1. The document describes techniques for performing an electrophysiology (EP) study, including catheter placement, measuring conduction intervals, refractory periods, retrograde and anterograde testing, and diagnostic pacing during sinus rhythm.
2. Specific techniques are outlined for using differential pacing and para-Hisian pacing to confirm the presence of a retrogradely conducting accessory pathway.
3. Factors that may influence the EP study are also discussed, such as using drugs to induce arrhythmias, ensuring the appropriate tissue is being captured, and considering special circumstances like myotonic dystrophy.
AV nodal reentrant tachycardia (AVNRT), or atrioventricular nodal reentrant tachycardia, is a type of tachycardia (fast rhythm) of the heart. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men (approximately 75% of cases occur in females). The main symptom is palpitations. Treatment may be with specific physical maneuvers, medication, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.
AVNRT occurs when a reentry circuit forms within or just next to the atrioventricular node. The circuit usually involves two anatomical pathways: the fast pathway and the slow pathway, which are both in the right atrium. The slow pathway (which is usually targeted for ablation) is located inferior and slightly posterior to the AV node, often following the anterior margin of the coronary sinus. The fast pathway is usually located just superior and posterior to the AV node. These pathways are formed from tissue that behaves very much like the AV node, and some authors regard them as part of the AV node.
The fast and slow pathways should not be confused with the accessory pathways that give rise to Wolff-Parkinson-White syndrome (WPW syndrome) or atrioventricular reciprocating tachycardia (AVRT). In AVNRT, the fast and slow pathways are located within the right atrium close to or within the AV node and exhibit electrophysiologic properties similar to AV nodal tissue. Accessory pathways that give rise to WPW syndrome and AVRT are located in the atrioventricular valvular rings. They provide a direct connection between the atria and ventricles, and have electrophysiologic properties similar to ventricular myocardium.
An electrocardiogram (ECG or EKG) records the electrical signal from your heart to check for different heart conditions. Electrodes are placed on your chest to record your heart's electrical signals, which cause your heart to beat. The signals are shown as waves on an attached computer monitor or printer
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM FoundationThe CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
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Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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2. • 1 -catheters
• 2 -baseline measurements
• 3 -evaluate conduction
– EP properties of A, V, AV node & AP
– tachycardia induction
• 4 –diagnostic pacing during sinus rhythm
• 5-special circumstances for EP
3. Catheters
• No of caths
• Full arsenal vs minimal
approach
• Position CS proximal at
ostium initially
• His placement
• Atrial signal on same bipole
as His
4. Baseline intervals – normal values
• Cycle length, QRSd, QT
• PA interval 25-55ms
– intra-atrial conduction time (IACT)
• AH 55-120ms
– conduction through AV node
• HV 35-55ms
– His through purkinje to V activation
9. Refractory periods
• Effective RF-the longest S2 that doesn’t
conduct or capture local tissue
• Functional RP-the shortest S2 that conducts
• Relative RP-the longest S2 that shows latency
10. Retrograde testing
• Retrograde testing – why?
– V refractory period
– Assess atrial activation
• Concentric
• Eccentric
– Assess properties of AV node and/or AP
• Decremental conduction
– VA Wenckebach point
– Induce tachycardia
11. Retro how
Synchronised fixed pacing of 8 beats (S1) at 600ms &
400ms with extrastimulus (S2)
1 2 3 4 5 6 7 8
600
12. • S2 down to VERP
•
• If VERP longer than AV node ERP can use shorter S1
• Add S3, S4 if necessary
No capture
with V stim
13. • Incremental ventricular pacing
increase the rate of V pacing until VA block occurs =
VA W’Bach cycle length
360ms 350ms360ms
VA
14. Retro things to look out for
• VA ‘jump’ due to retrograde RBBB
AVH AV H
H H
A
A
H A time the same,
no AV nodal jump
16. Anterograde testing why?
• Determine atrial effective refractory period
• Atrial & ventricular activation sequence
• Assess properties of AV conduction
– AV node duality
– Assess properties if accessory pathway
• Induce tachycardia
17. Anterograde testing how?
• Synchronised drive cycle (S1) of 8 beats at
600ms & 400ms with extrastimulus (S2)
• S2 down to AERP
• If AERP longer than AV node ERP can use
shorter S1
• Add S3, S4 if necessary
• Incremental atrial pacing
– Gradually increase the rate of A pacing until AV
Wenckebach occurs
18. Antero to look out for
• Measurement of AH interval
– Measure from AEGM on His cath, NOT stim spike
• AH jump may be present in up to 30%
• Intra-atrial re-entry
– ‘Junk’
• gap phenomenon
Block occurs with long S1S2 interval but resumes after a
‘gap’ at shorter S1S2 coupling intervals due to proximal
delay
19. Antero things to look out for
• gap phenomenon
• Block occurs with long S1S2 interval but resumes after a
‘gap’ at shorter S1S2 coupling intervals
• Long S1S2
H1 H2V1 V2
20. Antero things to look out for
• gap phenomenon
• Block occurs with long S1S2 interval but resumes after a
‘gap’ at shorter S1S2 coupling intervals
• Shorter S1S2 = block
H1 V1 H2
21. Antero things to look out for
• gap phenomenon
• Block occurs with long S1S2 interval but resumes after a
‘gap’ at shorter S1S2 coupling intervals
• Shortest S1S2 = conduction resumes
Resumes due to proximal delay
H1 H2V1 V2
22. Pacing to induce tach
• Pace from different
sites (on AP)
• Stim from 2 sites
simultaneously
Will often require
• Isuprel
• Atropine
23. • Short(S2) – long(S3) – short(S4)
• Burst pacing (triggered activity)
• 1x/2x/3x ectopics during SR (FP →SP)
sense sense
27. AP present: VAI = VA apex – VA base = >10ms
Avoid atrial capture
when pacing basally
Not useful in slowly
conducting APs
28. Parahisian pacing
• Used to confirm presence of retrogradely
conducting septal pathway
• Pace at high output from distal His cath
– Ensure capture of His & RV myocardium
– Lower output to achieve RV myocardial capture only
• Measure stim to A interval
Hirao K, Otomo K, Wang X et al. Para-Hisian pacing. A new method for differentiating retrograde
conduction over an accessory AV pathway from conduction over the AV node. Circulation 1996;94(5):1027–35
29. Parahisian pacing – NO septal accessory pathway
Hirao ,K et al Circulation 1996; 94:1027-1035
His bundle
High output:
Stim->A interval with His & V capture = short VA
High output pacing
30. Low output pacing
Parahisian pacing – NO septal accessory pathway
Hirao ,K et al Circulation 1996; 94:1027-1035
His bundle
Low output:
Stim-A with V only capture = longer VA
No AP; Stim-A increases >50ms with loss of His capture
31. Parahisian pacing–WITH septal accessory pathway
High output pacing
Trace modified from Obeyesekere M et al. Circ Arrhythm Electrophysiol 2011;4:510-514
32. Low output pacing
Parahisian pacing–WITH septal accessory pathway
AP present stim-A change with loss of His capture <40ms
Trace modified from Obeyesekere M et al. Circ Arrhythm Electrophysiol 2011;4:510-514
33. Parahisian pacing
• Avoid atrial capture
– Stim-A <60ms in CSp, stim-A >90ms no A capture
• May get His only capture
– Narrow complex matching QRS in sinus rhythm
– Stim-V interval ≈ HV in sinus rhythm
• No good for slowly conducting Aps
OBEYESEKERE, M. N., LEONG-SIT, P., GULA, L. J. and KLEIN, G. J. (2012), Seven Manifestations of Para-Hisian Pacing.
Journal of Cardiovascular Electrophysiology, 23: 1035–1036.
34. Other reasons
• Myotonic dystrophy
• HV >70ms
• VT stim – Wellens protocol
• Test ATP effectiveness of device
programming
• Evaluate drugs on tachy
• EP study though PPM/ICD/CRT
35. Take home
• Measure all intervals correctly
• Determine AV node conduction properties
• Will often need drugs to induce tach
• Make sure you’re capturing what you think
you’re capturing
• Use differential pacing/para-Hisian pacing
• Be prepared for the unexpected
• Enjoy EP!!
37. Further reading
• Handbook of Cardiac Electrophysiology: A Practical Guide to Invasive EP Studies and Catheter Ablation
• Francis Murgatroyd, Andrew D. Krahn, Raymond Yee, Allan Skanes, George J. Klein
• Martínez-Alday etal. Identification of concealed posteroseptal Kent pathways by comparison of ventriculoatrial intervals
from apical and posterobasal right ventricular sites. Circulation. 1994 Mar;89(3):1060-7.
• Obeyesekere M etal. Determination of inadvertent atrial capture during para-hisian pacing. Circ Arrhythm Electrophysiol
2010;4:510-514.
• Liew et al. A randomized-controlled trial comparing conventional with minimal catheter approaches for the mapping and
ablation of regular supraventricular tachycardias. Europace (2009) 11, 1057–1064
• Single-catheter approach to radiofrequency current ablation of left-sided accessory pathways in patients with Wolff-
Parkinson-White syndrome
• K H Kuck and M Schlüter Circulation. 1991;84:2366-2375
• Hirao K, Otomo K, Wang X et al. Para-Hisian pacing. A new method for differentiating retrograde conduction over an
accessory AV pathway from conduction over the AV node. Circulation 1996;94(5):1027–35.