An Insight to the Role of Thermal Effects on the Onset of Atrioesophageal Fistula: A Computer Model of Open-Irrigated Radiofrequency Ablation.

PURPOSE: Atrial fibrillation (AF) is the most common heart rhythm disorder in the world. Radiofrequency catheter ablation (RFCA) has become the preferred method of treatment for drug-refractory AF. One of the rare (< 0.2%) but deadly (≈ 80%) complications of RFCA is Atrioesophageal fistula (AEF). Although the exact pathophysiological events in developing AEF are not fully understood, one hypothesis is that the underlying cause may be thermal damage to the mucosa (the esophagus lumen). METHOD: The present study reports on a computer model of RFCA in the posterior wall of the left atrium (LA) which is in close proximity to the esophagus. A novel systematic approach was taken by considering a range of anatomical variations (obtained from clinical data) to study the spatial and temporal temperature data when RF energy was applied to cause a threshold temperature of 50 °C in the mucosa. The model is also used to investigate the spatial and temporal changes in mucosal temperature that may affect the reliability of the readings from esophageal temperature monitoring devices if they are not positioned accurately. RESULTS: The results suggest evidence of transmural esophageal lesions in all the anatomies except one, if the 50 °C temperature threshold is the only criteria used for identification of thermal damage. However, by taking into consideration the effect of time (temperature-time integral), only some anatomies were identified as being partially damaged. Investigating the temperature and the temperature gradient data during the ablation revealed that the increases in both the temperature and the temperature gradient were time, location and anatomy dependent. This finding may have significance in the design and development of next-generation temperature monitoring devices that will provide a temperature map rather than single point measurements. CONCLUSION: Studies such as the present work may provide more convenient platforms for investigating the effect of the many factors involved in the RF procedure and how they may link to the development of AEF.

Experimental investigation of far-field human cough airflows from healthy and influenza-infected subjects.

Seasonal influenza epidemics have been responsible for causing increased economic expenditures and many deaths worldwide. Evidence exists to support the claim that the virus can be spread through the air, but the relative significance of airborne transmission has not been well defined. Particle image velocimetry (PIV) and hot-wire anemometry (HWA) measurements were conducted at 1 m away from the mouth of human subjects to develop a model for cough flow behavior at greater distances from the mouth than were studied previously. Biological aerosol sampling was conducted to assess the risk of exposure to airborne viruses. Throughout the investigation, 77 experiments were conducted from 58 different subjects. From these subjects, 21 presented with influenza-like illness. Of these, 12 subjects had laboratory-confirmed respiratory infections. A model was developed for the cough centerline velocity magnitude time history. The experimental results were also used to validate computational fluid dynamics (CFD) models. The peak velocity observed at the cough jet center, averaged across all trials, was 1.2 m/s, and an average jet spread angle of θ = 24° was measured, similar to that of a steady free jet. No differences were observed in the velocity or turbulence characteristics between coughs from sick, convalescent, or healthy participants.

Bioaerosols and Transmission, a Diverse and Growing Community of Practice.

The transmission of infectious microbes via bioaerosols is of significant concern for both human and animal health. However, gaps in our understanding of respiratory pathogen transmission and methodological heterogeneity persist. New developments have enabled progress in this domain, and one of the major turning points has been the recognition that cross-disciplinary collaborations across spheres of human and animal health, microbiology, biophysics, engineering, aerobiology, infection control, public health, occupational health, and industrial hygiene are essential. Collaborative initiatives support advances in topics such as bioaerosol behavior, dispersion models, risk assessment, risk/exposure effects, and mitigation strategies in clinical, experimental, agricultural, and other field settings. There is a need to enhance the knowledge translation for researchers, stakeholders, and private partners to support a growing network of individuals and agencies to achieve common goals to mitigate inter- and intra-species pathogen transmission via bioaerosols.

Quantification of Morphological Modulation, F-Actin Remodeling, and PECAM-1 (CD-31) Redistribution in Endothelial Cells in Response to Fluid-Induced Shear Stress Under Various Flow Conditions.

Cardiovascular diseases (CVDs) are the number one cause of death globally. Arterial endothelial cell (EC) dysfunction plays a key role in many of these CVDs, such as atherosclerosis. Blood flow-induced wall shear stress (WSS), among many other pathophysiological factors, is known to significantly contribute to EC dysfunction. The present study reports an in vitro investigation of the effect of quantified WSS on ECs, analyzing the EC morphometric parameters and cytoskeletal remodeling. The effects of four different flow cases (low steady laminar (LSL), medium steady laminar (MSL), nonzero-mean sinusoidal laminar (NZMSL), and laminar carotid (LCRD) waveforms) on the EC area, perimeter, shape index (SI), angle of orientation, F-actin bundle remodeling, and platelet endothelial cell adhesion molecule-1 (PECAM-1) localization were studied. For the first time, a flow facility was fully quantified for the uniformity of flow over ECs and for WSS determination (as opposed to relying on analytical equations). The SI and angle of orientation were found to be the most flow-sensitive morphometric parameters. A two-dimensional fast Fourier transform (2D FFT) based image processing technique was applied to analyze the F-actin directionality, and an alignment index (AI) was defined accordingly. Also, a significant peripheral loss of PECAM-1 in ECs subjected to atheroprone cases (LSL and NZMSL) with a high cell surface/cytoplasm stain of this protein is reported, which may shed light on of the mechanosensory role of PECAM-1 in mechanotransduction.

An In Vitro Hemodynamic Flow System to Study the Effects of Quantified Shear Stresses on Endothelial Cells.

Numerous in vitro systems have previously been developed and employed for studying the effects of hemodynamics on endothelial cell (EC) dysfunction. In the majority of that work, accurate flow quantification (e.g., uniformity of the flow over the ECs) remains elusive and wall shear stress (WSS) quantifications are determined using theoretical relationships (without considering the flow channel aspect ratio effects). In addition, those relationships are not applicable to flows other than steady laminar cases. The present work discusses the development of a novel hemodynamic flow system for studying the effects of various well-quantified flow regimes over ECs. The current work presents a novel hemodynamic flow system applying the concept of a parallel plate flow chamber (PPFC) with live microscopy access for studying the effects of quantified WSS on ECs. A range of steady laminar, pulsatile (carotid wave form) and low-Reynolds number turbulent WSSs were quantified through velocity field measurements by a laser Doppler velocimetry (LDV) system, to validate the functionality of the current hemodynamic flow system. Uniformity of the flow across the channel width can be analyzed with the current system (e.g., the flow was uniform across about 65-75% of the channel width for the steady cases). The WSS obtained from the experiments had higher values in almost all of the cases when compared to the most commonly-used theoretical solution (9% < error < 16%), whereas another relationship, which considers the channel dimensions, had better agreement with the experimental results (1% < error < 8%). Additionally, the latter relationship predicted the uniform flow region in the PPFC with an average difference of <5% when compared to the experimental results. The experimental data also showed that the WSS at various locations (D, E and F) at the test section differed by less than 4% for the laminar cases representing a fully developed flow. WSS was also determined for a low-Re (Re = 2750) turbulent flow using (1) the Reynolds shears stress and (2) the time-averaged velocity profile gradient at the wall, with a good agreement (differences <16%) between the two where the first method returned a higher value than the second. Porcine aortic endothelial cell (PAEC) viability in the system and morphological cell response to laminar WSS of about 11 dyne/cm(2), were observed. These results provide performance validation of this novel in vitro system with many improved features compared to previous similar prototypes for investigation of flow effects on ECs. The integration of the LDV technique in the current study and the comparison of the results with those from theory revealed that great care must be taken when using PPFCs since the commonly used theoretical relation for laminar steady flows is unable to predict the flow uniformity (which may introduce significant statistical bias in biological studies) and the predicted WSS was subjected to greater error when compared to a more comprehensive equation presented in the current work. Moreover, application of the LDV technique in the current system is essential for studies of more complex cases, such as disturbed flows, where the WSS cannot be predicted using theoretical or numerical modelling methods.

The availability of prior ECGs improves paramedic accuracy in recognizing ST-segment elevation myocardial infarction.

INTRODUCTION: Early and accurate identification of ST-elevation myocardial infarction (STEMI) by prehospital providers has been shown to significantly improve door to balloon times and improve patient outcomes. Previous studies have shown that paramedic accuracy in reading 12 lead ECGs can range from 86% to 94%. However, recent studies have demonstrated that accuracy diminishes for the more uncommon STEMI presentations (e.g. lateral). Unlike hospital physicians, paramedics rarely have the ability to review previous ECGs for comparison. Whether or not a prior ECG can improve paramedic accuracy is not known. STUDY HYPOTHESIS: The availability of prior ECGs improves paramedic accuracy in ECG interpretation. METHODS: 130 paramedics were given a single clinical scenario. Then they were randomly assigned 12 computerized prehospital ECGs, 6 with and 6 without an accompanying prior ECG. All ECGs were obtained from a local STEMI registry. For each ECG paramedics were asked to determine whether or not there was a STEMI and to rate their confidence in their interpretation. To determine if the old ECGs improved accuracy we used a mixed effects logistic regression model to calculate p-values between the control and intervention. RESULTS: The addition of a previous ECG improved the accuracy of identifying STEMIs from 75.5% to 80.5% (p=0.015). A previous ECG also increased paramedic confidence in their interpretation (p=0.011). CONCLUSIONS: The availability of previous ECGs improves paramedic accuracy and enhances their confidence in interpreting STEMIs. Further studies are needed to evaluate this impact in a clinical setting.

Western Cold and Flu (WeCoF) aerosol study--preliminary results.

BACKGROUND: Influenza virus is responsible for annual deaths due to seasonal epidemics and is the cause of major pandemics which have claimed millions of human lives over the last century. Knowledge about respiratory virus transmission is advancing. Spread is likely through the air, but much work remains to be done to characterize the aerosols produced by infected individuals, including viral particle survival and infectivity. Although coughs have been characterized, little work has been done to examine coughs from infected individuals. The WeCoF project aims at providing evidence to support prevention measures to mitigate person-to-person influenza transmission in critical locations, such as hospitals, and during pandemics. FINDINGS: A novel experimental cough chamber facility - the FLUGIE - has been developed to study the far-field aerodynamics and aerosol transport of droplets produced by the coughs from humans naturally-infected with influenza. The flow field of each cough is measured using Particle Image Velocimetry (PIV). A preliminary study involving 12 healthy individuals has been carried out in order to quantify the strengths of their coughs at a distance of 1 m from the mouth. The spatially averaged maximum velocity was determined and the average value was 0.41 m/s across 27 coughs of good data quality. The peak value of velocity was also extracted and compared with the average velocity. CONCLUSIONS: Preliminary results show that there is significant air motion associated with a cough (on the order of 0.5 m/s) as far away as 1 m from the mouth of the healthy person who coughs. The results from this pilot study provide the framework for a more extensive participant recruitment campaign that will encompass a statistically-significant cohort.

End-of-life issues in the acute and critically ill patient.

The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.