Biphasic Waveform Research Articles

Utility of Clot Waveform Analysis in Russell's Viper Bite Victims with Hematotoxicity.

Introduction:In Russell's viper bites, due to the lack of a better alternative, whole blood clotting test (WBCT) remains the standard test even though its reliability and sensitivity has been shown to be low. Activated partial thromboplastin time (aPTT)-based clot waveform analysis (CWA) is an optic absorbance assay that can be used as a global clotting test. In this study, the objective was to assess the changes in CWA and to compare CWA to WBCT and aPTT in patients with Russell's viper envenomation.Methods:The datum was collected prospectively over 2 months as a pilot observational study in a tertiary care center. All proven cases of Russell's viper-envenomated individuals with preliminary CWA data and WBCT were included in the study. The clot wave (CW) of the five individuals, which met all the stringent inclusion criteria, was analyzed and interpreted.Results:CW absorbance sigmoid waveform was deranged in all 5 cases, of which 4 showed a change in CWA even before an abnormal aPTT. Three of the 5 had a normal WBCT but showed early changes in CWA. Atypical biphasic waveform reported in disseminated intravascular coagulation in other prior studies is seen in venom-induced consumptive coagulopathy also. In all patients where a second derivative was plotted, the second (lower) phase of the second derivative showed a slow rise to baseline.Conclusion:CWA showed changes which provided information earlier than the conventional coagulation studies in the snakebite victims studied. While aPTT or WBCT reflects clotting time, CWA conveys the dynamic process of clot formation and stabilization. CWA may reveal disorders of clotting in snakebite victims before the conventional tests become abnormal. Future research should assess the speed and accuracy of the test in diagnosing hemotoxic envenomation and its potential role in guiding antivenom therapy.

Interaction of defibrillation waveform with the time to defibrillation or the number of defibrillation attempts on survival from out-of-hospital cardiac arrest

AimEarly biphasic defibrillation is effective in out-of-hospital cardiac arrest (OHCA) cases. In the resuscitation of patients with OHCA, it is not clear how the defibrillation waveform interacts with the time to defibrillation to influence patient survival. The second, and any subsequent, shocks need to be administered by an on-line physician in Japan. Thus, we investigated the interaction between the defibrillation waveform and time to or the number of defibrillation on resuscitation outcomes. MethodsThis prospective observational study used data for all OHCAs that occurred between 2005 and 2014 in Japan. To investigate the interaction effect between the defibrillation waveform and the time to defibrillation or the number of defibrillations on the return to spontaneous circulation (ROSC), 1-month survival, and cerebral performance category (CPC) (1, 2), we assessed the modifying effects of the defibrillation waveform and the time to or the number of defibrillation on additive scale (i.e., the relative excessive risk due to interaction, RERI) and multiplicative scale (i.e., ratio of odds ratios (ORs)). ResultsIn total, 71,566 cases met the inclusion criteria. For the measure of interaction between the defibrillation waveform and the time to defibrillation, ratio of ORs for ROSC was 0.84 (0.75–0.94), implying that the effect of time to first defibrillation on ROSC was negatively modified by defibrillation waveform. For the interaction between the defibrillation waveform and the number of defibrillations, RERI and ratio of ORs for CPC (1, 2) was −0.25 (−0.47 to −0.06) and 0.79 (0.67–0.93), respectively. It is implied that the effect of number of defibrillation on CPC (1, 2) was negatively modified by defibrillation waveform. ConclusionsAn increased number of defibrillations was associated with a decreased ROSC in the case of biphasic and monophasic defibrillation, while an increased number of defibrillations was related to an increased 1-month survival rate and CPC (1, 2) only in the case of biphasic defibrillation. When two or more defibrillations were performed, a biphasic waveform was more effective in terms of long-term survival than a monophasic waveform.

Comparison of Monophasic and Biphasic Electrical Stimulation by Using Temporal Analysis for Different Inter-electrode Spacings in the Hexagonal Arrays

Recent multidisciplinary studies in the field of visual prosthesis rely on electrically stimulating retinal tissue by placing electrode array into different part of it, bypassing the nerve cells of the visual pathway which have lost their functionality due to various degenerative diseases. The visual prosthesis systems could be more efficient by mimicking physiologically natural electrical signals. In this study, the responses of the retina to biphasic and monophasic electrical stimulations were compared temporally using in-vitro rabbit retina. The retinal tissue was electrically stimulated with charge-balanced biphasic and monophasic pulses. When temporal diversity was comparatively analyzed, spike activity was observed to intensify in the first 20 ms after the moment of stimulation for biphasic stimulation. On the other hand, the spike activity was observed to form in a way that it can be classified into two categories, the primary one forming in the first 20 ms and the secondary delayed one forming between 80 and 100 ms for monophasic stimulation. Moreover, the effect of retina stimulation amplitude was also analyzed. The spike distribution was observed to cumulate mostly in the post-stimulation time interval of the first 20 ms as the stimulation amplitude for biphasic stimulation increased. In monophasic stimulation, secondary delayed spike activity was observed over 80 \({\upmu }\hbox {A}\). The obtained experimental findings suggested that lower amplitude charge-balanced short biphasic waveforms could better elicit the precise and proper stimulation patterns necessary to mimic the neural activity of retinal circuitry that resembles the natural ones when it was compared with monophasic stimulation.

Energy-efficient waveform for electrical stimulation of the cochlear nerve

The cochlear implant (CI) is the most successful neural prosthesis, restoring the sensation of sound in people with severe-to-profound hearing loss by electrically stimulating the cochlear nerve. Existing CIs have an external, visible unit, and an internal, surgically-placed unit. There are significant challenges associated with the external unit, as it has limited utility and CI users often report a social stigma associated with prosthesis visibility. A fully-implantable CI (FICI) would address these issues. However, the volume constraint imposed on the FICI requires less power consumption compared to today’s CI. Because neural stimulation by CI electrodes accounts for up to 90% of power consumption, reduction in stimulation power will result directly in CI power savings. To determine an energy-efficient waveform for cochlear nerve stimulation, we used a genetic algorithm approach, incorporating a computational model of a single mammalian myelinated cochlear nerve fiber coupled to a stimulator-electrode-tissue interface. The algorithm’s prediction was tested in vivo in human CI subjects. We find that implementation of a non-rectangular biphasic neural stimulation waveform may result in up to 25% charge savings and energy savings within the comfortable range of hearing for CI users. The alternative waveform may enable future development of a FICI.

Videodermoscopy and doppler-ultrasound in spider naevi: towards a new classification?

Spider naevi (SN) are considered a subtype of telangiectasias, currently classified as low-flow vascular malformations. To describe the videodermoscopy and Doppler-ultrasound (US) features of a large group of SN. A retrospective study of cases of SN collected at our Dermatology department during the period between June 2015 and June 2017 was performed. Clinical images, dermoscopic, videodermoscopic and Doppler-US files were reviewed. For each case, the age of the patient, time since onset, size and dermoscopic pattern of the lesions were recorded. The presence of pulsatility was also evaluated visually on the videodermoscopy. Two hundred and thirty-three SN in 189 patients were included. The mean age was 39.5years (range: 10-76years). Mean size of the lesions was 4.1±2.0mm. We described three dermoscopic patterns: network, star and looping. Older age, longer time since onset and larger size were found associated with higher frequency of the looping and star patterns compared to that of network pattern (P<0.01). Pulsatility during videodermoscopy was found in 88 patients (37%). This pulsatility phenomenon was more commonly associated with the looping pattern (64.7%) than star- (40.3%) or network-like patterns (29.9%) (P<0.001). In Doppler-US studies, a high-flow with arterial biphasic waveform was found. In the light of the results, we support that SN could be reconsidered in upcoming classifications as lesions closer to the group of high-flow arteriovenous malformations.

Vestibular Response to Electrical Stimulation of the Otolith Organs. Implications in the Development of A Vestibular Implant for the Improvement of the Sensation of Gravitoinertial Accelerations.

Electrical stimulation of the utricular and saccular portions of the vestibular nerve improves stability in patients suffering from vestibular dysfunction. The main objective of this study was to evaluate a new technique, vestibular response telemetry (VRT), for measuring the electrically evoked vestibular compound action potential (saccular and utricular) after stimulating the otolith organ (saccular and utricular) in adults. This study used evidence that the otolith organ can be electrically stimulated in order to develop a new vestibular implant design to improve the sensation of gravitoinertial acceleration. Four adult patients were evaluated by using a variety of measurement procedures with novel VRT software. VRT values were obtained by stimulating with three full-band Nucleus CI24RE (ST) electrodes. Specific stimuli were used. Simultaneously, electrical ocular vestibular evoked myogenic potentials (eoVEMPs) were recorded in the contralateral side. Electrically evoked compound action potentials were obtained in 10 of the 12 electrodes tested, and eoVEMPs were recorded when VRT was present. In addition to the validation of this technique, a set of default clinical test parameters was established. The VRT response morphology consisted of a biphasic waveform with an initial negative peak (N1) followed by a positive peak (P1), and latencies were typically 400 μs for N1 and 800 μs for P1. The consequences for the development of a vestibular implant for the improvement of gravitoinertial acceleration sensation are also presented. The VRT measurement technique has been shown to be a useful tool to record neural response on the otolith organ, and thus it is a convenient tool to evaluate whether the implanted electrodes provide a neural response or not. This can be used for the early development of vestibular implants to improve gravitoinertial acceleration sensation.

Non-selective His bundle pacing with a biphasic waveform: enhancing septal resynchronization.

His bundle pacing has shown to prevent detrimental effects from right ventricular apical pacing (RVA) and proved to resynchronize many conduction disturbances cases. However, the extent of His bundle pacing resynchronization is limited. An optimized stimulation waveform could expand this limit when implemented in His bundle pacing sets. In this work, we temporarily implemented RVA and Non-selective His bundle pacing with a biphasic anodal-first waveform (AF-nHB) and compared their effects against sinus rhythm (SR). Fifteen patients referred for electrophysiologic study with conduction disturbances, cardiomyopathy and ejection fraction below 35% were enrolled for the study. The following acute parameters were measured: QRS duration, left ventricular activation (RLVT), time of isovolumic contraction (IVCT), ejection fraction (EF), and dP/dtmax. QRS duration and RLVT decreased markedly under AF-nHB (SR: 169 ± 34 ms vs. nHB: 116 ± 31 ms, P < 0.0005) while RVA significantly increased QRS duration (SR: 169 ms vs. RVA: 198 ms, P < 0.05) and did not change RLVT (P = NS). Consistently, IVCT moderately decreased under AF-nHB (SR: 238 ms vs. RVA: 184 ms, P < 0.05 vs. SR) and dP/dtmax showed a 93.35 [mmHg] average increase under AF-nHB against SR. Also, T-wave inversions were observed during AF-nHB immediately after SR and RVA pacing suggesting the occurrence of cardiac memory. AF-nHB corrected bundle branch blocks in patients with severe conduction disturbances, even in those with dilated cardiomiopathy, outstanding from RVA. Also, the occurrence of cardiac memory during AF-nHB turned up as an observational finding of this study.

Cardioversion Efficacy Using Pulsed Biphasic or Biphasic Truncated Exponential Waveforms: A Randomized Clinical Trial.

BackgroundSeveral different defibrillators are currently used for cardioversion and defibrillation of cardiac arrhythmias. The efficacy of a novel pulsed biphasic (PB) waveform has not been compared to other biphasic waveforms. Accordingly, this study aims to compare the efficacy and safety of PB shocks with biphasic truncated exponential (BTE) shocks in patients undergoing cardioversion of atrial fibrillation or ‐flutter.Methods and ResultsThis prospective, randomized study included patients admitted for elective direct current cardioversion. Patients were randomized to receive cardioversion using either PB or BTE shocks. We used escalating shocks until sinus rhythm was obtained or to a maximum of 4 shocks. Patients randomized to PB shocks received 90, 120, 150, and 200 J and patients randomized to BTE shocks received 100, 150, 200, and 250 J, as recommended by the manufacturers. In total, 69 patients (51%) received PB shocks and 65 patients (49%) BTE shocks. Successful cardioversion, defined as sinus rhythm 4 hours after cardioversion, was achieved in 43 patients (62%) using PB shocks and in 56 patients (86%) using BTE shocks; ratio 1.4 (95% CI 1.1–1.7) (P=0.002). There was no difference in safety (ie, myocardial injury judged by changes in high‐sensitive troponin I levels; ratio 1.1) (95% CI 1.0–1.3), P=0.15. The study was terminated prematurely because of an adverse event.ConclusionsCardioversion using a BTE waveform was more effective when compared with a PB waveform. There was no difference in safety between the 2 waveforms, as judged by changes in troponin I levels.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02317029.

P087 Impact of coil waveform and orientation on TMS evoked potentials. A TMS-EEG study

Intro Mono and biphasic TMS pulses and coil orientation have been consistently found to produce different outcomes in terms of cortical and cortico-spinal outputs. Knowing how these TMS parameters affect the evoked cortical response becomes even more crucial when TMS is coupled with EEG, since it is necessary to elicit a reliable cortical response minimizing the stimulator intensity, in order to reduce muscle or magnetic artefacts. Aims Here, we investigated the impact of different coil orientations and biphasic vs monophasic pulses on prefrontal TMS Evoked Potentials recorded from a HD EEG system. We aimed at determining which cortical response were evoked from different waveforms and orientations, as well as which coil was more suitable for TMS-EEG studies. Methods Ten healthy subjects took part in the experiment, in which 4 different TMS-EEG recordings were performed. TMS was applied over the right DLPFC, changing coil waveform and direction: monophasic and biphasic coils were oriented antero-posteriorly, i.e. perpendicular to the stimulated gyrus, or latero-dorsally, i.e. parallel to the target gyrus. EEG was concurrently recorded from 60 electrodes. TMS stimulator output was adjusted individually to reach a current density at the hotspot of 95 V/m2. Results Preliminary results (7 ss) indicate a different effect of coil orientation for the two waveforms. Biphasic coils elicited greater TEPs than monophasic ones. Concerning TEP components, for the biphasic coil the parallel orientation evoked greater early components (Fig. 1 Download : Download high-res image (100KB) Download : Download full-size image ), which reflect cortical excitability properties of the underlying cortex, when compared to the perpendicular direction. Conversely, monophasic pulses when oriented perpendicularly to the stimulated gyrus, elicited a greater N100 (Fig. 2 Download : Download high-res image (119KB) Download : Download full-size image ), which is a reliable TEP component linked to GABAb-mediated inhibitory processes. Conclusion Since the biphasic waveform elicited greater TEPs at a lower output, this kind of coil might be more suitable for TMS-EEG studies: stimulating at lower intensities, indeed, means evoking less TMS- related artifacts. Moreover different waveforms seem to trigger different neural responses: biphasic pulses are more suitable for testing cortical excitability, while monophasic ones perpendicularly oriented are better to highlight inhibitory processes.

Correlation between severity of clinical signs and transcranial magnetic motor evoked potentials in dogs with intervertebral disc herniation

Transcranial magnetic motor evoked potentials (TMMEPs) can assess the functional integrity of the spinal cord descending motor pathways. In intervertebral disc herniation (IVDH), these pathways are compromised to varying degrees reflected by the severity of neurological deficits. The hypotheses of this study were as follows: (1) TMMEPs differ in dogs with IVDH and healthy control dogs; (2) TMMEPs reflect different severities of neurological signs; and (3) TMMEPs can document functional motor improvement and therefore monitor recovery of function. TMMEPs were recorded in 50 dogs with thoracolumbar IVDH. Clinical signs ranged from spinal hyperesthesia to non-ambulatory paraparesis in 19 dogs and paraplegia with/without deep pain sensation in 31 dogs. In these 31 paraplegic dogs, transcranial magnetic stimulation (TMS) was repeated during follow-up examinations. Ten healthy Beagle dogs served as controls.There was a significant increase in onset latency and decrease in peak-to-peak amplitude in the pelvic limb TMMEPs of dogs with spinal hyperesthesia to severe paraparesis compared to control dogs. Waveforms in dogs with IVDH were predominantly polyphasic in contrast to the biphasic waveforms of the control dogs. TMMEPs could not be generated in the pelvic limbs of paraplegic dogs. However, TMMEPs with markedly increased onset latencies and decreased peak-to-peak amplitudes reappeared in the pelvic limbs of dogs that were paraplegic before surgery and showed functional motor improvement during follow-up. The severity of neurological deficits was reflected by TMMEP findings, which could be used to document functional motor recovery in IVDH. TMS could therefore be used as an ancillary test to monitor response to therapy in dogs during rehabilitation.

Dynamic evaluation of myocardial dysfunction in rats after cardiopulmonary resuscitation

Objective To observe the dynamic changes of myocardial structure and dysfunction during post-resuscitation period in order to establish a rat mode of post-resuscitation myocardial dysfunction after cardiac arrest resulted from electric stimulation-induced ventricular fibrillation (VF) and cardiopulmonary resuscitation (CPR). Methods A total of 40 male Sprague-Dawley (SD) rats were randomly(random number) assigned into post-resuscitation (PR) 4 h, PR 12 h, PR 24 h, PR 72 h and sham groups. VF was induced by an alternating electric current delivered to the right ventricular endocardium and untreated for 8 min. Biphasic waveform defibrillation was attempted and mechanical ventilation was synchronized after 6 min of CPR. Myocardial function was assessed with serum myocardial enzyme activity, echocardiography, mitochondrial respiratory function and histopathologic findings at different intervals. Results Thirty-two animals were successfully resuscitated with restoration of spontaneous circulation (ROSC) in 86% (32/37)rats. Compared with sham group, severe systolic and diastolic heart failure were found at 4 h after ROSC and then gradually improved without significant difference(P>0.05) in ejection fraction at PR 72 h after ROSC was found, whereas thickened ventricular wall and increased myocardial performance index as well as interstitial proliferation were observed at 72 h after ROSC. Conclusions A rat model of post-resuscitation myocardial dysfunction after cardiac arrest resulted from electric stimulation-induced VF and CPR was successfully established. Key words: Cardiac arrest; Cardiopulmonary resuscitation; Myocardial dysfunction; Mitochondrion; Animal model

English

Ventricular fibrillation is a disorder in which present uncooperative shrivelling of the cardiac muscle of the ventricles in the mood, production them shiver rather than indenture properly. Ventricular fibrillation is the record normally recognized in cardiac trepidation patients.Two phasic defibrillation waveforms are most popularly recognized rather the effect of dismissing ventricularfibrillation (VF) than monophasic waveforms. The hypothesis phases improve the efficiency there are two phases are improved than one, this unsurprisinglyindications to the hypothesis. Our research leads to adding one additional phase to patterned hypothesis. We observed the effectiveness of 19dissimilartriphasic waveforms in chorus.We confirmed the degree of recovery, i.e., effective defibrillation, of 22 guinea livestock (825-1100 g) using single phasic, two phasic andtriphasic, defibrillation waveforms. We can control the single phase and bi phase waveforms. VF was electrically talked into twenty times per visceral and a single defibrillation challenge was prepared using a test waveform VF episode. All waveform was used to the energy prerequisite to defibrillate that bodily 55% of the time, by means of a biphasic waveform as acontrol.

Hepatic vein transit time of second-generation ultrasound contrast agent: new tool in the assessment of portal hypertension

It has been demonstrated that Doppler waveform of the hepatic vein (normally triphasic) is transformed into a biphasic or monophasic waveform in cirrhotic patients. The compressive mechanism of liver tissue has been considered up till now the cause of this change. Moreover, cirrhotics show, after USCA injection, a much earlier HVTT due to intrahepatic shunts. Our aim was to prospectively evaluate the correlation between Doppler pattern of hepatic vein and HVTT of a second-generation USCA; we also correlated HVTT with the most common indexes of portal hypertension. We enrolled 38 participants: 33 cirrhotics and 5 healthy controls. Doppler shift signals were obtained from the right hepatic vein. To characterize the hepatic vein pattern, we used the hepatic vein waveform index (HVWI). This index becomes >1 with the appearance of the triphasic waveform. We recorded a clip from 20s before to 2min after a peripheral intravenous bolus injection of 2.4ml of USCA (sulfur hexafluoride).The time employed by USCA to cross the liver from the hepatic artery and portal vein to the hepatic vein was defined as HA-HVTT and PV-HVTT, respectively. Cirrhotics with low HVWI showed an earlier transit time; participants with higher HVWI had a longer transit time (p<0.001). HVTT was earlier as MELD, Child-Pugh score and spleen diameter increased. Patients with ascites and varices of large size had significantly shorter transit times. Abnormal hepatic vein Doppler waveform in cirrhotic patients could be due to intrahepatic shunts. HVTT could be useful in the non-invasive evaluation of portal hypertension.

Paced monophasic and biphasic waveforms alter transmembrane potentials and metabolism of human fibroblasts

Resting transmembrane potential (TMP) of primary human fibroblast cells was altered in predictable directions by subjecting cell cultures to specific monophasic and biphasic waveforms. Cells electrically stimulated with an anodal pulse resulted in hyperpolarization while a cathodal waveform depolarized the TMP to below that of non-paced control cells. The biphasic waveform, consisting of an anodal pulse followed immediately by an inverse symmetric cathodal pulse, also lessened the TMP similar to that of the cathodal pulse. The effect of short-term pacing on the TMP can last up to 4h before the potentials equilibrate back to baseline. While subjecting the cells to this electrical field stimulation did not appear to damage the integrity of the cells, the three paced electrical stimulation waves inhibited expansion of the cultures when compared to non-paced control cells. With longer pacing treatments, elongation of the cells and electrotaxis towards the anodal polarity were observed. Pacing the fibroblasts also resulted in modest, yet very statistically significant (and likely underestimated) changes to cellular adenosine-5'-triphosphate (ATP) levels, and cells undergoing anodal and biphasic (anodal/cathodal) stimulation also exhibited altered mitochondrial morphology. These observations indicate an active role of electrical currents, especially with anodal content, in affecting cellular metabolism and function, and help explain accumulating evidence of cellular alterations and clinical outcomes in pacing of the heart and other tissues in general.

Facilitatory effect of paired-pulse stimulation by transcranial magnetic stimulation with biphasic wave-form

Transcranial magnetic stimulation (TMS) is used to probe corticospinal excitability by stimulating the motor cortex. Our aim was to enhance the effects of biphasic TMS by coupling a suprathreshold test pulse and a following subthreshold priming pulse to induce short-interval intracortical facilitation (SICF), which is conventionally produced with monophasic TMS. Biphasic TMS could potentially induce the SICF effect with better energy-efficiency and with lower stimulus intensities. This would make the biphasic paired-pulses better applicable in patients with reduced cortical excitability.A prototype stimulator was built to produce biphasic paired-pulses. Resting motor thresholds (rMTs) from the right and left hand abductor pollicis brevis muscles, and the right tibialis anterior muscle of eight healthy volunteers were determined using single-pulse paradigm with neuronavigated TMS. The rMTs and MEPs were measured using single-pulses and three paired-pulse setups (interstimulus interval, ISI of 3, 7 or 15ms).The rMTs were lower and MEPs were higher with biphasic paired-pulses compared to single-pulses. The SICF effect was greatest at 3ms ISI. This suggests that the application of biphasic paired-pulses to enhance stimulation effects is possible.

Continuous intraoperative monitoring of vagus and recurrent laryngeal nerve function in patients with advanced atrioventricular block.

Intraoperative neuromonitoring of recurrent laryngeal nerve function after stimulation of the vagus nerve has been embraced as a risk minimization tool in thyroid surgery to prevent recurrent laryngeal nerve injury. Because this technology is increasingly used in an elderly and sicker population, the present study was conducted to determine the safety of this method in patients with second- or third-degree atrioventricular block. This study aimed at evaluating the feasibility and safety of continuous intraoperative neuromonitoring (CIONM) in patients with second- or third-degree atrioventricular block. A total of six patients (12 nerves at risk), accounting for 0.3% of all 1800 patients (3049 nerves at risk) who underwent thyroid surgery during the study period, were found to have second- or third-degree atrioventricular block. All these patients maintained normal systolic and diastolic blood pressures; heart rate; and peripheral arterial oxygen saturation before, during, and after CIONM. No clinically relevant changes in heart rate or blood pressure, cardiac arrhythmia, or other hemodynamically important events were noted despite careful monitoring of these patients. There was no interference between the biphasic waveform of the vocal muscle electromyogram and the spikes generated by the implanted cardiac pacemakers. Outcomes were uneventful with normal vocal fold and parathyroid gland function. Within the limitations of this series and considering experimental, animal, and human data, continuous IONM of the vagus nerve at ≤2Hz seems to be reasonably safe. Additional research is warranted to confirm these results in larger groups of patients with advanced atrioventricular block.

The effects of second and third phase duration on defibrillation efficacy of triphasic rectangle waveforms

BackgroundBiphasic waveforms are superior to monophasic waveforms for the termination of ventricular fibrillation (VF). However, whether triphasic waveforms are more effective than biphasic ones is still controversial. In the present study, we investigated the effects of second and third phase duration of triphasic rectangle waveform on defibrillation efficacy in a rabbit model of VF. MethodsVF was electrically induced and untreated for 30s in 20 New Zealand rabbits. A defibrillatory shock was applied with one of the 7 waveforms: 6 triphasic rectangle waveforms and a biphasic rectangle waveform. The triphasic waveforms had identical first duration but with different second and third phase durations. A 5 step up-and-down protocol was utilized for determining the defibrillation threshold (DFT). After a 5min interval, the procedure was repeated. A total of 35 cardiac arrest events and defibrillations were investigated for each animal. ResultsTwo triphasic waveforms with identical first and second phase duration but shorter third phase duration had significantly lower DFT energy than biphasic waveform (0.57±0.18J vs. 0.80±0.28J, p=0.001; 0.60±0.18J vs. 0.80±0.28J, p=0.003). However, no statistical difference in DFT energy was observed between the two triaphsic waveforms that had identical phase duration but different voltages (0.57±0.18J vs. 0.60±0.18J, p=0.638). ConclusionsPhase durations played a main role on defibrillation success for triphasic rectangle waveforms. The optimal triphasic rectangle waveforms that composed of identical second and first phase durations but with shorter third pulse were superior to biphasic rectangle waveform for ventricular defibrillation.

Biphasic versus monophasic waveforms for transthoracic defibrillation in out-of-hospital cardiac arrest.

Transthoracic defibrillation is a potentially life-saving treatment for people with ventricular fibrillation (VF) and haemodynamically unstable ventricular tachycardia (VT). In recent years, biphasic waveforms have become more commonly used for defibrillation than monophasic waveforms. Clinical trials of internal defibrillation and transthoracic defibrillation of short-duration arrhythmias of up to 30 seconds have demonstrated the superiority of biphasic waveforms over monophasic waveforms. However, out-of-hospital cardiac arrest (OHCA) involves a duration of VF/VT of several minutes before defibrillation is attempted. To determine the efficacy and safety of biphasic defibrillation waveforms, compared to monophasic, for resuscitation of people experiencing out-of-hospital cardiac arrest. We searched the following electronic databases for potentially relevant studies up to 10 September 2014: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Also we checked the bibliographies of relevant studies and review articles, contacted authors of published reviews and reviewed webpages (including those of device manufacturers) relevant to the review topic. We handsearched the abstracts of conference proceedings for the American Heart Association, American College of Cardiology, European Society of Cardiology, European Resuscitation Council, Society of Critical Care Medicine and European Society of Intensive Care Medicine. Regarding language restrictions, we did not apply any. We included randomised controlled trials (RCTs) that compared biphasic and monophasic waveform defibrillation in adults with OHCA. Two review authors independently screened the literature search results. Two review authors independently extracted data from the included trials and performed 'Risk of bias' assessments. We resolved any disagreements by discussion and consensus. The primary outcome was the risk of failure to achieve return of spontaneous circulation (ROSC). Secondary outcomes included risk of failure to revert VF to an organised rhythm following the first shock or up to three shocks, survival to hospital admission and survival to discharge. We included four trials (552 participants) that compared biphasic and monophasic waveform defibrillation in people with OHCA. Based on the assessment of five quality domains, we identified two trials that were at high risk of bias, one trial at unclear risk of bias and one trial at low risk of bias. The risk ratio (RR) for failure to achieve ROSC after biphasic compared to monophasic waveform defibrillation was 0.86 (95% CI 0.62 to 1.20; four trials, 552 participants). The RR for failure to defibrillate on the first shock following biphasic defibrillation compared to monophasic was 0.84 (95% CI 0.70 to 1.01; three trials, 450 participants); and 0.81 (95% CI 0.61 to 1.09; two trials, 317 participants) for one to three stacked shocks. The RR for failure to achieve ROSC after the first shock was 0.92 (95% CI 0.81 to 1.04; two trials, 285 participants). Biphasic waveforms did not reduce the risk of death before hospital admission (RR 1.05, 95% CI 0.90 to 1.23; three trials, 383 participants) or before hospital discharge (RR 1.05, 95% CI 0.78 to 1.42; four trials, 550 participants). There was no statistically significant heterogeneity in any of the pooled analyses. None of the included trials reported adverse events. It is uncertain whether biphasic defibrillators have an important effect on defibrillation success in people with OHCA. Further large studies are needed to provide adequate statistical power.

Attention-dependent sound offset-related brain potentials.

When performing sensory tasks, knowing the potentially occurring goal-relevant and irrelevant stimulus events allows the establishment of selective attention sets, which result in enhanced sensory processing of goal-relevant events. In the auditory modality, such enhancements are reflected in the increased amplitude of the N1 ERP elicited by the onsets of task-relevant sounds. It has been recently suggested that ERPs to task-relevant sound offsets are similarly enhanced in a tone-focused state in comparison to a distracted one. The goal of the present study was to explore the influence of attention on ERPs elicited by sound offsets. ERPs elicited by tones in a duration-discrimination task were compared to ERPs elicited by the same tones in not-tone-focused attentional setting. Tone offsets elicited a consistent, attention-dependent biphasic (positive-negative--P1-N1) ERP waveform for tone durations ranging from 150 to 450 ms. The evidence, however, did not support the notion that the offset-related ERPs reflected an offset-specific attention set: The offset-related ERPs elicited in a duration-discrimination condition (in which offsets were task relevant) did not significantly differ from those elicited in a pitch-discrimination condition (in which the offsets were task irrelevant). Although an N2 reflecting the processing of offsets in task-related terms contributed to the observed waveform, this contribution was separable from the offset-related P1 and N1. The results demonstrate that when tones are attended, offset-related ERPs may substantially overlap endogenous ERP activity in the postoffset interval irrespective of tone duration, and attention differences may cause ERP differences in such postoffset intervals.

Tetanizing prepulse: A novel strategy to mitigate implantable cardioverter-defibrillator shock-related pain

Skeletal muscle activation has been implicated as the source of pain associated with implantable cardioverter-defibrillator shocks. We hypothesized that the skeletal muscle response to defibrillatory shocks could be attenuated with a tetanizing prepulse immediately before biphasic shock delivery. The purpose of this study was to test the ability of tetanizing prepulses to reduce the skeletal muscle activation associated with defibrillation. Seven adult pigs were studied. A left ventricular coil and subcutaneous dummy can in the right thorax were used to deliver either pure biphasic waveforms or test waveforms consisting of a tetanizing pulse of high-frequency alternating current (HFAC) ramped to an amplitude of 5-100 V over 0.25-1 second, immediately followed by a biphasic shock of approximately 9 J (ramped HFAC and biphasic [rHFAC+B]). We used limb acceleration and rate of force development as surrogate measures of pain. Test and control waveforms were delivered in sinus rhythm and induced ventricular fibrillation to test defibrillation efficacy. Defibrillation threshold energy was indistinguishable between rHFAC+B and pure biphasic shocks. Peak acceleration and rate of force development were reduced by 72% ± 7% and 71% ± 22%, respectively, with a 25-V, 1-second rHFAC+B waveform compared with pure biphasic shocks. Notably, rHFAC+B with a 9-J biphasic shock produced significantly less skeletal muscle activation than a 0.1-J pure biphasic shock. A putative source of implantable cardioverter-defibrillator shock-related pain can be mitigated using a tetanizing prepulse followed by biphasic shock. Human studies will be required to assess true pain reduction with this approach.