Morphological Study of Intracardiac Signals as a New Tool to Track the Efficiency of Stepwise Ablation of Persistent Atrial Fibrillation

Intracardiac organization indices such as atrial fibrillation (AF) cycle length (AFCL) have been used to track the efficiency of stepwise catheter ablation (step-CA) of longstanding persistent AF, however with limited success. The morphology of AF activation waves reflects the underlying activation patterns. Its temporal evolution is a local organization indicator that could be potentially used for tracking the efficiency of step-CA. We report a new method for characterizing the structure of the temporal evolution of activation wave morphology. Using recurrence plots, novel organization indices are proposed. By computing their relative evolution during the first step of ablation vs baseline, we found that these new parameters are superior to AFCL to track the effect of step-CA "en route" to AF termination.

Method for Estimating the Magnitude and Frequency of Floods at Ungaged Sites on Unregulated Rural Streams in Iowa, HR-268, 1987

This report provides techniques and procedures for estimating the probable magnitude and frequency of floods at ungaged sites on Iowa streams. Physiographic characteristics were used to define the boundaries of five hydrologic regions. Regional regression equations that relate the size of the drainage area to flood magnitude are defined for estimating peak discharges having specified recurrence intervals of 2, 5, 10, 25, 50, and 100 years. Regional regression equations are applicable to sites on streams that have drainage areas ranging from 0.04 to 5,150 square miles provided that the streams are not affected significantly by regulation upstream from the sites and that the drainage areas upstream from the sites are not mostly urban areas. Flood-frequency characteristics for the mainstems of selected rivers are presented in graphs as a function of drainage area.

Estimating Design-Flood Discharges for Streams in Iowa Using Drainage-Basin and Channel-Geometry Characteristics, HR-322, 1993

Drainage-basin and channel-geometry multiple-regression equations are presented for estimating design-flood discharges having recurrence intervals of 2, 5, 10, 25, 50, and 100 years at stream sites on rural, unregulated streams in Iowa. Design-flood discharge estimates determined by Pearson Type-III analyses using data collected through the 1990 water year are reported for the 188 streamflow-gaging stations used in either the drainage-basin or channel-geometry regression analyses. Ordinary least-squares multiple-regression techniques were used to identify selected drainage-basin and channel-geometry regions. Weighted least-squares multiple-regression techniques, which account for differences in the variance of flows at different gaging stations and for variable lengths in station records, were used to estimate the regression parameters. Statewide drainage-basin equations were developed from analyses of 164 streamflow-gaging stations. Drainage-basin characteristics were quantified using a geographic-information-system (GIS) procedure to process topographic maps and digital cartographic data. The significant characteristics identified for the drainage-basin equations included contributing drainage area, relative relief, drainage frequency, and 2-year, 24-hour precipitation intensity. The average standard errors of prediction for the drainage-basin equations ranged from 38.6% to 50.2%. The GIS procedure expanded the capability to quantitatively relate drainage-basin characteristics to the magnitude and frequency of floods for stream sites in Iowa and provides a flood-estimation method that is independent of hydrologic regionalization. Statewide and regional channel-geometry regression equations were developed from analyses of 157 streamflow-gaging stations. Channel-geometry characteristics were measured on site and on topographic maps. Statewide and regional channel-geometry regression equations that are dependent on whether a stream has been channelized were developed on the basis of bankfull and active-channel characteristics. The significant channel-geometry characteristics identified for the statewide and regional regression equations included bankfull width and bankfull depth for natural channels unaffected by channelization, and active-channel width for stabilized channels affected by channelization. The average standard errors of prediction ranged from 41.0% to 68.4% for the statewide channel-geometry equations and from 30.3% to 70.0% for the regional channel-geometry equations. Procedures provided for applying the drainage-basin and channel-geometry regression equations depend on whether the design-flood discharge estimate is for a site on an ungaged stream, an ungaged site on a gaged stream, or a gaged site. When both a drainage-basin and a channel-geometry regression-equation estimate are available for a stream site, a procedure is presented for determining a weighted average of the two flood estimates.

Entropions et ectropions involutionnels. [Involutional entropion and ectropion]

Entropion and ectropion are very common among old people. These malpositions concern mostly the lower lids. Involutional entropion and ectropion have some pathophysiologic mechanisms in common: lower lid horizontal laxity and lid retractor detachment. However, orbicularis muscle hypertrophy occurs only in entropion, and excess of posterior lamella has to be considered in ectropion. Clinical examination will guide surgical treatment. The authors present the main surgical procedures according to clinical findings. The goal is to prevent recurrence.

The unresolved case of sacral chordoma: from misdiagnosis to challenging surgery and medical therapy resistance.

PURPOSE: A sacral chordoma is a rare, slow-growing, primary bone tumor, arising from embryonic notochordal remnants. Radical surgery is the only hope for cure. The aim of our present study is to analyse our experience with the challenging treatment of this rare tumor, to review current treatment modalities and to assess the outcome based on R status. METHODS: Eight patients were treated in our institution between 2001 and 2011. All patients were discussed by a multidisciplinary tumor board, and an en bloc surgical resection by posterior perineal access only or by combined anterior/posterior accesses was planned based on tumor extension. RESULTS: Seven patients underwent radical surgery, and one was treated by using local cryotherapy alone due to low performance status. Three misdiagnosed patients had primary surgery at another hospital with R1 margins. Reresection margins in our institution were R1 in two and R0 in one, and all three recurred. Four patients were primarily operated on at our institution and had en bloc surgery with R0 resection margins. One had local recurrence after 18 months. The overall morbidity rate was 86% (6/7 patients) and was mostly related to the perineal wound. Overall, 3 out of 7 resected patients were disease-free at a median follow-up of 2.9 years (range, 1.6-8.0 years). CONCLUSION: Our experience confirms the importance of early correct diagnosis and of an R0 resection for a sacral chordoma invading pelvic structures. It is a rare disease that requires a challenging multidisciplinary treatment, which should ideally be performed in a tertiary referral center.

Dynamics of flow: a nonlinear perspective

The aims of this study are to consider the experience of flow from a nonlinear dynamics perspective. The processes and temporal nature of intrinsic motivation and flow, would suggest that flow experiences fluctuate over time in a dynamical fashion. Thus it can be argued that the potential for chaos is strong. The sample was composed of 20 employees (both full and part time) recruited from a number of different organizations and work backgrounds. The Experience Sampling Method (ESM) was used for data collection. Once obtained the temporal series, they were subjected to various analyses proper to the com- plexity theory (Visual Recurrence Analysis and Surrogate Data Analysis). Results showed that in 80% of the cases, flow presented a chaotic dynamic, in that, flow experiences delineated a complex dynamic whose patterns of change were not easy to predict. Implications of the study, its limitations and future research are discussed.

Patterns of pain-free response in 497 cases of classic trigeminal neuralgia treated with Gamma Knife surgery and followed up for least 1 year.

Object The goal of this study was to establish whether clear patterns of initial pain freedom could be identified when treating patients with classic trigeminal neuralgia (TN) by using Gamma Knife surgery (GKS). The authors compared hypesthesia and pain recurrence rates to see if statistically significant differences could be found. Methods Between July 1992 and November 2010, 737 patients presenting with TN underwent GKS and prospective evaluation at Timone University Hospital in Marseille, France. In this study the authors analyzed the cases of 497 of these patients, who participated in follow-up longer than 1 year, did not have megadolichobasilar artery- or multiple sclerosis-related TN, and underwent GKS only once; in other words, the focus was on cases of classic TN with a single radiosurgical treatment. Radiosurgery was performed with a Leksell Gamma Knife (model B, C, or Perfexion) using both MR and CT imaging targeting. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.8 mm (range 4.5-14 mm) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range 70-90 Gy) was delivered. Using empirical methods and assisted by a chart with clear cut-off periods of pain free distribution, the authors were able to divide patients who experienced freedom from pain into 3 separate groups: patients who became pain free within the first 48 hours post-GKS; those who became pain free between 48 hours and 30 days post-GKS; and those who became pain free more than 30 days after GKS. Results The median age in the 497 patients was 68.3 years (range 28.1-93.2 years). The median follow-up period was 43.75 months (range 12-174.41 months). Four hundred fifty-four patients (91.34%) were initially pain free within a median time of 10 days (range 1-459 days) after GKS. One hundred sixty-nine patients (37.2%) became pain free within the first 48 hours (Group PF(≤ 48 hours)), 194 patients (42.8%) between posttreatment Day 3 and Day 30 (Group PF((>48 hours, ≤ 30 days))), and 91 patients (20%) after 30 days post-GKS (Group PF(>30 days)). Differences in postoperative hypesthesia were found: in Group PF(≤ 48 hours) 18 patients (13.7%) developed postoperative hypesthesia, compared with 30 patients (19%) in Group PF((>48 hours, ≤ 30 days)) and 22 patients (30.6%) in Group PF(>30 days) (p = 0.014). One hundred fifty-seven patients (34.4%) who initially became free from pain experienced a recurrence of pain with a median delay of 24 months (range 0.62-150.06 months). There were no statistically significant differences between the patient groups with respect to pain recurrence: 66 patients (39%) in Group PF(≤ 48 hours) experienced pain recurrence, compared with 71 patients (36.6%) in Group PF((>48 hours, ≤ 30 days)) and 27 patients (29.7%) in Group PF(>30 days) (p = 0.515). Conclusions A substantial number of patients (169 cases, 37.2%) became pain free within the first 48 hours. The rate of hypesthesia was higher in patients who became pain free more than 30 days after GKS, with a statistically significant difference between patient groups (p = 0.014).

Anterior subluxation after reduction of a posterior traumatic sterno-clavicular dislocation: a case report and a review of the literature.

Sternoclavicular dislocations represent a rare injury. Based on our clinical experience with a patient showing an anterior subluxation after reduction of a posterior traumatic dislocation, we review the literature. The emergent reduction of the dislocation is mandatory, always keeping in mind the potentially devastating neurovascular complications. If the treatment of a residual anterior instability remains controversial, a residual posterior instability should be treated by a surgical procedure. The optimal treatment depends mainly on each surgeon's choice and practice.

Synovial sarcomas usually metastasize after >5 years: a multicenter retrospective analysis with minimum follow-up of 10 years for survivors.

Background: Synovial sarcoma (SS) is a malignant soft tissue sarcoma with a poor prognosis because of late local recurrence and distant metastases. To our knowledge, no studies have minimum follow-up of 10 years that evaluate long-term outcomes for survivors. Patients and methods: Data on 62 patients who had been treated for SS from 1968 to 1999 were studied retrospectively in a multicenter study. Mean follow-up of living patients was 17.2 years and of dead patients 7.7 years. Results: Mean age at diagnosis was 35.4 years (range 6-82 years). Overall survival was 38.7%. The 5-year survival was 74.2%; 10-year survival was 61.2%; and 15-year survival was 46.5%. Fifteen patients (24%) died of disease after 10 years of follow-up. Local recurrence occurred after a mean of 3.6 years (range 0.5-14.9 years) and metastases at a mean of 5.7 years (range 0.5-16.3 years). Only four patients were treated technically correctly with a planned biopsy followed by a wide resection or amputation. Factors associated with significantly worse prognosis included larger tumor size, metastases at the time of diagnosis, high-grade histology, trunk-related disease, and lack of wide resection as primary surgical treatment. Conclusions: In SS, metastases develop late with high mortality. Patients with SS should be followed for >10 years.

Flood of May 19, 1990, Along Perry Creek in Plymouth and Woodbury Counties, Iowa, HR-140, 1996

A water-surface-elevation profile and peak discharges for the flood of May 19, 1990, along Perry Creek in Plymouth and Woodbury Counties, Iowa, are presented in this report. The peak discharge for the May 19, 1990, flood on Perry Creek at 38th Street, Sioux City (06600000) is the second largest flood-peak discharge recorded at the streamflow-gaging station for the period 1939-95. The peak discharge for May 19, 1990, of 8,670 cubic feet per second, is approximately equal to the 35-year recurrence-interval discharge. The report provides information on flood stages and discharges and floodflow frequencies for streamflow- gaging stations in the Perry Creek Basin using flood information collected during 1939-95. Information on temporary bench marks and reference points established in the Perry Creek Basin during 1990-93 is also included in the report. A flood history describes rainfall conditions for the three largest floods that occurred during 1939-95 (July 1944, September 1949, and May 1990).

Floods of 1986 and 1990 in the Raccoon River Basin, West-Central Iowa, HR-140, 1992

Water-surface-elevation profiles and peak discharges for the floods of 1973 and 1979 are compared to those of 1986 and 1990 in the Raccoon River basin, west-central Iowa. The profiles illustrate the 1979 and 1986 floods on the Raccoon, South Raccoon, and Middle Raccoon Rivers, the 1973 and 1986 floods on Walnut Creek, and the 1986 flood on Willow Creek and Mosquito Creek. The 1986 flood is the largest on record at U.S. Geological Survey streamflowgaging stations on the Middle Raccoon River tributary at Carroll, Middle Raccoon River near Bayard, Middle Raccoon River at Panora, and Walnut Creek at Des Moines. The 1990 flood discharge is the largest on record at U.S. Geological Survey crest-stage gaging stations on Hardin Creek near Farlin and on East Fork Hardin Creek near Churdan. The flood history given in this report describes rainfall conditions for floods that occurred during 1986 and 1990. Discharge for the 1990 flood on East Fork Hardin Creek near Churdan was 1.01 times larger than the 100-year recurrence-interval discharge.

Floods of July 19-25, 1999, in the Wapsipinicon and Cedar River Basins, Northeast Iowa, HR-140

Severe flooding occurred during July 19-25, 1999, in the Wapsipinicon and Cedar River Basins following two thunderstorms over northeast Iowa. During July 18-19, as much as 6 inches ofrainfall was centered over Cerro Gordo, Floyd, Mitchell, and Worth Counties. During July 20-21, a second storm occurred in which an additional rainfall of as much as 8 inches was centered over Chickasaw and Floyd Counties. The cumulative effect of the storms produced floods with new maximum peak discharges at the following streamflow-gaging stations: Wapsipinicon River near Tripoli, 19,400 cubic feet per second; Cedar River at Charles City, 31,200 cubic feet per second (recurrence interval about 90 years); Cedar River at Janesville, 42,200 cubic feet per second (recurrence interval about 80 years); and Flood Creek near Powersville, 19,000 cubic feet per second. Profiles of flood elevations for the July 1999 flood are presented in this report for selected reaches along the Wapsipinicon, Cedar, and Shell Rock Rivers and along Flood Creek. Information about the river basins, rain storms, and flooding are presented along with information on temporary bench marks and reference points in the Wapsipinicon and Cedar River Basins.

Pacemaker therapy in patients with neurally mediated syncope and documented asystole: Third International Study on Syncope of Uncertain Etiology (ISSUE-3): a randomized trial.

BACKGROUND: The efficacy of cardiac pacing for prevention of syncopal recurrences in patients with neurally mediated syncope is controversial. We wanted to determine whether pacing therapy reduces syncopal recurrences in patients with severe asystolic neurally mediated syncope. METHODS AND RESULTS: Double-blind, randomized placebo-controlled study conducted in 29 centers in the Third International Study on Syncope of Uncertain Etiology (ISSUE-3) trial. Patients were ≥40 years, had experienced ≥3 syncopal episodes in the previous 2 years. Initially, 511 patients, received an implantable loop recorder; 89 of these had documentation of syncope with ≥3 s asystole or ≥6 s asystole without syncope within 12 ± 10 months and met criteria for pacemaker implantation; 77 of 89 patients were randomly assigned to dual-chamber pacing with rate drop response or to sensing only. The data were analyzed on intention-to-treat principle. There was syncope recurrence during follow-up in 27 patients, 19 of whom had been assigned to pacemaker OFF and 8 to pacemaker ON. The 2-year estimated syncope recurrence rate was 57% (95% CI, 40-74) with pacemaker OFF and 25% (95% CI, 13-45) with pacemaker ON (log rank: P=0.039 at the threshold of statistical significance of 0.04). The risk of recurrence was reduced by 57% (95% CI, 4-81). Five patients had procedural complications: lead dislodgment in 4 requiring correction and subclavian vein thrombosis in 1 patient. CONCLUSIONS: Dual-chamber permanent pacing is effective in reducing recurrence of syncope in patients ≥40 years with severe asystolic neurally mediated syncope. The observed 32% absolute and 57% relative reduction in syncope recurrence support this invasive treatment for the relatively benign neurally mediated syncope. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359203.

Hormonothérapie dans le cancer du sein: efficacité et effets adverses [Endocrine therapy in breast cancer: efficacy and adverse events].

Endocrine therapy remains a mainstay in the treatment of endocrine-sensitive breast cancer. In the adjuvant setting, 5 years of endocrine therapy significantly reduces recurrence rate and mortality. Tamoxifen is the molecule of choice for premenopausal women, whereas for postmenopausal women aromatase inhibitors are currently part of the standard treatment. Endocrine therapy can induce side effects, which can affect patient's quality of life and lead to premature treatment interruption. Identification and adequately addressing these side effects is fundamental to maintain good treatment compliance and therefore improve breast cancer specific outcome.

Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system.

OBJECTIVE: Most symptomatic chronic subdural hematomas are treated by subdural drainage. However, a subperiostal (i.e., extracranial) passive closed-drainage system in combination with double burr hole trepanation is used at our institution. Therefore, we wanted to analyze our results and compare them with the alternate treatment strategies reported in the current literature. METHODS: In a retrospective single-center study, we analyzed the data of all patients undergoing double burr hole trepanation with a subperiostal passive closed-drainage system. Data analysis included general patient data, complications, postoperative seizure rate, and outcome. RESULTS: One hundred forty-seven patients underwent surgery for 183 symptomatic chronic subdural hematomas. The perioperative mortality rate was 3.4%. Hematoma persistence or recurrence occurred in 13.1% of the cases. The postoperative seizure rate was 6.6%, and the infection rate was 1.6%, including 3 cases of superficial wound infection and 1 case with deep infection. The reintervention rate was 9.3%, including trepanation in 8.2% of the patients and craniotomy in 1.1%. The overall complication rate was 10.9%. CONCLUSION: Double burr hole trepanation combined with a subperiostal passive closed-drainage system is a technically easy, highly effective, safe, and cost-efficient treatment strategy for symptomatic chronic subdural hematomas. The absence of a drain in direct contact with the hematoma capsule may moderate the risk of postoperative seizure and limit the secondary spread of infection to intracranial compartments.