Ripple map delineation of the reentrant circuit in a tricuspid annular atrial tachycardia mimicking focal activity.

A 70-year-old man with hypertensive heart disease underwent catheter ablation of persistent atrial fibrillation. After completing the pulmonary vein isolation, atrial burst pacing induced an annular atrial tachycardia (AT). Overdrive pacing exhibited constant fusion, indicating a macroreentrant mechanism of the AT. However, the CARTO3 activation map created using the Octaray catheter (both Biosense Webster, Irvine, CA) exhibited a centrifugal spread with the earliest activation site at the 4 o'clock position of the tricuspid annulus. In contrast, the Ripple map revealed a clear reentrant circuit with its isthmus located at the 4-6 o'clock position of the tricuspid annulus. The local electrograms in these areas recorded systolic and diastolic potentials simultaneously, and the misannotation of the large far-field potentials caused this discrepant result. Handling low-amplitude complex fractionated electrograms remains a challenge in creating a precise activation mapping. The Ripple map, especially when combined with the Octaray catheter, was effective in dynamically visualizing all these electrograms and accurately delineating the reentrant circuit.

Implementing Interventions for Women and Youth with Traumatic Brain Injury at Transition from Custodial Settings: A Call to Action.

Traumatic brain injury (TBI) is a serious public health concern and overrepresented among justice-involved populations. An emerging area of research focuses on the complex, interrelated and unmet health and social needs of justice-involved women and youth with TBI. Evidence of these needs continues to grow, yet the health and justice systems continue to underperform in supporting the health and social care of justice-involved women and youth. This commentary is a call to action to begin to redress these gaps. We first provide an overview of the needs of women and youth with TBI that affect their transition from custody to community, including those related to victimization, trauma, mental health, substance use, and homelessness. We then highlight the current gaps in knowledge and practice with respect to interventions for women and youth with TBI at transition from custody. The available evidence for the impact of interventions on people with head injury who are justice-involved is sparse, especially studies of interventions focused on women and youth. We conclude with a call for implementation science studies to support translation from research to practice, emphasizing that researchers, practitioners, policy makers, and women and youth at transition should collaborate to develop, implement, and evaluate accommodations and interventions for TBI. To have meaningful, positive impacts on the systems that serve these women and youth, interdisciplinary service delivery approaches should aim to prevent, raise awareness, identify, and provide timely support and services for the varied needs of women and youth with TBI in transition.

Demonstration of Arrhythmia Substrate-Associated Dispersion of Repolarization by Epicardial Unipolar Mapping in Brugada Syndrome.

BACKGROUND: Epicardial unipolar mapping has not been thoroughly investigated in Brugada syndrome (BrS). OBJECTIVES: This study aims to examine the characteristics of epicardial unipolar potentials in BrS and investigate the differences from overt cardiomyopathy. METHODS: Epicardial mapping was performed in 8 patients with BrS and 6 patients with cardiomyopathy. We investigated the J-wave amplitudes using unipolar recordings at delayed potential (DP) sites via bipolar recordings. The repolarization time (RT) at and around the DP recording sites was measured, and maximum dispersion of the RT divided by the distance was defined as the RT dispersion index. RESULTS: Epicardial mapping at baseline revealed significantly higher J-wave amplitude with bipolar DP in patients with BrS than in patients with cardiomyopathy. J-wave amplitude ≥0.42 mV had 99.1% sensitivity and 100% specificity for diagnosing BrS. The RT dispersion index was significantly higher in patients with BrS than in patients with cardiomyopathy at baseline. In all patients with BrS, coved-type unipolar electrograms without negative T waves (short RT) appeared close to coved-type electrograms with negative T waves (long RT) at the DP recording sites after pilsicainide administration. Thus, a steep RT dispersion was observed in this region, and ventricular arrhythmias emerged from this shorter RT area in all 3 patients with BrS in whom ventricular arrhythmias were induced. CONCLUSIONS: Bipolar DP-related prominent unipolar J waves and steep repolarization gradients may be more specific for characterizing BrS than for overt cardiomyopathy. Ventricular arrhythmias in BrS are associated with a steep repolarization gradient, indicating phase 2 re-entry as a possible cause.

Observations of substance use treatment engagement during the period of community re-entry following residential treatment.

BACKGROUND: The period of community re-entry following residential substance use treatment is associated with elevated risk for return to substance use. Although continuity of care is best practice, many individuals do not engage in follow-up treatment, struggle to engage in follow-up treatment, or continue to use substances while participating in follow-up treatment. There is a need to both characterize treatment engagement during community re-entry following residential substance use treatment as well as understand how treatment impacts substance use during this high-risk period. METHOD: This observational study used retrospective self-report to examine treatment engagement and substance use among individuals who had exited residential substance use treatment. Participants completed a Timeline Follow-back interview reporting substance use and treatment engagement in the 30 days following residential treatment. RESULTS: Most participants (83.1 %) reported engaging in substance use treatment following discharge. The most common treatments were Alcoholics Anonymous/Narcotics Anonymous (61.1 %), medication for addiction treatment (40 %), and outpatient therapy (29.2 %). Participants were less likely to use substances on a day in which they engaged in outpatient therapy (OR = 0.32, 95 % CI [0.12, 0.90], p = 0.030) and more likely on days they engaged in medication treatment (OR = 21.49, 95 % CI [1.46, 316.74], p = 0.025). CONCLUSION: Findings characterize engagement in substance use treatment in the month following residential treatment. Treatment engagement was common during community re-entry; however, only outpatient therapy was found to reduce substance use during this high-risk period. Findings may inform intervention efforts during the high-risk period of community re-entry.

Effects of different seat inclination angles on lumbar dynamic response and injury during lunar-earth reentry.

The inclination angle of the spacecraft seat is related to the astronaut's reentry angle, which in turn affects the safety of the astronauts. This study quantitatively analyzed the effects of different seat inclination angles on astronauts' lumbar spine injuries using the finite element method during the Lunar-Earth reentry. Firstly, a finite element model of the astronaut's lumbar spine was constructed based on reverse engineering technology, and the effectiveness of the model was verified through mesh sensitivity, vertebral range of motion, and spinal impact experiments. Then, simulation calculations were carried out for different seat inclination angles (0°, 10°, 20°, and 30°) under the typical reentry return loads of Chang'e 5T1 (CE-5T1) and Apollo 10, and the prediction and evaluation of lumbar spine injuries were conducted in conjunction with the biological tissue injury criteria. The results indicated that the stress on the vertebrae and annulus fibrosus increased under both reentry loads with the rise of the seat inclination angle, but the increasing rates decreased. When the acceleration peak of CE-5T1 approached 9G, the risk of tissue injury was higher under the seat angle exceeded 20°. According to the Multi-Axis Dynamic Response Criteria for spinal injury, neither of the two load conditions would directly cause injury to the astronauts' lumbar spine when the seat inclination angle was below 30°. The study findings provide a numerical basis for designing and improving the spacecraft's inclination angle in crewed lunar missions, ensuring the safety of astronauts.

A His bundle pacing protocol for suppressing ventricular arrhythmia maintenance and improving defibrillation efficacy.

BACKGROUND: The excitable gap (EG), defined as the excitable tissue between two subsequent wavefronts of depolarization, is critical for maintaining reentry that underlies deadly ventricular arrhythmias. EG in the His-Purkinje Network (HPN) plays an important role in the maintenance of electrical wave reentry that underlies these arrhythmias. OBJECTIVE: To determine if rapid His bundle pacing (HBP) during reentry reduces the amount of EG in the HPN and ventricular myocardium to suppress reentry maintenance and/or improve defibrillation efficacy. METHODS: In a virtual human biventricular model, reentry was initiated with rapid line pacing followed by HBP delivered for 3, 6, or 9 s at pacing cycle lengths (PCLs) ranging from 10 to 300 ms (n=30). EG was calculated independently for the HPN and myocardium over each PCL. Defibrillation efficacy was assessed for each PCL by stimulating myocardial surface EG with delays ranging from 0.25 to 9 s (increments of 0.25 s, n=36) after the start of HBP. Defibrillation was successful if reentry terminated within 1 s after EG stimulation. This defibrillation protocol was repeated without HBP. To test the approach under different pathological conditions, all protocols were repeated in the model with right (RBBB) or left (LBBB) bundle branch block. RESULTS: Compared to without pacing, HBP for >3 seconds reduced average EG in the HPN and myocardium across a broad range of PCLs for the default, RBBB, and LBBB models. HBP >6 seconds terminated reentrant arrhythmia by converting HPN activation to a sinus rhythm behavior in the default (6/30 PCLs) and RBBB (7/30 PCLs) models. Myocardial EG stimulation during HBP increased the number of successful defibrillation attempts by 3%-19% for 30/30 PCLs in the default model, 3%-6% for 14/30 PCLs in the RBBB model, and 3%-11% for 27/30 PCLs in the LBBB model. CONCLUSION: HBP can reduce the amount of excitable gap and suppress reentry maintenance in the HPN and myocardium. HBP can also improve the efficacy of low-energy defibrillation approaches targeting excitable myocardium. HBP during reentrant arrhythmias is a promising anti-arrhythmic and defibrillation strategy.

Case report of a double-wave re-entry atrial flutter in a patient with atrial cardiomyopathy.

Background: Double-wave macrore-entry is a rare mechanism of atrial tachycardia with limited documentation in the literature. We present a three-dimensional documentation of a double-wave 'typical' atrial flutter in a patient with extensive atrial cardiomyopathy. Case summary: A 78-year-old female with a history of atrial cardiomyopathy and dual-chamber pacemaker for sinus node disease presented with palpitations and incessant atrial flutter. Electrophysiological study revealed a regular tachycardia with a cycle length (TCL) of 230 ms, with proximal to distal coronary sinus (CS) activation. Three-dimensional mapping identified two independent wavefronts circulating the cavotricuspid isthmus (CTI), each with a TCL of 460 ms. Cavotricuspid isthmus ablation resulted in conversion into a distinct tachycardia with left atrial roof origin. Linear ablation in this location slowed the TCL to 435 ms with concentric CS activation and another CTI dependent atrial flutter was mapped, this time with only one wavefront of activation. Further ablation with a second, more lateral, line in the CTI led to tachycardia interruption. Given the extensive atrial scarring and high arrhythmic recurrence risk, atrioventricular node ablation was performed. Discussion: Double-wave re-entrant tachycardias were primarily observed in experimental models, precipitating acceleration of ventricular and supraventricular tachycardias via extrastimulation. In our case, there is documentation of a spontaneous double-wave of activation around the CTI, representing the first documented double-wave 'typical' atrial flutter. Unlike other cases in the literature, the two wavefronts were equidistant, which resulted in a regular tachycardia with TCL that was half of the single-wave cycle length. Three-dimensional propagation mapping was essential to visualize the two distinct wavefronts.

Molecular Pathways and Animal Models of Arrhythmias.

Arrhythmias account for over 300,000 annual deaths in the United States, and approximately half of all deaths are associated with heart disease. Mechanisms underlying arrhythmia risk are complex; however, work in humans and animal models over the past 25 years has identified a host of molecular pathways linked with both arrhythmia substrates and triggers. This chapter will focus on select arrhythmia pathways solved by linking human clinical and genetic data with animal models.

Invited Commentary: Unveiling the Grim Reality- Suicide Mortality Among Formerly Incarcerated Individuals in North Carolina.

In the article by Fitch et al. (Am J Epidemiol. 2024; 193(3):489-499) the authors highlight the concerning prevalence of suicide mortality among formerly incarcerated individuals in North Carolina. Their retrospective study reveals a doubled suicide risk post-release, with notable disparities among demographic groups. Urgent interventions are needed, including comprehensive re-entry programs and systemic reforms to address structural inequalities. I suggest tailored support services to mitigate suicide risks and promote successful community reintegration, advocating for equity, justice, and human dignity in post-release efforts.

The effects of aftercare/resettlement services on crime and violence in children and youth: A systematic review.

Background: High rates of youth re-offending indicate that young custody-leavers face challenges when reintegrating into their communities. Aftercare and resettlement programs can occur pre-, during, and post-release and generally provide multiple forms of support services to address youths' transitional needs. Objectives: The present review examines (1) the impact of youth aftercare/resettlement programs on crime-related outcomes, (2) how treatment effect is moderated by participant, program, and study characteristics, (3) whether some types of interventions are more effective than others, (4) barriers/facilitators to effective program implementation, (5) the theory of change underlying resettlement interventions, and (6) available research on intervention cost. Search Methods: A comprehensive set of keywords and synonyms was combined in a Boolean search across 26 electronic databases. Multiple gray literature sources were also searched, including 23 journals, 4 meeting archives, 11 organization websites, 3 open access journal websites, and the CVs of 8 well-known researchers in the field. The search was completed in January 2023. Selection Criteria: For objectives 1-3, studies were included if they utilized a randomized controlled design or quasi-experimental comparison group design in which participants were matched on at least some baseline variables and included at least one quantitative individual-measure of crime. For objective 4, included studies presented process evaluations of aftercare/reentry programs, clearly stated their research goals, and used qualitative methods in an appropriate way to answer the stated research question. For objectives 5 and 6, no specific methods were required; any study meeting the criteria for objectives 1-4 which presented findings on theory of change or cost data were included. For all outcomes, only studies conducted in a westernized country, and published after 1991 in English, French, or German were considered. Data Collection and Analysis: Two coders conducted primary data extraction for the included studies. Data were entered into a Microsoft Excel database. After data extraction, the two coders validated the coding by cross-checking the database with each research report. Discrepancies between coders were discussed until consensus was reached. Where consensus could not be reached, a third coder was consulted. Study risk of bias was addressed using the ROBINS-I (Sterne et al., 2016), ROB-2 (Higgins et al., 2019), and the critical appraisal skills programme (CASP, 2018). Objectives 1-3 were addressed by synthesizing quantitative outcomes from rigorous impact evaluations of aftercare interventions using random effects models and meta-regression. Thematic and narrative analysis was conducted to address objectives 4-6. Results: The search resulted in 15 impact studies, representing 4,718 participants across 21 program sites, and 35 effect sizes. The 21 impact evaluations were rated as having either low/moderate bias (k = 11) or serious bias (k = 10). The synthesis of 15 impact studies found no significant effects for arrest (k = 14; OR = 1.044, 95% prediction interval [0.527, 2.075], t = 0.335) or incarceration (k = 8, OR = 0.806, 95% prediction interval [2.203, 1.433], t = -1.674). A significant pooled effect was found for conviction (k = 13, OR = 1.209, 95% prediction interval [1.000, 1.462], t = 2.256), but results were highly sensitive to the inclusion of specific studies. No meaningful pattern of results emerged in moderator analyses with respect to study, sample, program component, or program delivery characteristics. The 19 process studies were rated as either high quality (k = 12) or moderate quality (k = 7). Thematic synthesis of the process evaluations revealed 15 themes related to the strengths/challenges of program implementation. The assessment of program cost (k = 7) determined a lack of data within the literature, preventing any summative analysis. Authors' Conclusions: Current evidence is promising with respect to conviction outcomes but overall does not find that aftercare/resettlement interventions have a reliably positive impact on crime-related outcomes for young people who have offended. High variability across outcomes and reported data resulted in small sample sizes per outcome and limited moderator analyses. Multiple challenges for program implementation exist; additional rigorous research is sorely needed to further investigate the nuances of the program effects.

Anatomical and Electrophysiological Characteristics of Dual-Loop Re-Entry in Atypical Atrial Flutter: Implications for Mapping and Catheter Ablation.

Background: Atypical atrial flutter (AFL) can be challenging to ablate, especially when involving dual-loop re-entry. We sought to assess the electroanatomical characteristics of single- and dual-loop AFLs in patients undergoing catheter ablation. Methods: We analyzed 25 non-cavotricuspid isthmus-dependent macro-re-entrant AFL in 19 consecutive patients. Three-dimensional high-density activation mapping was performed, and active re-entry loops were confirmed by entrainment mapping. Results: Of 25 AFLs (24 left, 1 right atrial), 13 (52%) exhibited dual-loop re-entry. The most common circuits included, in 6/13 (46% of dual loops), a perimitral re-entry with a second loop around the right/left pulmonary veins (PV) and, in 6/13 (46%), involved a right PV ostium with a second loop around either a functional conduction block or another PV. Ablation at the common isthmus of dual-loop AFLs and at the critical isthmus of single-loop AFLs terminated the arrhythmia more frequently than ablation at a secondary isthmus of dual-loop AFLs (5/6 (83%) and 8/11 (73%) versus 1/8 (13%), respectively, p = 0.013). Conclusions: More than half of AFLs exhibited a dual-loop re-entrant mechanism. Most critical isthmuses were found at the mitral isthmus, the left atrial roof or right PV ostia. Ablation targeting the common isthmus resulted in a higher termination rate.

The characterization of functional conduction block in patients with multiple types of atrial tachycardia- A discussion on the mechanism of multiple atrial tachycardia.

BACKGROUND: High-resolution mapping offers superior accuracy in delineating conduction features; however, certain characteristics are still linked to elevated recurrence rates of atrial tachycardia (AT), suggesting the influence of additional mechanisms. This study systematically assessed the substrate of functional conduction block (FCB) regions in relation to the mechanisms of multiple ATs. METHODS: In this study, the Carto system facilitated the mapping of ATs in 13 patients undergoing ablation, each presenting with more than two AT variants. FCB regions were marked and further analyzed. RESULTS: A total of 33 sustained ATs were mapped across the patient cohort. FCB regions showed convertibility in 7 of 13 patients (54%). Three kinds of presentations can be summarized by the FCB region: Firstly, the FCB region could act as the main obstacle sustaining the localized reentrant pathway, for which rounding obviously has a direct correlation with the mechanism of the AT (27%). Secondly, the FCB regions could act as obstacle lines to reorganize the propagation of the reentry in localized AT and macroreentrant AT (55%). Lastly, the FCB region could act as a bystander and may not be related to the mechanism of the ATs (18%). The potentials in FCB regions mostly performed low voltages or fragmented potentials (FPs) in the ATs which they did not perform the conduction block (90%). CONCLUSION: In multiple ATs, FCB regions may not be uncommon. The participation of FCB regions in the mechanism of ATs showed three different kinds of performance. The dynamic nature of this substrate may provide insight into the reasons for the high recurrence of related ATs.

Double Ventricular Response with Aberrant Conduction Leading to Ventricular Dysfunction.

Double ventricular response (DVR), where a single P wave results in two QRS complexes, is a rare presentation of dual AV node physiology. It has been associated with ventricular dysfunction in the setting of incessant tachycardia. We present the case of an otherwise healthy adolescent who had frequent DVR without tachycardia leading to left ventricular dysfunction. Slow pathway modification led to a significant reduction in ectopy and normalization of ventricular function. This highlights that DVR without tachycardia might lead to ventricular dysfunction in pediatric patients. Slow pathway modification with reduction of ectopy may be sufficient to restore ventricular function.

Bipolar radiofrequency ablation for re-entrant ventricular tachycardia of right bundle branch block and left bundle branch block morphologies with the common slow conduction zone at the left ventricular summit: a case report.

Background: The left ventricular (LV) summit has anatomical limitations, so the detailed mapping is difficult. Therefore, the mechanism of ventricular tachycardia (VT) originating from the LV summit is not well understood. Case summary: A 70-year-old man had VTs with right bundle branch block (VT1 and VT3) and left bundle branch block (VT2) morphologies originating from the left ventricular summit (LV summit). During the VT2 and VT3, fragmented potentials, which occurred earlier than the QRS onset, were recorded from bipolar electrodes of a catheter at the anterior intraventricular vein (AIV). By pacing from right ventricular apex, constant and progressive fusion were observed. During the entrainment pacing, the fragmented potentials in the AIV catheter were activated orthodromically and those in the His bundle were activated antidromically. In addition, there were two components of the ventricular electrogram at the LV summit area with the interval of more than 100 ms during the VTs. We performed bipolar radiofrequency ablation between the LV endocardium and AIV, and the VTs became non-inducible. Discussion: Non-sustained VT/premature ventricular contraction originating from LV summit is generally considered to occur due to abnormal automaticity or triggered activity. In contrast, using entrainment technique, we demonstrated that the VTs with multiple morphologies were sustained with a re-entrant mechanism. Fragmentated potentials recorded in the AIV catheter were activated orthodromically with the entrainment pacing, indicating the slowly conducting isthmus. The intramural VT substrate was also suggested with a prolonged conduction time between the two ventricular components during the VTs.

Access to medications for opioid use disorder for formerly incarcerated individuals during community reentry: a mini narrative review.

Medications for opioid use disorder (MOUD) are especially important for formerly incarcerated individuals with opioid use disorder (OUD) and can reduce the risk of re-arrest and overdose during community reentry. Unfortunately, few formerly incarcerated individuals are able to access MOUD within the community, missing a critical tool for rehabilitation. A mini narrative review was conducted to highlight the published work that has been done to improve access to MOUD for formerly incarcerated individuals during reentry. The results yielded 15 records describing intervention evaluations, program descriptions, and research in progress. Most work is ongoing, showing promise that researchers have identified the importance of this problem. However additional research should be done to include other stakeholders and address the limitations of existing interventions and programs. Continued efforts can help ensure that formerly incarcerated individuals can safely and successfully reintegrate into society.

A Late Presentation of Right Common Iliac Vein Stent Embolization to the Right Atrium: Important Management Considerations.

Stent migration is a rare but serious complication of venous stenting, often presenting with chest pain, shortness of breath, and signs of heart failure. Potential complications include arrhythmia, perforation, and valve destruction. Here we present an asymptomatic patient with a late presentation of right common iliac vein stent migration to the right atrium.