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[Biphasic low-energy internal cardioversion in atrial fibrillation induced during electrophysiologic study].

INTRODUCTION: Atrial fibrillation is observed in 10% of electrophysiological studies. Previous studies have shown the efficacy of biphasic low energy internal cardioversion to restore sinus rhythm. We studied the efficacy and safety of low-energy internal cardioversion and the biphasic curve, in sustained atrial fibrillation (>15 min) during electrophysiologic procedures. MATERIALS AND METHODS: From January 1997 to August 1998, 320 patients underwent an electrophysiological study. An internal cardioversion was done on those patients who developed sustained atrial fibrillation. We delivered biphasic shocks between electrodes-catheters positioned in the right atrium and the coronary sinus. Increasing energy was applied until restoration of sinus rhythm or a maximum of 10 joules were achieved with no result. A right ventricle electrode was used to synchronize the V wave and for temporary pacing. RESULTS: Thirty one episodes of sustained atrial fibrillation were observed in 26 patients (1,23 episodes/patient) and a mean of 2,58 internal cardioversions were applied per every patient. Sinus rhythm was restored in twenty three patients. The mean energy delivered was 4.1 joules. The mean time for the recovery was 3,200 ms. Temporary pacing was used in 16% of the patients for up to 1 minute. No AV blocks were observed. CONCLUSIONS: Internal cardioversion successfully restored sinus rhythm in 88.5% of the patients who presented sustained atrial fibrillation (88.5%). Temporary pacing was necessary for the treatment of postsinus shock pauses.

Adult↗

Interferon-gamma gene polymorphisms and the development of sepsis in patients with trauma.

BACKGROUND: The outcome of patients with trauma does not always correlate with injury severity or premorbid health status. This study evaluates the relationship between polymorphisms in the first intron of the interferon-gamma gene and the development of sepsis after trauma. METHODS: DNA was extracted from peripheral leukocytes of patients with trauma and an injury severity score of 16 or greater. Data collected included demographics, injury mechanism, injuries sustained, development of sepsis, and outcome. A previously identified cytosine/adenine repeated polymorphism was amplified, alleles/genotypes identified, and the results correlated with patient outcome. RESULTS: Sixty-one patients were evaluated. Thirty patients (49%) became septic. The injury severity score, race, age, and gender distribution was similar for both the septic and nonseptic groups. Six alleles and 10 genotypes were identified. Alleles C (34%) and D (52%) were the most common. Patients who were septic had a 62% chance of having a D allele (P =.06), whereas they had only a 29% chance of having a C allele. Homozygotes for allele D (DD) were the most likely to become septic (65%). CONCLUSIONS: Homozygotes for the D allele (DD) of the interferon-gamma gene have an increased chance of developing sepsis after traumatic injury compared with other allelic combinations. This supports the hypothesis that genetic composition plays a role in patient outcome.

Adult↗

Methodology of management of dredging operations I. Conceptual developments.

This article presents a new methodology for the management of dredging operations. Partly derived from existing methodologies (OECD, UNEP, AIPCN), its aim is to be more complete, by integrating the qualities and complementarities of former methodologies. Moreover, it was carried out in a context of sustainable development. Indeed, it supports, according to a framework of industrial ecology, the development and the implementation of solutions of waste improvement of dredged materials, in order to minimize the environmental impact of dredging. It also uses a tool of MultiCriteria Decision-Making Aid (M.C.D.M.A.), in order to integrate local characteristics. In addition, this tool, called DRAGSED, allows to a dialogue to be established between all the parties concerned with a dredging project (harbour's authorities, industrialists, municipalities, administrations, populations, associations,...). Thus, the implementation of this methodology enables consensus to be reached for the dredging solution retained. It also proposes an environmental follow-up, which will allow an evaluation during its application.

Algorithms↗

Population and water are vital to the existence and development of China: Mme. Lei Jiegiang.

The seminar was opened by Mme. Lei Jiegiang, Deputy Speaker of the Standing Committee NPC. She said that "the per capital ownership of the water resources is only one-fourth of the world average, the 110th place in the world. Therefore, population growth control, economical utilization of resources, and environmental protection are fundamental channels to realize the socioeconomic development in our country." China is a country where water resources are not sufficient, causing a shortage of water in many areas. Furthermore, the water in some areas has been severely polluted. With the increase of population and the development of economy, the contradiction between population size and water resources is expected to increase. Mme. Jiegiang suggested that "we should encourage the establishment of a calculation system of water resources in order to save water. In addition, we should begin to treat pollution and strengthen the economic regulation of water resources." She concluded her speech by stating that "Population and Water Resources are two major issues that are closely related and needed to attain the 21st century modernization and they are vital to the existence and development of the Chinese Nation. As the population in China occupies 22% of the world total, a well solved population and water resources in China will be great contribution not only for the sustainable development of China, but also to the peace and development of Asia and the world."

Asia↗

Sustained bacteremia associated with transjugular intrahepatic portosystemic shunt (TIPS).

Transjugular intrahepatic portosystemic shunt (TIPS) has become a routine procedure in patients with portal hypertension, yet there are few data concerning the incidence of bacteremia associated with this shunt. All patients who underwent TIPS placement at a university hospital from January 1992 through January 1999 were studied. Ninety-nine TIPS were placed, and 10 patients subsequently developed sustained bacteremia; 5 patients had no identifiable source of bacteremia despite rigorous evaluation and were presumed to represent TIPS infections, for an estimated annual incidence of 7 cases/1000 TIPS procedures. Case patients developed bacteremia a median of 100 days after TIPS placement (range, 6-732 days). Bacteremia resolved in all patients after treatment with appropriate intravenous antibiotics (median, 2 weeks of therapy). Although the incidence of TIPS-associated bacteremia appears low, the increasing frequency of this procedure suggests that more information is needed to define this entity and to develop appropriate treatment recommendations.

Adult↗

Industrial estate planning and management in India--an integrated approach towards industrial ecology.

Industrial estates (IE) are today perceived as an integral part of development strategies of many countries worldwide. The environmental impacts from a concentration of large number of industries in a small area or unplanned IE, can pose a serious threat to both local and global sustainable development initiatives. The formation of ecologically balanced industrial systems can result in numerous environmental and economic benefits. This paper examines the relevance of industrial symbiosis and carrying capacity concepts and proposes an integrated approach towards IE planning in India based on grouping combinations of industries based on carrying capacity, formation of green industrial townships, development of environmental impact assessment guidelines for IE and implementation of environmental management systems.

Conservation of Natural Resources↗

Relation of syncope in young patients with Wolff-Parkinson-White syndrome to rapid ventricular response during atrial fibrillation.

Syncope in patients due to Wolff-Parkinson-White (WPW) syndrome may be related either to a rapid rate of supraventricular tachycardia or to rapid ventricular response over the accessory pathway during atrial fibrillation (AF). From 1982 to 1987, 74 patients less than or equal to 25 years old (mean age 12.6 years) with WPW syndrome on electrocardiogram underwent electrophysiologic study. Of the 74 patients, 14 (19%) had a history of syncope. During electrophysiologic study 9 of 14 patients with syncope had sustained (greater than 5 minutes or requiring termination due to hypotension) AF. Of the remaining 5 patients, 3 had inducible nonsustained AF and 2 had no AF. None of the 60 patients without syncope developed sustained AF; 34 had nonsustained and 26 had no AF. Occurrence of sustained AF had a sensitivity of 64% and specificity of 100% for history of syncope. All patients with syncope and AF (12) had a short RR interval between 2 consecutive preexcited QRS complexes during AF at less than or equal to 220 ms, in contrast to 9 of 34 patients without syncope (p less than 0.001, sensitivity 100%, specificity 74%). No patient with a short RR interval between 2 consecutive preexcited QRS complexes during AF of greater than 220 ms had a history of syncope. Thus, in these young patients with WPW syndrome, occurrence of AF with a rapid ventricular response during electrophysiologic study correlated well with a history of syncope and may be the cause of syncope in most patients. Electrophysiologic study may be helpful in identification of young patients with WPW at risk for syncope.

Adolescent↗

Sustainable ecosystem management using optimal control theory: part 1 (deterministic systems).

The concept of sustainability, an abstract one by its nature, has been given a mathematical representation through the use of Fisher information as a measure. It is used to propose the sustainability hypotheses for dynamical systems, which has paved the way to achieve sustainable development through externally enforced control schemes. For natural systems, this refers to the task of ecosystem management, which is complicated due the lack of clear objectives. This work attempts to incorporate the idea of sustainability in ecosystem management. The natural regulation of ecosystems suggests two possible control options, top-down control and bottom-up control. A comparison of these two control philosophies is made on generic food chain models using the objectives derived from the sustainability hypotheses. Optimal control theory is used to derive the control profiles to handle the complex nature of the models and the objectives. The results indicate a strong relationship between the hypotheses and the dynamic behavior of the models, supporting the use of Fisher information as a measure. As regards to ecosystem management, it has been observed that top-down control is more aggressive but can result in instability, while bottom-up control is guaranteed to give a stable and improved dynamic response. The results also indicate that bottom-up control is a better option to affect shifts in the dynamic regimes of a system, which may be required to recover the system from a natural disaster like the hurricane Katrina.

Animals↗

Participants' perceptions of a lifestyle approach to promoting physical activity: targeting deprived communities in Kingston-upon-Hull.

BACKGROUND: The health benefits of an active lifestyle have been extensively documented and generally accepted. In the UK, declining physical activity levels are a major contributing factor to a number of public health concerns such as obesity and coronary heart disease. Clearly, there is an urgent need to support people in developing sustainable active lifestyles. In 2003, a new lifestyle-based physical activity service called Active Lifestyles (AL) was set up in Kingston-upon-Hull to help local residents to become more active and develop healthier lifestyles. The service targeted the most deprived communities in the city. The aim of the study was to explore participants' perceptions of the operation and effectiveness of the AL service. METHODS: Five focus groups were conducted in community centres and offices in the health promotion service in Kingston-upon-Hull. Sixteen white adult males (n = 5) and females (n = 11) participated in the study. Ages ranged from 15-73 years (mean age = 53 years). Data were analysed using a content analysis technique based on the 'framework' approach. RESULTS: Three broad themes emerged from the focus groups; the referral process; operational aspects of the AL service; and perceived benefits of the service. Overall, participants were extremely positive about the AL service. Many reported increased activity levels, modified eating habits, and enhanced awareness and education regarding healthier living. Most participants reported that local awareness of the AL service was low and greater promotion was required so more people could benefit. The success of the service was highly dependent upon the qualities and approach of the AL advisor. CONCLUSION: The service appears to have filled a gap in service provision since it offered support to the most sedentary, older, unfit and overweight individuals, many of whom live in the most deprived parts of Kingston-upon-Hull. Traditional exercise referral schemes that focus solely on facility-based exercise should be broadened to encompass everyday lifestyle activity, where referral to a gym or exercise facility is just one of a number of physical activity options.

Adolescent↗

Redox activation of intracellular calcium release channels (ryanodine receptors) in the sustained phase of hypoxia-induced pulmonary vasoconstriction.

Hypoxia-induced pulmonary vasoconstriction (HPV) is an important adaptive process that remains incompletely understood. In preconstricted rat pulmonary arteries (inner diameter, 250 to 400 microm), hypoxia (pO2 approximately 10 mm Hg) induces an initial transient phase and a more slowly developing sustained phase of vasoconstriction. Since the release of calcium ions (Ca2+) from intracellular stores by redox-sensitive intracellular Ca2+ release channels known as ryanodine receptors (RyRs) in pulmonary arterial smooth-muscle cells (PASMCs) may play a role in HPV, and considerable evidence now supports that levels of reactive oxygen species (ROS) are paradoxically increased in PASMC under hypoxia, we investigated whether redox activation of RyRs by ROS may transduce HPV. By reverse transcriptase-polymerase chain reaction, we found that all three RyR isoforms are expressed in rat pulmonary arteries and in PASMCs. The sustained phase, but not the transient phase, of HPV can be prevented by pretreating pulmonary arteries with RyR inhibitors ryanodine (200 micromol/L) or dantrolene (50 micromol/L). The addition of dantrolene, ryanodine or the thiol-reducing agent dithiothreitol (1 mmol/L) during the sustained phase of HPV reversed the hypoxic vasoconstriction. In contrast, the superoxide scavenger nitroblue tetrazolium (500 nmol/L) prevented further hypoxic pulmonary vasoconstriction during the sustained phase of HPV but did not reverse it. Taken together, our data suggest that redox activation of RyRs by ROS has an important role in transducing the sustained contraction of pulmonary arteries under hypoxia.

Animals↗

Synergy between Competitive Intelligence (CI), Knowledge Management (KM) and Technological Foresight (TF) as a strategic model of prospecting--the use of biotechnology in the development of drugs against breast cancer.

The aim of this paper is to demonstrate the synergy between Competitive Intelligence, Knowledge Management and Technological Foresight, and to emphasize the proposal of a strategic model of data prospecting as a mechanism to support decision-making in regard to three approaches for sustainable development and innovation: technological, social and economic. The use of biotechnology in the development of drugs against breast cancer is the case study. The article shows the results of data and text mining in specialized medical and patent databases, identifying the most frequently cited drugs, as well as the authors of research, and the inventors of new technology at the beginning of the 21st century. In addition, the study includes reference to Brazilian competence in breast cancer area, the international trends in drugs for treatment of this cancer, leading international institutions and Brazilian competencies. A framework is presented, which could serve as a guide and support for the decision-making process.

Biotechnology↗

Getting serious about sustainability.

Sustainability and sustainable development are catchwords that dominate today's environmental science and policy discourse. It is easy to demonstrate that most of the activities of today's industrial society are unsustainable. Unfortunately, much of the talk about sustainability lacks a basic understanding of what truly sustainable activity would be. To set sustainability as a target or goal for our industrial society, we must be able to quantify that target or goal. We propose four basic steps to begin this process for one aspect of sustainability, the rate of use of resources: (i) establish the available supply of the chosen resource; (ii) allocate the annual permissible supply according to a reasonable formula or market process; (iii) establish the "recaptureable" resource base; and (iv) derive the sustainable limiting rate of use and compare to the current rate of use. We apply these sustainability measurement methods to three common materials in industrial society: zinc, germanium, and greenhouse gases. These examples demonstrate that with some basic (although potentially controversial) assumptions, quantitative sustainable use goals can be set and current performance relative to those goals can be evaluated. The assumptions and approximates we have used are meant to stimulate thought and debate, beginning a long conversation on the measurement of sustainability.

Conservation of Natural Resources↗

Pulmonary targeting of sustained release formulation of budesonide in neonatal rats.

Systemic corticosteroids are widely used for the treatment/prevention of chronic lung disease (CLD) in premature infants. The use of the inhalation route for delivering corticosteroids has been widely recognized, however so far pre-term babies continue to be treated with oral glucocorticoids, such as dexamethasone. We hypothesize that the pulmonary administration of sustained release formulations of inhaled corticosteroids to pre-term infants will result in a higher benefit/risk ratio as compared to traditional inhalation therapy. To achieve a slow release formulation budesonide particles were coated with a very thin film of polylactic acid using a pulse laser ablation technique. Coated material was characterized with respect to the dissolution behavior and particle size. Ex vivo receptor binding studies were performed to monitor the cumulative lung, liver and brain receptor occupancies after adminstration in neonatal (10-11 days old) rats after intratracheal instillation of either uncoated budesonide or poly (l-lactic acid) (PLA) coated budesonide. The mean dissolution timed for the uncoated and the polymer coated formulations were 1.2 +/- 0.5 and 4.7 +/- 0.1 h, respectively (p < 0.05). No significant differences in the respirable fraction were found between coated and uncoated formulation (p>0.05). The average receptor occupancies in the lung, liver and brain after administration of uncoated budesonide were 58.4 +/- 12.9, 56.4 +/- 6.8 and 38.3 +/- 6.7%, respectively. However, after administration of PLA coated budesonide, the average AUC estimates in the lung, liver and brain were 75.8 +/- 3.7%, 46.6 +/- 14.5 and 29 +/- 7, respectively. The results from our study suggest sustained receptor occupancy in the lungs of neonatal rats after administration of PLA coated budesonide results in lower systemic exposure (as indicated by low liver receptor occupancy). The data strongly underscore the urgent need to develop sustained release pulmonary-targeted delivery systems of corticosteroids for the treatment of CLD in pre-term infants. The administration of inhaled corticosteroids using targeted drug-delivery systems will potentially result in higher local effects and a reduction in systemic exposure.

Animals↗

This is more difficult than we thought! The responsibility of scientists, managers and stakeholders to mitigate the unsustainability of marine fisheries.

The management of marine fisheries needs to undergo dramatic change in the new millennium, in response to the well-documented evidence of global overfishing and the general depletion of commercial fish stocks. The axioms of sustainable development and equilibrium productivity of wild ecosystems are identified as misleading concepts, which nonetheless underlie current approaches to the management of living marine resources. Current trends in marine fisheries landings worldwide provide little evidence of sustainability of marine resources under current management paradigms, where biological, economic and social aspects of fisheries are usually treated as different disciplines. While open-access conditions are less widespread than formerly, except for many straddling and highly migratory resources, fishers usually have access to the resource year-round throughout its range. Despite quotas, the nominal control of capacity and technical measures protecting juveniles, top-down management has generally been unable to prevent stock depletion, particularly of the older spawners that for demersal stocks often support recruitment. An integrated solution to the complexity of managing wild resources seems not to have been achieved. Any new paradigm should assert the basic unpredictability of fisheries at the system level and require a broader range of performance indicators to be incorporated into the decisional framework. This must reflect the non-equilibrium nature of marine systems, and give greater importance to resource (as opposed to harvest) continuity in the face of regime shifts, and promote habitat restoration and conservation of genetic resources. The new management framework requires co-management and collective decision-making to be incorporated within a precautionary and pre-negotiated management framework. This must explicitly recognize that decision-making occurs in conditions of model-based uncertainty and precautionary approaches should be incorporated at all levels, not least of which is to avoid the assumption that all resources can be harvested in a sustainable fashion through time. Redundancy in data inputs to management are needed to avoid the surprises that model-based sampling occasionally leads to, for example, when regime changes reduce productivity in response to climatic fluctuations. Emergency frameworks imposing non-discretionary rules must be invoked when overfishing and/or regime change trigger reference points indicating stock depletion. Non-discretionary recovery plans should then override rights-based systems and persist until fish populations recover to pre-established healthy levels, which may in turn need to await the return of a favourable regime. In fact, some stocks may require periodic rebuilding after regime-induced collapses or because of a combination of ecological or economic impacts, hence a constant harvest policy may not always be possible. It will probably also be necessary to discard the axiom that a stock should be available to harvesting throughout its range and seasonal cycle. Technological advances mean that time- and area-specific access rights are now practical options, through satellite monitoring of vessel operations, even offshore. More fundamentally, the basic axiom of "enlightened self interest" underlying current methods of management will need to be tempered by an increased ethical concern for the fragility of natural ecosystems.

Animals↗

Neglected diseases of neglected populations: thinking to reshape the determinants of health in Latin America and the Caribbean.

BACKGROUND: People living in poverty throughout the developing world are heavily burdened with neglected communicable diseases and often marginalized by the health sector. These diseases are currently referred to as Neglected Diseases of Neglected Populations. The neglected diseases create social and financial burdens to the individual, the family, the community, and the nation. DISCUSSION: Numerous studies of successful individual interventions to manage communicable disease determinants in various types of communities have been published, but few have applied multiple interventions in an integrated, coordinated manner. We have identified a series of successful interventions and developed three hypothetical scenarios where such interventions could be applied in an integrated, multi-disease, inter-programmatic, and/or inter-sectoral approach for prevention and control of neglected diseases in three different populations: a slum, an indigenous community, and a city with a mix of populations. SUMMARY: The objective of this paper is to identify new opportunities to address neglected diseases, improve community health and promote sustainable development in neglected populations by highlighting examples of key risk and protective factors for neglected diseases which can be managed and implemented through multi-disease-based, integrated, inter-programmatic, and/or inter-sectoral approaches. Based on a literature review, analysis and development of scenarios we visualize how multiple interventions could manage multiple disease problems and propose these as possible strategies to be tested. We seek to stimulate intra- and inter-sectoral dialogue which will help in the construction of new strategies for neglected diseases (particularly for the parasitic diseases) which could benefit the poor and marginalized based on the principle of sustainability and understanding of key determinants of health, and lead to the establishment of pilot projects and activities which can contribute to the achievement of the Millennium Development Goals.

Animals↗

Sustainable ecosystem management using optimal control theory: part 2 (stochastic systems).

Sustainable development of ecosystems through external ecosystem management is assuming importance for the environmentalists. To that effect, previous work by the authors looked at the option of manipulating population dynamics of the species in an ecosystem to achieve sustainability. Fisher information is used as the quantifying measure of sustainability and optimal control theory is used to derive the control profiles. However, that work considered only deterministic systems. Uncertainty being prevalent in all systems, particularly in natural systems, this paper extends that work to analyse uncertain systems. Predator-prey models are used to model the species populations and different control philosophies are compared. Ito mean reverting process is used to model the stochastic process, and stochastic maximum principle is used to derive the control profiles. The results for the objective of FI variance minimization qualitatively agree with those for the deterministic system, while the results for the FI maximization objective differ. It is observed that the instability associated with the FI maximization objective for deterministic systems is absorbed by the noise introduced by the uncertainty. Quantitatively, it is observed that the degree of uncertainty, along with its presence, is also important to identify the most appropriate management strategy.

Animals↗

Bridging the "system's" gap between interprofessional care and patient safety: sociological insights.

This paper is based on the premise that a systemic approach is the crucial link between patient safety and interprofessional care. It is argued that there has been little concern with regard to the need for a critical assessment and development of a systems' theoretical model able to envisage the broad approach of delivery of health care that patient safety initiatives require. Based on a medical sociology approach, the paper analyzes four forces that threaten a well sustained development of research and problem-solving strategic proposals that are to be derived from the intersection of patient safety and interprofessional care, namely: (i) the absence of explicit theoretical models in empirical research work in both fields; (ii) the a-critical acceptance of an ideologically limited biomedical paradigm in the actual systemic definitions of the clinical model; (iii) a fragmentation of the underlying system concept that is unable to include all of the actors of the system; and, (iv) the need to go beyond the non-maleficence principle and include the remaining three bioethical principles in medical care. The paper concludes with the proposal of developing theoretically grounded empirical interprofessional research that allows the crucial inclusion of social sciences in the systemic approach.

Ethics, Clinical↗

Arrhythmogenic effects of antiarrhythmic drugs in patients with an old myocardial infarction and asymptomatic ventricular ectopic activity as studied by programmed electrical stimulation.

In 22 patients with a previous myocardial infarction and documented Lown class II to IV asymptomatic ventricular arrhythmias, the arrhythmogenic effect of mexiletine (18 patients) and propafenone (10 patients) has been assessed by programmed electrical stimulation. Ventricular arrhythmias induced during the basal study were: repetitive ventricular responses (RVR) (11/22, 50%), nonsustained ventricular tachycardia (VT) (3/22, 14%), sustained VT (7/22, 32%) and ventricular fibrillation (VF) (1/22, 4%). The induction of sustained VT or VF increased to 50% after mexiletine and to 80% following propafenone. An arrhythmogenic effect was found in 7/11 patients (64%) without VT at the control study (P = 0.004). One patient of this group spontaneously developed sustained VT both after mexiletine and propafenone. Only 1/8 patients (13%) with sustained VT/VF at the basal study had RVR after drug administration. The R-R interval of sustained VT at the basal state tended to be faster than that after the drugs (260 +/- 60 ms vs 293 +/- 56 and 332 +/- 77 ms for mexiletine and propafenone, respectively) (P = 0.052). Statistical significance was only reached in the propafenone group (P = 0.03). Facilitation of VT induction after antiarrhythmic drugs is most likely due to a modest lengthening of refractoriness in contrast with a more evident reduction in conduction velocity within the reentry pathway. Our study illustrates that treating asymptomatic ventricular ectopic activity in patients with an old myocardial infarction may be dangerous and that antiarrhythmic drugs show a significant arrhythmogenic potential at least in the laboratory setting.

Adult↗