Inverse relationship between fractionated electrograms and atrial fibrosis in persistent atrial fibrillation: combined magnetic resonance imaging and high-density mapping

OBJECTIVES This study sought to evaluate the relationship between fibrosis imaged by delayed-enhancement (DE) magnetic resonance imaging (MRI) and atrial electrograms (Egms) in persistent atrial fibrillation (AF). BACKGROUND Atrial fractionated Egms are strongly related to slow anisotropic conduction. Their relationship to atrial fibrosis has not yet been investigated. METHODS Atrial high-resolution MRI of 18 patients with persistent AF (11 long-lasting persistent AF) was registered with mapping geometry (NavX electro-anatomical system (version 8.0, St. Jude Medical, St. Paul, Minnesota)). DE areas were categorized as dense or patchy, depending on their DE content. Left atrial Egms during AF were acquired using a high-density, 20-pole catheter (514 ± 77 sites/map). Fractionation, organization/regularity, local mean cycle length (CL), and voltage were analyzed with regard to DE. RESULTS Patients with long-lasting persistent versus persistent AF had larger left atrial (LA) surface area (134 ± 38 cm(2) vs. 98 ± 9 cm(2), p = 0.02), a higher amount of atrial DE (70 ± 16 cm(2) vs. 49 ± 10 cm(2), p = 0.01), more complex fractionated atrial Egm (CFAE) extent (54 ± 16 cm(2) vs. 28 ± 15 cm(2), p = 0.02), and a shorter baseline AF CL (147 ± 10 ms vs. 182 ± 14 ms, p = 0.01). Continuous CFAE (CFEmean [NavX algorithm that quantifies Egm fractionation] <80 ms) occupied 38 ± 19% of total LA surface area. Dense DE was detected at the left posterior left atrium. In contrast, the right posterior left atrium contained predominantly patchy DE. Most CFAE (48 ± 14%) occurred at non-DE LA sites, followed by 41 ± 12% CFAE at patchy DE and 11 ± 6% at dense DE regions (p = 0.005 and p = 0.008, respectively); 19 ± 6% CFAE sites occurred at border zones of dense DE. Egms were less fractionated, with longer CL and lower voltage at dense DE versus non-DE regions: CFEmean: 97 ms versus 76 ms, p < 0.0001; local CL: 153 ms versus 143 ms, p < 0.0001; mean voltage: 0.63 mV versus 0.86 mV, p < 0.0001. CONCLUSIONS Atrial fibrosis as defined by DE MRI is associated with slower and more organized electrical activity but with lower voltage than healthy atrial areas. Ninety percent of continuous CFAE sites occur at non-DE and patchy DE LA sites. These findings are important when choosing the ablation strategy in persistent AF.

Prognostic role of subsequent atrial tachycardias occurring during ablation of persistent atrial fibrillation: a prospective randomized trial

BACKGROUND The role of subsequent atrial tachycardias (AT) in the context of persistent atrial fibrillation (AF) remains undetermined. This study evaluated the prognostic role of subsequent ATs for arrhythmia recurrences after catheter ablation of persistent AF. METHODS AND RESULTS A total of 110 patients with persistent AF (63±9 years; 22 women; 61 long-lasting persistent AF) underwent pulmonary vein isolation followed by electrogram-guided ablation. After AF terminated to AT, patients were separated by the randomization protocol to receive either direct cardioversion (group A) or further ablation of subsequent ATs to sinus rhythm (group B). After a mean follow-up of 20.1±13.3 months after the first procedure, significantly more group B patients were in sinus rhythm as compared with patients in group A (30 [57%] versus 18 [34%]; P=0.02). Moreover, recurrences of AF were significantly less frequent of group B than in group A patients (10 [19%] versus 26 [49%]; P=0.001). After the last procedure (follow-up, 34.0±6.4 months), significantly more group B patients were free of AF as compared with patients of group A (49 [92%] versus 39 [74%]; P=0.01). The proportion of AT recurrences did not differ between the 2 groups after the first and final procedures. The strongest predictor for an arrhythmia-free survival after a single procedure was randomization to the procedural end point of termination to sinus rhythm by elimination of subsequent ATs (P=0.004). CONCLUSIONS Catheter ablation of subsequent ATs increases freedom from AF but not AT, suggesting a contributing role of subsequent ATs in the mechanisms of persistent AF. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01896570.

Nonanimal stabilized hyaluronic acid for tissue augmentation of the dorsal hands: a prospective study on 38 patients

BACKGROUND Often ignored, hands are one of the most telltale signs of aging. This prospective study was initiated to evaluate the effect of subcutaneous hyaluronic acid (HA) injections in aging hands, with special attention to complications and long-term outcomes. METHODS Between January 2010 and December 2010, a total of 38 patients with skin phototypes II-IV and between 58 and 76 years old were treated with HA injection for aging hands. The quantity of injection never exceeded 1.0-1.5 ml HA per hand. A clinical follow-up was performed at 2 weeks, 4 weeks, 3 months, and 6 months after injection. Complications were reviewed for the whole series. At the first follow-up, 2 weeks after the procedure, ultrasound was carried out to determine if additional filling material was required. At each follow-up, patients were asked to fill out a satisfaction questionnaire. RESULTS Nine patients developed slight ecchymosis that disappeared after 1 week. No other complications were seen in the series. Pain during the injection and discomfort after the procedure were minimal. At the 2-week follow-up, after ultrasound control, nine patients received a complementary injection. At each follow-up, overall patient satisfaction was high and was validated by clearance of rhytids, veins, bony prominences, and dermal and subcutaneous atrophy. CONCLUSION Skin revitalization with injectable HA can improve the clinical appearance of the back of the hands. However, this therapy requires knowledge of the possible complications and their remediation as well as knowledge and respect of injected doses. Moreover, despite excellent results at each follow-up, the results of our series are not as good after 6 months, and a longer follow-up would be needed to determine if this procedure provides long-lasting benefit. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Age affects the adjustment of cognitive control after a conflict: evidence from the bivalency effect

Age affects cognitive control. When facing a conflict, older adults are less able to activate goal-relevant information and inhibit irrelevant information. However, cognitive control also affects the events after a conflict. The purpose of this study was to determine whether age affects the adjustment of cognitive control following a conflict. To this end, we investigated the bivalency effect, that is, the performance slowing occurring after the conflict induced by bivalent stimuli (i.e., stimuli with features for two tasks). In two experiments, we tested young adults (aged 20-30) and older adults (aged 65-85) in a paradigm requiring alternations between three tasks, with bivalent stimuli occasionally occurring on one task. The young adults showed a slowing for all trials following bivalent stimuli. This indicates a widespread and long-lasting bivalency effect, replicating previous findings. In contrast, the older adults showed a more specific and shorter-lived slowing. Thus, age affects the adjustment of cognitive control following a conflict.

Plasmodium berghei sporozoite challenge of vaccinated BALB/c mice leads to the induction of humoral immunity and improved function of CD8(+) memory T cells.

Protection against malaria can be achieved by induction of a strong CD8(+) T-cell response against the Plasmodium circumsporozoite protein (CSP), but most subunit vaccines suffer from insufficient memory responses. In the present study, we analyzed the impact of postimmunization sporozoite challenge on the development of long-lasting immunity. BALB/c mice were immunized by a heterologous prime/boost regimen against Plasmodium berghei CSP that induces a strong CD8(+) T-cell response and sterile protection, which is short-lived. Here, we show that protective immunity is prolonged by a sporozoite challenge after immunization. Repeated challenges induced sporozoite-specific antibodies that showed protective capacity. The numbers of CSP-specific CD8(+) T cells were not substantially enhanced by sporozoite infections; however, CSP-specific memory CD8(+) T cells of challenged mice displayed a higher cytotoxic activity than memory T cells of immunized-only mice. CD4(+) T cells contributed to protection as well; but CD8(+) memory T cells were found to be the central mediator of sterile protection. Based on these data, we suggest that prolonged protective immunity observed after immunization and infection is composed of different antiparasitic mechanisms including CD8(+) effector-memory T cells with increased cytotoxic activity as well as CD4(+) memory T cells and neutralizing antibodies.

The cannabinoid CB2 receptor-selective phytocannabinoid beta-caryophyllene exerts analgesic effects in mouse models of inflammatory and neuropathic pain

The widespread plant volatile beta-caryophyllene (BCP) was recently identified as a natural selective agonist of the peripherally expressed cannabinoid receptor 2 (CB2). It is found in relatively high concentrations in many spices and food plants. A number of studies have shown that CB2 is critically involved in the modulation of inflammatory and neuropathic pain responses. In this study, we have investigated the analgesic effects of BCP in animal models of inflammatory and neuropathic pain. We demonstrate that orally administered BCP reduced inflammatory (late phase) pain responses in the formalin test in a CB2 receptor-dependent manner, while it had no effect on acute (early phase) responses. In a neuropathic pain model the chronic oral administration of BCP attenuated thermal hyperalgesia and mechanical allodynia, and reduced spinal neuroinflammation. Importantly, we found no signs of tolerance to the anti-hyperalgesic effects of BCP after prolonged treatment. Oral BCP was more effective than the subcutaneously injected synthetic CB2 agonist JWH-133. Thus, the natural plant product BCP may be highly effective in the treatment of long lasting, debilitating pain states. Our results have important implications for the role of dietary factors in the development and modulation of chronic pain conditions.

Stricture of the Afferent Isoperistaltic Tubular Segment: A Late and Rare Cause of Bilateral Dilation of the Upper Urinary Tract After Ileal Bladder Substitution

OBJECTIVE To evaluate the etiology and treatment of bilateral hydronephrosis not responding to bladder substitute drainage after ileal bladder substitution using an afferent isoperistaltic tubular segment. MATERIALS AND METHODS A retrospective analysis was performed of a consecutive series of 739 patients who had undergone bladder substitution from April 1985 to August 2012. RESULTS Of the 739 ileal bladder substitute patients, 10 (1.4%) developed bilateral hydronephrosis unresponsive to complete bladder substitute drainage. The etiology was stenosis of the afferent isoperistaltic tubular segment. The median interval to presentation was 131 months (range 45-192). The incidence of afferent tubular segment stenosis was significantly higher in the 61 ileal bladder substitute patients with recurrent urinary tract infection (9 [15%]) than in the 678 without recurrent urinary tract infection (1 [0.15%]; P <.001). Urine cultures revealed mixed infections (34%), Escherichia coli (18%), Staphylococcus aureus (13%), enterococci (11%), Candida (8%), Klebsiella (8%), and others (8%). Seven patients underwent 10 endourologic interventions, only 1 of which was successful (10%). After failed endourologic treatment, 7 open surgical revisions with resection of the stricture were performed, with all 7 (100%) successful. CONCLUSION Bilateral dilation of the upper urinary tract after ileal orthotopic bladder substitution unresponsive to complete bladder substitute drainage is likely to be caused by stenosis of the afferent isoperistaltic tubular segment. The stenosis occurs almost exclusively in patients with long-lasting, recurrent urinary tract infection and can develop many years after the ileal bladder substitution. Minimally invasive endourologic treatment is usually unsuccessful; however, open surgical revision offers excellent results.

Climate and vegetation changes during the Lateglacial and early–middle Holocene at Lake Ledro (southern Alps, Italy)

Adding to the on-going debate regarding vegetation recolonisation (more particularly the timing) in Europe and climate change since the Lateglacial, this study investigates a long sediment core (LL081) from Lake Ledro (652ma.s.l., southern Alps, Italy). Environmental changes were reconstructed using multiproxy analysis (pollen-based vegetation and climate reconstruction, lake levels, magnetic susceptibility and X-ray fluorescence (XRF) measurements) recorded climate and land-use changes during the Lateglacial and early-middle Holocene. The well-dated and high-resolution pollen record of Lake Ledro is compared with vegetation records from the southern and northern Alps to trace the history of tree species distribution. An altitudedependent progressive time delay of the first continuous occurrence of Abies (fir) and of the Larix (larch) development has been observed since the Lateglacial in the southern Alps. This pattern suggests that the mid-altitude Lake Ledro area was not a refuge and that trees originated from lowlands or hilly areas (e.g. Euganean Hills) in northern Italy. Preboreal oscillations (ca. 11 000 cal BP), Boreal oscillations (ca. 10 200, 9300 cal BP) and the 8.2 kyr cold event suggest a centennial-scale climate forcing in the studied area. Picea (spruce) expansion occurred preferentially around 10 200 and 8200 cal BP in the south-eastern Alps, and therefore reflects the long-lasting cumulative effects of successive boreal and the 8.2 kyr cold event. The extension of Abies is contemporaneous with the 8.2 kyr event, but its development in the southern Alps benefits from the wettest interval 8200-7300 cal BP evidenced in high lake levels, flood activity and pollen-based climate reconstructions. Since ca. 7500 cal BP, a weak signal of pollen-based anthropogenic activities suggest weak human impact. The period between ca. 5700 and ca. 4100 cal BP is considered as a transition period to colder and wetter conditions (particularly during summers) that favoured a dense beech (Fagus) forest development which in return caused a distinctive yew (Taxus) decline.We conclude that climate was the dominant factor controlling vegetation changes and erosion processes during the early and middle Holocene (up to ca. 4100 cal BP).

Orbital changes, variation in solar activity and increased anthropogenic activities: controls on the Holocene flood frequency in the Lake Ledro area, Northern Italy

Adding to the on-going debate regarding vegetation recolonisation (more particularly the timing) in Europe and climate change since the Lateglacial, this study investigates a long sediment core (LL081) from Lake Ledro (652ma.s.l., southern Alps, Italy). Environmental changes were reconstructed using multiproxy analysis (pollen-based vegetation and climate reconstruction, lake levels, magnetic susceptibility and X-ray fluorescence (XRF) measurements) recorded climate and land-use changes during the Lateglacial and early-middle Holocene. The well-dated and high-resolution pollen record of Lake Ledro is compared with vegetation records from the southern and northern Alps to trace the history of tree species distribution. An altitudedependent progressive time delay of the first continuous occurrence of Abies (fir) and of the Larix (larch) development has been observed since the Lateglacial in the southern Alps. This pattern suggests that the mid-altitude Lake Ledro area was not a refuge and that trees originated from lowlands or hilly areas (e.g. Euganean Hills) in northern Italy. Preboreal oscillations (ca. 11 000 cal BP), Boreal oscillations (ca. 10 200, 9300 cal BP) and the 8.2 kyr cold event suggest a centennial-scale climate forcing in the studied area. Picea (spruce) expansion occurred preferentially around 10 200 and 8200 cal BP in the south-eastern Alps, and therefore reflects the long-lasting cumulative effects of successive boreal and the 8.2 kyr cold event. The extension of Abies is contemporaneous with the 8.2 kyr event, but its development in the southern Alps benefits from the wettest interval 8200-7300 cal BP evidenced in high lake levels, flood activity and pollen-based climate reconstructions. Since ca. 7500 cal BP, a weak signal of pollen-based anthropogenic activities suggest weak human impact. The period between ca. 5700 and ca. 4100 cal BP is considered as a transition period to colder and wetter conditions (particularly during summers) that favoured a dense beech (Fagus) forest development which in return caused a distinctive yew (Taxus) decline.We conclude that climate was the dominant factor controlling vegetation changes and erosion processes during the early and middle Holocene (up to ca. 4100 cal BP).

Glucocorticoid induced impairment of lung structure assessed by digital image analysis

Glucocorticoids (GC) are successfully applied in neonatology to improve lung maturation in preterm born babies. Animal studies show that GC can also impair lung development. In this investigation, we used a new approach based on digital image analysis. Microscopic images of lung parenchyma were skeletonised and the geometrical properties of the septal network characterised by analysing the 'skeletal' parameters. Inhibition of the process of alveolarisation after extensive administration of small doses of GC in newborn rats was confirmed by significant changes in the 'skeletal' parameters. The induced structural changes in the lung parenchyma were still present after 60 days in adult rats, clearly indicating a long lasting or even definitive impairment of lung development and maturation caused by GC. Conclusion: digital image analysis and skeletonisation proved to be a highly suited approach to assess structural changes in lung parenchyma.

The response of atmospheric nitrous oxide to climate variations during the last glacial period

Detailed insight into natural variations of the greenhouse gas nitrous oxide (N2O) in response to changes in the Earth's climate system is provided by new measurements along the ice core of the North Greenland Ice Core Project (NGRIP). The presented record reaches from the early Holocene back into the previous interglacial with a mean time resolution of about 75 years. Between 11 and 120 kyr BP, atmospheric N2O concentrations react substantially to the last glacial-interglacial transition (Termination 1) and millennial time scale climate variations of the last glacial period. For long-lasting Dansgaard/Oeschger (DO) events, the N2O increase precedes Greenland temperature change by several hundred years with an increase rate of about 0.8-1.3 ppbv/century, which accelerates to about 3.8-10.7 ppbv/century at the time of the rapid warming in Greenland. Within each bundle of DO events, the new record further reveals particularly low N2O concentrations at the approximate time of Heinrich events. This suggests that the response of marine and/or terrestrial N2O emissions on a global scale are different for stadials with and without Heinrich events.

A verified spider bite and a review of the literature confirm Indian ornamental tree spiders (Poecilotheria species) as underestimated theraphosids of medical importance.

Literature on bird spider or tarantula bites (Theraphosidae) is rare. This is astonishing as they are coveted pets and interaction with their keepers (feeding, cleaning the terrarium or taking them out to hold) might increase the possibility for bites. Yet, this seems to be a rare event and might be why most theraphosids are considered to be harmless, even though the urticating hairs of many American species can cause disagreeable allergic reactions. We are describing a case of a verified bite by an Indian ornamental tree spider (Poecilotheria regalis), where the patient developed severe, long lasting muscle cramps several hours after the bite. We present a comprehensive review of the literature on bites of these beautiful spiders and conclude that a delayed onset of severe muscle cramps, lasting for days, is characteristic for Poecilotheria bites. We discuss Poecilotheria species as an exception from the general assumption that theraphosid bites are harmless to humans.

Internal displacement and the Kampala Convention: an opportunity for development actors

According to the African Union (AU), Africa is "a continent disproportionately affected by internal displacement". The African region, with almost 10 million people internally displaced in 22 countries by armed conflict and other forms of violence, hosts more than one third of the 26.4 million internally displaced persons (IDPs) worldwide at the end of 2011. Sudan, the Democratic Republic of the Congo and Somalia rank globally among the states with the five biggest displacement situations. Even in African countries with smaller figures, very large percentages of people may be in displacement in regions primarily affected by violence. Such violence has multiple causes, including the long-lasting consequences of colonial heritage, outside intervention, crises of identity in multi-ethnic countries and conflicts over resources. Today, political exclusion and inequality between ethnic, regional or religious groups are particularly important drivers of violence.

Intracellular chemical messengers and neuronal function: Two examples

Two distinct classes of neurons have been examined in the nervous system of Aplysia. The membrane properties of these neurons are regulated by intracellular signalling molecules in both a short-term and a long-term fashion.^ The role of the phosphatidylinositol cycle in the control of neuronal properties was studied in a class of bursting pacemaker cells, the left upper-quadrant bursting neurons (cells L2, L3, L4, and L6) of the abdominal ganglion of Aplysia. These cells display a regular burst-firing pattern that is controlled by cyclic changes of intracellular Ca$\sp{2+}$ that occur during the bursting rhythm. The characteristic bursting pattern of these neurons occurs within a range of membrane potentials ($-35$ to $-50$ mV) called the pacemaker range. Intracellular pressure injection of inositol 1,4,5-trisphosphate (IP$\sb3$) altered the bursting rhythm of the bursting cells. Injection of IP$\sb3$ induced a brief depolarization that was followed by a long-lasting (2-15 min) hyperpolarization. When cells were voltage-clamped at potentials within the pacemaker range, injection of IP$\sb3$ generally induced a biphasic response that had a total duration of 2-15 min. An initial inward shift in holding current (I$\sb{\rm in}$), which lasted 5-120 sec, was followed by a slow outward shift in holding current (I$\sb{\rm out}$). At membrane potentials more negative than $-40$ mV, I$\sb{\rm in}$ was associated with a small and relatively voltage-independent increase in membrane conductance. I$\sb{\rm in}$ was not blocked by bath application of TTX or Co$\sp{2+}$. Although I$\sb{\rm in}$ was activated by injection of IP$\sb3$, it was not blocked by iontophoretic injection of ethyleneglycol-bis-(beta-aminoethyl ether), N, N$\sp\prime$-tetraacetic acid (EGTA) sufficient to block the Ca$\sp{2+}$-activated inward tail current (I$\sb{\rm B}$).^ Long-term (lasting at least 24 hours) effects of adenylate cyclase activation were examined in a well characterized class of mechanosensory neurons in Aplysia. The injected cells were analyzed 24 hours later by two-electrode voltage-clamp techniques. We found that K$\sp+$ currents of these cells were reduced 24 hours after injection of cAMP. The currents that were reduced by cAMP were very similar to those found to be reduced 24 hours after behavioral sensitization. These results suggest that cAMP is part of the intracellular signal that induces long-term sensitization in Aplysia. (Abstract shortened with permission of author.) ^

Modulatory effects of bag cell peptides in {\it Aplysia}: Behavioral and electrophysiological studies

Reproductive hormones have effects on the nervous system not directly related to reproductive function. In the rat, for example, luteinizing hormone releasing hormone has dramatic effects on learning and memory. The present work attempts to examine the effects of reproductive hormones on non-reproductive behaviors and the neural loci and mechanisms underlying these effects in Aplysia, an animal whose behaviors, reproductive hormones and neural circuitry have been well characterized.^ In Aplysia, the neurosecretory bag cells release several peptides that are responsible for eliciting egg laying. The effects of these peptides on the defensive tail-siphon withdrawal reflex, as well as sensitization of this reflex, were examined. Sensitization, a simple form of nonassociative learning, refers to the behavioral enhancement of a response to a test stimulus after the presentation of a strong stimulus, that may last minutes (short-term) or days (long-term). An extract of the bag cells (BCE) inhibited the baseline siphon component of the tail-siphon withdrawal reflex and suppressed long-term, but not short-term, sensitization of the reflex. Preliminary experiments suggest that BCE also affects the tail component of the tail-siphon withdrawal reflex.^ To determine the neural mechanisms underlying the inhibition of the baseline reflex, electrophysiological studies were performed using an in vitro analogue of the tail-siphon withdrawal reflex to examine the ability of BCE, as well as the individual bag cell peptides (BCPs), to modulate the circuitry of the reflex. Bag cell extract attenuated the synaptic strength of the monosynaptic connections between tail sensory neurons and tail motor neurons. When individually applied only $\beta$-BCP produced a similar attenuation. This effect of $\beta$-BCP was not dependent on changes in duration of the presynaptic action potential.^ An in vitro analogue of long-term sensitization training was developed to examine the mechanisms by which the BCPs may affect long-term sensitization of the tail-siphon withdrawal reflex. This analogue exhibited both short- and long-term facilitation of the connections between the tail sensory and motor neurons.^ The results of these behavioral and electrophysiological experiments suggest that the BCPs inhibit the tail-siphon withdrawal reflex, at least in part, by modulating the synaptic strength of the connections between the sensory neurons and motor neurons underlying the reflex. One candidate for this effect is $\beta$-BCP. Thus, the peptides which elicit egg laying may also serve other functions such as the inhibition of defensive reflexes. In addition, these experiments raise the possibility that BCPs may exert a long lasting effect ($>$24 hr), suppressing long-term sensitization of the tail-siphon withdrawal reflex. ^