Energy and carbon budgeting of traditional land use change with groundnut based cropping system for environmental quality, resilient soil health and farmers income in eastern Indian Himalayas

Energy intensive traditional cereals based monoculture often lead to high greenhouse gas emissions and degradation of land and environmental quality. Present study aimed at evaluating the energy and carbon budget of diversified groundnut (Arachis hypogea L) based cropping system with over existing traditional practice towards the development of a sustainable production technology through restoration of soil and environmental quality and enhancement of farming resiliency by stabilizing farmers' income. The trials comprised of three introduced groundnut based systems viz. groundnut- pea (Pisum sativum), groundnut-lentil (Lens esculenta) and groundnut-toria (Brasssica campestris var. Toria) replacing three existing systems viz. maize (Zea mays L) - fallow, maize - toria, and rice (Oryza sativa L)-fallow systems. Four years study revealed that adoption of groundnut based systems reduced non-renewable energy input use (fertilizers, chemical, machinery and fossil fuels) by 25.5%, consequently that reduced the cost of production. Repeated analysis of variance measurement also affirmed that groundnut based systems (groundnut-pea>groundnut-lentil> groundnut-toria) increased the energy use efficiency, energy productivity, carbon use efficiency, net returns and decreased the specific energy and energy intensiveness. Groundnut based systems increased the mean system productivity and water productivity in terms of groundnut equivalent yield by 3.7 and 3.1 folds over existing practice. The savings of fossil fuel reduced greenhouse gas emissions owing to reduced use of farm machinery and synthetic fertilizers. Groundnut based systems significantly (p < 0.05) enhanced the soil carbon concentration (8.7-18.1%) and enzymatic activities (27.1-51.8%) over existing practice. Consequently, estimated soil quality index values were 35.9-77.3% higher under groundnut based systems than existing practice. Thus, the study indicated the resilient nature of groundnut based systems as an environmentally safe and sustainable production technology for enhancing resource use efficiency, reduce carbon emission, energy intensiveness and cost of production in the Eastern Himalaya region of India and similar ecosystems.

Anti-PD-1 therapy in patients with advanced melanoma and preexisting autoimmune disorders or major toxicity with ipilimumab

Background

Anti-PD-1 antibodies (anti-PD-1) have clinical activity in a number of malignancies. All clinical trials have excluded patients with significant preexisting autoimmune disorders (ADs) and only one has included patients with immune-related adverse events (irAEs) with ipilimumab. We sought to explore the safety and efficacy of anti-PD-1 in such patients.

Patients and methods

Patients with advanced melanoma and preexisting ADs and/or major immune-related adverse events (irAEs) with ipilimumab (requiring systemic immunosuppression) that were treated with anti-PD-1 between 1 July 2012 and 30 September 2015 were retrospectively identified.

Results

One hundred and nineteen patients from 13 academic tertiary referral centers were treated with anti-PD-1. In patients with preexisting AD (N = 52), the response rate was 33%. 20 (38%) patients had a flare of AD requiring immunosuppression, including 7/13 with rheumatoid arthritis, 3/3 with polymyalgia rheumatica, 2/2 with Sjogren's syndrome, 2/2 with immune thrombocytopaenic purpura and 3/8 with psoriasis. No patients with gastrointestinal (N = 6) or neurological disorders (N = 5) flared. Only 2 (4%) patients discontinued treatment due to flare, but 15 (29%) developed other irAEs and 4 (8%) discontinued treatment. In patients with prior ipilimumab irAEs requiring immunosuppression (N = 67) the response rate was 40%. Two (3%) patients had a recurrence of the same ipilimumab irAEs, but 23 (34%) developed new irAEs (14, 21% grade 3-4) and 8 (12%) discontinued treatment. There were no treatment-related deaths.

Conclusions

In melanoma patients with preexisting ADs or major irAEs with ipilimumab, anti-PD-1 induced relatively frequent immune toxicities, but these were often mild, easily managed and did not necessitate discontinuation of therapy, and a significant proportion of patients achieved clinical responses. The results support that anti-PD-1 can be administered safely and can achieve clinical benefit in patients with preexisting ADs or prior major irAEs with ipilimumab.

When's dinner? Does timing of dinner affect the cardiometabolic risk profiles of South-Asian Canadians at risk for diabetes

AIM

To explore the relationship between the time dinner is consumed (dinnertime or timing of dinner) and cardiometabolic risk factors among South-Asian Canadians at risk for diabetes.

METHODS

We recruited 432 South-Asian adults affiliated with Sikh and Hindu Temples in Metro Vancouver. Participants deemed to be at risk of diabetes underwent a clinical and behavioural assessment. Dinnertime was measured via self-report. Clinical endpoints included HbA_1c , apolipoprotein, blood pressure, weight, BMI and waist circumference.

RESULTS

The mean age of participants was 65 years and 59% were male. Dinnertime was categorized into three groups: early (before 18:00 h); average (18:00 to 20:00 h); and late (later than 20:00 h). Among the participants, 19% (n = 79), 44% (n = 187) and 37% (n = 157) reported early, average and late dinnertimes, respectively. Significant differences were found for dinnertime groups and years of residence in Canada, gender and employment. Compared with the early dinnertime group, the late dinnertime group lived in Canada for a shorter duration, comprised a higher proportion of males (66 vs 48%; P = 0.01) and were currently employed (37 vs 22%; P = 0.02). With regard to clinical endpoints, compared with the early dinnertime group, the late dinnertime group had lower systolic blood pressure (135.9 vs 131.7 mmHg; P = 0.03). After controlling for demographic characteristics, this difference was diminished. No significant differences were found between dinnertime and HbA_1c , apolipoprotein, diastolic blood pressure, weight, BMI and waist circumference.

CONCLUSION

Findings suggest that, among this sample of South-Asian Canadians at risk of Type 2 diabetes, there was no association between timing of the evening meal and cardiometabolic profiles.

Evaluation of circulating tumor cell (CTC) enumeration as an efficacy response biomarker of overall survival (OS) in metastatic castration-resistant prostate cancer (mCRPC): Planned final analysis (FA) of COU-AA-301, a randomized, double-blind, placebo-controlled, phase III study of abiraterone acetate (AA) plus low-dose prednisone (P) post docetaxel

LBA4517

Background: A preplanned interim analysis of COU-AA-301 showed that AA, a selective androgen biosynthesis (CYP17) inhibitor, significantly improves OS in mCRPC. This is the first phase III study to prospectively assess CTC as a surrogate biomarker as part of a regulatory qualification process, here using updated OS data. Methods: 1,195 patients (pts) with mCRPC post docetaxel were randomized 2:1 to AA (1 g QD) + P (5 mg BID) (n = 797) or placebo + P (n = 398). CTCs (screening and baseline [BL]; post BL at weeks 4, 8 and 12) were enumerated (cells/7.5 mL) at MSKCC and The ICR using CellSearch and analyzed with other prognostic covariates as dichotomous and continuous variables using updated OS data at 775 events (prior to crossover from placebo to AA). CTC (as part of a biomarker panel - LDH, PSA, Hg, AlkPhos) was examined as a surrogate for OS. Multivariate (Cox model) analyses were conducted. Results: At median follow up (FU) of 20.2 mo, the difference in median OS between the 2 groups improved from 3.9 to 4.6 mo (AA 15.8 mo vs placebo 11.2 mo; HR = 0.74; p < .0001). CTC counts were evaluated in 972 pts at screening and BL, 838 at 4 wks, 783 at 8 wks and 723 pts at 12 wks. High concordance between screening and BL values was observed (r = 0.83). CTC conversion using standard definition for unfavorable (CTC ≥ 5) and favorable (CTC < 5) counts was predictive of OS as early as 4 wks after treatment and its inclusion significantly reduced the treatment effect at all post-treatment time points (HR: from 0.74 to 0.97). A reduced model incorporating CTCs and LDH was developed. Conclusions: The magnitude of the treatment effect of AA on OS increased with longer FU. Using standard definition of CTC conversion, the biomarker panel demonstrated a level of surrogacy for OS by correlating well with survival and in a model-adjusted analysis dramatically attenuating the treatment effect. BL CTCs and CTC conversion, along with LDH, were key predictors of OS. Future trials will further evaluate the CTC-based surrogate developed from COU-AA-301.

Prognosis of fracture: evaluation of predictive accuracy of the FRAX algorithm and Garvan nomogram

We evaluated the prognostic accuracy of fracture risk assessment tool (FRAX) and Garvan algorithms in an independent Australian cohort. The results suggest comparable performance in women but relatively poor fracture risk discrimination in men by FRAX. These data emphasize the importance of external validation before widespread clinical implementation of prognostic tools in different cohorts.

INTRODUCTION

Absolute risk assessment is now recognized as a preferred approach to guide treatment decision. The present study sought to evaluate accuracy of the FRAX and Garvan algorithms for predicting absolute risk of osteoporotic fracture (hip, spine, humerus, or wrist), defined as major in FRAX, in a clinical setting in Australia.

METHODS

A retrospective validation study was conducted in 144 women (69 fractures and 75 controls) and 56 men (31 fractures and 25 controls) aged between 60 and 90 years. Relevant clinical data prior to fracture event were ascertained. Based on these variables, predicted 10-year probabilities of major fracture were calculated from the Garvan and FRAX algorithms, using US (FRAX-US) and UK databases (FRAX-UK). Area under the receiver operating characteristic curves (AUC) was computed for each model.

RESULTS

In women, the average 10-year probability of major fracture was consistently higher in the fracture than in the nonfracture group: Garvan (0.33 vs. 0.15), FRAX-US (0.30 vs. 0.19), and FRAX-UK (0.17 vs. 0.10). In men, although the Garvan model yielded higher average probability of major fracture in the fracture group (0.32 vs. 0.14), the FRAX algorithm did not: FRAX-US (0.17 vs. 0.19) and FRAX-UK (0.09 vs. 0.12). In women, AUC for the Garvan, FRAX-US, and FRAX-UK algorithms were 0.84, 0.77, and 0.78, respectively, vs. 0.76, 0.54, and 0.57, respectively, in men.

CONCLUSION

In this analysis, although both approaches were reasonably accurate in women, FRAX discriminated fracture risk poorly in men. These data support the concept that all algorithms need external validation before clinical implementation.

First-in-human, first-in-class, phase I study of a human monoclonal antibody CNTO 888 to the CC-chemokine ligand 2 (CCL2/MCP-1) in patients with solid tumors

e13500

Background: The chemokine CCL2 promotes angiogenesis, tumor proliferation, migration and metastasis through PI3K and NFkB signaling. CNTO 888 is a human IgG1κ monoclonal antibody with high binding affinity for CCL2 and documented preclinical antitumor activity. Methods: Patients were administered a 90 minute infusion of CNTO 888 on day 1, day 28 and subsequently on a q14 schedule. Exploratory PD assessments include diffusion contrast enhanced CT, circulating tumor and endothelial cells, free and bound CCL2 levels, bone markers and paired tumor biopsies. Results: 21 patients in cohorts of 3–6 patients received repeated CNTO 888 infusions at 5 dose levels (0.3mg/kg, 1mg/kg, 3mg/kg, 10mg/kg, 15 mg/kg). A further 23 patients are currently being evaluated in 2 expansion cohorts; 10mg/kg (n=12) and 15mg/kg (n=11). No dose limiting toxicities were seen up to 15 mg/kg q14. Preliminary pharmacokinetic (PK) data for doses ≤ 10 mg/kg showed linear kinetics with a bi-exponential decline and a t1/2 of 4.4 - 8.7 days. The 10 mg/kg dose level resulted in steady-state minimum concentrations above that needed to inhibit chemotaxis and calcium mobilization in preclinical studies. Dose-dependent increase in bound CCL2 levels of > 1000-fold seen following treatment, supports target modulation. 2 patients demonstrated stable disease (SD) > 6 months at 15mg/kg CNTO 888 (ocular melanoma and neuroendocrine tumor). Another patient at 0.3mg/kg CNTO 888 with ovarian cancer had 50% CA125 decline and SD for 10 months. Conclusions: CNTO 888 is well tolerated with no DLTs when administered up to 15mg/kg q14. Preliminary evidence of antitumor activity is reported.

[Table: see text]

Phase I feasibility study of carboplatin plus capecitabine followed by maintenance capecitabine in patients (pts) with recurrent platinum-sensitive epithelial ovarian cancer (EOC)

5564

Background: In a previous study, we noted a response rate (RR) of 61% for the 3 drug combination of carboplatin, epirubicin and capecitabine in platinum-sensitive recurrent EOC. This combination however resulted in excessive grade (G) 3–4 haematological toxicity (55%) (BJC 2006; 94:74). The current trial therefore assessed the feasibility and efficacy of the 2 drugs, carboplatin and capecitabine as second- or third-line treatment. Methods: Pts were administered carboplatin (AUC5) day 1 and capecitabine at a starting dose of 750 mg/m2 bd, days 1–21, q21 (dose level 1). The capecitabine dose was deescalated to 625 mg/m2 (dose level -1) and 500 mg/m2 (dose level -2) according to toxicity. Pts with an objective response or stable disease received maintenance capecitabine (at the same dose level) for up to 12 months or until progression. Responses were assessed with RECIST criteria and CA-125. Results: 19 of the 20 pts enrolled were evaluable for toxicity and response. Dose-limiting toxicity was observed at dose level 1 (G3 fatigue, G3 diarrhoea, G3 neutropenia of > 14 days; n = 3/5), dose level -1 (G3 angina (n = 2), G3 vomiting, G3 palmar plantar erythema; n = 4/7) and dose level-2 (diarrhoea / fatigue; n = 1/7). One patient had a G3 carboplatin hypersensivity reaction. 8 pts received maintenance capecitabine which was well tolerated. The overall RR was 53% with 10 partial responses and 5 stable diseases. The median progression free survival (PFS) was 6.5 months (m) and the 6mPFS was 63% with 2 pts currently ongoing treatment. The median PFS on maintenance was 3.2 m. Conclusions: The combination was well tolerated at the recommended phase II dose of carboplatin (AUC 5) and capecitabine (500 mg/m2 bd) with partial responses in over half of the cases.

[Table: see text]

The role of embolization therapy in the treatment of congenital heart disease

Embolization therapy plays a significant role in the treatment and palliation of congenital heart disease. Currently, there are several devices available to occlude these superfluous vascular connections. This article reviews the indications, results and the current technology available for transcatheter embolization of vessels.

Repair of coarctation in a right-sided circumflex retroesophageal aortic arch

We describe an unusual case of a 3-month-old infant with normal cardiac situs and coarctation of the aorta occurring proximal to the right subclavian artery in the presence of a right-sided retroesophageal circumflex aortic arch and aberrant left subclavian artery. Preoperative evaluation with magnetic resonance imaging and conventional aortography led us to surgically approach this lesion through a right thoracotomy with a successful outcome.

Transcatheter closure of patent ductus arteriosus with the Amplatzer duct occluder: short-term follow-up

BACKGROUND

Transcatheter closure of the patent ductus arteriosus is a well established procedure. The objective of this study was to assess the effectiveness and the safety of the Amplatzer duct occluder.

METHODS AND RESULTS

Occlusion of the patent ductus arteriosus was attempted in 23 patients. The median weight was 11.7 Kg (range, 5 kg - 42.4 kg) with a mean ductus diameter of 3.7 mm (range, 1.6 - 7.2 mm). The immediate closure rate was 86% with a closure rate of 100% at 6 months, 1 year and 2 years following device placement. There was one device embolization that occurred immediately following device placement. No patient had aortic narrowing or pulmonary artery stenosis following the procedure.

CONCLUSIONS

The Amplatzer duct occluder is safe and effective in the closure of a patent ductus arteriosus up to 7.2 mm in diameter. Selecting a device at least 12 mm larger than the minimal ductal diameter can minimize embolization.

Alterations in signal transduction cascade in young and adult rat brain and lymphocytes

Signal transduction cascade, phosphoinositide metabolism, and protein kinases were studied from discrete areas of rat brain like cerebral hemispheres, cerebellum, brainstem, and diencephalon as well as lymphocytes isolated from three different age groups of rats; young (1 month), young adult (3-4 months), and adult (12 months) rats. The activities of protein kinase A, protein kinase C, phospholipase A(2) and phospholipase C and inositol 1, 4, 5-triphosphate, diacylglycerol, cyclic adenosine monophosphate contents were assayed from different brain areas and lymphocytes from these three age group rats. An upregulatory effect on the signal transduction system was observed from 1 month to 3-4-month age group, whereas, the brain tissue and lymphocytes of adult rats showed lower contents and activities of signal transduction components as compared to young adults. In view of the established 'cross talk' between signal transduction system, the present results suggests that molecular/cellular changes in brain and immune cells signal transduction pathway along with neuronal cell loss may contribute to age-related decline in nervous as well as immune system functions.

Influenza in the older adult. Indications for the use of vaccine and antiviral therapy

Each year, the influenza virus is responsible for 20,000 to 40,000 deaths and up to 300,000 hospitalizations in the United States. Although children and younger adults experience more cases of influenza, older individuals who are infected with the virus experience greater morbidity and mortality. The most effective means of influenza prevention for older adults is the influenza vaccine. Antivirals are used as adjuvant therapy, but they are not intended as primary prevention except for at-risk patients who are allergic to the vaccine. The neuroaminidase inhibitors may cause fewer side effects than the older antivirals and therefore may be a useful alternative in the treatment of influenza symptoms in older adults.

Impact of diabetes on CNS: role of signal transduction cascade

Diabetic neuropathy is the most common secondary complication of diabetes mellitus. Several pathogenetic factors have been proposed for diabetic neuropathy. The present investigation was undertaken to study different components of signal transduction from discrete brain regions from streptozotocin-induced diabetic rats. Rats were sacrificed after 1 and 3 months of induction of diabetes, and a control group was also studied in parallel to ascertain the specificity of diabetes-associated changes. Blood glucose level and protein content of discrete brain regions were also estimated. Signal transduction cascade components like protein kinase A, protein kinase C, cAMP, phospholipase C, phospholipase A2, diacylglycerol and inositol phosphate levels were assayed in control and diabetic groups of rats. Significant attenuation in phosphoinositide metabolism along with activation of protein kinase activities were observed. These findings provide evidence to suggest a mechanism linking changes in signal transduction cascade, which is observed in 1- and 3-month diabetic rats, which ultimately leads to development of diabetic neuropathy.

Ventricular function

Multiple modalities contribute to the evaluation of ventricular function. The role of cineangiography, echocardiography, MR imaging, ultrafast CT, and nuclear medicine continue to evolve and improve our understanding of the physiology and pathophysiology of ventricular function. This article discusses the use and limitation of each modality.

Usefulness of transesophageal imaging of flow convergence region in the operating room for evaluating isolated patent ductus arteriosus

Transesophageal echocardiography (TEE) was performed in 21 patients with isolated patent ductus arteriosus (PDA) with a color Doppler flow convergence method during surgical closure of the ductus. Evaluation of PDA by TEE with the flow convergence method may provide valuable information during surgery and/or thorascopic ductus clipping.

Hemodynamic characteristics of neonates following first stage palliation for hypoplastic left heart syndrome

BACKGROUND

It is widely held that the postoperative course of patients with hypoplastic left heart syndrome (HLHS) after stage 1 palliation is characterized by hemodynamic instability, which in part may be due to excessive pulmonary blood flow. Hence, avoidance of alkalosis and the use of minimally oxygen-enriched inspiratory gas are thought by many to be important, although there is little pertinent published data. This study was undertaken to characterize the postoperative course and to determine whether the FIO2 and blood pH are related to indices of hemodynamic stability in these infants.

METHODS AND RESULTS

The postoperative course of 25 consecutive infants undergoing first stage palliation for HLHS were retrospectively reviewed and the following data were obtained: arterial pressure, arterial blood gas measurements, the inotropic agents used, and multiple respiratory parameters. There was one operative death, and 2 patients died within 2 days, but 22 were extubated (mean, 5.2 +/- 4.1 days after surgery). Hospital mortality was 24%. Mean pH was > or = 7.51 for the first 9 hours after surgery and was > or = 7.45 for the entire period. The mean FIO2 was > or = 50% for the first 18 hours. The PaO2 was appropriate (37 +/- 6 mm Hg at 1 hour after surgery, increasing to 45 +/- 5 mm Hg by hour 73). Only modest inotropic support was needed to maintain appropriate blood pressure.

CONCLUSIONS

These data suggest that neither alkalosis nor relatively high inspired oxygen necessarily cause hemodynamic instability in these patients. To what extent these results are generalizable is unclear, but they suggest that there is nothing inherent with HLHS that mandates postoperative hemodynamic instability or unacceptable mortality.

Effectiveness of balloon valvuloplasty in the young adult with congenital aortic stenosis

The objective of this study was to assess the effectiveness of balloon valvuloplasty in the young adult with congenital aortic stenosis and to compare its effectiveness with children. Percutaneous balloon valvuloplasty is effective in children with congenital aortic stenosis, but not in adults with acquired calcific aortic stenosis. Because effectiveness of balloon valvuloplasty in young adults with congenital aortic stenosis is not well defined, we evaluated the outcome in 15 patients aged 16-24 years (18 +/- 0.6; mean +/- SEM) who underwent balloon valvuloplasty from 1985 to 1993. The aortic valve annulus diameter ranged from 18.5 to 30 mm (24 +/- 0.9). The aortic valve was bicuspid in 12 and tricuspid in 3 patients, and calcification was present in one patient. Balloon valvuloplasty was performed using a double balloon technique in 12 patients and a single balloon technique in three patients. Three patients had inadequate relief of gradient with a residual peak systolic gradient > or = 70 mm Hg. Three patients required valve replacement-two patients for a residual gradient > or = 70 mg Hg, and one patient 4 years later for severe aortic valve regurgitation. Eight of the remaining 12 have undergone elective follow-up catheterization 1.2-2.5 years (1.5 +/- 0.1) later. The peak systolic aortic valve gradient decreased by 55% from 73 +/- 5.8 mm Hg to 35 +/- 5.4 mm Hg immediately postvalvuloplasty, and was 30 +/- 4.4 mm Hg at follow-up (P < 0.001). The left ventricular systolic pressure decreased from 179 +/- 7.5 to 147 +/- 6.5 mm Hg immediately postvalvuloplasty and was 147 +/- 4 mm Hg at follow-up. Aortic insufficiency was unchanged after valvuloplasty in 9, increased by 1+ in 4, and by 2+ in 2 patients. Balloon valvuloplasty was as effective in these young adults as in 70 children (age 6 +/- 0.7 years) with congenital aortic stenosis (peak systolic gradient pre- 79 +/- 3 mm Hg versus post- 34 +/- 2 mg Hg; at 1-2 years follow-up 34 +/- 4 mm Hg). Balloon valvuloplasty provides effective treatment in most young adults with congenital aortic stenosis, without early restenosis. Balloon valvuloplasty is as effective in young adults as in children, where it is currently the treatment of choice.

Balloon aortic valvuloplasty for aortic stenosis in neonates, children, and young adults

Balloon aortic valvuloplasty is a safe and effective treatment for aortic stenosis in neonates, children, and young adults. The indication for balloon valvuloplasty in children is a peak systolic gradient > 70 mmHg or > 50 mmHg in any patient with symptoms. Published results indicate that the procedure results in an acute reduction in gradient ranging from 49%-70%, and this reduction appears to persist through at least an intermediate follow-up. The percentage reduction in gradient is similar for neonates as well as older children. In neonates, it is imperative to evaluate the size of the left ventricle prior to balloon valvuloplasty since mortality is highest in those with variants of hypoplastic left heart syndrome. Though morbidity and mortality is higher in the neonatal age group, the results are similar to those following surgical intervention. In children older than 1 month of age, the major complication is the development of aortic regurgitation, although it usually appears to be well-tolerated. Previous surgical valvotomy is not a contraindication to balloon aortic valvuloplasty. In the current era, we believe that balloon aortic valvuloplasty should be considered as the first option in neonates, children and young adults with significant aortic valve obstruction.

Psychosocial aspect of planned induction of labour

One hundred patients of planned induction and 25 cases of spontaneous delivery were interviewed on the various aspects of labour care in the postpartum period. Majority were satisfied with overall care and 65% were of the opinion of opting for induction next time.

Single-stage repair of aortic arch obstruction and associated intracardiac defects in the neonate

The effectiveness of a single-stage anterior approach for the repair of aortic arch obstruction and associated intracardiac defects has not been well evaluated. We therefore reviewed our experience with 60 neonates (median age 8 days, range 1 to 28) who underwent a single-stage repair by way of a median sternotomy at our institution between 1986 and 1994. Nineteen (32%) had coarctation with ventricular septal defect, 18 (30%) had interrupted aortic arch with ventricular septal defect, and 23 (38%) had coarctation or interrupted aortic arch with complex intracardiac anatomy. The arch obstruction was repaired using resection and primary anastomosis in 54 patients, synthetic patch aortoplasty in 3, subclavian flap aortoplasty in 2, and an interposition gortex graft placement in 1. Total circulatory arrest time was 48 +/- 3 minutes (mean +/- SEM). There were 7 early postoperative deaths (11.7%; 70% confidence limit 8% to 16.6%). The 53 survivors were followed for a mean of 23 months (range 1 to 78), for a total of 1,219 patient-months. Recurrent arch obstruction > or = 20 mm Hg has occurred in 2 of 53 patients (3.8%; 70% confidence limit 1.9% to 7.5%); both underwent successful balloon angioplasty. There were 2 late deaths, 1 of which was noncardiac. We conclude that repair of aortic arch obstruction and intracardiac defects by a single-stage approach through median sternotomy can be accomplished with low mortality in infancy, even with associated complex intra-cardiac anatomy. Recurrent coarctation is relatively uncommon and can be successfully managed with balloon angioplasty.

Deletions in the 5' region of dystrophin and resulting phenotypes

Deletions in the dystrophin gene give rise to both Duchenne and Becker muscular dystrophies. Good correlation is generally found between the severity of the phenotype and the effect of the deletion on the reading frame: deletions that disrupt the reading frame result in a severe phenotype, while in frame deletions are associated with a milder disease course. Rare exceptions to this rule, mainly owing to frameshift mutations in the 5' region of the gene (in particular deletions involving exons 3 to 7) which are associated with a milder than expected phenotype, have been reported previously. In order to characterise better the relationship between genotype and phenotype as a result of mutations arising in the 5' region of the gene, we have studied a large cohort of patients with small in frame and out of frame deletions in the first 13 exons of the dystrophin gene. Fifty-five patients with a deletion in this area were identified; approximately one third of them had a phenotype different from that theoretically expected. Patients were divided into two groups: (1) patients with a severe clinical phenotype despite the presence of a small, in frame deletion and (2) patients with a mild phenotype and an out of frame deletion. Noticeable examples observed in the first group were Duchenne boys with a deletion of exon 5, of exon 3, and of exons 3-13. In the second group we observed several patients with an intermediate or Becker phenotype and out of frame deletions involving not only the usual exons 3-7 but also 5-7 and 3-6. These data indicate that a high proportion of patients with a deletion in the 5' end of the gene have a phenotype that is not predictable on the basis of the effect of the deletion on the reading frame. The N-terminus of dystrophin has at least one actin binding domain that might be affected by the small, in frame deletions in this area. The effect of the in frame deletions of exon 3, 5, and 3-13 on this domain might account for the severe phenotype observed in these patients. Other mechanisms, such as unexpected effect of the deletion on splicing behaviour, might, however, also be implicated in determining the phenotype outcome.

Late follow-up of balloon angioplasty in children with a native coarctation of the aorta

Between May 1984 and April 1993, 59 children underwent balloon angioplasty of a native coarctation at our institution. The follow-up protocol included a cardiac catheterization 1 to 2 years after angioplasty, which was performed in 90% of patients with > or = 2 years follow-up. Angioplasty caused an acute decrease in peak systolic gradient from 46 +/- 2 to 15 +/- 2 mm Hg, without early aneurysm or emergent surgical intervention in any patient. Based on follow-up data, a satisfactory result was obtained in 38 patients (64%; 70% confidence limit: 58% to 71%), defined as a residual systolic gradient < 20 mm Hg and no aneurysm. In these patients the gradient decreased acutely from 43 +/- 2 to 9 +/- 1 mm Hg, was 6 +/- 1 mm Hg at follow-up catheterization, and 9 +/- 2 mm Hg by clinical evaluation 4.4 +/- 0.3 years after angioplasty. Twenty-one patients (36%; 70% confidence limit: 29% to 42%) had an unsatisfactory result due to a residual gradient > or = 20 mm Hg (n = 19) or aneurysm formation (n = 3), or both. Restenosis occurred in 6 patients, and occurred more in infants than in children > or = 12 months of age (3 of 5 infants vs 3 of 41 children, p = 0.01). Thus, balloon angioplasty provides an effective initial treatment strategy for native coarctation in most children aged > 12 months.

Chronic alterations in cardiac mechanics after fetal closed heart operation

Pulmonary artery banding was performed in 8 fetal sheep at 125 days' gestation to evaluate the feasibility of fetal closed cardiac operation. At 135 days' gestation, the fetuses were delivered and the cardiac mechanics were evaluated using a modified Langendorff isolated heart preparation. Two of the 8 fetuses aborted spontaneously 2 and 7 days after operation. Six fetuses (75%) survived the 10 days after delivery. The left ventricular cardiac mechanics in the banded fetuses (group I) were compared with those in 8 control fetuses (group II). All fetal hearts in both groups displayed a significant volume-pressure relationship. The volume-pressure curve was found to be shifted upward and to the left in the fetal hearts after pulmonary artery banding. The left ventricles subjected to increased in utero preload secondary to pulmonary artery banding were capable of generating greater peak systolic and developed pressures. Because the fetal heart manifests a Starling type of preload reserve, as such, it demonstrates that the possibility exists for subsequent fetal development to be altered by intrauterine intervention.

Transcatheter occlusion of patent ductus arteriosus with Gianturco coils

BACKGROUND

Transcatheter occlusion with Gianturco coils has been attempted in a small number of patients with tiny (< or = 1.5-mm diameter) patent ductus arteriosus, and preliminary results have been encouraging. The present study extends this method to larger ductus sizes and makes recommendations for proper coil size selection.

METHODS AND RESULTS

Coil occlusion was attempted in 24 consecutive patients with patent ductus arteriosus who did not require other cardiac surgery. Median patient age was 4.2 years (8 months to 30 years), and mean ductus diameter was 1.7 +/- 0.8 mm. Two instances of coil embolization occurred in the first 4 patients, with successful coil retrieval. Based on this experience, we proposed that the coil helical diameter should be twice or more the minimum ductus diameter, with coil length sufficient for three or more loops. With these recommendations, coils were successfully implanted in the subsequent 20 consecutive patients. Of the 22 patients with successful coil implantation, 15 (68%) had no residual shunting, and 7 had trace residual shunting by angiography. The continuous murmur was abolished in all 22 patients. No significant complications occurred, and all patients were discharged within 24 hours of successful coil implantation. No change in the systolic pressure gradient between main and left pulmonary artery or ascending and descending aorta was observed.

CONCLUSIONS

Transcatheter occlusion of patent ductus arteriosus can be safely and effectively achieved in patients with ductus diameters up to 3.3 mm. Coil occlusion does not cause obstruction to flow in the left pulmonary artery or descending aorta. Coils should be selected to provide a helical diameter twice or more the minimum ductus diameter and a length sufficient for three or more loops.