Neural correlates of appetite in adolescents

Appetitive characteristics are associated with child adiposity, but their biological underpinnings are unclear. We sought to investigate the neural correlates of psychometric and behavioral measures of appetitive characteristics in youth. Adolescents (14-18y; 39F, 37M) varying in familial obesity risk and body weight (20% with overweight, 24% with obesity) viewed pictures of high energy-density (ED) foods, low-ED foods and non-foods during fMRI scanning on two separate days. On one day participants consumed a 474 ml preload of water (0 kcal, fasted) and on another (counter-balanced) 474 ml milkshake (480 kcal, fed), before scanning. A multi-item ad libitum meal (ALM) followed scanning. Parents completed Child Eating Behavior Questionnaire (CEBQ) sub-scales assessing food approach and food self-regulation. Caloric compensation was calculated as the percentage of preload intake compensated for by down-regulation of ALM intake in the fed vs. fasted condition. Analyses correcting for multiple comparisons demonstrated that, for the fasted condition, higher CEBQ Food Responsiveness scores were associated with greater activation to high-ED (vs. low-ED) foods in regions implicated in food reward (insula, rolandic operculum, putamen). In addition, higher caloric compensation was associated with greater fed vs. fasted activations in response to foods (vs. non-foods) in thalamus and supramarginal gyrus. Uncorrected analyses provided further support for associations of different measures of appetitive characteristics with brain responses to food cues in each condition. Measures of appetitive characteristics demonstrated overlapping and distinct associations with patterns of brain activation elicited by food cues in fasted and fed states. Understanding the neural basis of appetitive characteristics could aid development of biobehaviorally-informed obesity interventions.

EPIC: an evaluation of the psychological impact of early-phase clinical trials in cancer patients

Background

Anxiety and depression in patients with cancer is associated with decreased quality of life and increased morbidity and mortality. However, these are often overlooked and untreated. Early-phase clinical trials (EPCTs) recruit patients with advanced cancers who frequently lack future treatment options, which may lead to increased anxiety and depression. Despite this, EPCTs do not routinely consider psychological screening for patients.

Patients and methods

This prospective observational study explored levels of anxiety and depression alongside impact of trial participation in the context of EPCTs. The Hospital Anxiety and Depression Scale and the Brief Illness Perceptions Questionnaire were completed at the point of EPCT consent, the end of screening and at pre-specified time points thereafter.

Results

Sixty-four patients (median age 56 years; median Eastern Cooperative Oncology Group performance status 1) were recruited. At consent, 57 patients returned questionnaires; 39% reported clinically relevant levels of anxiety whilst 18% reported clinically relevant levels of depression. Sixty-three percent of patients experiencing psychological distress had never previously reported this. Males were more likely to be depressed (P = 0.037) and females were more likely to be anxious (P = 0.011). Changes in anxiety or depression were observed after trial enrolment on an individual level, but not significant on a population level.

Conclusions

Patients on EPCTs are at an increased risk of anxiety and depression but may not seek relevant support. Sites offering EPCTs should consider including psychological screening to encourage a more holistic approach to cancer care and consider the sex of individuals when tailoring psychological support to meet specific needs.

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Early-phase cancer trial patients have an increased risk of anxiety and depression.

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Patients at risk were not seeking support for anxiety and depression.

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Male patients were more likely to be depressed; female patients were more likely to be anxious.

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This work highlights the need to screen for psychological symptoms in patients entering early-phase trials.

Catheter ablation for patients with atrial fibrillation and heart failure: insights from the swedish heart failure registry

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): DFG (Deutsche Forschungsgemeinschaft) to G.O.

Aims

To investigate the association between catheter ablation and mortality as well as hospitalization for heart failure (HF) in patients with atrial fibrillation (AF) and HF across the ejection fraction (EF) spectrum in a contemporary cohort.

Methods

Between 2005 and 2019, patients with first-time catheter ablation for AF (ablation group) compared to only medical treated AF patients (medical therapy group) were identified from the Swedish Heart Failure Registry. The primary outcome (all-cause mortality/first HF hospitalization) was assessed by cox regression models in a 1:2 propensity score (PS) matched cohort and pre-specified EF subgroups (preserved EF [HFpEF] [EF≥50%], mildly reduced EF [HFmrEF] [EF 40% to 49%], reduced EF [HFrEF] [EF<40%]) of this cohort.

Results

452 patients in the ablation and 43766 patients in the medical therapy group were identified. After PS matching, 437 patients in the ablation group were compared to 874 patients in the medical therapy group. Over the entire follow-up, catheter ablation was associated with a lower risk of the primary outcome (Hazard ratio [HR] 0.71 [95%CI, 0.59-0.85]) and first cardiovascular (CV) hospitalization (HR 0.85 [95%CI, 0.72-0.99]) in PS matched analysis. Results were consistent across all EF subgroups. In HFpEF patients, catheter ablation was associated with a significantly lower risk of recurrent HF hospitalization (Incidence rate ratio (IRR) 0.17 [95%CI, 0.07-0.42]).

Conclusion

In this nationwide study, catheter ablation was associated with a significant lower risk of the primary outcome (all-cause mortality/first HF hospitalization) in HF patients with AF. This study advocates catheter ablation as a potent treatment option for AF in HF patients across all EF subgroups, including HFpEF.

Outcome of catheter ablation of arrhythmias in adult congenital heart disease with high density multi-electrode mapping with automatic annotation algorithm

Funding Acknowledgements

Type of funding sources: None.

Introduction

Arrhythmias are frequently encountered in adult congenital heart disease (ACHD) and respond poorly to pharmacological therapies. Catheter ablation is challenging due to anatomical variation and complexity of the arrhythmia substrate. High density multi electrode mapping (MEM) with automatic annotation of activation time may aid mapping of arrhythmia, decrease procedure time and improve the accuracy of targeting of ablation therapy.

Purpose

To compare the acute and long term outcomes and procedural characteristics of catheter ablation in ACHD patients with and without automatic annotation of activation with MEM.

Methods

Retrospective analysis of the acute and long term outcomes of ACHD patients in a single centre undergoing ablation procedures from 1 Jan 2014 to 18 August 2017 was undertaken. 2 groups were identified.

Group 1 included patients who had arrhythmia mapping performed with the CARTO 3D electroanatomic mapping system without the use of automatic signal annotation. Most patients in this group had sequential mapping performed with the ablation catheter (78%), the rest had multi-electrode mapping with the PentaRay 20 pole catheter.

Group 2 included patients who had arrhythmia mapping performed with the CARTO 3D electroanatomic mapping system using the automated CONFIDENSE mapping algorithm.

Results

Group 1: n = 27, mean age 44.6 +/-3 years. Male 46.6%. Group 2: n = 38, mean age 44.0 +/- 1.9 years. Male 56.7%. All patients had CHD of at least moderate complexity. 25% of patients in group 1 and 45% in group 2 were repeat ablations. 45 arrhythmias were induced in group 1 of which 29 were targeted and 74 arrhythmias were induced in group 2 of which 46 were targeted. Acute success rates (after attempts at reinduction) were 96.3% in group 1 and 94.7% in group 2. Recurrences of arrhythmia occurred significantly less in patients in group 2 compared to group 1  (44.7% and 70.4% respectively,  p < 0.05) after a follow up duration of 17.3+/-0.43 months in group 2 and 45.3 +/-1.19 months in group 1. Fluoroscopy time, procedure time and ablation time were not significantly different between groups.

Conclusions

The use of multi-electrode mapping with an automatic annotation algorithm was associated with a significantly lower risk of recurrence during the follow up period of this study.

Eligibility for sacubitril/valsartan in heart failure across the ejection fraction spectrum: real-world data from the Swedish Heart Failure Registry

BACKGROUND

Randomized controlled trials (RCT) generalizability may be limited due to strict patient selection.

OBJECTIVE

In a real-world heart failure (HF) population, we assessed eligibility for sacubitril/valsartan based on PARADIGM-HF (sacubitril/valsartan effective)/PARAGON-HF [sacubitril/valsartan effective in mildly reduced ejection fraction (EF)].

METHODS

Outpatients from the Swedish HF Registry (SwedeHF) were analysed. In SwedeHF, EF is recorded as <30, 30-39, 40-49 and ≥50%. In PARAGON-HF, sacubitril/valsartan was effective with EF ≤ 57% (i.e. median). We defined reduced EF/PARADIGM-HF as EF < 40%, mildly reduced EF/PARAGON-HF ≤ median as EF 40-49%, and normal EF/PARAGON-HF > median as EF ≥ 50%. We assessed 2 scenarios: (i) criteria likely to influence treatment decisions (pragmatic scenario); (ii) all criteria (literal scenario).

RESULTS

Of 37 790 outpatients, 57% had EF < 40%, 24% EF 40-49% and 19% EF ≥ 50%. In the pragmatic scenario, 63% were eligible in EF < 50% (67% for EF < 40% and 52% for 40-49%) and 52% in EF ≥ 40% (52% for EF ≥ 50%). For the literal scenario, 32% were eligible in EF < 50% (38% of EF < 40%, 20% of EF 40-49%) and 22% in EF ≥ 40% (25% for EF ≥ 50%). Eligible vs. noneligible patients had more severe HF, more comorbidities and overall worse outcomes.

CONCLUSION

In a real-world HF outpatient cohort, 81% of patients had EF < 50%, with 63% eligible for sacubitril/valsartan based on pragmatic criteria and 32% eligible based on literal trial criteria. Similar eligibility was observed for EF 40-49% and ≥50%, suggesting that our estimates for EF < 50% may be reproduced whether or not a higher cut-off for EF is considered.

Long-term outcome of patients with invasive electrophysiology procedure related cardiac tamponade

Aims

Iatrogenic cardiac tamponades are a rare but dreaded complication of invasive electrophysiology procedures (EPs). Their long-term impact on clinical outcomes is unknown. This study analyzed the risk of death or serious cardiovascular events in patients suffering from EP related cardiac tamponade requiring pericardiocentesis during long-term follow-up.

Methods and results

Out of 19997 invasive EPs at our university hospital between January 1998 and September 2018, all patients with EP related periprocedural cardiac tamponade were identified (n=60) and matched (1:3 ratio) to a control group (n=180). After a follow-up of 5 years, the composite primary end point - death from any cause, acute myocardial infarction, TIA/stroke and hospitalization for heart failure – occurred in significantly more patients in the tamponade than in the control group (12 patients (20.0%) vs 19 patients (10.6%); Hazard ratio (HR) 2.53 (95% CI, 1.15–5.58); p=0.021). This was mainly driven by a higher incidence of TIA/stroke in the tamponade than in the control group (HR 3.75 (95% CI, 1.01–13.97); p=0.049). Death from any cause, acute myocardial infarction and hospitalization for heart failure did not show a significant difference between the groups. Hospitalization for pericarditis occurred in significantly more patients in the tamponade than in the control group (HR 36.0 (95% CI, 4.68–276.86); p=0.001).

Conclusion

Patients with EP related cardiac tamponade are at higher risk for cerebrovascular events during the first two weeks and hospitalization for pericarditis during the first months after index procedure. Despite the increased risk for early complications tamponade patients have a good long-term prognosis without increased risk for mortality or other serious cardiovascular events.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation

Dietary factors and pediatric multiple sclerosis: A case-control study

BACKGROUND

The role of diet in multiple sclerosis (MS) is largely uncharacterized, particularly as it pertains to pediatric-onset disease.

OBJECTIVE

To determine the association between dietary factors and MS in children.

METHODS

Pediatric MS patients and controls were recruited from 16 US centers (MS or clinically isolated syndrome onset before age 18, <4 years from symptom onset and at least 2 silent lesions on magnetic resonance imaging). The validated Block Kids Food Screener questionnaire was administered 2011-2016. Chi-squared test compared categorical variables, Kruskal-Wallis test compared continuous variables, and multivariable logistic regression analysis was performed.

RESULTS

In total, 312 cases and 456 controls were included (mean ages 15.1 and 14.4 years). In unadjusted analyses, there was no difference in intake of fats, proteins, carbohydrates, sugars, fruits, or vegetables. Dietary iron was lower in cases ( p = 0.04), and cases were more likely to consume below recommended guidelines of iron (77.2% of cases vs 62.9% of controls, p < 0.001). In multivariable analysis, iron consumption below recommended guidelines was associated with MS (odds ratio = 1.80, p < 0.01).

CONCLUSION

Pediatric MS cases may be less likely to consume sufficient iron compared to controls, and this warrants broader study to characterize a temporal relationship. No other significant difference in intake of most dietary factors was found.

Caloric compensation in preschool children: Relationships with body mass and differences by food category

Maintaining a healthy weight may involve compensating for previously consumed calories at subsequent meals. To test whether heavier children demonstrated poorer caloric compensation across a range of conditions, and to explore whether compensation failure was the result of inadequate adjustment of overall intake or specific over-consumption of highly palatable, high energy-density 'junk' foods, we administered two compensation tests to a sample of 4-5 y olds. For Test A, preloads varied only in carbohydrate content and were organoleptically indistinguishable (200 ml orange-flavored beverage [0 kcal vs. 200 kcal]). For Test B, the preloads varied substantially in both macronutrient composition and learned gustatory cues to caloric content (200 ml water [0 kcal] vs. 200 ml strawberry milkshake [200 kcal]). Each preload was followed 30 min later by a multi-item ad-libitum meal containing junk foods (chocolate cookies, cheese-flavored crackers) and core foods (fruits and vegetables, bread rolls, protein foods). Testing took place at the children's own school under normal lunch-time conditions. Children were weighed and measured. Caloric compensation occurred in both tests, in terms of total, junk and core food intake (RMANOVA, all p < 0.01). Higher BMI z scores were associated with greater average caloric compensation (r = -0.26; p < 0.05), such that overweight/obese children showed least compensation (41%), children over the 50^th centile the next least (59%), and children under the 50^th centile (80%) the most. For Test A only, obese/overweight children compensated less well than normal-weight children in terms of junk food intake (RMANOVA preload-by-weight group interaction p < 0.05), with no significant effect for core foods. Our results suggest that caloric compensation is consistently poorer in heavier children, and that overweight/obese children's preferences for junk foods may overwhelm intake regulation mechanisms within meals containing those foods.

Evaluating the association of allergies with multiple sclerosis susceptibility risk and disease activity in a pediatric population

BACKGROUND

Multiple sclerosis (MS) and allergies are both considered to be related to imbalanced Th1 and Th2 immune responses. Previous studies evaluating the relationship between MS and allergies provide conflicting results.

OBJECTIVE

To assess allergies and asthma as risk factors for MS and as predictors of MS relapses in a pediatric cohort.

METHODS

The environment and genetic risk factors for pediatric MS study is a national case-control project with 16 participating US sites. An environmental questionnaire is used that includes history of allergies in the first five years of life. Case-control data are entered in the pediatric MS Network database and cases at 12 of the 16 sites enter relapse data prospectively. Annualized relapse rate was calculated for patients with follow-up and adjusted for age at disease onset, gender, race, ethnicity, and use of disease-modifying therapy (DMT).

RESULTS

We included 271 cases (mean age at disease onset of 15.7years and 62% female) and 418 controls. Relapse data were available for 193 cases. There was no difference in prevalence of allergies or asthma between cases and controls. Patients with food allergies had fewer relapses compared to patients without food allergies (0.14 vs 0.48, p=0.01).

CONCLUSIONS

While allergies and asthma are not associated with pediatric MS, cases with food allergies have fewer relapses compared to those without food allergies.

Magnetic Resonance Imaging in Primary Amyloidosis

Twelve patients with primary amyloidosis (AL) were investigated with magnetic resonance imaging (MRI). In 9 patients an abnormal thickening of the heart walls was present and in 2 macroglossia was found at MRI. T1 was significantly increased in liver (p<0.05) and subcutaneous fat (p<0.01) while it was decreased in the spleen (p<0.05). T2 was significantly decreased (p<0.01) in the spleen in patients with amyloidosis, while it was not significantly altered in the liver or subcutaneous fat. After therapy T1 of the liver was reduced towards normal values in 4 patients. It is concluded that MRI might be a method to quantitate the amount of amyloid deposits in the tissue, and that the effect of therapy may be monitored with this technique.

Lunch-time food choices in preschoolers: Relationships between absolute and relative intakes of different food categories, and appetitive characteristics and weight

Children's appetitive characteristics measured by parent-report questionnaires are reliably associated with body weight, as well as behavioral tests of appetite, but relatively little is known about relationships with food choice. As part of a larger preloading study, we served 4-5year olds from primary school classes five school lunches at which they were presented with the same standardized multi-item meal. Parents completed Child Eating Behavior Questionnaire (CEBQ) sub-scales assessing satiety responsiveness (CEBQ-SR), food responsiveness (CEBQ-FR) and enjoyment of food (CEBQ-EF), and children were weighed and measured. Despite differing preload conditions, children showed remarkable consistency of intake patterns across all five meals with day-to-day intra-class correlations in absolute and percentage intake of each food category ranging from 0.78 to 0.91. Higher CEBQ-SR was associated with lower mean intake of all food categories across all five meals, with the weakest association apparent for snack foods. Higher CEBQ-FR was associated with higher intake of white bread and fruits and vegetables, and higher CEBQ-EF was associated with greater intake of all categories, with the strongest association apparent for white bread. Analyses of intake of each food group as a percentage of total intake, treated here as an index of the child's choice to consume relatively more or relatively less of each different food category when composing their total lunch-time meal, further suggested that children who were higher in CEBQ-SR ate relatively more snack foods and relatively less fruits and vegetables, while children with higher CEBQ-EF ate relatively less snack foods and relatively more white bread. Higher absolute intakes of white bread and snack foods were associated with higher BMI z score. CEBQ sub-scale associations with food intake variables were largely unchanged by controlling for daily metabolic needs. However, descriptive comparisons of lunch intakes with expected amounts based on metabolic needs suggested that overweight/obese boys were at particularly high risk of overeating. Parents' reports of children's appetitive characteristics on the CEBQ are associated with differential patterns of food choice as indexed by absolute and relative intake of various food categories assessed on multiple occasions in a naturalistic, school-based setting, without parents present.

Paracervical block as pain treatment during second-trimester medical termination of pregnancy: an RCT with bupivacaine versus sodium chloride

STUDY QUESTION

Can paracervical block (PCB) administered before the onset of pain decrease women's pain experience during second-trimester medical termination of pregnancy (MToP)?

SUMMARY ANSWER

There were no clinically significant differences between groups receiving PCB with bupivacaine or saline with regard to the highest and lowest pain intensity, morphine consumption or induction-to abortion interval.

WHAT IS KNOWN ALREADY

The most common side effect of misoprostol is pain; nevertheless, there are sparse studies in pain and pain treatment during MToP, especially in second-trimester abortion. Pain reported in second-trimester medical abortion is often intense, and peaks when the fetal expulsion occurs.

STUDY DESIGN, SIZE, DURATION

A double-blinded RCT was carried out from May 2012 until April 2015. A power calculation was based on a previous pilot study showing that the proportion of women with severe pain [visual analogue scale (VAS) ≥7] was 63%. A clinically significant reduction was considered to yield 35% with severe pain, and with a power of 80% and significance level of 5% (two-sided) 112 women were needed. Accounting for a 20% drop-out rate, a total of 140 women were needed. The primary outcome, pain intensity measured as any VAS ≥7, was analysed using a generalized estimating equations model. The level of significance was set to P < 0.05 two-sided. A computer generated randomization list with block size of 10 was used. The treatment allocation was placed in a sealed, opaque, envelope and picked consecutively.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 589 women attending a gynaecological clinic had a second-trimester abortion during the study period and 276 were invited to participate. A total of 113 women undergoing abortion from 13 weeks of gestation and above were recruited, of which 55 were randomly allocated to receive a PCB with bupivacaine and 58 a PCB with sodium chloride 1 h after the first dose of misoprostol. The full analysis set (FAS) population was defined as all randomized women that had at least one value for any of the outcomes (n = 102). The per-protocol (PP) population was defined as a subset of the FAS excluding patients with major protocol deviations or without a value for the primary outcome (n = 99). Pain was measured by VAS at misoprostol initiation (baseline) and repeated every 30 min until fetal expulsion. The primary outcome was the highest VAS pain intensity at any time point.

MAIN RESULTS AND THE ROLE OF CHANCE

The highest pain intensity, did not show any differences at a cut-off of VAS ≥7 [risk ratio (RR): 1.1; 95% confidence interval (CI): 0.9-1.5; P = 0.0.292]. In the PP analyses, there were 75% women in the bupivacaine group and 64% in the sodium chloride group with VAS ≥7 (RR: 1.2; 95% CI: 0.9-1.5; P = 0.235). Most women did not experience pain at the misoprostol start, 19 women scored a VAS of >0, ranging from 1 to 4 with a mean of 1.8 and median of 2 (P = 1.000). Immediately prior to PCB, 61 women scored a VAS of >0, from 1 to 10 with a mean of 2.0 and median of 1 (P = 0.771). There was a 48% loss of VAS scores at the time of expulsion and the remaining scores did not differ between groups (RR: 1.5; 95% CI: 0.9-2.5). A subgroup analysis of primipara did not show any difference in highest pain intensity VAS ≥7 (RR: 1.2; 95% CI: 0.9-1.6; P = 0.283). No statistically significant differences were observed between groups with regard to the highest and lowest (P = 553 and 0.182) pain intensity and morphine consumption (P = 0.772). Side effects were reported by 28 women (14 women in each group), with no differences between groups. Most common was nausea and vomiting in connection to morphine injection.

LIMITATIONS, REASONS FOR CAUTION

Nearly 60% of the invited women did not want to participate in the study (fear of needles and fear of receiving the placebo) therefore women who tolerate pain may have been overrepresented in the study population. Data collection was stopped, in error, when 113 participants had been recruited. The loss to follow-up was, however, only 11 women (10%), which was lower than expected but intrinsically the study did not fully reach the intended number of women, which may have influenced the results. In addition, the obstetrical and gynaecological background of participating women differs. The participants were informed that they had a 50% chance of receiving a PCB with active substance, which could theoretically have affected their expectations and pain experience (placebo effect). The frequent attention at VAS scoring and the overall care provided may also have affected the participants in a positive way, and helped women to feel supported and more relaxed during the abortion.

WIDER IMPLICATIONS OF THE FINDINGS

The highest pain intensity was severe (VAS: 7-10) among 65-75% of the participants, as reported for first-trimester medical abortion; however, the maximal pain scores remain high despite the PCB. There is, therefore, a clear need for more optimal pain treatment but only limited data exist on pain treatment during MToP over all gestational lengths. As PCB was well tolerated, did not cause any serious side effects and had no negative impact on the abortion process and efficacy, another approach may be worth exploring, namely PCB given on demand at the onset of painful contractions.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by grants from the Swedish Research Council (grant no: 2012-2844), ALF (Karolinska Institutet - Stockholm County Council, Agreement on Medical Research and Training) funding, the Karolinska Institutet, Stockholm South General Hospital, and Swedish Nurses in the Area of Pain - SSOS together with GlaxoSmithKline. None of the authors have any conflicts of interest.

TRIAL REGISTRATION NUMBER

The trial was registered with ClinicalTrials.gov (identifier: NCT01617564) and The EudraCT (number: 2010-020780-21) and was approved by The Regional Ethical Review Board at Karolinska Institutet (dnr: 2007/1277-31/2 and 2010/410-31/1).

TRIAL REGISTRATION DATE

Clinical trial registration was done in May 2012 before initiation of patient recruitment.

DATE OF FIRST PATIENT'S ENROLMENT

29 May 2012.

Successful transcatheter occlusion of an anomalous pulmonary vein with dual drainage to the left atrium

We describe a case of a scimitar syndrome "variant" where dual drainage existed from the right upper and middle pulmonary veins to the inferior vena cava and left atrium. Device closure of the anomalous vein at the level of the connection to the IVC was successful in achieving diversion of pulmonary venous flow to the left atrium. Vigilance during work-up of anomalous pulmonary venous drainage (whether isolated or associated with other cardiac defects that may be amenable to device closure) is important to define the presence of dual connections to the left atrium, in which case a less-invasive transcatheter approach may be feasible.

Neuroimaging and obesity: current knowledge and future directions

Neuroimaging is becoming increasingly common in obesity research as investigators try to understand the neurological underpinnings of appetite and body weight in humans. Positron emission tomography (PET), functional magnetic resonance imaging (fMRI) and magnetic resonance imaging (MRI) studies examining responses to food intake and food cues, dopamine function and brain volume in lean vs. obese individuals are now beginning to coalesce in identifying irregularities in a range of regions implicated in reward (e.g. striatum, orbitofrontal cortex, insula), emotion and memory (e.g. amygdala, hippocampus), homeostatic regulation of intake (e.g. hypothalamus), sensory and motor processing (e.g. insula, precentral gyrus), and cognitive control and attention (e.g. prefrontal cortex, cingulate). Studies of weight change in children and adolescents, and those at high genetic risk for obesity, promise to illuminate causal processes. Studies examining specific eating behaviours (e.g. external eating, emotional eating, dietary restraint) are teaching us about the distinct neural networks that drive components of appetite, and contribute to the phenotype of body weight. Finally, innovative investigations of appetite-related hormones, including studies of abnormalities (e.g. leptin deficiency) and interventions (e.g. leptin replacement, bariatric surgery), are shedding light on the interactive relationship between gut and brain. The dynamic distributed vulnerability model of eating behaviour in obesity that we propose has scientific and practical implications.

Effects of Epinephrine and Norepinephrine on Serum Parathyroid Hormone and Calcium in Normal Subjects

Infusions with stepwise increasing concentrations of epinephrine (from 2.5 to 10 micrograms/min) and norepinephrine (0.5-2.0 micrograms/min) were given to normal subjects. During infusion of epinephrine there was a clear rise of the serum parathyroid hormone (PTH) levels already at the lowest concentration. Concomitantly there was a fall in the serum concentrations of calcium. The PTH levels returned to baseline promptly after termination of infusion whereas hypocalcaemia persisted up to 30 minutes, indicating a primary response of PTH to epinephrine. When propranolol was given prior to and during the epinephrine infusion no significant changes occurred for either PTH or calcium. During infusion of norepinephrine no consistent significant changes were noted for either PTH or serum calcium. Thus, our data do not support any concept of a basal adrenergic tone which normally modulates the secretion of PTH. However, during conditions of stress the beta-adrenergic stimulation night be of importance.

Effects of secretin on parathyroid hormone and calcium in normal subjects, patients with hyperparathyroidism and patients with gastrinoma

In vitro studies have demonstrated that secretin can stimulate the release of parathyroid hormone (PTH), but reports concerning its effects on PTH and calcium in vivo are contradictory. To examine this question further, a bolus injection of secretin (75 IU) was given to 12 normal subjects and 10 patients with primary hyperparathyroidism (HPT). Six of the patients had multiple endocrine neoplasia and five had endocrine pancreatic tumours (EPT). Three normocalcaemic patients with EPT were also included in the study. The mean serum gastrin level rose significantly (from 19 to 40 pmol/l, p less than 0.01) within 15 min of secretin injection in the normal subjects. HPT patients without EPT had a somewhat higher mean basal level of gastrin (39 pmol/l, p less than 0.05 compared with controls), but it did not increase significantly after the secretin bolus. In six EPT patients the gastrin concentrations rose by more than 300 pmol/l. Although secretin had a biological capacity to release gastrin, it had no discernible effects on either serum PTH or serum calcium in any of the groups studied. Nor were any changes in PTH or calcium observed when secretin was given as a continuous infusion (3 IU/kg/h) over 90 min. Thus, our data do not support the concept that secretin, in vivo, is a secretagogue of PTH.

Clodronate treatment in patients with malignancy-associated hypercalcemia

The possibility of reducing symptomatic hypercalcemia and of maintaining total serum calcium concentrations less than 2.8 mmol/l with clodronate (dichloromethylene bisphosphonate) was evaluated in 28 patients with various types of malignant tumors. Four episodes of hypercalcemic crisis with mean serum calcium concentrations of 4.43 mmol/l were controlled within 4-6 days of intravenous clodronate (4 mg/kg BW/day). This was accompanied by a moderate increase in serum creatinine values which, however, returned to pretreatment levels after therapy withdrawal in all but one case. Oral clodronate successfully reduced a mean serum calcium concentration of 3.16 mmol/l in 22 out of 25 patients after 3-12 days (800-3,200 mg/day). After reversal of the hypercalcemias oral clodronate controlled the serum calcium concentration for up to 42 weeks in six out of 15 patients After discontinuation of initial therapy five of seven recurrent hypercalcemias were successfully treated with oral or intravenous clodronate. Hypocalcemia and subjective side-effects were uncommon. It is concluded that clodronate is a valuable clinical tool in the management of patients with malignancy-associated hypercalcemia.

Percutaneous ultrasound-guided stenting of the atrial septum in fetal sheep

OBJECTIVES

Hypoplastic left heart syndrome (HLHS) with a restricitive foramen ovale is associated with high mortality related to fetal left atrial hypertension. Fetal atrial balloon septoplasty has largely failed to achieve adequate decompression due to the small size of the holes produced. We attempted to produce larger atrial communications by stenting the atrial septum in fetal sheep using a minimally invasive technique.

METHODS

We used a percutaneous, ultrasound-guided transpulmonary or transhepatic approach to attempt deployment of coronary stents (2-5 mm in diameter and 13-23 mm in length) in the atrial septum primum of 10 normal fetal sheep.

RESULTS

Coronary stents were deployed in eight of the 10 fetal sheep (119-139 days' gestation). The transhepatic route was unsuccessful (n = 2). Transpulmonary implantation was only possible in prone fetuses, so three initially supine fetuses underwent external version. Small coronary stents (2.0-2.5 mm in diameter) were deployed rapidly without complication via an 18G needle (n = 4). Larger coronary stents (5 mm in diameter) were delivered through a 4F sheath, but a right pleural effusion occurred in three of the four cases, related to inferior vena cava injury by the balloon. One stent dislodged from a floppy septum. Another was partially occluded within a week by endocardial cells.

CONCLUSIONS

Percutaneous ultrasound-guided deployment of coronary stents into the septum primum is feasible without laparotomy or uterine exteriorization in fetal sheep. Partial luminal occlusion by rapid proliferation of endocardial cells is a concern.

Successful percutaneous treatment of anomalous left coronary artery from pulmonary artery

Anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA) is an uncommon congenital condition seen in the adult population, with most patients developing symptoms in infancy. We describe successful closure of an ALCAPA in an adult using a percutaneous transcatheter approach in a patient with evidence of anterior wall ischemia believed to be the consequence of myocardial steal. A 30-year-old female was noted to have continuous flow in the right ventricular septum on transthoracic echocardiography, with subsequent imaging confirming the presence of an ALCAPA. Myocardial perfusion imaging confirmed anterior wall ischemia, and as a strategy to optimize coronary perfusion pressure, the patient underwent percutaneous ALCAPA closure using an Amplatzer vascular plug. The procedure was well tolerated, with no evidence of anterior ischemia or myocardial dysfunction. Follow up perfusion imaging demonstrated no residual anterior wall ischemia. Transcatheter closure of an ALCAPA is a potentially safe and effective alternative treatment strategy in this patient population.

Transcatheter device closure of atrial septal defects in the elderly: Technical considerations and short-term outcomes

BACKGROUND

Device closure of an atrial septal defect (ASD) results in symptom-reduction, right heart remodelling and lower pulmonary artery pressures. However it is unclear if there is a chronological limit to these benefits and whether device closure is safe in elderly subjects. The aim of this study was, therefore, to assess the safety and efficacy of device closure in patients >60 years.

METHODS

Retrospective study of Amplatzer Septal Occluder device closures from a single institution (May 1999-August 2002).

RESULTS

Fifty subjects aged >60 years (range 60-85 years) had ASD device closure (27% of the total cohort). Defect size and shunt size were similar for both younger and older groups (2.2:1 in both groups, p=0.9) as were procedural duration, fluoroscopy time and device size deployed. Baseline right ventricular (RV) systolic pressure ((younger vs. older) 39 vs. 49 mmHg, p<0.001) and right ventricular size (45 vs. 51 mm, p<0.001) were greater in the older group. Following closure RV systolic pressure (49 vs. 45 mmHg, p<0.01) and RV size (51 vs. 44 mm, p=0.01) decreased in the older group.

CONCLUSION

Device closure of an ASD can be performed safely in older patients. The right heart shows signs of remodelling even in elderly subjects.

Fenestration of the Fontan circuit as treatment for plastic bronchitis

Plastic bronchitis is a rare, potentially life-threatening condition in which protein casts form within and occlude the bronchus, resulting in pulmonary failure, and has been identified as a complication after the Fontan procedure. We present a case of a 5-year-old girl who had undergone an extracardiac fenestrated Fontan repair as a component of staged palliation for tricuspid atresia. Six weeks following surgery, the patient presented with airway obstruction, coughing a bronchial cast. Medical therapies to optimize heart function and attempt to control cast formation were implemented, with little clinical impact. Following cardiac catheterization to stent open the fenestration, the symptoms of plastic bronchitis resolved. Cast expectoration recurred following spontaneous closure of the stented fenestration and again resolved with recreation of the baffle defect. Fenestration of the Fontan circuit alters hemodynamics, thereby providing an additional therapeutic option for this devastating disorder.

Symptomatic atrial arrhythmias and transcatheter closure of atrial septal defects in adult patients

OBJECTIVE

To determine whether transcatheter device closure of a secundum atrial septal defect (ASD) will reduce the risk of developing subsequent atrial arrhythmias.

DESIGN

The incidence and predictors of symptomatic atrial tachyarrhythmias (AT) were examined in adults undergoing transcatheter closure of ASDs.

SETTING

Toronto Congenital Cardiac Centre for Adults.

PATIENTS

132 consecutive patients, mean (SD) age 44 (16) years; 74% female.

MAIN OUTCOME MEASURE

Sustained or symptomatic atrial arrhythmias at early follow up (six weeks; n = 115) and intermediate follow up (last clinic visit 17 (11) months post surgery; n = 121).

RESULTS

15% of the patients (20 of 132) had AT before the procedure (14 paroxysmal, six persistent). Patients without a history of arrhythmia had a low incidence of AT during early follow up (6%) and intermediate follow up (1%/year), while all patients with persistent AT before closure remained in atrial fibrillation or flutter. Of patients in sinus rhythm but with a previous history of AT, two thirds remained arrhythmia-free at follow up, with overall incidences of paroxysmal and persistent AT of 17%/year and 11%/year. A history of AT before closure (risk ratio (RR) 35.0, 95% confidence interval (CI) 7.2 to 169.0) and age > or = 55 years at the time of device insertion (RR 5.6, 95% CI 1.2 to 25.0) predicted AT after closure.

CONCLUSIONS

Device closure of an ASD before the onset of atrial arrhythmias may protect against the subsequent development of arrhythmia, in particular in patients less than 55 years of age.

Balloon dilation of native aortic coarctation in infancy

Balloon dilation of aortic coarctation in neonates and infants remains controversial. Between 2/1985 and 8/1999, 80 patients <12 months of age, with native aortic coarctation underwent balloon dilation. The systolic pressure gradient across the stenosed area was reduced significantly acutely from a mean of 45.6+/-19.4 mmHg to 17.9+/-13.8 mmHg. In 55 (68.8%) patients, the procedure was initially successful with a residual gradient of <20 mmHg. In 12.5% of patients, intimal tears were detected after dilation. In 21.3% of patients, obstruction of the femoral artery occurred, which responded to heparin or streptokinase in all. Two patients developed aneuryms immediately after the first intervention. In 1 case, surgery was performed with a successful aneurysmectomy. Severe complications or death in relation to the procedure were not detected. Long-term follow-up was obtained in 66 of 80 (82.5%) patients in a period between 6 to 174 months (median 29 months). In 22/66 (33%) of the infants, within a mean period of 10.9+/-15.2 months after first intervention, a redilation was necessary. Sixteen of 22 were successful procedures. In the remaining six patients, surgery was performed electively. A total of 30/66 who had follow-up (45%) patients remained free from reintervention or surgery after the first procedure. Further analysis of the data according to age showed that neonates and infants < or =3 months of age had a 90% and 62% higher residual stenosis rate, respectively, than infants >3 months. In this young age group, balloon dilation can only be recommended as palliation in young infants with severe left venticular dysfunction or in the case surgery is prohibitive for other reasons.

From competition to collaboration in the delivery of health care: England and Scotland compared

AIM

The purpose of this paper is to outline and critically appraise the NHS reforms that were operationalized in April 1999.

DISCUSSION

The paper recognizes that there are important differences between England and Scotland in the design and implementation of change. Differences are discernible in terms of the organization of the commissioning role and of the acute hospital sector, but more significant differences are evident in terms of the nature and organization of primary care.

CONCLUSIONS

The paper concludes by indicating that a major challenge exists in the change management agenda with reference to primary care. Thus, while differences exist both north and south of the border, a shared feature is that the change management agenda in both England and Scotland is formidable. The main element of this challenge is that GPs have, in different ways, had to be drawn into the mainstream of the NHS.

Cardiopulmonary exercise performance in adult survivors of the Mustard procedure

Most patients with the Mustard procedure are now adults. To date, however, there have been few reports on resting and exercise hemodynamics in a large population of adults with this circulation. The aim of this study is to describe such parameters in one of the largest and oldest populations of adults with the Mustard procedure. The database of the University of Toronto Congenital Cardiac Centre for Adults was examined to identify 84 adults with the Mustard procedure who have undergone cardiopulmonary exercise tests. Magnetic resonance imaging and echocardiography studies were obtained in order to assess right ventricular size, function and baseline hemodynamics. Patients achieved lower maximum uptake of oxygen, maximal heart rate, forced vital capacity, forced expiratory volume in 1 second, and oxygen saturations at maximal exercise compared to a healthy population. Magnetic resonance imaging showed significantly different right ventricular ejection fractions between patients and controls. There were no effects of operative variables or preoperative hemodynamics on current exercise capacity. Patients after the Mustard procedure have subnormal exercise capacities. Factors such as chronotropic incompetence, peripheral deconditioning, and impaired lung function may be responsible for these results.

Pediatric heart transplantation: improving results in high-risk patients

OBJECTIVES

Our institutional experience with 73 pediatric patients undergoing cardiac transplantation between January 1, 1990, and December 31, 1999, was reviewed to determine the impact of unconventional donor and recipient management protocols implemented to extend the availability of this therapy.

METHODS AND RESULTS

The introduction of donor blood cardioplegic solution with added insulin was associated with a significant improvement in patient and graft survival (hazard ratio [Cox] = 0.25, P =.08), despite significantly longer ischemic times with this protocol compared with the use of crystalloid-based donor procurement techniques (P <.01). Eleven patients underwent intentional transplantation of ABO-incompatible donor hearts with the aid of a protocol of plasma exchange on bypass. In this subgroup, there were 2 early deaths caused by nonspecific graft failure (n = 1) and respiratory complications with mild vascular rejection (n = 1), and there was 1 late death caused by lymphoma. ABO-incompatible transplantation was not a risk factor for death by multivariate analysis. The postoperative course in these patients suggests minimal reactivity directed against incompatible grafts on the basis of low anti-donor blood group antibody production, in association with a favorable rejection profile. Ten of 13 patients requiring preoperative support with an extracorporeal membrane oxygenator survived transplantation; there were 3 additional late deaths in this subgroup (hazard ratio = 2.88, P =.05).

CONCLUSIONS

The results with pediatric cardiac transplantation continue to improve as a result of changes in both surgical and medical protocols permitting successful treatment of patients conventionally considered at high risk or unsuitable for transplantation.

Mycophenolate mofetil in pediatric heart transplant recipients: a single-center experience

Mycophenolate mofetil (MMF) is emerging as an effective agent for the treatment of both established rejection and primary rejection prophylaxis in solid-organ transplantation (Tx). However, little data is available on the use of MMF in the pediatric population. We therefore report on our experience with MMF in 21 pediatric heart transplant recipients. Data were obtained by retrospective chart review. Median age at time of review was 12.3 yr (range 11 months to 16.9 yr). Median age at Tx was 10.7 yr (range 55 days to 16.7 yr). MMF was started at a median of 4.3 months after Tx (range 1 day to 4.5 yr). At the time of MMF institution, all patients were concurrently on prednisone and azathioprine; 20 of these patients were also undergoing treatment with tacrolimus (median dose 0.18 mg/kg, range 0.03-0.64 mg/kg) and one with cyclo-sporin A (10 mg/kg). Azathioprine was discontinued at the time of commencing MMF. The average MMF dose was 40 +/- 14 mg/kg. The rationale for switching to MMF included rejection (International Society for Heart and Lung Transplantation [ISHLT] 3A/B), 66%; inability to wean steroids, 14%; ABO blood group donor-recipient mismatch, 10%; coronary artery disease (CAD), 5%; and side-effects of immuno-suppression, 5%. Of the patients switched for rejection, 93% demonstrated resolved or improving rejection. Both ABO donor-recipient mismatch patients were started on tacrolimus/MMF as primary therapy and had no significant episodes of rejection. Two patients had rejection classified as unchanged (one with CAD, one treated with addition of sirolimus prior to improvement). Corticosteroids were successfully discontinued in 28% of patients, and 20% are currently on a reduced dose. Fourteen per cent developed significant rejection while attempting to reduce the steroid dose. Steroid reduction has not yet been attempted in 38% of patients. The following side-effects were reported in 38% of the patients: diarrhea, 10%; gastrointestinal discomfort, 20%; and leukopenia, 20%. Dose reduction or temporary discontinuation was required in 63% of the patients who experienced side-effects (24% of the total number of patients). Opportunistic infections developed in 10% (cryptococcus, cytomegalovirus). Hence, MMF appears to be effective for treatment of rejection in the pediatric heart transplant population and has an acceptable side-effect profile. In addition, it may have a role in primary rejection prophylaxis and may facilitate a reduced steroid dosage or a steroid-free immunosuppression regimen.