Flecainide toxicity with high pacemaker capture thresholds and associated takotsubo syndrome.

We describe a case of a woman in her 80s with persistent atrial fibrillation (AF) despite being on flecainide who was admitted for AF with rapid ventricular response. Attempts with direct-current cardioversions were unsuccessful despite increased doses of the antiarrhythmic therapy. At atrioventricular (AV) nodal ablation, very high right ventricular capture thresholds resulted in abortion of the procedure as back-up ventricular pacing could not be assured with adequate margin for safety. Shortly following the electrophysiology (EP) study, the patient developed cardiogenic shock with new apical left ventricular regional wall motion abnormality suggestive of apical ballooning and a toxic-appearing wide QRS complex electrocardiogram (EKG). The patient was successfully treated with sodium bicarbonate infusion for presumed flecainide toxicity. The regional wall motion abnormality and EKG changes resolved along with normalisation of capture thresholds after 2 days of treatment. The patient underwent an uncomplicated successful AV nodal ablation several weeks later.

Low-Temperature Molten-Salt Production of Silicon Nanowires by the Electrochemical Reduction of CaSiO3.

Silicon is an extremely important technological material, but its current industrial production by the carbothermic reduction of SiO2 is energy intensive and generates CO2 emissions. Herein, we developed a more sustainable method to produce silicon nanowires (Si NWs) in bulk quantities through the direct electrochemical reduction of CaSiO3 , an abundant and inexpensive Si source soluble in molten salts, at a low temperature of 650 °C by using low-melting-point ternary molten salts CaCl2 -MgCl2 -NaCl, which still retains high CaSiO3 solubility, and a supporting electrolyte of CaO, which facilitates the transport of O2- anions, drastically improves the reaction kinetics, and enables the electrolysis at low temperatures. The Si nanowire product can be used as high-capacity Li-ion battery anode materials with excellent cycling performance. This environmentally friendly strategy for the practical production of Si at lower temperatures can be applied to other molten salt systems and is also promising for waste glass and coal ash recycling.

Missed opportunity for anticoagulation in a patient with AL cardiac amyloidosis and rapidly progressive heart failure.

A previously healthy 65-year-old woman presented with progressive symptoms of heart failure. Low-voltage ECG and findings on echocardiography were concerning for infiltrative cardiomyopathy. Cardiac MRI showed biventricular late gadolinium enhancement, and endomyocardial biopsy confirmed monoclonal immunoglobulin light-chain (AL) amyloidosis. Bortezomib-based chemotherapy was initiated, but the patient continued to clinically deteriorate. She required hospital readmission after resuscitated out-of-hospital cardiac arrest attributed to progressive conduction disease, and a permanent pacemaker was implanted. Chest CT angiography showed a small subsegmental pulmonary embolism (PE), but anticoagulation was withheld as her lower extremity Doppler was negative. One month later, another pulseless electrical arrest occurred, due to massive PE. Thereafter, she had refractory class IV congestive heart failure with severe right ventricular dysfunction, and was deemed unsuitable for stem-cell or heart transplantation. This case highlights the predilection for thromboembolism in AL cardiac amyloidosis.

Twisting phonons in complex crystals with quasi-one-dimensional substructures.

A variety of crystals contain quasi-one-dimensional substructures, which yield distinctive electronic, spintronic, optical and thermoelectric properties. There is a lack of understanding of the lattice dynamics that influences the properties of such complex crystals. Here we employ inelastic neutron scatting measurements and density functional theory calculations to show that numerous low-energy optical vibrational modes exist in higher manganese silicides, an example of such crystals. These optical modes, including unusually low-frequency twisting motions of the Si ladders inside the Mn chimneys, provide a large phase space for scattering acoustic phonons. A hybrid phonon and diffuson model is proposed to explain the low and anisotropic thermal conductivity of higher manganese silicides and to evaluate nanostructuring as an approach to further suppress the thermal conductivity and enhance the thermoelectric energy conversion efficiency. This discovery offers new insights into the structure-property relationships of a broad class of materials with quasi-one-dimensional substructures for various applications.

High-purity iron pyrite (FeS2) nanowires as high-capacity nanostructured cathodes for lithium-ion batteries.

Iron pyrite is an earth-abundant and inexpensive material that has long been interesting for electrochemical energy storage and solar energy conversion. A large-scale conversion synthesis of phase-pure pyrite nanowires has been developed for the first time. Nano-pyrite cathodes exhibited high Li-storage capacity and excellent capacity retention in Li/pyrite batteries using a liquid electrolyte, which retained a discharge capacity of 350 mAh g(-1) and a discharge energy density of 534 Wh kg(-1) after 50 cycles at 0.1 C rate.

Facile and scalable synthesis of Ti5Si3 nanoparticles in molten salts for metal-matrix nanocomposites.

We report a novel synthesis of Ti5Si3 nanoparticles (NPs) via the magnesio-reduction of TiO2 NPs and SiO2 in eutectic LiCl-KCl molten salts at 700 °C. The Ti5Si3 particle size (∼25 nm) is confined to the nanoscale due to the partial dissolution of Mg and silica in the molten salts and a subsequent heterogeneous reduction on the surface of the TiO2 NPs.

Validation of an advanced practice physiotherapy model of care in an orthopaedic outpatient clinic.

BACKGROUND: In Canada, new models of orthopaedic care involving advanced practice physiotherapists (APP) are being implemented. In these new models, aimed at improving the efficiency of care for patients with musculoskeletal disorders, APPs diagnose, triage and conservatively treat patients. Formal validation of the efficiency and appropriateness of these emerging models is scarce. The purpose of this study is to assess the diagnostic agreement of an APP compared to orthopaedic surgeons as well as to assess treatment concordance, healthcare resource use, and patient satisfaction in this new model. METHODS: 120 patients presenting for an initial consult for hip or knee complaints in an outpatient orthopaedic hospital clinic in Montreal, Canada, were independently assessed by an APP and by one of three participating orthopaedic surgeons. Each health care provider independently diagnosed the patients and provided triage recommendations (conservative or surgical management). Proportion of raw agreement and Cohen's kappa were used to assess inter-rater agreement for diagnosis, triage, treatment recommendations and imaging tests ordered. Chi-Square tests were done in order to compare the type of conservative treatment recommendations made by the APP and the surgeons and Student t-tests to compare patient satisfaction between the two types of care. RESULTS: The majority of patients assessed were female (54%), mean age was 54.1 years and 91% consulted for a knee complaint. The raw agreement proportion for diagnosis was 88% and diagnostic inter-rater agreement was very high (κ=0.86; 95% CI: 0.80-0.93). The triage recommendations (conservative or surgical management) raw agreement proportion was found to be 88% and inter-rater agreement for triage recommendation was high (κ=0.77; 95% CI: 0.65-0.88). No differences were found between providers with respect to imaging tests ordered (p≥0.05). In terms of conservative treatment recommendations made, the APP gave significantly more education and prescribed more NSAIDs, joint injections, exercises and supervised physiotherapy (p<0.05). Patient satisfaction was significantly higher for APP care than for the surgeons care (p<0.05). CONCLUSION: The diagnoses and triage recommendations for patients with hip and knee disorders made by the APP were similar to the orthopaedic surgeons. These results provide evidence supporting the APP model for orthopaedic care.

Impact of a continuous quality improvement initiative on appropriate use of coronary computed tomography angiography. Results from a multicenter, statewide registry, the Advanced Cardiovascular Imaging Consortium.

OBJECTIVES: The purpose of the study was to determine the effectiveness of a collaborative educational, continuous quality improvement (CQI) initiative to increase appropriate use of coronary computed tomography angiography (CCTA). BACKGROUND: Potential overuse of CCTA has prompted multisociety appropriate use criteria (AUC) publications. METHODS: This prospective, observational study was conducted with pre-intervention (July 2007 to June 2008), intervention (July 2008 to June 2010), and follow-up (July 2010 to December 2010) periods during which patients were enrolled in the Advanced Cardiovascular Imaging Consortium (ACIC) at 47 Michigan hospitals. Continuous education was provided to referring physicians. The possibility of losing third-party payer coverage in the absence of a measurable change in AUC was emphasized. AUC was compared between the 3 periods. RESULTS: The study group included 25,387 patients. Compared with the pre-intervention period, there was a 23.4% increase in appropriate (61.3% to 80%, p < 0.0001), 60.3% decrease in inappropriate (14.6% to 5.8%, p < 0.0001), 40.8% decrease in uncertain (10.3% to 6.1%, p < 0.0001), and 41.7% decrease in unclassifiable (13.9% to 8.1%, p < 0.0001) scans during follow-up. Between pre-intervention and follow-up, change in CCTA referrals by provider specialty were cardiology (appropriate: 60.4% to 79.5%; inappropriate: 13% to 5.2%; p < 0.0001), internal medicine/family practice (appropriate: 51.1% to 70.4%; inappropriate: 20.2% to 12.5%; p < 0.0001), emergency medicine (appropriate: 83.6% to 91.6%; inappropriate: 9.1% to 0.6%; p < 0.0001), and other (appropriate: 61.1% to 83.2%; inappropriate: 18.6% to 5.9%; p < 0.0001). CONCLUSIONS: Application of a systematic CQI and emphasis on possible loss of coverage were associated with a significant improvement in the proportion of CCTA examinations meeting AUC across referring physician specialties.

Strong phonon scattering by layer structured PbSnS(2) in PbTe based thermoelectric materials.

The incorporation of PbSnS(2) in PbTe results in a tremendous reduction of the lattice thermal conductivity to 0.8 W/mK at room temperature, a reduction of almost 60% over bulk PbTe. Transmission electron microscopy reveals very high density displacement layers, misfit dislocations, and phase boundaries. Our thermal transport calculations based on modified Debye-Callaway model, well in agreement with the experimental measurements, reveal that the layer structured PbSnS(2) plays an important role in reducing the lattice thermal conductivity.

Rationale, design, and goals of the Advanced Cardiovascular Imaging Consortium (ACIC): A Blue Cross Blue Shield of Michigan collaborative quality improvement project.

BACKGROUND: Coronary computed tomography angiography (CCTA) is an emerging noninvasive anatomical method for evaluation of patients with suspected coronary artery disease (CAD). Multicenter clinical registries are key to efforts to establish the role of CCTA in CAD diagnosis and management. The Advanced Cardiovascular Imaging Consortium (ACIC) is a statewide, multicenter collaborative quality initiative with the intent to establish quality and appropriate use of CCTA in Michigan. METHODS: The ACIC is sponsored by the Blue Cross Blue Shield of Michigan/Blue Care Network, and its 47 sites include imaging centers that offer CCTA and meet established structure and process standards for participation. Patients enrolled include those with suspected ischemia with or without known CAD, and individuals across the entire spectrum of CAD risk. Patient demographics, history, CCTA scan-related data and findings, and 90-day follow-up data are entered prospectively into a centralized database with strict validation tools and processes. Collaborative quality initiatives include radiation dose reduction and appropriate CCTA use by education and feedback to participating sites and referring physicians. CONCLUSIONS: Across a wide range of institutions, the ACIC permits evaluation of "real-world" utilization and effectiveness of CCTA and examines an alternative, nontraditional approach to utilization management wherein physicians and payers collaborate to address the growing problem of cardiac imaging overutilization.

High performance Na-doped PbTe-PbS thermoelectric materials: electronic density of states modification and shape-controlled nanostructures.

Thermoelectric heat-to-power generation is an attractive option for robust and environmentally friendly renewable energy production. Historically, the performance of thermoelectric materials has been limited by low efficiencies, related to the thermoelectric figure-of-merit ZT. Nanostructuring thermoelectric materials have shown to enhance ZT primarily via increasing phonon scattering, beneficially reducing lattice thermal conductivity. Conversely, density-of-states (DOS) engineering has also enhanced electronic transport properties. However, successfully joining the two approaches has proved elusive. Herein, we report a thermoelectric materials system whereby we can control both nanostructure formations to effectively reduce thermal conductivity, while concurrently modifying the electronic structure to significantly enhance thermoelectric power factor. We report that the thermoelectric system PbTe-PbS 12% doped with 2% Na produces shape-controlled cubic PbS nanostructures, which help reduce lattice thermal conductivity, while altering the solubility of PbS within the PbTe matrix beneficially modifies the DOS that allow for enhancements in thermoelectric power factor. These concomitant and synergistic effects result in a maximum ZT for 2% Na-doped PbTe-PbS 12% of 1.8 at 800 K.

In situ nanostructure generation and evolution within a bulk thermoelectric material to reduce lattice thermal conductivity.

We show experimentally the direct reduction in lattice thermal conductivity as a result of in situ nanostructure generation within a thermoelectric material. Solid solution alloys of the high-performance thermoelectric PbTe-PbS 8% can be synthesized through rapid cooling and subsequent high-temperature activation that induces a spontaneous nucleation and growth of PbS nanocrystals. The emergence of coherent PbS nanostructures reduces the lattice thermal conductivity from approximately 1 to approximately 0.4 W/mK between 400 and 500 K.

On the origin of increased phonon scattering in nanostructured PbTe based thermoelectric materials.

We have investigated the possible mechanisms of phonon scattering by nanostructures and defects in PbTe-X (X = 2% Sb, Bi, or Pb) thermoelectric materials systems. We find that among these three compositions, PbTe-2% Sb has the lowest lattice thermal conductivity and exhibits a larger strain and notably more misfit dislocations at the precipitate/PbTe interfaces than the other two compositions. In the PbTe-Bi 2% sample, we infer some weaker phonon scattering BiTe precipitates, in addition to the abundant Bi nanostructures. In the PbTe-Pb 2% sample, we also find that pure Pb nanoparticles exhibit stronger phonon scattering than nanostructures with Te vacancies. Within the accepted error range, the theoretical calculations of the lattice thermal conductivity in the three systems are in close agreement with the experimental measurements, highlighting the important role of misfit dislocations, nanoscale particles, and associated interfacial elastic strain play in phonon scattering. We further propose that such particle-induced local elastic perturbations interfere with the phonon propagation pathway, thereby contributing to further reduction in lattice thermal conductivity, and consequently can enhance the overall thermoelectric figure of merit.

Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated operative risk.

BACKGROUND: Some patients with severe symptomatic aortic stenosis (AS) do not undergo aortic valve replacement (AVR) despite demonstrated symptomatic and survival advantages and despite unequivocal guideline recommendations for surgical evaluation. METHODS AND RESULTS: In 3 large tertiary care institutions (university, Veterans Affairs, and private practice) in Washtenaw County, Mich, patients were identified with unrefuted echocardiography/Doppler evidence of severe AS during calendar year 2005. Medical records were retrospectively reviewed for symptoms, referral for AVR, calculated operative risk for AVR, and rationale as to why patients did not undergo valve replacement. Of 369 patients with severe AS, 191 (52%) did not undergo AVR. Of these, 126 (66%, 34% of total) had symptoms consistent with AS. The most common reasons cited for absent intervention were comorbidities with high operative risk (61 patients [48%]), patent refusal (24 patients [19%]), and symptoms unrelated to AS (24 patients [19%]). Operated patients had a lower Society of Thoracic Surgery-calculated perioperative mortality risk than unoperated patients (1.8% [interquartile range, 1.0 to 3.0%] versus 2.7% [interquartile range, 1.6 to 5.5%], P<0.001). However, 28 (24%) of 126 unoperated symptomatic patients had a calculated perioperative risk less than the median risk for patients who underwent AVR. Only 57 (30%) of 191 unoperated patients were evaluated by a cardiac surgeon. There were similar rates of intervention across practice settings, and similar rates of unoperated patients despite symptoms and low operative risk. CONCLUSIONS: One third of patients with severe AS are symptomatic but do not undergo AVR, with similar findings in multiple practice environments. For most unoperated patients, objectively calculated operative risks did not appear prohibitive. Despite this, a minority of unoperated patients were referred for surgical consultation. Some patients with severe symptomatic AS may be inappropriately denied access to potentially life-saving therapy.

Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry.

OBJECTIVES: The goal of this study was to evaluate whether quantitation of thrombus burden with transesophageal echocardiography (TEE) can help risk-stratify patients undergoing thrombolysis of prosthetic valve thrombosis (PVT). BACKGROUND: Thrombolytic therapy of PVT has an unpredictable risk of embolization and complications. METHODS: An international registry of patients with suspected PVT undergoing two-dimensional/Doppler and TEE before thrombolysis was established. All TEE studies were reviewed and quantitated by a single observer blinded to all data. RESULTS: From 1985 to 2001, 107 patients (71 females; age 24 to 86 years) from 14 centers (6 in the U.S.) were identified. The majority of cases involved the mitral valve (79 mitral, 13 aortic, and 15 tricuspid). Hemodynamic success rate was achieved in 85% and was similar across valves. Overall complications were observed in 17.8%, and death in 5.6%. Predictors of complications were: New York Heart Association (NYHA) functional class, presence of shock, sinus tachycardia, hypotension, previous history of stroke, thrombus extension beyond the valve ring, and thrombus area. Multivariate analysis demonstrated that two variables were independent predictors of complications: thrombus area by TEE (odds ratio [OR] 2.41 per 1 cm2 increment, 95% confidence interval [CI] 1.12 to 5.19) and prior history of stroke (OR 4.55, 95% CI 1.35 to 15.38). A thrombus area <0.8 cm2 identified patients at lower risk for complications from thrombolysis, irrespective of NYHA functional class. CONCLUSIONS: In PVT, the thrombus size imaged with TEE is a significant independent predictor of outcome. Transesophageal echocardiography can identify low-risk groups for thrombolysis irrespective of symptom severity and is therefore recommended in the management of prosthetic valve thrombosis.

Transesophageal echocardiography improves risk assessment of thrombolysis prosthetic valve thrombosis: results of the international PRO-TEE registry

The goal of this study was to evaluate whether antitation of thrombus burden with transesophageal echocardiography (TEE) can help risk-stratify patients undergoing thrombolysis of prosthetic valve thrombosis (PVT). BACKGROUND: Thrombolytic therapy of PVT has an unpredictable risk of embolization and complications. METHODS: An international registry of patients with suspected PVT undergoing two-dimensional/Doppler and TEE before thrombolysis was established. All TEE studies were reviewed and quantitated by a single observer blinded to all data. RESULTS: From 1985 to 2001, 107 patients (71 females; age 24 to 86 years) from 14 centers (6 in the U.S.) were identified. The majority of cases involved the mitral valve (79 mitral, 13 aortic, and 15 tricuspid). Hemodynamic success rate was achieved in 85% and was similar across valves. Overall complications were observed in 17.8%, and death in 5.6%.Predictors of complications were: New York Heart Association (NYHA) functional class, presence of shock, sinus tachycardia, hypotension,previous history of stroke, thrombus extension beyond the valve ring, and thrombus area. Multivariate analysis demonstrated that two variables were independent predictors of complications: thrombus area by TEE (odds ratio [OR] 2.41 per 1 cm2 increment, 95% confidence interval [CI] 1.12 to 5.19)and prior history of stroke (OR 4.55, 95% CI 1.35 to 15.38). A thrombus area <0.8 cm2 identified patients at lower risk for complications from thrombolysis, irrespective of NYHA functional class...