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Atrial size reduction as a predictor of the success of radiofrequency maze procedure for chronic atrial fibrillation in patients undergoing concomitant valvular surgery effective 10mg alavert. D-22 Chiladakis JA cheap alavert 10 mg free shipping, Kalogeropoulos A, Patsouras N, et al. Ibutilide added to propafenone for the conversion of atrial fibrillation and atrial flutter. Predictive value of obstructive sleep apnoea assessed by the Berlin Questionnaire for outcomes after the catheter ablation of atrial fibrillation. Prevalence, mechanisms, and clinical significance of macroreentrant atrial tachycardia during and following left atrial ablation for atrial fibrillation. Efficacy, safety, and outcome of atrial fibrillation ablation in septuagenarians. Clinical value of noninducibility by high-dose isoproterenol versus rapid atrial pacing after catheter ablation of paroxysmal atrial fibrillation. Sinus rhythm restoration after atrial fibrillation: the clinical value of N-terminal pro-BNP measurements. Proarrhythmia of circumferential left atrial lesions for management of atrial fibrillation. Cardioversion of atrial fibrillation with ibutilide: when is it most effective? Impact of left atrial fibrosis and left atrial size on the outcome of catheter ablation for atrial fibrillation. Intra-operative cooled-tip radiofrequency linear atrial ablation to treat permanent atrial fibrillation. Long-term monitoring after surgical ablation for atrial fibrillation: how much is enough? Circumferential pulmonary vein isolation and linear left atrial ablation as a single-catheter technique to achieve bidirectional conduction block: the pace- and-ablate approach. Safety of electrical cardioversion in patients with previous embolic events. Efficacy of biphasic waveform cardioversion for atrial fibrillation and atrial flutter compared with conventional monophasic waveforms. Initial energy for external electrical cardioversion of atrial fibrillation. Efficacy and safety of ibutilide for cardioversion of atrial flutter and fibrillation in patients receiving amiodarone or propafenone. Design and rationale of a randomized study to compare amiodarone and Class IC anti-arrhythmic drugs in terms of atrial fibrillation treatment efficacy in patients paced for sinus node disease: the PITAGORA trial. Intravenous amiodarone bolus immediately controls heart rate in patients with atrial fibrillation accompanied by severe congestive heart failure. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Beta-blockers or digoxin for rate control of acute atrial fibrillation in the emergency department. Specific linear left atrial lesions in atrial fibrillation: intraoperative radiofrequency ablation using minimally invasive surgical techniques. Time courses and quantitative analysis of atrial fibrillation episode number and duration after circular plus linear left atrial lesions: trigger elimination or substrate modification: early or delayed cure? Mid-term results of endoscopic mitral valve repair in combination with endocardial or epicardial ablation. Low risk of major complications associated with pulmonary vein antral isolation for atrial fibrillation: results of 500 consecutive ablation procedures in patients with low prevalence of structural heart disease from a single center. Early recurrences after atrial fibrillation ablation: prognostic value and effect of early reablation. Comparison of recurrence rates after direct-current cardioversion for new-onset atrial fibrillation in patients receiving versus those not receiving rhythm-control drug therapy. The effect of different treatment strategies on left atrial size in patients with lone paroxysmal atrial fibrillation-a prospective cohort study. Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Ablate and pace revisited: long term survival and predictors of permanent atrial fibrillation. Improved outcome following restoration of sinus rhythm prior to catheter ablation of persistent atrial fibrillation: A comparative multicenter study. Journal of Interventional Cardiac Electrophysiology 2012;33(3):297.

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Rapid kindling with recurrent in rats: visualization after retrograde transport of biocytin order 10 mg alavert overnight delivery. J hipocampal seizures: effect of stimulus frequency and train dura- Comparative Neurology 1995;352:515–534 buy alavert 10mg without a prescription. Neurosurgery 1978;3: rent excitatory circuits in the dentate gyrus of hippocampal 234–252. Subcortical structures and pathways involved in convul- campal kainate in the rat. Possible functional consequences of synaptic reor- 46. FAST and SLOW amyg- ganization in the dentate gyrus of kainate-treated rats. Neurosci dala kindling rat strains: comparison of amygdala, hippocampal, Lett 1992;137:91–96. Limbic seizure and brain damage produced by kainic 1854 Neuropsychopharmacology: The Fifth Generation of Progress acid: mechanisms and relevance to human temporal lobe epi- epileptogenesis: does disinhibition play a role? Permanently altered hippocampal structure, excita- of pilocarpine in rats: structural damage of the brain triggers bility, and inhibition after experimental status epilepticus in kindling and spontaneous recurrent seizures. Epilepsia 1991;32: the rat: the 'dormant basket cell' hypothesis and its possible 778–782. Hip- campus versus a chronic, kainate rat model of hippocampal pocampus 1996;6:347–470. Recurrent sponta- aminobutyric acid type A receptor function in CA1pyramidal neous hippocampal seizures in the rat as a chronic sequela to neurons. A new model of chronic GABA A receptor subunits in the hippocampus of the rat after temporal lobe epilepsy induced by electrical stimulation of the kainic acid-induced seizures. Self-sustaining induced by lowering extracellular [Mg2 ] in combined hippo- status epilepticus after brief electrical stimulation of the perfor- campal-entorhinal cortex slices: modulation by receptors for ant path. The TINS/TIPS lecture The molecular biology lepsy Res 1995;20:93–104. Model of chronic spontaneous limbic 1993;16:359–365. J entorhinal cortex are epileptiform in an electrogenic rat model Pharmacol Exp Ther 1995;274:1113–1121. Hyperexcitability of entorhinal cortex and hip- sion in young and adult rats. Expression of the medial entorhinal cortex in combined entorhinal and hippo- glutamate transporters in human temporal lobe epilepsy. Shortened duration GABA A receptor Neuroscience 1996;72:399–408. Spontaneous in a chronic model of temporal lobe epilepsy. Neuroscience 1997; recurrent seizures in rats: amino acid and monamine determina- 80:1101–1111. Neuropeptide Y: emerging tor subunits GluR1and GluR2/3 distribution shows reorganiza- evidence for a functional role in seizure modulation. GABA receptors in human epileptic neocortical tissue: quantita- 81. Hyperexcitability in combined entorhinal/hip- tive in vitro receptor autoradiography. Neuroscience 1999;94: pocampal slices of adult rat after exposure to brain-derived neu- 1051–1061. Effects of kainic acid on of the NMDAR1glutamate receptor subunit in human tem- messenger RNA levels of IL1IL6, TNF , and Lif in the rat poral lobe epilepsy. Increased neuronal - so dormant in temporal lobe epilepsy: a critical reappraisal of the amyloid precursor protein expression in human temporal lobe dormant basket cell hypothesis. Evidence of functional mossy fiber Neurochem 1994;63:1872–1879. Seizure activity causes elevation of en- cortex following aminoxyacetic acid-induced seizures. Exp Brain dogenous extracellular kynurenic acid in the rat brain. Rat 3-hydroxyanthranilic acid¨ ical changes of the cortical GABAergic system in epileptic foci. Chronic focal neocortical tivity and microglia are enhanced in the rat hippocampus by Chapter 127: Temporal Lobe Epilepsy 1855 focal kainate application: functional evidence for enhancement 97. Neuron loss, granule cell axon reor- of electrographic seizures. Loss of 2/NeuroD leads mental temporal lobe epilepsy. J Comp Neurol 1999;408: to malformation of the dentate gyrus and epilepsy. Hippocampal granule cells empress glu- of dentate gyrus neurons after single and intermittent limbic tamic acid decarboxylase-67 after limbic seizures in the rat.

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Two recent developments have reduced the memory disturbance associated with ECT cheap alavert 10mg with amex. First cheap alavert 10 mg fast delivery, the introduction of stimulation by brief (1 ms) square waves. Early ECT devices delivered sine waves, which have limited stimulation potential relative to the amount of energy they deliver, and the unnecessary energy greatly disturbed memory. Second, was the introduction of unilateral ECT, which is not usually associated with the subjective experience of memory difficulties (Squire and Slater, 1983). Major depression per se, perhaps through distractibility and perhaps through the slowing of thought processes, has a detrimental effect on memory. Also, many antidepressants (the alternative treatment) may also have a mild, temporary, detrimental effect on memory. Thus people who suffer an episode of major depression may have a poor memory for this period of their lives whether they had ECT or not. Using sophisticated neuropsychological testing methods, disturbance of memory can sometimes be demonstrated following ECT (Schulze-Rauchenbach et al, 2005). Memory difficulty is the most commonly claimed side effect of ECT. Frequently, no objective evidence can be demonstrated. However, as Vamos (2008) points out, despite the low correlation, both perspectives must be taken into consideration. The following summarize our present knowledge regarding ECT and memory: • Memory difficulties may follow ECT, and while these usually subside within a few weeks, evidence indicates that some individual have long term difficulties. This may be extended by the introduction of ultra-brief pulses. Case history, 1 Harold Watts was an accountant of 44 years of age, he was married to Ellen and the father of Josephine aged 21, who had recently married, and Paula aged 19, who had recently left home to live in a de facto relationship. Harold was brought to hospital by ambulance, accompanied by police, Ellen and a next-door neighbour. Ellen had gone to investigate two loud noises in the garage. She had found Harold on the floor next to an overturned chair, apparently dead. She rushed to her friends next door and they ran back with her. By this time Harold was beginning to move and groan on the floor. There was a belt tied to a rafter with the buckle end hanging down. The first noise Ellen heard may have been the jerking of the rafter or the chair falling over, and the second, some moments later, may have been when the buckle broke and Harold landed on the floor. The ambulance officers noted thick purple marks around his neck and that the whites of his eyes were pinkish. The police were shown the hanging belt and Harold was taken to hospital. Harold was orientated in time, place and person and an X-ray of his neck revealed no bony abnormality. He could move all limbs and did not appear to have sustained any permanent physical damage. He cried and said he was just missing “the girls” since they both left home about the same time. Ellen, a neighbour, a hospital doctor and an ambulance officer were discussing the situation in the corridor. Ellen was saying she would take Harold home and perhaps they should take a holiday together, when a nurse passing his cubicle noticed Harold was attempting to strangle himself with the leads of a cardiac monitor. They rushed back, removed the leads and called a psychiatrist. Harold had been drinking excessively over the last month. He denied feeling depressed, but had been moved to tears when watching sentimental television programs. He had been preoccupied with thoughts of his dead parents and dead brother. He had found himself thinking about cemeteries and his own funeral. He then started to experience strong urges to kill himself. He could not explain these urges, nor could he guarantee he would not act on them. Harold was transferred to a psychiatric ward for observation, with a probable diagnosis of major depressive disorder. There was some uncertainty as he denied feeling depressed.

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Topiramate at 3 mg/kg was administered to six volunteers without epilepsy buy alavert 10mg line. Through modification GABA levels were measured to peak within 3 hours after adminis- of the editing selectivity buy discount alavert 10mg on-line, the GABA derivative pyrolidinone tration of topiramate at approximately two times the predrug levels. A study looking at the acute effect of topiramate on GABA may also be measured in the edited spectrum (131). It was levels of epileptic patients found that the increase was almost recently shown that GABA, homocarnosine, and pyrolidi- entirely due to GABA (121). The GABA plus homocarnosine con- none have different time courses in response to a first-time centrations are normalized to a creatine concentration of 9 mol/ g for comparison with measurements by Petroff and co-workers challenge with vigabatrin (109). Topira- mate increases cerebral GABA in healthy humans. However, the ability to directly Disease on GABA Concentration measure GABA synthesis at 2. Consistent with this proposal, 1H MRS editing studies have found decreased GABA in Due to the entry of GABA into the glial TCA cycle at adult epilepsy (111,125) and pediatric epilepsy (126). In the level of succinate, the labeling kinetics of C4-glutamine epilepsy the release of cytosolic GABA has been proposed derived from GABA are indistinguishable from label enter- as an important mechanisms for seizure suppression (127, ing through anaplerosis. The finding that a low GABA concentration was the maximum estimate of the rate of the GABA/glutamine strongly associated with poor seizure control in epilepsy sup- cycle, obtained by assuming that Vana, is entirely due to ports this proposal. Further support for a role of cytosolic GABA, would be approximately 10% of the rate of gluta- GABA concentration in inhibiting cortical excitability mine synthesis (29). In addition to epilepsy, reduced GABA concentration has been found in unipolar depression (129), alcohol with- Summary and Remaining Questions drawal, and hepatic encephalopathy (130). These disorders are associated with an alteration in inhibitory GABAergic The ability of 1H MRS to measure regional levels of GABA function. The finding of low GABA associated with these and GABA derivatives has provided a new window on the disorders is additional evidence that the brain metabolic GABAergic system in neurologic and psychiatric disease. GABA pool has an important role in GABAergic function. Reduced levels of cerebral cortex GABA have been found The finding in unipolar depression appears paradoxical be- in patients with adult and pediatric epilepsy, depression, cause the condition is not associated with enhanced cortical and alcohol withdrawal. A potential explanation of this finding is that the new generation of antiepileptic drugs raise GABA levels, 332 Neuropsychopharmacology: The Fifth Generation of Progress and GABA elevation may be related to their effectiveness surements of the Rate of the Glutamate/Glutamine Cycle: in seizure depression. The recently demonstrated ability to Findings and Validation, and Determination of the In Vivo perform GABA spectroscopic imaging (105) opens up the Coupling Between the Rate of the Glutamate/Glutamine potential for using regional variations in GABA level diag- Neurotransmitter Cycle and Neuronal Glucose Oxidation). As discussed below (see Implications of MRS What is the relationship between GABA levels and the rate Studies for Understanding Brain Function), the ambiguity of the GABA/glutamine cycle? What is the relationship be- created by the variable degree of uncoupling between glu- tween the GABA/glutamine cycle and cortical excitability? This strategy, in of metabolic coupling between glucose and oxygen by allow- combination with the manipulation of GABA levels either ing measurements of the rates of nonoxidative glycolysis pharmacologically or through transgenic methods, may pro- and glucose oxidation. MRS experiments have shown that vide significant insight into how the regulation of GABA under stimulated conditions the majority of energy for func- concentration affects GABAergic function. They have also confirmed the presence of metabolic uncoupling at high levels of brain activity (136–138). A model has been IN VIVO MRS MEASUREMENTS OF proposed to explain the uncoupling of glucose consumption NEUROENERGETICS DURING FUNCTIONAL and oxidation during certain types of stimulation as an ex- ACTIVATION tension of the normal energetic processes used to support the glutamate/glutamine cycle (139). Under physiologic conditions brain oxygen and glucose consumption are tightly coupled (49), with between 90% MRS Studiesof Lactate Generation and and 95% of glucose uptake being completely oxidized. The Glucose Oxidation During Sensory tightness of this coupling during brain activation was ques- Stimulation tioned when Fox and co-workers (132) measured by PET a mean increase of 51% in CMRglc in the primary visual A prediction of the presence of uncoupling of the increase cortex of humans during stimulation by a flashing checker- of glucose consumption and oxidation during visual activa- board pattern accompanied by only a 5% increase in oxygen tion is that there will be an elevation of lactate in the visual consumption (CMRO2). Several laboratories have found an increase in lactate cause of the 16- to 18-fold lower ATP production from concentration (136–138) during visual stimulation of the nonoxidative glycolysis compared with the complete oxida- human visual cortex by 1H MRS of approximately 0. It was concluded from these 4 mol/g-min within 2 to 6 minutes of activation. The results that the energy for supporting electrical activity de- small increase in lactate is consistent with earlier findings rives primarily from nonoxidative glycolysis as opposed to in animal models (40). More recently, the greater in- The degree of mismatch between the increase in glucose crease in cerebral blood flow than oxygen consumption that consumption and oxidation during sensory stimulation was leads to the BOLD (blood oxygenation level dependent) studied by Hyder and co-workers (14,15) using forepaw effect has been taken as evidence of the hypothesis of stimu- stimulation of an anesthetized rat measured the rate of in- lated neuronal activity requiring little energy (134). These studies found a large in- doxical because of the considerable evidence that the major- crease in the rate of glucose oxidation during sensory stimu- ity of energy consumption in the nonstimulated brain, lation (Fig. This increase was in good agreement which primarily uses glucose oxidation, is to support neu- with previous measurements of the increase in total glucose ronal electrical activity. This evidence includes the critical consumption (140). While within the accuracy of the mea- dependence of brain function on oxygen delivery, the 50% surements there was room for a significant rate of nonoxida- to 70% reduction of brain energy requirements under iso- tive glycolysis, the contribution of nonoxidative glycolysis electric conditions (133), and the 13C MRS findings of a to total cerebral ATP production during activation would high activity of the glutamate/glutamine cycle in the resting be minor due to the much greater number of ATP molecules awake brain and the linear coupling of this rate to neuronal produced by the complete oxidation of glucose (32–36) glucose oxidation (see the above sections In Vivo MRS Mea- than by nonoxidative glycolysis to lactate (2). Time course of C4 glutamate labeling in the ipsi- and contralateral somatosensory cortex of a rat during single forepaw electrical stimulation. In vivo 1H-13C MRS spectra were ob- tained from two 24- L volumes, positioned in the ipsi- and contralateral somatosensory cortex of rats at 7 T.