2160Continuous shock-free termination of atrial fibrillation by local optogenetic therapy and arrhythmia-triggered activation of an implanted light source

Background Maintenance of sinus rhythm is the primary therapeutic goal for symptomatic atrial fibrillation (AF) patients but remains difficult to achieve because of suboptimal treatment options. While being effective in detecting and terminating AF, the widespread use of implantable atrial defibrillators is limited due to patients intolerance to repeated shocks. The negative adverse effects of electroshock therapy can hypothetically be overcome by allowing the heart itself to produce the electric current required for arrhythmia termination. As a result, the effector function of an electrical defibrillator would be provided by the heart itself, and therefore no longer rely on electronics, but on bioelectricity instead. Purpose To develop a hybrid bio-electronic system for automated and acute shock-free AF treatment. Methods To equip the heart with the effector function of the envisioned AF termination system, adeno-associated virus (AAV) vectors encoding red-activatable channelrhodopsin (ReaChR) (n=12) or citrine (n=4) were delivered locally to the right atrium (RA) of adult Wistar rats by gene painting. Four to 8 weeks later, AF was induced in vivo by atrial burst pacing after carbachol administration, followed by programmed local illumination of the RA by an implanted intrathoracic LED device whose activation was automatically regulated by an electrocardiogram (ECG)-based cardiac rhythm monitor. Results Gene painting of the RA resulted in transmural transduction of right atrial myocytes (78±6%) with minimum transgene expression of the left atrium and ventricles (6±2% and <0.5%, respectively). Electrophysiological assessments revealed no significant differences in ECG characteristics, atrial action potential duration and conduction velocity when compared to baseline or citrine control animals. Feasibility of optical AF termination was first assessed in an open-chest rat model, showing that a single 470-nm light pulse (3.5 mW/mm2, 1000 ms) efficiently terminated AF in all ReaChR-expressing rats with an average termination efficacy of 94±3% (n=12) vs. 3±3% (n=4) in citrine-expressing control animals (p<0.01). AF termination efficacy remained superb following automated detection and termination of AF by ECG-triggered activation of the implanted intra-thoracic LED in closed-chest ReaChR-expressing rats (96±4%), n=4), whereas none of the AF episodes were terminated in control rats (0%, n=4) (p<0.01). No bradycardias or other arrhythmias were observed following optical AF termination. Conclusions By using a hybrid bio-electronic approach to modulate cardiac excitability, our study delivers proof that AF can be detected and terminated automatically in a safe, effective and repetitive, yet shock-free manner. These findings may create the basis for the development of pain-free device therapy for cardiac arrhythmias, thereby paving the way for ambulatory AF treatment with the perspective to improve patients' prognosis and quality of life. Acknowledgement/Funding NWO Vidi grant (1714336) and ERC Starting Grant (716509) both to D.A.P.

Namelessness from Artaud to Beckett

After a period of electroshock therapy, Antonin Artaud claimed to have been able to regain his name and sense of self. The dehiscence of name and identification is reprised in Artaud’s final work, the radio play Pour en finir avec le jugement de Dieu. This consists of five texts, read by four people. Each text is followed by unintelligible, glossolalic screams performed by Artaud, as if Artaud were reacting against the speech acts performed by others in his name. The structure of this play suggests the predicament of Beckett’s Unnamable: an entity reacting in pain to its attempts to articulate itself in a language that is not his, but theirs.

War with the Internet Demon

Trent Bax seeks to contextualize and interpret how alleged internet addicts in boot-camps are treated in China. Bax asks how an unqualified and uncertified psychiatrist, working under the protective umbrella of a government-run hospital, could misuse electroshock therapy on 3,000 adolescents as a ‘cure’ for an unrecognized psychiatric condition labelled ‘Internet addiction’? And how could parents willingly take their beloved only child to this institution to be subjected to a punishment-based illegal practice that international law would categorize as torture? The answer is only partly to be to be found in the misuse of psychiatry and science. To unravel this mystery of using electroshocks as a form of punishment of youth deviance has ideological roots in Maoist political socialization, sometimes even resembling the Bush administration’s ‘shock-and-awe’ military doctrine. To help provide further explanatory power, Kafka and Orwell join this journey through the ‘war with the Internet demon’.

‘Electroshock Therapy’ in the Third Reich

The history of ‘electroshock therapy’ (now known as electroconvulsive therapy (ECT)) in Europe in the Third Reich is still a neglected chapter in medical history. Since Thomas Szasz’s ‘From the Slaughterhouse to the Madhouse’, prejudices have hindered a thorough historical analysis of the introduction and early application of electroshock therapy during the period of National Socialism and the Second World War. Contrary to the assumption of a ‘dialectics of healing and killing’, the introduction of electroshock therapy in the German Reich and occupied territories was neither especially swift nor radical. Electroshock therapy, much like the preceding ‘shock therapies’, insulin coma therapy and cardiazol convulsive therapy, contradicted the genetic dogma of schizophrenia, in which only one ‘treatment’ was permissible: primary prevention by sterilisation. However, industrial companies such as Siemens–Reiniger–Werke AG (SRW) embraced the new development in medical technology. Moreover, they knew how to use existing patents on the electrical anaesthesia used for slaughtering to maintain a leading position in the new electroshock therapy market. Only after the end of the official ‘euthanasia’ murder operation in August 1941, entitled T4, did the psychiatric elite begin to promote electroshock therapy as a modern ‘unspecific’ treatment in order to reframe psychiatry as an ‘honorable’ medical discipline. War-related shortages hindered even the then politically supported production of electroshock devices. Research into electroshock therapy remained minimal and was mainly concerned with internationally shared safety concerns regarding its clinical application. However, within the Third Reich, electroshock therapy was not only introduced in psychiatric hospitals, asylums, and in the Auschwitz concentration camp in order to get patients back to work, it was also modified for ‘euthanasia’ murder.

Letter to the British Medical Journal , Prefrontal Leucotomy

A letter from Winnicott to the British Medical Journal stating his views that leucotomy is the “worst honest error” to emerge in recent medical practice. He believes that the increased use of surgery, instead of psychotherapy, has led mentally ill patients to fear being subjected to the procedure and that doctors are using it, and electroshock therapy, as quick fixes to complex mental problems.

2009: The Resurgence of Electroconvulsive Therapy in a Medium Stay Unit

IntroductionThe electroconvulsive therapy (ECT) is an ancient treatment used in psychiatry but sometimes has been forgotten, considered outdated. Since 2008 with the new electroconvulsive protocol in use elaborated in the Hospital of Zamudio, this therapy is part of the usual clinical practice, mainly in the medium stay unit.ObjectivesThe principal aim of this project is to describe the profile and the programs of ECT sessions given to hospitalized patients in a medium stay unit during 2009.Results19 of the 344 patients hospitalized in this unit in 2009 need electroshock therapy. Each patient received an initial amount of sessions, in average 5-6, considered as part of what is commonly known as Treatment electrotherapy (sessions required to psychopathological stabilization or remission).Most of this patients (68,42%) required Maintenance electrotherapy (sessions needed to consolidate the clinical improvement and stabilization achieved with the Treatment electrotherapy) but 15,38% of them refused to continue with the sessions and the treatment. During maintenance electrotherapy, sessions are initially weekly and gradually less frequent.The profile of the standard patient receiving ECT is woman, between 40 and 65 years old and who suffers from Recurrent Major Depression.ConclusionsSince the protocol established in 2008, a year has been enough to normalized the use of ECT in a medium stay unit.ECT is a personalized therapy with different applications in each patient, although the indications and objectives followed are almost the same and are protocolized, because the response, the adverse effects etc have to be taken into account.