucc/Tmax (transient 0.76 +/- 0.23 vs permanent 0.57 +/- 0.27, P = 0.0007) and ratio of tsucc/tmax (transient 0.91 +/- 0.69 vs permanent 0.41 +/- 0.41, P = 0.0001). By logistic regression analysis, no single variable or combination of variables was superior to tsucc for prediction of outcome, with a breakpoint of 2.3 seconds having a sensitivity of 74% and a specificity of 65%. During temperature controlled RF application, indices of time and temperature were well-correlated with permanent elimination of AP conduction. Time to interruption of AP conduction < 2.3 seconds after the onset of RF application was predictive of the permanence of successful RF applications. Known relations between RF lesion volume and catheter tip temperature suggest that early conduction block may be an indicator of anatomical proximity of the catheter tip and the AP. These data suggest that, in conjunction with electrogram criteria, selection criteria for optimal sites for RF, application may continue to be refined after the onset of RF application, and support the practice of terminating RF application if AP conduction is not rapidly interrupted.

Adolescent↗

Significance of two potentials for predicting successful catheter ablation from the left sinus of Valsalva for left ventricular epicardial tachycardia.

The aim of this study was to identify the characteristics of electrograms that may be helpful in predicting successful ablation of idiopathic ventricular tachycardia from the aortic sinus of Valsalva. Data were obtained from 23 patients with symptomatic ventricular tachycardia or premature ventricular contractions (LV-VT) who underwent RF catheter ablation from the left sinus of Valsalva. Electrograms before and after application of RF energy during sinus rhythm and during LV-VT were analyzed. Complete elimination of LV-VT was finally achieved in 21 (91%) patients. The incidence of presystolic potentials preceding the QRS complex of LV-VT (P1 potential) was 90% for the 21 successful ablation sites, which did not differ from the incidence for the 24 unsuccessful sites (79%; P = 0.5). During sinus rhythm, a potential following the QRS complex (P2 potential) was more often recorded at the successful ablation site than at an unsuccessful ablation site before and after application of RF energy (before, P < 0.05; after, P < 0.001). The appearance of the P2 potential or a delay in the preexisting P2 potential after application of RF energy was observed only at the successful ablation sites (P < 0.001). In 18 control individuals who had no LV-VT, no P2 potential was recorded within the left sinus of Valsalva. Although the P1 potential may be useful for identifying the successful ablation site, its sensitivity is low. The appearance of the P2 potential or an increasingly delayed P2 potential after application of RF energy may be more useful than the P1 potential for predicting successful ablation.

Catheter Ablation↗

High success rate with cryomapping and cryoablation of atrioventricular nodal reentrytachycardia.

INTRODUCTION: Cryoablation is a new alternative to radiofrequency (RF) ablation for treatment of atrioventricular nodal reentry tachycardias (AVNRT). Mapping with reversible effect on the arrhythmia substrate or the AV node can be done before irreversible ablation is performed. This study evaluates an approach with systematic cryomapping, ablating only in areas with prompt effect on the arrhythmia substrate and evaluates whether the success rates and procedure times are similar to RF ablation. METHODS AND RESULTS: Seventy-five consecutive patients with typical slow-fast AVNRT were studied. Cryomapping at -30 degrees C was performed before ablation with a goal temperature of -70 degrees C for 240 seconds. The ablation procedure was successful in 74 of the 75 patients, giving an acute success rate of 99%. During a mean follow-up of 338 days, 70 of the 74 primarily successfully ablated patients were free from the treated arrhythmia, giving a recurrence rate of 5% and a total success rate of 93%. Total procedure time including a 30-minute test after successful ablation was 126+/-55 minutes. Fluoroscopy time was 18.5+/-14.9 minutes. CONCLUSION: Cryoablation of AVNRT appears to be as effective as RF ablation both acute and in long term with minimal risks for unwanted injuries on the conduction system. The procedure can be done with reasonable procedure and fluoroscopy times.

Body Surface Potential Mapping↗

The immediate and short-term effect of successful percutaneous coronary intervention on repolarization in acute myocardial infarction patients.

OBJECTIVES: The primary objective was to assess the immediate and short-term impact of successful percutaneous coronary intervention (PCI) on QT dispersion (QT disp) and corrected QT dispersion (QTc disp). Secondarily, the impact of PCI on QT and QTc disp within different infarct-related arteries and the impact of successful PCI in these different arteries were evaluated. METHODS: Patients (n = 140, age 61.6 +/- 12.9, 69% male) undergoing direct primary PCI for acute MI were evaluated. Twelve-lead ECGs were obtained before (baseline), immediately after (0 h), 24hours after, and 3 days after PCI. The QT and QTc interval in each of the 12-leads were measured and the shortest interval was subtracted from the longest to derive the QT disp and QTc disp, respectively. RESULTS: Angiography showed blockages in the left anterior descending, right coronary artery, and circumflex in 37.1, 48.9, and 15.0% of patients, respectively. Overall, 97 patients achieved successful reflow. QT and QTc disp were significantly improved in the group with successful reflow at each follow-up time after PCI versus baseline and corresponding values in the unsuccessful reflow group. QT disp was improved among patients with successful reflow irrespective of which infarct artery was responsible for the acute myocardial infarction. CONCLUSIONS: Successful reflow with PCI is associated with a rapid reduction in QT disp and QTc disp that is maintained for at least 3 days after the event. Conversely, unsuccessful reflow was not associated with significant reductions in QT or QTc disp.

Aged↗

Correlation between surgical success rate and severity of congenital glaucoma.

AIM: To study the correlation between severity of primary congenital glaucoma (PCG) and success of three types of surgery. METHODS: This was a retrospective review of all records of patients diagnosed with PCG up to age 1 year who underwent goniotomy, trabeculotomy, or combined trabeculotomy-trabeculectomy with mitomycin C as initial procedure between 1982 and 2002 at the King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. 532 paediatric glaucoma patients below age 1 year (820 eyes) with a minimum 1 year follow up were identified. The main outcome measures used for the surgeries were postoperative intraocular pressure, stability of the corneal diameter, and maintenance of corneal clarity. Surgical success was defined as a postoperative intraocular pressure of < or = 21 mm Hg without additional medical or surgical therapy, and with decreased corneal oedema, stabilised corneal diameter, and no additional optic nerve damage for at least 1 year after surgery. Complications, time of surgical failure, and follow up were recorded. RESULTS: The eyes were grouped into mild (249), moderate (342), and severe (229) PCG, based on intraocular pressure, corneal diameter, and clarity. All three surgical procedures resulted in high success rates of 81-100% for the mild form of PCG. Eyes classified with moderate glaucoma had a 13%, 40%, and 80% success rate respectively for goniotomy, trabeculotomy, and combined trabeculotomy-trabeculectomy with mitomycin C. The success rate for severe PCG was 10% and 70% for trabeculotomy and combined surgery respectively. Goniotomy was never done for eyes with this condition. CONCLUSION: Clinical classification of PCG is helpful for surgical decision making. The mild form has a high surgical success regardless of the procedure chosen. Combined trabeculotomy-trabeculectomy with mitomycin C gave the best results for moderate and severe cases of PCG.

Chemotherapy, Adjuvant↗

Turning a blind eye: the success of blinding reported in a random sample of randomised, placebo controlled trials.

OBJECTIVE: To examine the reporting and success of double blinding in a sample of randomised, placebo controlled trials from leading general medicine and psychiatry journals. METHODS: Identification of placebo controlled, randomised controlled trials from prespecified general medical and psychiatric journals indexed on Medline between 1 January 1998 and 1 October 2001, from which a random sample of 200 randomised clinical trials was chosen, of which 191 trials were evaluated. RESULTS: Only seven of the 97 (7%) general medicine trials provided evidence on the success of blinding, with five reporting that the success of blinding was imperfect. In trials from psychiatric journals, the success of blinding was reported in eight of the 94 trials, with four reporting that the blinding was imperfect. Overall, only four of the 191 (2%) trials assessed blinding in the participants and either the outcome assessors or the investigators. CONCLUSIONS: The current lack of reporting on the success of blinding provides little evidence that success of blinding is maintained in placebo controlled trials. Trialists and editors should make a concerted effort to incorporate, report, and publish such information and its potential effect on study results.

Double-Blind Method↗

Echocardiographic restenosis after successful balloon dilatation of the mitral valve with the Inoue balloon: experience of a United Kingdom centre.

OBJECTIVES: (a) To assess the echocardiographic incidence of restenosis after successful balloon dilatation of the mitral valve at a mid-term follow up of one year among a population of predominantly United Kingdom patients. (b) To identify any factors, assessed before or during dilatation, which may predict the development of restenosis. DESIGN: Successful dilatation of the mitral valve was defined as an increase in mitral valve area of > 25% and a final valve area of at least 1.5 cm2. Echocardiographic restenosis was defined at follow up as a loss of 50% of initial gain and a valve area of less than 1.5 cm2. Mitral valve area was assessed by transthoracic echocardiography before, during, 48 hours after, and one year after successful balloon dilatation of the mitral valve. Echo score before dilatation (an assessment of valvar and subvalvar calcification, thickening, and mobility), age, rhythm, echocardiographic mitral valve area before and after dilatation, left atrial pressure before and after dilatation, and end diastolic mitral valve gradient before and after dilatation were compared in those patients with and without echocardiographic restenosis at one year. SETTING: A regional cardiothoracic centre in the United Kingdom that performs 20-30 balloon dilatations of mitral valves each year. PATIENTS: 39 patients, with symptomatic dominant mitral stenosis, who had undergone successful balloon dilatation of the mitral valve, and in whom echocardiographic assessment of mitral valve area was available at one year. 92% of patients were citizens of the United Kingdom. INTERVENTIONS: Balloon dilatation of the mitral valve by the Inoue technique. MAIN OUTCOME MEASURES: Mitral valve area and patient symptom class (New York Heart Association) one year after successful dilatation of the mitral valve. RESULTS: The incidence of echocardiographic restenosis was eight of 39 patients (21%). Of the eight patients with restenosis four underwent mitral valve replacement, two had repeat dilatation of the mitral valve, and two remained on medical treatment. With univariant analysis, factors associated with restenosis were increased age, higher echo score before dilatation, and a lower mitral valve area immediately after the operation. The only independent risk factor for restenosis, shown by multivariant analysis, was a high echo score before dilatation. There was no significant fall in mitral valve area at one year in those patients without restenosis. Most (28/31) of these patients had echocardiographic evidence of splitting of at least one commissure after dilatation compared with only two of eight patients who developed restenosis. Of 10 patients with an echo score before dilatation > or = 10 only two had an initially successful operation and no restenosis at one year. CONCLUSIONS: The echocardiographic incidence of restenosis after dilatation of the mitral valve by the Inoue technique in patients of the United Kingdom is 21%. The principal factor associated with restenosis is a high echo score before dilatation. Increases in mitral valve area are maintained in those patients without restenosis and it is likely that the mechanism of initial increase in valve area is different in the two groups, being commissural splitting in those patients who do not get restenosis and valve stretching in those that do. In patients with an echo score > or = 10 dilatation of the mitral valve should be considered only as a palliative procedure.

Adult↗

Mechanical, but not infective, pacemaker erosion may be successfully managed by re-implantation of pacemakers.

OBJECTIVE: When a pacemaker box causes erosion it is usually removed and a new pacemaker implanted at a contralateral site. In this study when there was no evidence of systemic infection an attempt was made to clean and reimplant the same pacemaker in the same site. RESULTS: Over 10 years 62 patients had pacemaker reimplantation. In 18 patients the procedure was repeated a second time. Reimplantation was successful after at least six months follow up in 38 patients (61%): in nine two attempts had been made. Mean hospital stay for all patients was 21.3 days; for patients in whom the procedure was successful it was 12.5 days and for those in whom it was unsuccessful it was 35.4 days. 31 (82%) of the 38 patients in whom reimplantation was successful had no bacterial growth from wound swabs from 17/24 (71%) patients in whom reimplantation was unsuccessful (p < 0.001). Bacteria were grown from swabs from 7/8 patients with a protruding wire compared with 9/23 patients with a protruding pacemaker (p = 0.05). Thin patients and those who were older were more likely to have successful reimplantation: neither association reached statistical significance. A clinical impression of infection was not helpful. If re-implantation had been attempted only in the patients with negative wound swabs or intact skin the success rate would have been 74% at a cost of 5010 pounds per patient compared with a cost of 6509 pounds per patient for explantation and a reimplantation of a new contralateral pacemaker. CONCLUSION: These data support the hypothesis that pacemaker erosion is caused by primary infection or by a non-infective process (probably mechanical pressure). Pacemaker erosion that is not caused by infection can be successfully managed by ipsilateral reimplantation and this approach saves money.

Adult↗

Does a waiting time for elective coronary angioplasty affect the primary success rate?

OBJECTIVE: To evaluate the effect of the waiting time for elective percutaneous transluminal coronary angioplasty (PTCA) on the primary success rate. SETTING: University hospital in The Netherlands. PATIENTS: A cohort of 817 consecutive patients awaiting elective PTCA. Scheduled PTCA was performed in all 817 patients, involving 1237 coronary lesions. MAIN OUTCOME MEASURES: The relation between procedural success and the duration of the waiting time was evaluated. Major cardiac events, that is, death and myocardial infarction while awaiting PTCA, were documented. Alterations in lesion characteristics during the waiting time were assessed in unsuccessful procedures. RESULTS: Elective PTCA was performed within one to six weeks after acceptance in 388 patients (587 lesions; 47.5%), between six and 12 weeks in 203 patients (308 lesions; 25%), and after more than 12 weeks in 226 patients (342 lesions; 27.5%). The procedural success rates in the defined time intervals were 97%, 99%, and 97% in ACC/AHA type A lesions, 93%, 87% and 90% in type B lesions, and 63%, 55% and 38% in type C lesions respectively; 96% of type C lesions were total coronary occlusions. There was a significant decrease in primary success rate in type C lesions after a waiting time beyond 12 weeks. A reasonable explanation for an unsuccessful angioplasty related to alterations in lesion characteristics during the waiting time was documented in only four of 115 procedures. CONCLUSIONS: The primary success in type A and B lesions is unaffected by the duration of a waiting period for elective PTCA. A waiting time of more than 12 weeks is associated with a lower success rate in patients with total coronary occlusions.

Aged↗

Renal cell carcinoma: clinical experience and technical success with radio-frequency ablation of 42 tumors.

PURPOSE: To evaluate clinical experience with percutaneous image-guided radio-frequency (RF) ablation of renal cell carcinoma (RCC) and to assess factors that may influence technical success. MATERIALS AND METHODS: Thirty-four patients who underwent RF ablation of 42 RCC tumors during a 3.5-year period were evaluated. Overlapping ablations were performed on the basis of tumor size and geometry. Technical success was defined as elimination of areas that enhanced at imaging within the entire tumor. With the exception of those patients with renal insufficiency, who were followed up with unenhanced and gadolinium-enhanced magnetic resonance imaging, patients were followed up with unenhanced and contrast material-enhanced computed tomography. Univariate analysis of the results was performed with the Fisher exact test to assess the effect of tumor size and location on technical success. P 3.0 cm) tumors, presence of a tumor component in the renal sinus was a significant negative predictor of technical success (P =.004); only five of these 11 tumors were completely treated, compared with 11 of 11 tumors without a renal sinus component. A similar analysis was not possible for small tumors because no small tumors involved the renal sinus. Four complications occurred in a total of 54 ablation sessions: one minor hemorrhage, two major hemorrhages, and one ureteral stricture. CONCLUSION: RF ablation of RCC can be successful in exophytic RCC tumors up to 5.0 cm in size. Tumors larger than 3.0 cm with a component in the renal sinus are more difficult to treat but can be ablated successfully.

Adult↗

Radiofrequency ablation of hepatocellular carcinoma: treatment success as defined by histologic examination of the explanted liver.

PURPOSE: To retrospectively evaluate the effectiveness of radiofrequency (RF) ablation of hepatocellular carcinoma (HCC) by using histologic examination of the explanted liver. MATERIALS AND METHODS: The study was approved by the medical center Institutional Review Board, with waiver of informed consent. Forty-seven HCC nodules in 24 patients (18 men, six women; age range, 33-71 years; mean age, 56 years) were treated with single or double RF ablation sessions prior to liver transplantation. Histologic data from hematoxylin-eosin staining of explanted liver specimens were retrospectively reviewed to determine treatment success, which was defined as the absence of residual or recurrent viable carcinoma cells at treatment site. Tumor size and the presence of large (> or =3 mm) abutting vessels that were observed during imaging were tested as potential predictors of treatment success or failure (Fisher exact test). In patients who underwent postablation computed tomographic (CT) or magnetic resonance (MR) imaging within 3 months prior to transplantation (21 patients with 44 tumors), imaging results were analyzed for sensitivity and specificity of residual or recurrent tumor by using histologic data as the reference standard. RESULTS: Thirty-five (74%) of 47 ablated tumors, including 29 (83%) of 35 tumors less than 3 cm, were found to be successfully treated on the basis of histologic findings after a mean interval of 7.5 months between RF ablation and transplantation. Nodules that were successfully treated had mean maximal diameter of 2.0 cm, and nodules that were unsuccessfully treated had mean maximal diameter of 3.1 cm (P=.014). Seven (47%) of 15 perivascular lesions were successfully treated whereas 28 (88%) of 32 nonperivascular lesions were successfully treated (P <.01). Imaging correlation showed 100% (33 of 33) specificity and 36% (four of 11) sensitivity of postablation CT and MR imaging for the depiction of residual or recurrent tumor. CONCLUSION: Histologic evidence directly validates RF ablation as an effective treatment of small (<3 cm) HCC.

Adult↗

Relationship between "extension of refractoriness" and probability of successful defibrillation.

The "extension of refractoriness" hypothesis, which suggests that the shock halts fibrillation by extending the refractory period, has not been directly tested. Defibrillation (5 isolated rabbit hearts; 111 episodes) was attempted by 8-ms pulses (65% tilt) delivered through epicardial patches. Monophasic action potentials were recorded in a low current density region (6.3 V/cm at 90% success). Fifty shocks failed to convert; 61 shocks successfully defibrillated. Postshock response duration (from shock to repolarization) was significantly longer for successful type A (with no postshock activations) defibrillation (102.3 +/- 7.5 ms) than for unsuccessful defibrillation (47.6 +/- 4.3 ms; P < 0.0001) for shocks occurring during the last 40% of the fibrillation action potential. Probability of success and postshock response duration both increased with current intensity. However, at each intensity, response durations for successful defibrillation were significantly longer than those for unsuccessful defibrillation. A minimum prolongation of 75 ms was associated with type A defibrillation. These results suggest that shock-induced response duration correlates with successful defibrillation and that a response of 75 ms is required to completely block fibrillation wavefronts.

Action Potentials↗

Balloon dilation of severe aortic stenosis in the fetus: potential for prevention of hypoplastic left heart syndrome: candidate selection, technique, and results of successful intervention.

BACKGROUND: Preventing the progression of fetal aortic stenosis (AS) to hypoplastic left heart syndrome (HLHS) requires identification of fetuses with salvageable left hearts who would progress to HLHS if left untreated, a successful in utero valvotomy, and demonstration that a successful valvotomy promotes left heart growth in utero. Fetuses meeting the first criterion are undefined, and previous reports of fetal AS dilation have not evaluated the impact of intervention on in utero growth of left heart structures. METHODS AND RESULTS: We offered fetal AS dilation to 24 mothers whose fetuses had AS. At least 3 echocardiographers assigned a high probability that all 24 fetuses would progress to HLHS if left untreated. Twenty (21 to 29 weeks' gestation) underwent attempted AS dilation, with technical success in 14. Ideal fetal positioning for cannula puncture site and course of the needle (with or without laparotomy) proved to be necessary for procedural success. Serial fetal echocardiograms after intervention demonstrated growth arrest of the left heart structures in unsuccessful cases and in those who declined the procedure, while ongoing left heart growth was seen in successful cases. Resumed left heart growth led to a 2-ventricle circulation at birth in 3 babies. CONCLUSIONS: Fetal echocardiography can identify midgestation fetuses with AS who are at high risk for developing HLHS. Timely and successful aortic valve dilation requires ideal fetal and cannula positioning, prevents left heart growth arrest, and may result in normal ventricular anatomy and function at birth.

Aortic Valve Stenosis↗

Early noninvasive detection of successful reperfusion in patients with acute myocardial infarction.

Myoglobin (Mb) is a protein that enters rapidly and is rapidly cleared from plasma after coronary reperfusion. We sought to determine the accuracy with which a rapid rise in plasma [Mb] could predict successful coronary artery reopening in patients undergoing coronary arteriography in conjunction with attempted reperfusion in acute myocardial infarction. In 42 patients, plasma Mb levels were measured before and for at least 4 hours after attempted reperfusion. Thirty-five patients were successfully reperfused. In each, the plasma Mb level rose rapidly with peak [Mb] occurring at 111 +/- 8.1 (+/- SEM) minutes after application of therapy. In contrast, Mb levels rose more slowly in the seven patients who were not reperfused, with peak [Mb] occurring 360 +/- 61.4 minutes after attempted reperfusion. T25-100 (the time required for [Mb] to rise from 25% to 100% of peak value) was shorter in patients successfully reperfused (71 +/- 7.9 minutes) and longer (341 +/- 35.3 minutes) in patients in whom therapy was unsuccessful. A rapid rise in [Mb] after successful reperfusion was also evident by a more than 4.6-fold rise in [Mb] over the first 2 hours after reperfusion in all but five patients; in contrast, [Mb] rose by less than 4.6-fold over this same interval in every patient not successfully reperfused (sensitivity, 85%; specificity, 100%; predictive accuracy, 88%). We conclude that a rapid rise in plasma Mb level over the initial 2 hours after attempted reperfusion in acute myocardial infarction provides a useful index of successful reperfusion.

Adult↗