Frailty-Related Factors among Women Living with and without HIV Aged 40 Years and Older. The Women's Interagency HIV Study

BACKGROUND

Frailty is a clinical, geriatric syndrome linked to disability and mortality; and may be associated with a variety of factors among underrepresented and underserved women living with HIV (WLWH) and without HIV (WLWOH) transitioning through the adult life course.

OBJECTIVES

Determine whether a published set of factors associated cross-sectionally with frailty in WLWH and similar WLWOH at average age 39 years in 2005/2006 were associated with frailty in 2018/2019 among women who initiated frailty assessments at age ≥40 years, or whether a new set of factors were associated with frailty.

DESIGN

Cross-sectional analyses within a longitudinal cohort study.

SETTING

The multi-center Women's Interagency HIV Study (WIHS).

PARTICIPANTS

1285 participants (951 WLWH, 334 WLWOH), median age 53 years (interquartile range 47-58 years).

MEASUREMENTS

The Fried Frailty Phenotype (FFP) in association with 23 factors representing HIV serostatus, other infections, sociodemographic factors, health behaviors, and chronic diseases.

RESULTS

Frailty prevalence was 11.1% in 2018/2019 (12.6% among WLWOH, 9.6% among WLWH, p=0.121). The published 2005/2006 final multivariable stepwise regression model contained 9 predictors of frailty. When refit to women in 2018/2019, only age ≥50 years and annual income ≤$12,000 were independently positively associated with frailty; other significant 2005/2006 factors, HIV serostatus, CD4+ count <500 cells/mL among WLWH, smoking, drinking, FIB-4 and eGFR, were not. A newly-derived stepwise model considering all 23 predictors measured in 2018/2019, showed independent positive associations between frailty and age ≥50 years, annual income ≤$12,000, obesity (body mass index (BMI) ≥30kg/m2), and history of tuberculosis and cancer.

CONCLUSION

Different chronic and infectious disease factors were associated with frailty among WLWH and WLWOH over the adult life course. Understanding factors associated with frailty by adult life stage, allows identification and implementation of novel, temporal interventions to alleviate frailty-associated outcomes and enhance quality of life among WLWH and WLWOH.

Long-Term Decrease in Intraocular Pressure in Survivors of Ebola Virus Disease in the Partnership for Research on Vaccines and Infectious Diseases in Liberia (PREVAIL) III Study

Objective

Survivors of Ebola virus disease (EVD) experience decreased intraocular pressure (IOP) relative to unaffected close contacts during the first year of convalescence. Whether this effect persists over time and its relationship to intraocular pathology are unclear. We sought to determine whether IOP remained lower in survivors of EVD over 4 years of follow-up and to identify associated risk factors.

Design

Partnership for Research on Vaccines and Infectious Diseases in Liberia (PREVAIL) III is a 5-year, longitudinal cohort study of survivors of EVD and their close contacts and is a collaboration between the Liberian Ministry of Health and the United States National Institutes of Health.

Participants

Participants who enrolled in PREVAIL III at John F. Kennedy Medical Center in Liberia, West Africa from June 2015 to March 2016 who underwent comprehensive ophthalmic evaluation annually for 5 consecutive visits.

Methods

Intraocular pressure was measured at each visit by a handheld rebound tonometer using sterile tips. Comparisons are made between antibody-positive survivors and antibody-negative close contacts.

Main Outcome Measures

Intraocular pressure, measured in mmHg, at each study visit.

Results

Of 565 antibody-positive survivors and 644 antibody-negative close contacts enrolled in the study at baseline, the majority of participants returned annually, with 383 (67.8%) and 407 (63.2%) participants, respectively, presenting for the final study visit at a median of 60 months after symptom onset. A sustained, relative decrease in IOP was observed in survivors relative to close contacts, with mean difference of -0.72 mmHg (95% confidence interval [CI] -1.18 to -0.27) at the final study visit. This difference remained constant throughout the study period (P = 0.4 for interaction over time). Among survivors, physical examination findings of vitreous cell and OCT findings of vitreous opacities both demonstrated a significant association with decreased IOP at baseline (P < 0.05 for both). After adjusting for such factors, the difference throughout the follow-up (-0.93 mmHg, 95% CI, -1.23 to -0.63) remained significant.

Conclusions

Survivors of EVD experienced a sustained decrease in IOP relative to close contacts over a 5-year period after EVD. The results highlight the importance of considering long-term sequelae of emerging infectious diseases within a population.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Efficacy and Safety Outcomes of Cataract Surgery in Survivors of Ebola Virus Disease: 12-Month Results From the PREVAIL VII Study

Purpose

In survivors of Ebola virus disease (EVD), intraocular viral persistence raises questions about the timing and safety of cataract surgery. To the best of our knowledge, this is the first controlled study evaluating Ebola virus persistence and cataract surgery safety and outcomes in EVD survivors.

Methods

Seropositive EVD survivors and seronegative controls with vision worse than 20/40 from cataract and without active intraocular inflammation were enrolled. Aqueous humor from survivors was tested with reverse transcription-polymerase chain reaction for Ebola viral RNA. Participants underwent manual small-incision cataract surgery and 1 year of follow-up examinations.

Results

Twenty-two eyes of 22 survivors and 12 eyes of eight controls underwent cataract surgery. All of the aqueous samples tested negative for Ebola viral RNA. Median visual acuity improved from 20/200 at baseline to 20/25 at 1 year in survivors and from count fingers to 20/50 in controls (overall, P < 0.001; between groups, P = 0.07). After a 1-month course of topical corticosteroids, 55% of survivors and 67% of controls demonstrated at least 1+ anterior chamber cell. Twelve months after surgery, optical coherence tomography revealed a median increase in macular central subfield thickness of 42 µm compared with baseline (overall, P = 0.029; between groups, P = 0.995).

Conclusions

EVD survivors and controls demonstrated significant visual improvement from cataract surgery. The persistence of intraocular inflammation highlights the importance of follow-up. The absence of detectable intraocular Ebola viral RNA provides guidance regarding the safety of eye surgery in Ebola survivors.

Translational Relevance

These findings demonstrate the safety and efficacy of cataract surgery in Ebola survivors and will inform ocular surgery guidelines in this population.

Characterization of Ebola Virus-Associated Eye Disease

IMPORTANCE

Survivors of Ebola virus disease (EVD) may experience ocular sequelae. Comparison with antibody-negative individuals from the local population is required to characterize the disease.

OBJECTIVE

To assess features of ophthalmic disease specific to EVD.

DESIGN, SETTING, AND PARTICIPANTS

This baseline cross-sectional analysis of survivors of EVD and their close contacts was conducted within PREVAIL III, a 5-year, longitudinal cohort study. Participants who enrolled at John F. Kennedy Medical Center in Liberia, West Africa from June 2015 to March 2016 were included in this analysis. Close contacts were defined as household members or sex partners of survivors of EVD. Data were analyzed from July 2016 to July 2020.

EXPOSURES

All participants, both survivors and close contacts, underwent testing of IgG antibody levels against Ebola virus surface glycoprotein.

MAIN OUTCOMES AND MEASURES

Ocular symptoms, anterior and posterior ophthalmologic examination findings, and optical coherence tomography images were compared between antibody-positive survivors and antibody-negative close contacts.

RESULTS

A total of 564 antibody-positive survivors (320 [56.7%] female; mean [SD] age, 30.3 [14.0] years) and 635 antibody-negative close contacts (347 [54.6%] female; mean [SD] age, 25.8 [15.5] years) were enrolled in this study. Survivors were more likely to demonstrate color vision deficit (28.9% vs 19.0%, odds ratio [OR], 1.6; 95% CI, 1.2-2.1) and lower intraocular pressure (12.4 vs 13.5 mm Hg; mean difference, -1.2 mm Hg; 95% CI, -1.6 to -0.8 mm Hg) compared with close contacts. Dilated fundus examination revealed a higher percentage of vitreous cells (7.8% vs 0.5%; OR, 16.6; 95% CI, 5.0-55.2) and macular scars (4.6% vs 1.6%; OR, 2.8; 95% CI, 1.4-5.5) in survivors than in close contacts. Uveitis was present in 26.4% of survivors and 12.1% of close contacts (OR, 2.4; 95% CI, 1.8-3.2). Among all participants with uveitis, survivors were more likely than close contacts to have intermediate uveitis (34.2% vs 6.5% of all cases; OR, 7.8; 95% CI, 3.1-19.7) and had thicker mean central subfield thickness on optical coherence tomography (222 vs 212 μm; mean difference, 14.4 μm; 95% CI, 1.9-26.9 μm).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, survivors of EVD had a distinct spectrum of ocular and neuro-ophthalmologic findings compared with close contacts that potentially require medical and surgical treatment.

Particle-induced osteolysis is not accompanied by systemic remodeling but is reflected by systemic bone biomarkers

Particle-induced osteolysis is caused by an imbalance in bone resorption and formation, often leading to loss of implant fixation. Bone remodeling biomarkers may be useful for identification of osteolysis and studying pathogenesis, but interpretation of biomarker data could be confounded if local osteolysis engenders systemic bone remodeling. Our goal was to determine if remote bone remodeling contributes to biomarker levels. Serum concentrations of eight biomarkers and bone remodeling rates at local (femur), contiguous (tibia), and remote (humerus and lumbar vertebra) sites were evaluated in a rat model of particle-induced osteolysis. Serum CTX-1, cathepsin K, PINP, and OPG were elevated and osteocalcin was suppressed in the osteolytic group, but RANKL, TRAP 5b, and sclerostin were not affected at the termination of the study at 12 weeks. The one marker tested longitudinally (CTX-1) was elevated by 3 weeks. We found increased bone resorption and decreased bone formation locally, subtle differences in contiguous sites, but no differences remotely at 12 weeks. Thus, the skeletal response to local particle challenge was not systemic, implying that the observed differences in serum biomarker levels reflect differences in local remodeling.

Pharmacologic augmentation of implant fixation in osteopenic bone

Osteoporosis presents a challenge for successful implant fixation due to an impaired healing response. Preclinical studies have consistently reported reduced osseointegration capability in trabecular bone. Although clinical studies of implant success in dentistry have not found a negative effect due to osteoporosis, low bone mass is a significant risk factor for implant migration in orthopedics. Pharmacologic treatment options that limit bone resorption or upregulate formation have been studied preclinically. While, both treatment options improve implant fixation, direct comparisons to-date have found anti-catabolic more effective than anabolic treatments for establishing implant fixation, but combination approaches are better than either treatment alone. Clinically, anti-catabolic treatments, particularly bisphosphonates have been shown to increase the longevity of implants, while limited clinical evidence on the effects of anabolic treatment exists. Preclinical experiments are needed to determine the effects of osteoporosis and subsequent treatment on the long-term maintenance of fixation and recovery after bone loss.

Ecophysiological function of leaf 'windows' in Lithops species - 'Living Stones' that grow underground

Leaf temperatures were lower when light entry at the leaf tip window was prevented through covering the window with reflective tape, relative to leaf temperatures of plants with leaf tip windows covered with transparent tape. This was true when leaf temperatures were measured with an infrared thermometer, but not with a fine-wire thermocouple. Leaf tip windows of Lithops growing in high-rainfall regions of southern Africa were larger than the windows of plants (numerous individuals of 17 species) growing in areas with less rainfall and, thus, more annual insolation. The results of this study indicate that leaf tip windows of desert plants with an underground growth habit can allow entry of supra-optimal levels of radiant energy, thus most likely inhibiting photosynthetic activity. Consequently, the size of the leaf tip windows correlates inversely with habitat solar irradiance, minimising the probability of photoinhibition, while maximising the absorption of irradiance in cloudy, high-rainfall regions.

Conditions mimicking coarctation of the aorta

Coarctation of the aorta is a cause of right arm hypertension in children and of heart failure in infants after ductal closure. We present two cases with these presentations that were initially thought to be coarctation of the aorta. They were subsequently diagnosed as Takayasu's arteritis in the older child and a large cerebral arteriovenous malformation in the infant. These conditions should be in the differential of right arm hypertension and of aortic flow reversal on echocardiography.

Vitrectomy for chronic macular holes

PURPOSE

To address the efficacy of surgical intervention for chronic macular holes.

METHODS

The cases of 22 patients (23 eyes) who underwent pars plana vitrectomy with or without internal limiting membrane (ILM) peeling and use of 10% to 16% C3F8 gas for macular holes of duration of >1 year (mean, 4.2 years; range, 1.2-15 years) were retrospectively reviewed. Preoperative visual acuity ranged from 20/60 to 5/200 (mean, 20/278). Thirteen eyes (56.5%) had stage 3 macular holes, and 10 eyes (43.5%) had stage 4 macular holes. The mean age of the patients was 70.2 years (range, 47-78 years), and 20 (87%) were female.

RESULTS

Nineteen (83%) of 23 macular holes were closed at final follow-ups at >/=9 months (mean, 4.67 years; range, 0.9-10.8 years). With one operation that included ILM peeling, 13 (81%) of 16 eyes had holes that closed. Seven eyes on which initial surgery without ILM peeling failed underwent reoperation with ILM peeling, and all but one had closed holes. ILM peeling was significant for surgical success of one operation (Fisher exact test, P = 0.0005). Postoperative visual acuity ranged from 20/30 to 20/800 (mean, 20/166). Improved vision with halving of the visual angle occurred in 16 eyes (70%). Nine eyes (39%) achieved visual acuity of 20/70 or better, and two eyes (8.7%) achieved visual acuity of 20/40 or better. One eye (4%) had worse visual acuity, and three eyes (13%) remained unchanged. Cataract was a possible cause of decreased vision in six eyes (26%) at the end of follow-up.

CONCLUSION

Chronic macular holes can be surgically closed with visual improvement in most patients. ILM peeling is an important surgical factor for closure of the macular hole with one operation.

Social support and avoidant coping: correlates of depressed mood during pregnancy in minority women

INTRODUCTION

The purpose of this study was to evaluate several psychosocial correlates of depressed mood during pregnancy. The psychosocial factors examined included background characteristics (socioeconomic status, planning of pregnancy), perceived social support, and coping styles.

METHODS

One hundred fifty pregnant lower income, minority women were recruited from an obstetrics clinic at an urban hospital. Patients completed a battery of psychosocial measures including measures of social support, coping style, and depressed mood.

RESULTS

Perceived social support and an avoidant coping style were the most salient psychosocial correlates of depressed mood during pregnancy, accounting for 34% of the variance in the model. More specifically, women who reported less social support satisfaction experienced greater avoidant coping strategies, which was then associated with higher levels of depressed mood.

CONCLUSIONS

This study suggests that women who perceive less social support satisfaction utilize more avoidant coping strategies and experience greater depression mood. Thus, although these associations are not indicative of a causal relationship, results raise the possibility that women at-risk for depressed mood during pregnancy can be identified by assessing perceived social support and coping styles. Future prospective studies are needed to test the causal relationships among these variables. Clinical interventions to target these psychosocial factors during pregnancy are discussed.

Carvedilol reverses elevated pulmonary vascular resistance in a child with dilated cardiomyopathy

There is little experience using beta-blocker therapy for the management of congestive heart failure (CHF) in children. We present the case of a child with idiopathic dilated cardiomyopathy and CHF, referred for cardiac transplantation, in whom carvedilol reversed elevated pulmonary vascular resistance.

Presumed acquired ocular toxoplasmosis in deer hunters

PURPOSE

To describe acquired ocular toxoplasmosis in deer hunters.

METHODS AND RESULTS

The authors describe five young men presenting with flu-like symptoms followed by visual loss due to a unilateral, focal necrotizing retinitis. All five men gave a history of ingesting undercooked or uncooked venison. All five had elevated toxoplasma serology, and all five improved clinically with an antitoxoplasma regimen.

CONCLUSION

In previously healthy young men, flu-like symptoms associated with visual loss and retinitis should prompt questioning about hunting and raw game meat ingestion, especially when toxoplasmosis is suspected.

Activity of the renin–angiotensin–aldosterone and sympathetic nervous system and their relation to hemodynamic and clinical abnormalities in infants with left-to-right shunts

We studied neurohormonal, clinical and invasively measured hemodynamic data of 47 infants with left-to-right shunts and varying degrees of congestive failure. When referred to a clinical heart failure score, plasma renin activities (r=0.71) and norepinephrine levels (r=0.43) are significantly increased. Arterial hypotension seems to be the hemodynamic trigger of renin release (r=-0.72), but not decreased systemic cardiac index (r=-0.43), the magnitude of the left-to-right shunt (r=0.33) or a reduced ejection fraction (r=0.12). These data indicate neurohormonal activation in infants with left-to-right shunts with preserved myocardial function is similar to the activation in adults with heart failure secondary to myocardial pump failure. These findings have to be considered for optimal medical treatment of these infants with angiotensin-converting enzyme inhibitors or beta-blockers.

Medical management of chronic heart failure in children

Chronic heart failure (CHF) in children occurs mostly as a result of systolic dysfunction of the systemic ventricle or of congenital defects leading to large left-to-right shunts and pulmonary overcirculation. The ensuing symptoms and signs are similar in both cases, and include respiratory distress, poor feeding and growth, and hepatic congestion. Grading the severity of the symptoms accurately and reproducibly is important for studying CHF and the response to therapy. The Ross classification for young children and the New York Heart Association classification for older children are frequently utilized for such grading. The standard therapy for CHF in children consists of diuretics, to reduce cardiac preload and improve symptoms, and the maximization of nutritional support. The role of digoxin in treating CHF in children is controversial, especially regarding those children with pulmonary overcirculation where the function of the systemic ventricle is usually well preserved. As the importance of neurohormonal changes in the pathogenesis of worsening CHF is elucidated, newer medications aimed at counteracting such changes are becoming more important in the medical therapy of CHF in children. ACE inhibitors improve function and survival in adults with CHF, and they probably do the same in children with systemic ventricular dysfunction. It is less clear how effective they are in pulmonary overcirculation, but patients with high flow and low pulmonary resistance are most likely to benefit. In infants receiving treatment with ACE inhibitors, it is necessary to monitor for renal insufficiency or renal failure. beta-Adrenoceptor blockade has also been established as an effective therapy for adults with CHF with beneficial effects on survival and left ventricular function. While data for the pediatric population are limited, early studies suggest that beta-adrenoceptor antagonists (beta-blockers) may work well in infants and children with CHF. Caution must be used by starting treatment with very low dosages of beta-blockers and gradually increasing to the desired goals with close monitoring of blood pressure and heart rate. It is clear that larger multicenter trials are crucial to our ability to provide the most appropriate treatment for children with CHF. The demand for effective medical treatment will increase as more patients with palliated single ventricles survive surgery and then develop CHF from dysfunction of a hypertrophic and dilated single ventricle.

Initial experience using the Palmaz Corinthian stent for right ventricular outflow obstruction in infants and small children

The original Palmaz balloon expandable stent has been used extensively for the treatment of vascular stenoses in older children and young adults. Placement of the Palmaz stent in infants and small children, however, is limited by stent inflexibility, large delivery sheath size, and concerns about creating fixed obstructions after the placement of small diameter stents in growing patients. New Palmaz Corinthian stents were placed through 6 French sheaths in four high-risk patients with postoperative right ventricular outflow obstruction. Patients were not considered candidates for surgical repair. Median patient age and weight were 17 months (range 5-32 months) and 7.7 kg (range 4.6-11.1 kg), respectively. Median fluoroscopy time was 58.2 min (range 55.2-172 min). No complications were encountered. In each case, successful stent placement was achieved, and surgery with cardiopulmonary bypass was avoided. Palmaz Corinthian stents are more flexible, require a smaller delivery sheath, have equal or increased radial strength, and can be maximally expanded to a greater cross sectional area when compared to the original Palmaz stent. These characteristics make the Palmaz Corinthian stent a reasonable alternative for use in a select group of infants and small children who are not candidates for surgical repair of postoperative right ventricular outflow obstruction.

Effectiveness of low dose captopril versus propranolol therapy in infants with severe congestive failure due to left-to-right shunts

To evaluate the therapeutical effects of the angiotensin converting enzyme inhibitor Captopril to the beta-blocker Propranolol in infants with congestive failure due to pulmonary overcirculation, we retrospectively analysed clinical, neurohormonal and hemodynamic data in 22 infants, 11 of whom were treated with Captopril (Group 1), 11 with Propranolol (Group 2). Age, weight, number of palliative operations, plasma renin activities and pulmonary to systemic flow ratios (3.5 vs. 3.5) were not significantly different prior to Captopril or Propranolol therapy. If treatment with digoxin and diuretics did not succeed, the infants were additionally treated with Captopril (1 mg/kg) for a mean of 7.4 months, or with 1.9 mg/kg Propranolol for 9.2 months.

RESULTS

1 mg/kg Captopril did not effectively suppress angiotensin converting enzyme in the steady state at trough level (92+/-52 vs. 87+/-50 nmol/min/ml). In the Propranolol group, the clinical heart failure score (2.6+/-1.5 vs. 7. 4+/-2.5) and plasma renin activities (14+/-10 vs. 101+/-70 ng/ml/h) were significantly lower, compared to the Captopril group. Length of hospital stay (23+/-9 vs. 52+/-24 days) was lower and weight gain (126+/-38 vs. 86+/-84 g/week) was higher within 3 months after starting Propranolol therapy. Significantly lower left atrial pressures (6.2+/-2.2 vs. 13.4+/-9.2 mmHg) and lower endiastolic ventricular pressures (7.6+/-2.5 vs. 12.6+/-4.0 mmHg) during pre-operative cardiac catheterization indicated a better diastolic ventricular function under chronic Propranolol treatment.

CONCLUSION

Although high dose Captopril was not evaluated in this study, when compared to patients on low Captopril dosages, infants who received Propranolol treatment showed improvement in heart failure scores, shorter lengths of hospital stay, lower plasma renin activities and better diastolic ventricular functions.

Pars plana vitrectomy and subretinal surgery for ocular toxocariasis

The clinical course of ocular toxocariasis and the chronological development of peripheral retinal and macular granulomas are reported. Removing the epiretinal as well as subretinal component of the granuloma via pars plana vitrectomy and retinotomy techniques yielded an excellent clinical result. Clinicopathologic correlation of the specimen confirmed the diagnosis with histological evidence of degenerated larval structures in granulomatous inflammation.

Presumed macular choroidal watershed vascular filling, choroidal neovascularization, and systemic vascular disease in patients with age-related macular degeneration

PURPOSE

To investigate the possible association of presumed macular choroidal watershed vascular filling (PMWF), choroidal neovascularization, and systemic vascular disease in patients with age-related macular degeneration.

METHODS

In a retrospective study, we evaluated 74 randomly selected indocyanine green videoangiograms of 74 patients with age-related macular degeneration. We also reviewed the charts of 20 randomly selected, age-matched control patients without age-related macular degeneration, initially referred for uniocular conditions, and subsequently performed indocyanine green videoangiography on their normal fellow eyes. We evaluated these videoangiograms for the presence of PMWF, manifesting as characteristic early choroidal hypofluorescence and its relation to choroidal neovascularization when present. Additionally, the incidence of hypertension, coronary artery disease, peripheral vascular disease, and diabetes mellitus was determined.

RESULTS

Forty-one (55.4%) of 74 patients with age-related macular degeneration vs three (15.0%) of 20 normal control patients exhibited PMWF on indocyanine green videoangiography (P = .0014). Of the 61 patients with age-related macular degeneration and choroidal neovascularization, 36 (59.0%) exhibited PMWF on videoangiography. Associated choroidal neovascularization arose from the PMWF zone in 33 (91.7%) of these cases. Hypertension was observed in 24 (58.5%) of 41 patients with age-related macular degeneration and PMWF vs nine (27.3%) of 33 patients with age-related macular degeneration who did not exhibit PMWF (P = .007).

CONCLUSIONS

An increased incidence of PMWF occurs in patients with age-related macular degeneration with a possible predisposition for the development of associated choroidal neovascularization. Additionally, PMWF may be accentuated by associated hypertensive choroidal microvascular insult.

Enhanced resting left ventricular filling in patients with successful coarctation repair and exercise-induced hypertension

M-mode and Doppler echocardiographic analyses of left ventricular (LV) shortening and filling were performed in 50 patients who underwent coarctectomy (median follow-up 9.5 years) and in 16 athletes in a control group before an exercise stress test with upright bicycle ergometry was performed. Thirty-two of 50 patients and 18 of 50 patients had a normotensive and hypertensive response to exercise, respectively. Preexercise echocardiographic data were compared among the control, normotensive, and hypertensive patient groups. LV peak filling rates (dD/dt, diastole) were increased in the hypertensive group (18.3 +/- 3.5) compared with those in the normotensive group (14.4 +/- 3.2; p < 0.001) and the control group (13.6 +/- 2.8; p < 0.001). LV shortening was enhanced in the coarctectomy group compared with that in the control group. A higher aortic isthmus Doppler gradient at peak exercise was not found in the hypertensive group compared with that in the normotensive group. Therefore patients with successful coarctectomy in childhood have enhanced LV shortening and relaxation at rest. Demonstration of enhanced LV peak filling rates may help identify patients at risk for exercise-induced hypertension.

Reduced radiation during cardiac catheterization of infants using acquisition zoom technology

The new digital technology of obtaining images in an AZ mode effectively reduces the radiation dose to infants undergoing cardiac catheterization. Future software advances in this technique should enhance the image quality and potentially broaden its application to older patients.

Repair of an unusual type of total anomalous pulmonary venous connection

A 9-day-old, 4.5-kg female infant was diagnosed with total anomalous pulmonary venous connections by echocardiography. The unusual nature of the pulmonary veins and their connections led to cardiac catheterization and angiography. Angiography demonstrated the left-sided veins connected, via a retropulmonary artery vertical vein, to the left inominate vein whereas the right-sided pulmonary veins connected to the right superior vena cava. We repaired this lesion uneventfully by creating a neo-common pulmonary vein and anastomosing this confluence to the left atrium.

Decreased incidence of postoperative pericardial effusions after cardiac surgery for congenital heart disease

There has been a striking decrease in the incidence of postoperative pericardial effusion to 13.6%. A higher incidence of postoperative pericardial effusion was found in the winter months.

Coronary sinus ostial atresia with persistent left superior vena cava

BACKGROUND

Atresia of the coronary sinus orifice with a persistent left superior vena cava is an intrinsically benign cardiac anomaly with important surgical implications.

METHODS

THe medical records of 5 patients with atresia of the coronary sinus orifice with a persistent left superior vena cava were reviewed retrospectively, and a computer search of the world literature describing this cardiac malformation was undertaken.

RESULTS

The 5 patients ranged in age from 9 months to 5 years. In 2, the diagnosis was made preoperatively by angiocardiography, and in 3, the abnormality was found incidentally at the time of cardiotomy for repair of associated congenital heart disease. Four of the 5 patients underwent repair of associated cardiac lesions. During operation, care was taken to avoid disruption of left superior vena cava flow to prevent coronary venous obstruction. All patients survived and are doing well at follow-up.

CONCLUSIONS

Atresia of the coronary sinus orifice with persistent left superior vena cava is, in itself, a benign anomaly without physiologic consequence. However, the recognition of this lesion during repair of associated cardiac lesions is of vital importance to the cardiac surgeon. Interruption of this sole route of coronary venous drainage can potentially lead to myocardial ischemia and necrosis.

The use of intravitreal tissue plasminogen activator in the treatment of experimental subretinal hemorrhage in the pig model

PURPOSE

To clinically and surgically evaluate clot lysis in an animal model of subretinal hemorrhage after intravitreal injection of tissue plasminogen activator.

METHODS

Autologous subretinal hemorrhages were created via a transvitreal approach in 18 pigs. The next day (day 1) animals were randomly selected to receive either an intravitreal injection of 0.1 mL balanced salt solution or 0.1 mL tissue plasminogen activator (25 micrograms) followed by observation or vitrectomy a day later. On day 2, six pigs (all treated with tissue plasminogen activator) underwent a vitrectomy in which aspiration of the subretinal hemorrhage was attempted. The other eyes were evaluated for clot lysis by ophthalmoscopy at days 3, 10, and 30. All eyes were examined histopathologically.

RESULTS

The eyes that had been treated with tissue plasminogen activator demonstrated a color change at the peripheral margin, which suggested that clot lysis had occurred. At the time of the vitrectomy, the clots were liquefied partially; removal by aspiration alone, however, was not possible. Photoreceptor damage was moderate to severe by day 10 in all eyes, whether they were treated with tissue plasminogen activator or balanced salt solution. All eyes that underwent vitrectomy had moderate to severe photoreceptor damage.

CONCLUSIONS

In this animal model, intravitreal tissue plasminogen activator was associated with features that suggested partial clot lysis; tissue plasminogen activator did not produce sufficient lysis to allow surgical removal by aspiration alone, however.

Idiopathic polypoidal choroidal vasculopathy associated with retinal arterial macroaneurysm and hypertensive retinopathy

BACKGROUND

Idiopathic polypoidal choroidal vasculopathy (IPCV), the posterior uveal bleeding syndrome, and multiple recurrent serosanguineous pigment epithelial detachments in black women are a heterogeneous group of related entities seen in elderly hypertensive females. Similar associations are known for retinal arterial macroaneurysm (RAM).

METHODS

This report documents the clinical, fluorescein, and indocyanine green videoangiographic findings of two elderly black female hypertensive patients who presented with IPCV, RAM, and hypertensive retinopathy.

RESULTS

Clinical, fluorescein, and indocyanine green videoangiographic analysis of these two patients revealed hypertensive retinopathy, RAM, and anomalous polypoidal vascular networks associated with focal "bead-string" constrictions, terminal vascular loops, and polypoidal and pinpoint choroidal nodules.

CONCLUSION

Certain subgroups of IPCV and related entities and RAM may be pathophysiologically related as analogous hypertensive insults to the choroidal and retinal vascular beds.

Prenatal ultrasonographic diagnosis of ductus arteriosus aneurysm with spontaneous neonatal closure

Aneurysm of the ductus arteriosus may be either spontaneous or acquired as a complication of surgical closure of a patent duct. Patients may be asymptomatic or present with a wide spectrum of symptoms, including hoarseness, respiratory symptoms, aortic or pulmonary thrombosis or embolism, or rupture of the aneurysm. We present the first report of prenatal ultrasonographic diagnosis of isolated ductus arteriosus aneurysm. The aneurysm presented at 39 weeks as an enlarged, dilated, vascular structure 15 mm in diameter, which began at the bifurcation of the main pulmonary artery and ended in the descending aorta. Doppler imaging demonstrated turbulent flow in this lesion. Following spontaneous delivery, a bidirectional shunt in the ductus arteriosus was found on the 1st day, but the caliber of the vessel was normal. An almost completely functionally closed ductus was found on the 2nd day. Spontaneous resolution of the lesion was confirmed by magnetic resonance imaging at 4 weeks of age.

Acute changes in endothelin-1 after hemodialysis for chronic renal failure

Endothelin is a recently described, potent renal vascular and systemic vasoconstrictor peptide. To evaluate the response of this peptide to volume contraction, we measured eight baseline and posthemodialysis samples from seven children, aged 14.5 +/- 3 years, with chronic renal failure. Plasma was extracted and endothelin-1 was measured by radioimmunoassay. Dialysis was performed for a 3- to 3 1/2-hour period, and body weight decreased from 38.0 +/- 14.3 to 36.2 +/- 13.8 kg (p < 0.01) during this time. There were no significant changes in heart rate or respiratory rate after dialysis, but blood pressure fell from 127/80 +/- 22/16 to 114/72 +/- 20/21 mm Hg (p = 0.05 for the systolic pressure). Plasma endothelin-1 concentration increased from 1.5 +/- 1.2 pg/ml at baseline to 7.3 +/- 8.9 pg/ml (p = 0.06) after dialysis; the fall in body weight from dialysis correlated with the increase in endothelin (r = -0.75; p = 0.05). Thus volume contraction from hemodialysis is associated with a rise in plasma endothelin-1, which is related to the acute change in body weight.

Relation of elevated plasma endothelin in congenital heart disease to increased pulmonary blood flow

Endothelin-1 (ET), a potent vasoconstrictor peptide, has been found to be elevated in children with pulmonary hypertension associated with congenital heart defects. To evaluate the effect of pulmonary blood flow on ET concentrations, 5 ml blood samples were obtained peripherally at cardiac catheterization from 35 patients, ages 0.13 to 17 years (median 2). Plasma was extracted and ET measured by radioimmunoassay. Patients were classified into 2 groups based on the presence (group A) or absence (group B) of increased pulmonary blood flow defined as a Qp/Qs > or = 1.5. When the 13 patients (37%) in group A were compared with the 22 patients (63%) in group B there were no significant differences in age, cardiac index, or pulmonary and systemic resistances. ET concentrations were significantly higher in group A patients (median 3.25, range 0 to 16.5 vs median 0, range 0 to 6.35 pg/ml; p < or = 0.05). Pulmonary blood flow and pulmonary artery pressure were also higher in group A patients (p < or = 0.01). When patients within group A were subdivided into those with and without pulmonary hypertension, no difference was present in their ET concentrations (mean/SD: 4.4/4.3 vs 4.0/6.4 pg/ml, p = NS). Thus, ET is elevated in patients with congenital heart disease associated with left-to-right shunts and it appears that this increase is related to increased pulmonary blood flow independent of pulmonary artery pressure.

Pediatric sedation: short-term effects

A prospective investigation on the short-term effects of various sedation regimens on 549 nonhospitalized magnetic resonance (MR) patients was performed. The drugs evaluated were chloral hydrate, pentobarbital, midazolam, and diazepam (fentanyl was used for enhancement after any of these drugs). The overall safety and efficacy were quite good with all the regimens. Overall, 84% of children slept less than 8 h after the examination, 90% were drowsy and/or unsteady for less than 8 h after they awoke, and 97% resumed their usual activities by 24 h. Significant hyperactivity was seen only with pentobarbital and occurred in 8.4% of children over 8 years of age. The multiple-dose regimen of pentobarbital and fentanyl had a significant short-term effect on the children less than 8 years of age, with 35% sleeping longer than 8 h after the MR. Ten children who had needed the multiple-dose pentobarbital regimen or who had failed prior pentobarbital sedation presented for repeat sedation. Midazolam was effective in 9 of these 10 children.

Augmented norepinephrine and renin output in response to maximal exercise in hypertensive coarctectomy patients

To evaluate a possible neural or renal contribution to the hypertension that occurs in some patients following coarctation of aorta repair, 35 patients underwent graded bicycle exercise with serial measurements of plasma norepinephrine concentrations and plasma renin activity. Sixteen patients with coarctectomy who had systolic or diastolic hypertension at peak exercise were compared with 19 normotensive patients with coarctectomy. The average time interval between coarctation repair and study was significantly longer (p less than 0.05) in the hypertensive group than in the normotensive patients (12.8 +/- 4.8 versus 8.7 +/- 2.2 years). The heart rate response to exercise was similar for both patient groups. The systolic blood pressure in the hypertensive group was higher than in the normotensive group at rest in the supine and upright positions and at 5 minutes of recovery, in addition to peak exercise, and the diastolic blood pressure was increased at peak exercise. Plasma norepinephrine concentrations were significantly higher at peak exercise and during recovery in the hypertensive group than in the normotensive patients. Plasma renin activity was also significantly higher in the hypertensive group at peak exercise. These data suggest that patients with coarctectomy who have a hypertensive response to exercise have an augmented sympathetic nervous system output and increased plasma renin activity that may lead to peripheral vasoconstriction at peak exercise and that may contribute to the development of their hypertension.

Grading the severity of congestive heart failure in infants

To determine which variables most accurately define congestive heart failure (CHF) in infants, 41 patients (median age 2.5 months) were graded by four pediatric cardiologists for the presence and severity of CHF based on the following variables: amount of formula consumed per feeding, feeding time, history of diaphoresis or tachypnea, growth parameters, respiratory and heart rates, respiratory pattern, perfusion, presence of edema, diastolic filling sounds, and hepatomegaly. There were 19 patients graded as having no CHF, nine as mild, seven moderate, and six severe CHF. The most sensitive and specific variables (p less than 0.0001) for the presence of CHF were a history of less than 3.5 oz/feed, respiratory rate greater than 50/min, an abnormal respiratory pattern, diastolic filling sounds, and hepatomegaly. Moderate to severe CHF was present when patients took less than 3 oz/feed or greater than 40 min/feed, had an abnormal respiratory pattern with a resting respiratory rate greater than 60/min, and had a diastolic filling sound and moderate hepatomegaly. Severe CHF was accompanied by a heart rate greater than 170/min, decreased perfusion, and severe hepatomegaly. Thus, the grading of the severity of CHF in infants should include an accurate description of these historical and clinical variables.

Atrial natriuretic factor and sympathetic nervous output in response to volume shifts in the immature canine circulation

This study evaluated the immature circulation's response to acute shifts in intravascular volume with respect to atrial natriuretic factor and plasma catecholamines. Serial measurements were performed on thirteen beagle puppies during volume expansion with a saline and albumin solution followed by volume contraction with furosemide. Atrial natriuretic factor correlated with right (r = .73, p less than 0.001) and left (r = .62, p less than 0.001) atrial pressures and increased to much greater levels than previously reported for mature animals. Simultaneously, 10 puppies had a progressive decrease in plasma norepinephrine over the 60-minute infusion (p less than 0.05) while two puppies demonstrated a marked increase between the 30- and 60-minute samples. Furosemide increased urine output and reversed the hormonal changes caused by volume expansion. Thus a greatly augmented output of atrial natriuretic factor occurs in the immature canine circulation in response to increased atrial and pulmonary pressures, while sympathetic output remains unchanged or falls with increasing intravascular volume until a critical decrease in cardiac output triggers a catecholamine surge.

Myocardial performance and perfusion during exercise in patients with coronary artery disease caused by Kawasaki disease

For a study of the natural history of coronary artery lesions after Kawasaki disease and their effect on myocardial blood flow reserve with exercise, five such patients underwent exercise testing on a bicycle. Oxygen consumption, carbon dioxide production, minute ventilation, and electrocardiograms were monitored continuously. Thallium-201 scintigraphy was performed for all patients. One patient stopped exercise before exhaustion of cardiovascular reserve but had no evidence of myocardial perfusion abnormalities. Four patients terminated exercise because of exhaustion of cardiovascular reserve; one had normal cardiovascular reserve and thallium scintiscans, but the remaining patients had diminished cardiovascular reserve. Thallium scintigrams showed myocardial ischemia in two and infarction in one. No patient had exercise-induced electrocardiographic changes. These results indicate that patients with residual coronary artery lesions after Kawasaki disease frequently have reduced cardiovascular reserve during exercise. The addition of thallium scintigraphy and metabolic measurements to exercise testing improved the detection of exercise-induced abnormalities of myocardial perfusion.

Plasma norepinephrine levels in infants and children with congestive heart failure

To characterize the sympathetic nervous system response to congestive heart failure (CHF) in infants and children, plasma catecholamine levels were measured in 102 subjects undergoing routine cardiac catheterization (mean age 3.3 years, range 0.1 to 14.7), including 61 with left-to-right shunts. Plasma norepinephrine levels were significantly higher (p less than 0.0001) in children with CHF than in those without CHF. A highly significant association (p less than 0.0001) was found between the level of plasma norepinephrine and severity of CHF symptoms. This relation was found for CHF secondary to lesions producing a left-to-right shunt and CHF resulting from primary myocardial dysfunction. In congenital lesions with a left-to-right shunt, plasma norepinephrine levels correlated well with size of the shunt (Qp/Qs) (r = 0.75, p less than 0.001) and degree of pulmonary arterial hypertension (r = 0.70, p less than 0.001). Elevation of plasma norepinephrine concentrations in infants and children are seen with severe CHF regardless of its origin.

Gas-liquid chromatography of 3-chloropropanediol

To improve the gas chromatographic properties of 3-chloropropanediol, a phenylboronic acid derivative was prepared. This method appears to be suitable for trace analysis of the title compound. Epichlorohydrin, 1,2-propanediol, and 1,2-dichloropropanol were among the structurally related compounds shown not to interfere. The structure of the derivative was confirmed by gas chromatography-Fourier transform infrared spectroscopy utilizing a matrix isolation interface and gas chromatography-mass spectrometry.

Effects of source and particle size on the biological availability of calcium in calcium supplements for growing pigs

Five experiments were conducted to determine the biological availability of the Ca in high-Ca (calcitic) limestone, dolomitic limestone, oyster shell flour, gypsum, marble dust and aragonite for the growing pig, and to determine the influence of particle size of the Ca source on the bioavailability of Ca. A low-Ca, fortified, corn soybean meal basal diet calculated to contain .2% Ca and .6% P was used. This diet was supplemented with 0 or .3% Ca from either CaCO3 precipitate (the standard) or the test source of Ca. Diets were fed on an ad libitum basis to three to eight replicate pens of pigs (one or two/pen) for 35 to 42 d. Average initial weight of the pigs was 15 kg. At the end of each experiment the pigs were killed, the third and fourth metacarpals and metatarsals and the femurs were removed, and breaking strength and ash were determined. The increase in bone strength from feeding the test source of Ca relative to the increase in bone strength from feeding the CaCO3 standard was used to calculate the relative availability of Ca in the supplements. The bioavailability of Ca in calcitic limestone (two sources), oyster shell flour, gypsum, marble dust and aragonite was similar, ranging from 93 to 102%. However, the Ca in two sources of dolomitic limestone was less available (51 and 78%) than in the other sources. Particle size of the Ca sources (geometric mean diameter of .10 to .54 mm) did not influence the availability of Ca.