Bibliothek

Notizen: Recent interest in curriculum integration in the decision sciences has led to the proposal that topics in computer science, statistics, quantitative methods, operations research, and possibly mathematics might be integrated into a single unified set of courses. Such a unification may reinforce the learning process of the student and form the basis for the eventual synthesis of tools topics with functional area decision making. This integration proposal and speculation is examined using research in learning and motivation theory, and concludes that the integration of tools concepts with functional area topics is much more promising than the integration of tools topics alone. A pair of example course integrations is provided to illustrate in detail the application of learning and motivation principles to tools-into-functions curriculum integration.

Notizen: 90-μF and 120-μF Biphasic Pulse Transvenous Defibrillation. Introduction: Capacitance is known to influence defibrillation. Optimal biphasic waveform capacitance for transvenous unipolar defibrillation systems in man is currently being defined. In an effort to improve defibrillation efficacy, we examined the relative defibrillation efficacy of a 65% tilt biphasic pulse from a 90-μF capacitor compared to a 65% tilt biphasic pulse from a 120-μF capacitor in a prospective, randomized fashion in 16 consecutive cardiac arrest survivors undergoing defibrillator surgery. Methods and Results: The transvenous unipolar pectoral defibrillation system uses a single endocardial RV anodal defibrillation coil and the shell of an 80-cc volume (88 cm2 surface area) pulse generator (Medtronic Model 7219C PCD “active CAN”) as the cathode for the first phase of the biphasic shock: RV+→ CAN−. Defibrillation thresholds for each capacitance were determined prospectively in a randomized fashion. The defibrillation threshold results for the 90-μF capacitance were: leading edge voltage 383 ± 132 V; stored energy 7.4 ± 5.0 J; and resistance 57 ± 10 ω. The results for the 120-μF capacitance were: leading edge voltage 315 ± 93 V (P = 0.002); stored energy 6.5 ± 3.7 J (P = 0.21); and resistance 57.0 ± 11 ω (P = 0.87). Conclusions: We conclude that 90-μF, 65% tilt biphasic pulses used with unipolar pectoral defibrillation systems have equivalent stored energy defibrillation efficacy compared to 120-μF, 65% tilt pulses. Use of lower capacitance is possible in present implantable defibrillators without compromising defibrillation.

Notizen: Implantable Defibrillators in Women. Clinical rhythm, heart disease, ejection fraction, defibrillation threshold, recurrent arrhythmias, and mortality were compared in 268 consecutive recipients (213 men and 55 women) of their first implantable cardioverter defibrillator for life-threatening ventricular tachycardia or fibrillation. Women were younger than men, less likely to have structural heart disease, and more likely to have clinical ventricular fibrillation, a higher ejection fraction, and a lower defibrillation threshold. Complications of defibrillator placement were similar in both sexes. Unadjusted survival tended to be higher in women than in men (97% vs 90%, respectively, at 2 years, P = 0.08), largely due to fewer deaths from noncardiac causes or cardiac causes other than arrhythmia (P = 0.04). Women also tended to be at lower, albeit still substantial, risk for recurrent arrhythmias during follow-up (37% vs 52% in men at 2 years, P = 0.11). After adjustment for baseline differences, overall survival, arrhythmia death-free survival, nouarrhythmia death-free survival, and frequency of recurrent arrhythmias were not found to be gender related. Despite their apparent “lower risk” status on initial presentation, women remained at substantial risk for recurrent arrhythmias. This underscores the need to avoid being unduly biased by the “appearance” of health in managing women with malignant arrhythmias. That survival and other clinical endpoints were all ultimately independent of gender emphasizes the importance of other clinical variables in assessing risk from ventricular tachyarrhythmias.

Notizen: Serial DFT Measures in Man. Introduction; The defibrillation threshold (DFT) may change throughout the first year following implantation of a cardioverter defibrillator, but it remains uncertain if changes are a consequence of changes in clinical condition or are related to fundamental alterations at the electrode-tissue interface. The purpose of this study was to evaluate the extent and time course of DFT changes over the first year following implantable cardioverter defibrillator (ICD) surgery when extraneous clinical and device variables potentially affecting the DFT were excluded. Methods and Results.: We prospectively enrolled 61 patients undergoing epicardial or non-thoracotomy/transvenous ICD therapy into a series of follow-up studies where the DFT was measured at implant and at 1, 6,12, and 52 weeks following implantation in a uniform manner. Stored energy DFT was measured and recorded for all patients. Patient exclusion criteria were: (1) inability to complete all five measures of the DFT; (2) institution of Class I or Class III antiarrhythmic drugs at any time during the study; (3) lead system changes (relocation or new leads) or programming changes in pulse width or current pathway; or (4) development of a significant change in their clinical status, such as decompensated congestive heart failure or acute ischemia. Only 20 of the 61 patients satisfied the criteria required to complete the study. Two of the excluded patients developed high DFTs, which required reprogramming of the current pathway. Eight patients had an epicardial lead system, and 12 had a nonthoracotomy lead system. The rise in DFT over the first 12 weeks was significant for the eight epicardial lead system patients (P = 0.05) and for the 12 nonthoracotomy lead system patients (P = 0.004). The peak rise in DFT occurred at 1 week for the patients with an epicardial lead system (3.4 ± 1.8 J to 7.9 ± 3.8 J) and at 12 weeks for the patients with a transvenous lead system (10.3 ± 5.3 J to 16.1 ± 7.4 J). Conclusions: This study confirms a transient significant rise in the DFT in the first 12 weeks following ICD surgery that partially returns to the implant value over the remainder of the year. Because specific clinical and technical variables were excluded from this study, the observations made in this patient population suggest that the rise in DFT may be a consequence of changes at the electrode-tissue interface.

Notizen: Abstract. When human T cell receptor for antigen (TCR) alpha chain V-genes were compared pair-wise, the numbers of nucleotide differences showed a characteristic distribution; most were in the range of 100 to 200 differences out of a total of about 300 bases. The same distribution was observed for mouse TCR alpha chains. Even more interesting was that comparing human alpha chains and mouse alpha chains gave essentially the same nucleotide difference pattern. It is inferred from the large number of differences and from the nonspecificity of trans-species (human and mouse) nucleotide sequence differences of TCR V-genes that TCR alpha chains probably diverged early during evolution. The same feature was also observed for human and mouse TCR beta chains, although the alpha and beta chain V-genes were distinct. This evolutionary preservation could be of vital importance to the fidelity of the complicated trimolecular interactions among TCR alpha and beta chains, the processed peptide, and the major histocompatibility complex (MHC) class I or II molecules.

Notizen: A SYMPOSIUM