Trajectories of oxygen saturation within 6-72 hours after birth in neonates at moderate altitude: a prospective longitudinal cohort study

BACKGROUND

Trajectories of pulse oxygen saturation (SpO2) within the first few days after birth are important to inform the strategy for identifying asymptomatic hypoxemic disease but remain poorly substantiated at higher altitudes.

METHODS

We performed a longitudinal cohort study with consecutive neonates at a local hospital in Luchun County, China, at an altitude of 1650 m between January and July 2020. We repeatedly measured the pre- and post-ductal SpO2 values at 6, 12, 18, 24, 36, 48, and 72 hours after birth for neonates without oxygen supplements. All neonates underwent echocardiography and were followed up to 42 days after discharge. We included neonates without hypoxemic diseases to characterize the trajectories of SpO2 over time using a linear mixed model. We considered the 2.5th percentile as the reference value to define hypoxemic conditions.

RESULTS

A total of 1061 neonates were enrolled. Twenty-five had non-cardiac hypoxemic diseases, with 84% (21/25) presenting with abnormal SpO2 within 24 hours. One had tetralogy of Fallot identified by echocardiography. Among the 1035 asymptomatic neonates, SpO2 values declined from 6 hours after birth, reached a nadir at 48 hours, and tended to level off thereafter, with identical patterns for both pre- and post-ductal SpO2. The reference percentile was 92% for both pre- and post-ductal SpO2 and was time independent.

CONCLUSIONS

A decline within 48 hours features SpO2 trajectories within the first 72 hours at moderate altitude. Our findings suggest that earlier screening may favorably achieve a benefit-risk balance in identifying asymptomatic hypoxemic diseases in this population.

Mid-aortic syndrome: a rare cause of heart failure in infants

This case reports describe a rare disease, mid-aortic syndrome (MAS), that can cause severe heart failure and hypertension in infancy. The typical images, key points of diagnosis, and therapy methods of the disease have also been presented. We report two critical thoracoabdominal aortic coarctation cases in infants aged 2 and 11 months with severe heart failure. The patients were initially misdiagnosed as dilated myocardiopathy, with the correct diagnosis confirmed through imaging. Both patients underwent balloon angioplasty; one patient also had bare-metal stents implanted. The patient treated with balloon angioplasty alone died after the procedure, whereas the other patient recovered well. In conclusion, careful physical examinations, especially upper and lower extremity blood pressure differences and palpation of upper and lower limb pulses, are critical in unexplained infant heart failure cases. Stent implantation may be a safer and more effective treatment than simple balloon angioplasty in infants with MAS.

[Retrospective analysis of infliximab in the treatment of Kawasaki disease]

Objective: To investigate the efficacy and safety of infliximab (IFX) therapy for children with Kawasaki disease. Methods: Sixty-eight children with Kawasaki disease who received IFX therapy in Children's Hospital of Fudan University from January 2014 to April 2021 were enrolled. The indications for IFX administration, changes in laboratory parameters before and after IFX administration, response rate, drug adverse events and complications and outcomes of coronary artery aneurysms (CAA) were retrospectively analyzed. Comparisons between groups were performed with unpaired Student t test or Mann-Whitney U test or chi-square test. Results: Among 68 children with Kawasaki disease, 52 (76%) were males and 16 (24%) were females. The age of onset was 2.1 (0.5, 3.8) years. IFX was administered to: (1) 35 children (51%) with persistent fever who did not respond to intravenous immunoglobulin (IVIG) or steroids, 28 of the 35 children (80%) developed CAA before IFX therapy; (2) 32 children (47%) with continuous progression of CAA; (3) 1 child with persistent arthritis. In all cases, IFX was administered as an additional treatment (the time from the onset of illness to IFX therapy was 21 (15, 30) days) which consisted of second line therapy in 20 (29%), third line therapy in 20 (29%), and fourth (or more) line therapy in 28 (41%). C-reactive protein (8 (4, 15) vs. 16 (8, 43) mg/L, Z=-3.38, P=0.001), serum amyloid protein A (17 (10, 42) vs. 88 (11, 327) mg/L, Z=-2.36, P=0.018) and the percentage of neutrophils (0.39±0.20 vs. 0.49±0.21, t=2.63, P=0.010) decreased significantly after IFX administration. Fourteen children (21%) did not respond to IFX and received additional therapies mainly including steroids and cyclophosphamide. There was no significant difference in gender, age at IFX administration, time from the onset of illness to IFX administration, the maximum coronary Z value before IFX administration, and the incidence of systemic aneurysms between IFX-sensitive group and IFX-resistant group (all P>0.05). Infections occurred in 11 cases (16%) after IFX administration, including respiratory tract, digestive tract, urinary tract, skin and oral infections. One case had Calmette-Guérin bacillus-related adverse reactions 2 months after IFX administration. All of these adverse events were cured successfully. One child died of CAA rupture, 6 children were lost to follow up, the remaining 61 children were followed up for 6 (4, 15) months. No CAA occurred in 7 children before and after IFX treatment, while CAA occurred in 54 children before IFX treatment. CAA regressed in 23 (43%) children at the last follow-up, and the diameter of coronary artery recovered to normal in 10 children. Conclusion: IFX is an effective and safe therapeutic choice for children with Kawasaki disease who are refractory to IVIG or steroids therapy or with continuous progression of CAA.

Case Report: Lessons Learned From Aortic Valve Rupture After Blunt Chest Trauma

Aortic valve rupture (AVR) due to blunt chest trauma is extremely rare in the pediatric population, and little attention has been paid to such damages. Early diagnosis of AVR may not be easy in patients with multiple competing injuries and poor acoustic windows. We report a case of delayed diagnosis of AVR in a 12-year-old boy after falling from a height of 15 meters, who presented with recurrent hemoptysis and ventilator dependence. This rare case highlights the importance of performing transesophageal echocardiography in trauma patients when the images of transthoracic echocardiography are suboptimal, especially for those presenting with signs and symptoms suggestive of heart failure. The overall prognosis of aortic valve replacement is good.

Case Report: Recurrent Left Posterior Fascicular Ventricular Tachycardia in a Newborn

Left posterior fascicular ventricular tachycardia (LPFVT) is extremely rare in neonates. We described a 17-day-old girl with LPFVT who was initially misdiagnosed as supraventricular tachycardia (SVT). Eventually, she was successfully treated by amiodarone infusion followed by oral amiodarone with propranolol for 9 months, and LPFVT spontaneously resolved after a 1-year follow-up. This case report illustrated the basic principles and caveats in differential diagnosis of LPFVT in the neonatal age group. With proper diagnosis and therapy, neonatal LPFVT might regress in the first year of life.

Systemic Artery Aneurysms and Kawasaki Disease

BACKGROUND

Coronary artery aneurysms (CAAs) are a well-known complication of Kawasaki disease (KD), but there are no data on incidence or outcomes of systemic artery aneurysms (SAAs) in the current era.

METHODS

From April 1, 2016, to March 31, 2019, we screened for SAAs in 162 patients with KD at risk for SAAs with magnetic resonance angiography or peripheral angiography and analyzed incidence and early outcomes of SAAs.

RESULTS

Twenty-three patients had SAAs, demonstrating an incidence of 14.2% (23 of 162) in patients who were screened at 1 month after onset. The proportion of patients with SAAs was estimated to be 2% (23 of 1148) of all patients with KD. The median age at onset of KD with SAAs was 5 months. All patients with SAAs had CAAs, with z scores >8. Of patients with giant CAAs, 38.6% (17 of 44) had SAAs. A total of 129 SAAs occurred in 17 different named arteries. The most common sites for SAAs were the axillary (18.6%), common iliac (12.4%), and brachial (11.6%) arteries. During a median follow-up time of 6 months, 92.9% (79 of 85) of SAAs had some degree of regression, with 80% (68 of 85) of SAAs returning to normal. The overall regression rate was higher for medium to large SAAs than for medium to giant CAAs.

CONCLUSIONS

Although the incidence of SAAs may not be as dramatically reduced as we expected compared with previous data, SAAs have a high regression rate during short-term follow-up.

[The value of (18)F-fluorodeoxyglucose positron emission tomography-computed tomography ((18)F-FDG PET-CT) in evaluating the stability of atherosclerotic plaques]

Objective: Positron emission tomography-computed tomography (PET-CT) has been used to quantify inflammatory response in the body. The aim of the present study was to explore the possibility of using this method to evaluate the stability of atherosclerotic plaques and the efficacy of atorvastatin in stabilizing atherosclerotic plaques. Methods: Twenty New Zealand male white rabbits were included and divided into the atorvastatin intervention group and the control group, with 10 rabbits in each group. Rabbits in both groups were fed with a high fat diet for 20 weeks, and treated with thoracoabdominal aortic balloon-pulling to establish atherosclerosis model at the end of the 2nd week. Rabbits in atorvastatin intervention group was given atorvastatin intragastrically once a day. At the 8th week, thoracoabdominal aortic ultrasound was used to detect plaques in all rabbits. Blood was drawn at the 3rd and the 20th week, respectively, to measure blood lipids, high-sensitive C-reactive protein (hs-CRP) and matrix metalloproteinase-9 (MMP-9). At the end of experiment, survival animals were scanned by (18)F-FDG PET-CT, and the average and maximum standard uptake values (SUVmean, SUVmax) of aortic segments were measured. Thereafter, the animals were sacrificed and aortic specimens of rabbits were taken and examined by immunohistochemistry. The pathological indexes were measured and compared. Results: At the end of experiment, the total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), hs-CRP [ (4.58±0.51) ng/ml vs.(5.87±0.66) ng/ml, P<0.01], MMP-9[ (43.93±2.16) ng/ml vs. (50.77±2.32) ng/ml, P<0.01], SUVmean (0.59±0.15 vs. 0.68±0.20, P<0.05) , SUVmax (0.68±0.20 vs. 0.81±0.27, P<0.05) , plaque area [ (0.36±0.24) mm(2) vs. (0.50±0.34) mm(2), P<0.05) ] and density of macrophage[ (4.34±1.54) % vs. (5.65±1.89) %, P<0.01] in the atorvastatin intervention group were significantly lower than those in the control group. In contrast, fiber cap thickness of the plaque[ (4.12±0.66) μm vs. (2.96±0.37) μm, P<0.01] in the atorvastatin intervention group was higher than that of the control group, and the difference was statistically significant. The arterial plaque areas were positively correlated with SUVmean (r=0.27, P<0.05) and SUVmax (r=0.43, P<0.01) . Fiber cap thickness was negatively correlated with SUVmean (r=-0.38, P<0.05) and SUVmax (r=-0.47, P<0.01) . The density of macrophage were positively correlated with SUVmean (r=0.52, P<0.01) and SUVmax (r=0.51, P<0.01) . Conclusion: (18)F-FDG PET/CT can be used to evaluate the efficacy of atorvastatin by the stability of atherosclerotic plaques.

Prevalence of Congenital Heart Disease at Live Birth in China

OBJECTIVE

To investigate the prevalence of congenital heart disease (CHD) in China based on a large prospective multicenter screening study.

STUDY DESIGN

A total of 122 765 consecutive infants born at 18 hospitals throughout China between August 1, 2011, and November 30, 2012, were included. Cases of CHD were identified by echocardiography, clinical assessment, and telephone follow-up.

RESULTS

The overall prevalence of CHD was 8.98 per 1000 live births (critical, 1.46; serious, 1.47; significant, 5.00; nonsignificant, 1.07), including 7.15 in male infants and 11.11 in female infants. The most common CHD was ventricular septal defect (3.3), followed by atrial septal defect (1.7), patent ductus arteriosus (0.78), pulmonary stenosis (0.73), tetralogy of Fallot (0.47), and transposition of the great arteries (0.35). Female predominance was observed for all CHD and mild CHD (significant and nonsignificant), and male predominance was observed for the critical CHDs. The proportion of preterm newborns was substantially higher among the major CHD cases (critical and serious) compared with normal newborns. There were appreciably more low birth weight infants among the critical CHD cases compared with normal newborns. Significantly higher rates of ventricular septal defect and atrioventricular septal defect were found in infants born to mothers aged ≥35 years. Extracardiac anomalies were found in 9.3% of CHD cases. The risk of CHD was increased by approximately 3-fold when a first-degree relative had CHD.

CONCLUSIONS

Our estimates are concordant with data from Western studies. This screening study may provide more accurate and complete information on the overall prevalence of CHD in China.

[Clinical effect of endovascular embolization in treatment of hemoptysis of systemic arterial origin in children]

OBJECTIVE

To investigate the clinical effect of endovascular embolization (EVE) in the treatment of hemoptysis of systemic arterial origin in children.

METHODS

A total of 20 children with hemoptysis of systemic arterial origin who underwent EVE from January 2016 to November 2017 were enrolled. The method for embolization was analyzed and the clinical outcome was evaluated.

RESULTS

Offending vessels were bronchial artery (BA) in 14 children, non-bronchial systemic artery (NBSA) in 1 child, and BA and NBSA in 5 children. Of all the children, 13 underwent EVE with peripheral embolization agents and 7 underwent EVE with mechanical coils. A total of 41 offending vessels were embolized (34 BAs and 7 NBSAs) and all the children achieved immediate arrest of hemoptysis. Two children experienced recurrence within 6 months after EVE and 2 experienced recurrence with 6-24 months after EVE. The peripheral embolization agent group had a lower overall recurrence rate than the mechanical coil group [8%(1/13) vs 43%(3/7); P=0.10]. One child experienced intracranial ectopic embolism after surgery and had good quality of life during 20 months of follow-up after treatment. No other complications were observed.

CONCLUSIONS

EVE is a safe and effective method for the treatment of hemoptysis of systemic arterial origin in children and thus holds promise for clinical application.

[Clinical effect of endovascular embolization in treatment of hemoptysis of systemic arterial origin in children]

OBJECTIVE

To investigate the clinical effect of endovascular embolization (EVE) in the treatment of hemoptysis of systemic arterial origin in children.

METHODS

A total of 20 children with hemoptysis of systemic arterial origin who underwent EVE from January 2016 to November 2017 were enrolled. The method for embolization was analyzed and the clinical outcome was evaluated.

RESULTS

Offending vessels were bronchial artery (BA) in 14 children, non-bronchial systemic artery (NBSA) in 1 child, and BA and NBSA in 5 children. Of all the children, 13 underwent EVE with peripheral embolization agents and 7 underwent EVE with mechanical coils. A total of 41 offending vessels were embolized (34 BAs and 7 NBSAs) and all the children achieved immediate arrest of hemoptysis. Two children experienced recurrence within 6 months after EVE and 2 experienced recurrence with 6-24 months after EVE. The peripheral embolization agent group had a lower overall recurrence rate than the mechanical coil group [8%(1/13) vs 43%(3/7); P=0.10]. One child experienced intracranial ectopic embolism after surgery and had good quality of life during 20 months of follow-up after treatment. No other complications were observed.

CONCLUSIONS

EVE is a safe and effective method for the treatment of hemoptysis of systemic arterial origin in children and thus holds promise for clinical application.

[Comparison of safety between continued warfarin therapy and bridging anticoagulation therapy in patients undergoing coronary intervention]

Objective: To compare the safety of continued warfarin therapy and bridging anticoagulation therapy during hospital stay in patients undergoing percutaneous coronary intervention (PCI). Methods: We retrospectively analyzed patients on warfarin therapy referred for PCI in Beijing Anzhen Hospital from January 2008 to December 2016. The patients were divided into continued warfarin therapy (n=195) or bridging anticoagulation therapy (n=311) groups. After Propensity Score Matching, data from matched patients (n=123 in each group) were analyzed. Bleeding complications and major adverse cardiac events including death, myocardial infarction, target vessel revascularization, and stent thrombosis were assessed. Results: There were no significant difference in the rate of death (2.4%(3/123) vs. 1.6%(2/123),P=0.54), acute myocardial infarction (4.1%(5/123) vs. 4.9%(6/123), P=0.78),re-revascularization (0.8%(1/123) vs. 1.6%(2/123),P=0.16), stent thrombosis (1.6%(2/123) vs. 1.6%(2/123),P=1.00) and stroke between the two groups. Prevalence of minor bleeding complications was significantly higher in the bridging therapy group (15.4%(19/123) vs. 9.8%(12/123),P=0.01). Rate of access-site complications (hematoma:4.1%(5/123) vs. 2.4%(3/123),P=0.20; pseudoaneurysm:2.4%(3/123) vs. 2.4%(3/123),P=1.00; arteriovenous fistula:0.8%(1/123) vs. 1.6%(2/123),P=0.09; and retroperitoneal hematoma:0(0/123) vs. 0.8%(1/123),P=0.23) were similar between the two groups. Conclusion: For patients receiving chronic warfarin therapy, the uninterrupted oral anticoagulant treatment is as safe as bridging therapy in PCI patients.

Pulse Oximetry and Auscultation for Congenital Heart Disease Detection

OBJECTIVES

Pulse oximetry (POX) has been confirmed as a specific screening modality for critical congenital heart disease (CCHD), with moderate sensitivity. However, POX is not able to detect most serious and critical cardiac lesions (major congenital heart disease [CHD]) without hypoxemia. In this study, we investigated the accuracy and feasibility of the addition of cardiac auscultation to POX as a screening method for asymptomatic major CHD.

METHODS

A multicenter prospective observational screening study was conducted at 15 hospitals in Shanghai between July 1, 2012, and December 31, 2014. Newborns with either an abnormal POX or cardiac auscultation were defined as screen positive. All screen-positive newborns underwent further echocardiography. False-negative results were identified by clinical follow-up, parents' feedback, and telephone review. We assessed the accuracy of POX plus cardiac auscultation for the detection of major CHD.

RESULTS

CHD screening was completed in all 15 hospitals, with a screening rate of 94.0% to 99.8%. In total, 167 190 consecutive asymptomatic newborn infants were screened, of which 203 had major CHD (44 critical and 159 serious). The sensitivity of POX plus cardiac auscultation was 95.5% (95% confidence interval 84.9%-98.7%) for CCHD and 92.1% (95% confidence interval 87.7%-95.1%) for major CHD. The false-positive rate was 1.2% for detecting CCHD and 1.1% for detecting major CHD.

CONCLUSIONS

In our current study, we show that using POX plus cardiac auscultation significantly improved the detection rate of major CHD in the early neonatal stage, with high sensitivity and a reasonable false-positive rate. It provides strong evidence and a reliable method for neonatal CHD screening.

[Assessment of undiagnosed critical congenital heart disease before discharge from the maternity hospital]

Objective: Undiagnosed critical congenital heart disease (CCHD) was assessed before discharge from maternity hospital.Basic information was provided for screening CCHD in the early neonatal stage.Chi-squared test was used for comparison of categorical variables(detection rate of different types of CCHD). Method: A retrospective cohort study was conducted in neonates with CCHD who were admitted to Children's Hospital of Fudan University between 1 January 2012 and 31 December 2015. For comparing with the previously reported undiagnosed rate of CCHD at discharge, CCHD was defined as all duct dependent congenital heart disease (DDCHD) and any cyanotic CHD that required early surgery. Result: A total of 1 036 infants with CCHD were included. The prenatal detection rate of CCHD was 14.04%(122/869). As a whole, 52.51% (544/1 036) of CCHD cases were undiagnosed at discharge, and 14.09%(146/1 036)were still missed after 6-week examination. The diagnoses most likely to be unrecognized at discharge included critical coarctation of the aorta (COA) (75.00%), total anomalous pulmonary venous connection (61.54%), pulmonary atresia (PA) with ventricle septal defect (VSD) (61.45%), single ventricle (SV) (60.10%) and critical aortic stenosis (52.94%). Among newborns diagnosed prior to discharge, 54.88% (270/492) due to symptom or prenatal ultrasonographic diagnosis, 45.12% (222/492) due to abnormal findings in routine examination. Among asymptomatic CCHD cases without prenatal diagnosis, 71.02% (544/766) were undiagnosed and the most common delayed diagnosis was SV (82.78%), interrupted aortic arch (81.82%), transposition of the great arteries with intact ventricular septum (79.63%), PA/VSD (79.07%), and critical COA (78.57%). Newborns with DDC were more likely to develop symptoms within the first few days after birth, in comparison with non-DDC cases. However, their detection rates were close to each other. Conclusion: The rate of misdiagnosis of CCHD before discharge from maternity hospitals is high in China, indicates the importance of implementation of CCHD screening in Chinese maternity hospitals, so as to give timely diagnosis and proper treatment.

Monitoring of atherosclerosis evolution by detection of inflammatory states of aortae in a rabbit model using 18F-FDG -PET/CT

AIM

In vivo dynamic evaluation of atherosclerosis could be clinically significant in the prevention of cardiovascular events. We aimed to monitor Fluorine-18 fluorodeoxyglucose (18F-FDG) uptake in different stages of atherosclerosis, and investigate the feasibility of detecting vulnerable plaques using positron emission tomography/computed tomography (PET/CT) angiography.

METHODS

Twenty-two male NZW rabbits were divided into two groups: atherosclerosis group (group A, N.=11) and atherosclerosis and statin group (group S, N.=11). The rabbits underwent two pharmacological triggerings to induce thrombus at the 18th week. In vivo PET/CT scans were performed on four time points: before cholesterol diet (baseline, N.=6), at 8th week (the middle-of-feeding, N.=4), at 18th week (the end-of-feeding, N.=22) and after triggering (post-triggering, N.=15). 18F-FDG uptake by the aorta was expressed as maximal standardized uptake value (SUVmax) and mean SUV (SUVmean). SUVs were measured on serial 7.5 mm arterial segments.

RESULTS

SUVmean and SUVmax were 0.449±0.108 and 0.550±0.132 at baseline, 0.694±0.117 and 0.754±0.129 at the middle-of-feeding, 0.788±0.121 and 0.861±0.139 in group A, and 0.651±0.194 and 0.736±0.243 in group S at the end-of feeding before triggering. SUVmean and SUVmax were 1.128±0.420 and 1.302±0.489 in thrombosis group, 0.774±0.159 and 0.859±0.191 in non-thrombosis group after triggering. Thrombus were identified in 10 of 22 rabbits (45.5%): 8 of 11 (72.3%) in group A, and 2 of 11 (18.2%) in group S (P<0.001).

CONCLUSION

The inflammatory states of atherosclerosis and vulnerable plaque can be detected by quantitative analysis of 18F-FDG uptake. PET/CT may be used for predicting thrombosis events in patients with atherosclerotic disease.

Sequence variations in the MBL gene and their relationship to pulmonary tuberculosis in the Chinese Han population

SETTING

The mannan binding lectin (MBL) gene is thought to play a role in human innate immune response to tuberculosis (TB) infection.

OBJECTIVE

To investigate the possible association between MBL sequence variants and TB infection in the Chinese Han population.

DESIGN

A total of 152 male pulmonary tuberculosis (PTB) patients and 293 healthy male subjects were recruited. Six MBL single nucleotide polymorphisms (SNPs) (A/B, A/C, A/D, H/L, Y/X and P/Q) were genotyped and haplotyped using the combined analysis of polymerase chain reaction using sequence-specific primers (PCR-SSP) and the PCR-sequence specific oligonucleotide probe (PCR-SSOP) assay. The genotype and haplotype frequencies were compared between TB cases and controls using an unconditional logistic regression model.

RESULTS

Neither the genotypes nor the haplotypes of the five loci were significantly associated with the disease when considered individually. After the haplotypes were regrouped, however, the XB haplotype group coding for diminished MBL levels was present at a significantly higher frequency in the patients compared with the YA group (OR 1.57, 95% CI 1.02-2.41, P < 0.05).

CONCLUSION

No convincing evidence of association between MBL sequence variants and PTB was observed individually, although the low-producing XB haplotype group may serve as a minor risk factor for PTB infection in the male Chinese Han population.

VDR and NRAMP1 gene polymorphisms in susceptibility to pulmonary tuberculosis among the Chinese Han population: a case-control study

OBJECTIVE

To explore the potential role of vitamin D receptor (VDR) gene and natural-resistance-associated macrophage protein 1 (NRAMP1) gene polymorphisms in susceptibility to pulmonary tuberculosis (PTB) in the Chinese Han population.

DESIGN

In an unmatched case-control study, 120 well defined PTB patients and 240 unrelated normal controls were enrolled. Information on potential risk factors of PTB was collected using a standard questionnaire. Genetic polymorphisms of VDR gene (TaqI and FokI) and NRAMP1 gene (INT4, D543N and 3'UTR) were analysed using PCR and RFLP. Unconditional logistic regression was performed, and odds ratios (ORs), their 95% confidence intervals (CI) and P values were estimated using maximum likelihood methods.

RESULTS

Univariate analysis demonstrated that FokI-ff homozygotes, D543N G/A and 3'UTR TGTG+/del heterozygotes occurred more frequently in patients than in controls. The crude ORs were 2.345 (95%CI 1.222-4.499), 2.590 (95%CI 1.043-6.434) and 1.890 (95%CI 1.171-3.051), respectively, compared with their corresponding common genotypes. The P values were 0.033, 0.041 and 0.030, respectively. After adjusting for exposure history and BCG immunisation in the multivariate analysis, the adjusted ORs were 4.625 (95%CI 1.737-12.312), 2.415 (95%CI 1.079-8.759) and 2.187 (95%CI 1.146-4.175), with P values of 0.002, 0.036 and 0.018, respectively. Neither univariate nor multivariate analysis disclosed any significant association between the disease and TaqI or INT4.

CONCLUSIONS

Polymorphisms in the VDR and NRAMP1 gene are statistically associated with susceptibility to PTB in the Chinese Han population.

Exercise training with a heart device: a hemodynamic, metabolic, and hormonal study

PURPOSE

The mechanisms of the training-induced improvements in left ventricular assist (LVAD) patients are unknown.

METHODS

We measured the hemodynamic, gas exchange, and metabolic and hormonal effects of 6-wk exercise training in a cardiogenic shock patient who was assisted by an LVAD.

RESULTS

After training, the peak power and VO2 increased by 166% and 56%, respectively (80 W and 16.1 mL x min(-1) x kg(-1)), whereas the ventilatory drive decreased. Although the LVAD output increased little with exercise, the systemic cardiac output rose (adequately for the VO2) from 5.91 and 4.90 L x min(-1) at rest to 9.75 and 9.47 L x min(-1) at peak work rate, before and after training, respectively. Thus, the left ventricle ejected again through the aortic valve. Unloading and/or retraining resulted in a left ventricular filling pressure decrease. Although the right ventricular ejection fraction increased with exercise, it decreased again at the maximal load after training. For a given work rate the arterial lactate, the norepinephrine (NE) and epinephrine (E) concentrations fell after training, but the enhanced maximal work rate elicited higher NE and E concentrations (4396 and 1848 pg x mL(-1), respectively). The lack of right ventricular unloading might have kept the atrial natriuretic peptide higher after training, but the blood cyclic GMP and endothelin were lower after training.

CONCLUSION

In an LVAD patient, retraining returns the exercise capacity to the class III level by peripheral and left ventricular hemodynamic improvements, but the safety of maximal exercise remains to be proven in terms of right ventricular function and orthosympathetic drive.

Granulocytic Ehrlichiae in Ixodes persulcatus ticks from an area in China where Lyme disease is endemic

A total of 372 adult Ixodes persulcatus ticks were collected from vegetation in a forest area of Heilongjiang Province in northeastern China, where Lyme disease is known to be endemic. The ticks were examined for the presence of granulocytic ehrlichiae by heminested PCR with primers derived from the 16S rRNA gene. Of 310 ticks obtained from the Dahe forestry farm, two pools (each containing 5 ticks) were found positive, with a minimum infection rate of 0.6%. Ehrlichial DNA was also detected in one female (1.6%) of 62 ticks collected from the Yulin forestry farm. The overall minimum infection rate of the 372 I. persulcatus adults was 0.8%. The nucleotide sequences of 919-bp PCR products from the three positive tick specimens were identical to each other and very closely related to the members of the Ehrlichia phagocytophila genogroup. This is the first identification of granulocytic ehrlichiae in ticks in Asia and the first report of infection in I. persulcatus anywhere.

VO(2) kinetics reveal a central limitation at the onset of subthreshold exercise in heart transplant recipients

Because the cardiocirculatory response of heart transplant recipients (HTR) to exercise is delayed, we hypothesized that their O(2) uptake (VO(2)) kinetics at the onset of subthreshold exercise are slowed because of an impaired early "cardiodynamic" phase 1, rather than an abnormal subsequent "metabolic" phase 2. Thus we compared the VO(2) kinetics in 10 HTR submitted to six identical 10-min square-wave exercises set at 75% (36 +/- 5 W) of the load at their ventilatory threshold (VT) to those of 10 controls (C) similarly exercising at the same absolute (40 W; C40W group) and relative load (67 +/- 14 W; C67W group). Time-averaged heart rate, breath-by-breath VO(2), and O(2) pulse (O(2)p) data yielded monoexponential time constants of the VO(2) (s) and O(2)p increase. Separating phase 1 and 2 data permitted assessment of the phase 1 duration and phase 2 VO(2) time constant (). The VO(2) time constant was higher in HTR (38.4 +/- 7.5) than in C40W (22.9 +/- 9.6; P < or = 0. 002) or C67W (30.8 +/- 8.2; P < or = 0.05), as was the O(2)p time constant, resulting from a lower phase 1 VO(2) increase (287 +/- 59 vs. 349 +/- 66 ml/min; P < or = 0.05), O(2)p increase (2.8 +/- 0.6 vs. 3.6 +/- 1.0 ml/beat; P < or = 0.0001), and a longer phase 1 duration (36.7 +/- 12.3 vs. 26.8 +/- 6.0 s; P < or = 0.05), whereas the was similar in HTR and C (31.4 +/- 9.6 vs. 29.9 +/- 5.6 s; P = 0.85). Thus the HTR have slower subthreshold VO(2) kinetics due to an abnormal phase 1, suggesting that the heart is unable to increase its output abruptly when exercise begins. We expected a faster in HTR because of their prolonged phase 1 duration. Because this was not the case, their muscular metabolism may also be impaired at the onset of subthreshold exercise.

Lung membrane diffusing capacity, heart failure, and heart transplantation

The pulmonary diffusing capacity for carbon monoxide (DLCO) is reduced in chronic heart failure and remains decreased after heart transplantation. This decrease in DLCO may depend on a permanent alteration after transplantation of one or the other of its components: diffusion of the alveolar capillary membrane or the pulmonary capillary blood volume (Vc). Therefore, we measured DLCO, the membrane conductance, and Vc before and after heart transplantation. At the time of hemodynamic measurements, the Roughton and Forster method of measuring DLCO at varying alveolar oxygen concentrations was used to determine the membrane conductance, Vc, DLCO/alveolar volume (VA), the membrane conductance/VA and thetaVc/VA (theta = carbon monoxide conductance of blood, VA = alveolar volume) in 21 patients with class III to IV heart failure before and after transplantation, and in 21 healthy controls. Transplantation normalized pulmonary capillary pressure and increased cardiac index. DLCO was decreased before transplantation (7.11 vs 10.0 mmol/min/kPa in controls), but DLCO/VA was normal (1.67+/-0.44 vs 1.71+/-0.26 mmol/min/kPa/L in controls). DLCO/VA remained unchanged after transplantation, because the decrease in Vc (82+/-30 vs 65+/-18 ml before and after transplantation) and thetaVc/VA was not compensated by the changes in membrane conductance (11+/-4 vs 12+/-5 mmol/min/kPa before and after transplantation, respectively) and membrane conductance/VA. We conclude that the decrease in DLCO in patients with chronic heart failure is due to a restrictive ventilatory pattern because their DLCO/VA remains normal; the decrease in the membrane conductance is compensated by the increase in Vc. After transplantation, the decrease in Vc due to normalization of pulmonary hemodynamics is not completely compensated for by an increase in membrane conductance. Because the membrane conductances, measured before and after transplantation, are negatively correlated with duration of heart failure, its abnormal pulmonary hemodynamics may have irreversibly altered the alveolar capillary membrane.

[Clinical observation of face peeling treatment for ephelides and phenol excretion in urine]

Since 1986, 710 patients with freckles were hospitalized, and the effects of face peeling were studied. Before treatment, blood and urine routines and hepatic and renal function tests were performed in every patient. Comparisons have been made between the hepatic and renal functions before and after treatment in 100 patients. ECG was performed in all the patients before treatment, and 20 of them have been monitored continuously with ECG after treatment. Comparison of 24h urinary phenol excretion before and after treatment were made in 27 patients. In 5 patients it was showed that the amount of urine phenol declined rapidly with the time. The treatment was effective in 100% of the patients. The cure rate was 84.2%. We concluded that the treatment is an effective and safe method for ephelides in healthy persons.