First Directional Measurement of Sub-MeV Solar Neutrinos with Borexino

We report the measurement of sub-MeV solar neutrinos through the use of their associated Cherenkov radiation, performed with the Borexino detector at the Laboratori Nazionali del Gran Sasso. The measurement is achieved using a novel technique that correlates individual photon hits of events to the known position of the Sun. In an energy window between 0.54 to 0.74 MeV, selected using the dominant scintillation light, we have measured 10 887_{-2103}^{+2386}(stat)±947(syst) (68% confidence interval) solar neutrinos out of 19 904 total events. This corresponds to a ^{7}Be neutrino interaction rate of 51.6_{-12.5}^{+13.9}  counts/(day·100  ton), which is in agreement with the standard solar model predictions and the previous spectroscopic results of Borexino. The no-neutrino hypothesis can be excluded with >5σ confidence level. For the first time, we have demonstrated the possibility of utilizing the directional Cherenkov information for sub-MeV solar neutrinos, in a large-scale, high light yield liquid scintillator detector. This measurement provides an experimental proof of principle for future hybrid event reconstruction using both Cherenkov and scintillation signatures simultaneously.

Removal of temporary pacemaker after cardiac surgery in infants: A harmless procedure?

External pacemakers (PM) via temporary epicardial leads are routinely applied to infants and children during heart surgery, which usually, after an uneventful post surgical course, can be removed without complications. We report about two infants with complex congenital heart defects after cardiac surgery (arterial switch and Mustard operation for Transposition of the great arteries). Intraoperative these patients received temporary epicardial PM wires. Thirteen and 18 days post surgery, respectively, the PM wires were removed under electrocardiogram (ECG) monitoring. The patients showed acute ECG changes in terms of significant ST elevation during and after removing their pacing wires. Clinically, patients were stable and subsequent echocardiographic examination showed no evidence of myocardial dysfunction or pericardial effusion. In the course of time, patients showed no signs of arrhythmia or abnormal ECG changes. The decision to place temporary pacing wires during the cardiac surgery in patients with congenital heart defects should be considered carefully and their removal should occur under ECG monitoring as soon as the situation of the patient allows. It should be taken into consideration that a complication like this case may be related to delayed removal of temporary PM's leads.

Comparison of late results of arterial switch versus atrial switch (mustard procedure) operation for transposition of the great arteries

Two decades after surgery for transposition of the great arteries, the clinical status, cardiac function, cardiorespiratory performance, and neurohormonal activity of patients who underwent either atrial switch (Mustard) operations or arterial switch operations (ASOs) were compared. Sixty-two patients with simple transposition of the great arteries who underwent either Mustard (n = 34) or ASO (n = 28) procedures were included in this cross-sectional study. Following the same study protocol, clinical workup including echocardiography, stress testing, and blood work was completed for all patients. Mean ages in the 2 groups were comparable, at 20.6 ± 2.1 and 20.6 ± 3.4 years in the ASO and Mustard groups, respectively. All ASO patients were in New York Heart Association class I, whereas 59% of Mustard patients were in class II or III. Peak oxygen uptake was higher in ASO patients (percentage of predicted 80% vs 69%, p <0.01). Compared with healthy subjects, the mean Tei index for systemic ventricle was high in the 2 groups, but this parameter was significantly higher in Mustard than ASO patients (0.60 ± 0.16 vs 0.47 ± 0.14, p <0.01). The median plasma N-terminal pro-brain natriuretic peptide level in ASO patients was within the normal range, but the Mustard group had significantly higher levels (42 ng/ml [range 18 to 323] vs 172 ng/ml [range 26 to 1,018], p <0.0001). In conclusion, this cross-sectional assessment 2 decades after surgery reveals better clinical status in patients who underwent ASO compared with Mustard patients. This holds in terms of cardiac function, cardiorespiratory performance, and neurohormonal activity.

Skeletal health in adult patients with classic galactosemia

SUMMARY

This study evaluated bone health in adults with galactosemia. Associations between bone mineral density (BMD) and nutritional and biochemical variables were explored. Calcium level predicted hip and spine BMD, and gonadotropin levels were inversely associated with spinal BMD in women. These results afford insights into management strategies for these patients.

INTRODUCTION

Bone loss is a complication of galactosemia. Dietary restriction, primary ovarian insufficiency in women, and disease-related alterations of bone metabolism may contribute. This study examined relationships between clinical factors and BMD in patients with galactosemia.

METHODS

This cross-sectional sample included 33 adults (16 women) with classic galactosemia, mean age 32.0 ± 11.8 years. BMD was measured by dual-energy X-ray absorptiometry, and was correlated with age, height, weight, fractures, nutritional factors, hormonal status, and bone biomarkers.

RESULTS

There was a significant difference in hip BMD between women and men (0.799 vs. 0.896 g/cm(2), p = 0.014). The percentage of subjects with BMD-Z <-2.0 was also greater for women than men [33 vs. 18 % (spine), 27 vs. 6 % (hip)], and more women reported sustaining fractures. Bivariate analyses yielded correlations between BMI and BMD-Z [at the hip in women (r = 0.58, p < 0.05) and spine in men (r = 0.53, p < 0.05)]. In women, weight was also correlated with BMD-Z (r = 0.57, p < 0.05 at hip), and C-telopeptides (r = -0.59 at spine and -0.63 hip, p < 0.05) and osteocalcin (r = -0.71 at spine and -0.72 hip, p < 0.05) were inversely correlated with BMD-Z. In final regression models, higher gonadotropin levels were associated with lower spinal BMD in women (p = 0.017); serum calcium was a significant predictor of hip (p = 0.014) and spine (p = 0.013) BMD in both sexes.

CONCLUSIONS

Bone density in adults with galactosemia is low, indicating the potential for increased fracture risk, the etiology of which appears to be multifactorial.

[Intranasal fentanyl for breakthrough cancer pain. A pilot study.]

BACKGROUND AND AIM OF THE STUDY

Despite regular administration of analgesics, a high percentage of patients with chronic malignant pain experience break-through cancer pain or incident pain. Such pain peaks in patients with chronic malignant pain require "rescue" medication in addition to basic analgesia with for example slow-release morphine or buprenorphine. For rescue medication a fast acting and powerful analgesic should be available to the patient. Recent studies have shown that intranasal fentanyl provides rapid onset of pain relief.

PATIENTS AND METHODS

In this open pilot study five patients with chronic cancer pain (age: 42-62 years; weight: 55-80 kg) received demand-adapted intranasal fentanyl titration for treatment of acute breakthrough cancer pain. Intranasal fentanyl doses (0.027 mg) were repeated at 5-min intervals until the patients experienced marked pain relief. Pain intensity was evaluated (0-30 min: 5-min intervals; 30-120 min: 10-min intervals) with the aid of a numerical rating scale (0 = no pain; 100 worst pain possible).

RESULTS AND DISCUSSION

The patients received 2, 4, 6, 7 or 8 fentanyl boluses (totalling 0.054 mg, 0.108 mg, 0.162 mg, 0.189 mg or 0.216 mg, respectively). Rapid onset and marked reduction of pain intensity was achieved in all five patients. There were no clinically relevant changes in arterial haemoglobin oxygen saturation, heart rate, arterial blood pressure or respiratory rate. All five patients scored the pain relief obtained as good or very good. There were no reports of pain or burning sensations in the nose or other side-effects.

Comparison of transpulmonary thermodilution and ultrasound dilution technique: novel insights into volumetric parameters from an animal model

Especially in critically ill children with cardiac diseases, fluid management and monitoring of cardiovascular function are essential. Ultrasound dilution technique (UDT) was recently introduced to measure cardiac output (CO) and volumetric parameters, such as intrathoracic and end-diastolic blood volume. We compared UDT with the well-established transpulmonary thermodilution (TPTD) method (PiCCO) for determining CO measurements and derived volumes in a juvenile animal model. Experiments were performed in 18 ventilated, anesthetized piglets during normovolemia and after isovolemic hemodilution. At baseline and 20 min after each step of isovolemic hemodilution, 3 independent measurements of CO and volumetric parameters were conducted with TPTD and UDT, consecutively, under hemodynamically stable conditions. We observed comparable results for CO measurements with both methods (mean 1.98 l/min; range 1.12-2.87) with a percentage error of 17.3% (r = 0.92, mean bias = 0.28 l/min). Global end-diastolic volume (GEDV) and intrathoracic blood volume (ITBV) by TPTD were almost two times greater than analogous volumes [central blood volume (CBV); total end-diastolic volume (TEDV)] quantified by UDT (CBV = 0.58 × ITBV + 27.1 ml; TEDV = 0.48 × GEDV + 23.1 ml). CO measurements by UDT were found to be equivalent and hence interchangeable with TPTD. Discrepancies in volumetric parameters could either be due to the underlying algorithm or different types of indicators (diffusible vs. nondiffusible). Compared with the anatomically defined heart volume, TPTD seems to overestimate end-diastolic volumes. Future studies will be necessary to assign these results to critically ill children and to validate volumetric parameters with reference techniques.

Growth differentiation factor 15: an additional diagnostic tool for the risk stratification of developing heart failure in patients with operated congenital heart defects?

BACKGROUND

Many young adults who have congenital heart defects develop heart failure despite corrective surgeries. Growth differentiation factor 15 (GDF-15) has an established role as a marker for risk stratification and mortality both in patients after acute myocardial infarction and in patients with heart failure. Our aim was to establish a role for GDF-15 for monitoring heart failure in operated congenital heart defects (ACHD). This potential biomarker was validated through comparison with maximal oxygen uptake (VO(2max)) and to another biomarker, N-terminal pro-brain natriuretic peptide (NT-proBNP).

METHODS

A total of 317 ACHD patients (129 females) with an average age of 26.5 ± 8.5 years (mean ± SD) enrolled in the study. We studied the relation between GDF-15 and NT-proBNP and VO(2max%) (percent predicted for age and gender). The cutoffs for the groups were as follows: NT-proBNP <100, 100 to 300, and >300 pg/mL; VO(2max%) <65%, 65% to 85%, and >85% of predicted normal.

RESULTS

Significant differences in mean GDF-15 levels were found between the NT-proBNP <100 and NT-proBNP >300 groups, as well as between the 100 to 300 and the >300 groups. For VO(2max%), significant differences were found in GDF-15 levels between <65% and >85% and between <65% and 65% to 85%, respectively. The lowest mean GDF-15 was found in groups with NT-proBNP <100 pg/mL and VO(2max%) >85%. The highest mean GDF-15 was found in the groups with NT-proBNP >300 pg/mL and VO(2max%) <65%. A subgroup analysis, including 82 patients with operated tetralogy of Fallot, showed that patients in the New York Heart Association I class have significantly lower NT-proBNP and GDF-15 level and markedly higher VO(2max) compared with the patients in higher New York Heart Association class.

CONCLUSION

Growth differentiation factor 15 might be used as a surrogate marker for latent heart failure and could help to identify patients with ACHD who are at risk for developing heart failure, even if they are clinically asymptomatic.

How does the tubular embryonic heart work? Looking for the physical mechanism generating unidirectional blood flow in the valveless embryonic heart tube

The heart is the first organ to function in vertebrate embryos. The human heart, for example, starts beating around the 21st embryonic day. During the initial phase of its pumping action, the embryonic heart is seen as a pulsating blood vessel that is built up by (1) an inner endothelial tube lacking valves, (2) a middle layer of extracellular matrix, and (3) an outer myocardial tube. Despite the absence of valves, this tubular heart generates unidirectional blood flow. This fact poses the question how it works. Visual examination of the pulsating embryonic heart tube shows that its pumping action is characterized by traveling mechanical waves sweeping from its venous to its arterial end. These traveling waves were traditionally described as myocardial peristaltic waves. It has, therefore, been speculated that the tubular embryonic heart works as a technical peristaltic pump. Recent hemodynamic data from living embryos, however, have shown that the pumping function of the embryonic heart tube differs in several respects from that of a technical peristaltic pump. Some of these data suggest that embryonic heart tubes work as valveless "Liebau pumps." In the present study, a review is given on the evolution of the two above-mentioned theories of early cardiac pumping mechanics. We discuss pros and cons for both of these theories. We show that the tubular embryonic heart works neither as a technical peristaltic pump nor as a classic Liebau pump. The question regarding how the embryonic heart tube works still awaits an answer.

Pulmonary valve replacement in chronic pulmonary regurgitation in adults with congenital heart disease: impact of preoperative QRS-duration and NT-proBNP levels on postoperative right ventricular function

BACKGROUND

Chronic severe pulmonary regurgitation (PR) causes progressive right ventricular (RV) dysfunction and heart failure. Parameters defining the optimal time point for surgery of chronic PR are lacking. The present study prospectively evaluated the impact of preoperative clinical parameters, cardiorespiratory function, QRS duration and NT-proBNP levels on post operative RV function and volumes assessed by cardiac magnetic resonance imaging (CMR) in patients with chronic severe PR undergoing pulmonary valve replacement.

METHODS AND RESULTS

CMR was performed pre- and 6 months postoperatively in 27 patients (23.6 ± 2.9 years, 15 women) with severe PR. Postoperatively, RV endsystolic (RVESVI) and enddiastolic volume indices (RVEDVI) decreased significantly (RVESVI pre 78.2 ± 20.4 ml/m² BSA vs. RVESVI post 52.2 ± 16.8 ml/m²BSA, p<0.001; RVEDVI pre 150.7 ± 27.7 ml/m²BSA vs. RVEDVI post 105.7 ± 26.7 ml/m²BSA; p<0,001). With increasing preoperative QRS-duration, postoperative RVEF decreased significantly (r=-0.57; p<0.005). Preoperative QRS-duration smaller than the median (156 ms) predicted an improved RVEF compared to QRS-duration≥ 156 ms (54.9% vs 46.8%, p<0.05). Multivariate analysis identified preoperative QRS duration as an independent predictor of postoperative RVEF (p<0.005). NT-proBNP levels correlated with changes in RVEDI (r=0.58 p<0,005) and RVESVI (r=0.63; p<0,0001). Multivariate analysis identified NT-proBNP levels prior to PVR as an independent predictor of volume changes (p<0.05).

CONCLUSION

Valve replacement in severe pulmonary regurgitation causes significant reduction of RV volumes. Both, preoperative NT-proBNP level elevation and QRS prolongation indicate patients with poorer outcome regarding RV function and volumes.

Analysis of particulate contaminations of infusion solutions in a pediatric intensive care unit

Purpose

To examine the physical properties and chemical composition of particles captured by in-line microfilters in critically ill children, and to investigate the inflammatory and cytotoxic effects of particles on endothelial cells (HUVEC) and macrophages in vitro.

Methods

Prospective, observational study of microfilters following their use in the pediatric intensive care unit. In vitro model utilizing cytokine assays to investigate the effects of particles on human endothelial cells and murine macrophages.

Results

Twenty filter membranes from nine patients and five controls were examined by electron microscopy (EM) and energy dispersion spectroscopy (EDX). The average number of particles found on the surface of the used membranes was 550 cm². EDX analysis confirmed silicon as a major particle constituent. Half of the filter membranes showed conglomerates containing an uncountable number of smaller particles. In vitro, glass particles were used to mimic the high silicon content particles. HUVEC and murine macrophages were exposed to different contents of particles, and cytokine levels were assayed to assess their immune response. Levels of interleukin-1beta, interleukin-6, interleukin-8, and tumor necrosis factor alpha were suppressed.

Conclusions

Particle contamination of infusion solutions exists despite a stringent infusion regiment. The number and composition of particles depends on the complexity of the applied admixtures. Beyond possible physical effects, the suppression of macrophage and endothelial cell cytokine secretion in vitro suggests that microparticle infusion in vivo may have immune-modulating effects. Further clinical trials are necessary to determine whether particle retention by in-line filtration has an influence on the outcome of intensive care patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-010-1775-y) contains supplementary material, which is available to authorized users.

A coleopteran triosephosphate isomerase: X-ray structure and phylogenetic impact of insect sequences

A coleopteran triosephosphate isomerase (TIM) from Tenebrio molitor (yellow mealworm beetle) was recombinantly expressed in Escherichia coli and characterized with respect to thermal stability, kinetic parameters and oligomeric state. The enzyme was successfully crystallized and the structure determined by X-ray analysis to 2.0 A resolution. This is the first example of an invertebrate TIM. We compare structural features with known structures of TIMs from microorganisms, plants and vertebrates, and discuss the utility of the Tenebrio TIM sequence, together with several newly sequenced insect TIMs, for molecular phylogenetic analysis.

Early-onset and persisting thrombocytopenia in post-cardiac surgery patients is rarely due to heparin-induced thrombocytopenia, even when antibody tests are positive

BACKGROUND

The high frequency of thrombocytopenia in post-cardiac surgery patients makes it challenging to diagnose heparin-induced thrombocytopenia (HIT). Two platelet count profiles are reported as indicating possible HIT in these patients: profile 1 describes a platelet count fall that begins between postoperative days 5 and 10, whereas profile 2 denotes early-onset thrombocytopenia that persists beyond day 5.

OBJECTIVES

To examine how these platelet count profiles correlate with antibody status and HIT post-cardiac surgery.

METHODS

We prospectively screened 581 cardiac surgery patients for heparin-dependent antibodies by platelet factor 4 (PF4)-heparin immunoassay and platelet-activation test, and performed daily platelet counts (until day 10) with 30-day follow-up.

RESULTS

All three patients with platelet count profile 1 tested positive for platelet-activating anti-PF4-heparin IgG antibodies [odds ratio (OR) 521.7, 95% confidence interval (CI) 3.9-34,000, P = 0.002], and were judged to have HIT. In contrast, none of 25 patients with early-onset and persisting thrombocytopenia (profile 2) was judged to have HIT, including five patients testing positive for platelet-activating anti-PF4-heparin IgG antibodies. In these patients, the frequency of heparin-dependent antibodies did not differ from that in non-thrombocytopenic controls, either for anti-PF4-heparin IgG (OR 1.7, 95% CI 0.7-4.1, P = 0.31) or for platelet-activating antibodies (OR 1.9, 95% CI 0.6-5.7, P = 0.20). Multivariate analysis revealed that type of cardiac surgery, but not HIT antibody status, predicted early-onset and persisting thrombocytopenia. Together, these findings show that HIT was uncommon in this study population [overall frequency, 3/581 (0.5%), 95% CI 0.1-1.5%].

CONCLUSIONS

Thrombocytopenia that begins between 5 and 10 days post-cardiac surgery is highly predictive for HIT. In contrast, early-onset and persisting thrombocytopenia is usually caused by non-HIT factors with coinciding heparin-dependent antibody seroconversion.

Intravenous luteinizing hormone-releasing hormone has no effect on serum N-terminal pro-brain natriuretic peptide in children and adolescents

BACKGROUND

Little is known about the acute effects of i.v. luteinizing hormone-releasing hormone (LHRH) on the heart function, therefore the aim of the present study was to measure N-terminal pro-brain natriuretic peptide (N-BNP) in children, who underwent a diagnostic work up for short stature or delayed puberty.

METHODS

N-BNP was measured in 52 children before and after administration of LHRH. Serum N-BNP obtained from 255 healthy children and adolescents (aged birth-18.3 years) served as a reference.

RESULTS

There was no significant difference between baseline N-BNP of children who underwent the LHRH diagnostic test and their healthy peers. There was no significant serum N-BNP level change before or after administration of LHRH (59 +/- 36 pg/mL vs 58 +/- 34 pg/mL). N-BNP fell from 399 +/- 425 pg/mL in newborns and reached 44 +/- 36 pg/mL in children aged 12-18 years.

CONCLUSION

Short stature or delayed puberty had no effect on heart function determined by serum N-BNP; i.v. LHRH does not acutely influence the level of serum N-BNP.

A new modified Seldinger technique for 2- and 3-French peripherally inserted central venous catheters

This study describes a modified Seldinger technique for 2- and 3-French peripherally inserted central venous catheters: A device similar to that used in heart catherisation with a standard micro-introducer serving as sheath and an arterial catheter serving as inner dilator was pushed forward over a wire guide that had before been inserted via a peripheral venous catheter. With this method 2-and 3-French catheters could be safely inserted into peripheral veins of 14 paediatric patients. In conclusion successful insertion of a small peripheral venous catheter offers in most cases a possibility for the placement of a central venous line.

Study participation and nonresponse in a population of adolescents and adults with operated congenital heart disease (GUCH patients)

OBJECTIVE

A group of patients after surgery of congenital heart defects was examined as to whether participants and nonparticipants (refusers, nonresponders, moved away, and deceased subjects) differed in terms of the type of congenital heart disease, the type of surgery (curative, reparative, and palliative), age and gender.

DESIGN

A group of 698 subjects between 15 and 45 years were invited to participate in a study where a standardized interview was combined with a series of medical examinations.

RESULTS

Finally, 361 patients participated, 121 explicitly refused, 92 did not respond, 91 had moved away, and 33 had died. Comparing participants and nonparticipants at the level of bivariate analyses using type of surgery, type of congenital malformation, gender, and age did not yield statistically significant differences. The final analysis using multivariate logistic regression revealed that individuals who underwent palliative treatment, the most severe type of surgery, had the same likelihood of not participating than patients with curative treatment. Classifying patients by the type of heart defect did not reveal group differences in the likelihood to participate. No differences for gender and age emerged.

CONCLUSIONS

The analyses have shown that a worse health status may not lead to nonparticipation. As a consequence, we may conclude that selective nonparticipation because of the measures considered may not have occurred, and the likelihood for obtaining biased results can be considered as low.

Heart-lung transplantation in a 14-year-old boy with Alström syndrome

We present a 14-year-old boy who suffered from progressive biventricular cardiac failure and secondary pulmonary artery hypertension associated with the rarely seen Alström syndrome. The boy underwent successful heart-lung transplantation. We conclude from this report that heart-lung transplantation in patients with Alström syndrome is a viable therapeutic option in select cases.

Electrical velocimetry for measuring cardiac output in children with congenital heart disease

BACKGROUND

The purpose of this study was to evaluate the agreement of cardiac output measurements obtained by electrical velocimetry (CO(EV)) and those that derived from the direct Fick-oxygen principle (CO(F)) in infants and children with congenital heart defects.

METHODS

Simultaneous measurements of CO(EV) and CO(F) were compared in 32 paediatric patients, aged 11 days to 17.8 yr, undergoing diagnostic right and left heart catheterization. For non-invasive measurements of cardiac output by electrical velocimetry, which is a variation of impedance cardiography, standard surface electrodes were applied to the left side of the neck and the left side of the thorax at the level of the xiphoid process. Cardiac output determined using direct Fick-oxygen principle was calculated by direct measurement of oxygen consumption (VO2) and invasive determination of the arterio-venous oxygen content difference.

RESULTS

An excellent correlation (r=0.97) was found between CO(EV) and CO(F) (P<0.001). The slope of the regression equation [0.96 (SD 0.04)] was not significantly different from the line of identity. The bias between the two methods (CO(EV)-CO(F)) was 0.01 litre min(-1) and the limits of agreement, defined as the bias (2 SD), were -0.47 and +0.45 litre min(-1).

CONCLUSIONS

CO(EV) demonstrates acceptable agreement with data derived from CO(F) in infants and children with congenital heart disease. The new technique is simple, completely non-invasive, and provides beat-to-beat estimation of CO.

Heparin-induced thrombocytopenia: a prospective study on the incidence, platelet-activating capacity and clinical significance of antiplatelet factor 4/heparin antibodies of the IgG, IgM, and IgA classes

INTRODUCTION

Platelet-activating antiplatelet factor 4/heparin (anti-PF4/heparin) antibodies are the major cause of heparin-induced thrombocytopenia (HIT). However, the relative utility of functional (platelet activation) vs. antigen [enzyme-immunoassay (EIA)] assays, and the significance of assay discrepancies remain unresolved.

METHODS

Consecutive patient sera (n = 1650) referred for diagnostic HIT testing were screened prospectively by both the heparin-induced platelet activation (HIPA) test and anti-PF4/heparin EIA - including individual classes (IgG, IgA, IgM) - with clinical correlations studied. Platelet microparticle and annexin-V-binding properties of the sera were also investigated.

RESULTS

Only 205 (12.4%) sera tested positive in either the HIPA and/or EIA: 95 (46.3%) were positive in both, 109 (53.1%) were only EIA-positive, and, notably, only one serum was HIPA-positive/EIA-negative. Of 185 EIA-positive sera, only 17.6% had detectable IgM and/or IgA without detectable IgG. Among sera positive for EIA IgG, optical density values were higher when the sera were HIPA-positive (1.117 vs. 0.768; P < 0.0001), with widely overlapping values. Two HIPA-positive but EIA-IgG-negative sera became HIPA-negative following IgG depletion, suggesting platelet-activating antibodies against non-PF4-dependent antigens. Clinical correlations showed that HIPA-negative/EIA-positive patients did not develop thrombosis and had reasons other than HIT to explain thrombocytopenia. IgM/A antibodies did not increase microparticle penetration, but increased annexin-V binding.

CONCLUSIONS

The anti-PF4/heparin EIA has high ( approximately 99%) sensitivity for HIT. However, only about half of EIA-positive patients are likely to have HIT. Anti-PF4/heparin antibodies of IgM/A class and non-PF4-dependent antigens have only a minor role in HIT.

Comparison of electrical velocimetry and transpulmonary thermodilution for measuring cardiac output in piglets

BACKGROUND

Monitoring of cardiovascular function is essential during major pediatric and pediatric cardiac surgery. Invasive monitoring of cardiac output (CO) and oxygen delivery is expensive and sometimes associated with adverse events. Therefore, we investigated the accuracy of a new noninvasive CO monitoring device using electrical velocimetry (EV) in comparison with the more invasive transpulmonary thermodilution (TPTD) method.

METHODS

In five fasted, anesthetized and mechanically ventilated piglets, CO was measured simultaneously using EV and TPTD under normal conditions, volume loading, inotropic support and exsanguination.

RESULTS

In five piglets, 169 measurements could be performed. The correlations between EV-CO and TPTD-CO were significant for absolute values (P < 0.0001, r = 0.82) and relative changes from baseline (P < 0.0001, r = 0.93). The receiver operating characteristic (ROC) curve analysis of the relative changes of the EV-CO values in relation to the first EV-CO measurement showed a sensitivity of 91% and specificity of 94% (AUC 0.974, 95% CI 0.96-0.99). Changes in TPTD-CO greater than 15% lead to a change of EV-CO in the same direction in 93%. Bland-Altman analysis showed a mean difference between the two methods of -0.63 l x min(-1) with an sd of 0.64 l x min(-1). The lower and upper limits of agreement were -1.88 and 0.62 l x min(-1), percentage limit of agreement was +/-82.8%.

CONCLUSIONS

The results show that EV is a safe, simple, noninvasive and cost-effective method for continuous trend monitoring of CO in piglets. The agreement of the EV-CO with TPTD-CO is not good enough to replace the standard method in our animal model. A correction factor for body habitus in piglets may be beneficial.

A prospective, randomized, double-blind, placebo controlled trial of beta-blockade in patients who have undergone surgical correction of tetralogy of Fallot

AIMS

Our purpose was to evaluate the effect of a treatment over six months with bisoprolol on the surrogate parameters of N-Terminal-pro brain natriuretic peptide, subsequently to be described as brain natriuretic peptide, peak uptake of oxygen, and ventricular function assessed by magnetic resonance imaging in grown ups and adults who had undergone surgical correction of tetralogy of Fallot.

METHODS AND RESULTS

We designed a prospective, randomized, double-blind, placebo controlled trial. We enrolled 33 patients, aged 30.9 plus or minus 9.5 years in either class 1 or 2 of the grading of the New York Heart Association class with both levels of brain natriuretic peptide greater than 100 pg/ml and a reduced peak uptake of oxygen less than 25 ml/kg/min. During treatment with Bisoprolol, the levels of brain natriuretic peptide increased significantly from 206 plus or minus 95 to 341 plus or minus 250 pg/ml (p< 0.05), and those of atrial natriuretic peptide from 4117 plus or minus 1837 to 5340 plus or minus 2102 fmol/ml (p = 0.0005). These measures remained unchanged in the group of patients receiving the placebo. Peak uptake of oxygen did not differ significantly in either group, nor did treatment have any significant effect on right and left ventricular volumes and ejection fractions as determined by magnetic resonance imaging. The clinical state as judged within the grading system of the New York Heart Association was also unchanged by beta-blockade.

CONCLUSION

Beta blockade with Bisoprolol seems to have no beneficial effect on asymptomatic or mildly symptomatic patients with right ventricular dysfunction secondary to repaired tetralogy of Fallot with residual pulmonary regurgitation and/or stenosis.

Is the Ability index superior to the NYHA classification for assessing heart failure?

BACKGROUND

Heart failure (HF) is a major problem in the long-term follow-up of adolescents and adults with congenital heart disease (ACHD) after cardiac surgery. The functional status of ACHD may be assessed in terms of the NYHA classification or the Ability index (ABILITY).

OBJECTIVE

The purpose of our study was to examine which of the two classification systems is more closely related to objectively defined HF.

METHODS

NT-pro brain natriuretic peptide (N-BNP) and maximal oxygen uptake (VO(2max)) were measured in 360 consecutive ACHD patients. HF was defined as an elevated N-BNP level > or =100 pg/ml combined with a reduced VO(2max) < or =25 ml/kg/min.

RESULTS

There were no significant differences between the NYHA and ABILITY in grading HF in these patients. In both classifications, the risk of HF increases continuously over the classes and grades from odds ratio (OR) 1 in NYHA I/ABILITY 1 to an OR=3.4 in NYHA II/ ABILITY 2 up to 11.6 or 5.4 (ns) in NYHA III/ABILITY 3. Thus in the highest scores HF is found in 70-77% of the patients. The fact that in NYHA class I and ABILITY grade 1, 15% and 19% of the patients exhibited HF according to the measured indices underscores the discrepancy between subjective and objective assessment of the individual patients condition.

CONCLUSION

The NYHA classification and the Ability index take different approaches to the patients with congenital heart defects but are equally suitable for the judgement of HF in post surgical ACHD.

Construction and establishment of a new environmental chamber to study real-time cardiac development

Heart development, especially the critical phase of cardiac looping, is a complex and intricate process that has not yet been visualized "live" over long periods of time. We have constructed and established a new environmental incubator chamber that provides stable conditions for embryonic development with regard to temperature, humidity, and oxygen levels. We have integrated a video microscope in the chamber to visualize the developing heart in real time and present the first "live" recordings of a chick embryo in shell-less culture acquired over a period of 2 days. The time-lapse images we show depict a significant time window that covers the most critical and typical morphogenetic events during normal cardiac looping. Our system is of interest to researchers in the field of embryogenesis, as it can be adapted to a variety of animal models for organogenesis studies including heart and limb development.

Life chances after surgery of congenital heart disease: the influence of cardiac surgery on intergenerational social mobility. A comparison between patients and general population data

BACKGROUND

To examine whether operated congenital heart disease (CHD) is setting preconditions for an active life by comparing intergenerational social mobility in patients with a population sample.

DESIGN AND METHODS

The patient sample consisted of 314 females (42.1%) and males who underwent surgery for CHD (mean age at surgery 7.3 years, SD 7.8). According to the type of surgery, patients were classified as curative, reparative, or palliative. Consequently, the three groups reflect increasing severities of the initial heart defect. The mean age at examination was 26.9 years (7.6). Controls consisted of individuals who participated in the 2002 survey of the German Socio-Economic Panel. All individuals with complete sociodemographic information were included, and the final sample consisted of 4864 women (46.1%) and men (mean age 32.5 years, SD 7.2).

RESULTS

Once having entered the labour market, intergenerational social mobility between patients and controls did not differ. For upward mobility respondents' social background was the key determinant; the respective standardized regression effect was beta=0.66. After dividing the study population, the social background turned out to having a slightly stronger effect in patients (beta=0.73) than in controls (beta=0.65). For downward mobility effects of the social background were smaller than for upward mobility (beta=0.19 in patients and beta=0.21 in controls). In economically active patients CHD severity did not determine social mobility.

DISCUSSION

We conclude that a large proportion of patients could not or did not enter the labour market. Those who did experienced social mobility rates that are comparable with the general population.

Chronotropic Incompetence in Adolescents and Adults With Congenital Heart Disease After Cardiac Surgery

BACKGROUND

Chronotropic incompetence (CI) is one of the major problems in adults with congestive heart. Little is known about CI in adults with congenital heart disease (ACHD) after cardiac surgery. The purpose of our study was to investigate the presence and risk factors of CI in ACHD patients.

METHODS AND RESULTS

Clinical and echocardiographic data, NT-pro brain natriuretic peptide (N-BNP), and peak oxygen uptake (VO2peak) during spiroergometry were obtained in 345 consecutive ACHD patients. CI was defined as the failure to achieve > or = 80% of the predicted maximal heart rate. A total of 117 (34%) of study patients fulfilled the CI criterion. These patients were in a higher New York Heart Association class (1.7 +/- 0.06 versus 1.4 +/- 0.03, P < .0001; mean +/- SEM), had significantly higher N-BNP levels (230 +/- 31 versus 121 +/- 10 pg/mL, P < .0001) and a more pronounced impairment of VO2peak (23.8 +/- 0.6 versus 28.4 +/- 0.5 mL x kg x min, P < .0001) than those without CI. Elevated odds ratios for CI were found in patients with a single ventricle (4.03), Mustard operation for transposition of the great arteries (3.11), and aortic coarctation (2.14).

CONCLUSIONS

Our results indicate that CI in ACHD patients is a frequent problem and is related to the severity of the heart failure as measured by symptom assessment (New York Heart Association class), plasma N-BNP level and peak oxygen uptake.

[Psychological symptoms and body image in patients after surgery of congenital heart disease]

In the last 20 years the survival rate of patients with congenital heart disease has increased considerably, thus psychological consequences of living with a heart defect have attracted considerable scientific attention. In our study psychological symptoms and the body image of patients with congenital heart disease were compared with the respective scores of general population samples (age: 14 - 45 years). Psychological symptoms were measured by means of the Brief Symptom Inventory (BSI; subscales: somatization, obsessive-compulsive thoughts, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism). Body image was assessed with the FKB-20 body image questionnaire (subscales: rejection of the body, vitality). The patient group consisted of 361 women and men with congenital heart disease. For comparisons with the BSI, a sample of 1165 subjects was available. Comparisons with the FKB-20 were performed with data from a separate survey (N = 1169). After stratification for age and gender, in females only a few differences were found for both instruments. In males higher scores were obtained for "rejection of the body", and lower ones for "vitality". This does not apply to the highest age group (36 - 45 years). For all BSI-subscales except "depression", "phobic anxiety", and "psychoticism" marked differences between patients and controls were found in males and over all age groups. In women group differences emerged on some subscales (obsessive-compulsive thoughts, interpersonal sensitivity, anxiety, hostility, and phobic anxiety), but this does not hold for all age groups. These results do not apply to patients with the severest impairments due to congenital heart disease, because their number in our study was too low.

[Chronic fatigue in complementary rehabilitative medicine--predictors of the outcomes]

Chronic exhaustion and fatigue are increasingly important in rehabilitation medicine. Objectives of this study were (a) to describe the effects of in-patient rehabilitation on patients with chronic fatigue syndromes, (b) to identify predictors for treatment outcome, and (c) to analyze the impact of comprehensive diagnosing on these issues. A total of 171 patients with chronic exhaustion or fatigue (90 % female, mean age 55 +/- 10 yrs) from a rehabilitation hospital with a complementary medicine-based treatment concept were included in a prospective observational study. Within the longitudinal study patients were examined three times (on admission to hospital, at discharge as well as six months later). Participation rate of the postal inquiry was 69 %. Besides items constructed ad hoc, Patient questionnaires included the Symptom Checklist and assessment instruments for depression, quality of life, sense of coherence as well as for changes in experience and behaviour. Treatment outcome was defined as sum score of binary-coded response criteria. The pattern of complaints differed clearly between diagnostic subgroups (neurasthenia, affective disorders, adjustment disorders) before treatment. At discharge from hospital patients showed clinically relevant improvements lasting for six months after rehabilitation. Multiple regression analyses revealed a statistically significant relationship (R (mult) = 0.59) between predictors and outcome at discharge from hospital. A better result was associated with higher trust in treatment success, active information seeking on complementary medicine, healthier feeding habits, better somatic health and a decreased mental status, with regard to the status before treatment. The prediction of outcome after six months was comparably poorer (R (mult) = 0.42). Treatment success was higher in the absence of a diagnosis of neurasthenia, in patients accepting the group-oriented treatment concept and in patients not believing that their disease was due to their own way of living. Trust in the success of the treatment was a highly ranked predictor for longer lasting outcome, too. The results underline the importance of motivation aspects for treatment outcome indicating that individual expectations and attitudes should be considered in a more distinct way when allocating patients to rehabilitative programmes.