Predictors of long-term outcomes in patients with persistent atrial fibrillation undergoing electrical cardioversion.

Introduction: Cardioversion for atrial fibrillation (AF) is routinely implemented in daily practice; however, it can be associated with the development of recurrent AF. In this study we aimed to evaluate the predictors of AF recurrence after electrical cardioversion, and to compare the outcomes of patients with or without AF recurrence during follow-up. Methods: Patients with persistent AF were enrolled from March 2015 to September 2018. Patients with recurrent AF within 6 months after the index cardioversion were considered as AF recurrence (AFR) group, and those with normal sinus rhythm were defined as normal sinus rhythm (NSR) group. Thereafter, all patients were followed up for the incidence of adverse events, including death, requiring dialysis, coronary artery intervention/surgeries, cerebrovascular events, heart failure, and recurrent AF beyond 6 months. Results: Of 129 patients, 11 patients had failed cardioversion and 7 patients lost to follow-up. So, 34 and 77 patients were categorized as the NSR and the AFR groups. During a median follow-up time of 54 (46-75) months, there was a trend for a higher incidence of major adverse events in the AFR group compared to the NSR group (P=0.063). Lower body mass index (odds ratio [OR] 0.885, 95% confidence interval [CI] 0.794-0.986, P=0.027) and coarse AF before the index cardioversion (OR 3.846, 95% CI 1.189-12.443, P=0.025) were the independent predictors of recurrent AF. Conclusion: In patients with persistent AF undergoing cardioversion, the presence of coarse AF and the lower values of body mass index were found to be associated with the AF recurrence.

The effect of supplementary light on the photosynthetic apparatus of strawberry plants under salinity and alkalinity stress.

Considering the destructive effect of stresses on the photosynthetic apparatus of plants and the important role of light in photosynthesis, we investigated the effect of complementary light on the photosynthetic apparatus under salinity and alkalinity stress conditions. Light-emitting diodes (LEDs) in monochromatic blue (460 nm), monochromatic red (660 nm), dichromatic blue/red (1:3), white/yellow (400-700 nm) at 200 µmol m-2 S-1, and without LED treatment were used. The stress treatments were in three stages: Control (no stress), Alkalinity (40 mM NaHCO3), and Salinity (80 mM NaCl). Our results showed that salinity and alkaline stress reduced CO2 assimilation by 62.64% and 40.81%, respectively, compared to the control treatment. The blue light spectrum had the highest increase in water use efficiency (54%) compared to the treatment without supplementary light. Under salinity and alkalinity stress, L, K, and H bands increased and G bands decreased compared to the control treatment, with blue/red light causing the highest increase in L and K bands under both stress conditions. In salinity and alkalinity stress, white/yellow and blue/red spectra caused the highest increase in H bands. Complementary light spectra increased the G band compared to the treatment without complementary light. There was a significant decrease in power indices and quantum power parameters due to salt and alkalinity stress. The use of light spectra, especially blue, red, and blue/red light, increased these parameters compared with treatment without complementary light. Different light spectra have different effects on the photosynthetic apparatus of plants. It can be concluded that using red, blue spectra and their combination can increase the resistance of plants to stress conditions and be adopted as a strategy in planting plants under stress conditions.

How photoautotrophy, photomixotrophy, and ventilation affect the stomata and fluorescence emission of pistachios rootstock?

The effects of ventilation and sucrose concentration on proliferation and organogenesis of pistachio cutting and photosynthetic performance of two in vitro cultures of pistachio rootstocks have been assessed. The apical leaf buds (Qazvini and UCB1 cultivars) were cultured in filter vessels containing Murashige and Skoog medium supplemented with 0, 10, 15, and 30 g L -1 of sucrose. The plants treated with 10, 15, and 30 g L -1 sucrose showed no significant differences regarding the measured traits; therefore, this treatment was set aside from the final statistical analyses. Use of different ventilation systems showed to be suitable for increasing the growth of pistachio. Referring to root production difficulties under in vitro cultivation of pistachio, ventilation increased the root production and length. However, the full ventilation system was more effective in improving the growth properties. Regression between fluorescence feature vs root length showed that F v/F m had a significant positive relationship with root length. Stomata of cell parameters under ventilation systems improved compared to no ventilation, which was highly similar to the trend in the greenhouse. The overall results indicated that low concentrations of sucrose (e.g., 10 g L -1) and full ventilation are recommended for producing high quality and vigorous pistachio plantlets under in vitro conditions.

Prognostic value of fragmented QRS complex in patients with acute myocardial infarction.

BACKGROUND: Several factors and risk stratification tools have been studied to determine the prognosis of acute coronary syndrome. Fragmented QRS (fQRS) is a marker of myocardial scar and its prognostic role has recently been demonstrated. The present study aimed to investigate the association between the presence of fQRS in electrocardiogram and the prognosis of ST-segment elevation and non-ST-segment elevation myocardial infarction (STEMI and NSTEMI). METHODS: A total of 661 patients with myocardial infarction (MI) were enrolled in a retrospective study. Based on the presence of fQRS in admission electrocardiogram, patients were divided into two groups. All patients were followed up for 6 months, and all major adverse cardiovascular events (MACE) were recorded. RESULTS: The mean age of patients was 61.3 ± 1.2 years, and 71.7% were male. In the acute phase, the detection rates of regional wall motion abnormality and aortic valve insufficiency were higher in positive fQRS compared to negative fQRS group (p = 0.003). The incidence of total MACE was significantly higher in the positive fQRS compared to the negative fQRS group among all patients and in both STEMI and NSTEMI subgroups (p < 0.001). Based on multivariate analysis, the presence of fQRS and hypertension were the strongest predictors of total MACE at 6­month follow-up (odds ratio [OR] = 5.929; 95% confidence interval [CI] = 3.620-9.709; p < 0.001 and OR = 2.220; 95% CI = 1.390-3.547; p < 0.001, respectively). CONCLUSION: Regardless of the type of MI, it was found that the presence of fQRS on admission electrocardiogram can be implemented in risk stratification tools in patients with acute MI.

Fragmented QRS and subclinical left ventricular dysfunction in individuals with preserved ejection fraction: A speckle-tracking echocardiographic study.

INTRODUCTION: Fragmented QRS (fQRS) complex on routine 12-lead electrocardiogram (ECG) predicts adverse outcomes in patients with cardiovascular diseases. In addition, it has been found to be associated with subclinical myocardial dysfunction in chronic diseases. We sought to investigate the relationship between the presence of fQRS with the myocardial functions in individuals free from known systemic cardiovascular diseases. METHODS: In a case-control study, we evaluated normal individuals from March 2017 to February 2018. All participants underwent a 2-dimensional transthoracic echocardiographic examination using tissue Doppler imaging (TDI) and speckle-tracking echocardiography. In addition, all participants were examined using a 12-lead surface ECG, and patients with fQRS and a group of age- and sex-matched controls without fQRS were enrolled in our study. RESULTS: The patients' mean age was 40.3 ± 10.7 and 35.4 ± 11.2 years in fQRS-positive and fQRS-negative groups, respectively (P = .110). Patients with fQRS had significantly lower values of apical left ventricular global longitudinal strain (LV GLS) in 2-chamber (16.9 ± 2.5 vs. 20.5 ± 3.3, P < .001), 4-chamber (16.9 ± 3.4 vs. 20.1 ± 3, P = .001), LAX views (17.7 ± 2.8 vs. 20.8 ± 3.5, P = .001), and averaged LV GLS (17 ± 2.6 vs. 20.4 ± 2.7, P < .001) values compared to patients without fQRS. In a multivariate analysis, averaged LV GLS and smoking history were independent predictors for positive fQRS. CONCLUSION: The presence of fQRS on 12-lead ECG in healthy population was associated with lower values of LV GLS compared to normal individuals without fQRS.

Postoperative Atrial Fibrillation Following Cardiac Surgery: From Pathogenesis to Potential Therapies.

Postoperative atrial fibrillation (POAF) is a major complication after cardiac surgery which can lead to high rates of morbidity and mortality, an enhanced length of hospital stay, and an increased cost of care. POAF is postulated to be a multifactorial phenomenon; however, some major pathogeneses have been proposed, including inflammatory pathways, oxidative stress, and autonomic dysfunction. Genetic studies also showed that inflammatory pathways, beta-1 adrenoreceptor variants, G protein-coupled receptor kinase 5 gene variants, and non-coding single-nucleotide polymorphisms in the 4q25 chromosomal locus are involved in this phenomenon. Moreover, several predisposing factors lead to the development of POAF, consisting of pre-, intra-, and postoperative contributors. The main predisposing factors comprise age, prior history of major cardiovascular risk factors, and ischemia-reperfusion injury during surgery. The management of POAF is based on the usual therapies used for non-surgical AF, including medications for either rate control or rhythm control in hemodynamically unstable patients. The perioperative administration of ß-blockers and some antiarrhythmic agents has been recommended in major international guidelines. In addition, upstream therapies consisting of colchicine, magnesium, statins, and antioxidants have attenuated the incidence of POAF; however, some uncomfortable side effects developed in large randomized trials. The use of anticoagulation has also resulted in less mortality in patients with POAF at higher risk of thromboembolic events. Despite these recommendations, the actual regimen for the prevention of POAF remains controversial. In this review, we highlight the pathogenesis, predisposing factors, and potential therapeutic options for the management of patients at risk for or with POAF following cardiac surgery.

Experiences of students and faculty members about using virtual social networks in education: A qualitative content analysis.

INTRODUCTION: Virtual social networks are increasingly being used by academics and students in health sciences. It is necessary to examine opportunities and challenges of these networks based on the views of faculty and students to describe the existing situation and planning for proper use. The purpose of this study was to explore the experiences of students and faculty members about opportunities and challenges of using virtual social networks in education. METHODS: In this qualitative content analysis study, twenty-two semi-structured interviews were conducted with 8 faculty members and 14 students at Jahrom Universities of Medical Sciences. Participants were selected by purposive sampling. To analyze the data, an inductive content analysis method was used. The rigor of qualitative data was checked, using Guba and Lincoln's criteria. RESULTS: Five main categories were extracted from the data as opportunities for using virtual networks in education including improving communication skills; promoting learning; strengthening and facilitating learning of clinical procedures; creating research questions; and educating patients. Four main categories were also derived as challenges of using virtual networks in education including accuracy and validity of information; security and privacy; proper contextualization and culture-building; and control and monitor on virtual networks. CONCLUSION: According to the results, unique opportunities and challenges were explored regarding using virtual networks in education. These opportunities and challenges and finding ways to obviate challenges and converting it to the opportunities can lead to effective virtual learning, particularly in students who mainly use this method of education, and consequently increase the quality of learning.

Potential role of gender specific effect of leptin receptor deficiency in an extended consanguineous family with severe early-onset obesity.

Congenital Leptin receptor (LEPR) deficiency is a rare genetic cause of early-onset morbid obesity characterised by severe early onset obesity, major hyperphagia, hypogonadotropic hypogonadism and immune and neuroendocrine/metabolic dysfunction. We identified a homozygous loss-of-function mutation, NM_002303.5:c.464 T > G; p.(Tyr155*), in the LEPR in an extended consanguineous family with multiple individuals affected by early-onset severe obesity and hyperphagia. Interestingly, the LEPR-deficient adult females have extremely high body mass index (BMI) with hypogonadal infertility, the BMI of the affected males began to decline around the onset of puberty (13-15 years) with fertility being preserved. These findings lead to the speculation that LEPR deficiency may have a gender-specific effect on the regulation of body weight. In order to elucidate gender-specific effects of LEPR deficiency on reproduction further investigations are needed. The limitations of this study are that our conclusion is based on observations of two males and two females. Further LEPR deficient males and females are required for comparison in order to support this finding more confidently.

Program evaluation of an Integrated Basic Science Medical Curriculum in Shiraz Medical School, Using CIPP Evaluation Model.

INTRODUCTION: In recent years curriculum reform and integration was done in many medical schools. The integrated curriculum is a popular concept all over the world. In Shiraz medical school, the reform was initiated by stablishing the horizontal basic science integration model and Early Clinical Exposure (ECE) for undergraduate medical education. The purpose of this study was to provide the required data for the program evaluation of this curriculum for undergraduate medical students, using CIPP program evaluation model. METHODS: This study is an analytic descriptive and triangulation mixed method study which was carried out in Shiraz Medical School in 2012, based on the views of professors of basic sciences courses and first and second year medical students. The study evaluated the quality of the relationship between basic sciences and clinical courses and the method of presenting such courses based on the Context, Input, Process and Product (CIPP) model. The tools for collecting data, both quantitatively and qualitatively, were some questionnaires, content analysis of portfolios, semi- structured interview and brain storming sessions. For quantitative data analysis, SPSS software, version 14, was used. RESULTS: In the context evaluation by modified DREEM questionnaire, 77.75%of the students believed that this educational system encourages them to actively participate in classes. Course schedule and atmosphere of class were reported suitable by 87.81% and 83.86% of students. In input domain that was measured by a researcher made questionnaire, the facilities for education were acceptable except for shortage of cadavers. In process evaluation, the quality of integrated modules presentation and Early Clinical Exposure (ECE) was good from the students' viewpoint. In product evaluation, students' brain storming, students' portfolio and semi-structured interview with faculties were done, showing some positive aspects of integration and some areas that need improvement. CONCLUSION: The main advantage of assessing an educational program based on CIPP evaluation model is that the context, input, process and product of the program are viewed and evaluated systematically. This will help the educational authorities to make proper decisions based on the weaknesses and strengths of the program on its continuation, cessation and revision. Based on the results of this study, the integrated basic sciences course for undergraduate medical students in Shiraz Medical School is at a desirable level. However, attempts to improve or reform some sections and continual evaluation of the program and its accreditation seem to be necessary.

Medical students' academic emotions: the role of perceived learning environment.

INTRODUCTION: Research shows that there is a relationship between students' perceptions of classroom and learning environment and their cognitive, affective, emotional and behavioral outcomes, so, in this study the relationship between medical students' perception of learning environment and academic emotions was examined. METHOD: The research method used was descriptive-correlative. The statistical population consisted of medical students of Shiraz University of Medical Sciences. Stratified sampling method was used to select 342 participants. They completed self-report questionnaires of Dundee Ready Educational Environment Measure (DREEM) and Achievement Emotions Questionnaire (AEQ). All descriptive statistics, Pearson's correlations and simultaneous multiple regression were performed using SPSS 14 software. RESULTS: Simultaneous multiple regression of the students' perceived learning environment on their academic achievement emotions showed that the perceived learning environment predicts the students' academic emotions.

Plasmid DNA affinity partitioning using polyethylene glycol - sodium sulfate aqueous two-phase systems.

Extraction of plasmid DNA (pDNA) from an alkaline bacterial cell lysate has been investigated using partitioning and affinity partitioning in aqueous two-phase systems (ATPSs) containing 12% (w/w) polyethylene glycol and 12% (w/w) sodium sulfate. In this work, a modified 20bp pyrimidine oligonucleotide acting as a triplex-forming oligonucleotide (TFO) was employed as an affinity ligand to improve the partition behavior. The pUC118 plasmid was chosen to be extracted because of its specific oligonucleotide recognition sequence. In order to find the proper conditions, operational parameters such as PEG molecular weight, pH and lysate load were also studied. The results showed that adding the affinity ligand strongly changed the partitioning behavior of pDNA without any considerable impact on the partitioning of RNA and protein content. The best achieved result was at pH=6 and PEG MW of 600Da and 60% of lysate load. In these conditions, 67% of pDNA was recovered in the top phase while the contaminants mainly accumulated in the bottom phase.

Psychometric properties of the Persian version of the Ambulatory Care Learning Educational Environment Measure (ACLEEM) questionnaire, Shiraz, Iran.

PURPOSE: Evaluation is the main component in design and implementation of educational activities and rapid growth of educational institution programs. Outpatient medical education and clinical training environment is one of the most important parts of training of medical residents. This study aimed to determine the validity and reliability of the Persian version of Ambulatory Care Learning Educational Environment Measure (ACLEEM) questionnaire, as an instrument for assessment of educational environments in residency medical clinics. MATERIALS AND METHODS: This study was performed on 180 residents in Shiraz University of Medical Sciences, Shiraz, Iran, in 2014-2015. The questionnaire designers' electronic permission (by email) and the residents' verbal consent were obtained before distributing the questionnaires. The study data were gathered using ACLEEM questionnaire developed by Arnoldo Riquelme in 2013. The data were analyzed using the SPSS statistical software, version 14, and MedCalc® software. Then, the construct validity, including convergent and discriminant validities, of the Persian version of ACLEEM questionnaire was assessed. Its internal consistency was also checked by Cronbach's alpha coefficient. RESULTS: Five team members who were experts in medical education were consulted to test the cultural adaptation, linguistic equivalency, and content validity of the Persian version of the questionnaire. Content validity indexes were >0.9 in all items. In factor analysis of the instrument, the Kaiser-Meyer-Olkin index was 0.928 and Barlett's sphericity test yielded the following results: X2=6,717.551, df =1,225, and P≤0.001. Besides, Cronbach's alpha coefficient of ACLEEM questionnaire was 0.964. Cronbach's alpha coefficients were also >0.80 in all the three domains of the questionnaire. Overall, the Persian version of ACLEEM showed excellent convergent validity and acceptable discriminant validity, except for the clinical training domain. CONCLUSION: According to the results, the Persian version of ACLEEM questionnaire was a valid and reliable instrument for Iranian residents to assess specialized clinics and residency ambulatory settings.

White Blood Cell Count to Mean Platelet Volume Ratio Is a Prognostic Factor in Patients with Non-ST Elevation Acute Coronary Syndrome with or without Metabolic Syndrome.

BACKGROUND AND OBJECTIVES: Leukocyte and platelet have been found to be associated with metabolic syndrome (MetS). We aimed to determine the usefulness of a novel marker named white blood cell count to mean platelet volume ratio (WMR) for predicting outcomes of non-ST elevation acute coronary syndrome (NSTE-ACS) with or without MetS. SUBJECTS AND METHODS: A total of 331 NSTE-ACS individuals (60±12.5 years, 57.4% male) were enrolled and followed for a median of 24 months. MetS was identified using the National Cholesterol Education Program Adult Treatment Panel III criteria. RESULTS: Patients were divided into two groups: high WMR (WMR≥720) and low WMR (WMR<720). Major adverse cardiovascular events (MACE) and MetS rates were significantly greater in the higher WMR group compared to those in the low WMR group (MACE: 14.3% vs. 25%, p=0.014; MetS: 50.9% vs. 75%, p<0.001). MetS was diagnosed in 62.2% of patients. MACE incidence in patients with or without MetS was comparable (p=0.737). Among MetS individuals, patients in the high WMR group had more MACE than the low WMR group (11.2% vs. 26.5%, p=0.007). However, MACE was comparable among non-MetS individuals (p=0.681). In multivariable Cox regression analysis, hazard ratios (HR) of MACE incidence for high-WMR in MetS individuals was 2.616 (95% confidence interval: 1.282-5.339, p=0.008). However, HR of MACE incidence for high WMR in non-MetS individuals was not significant. CONCLUSION: Among NSTE-ACS patients without revascularization therapy, elevated admission WMR was associated with an increased risk of developing composite MACE in MetS individuals but not in non-MetS patients.

Statin Antiarrhythmic Effect on Atrial Fibrillation in Statin-Naive Patients Undergoing Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Statin therapy has been thought to improve outcomes in cardiac surgeries. We aimed to determine the statin effects on the development of postoperative atrial fibrillation (AF), hospital length of stay (LOS), and inflammatory status in patients undergoing cardiac surgeries. METHODS: A systematic literature search in databases was performed, until January 2015. Randomized clinical trial (RCT) studies evaluating statin effect on statin-naive patients with sinus rhythm undergoing cardiac surgeries were eligible to be analyzed. RESULTS: Twelve RCTs involving 1116 patients, 559 receiving statin and 557 receiving control regimen, were analyzed. Postoperative AF occurred in 17.9% and 36.1% of patients in the statin and control groups, respectively. The statin therapy was associated with decreases in the postoperative AF (risk ratio [RR] 0.50, 95% confidence interval [CI] 0.41-0.61, P < .000010), hospital LOS (mean difference in days, RR -0.44, 95% CI -0.67 to -0.20, P = .0002), and postoperative C-reactive protein (CRP) compared with control (mean difference in mg/L, RR -12.37, 95% CI -23.87 to -0.87, P = .04). The beneficial effects on AF and CRP were more marked in patients receiving atorvastatin compared to other statins. Decrease in postoperative AF was greater in coronary artery bypass graft surgery compared to that in isolated valvular surgery. CONCLUSION: Perioperative statin therapy in statin-naive patients with sinus rhythm undergoing cardiac surgeries was associated with decreases in the development of postoperative AF, the hospital LOS, and the CRP level. However, there were insufficient data to provide evidences regarding statin impacts in patients undergoing isolated valvular surgery.

White blood cell count to mean platelet volume ratio as a novel non-invasive marker predicting long-term outcomes in patients with non-ST elevation acute coronary syndrome.

BACKGROUND: Total white blood cell (WBC) count and mean platelet volume have previously been shown to predict outcomes in acute coronary syndrome (ACS) patients. In this prospective study, we sought to determine the prognostic value of baseline WBC count to mean platelet volume ratio (WMR) in patients with non-ST elevation acute coronary syndrome (NSTE-ACS). METHODS: A total of 490 patients with NSTE-ACS were prospectively enrolled. The relationship between baseline WMR and major adverse cardiovascular events (MACE) incidence was assessed during a mean follow-up of 330.8 ± 38 days. RESULTS: The patients' mean age was 60.4 ± 12.9 year, 59% of them were male. The patients were categorized into two groups based on WMR values, high- and low-WMR groups (< 755 vs. ≥ 755). The incidence of MACE was significantly higher in high-WMR compared with that of low-WMR group (22.4% vs. 10.7%, p < 0.001). Total WBC counts (median 7.9 vs. 6.9 ×103/µL, p = 0.004), neutrophil count (median 4.6 vs. 4.2 ×103/µL, p = 0.021), and WMR (median 863.2 vs. 731.5, p = 0.001) were significantly higher in the MACE-positive than MACE-negative group. The high-WMR was found to be significantly associated with the MACE-free survival rate (p < 0.001). In an adjusted cox regression model, the elevated WMR was independently predicted the incidence of MACE (hazard ratio 2.419, 95% CI 1.515-3.862, p < 0.001). CONCLUSIONS: The elevated baseline WMR independently predicted the MACE incidence in patients with NSTE-ACS during long-term follow-up.