Predicting silent atrial fibrillation in the elderly – NOMED-AF study

Background

Asymptomatic (“silent”) atrial fibrillation is common and associated with poor outcomes. It is important to determine the risk factors that predispose elderly individuals from the general population to atrial fibrillation (AF). However, population-based data for silent AF (SAF) are limited.

Design

First, to study the risk factors for symptomatic AF and SAF in an elderly (≥65 years) general population. Second, to develop a risk stratification model for predicting SAF.

Methods

Continuous ECG monitoring was performed for up to 30 days using a vest-based system in a cohort from NOMED-AF, a cross-sectional study based on a nationwide population sample. The independent risk factors for AF and SAF were determined using multiple logistic regression. ROC analysis was applied to validate developed risk stratification score.

Results

From the total cohort of 3014 subjects, AF was diagnosed in 680 individuals (mean age, 77.5±7.9; 50.1% men) with AF, and of these, 279 (41%) had SAF. Independent associations with an increased risk of AF were age, male gender, coronary heart disease, thyroid diseases, prior ischemic stroke or transient ischemic attack (ICS/TIA), diabetes, heart failure, chronic kidney disease (CKD), obesity (BMI>30) and NT-proBNP >125 ng/ml. Prior revascularization was negatively associated with risk of AF.

The main risk factors for SAF were age, male gender, prior ICS/TIA, diabetes, heart failure, CKD and NT-proBNP >125 ng/ml.

We developed a simple clinical risk scale (MR-DASH score) which had good prediction in the derivation cohort (AUC 0.726) and the validation cohort (AUC 0.730).

Conclusions

SAF is associated with various clinical risk factors in a population sample of individuals ≥65 years. Stratifying individuals from the general population according to their risk for SAF may be possible using the MR-DASH score, facilitating targeted screening programs of individuals with high risk of SAF

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Centre for Research and Development

Risk factors for silent and symptomatic atrial fibrillation in an elderly population screening programme:a report from the noninvasive monitoring for early detection of atrial fibrillation (NOMED-AF)

Background

It is important to determine the risk factors that predispose elderly subjects from the general population for symptomatic atrial fibrillation and atrial flutter (AF/AFl), but population-based data for silent AF (SAF) are limited.

Aim

To study risk factors for symptomatic AF and SAF in a general population screen for subjects age ≥65 where continuous monitoring was performed up to 30 days with a vest-based monitor.

Methods

The NOMED-AF study was a cross-sectional study based on a representative population sample (n=3014; mean age 77.5±7.9 years; F=1479). In 680 subjects AF/AFl (including 279 with SAF) was diagnosed. Independent risk factors for AF/AFl and SAF were determine on weighted data using multiple logistic regression.

Results

The independent risk factors for AF/AFl and SAF are summarised in the Table. There are nine independent risk factors for AF/AFl and eight for SAF. Revascularization and obesity were independently associated with patients with (symptomatic) AF/AFl, and CKD was associated with SAF. Other risk factors are common for AF/AFl and SAF.

Conclusions

AF/AFl and SAF have slightly different associated clinical risk factors in this representative population sample aged ≥65 years. This may facilitated targeted screening programmes for high risk subgroups, particularly for SAF.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The research has received funding from the National Centre for Research and Development under grant agreement (STRATEGMED2/269343/18/NCBR/2016)

Prevalence of diabetes and impaired fasting glucose in Poland in 2005-2014: results of the WOBASZ surveys

AIMS

To evaluate the prevalence of diabetes and impaired fasting glucose in Poland in 2013-2014 and to determine the temporal trends between 2003-2005 and 2013-2014.

METHODS

A questionnaire survey was conducted in a representative sample of Polish adults, complemented by anthropometric and fasting plasma glucose measurements. The research was part of the national cross-sectional WOBASZ study. Diabetes was assessed as self-reported or screened (fasting plasma glucose level ≥ 7 mmol/l, based on one blood sample).

RESULTS

In the years 2013-2014 among 5694 participants aged 20-74 years, 6.0% (95% CI 5.4-6.6) reported a previous diagnosis of diabetes (5.8% in women and 6.2% in men). In addition, 2.4% of the participants (95% CI 2.0-2.8) without a previous diagnosis of diabetes (1.8% of women and 3.1% of men) had a fasting blood glucose level ≥7.0 mmol/l in a single measurement. In a single measurement, 18.4% of the participants (95% CI 17.4-19.4; 13.2% of women and 23.8% of men) had impaired fasting glucose. The prevalence of dysglycaemia in the WOBASZ II study was significantly higher compared to the WOBASZ I study findings from 2003-2005, increased from 6.6% to 8.4% for diabetes and from 9.3% to 18.4% for impaired fasting glucose (after age and sex standardization to the 2013 Polish population).

CONCLUSIONS

The prevalence of diabetes in Poland is similar to that observed in other European populations and has increased significantly over the last decade.

[Use of synthetic slings and mesh implants in the treatment of female stress urinary incontinence and prolapse : Statement of the Working Group on Urological Functional Diagnostics and Female Urology of the Academy of the German Society of Urology]

Due to a safety alert issued by the US Food and Drug Administration (FDA) in 2011 for transvaginal mesh implants to treat female prolapse as a result of numerous reports of complications such as infection, chronic pain, dyspareunia, vaginal erosion, shrinkage and erosion into other organs nearly all industrial products have been withdrawn from the market in the meantime. The United Kingdom, Australia, and New Zealand extended warnings and prohibitions even on the implantation of midurethral slings (TVT, TOT). In view of these current international controversies regarding the use of implanted materials for the treatment of stress incontinence and prolapse and the lack of clear guidelines for the use of biomaterials, the opinion of the Working Group on Urological Functional Diagnostics and Female Urology should provide clarity. The Opinion is based on the SCENIHR Report of the "European Commission's Scientific Committee on Emerging and Newly Identified Health Risks", the "Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence" and in compliance with relevant EAU and national guidelines and the opinion of the Association for Urogynaecology and Plastic Pelvic Floor Reconstruction (AGUB eV). In addition, recommendations are given for the future handling of implants of slings and meshes for the treatment of stress incontinence and prolapse from a urologic viewpoint.

Management of iatrogenic cystoscopic urethral lesion associated with sequela of cuff erosion in a patient after previous AMS 800 implantation. One-step technique with revision, without cuff explantation

INTRODUCTION

Iatrogenic urethral lesion with subsequent cuff erosion during cystoscopy is a rare complication. The alternative surgical strategy with in situ urethroplasty while maintaining the open cuff left in situ will be presented.

MATERIALS AND METHODS

The authors report 3cases of iatrogenic urethral lesion with cuff erosion during cystoscopic evaluation to exclude stricture or cuff erosion due to new onset of obstructive lower urinary tract symptoms. All patients had a history of a AMS 800 implantation due to posprostatectomy incontinence. Rigid cystoscopy was performed, which revelaed no pathologies; however, iatrogenic small urethral lesion was identified during the removal of the cystoscope at the projection of the cuff.

RESULTS

In situ urethroplasty was performed, and the cuff was left open in situ. Additionally a protection fat flap was placed around the urethra from the dorsolateral aspect, separating the cuff and urethra from the direct contact with each other. After 6 weeks the urethral defect was completely healed and via a primary perineal incision the cuff was readapted and closed. The device was fully functioning without any additional adjustments.

CONCLUSION

Our modification should be considered in select cases with absence of infection as part of management strategy for cases of iatrogenic urethral lesions with subsequent cuff erosion. Thereby the original cuff can be spared and the possibly difficult preparation of the urethra during reoperation can be avoided. However, additional more cases should be presented in the world-wide literature, to confirm the utility of this surgical principle.

Prevalence of diabetes and impaired fasting glucose in Poland--the NATPOL 2011 Study

AIMS

The aim of the analysis was to assess the prevalence of diabetes and impaired fasting glucose in Poland.

METHODS

A questionnaire survey on a representative sample of 2411 Polish adults, complemented by blood pressure, anthropometric and fasting plasma glucose measurements. The research was part of the national cross-sectional NATPOL 2011 Study. Diabetes was assessed as self-reported (diagnosed) or screened (fasting plasma glucose level ≥ 7 mmol/l, based on one blood draw).

RESULTS

Total prevalence of diabetes in 2011 was 6.7% (95% CI 5.6-7.9); 6.4% (95% CI 5.0-8.0) in women and 7.0% (95% CI 5.4-8.8) in men and did not change from 2002 (6.8%, 95% CI 95% CI 5.8-7.9). Over one quarter of individuals with diabetes were not aware of having the condition. Obesity, arterial hypertension and male gender were strong predictors of screened diabetes. Total prevalence of impaired fasting glucose in the surveyed population was 15.6% (95% CI 14.0-17.2).

CONCLUSIONS

The prevalence of diabetes in Poland is similar to that observed in other European populations and has not changed over the last decade. The fact that every fourth person with diabetes is unaware of the disease creates important opportunities for screening and detection of the disease.

Desorption of ionic species from ice/graphite by femtosecond XUV free-electron laser pulses

We report results of laser desorption from water ice surfaces using XUV pulses from the free-electron laser in Hamburg (FLASH). This XUV to soft x-ray FEL provides femtosecond pulses at 20-200 eV photon energy with pulse energies up to 100 µJ. The interaction of this intense soft x-ray radiation with ice (H2O, D2O) adsorbed on highly oriented pyrolytic graphite (HOPG) yields the desorption of various ions, particularly H (+) (D (+) ), O (+) , O2 (+) and others. For H (+) and O (+) ions linear desorption yields are observed, while for O2 (+) a highly nonlinear desorption yield with n = (2.5 ± 0.2) is found. Kinetic energies of 1.8 eV, 559 meV and 390 meV for H (+) , O (+) , and O2 (+) , respectively, account for only a small part of the available excess energy.

Prevalence and predictors of acute renal injury in liver transplant recipients

Renal failure is a major factor impacting liver transplant outcomes. Renal functional impairment predicts decreased survival, leading to increased morbidity and mortality. The aim of this study was to estimate the incidence, risk factors, and resolution of acute kidney injury (AKI) among liver transplant recipients during the operative hospital stay. We analyzed data from 99 orthotopic liver transplantations (OLT) performed at our center in 2008. Posttransplantation occurrence of AKI was defined as an increase in serum creatinine (SCr) concentration of 0.3 mg/dL or more, namely, 1.5-fold from baseline. AKI was observed among 31.31% of liver transplant recipients (n = 31). The mean increase in SCr was 2.49 +/- 0.78-fold from baseline. The mean posttransplant SCr level was 2.59 +/- 0.92 mg/dL. Renal replacement therapy was introduced to 16.12% (n = 5) liver recipients developing AKI. Among them, 2 subjects (6.45%) died. The mean SCr level at the time of discharge from the hospital was 1.17 +/- 0.57 mg/dL among the AKI group compared with 0.77 +/- 0.32 mg/dL among the group without AKI. Pretransplant renal impairment expressed by an elevated SCr concentration (relative risk [RR] = 1.25; P = .0386) and treatment with exogenous vasoconstrictors during the operation (RR = 2.27; P = .016) were identified as risk factors for developing AKI after liver transplantation.

Spatio-temporal coherence of free electron laser pulses in the soft x-ray regime

The temporal coherence properties of soft x-ray free electron laser pulses at FLASH are measured at 23.9 nm by interfering two time-delayed partial beams directly on a CCD camera. The partial beams are obtained by wave front beam splitting in an autocorrelator operating at photon energies from h nu = 30 to 200 eV. At zero delay a visibility of (0.63+/- 0.04) is measured. The delay of one partial beam reveals a coherence time of 6 fs at 23.9 nm. The visibility further displays a non-monotonic decay, which can be rationalized by the presence of multiple pulse structure.

Mechanism of the poisoning action of sulfur on catalytically active Pd(100)

The influence of sulfur adsorbates on the stereodynamics of surface reactions is evaluated for the associative desorption of D2 from Pd(100). The experimental results show that translational and rotational steering is more effective than at the clean surface, which implies that the potential energy surface (PES) for the reaction shows a larger spatial extension into the vacuum than for the clean surface. A significant polar corrugation of the PES becomes evident at high J" states. At J" = 8 a very strong coverage dependence of the alignment with A(2)0 = 0.07+/-0.06 at the clean surface and A(2)0 = 0.60+/-0.11 at Theta(S) = 0.5 monolayer is observed. This coverage dependence indicates a shift of the reaction site from the bridge to the c-type hollow position at a sulfur coverage of more than Theta(S) = 0.25 monolayer.

The New York University Pediatric Heart Failure Index: a new method of quantifying chronic heart failure severity in children

OBJECTIVE

The assessment of the severity of heart failure in pediatric patients is handicapped by the subjectivity of diagnostic parameters. This study evaluated the feasibility of a new standardized heart failure index, the New York University Pediatric Heart Failure Index (NYU PHFI), to quantify the degree of heart failure in a selected pediatric population.

METHODS AND RESULTS

The index is a weighted, linear combination of scores based on symptoms, physical signs, and medical regimen. Overall, healthy children (n = 12) scored very low (0 to 2) on this index. Mean scores of children (<2 years; mean age, 4.8 months; n = 12) with a left-to-right shunt lesion declined from 11.4 (SD +/- 4.1, P <.001, 2-tailed test) before surgery to 1.8 (SD +/- 1.3) after surgical correction of their cardiac defects. The average inter-observer correlation coefficient was 0.95 (P <.001), despite a wide range of scores.

CONCLUSIONS

The NYU PHFI appears to be a reliable and convenient instrument for measuring heart failure severity in children. These initial results support further testing in broader diagnostic and age groups and over longer periods.

Efficacy and side effects of intermittent intravenous and oral doxercalciferol (1alpha-hydroxyvitamin D(2)) in dialysis patients with secondary hyperparathyroidism: a sequential comparison

Most reports on the effectiveness and side effects of oral versus parenteral calcitriol or alfacalcidol in hemodialysis patients with secondary hyperparathyroidism show no advantage of parenteral treatment. The efficacy and safety of intravenous doxercalciferol (1alphaD(2)) were studied in hemodialysis patients with secondary hyperparathyroidism (plasma intact parathyroid hormone [iPTH]: range, 266 to 3,644 pg/mL; median, 707 pg/mL). These results were compared with those of a previous trial using intermittent oral 1alphaD(2); the same 70 patients were entered onto both trials, and 64 patients completed both trials per protocol. Twelve weeks of open-label treatment in both trials were preceded by identical 8-week washout periods. Degrees of iPTH suppression from baseline were similar in the two trials, with iPTH level reductions less than 50% in 89% and 78% of patients during oral and intravenous treatment, respectively. Grouping patients according to entry iPTH levels (<750 and >/=750 pg/mL) showed similar but more rapid iPTH suppression in the low-iPTH groups, whereas longer treatment and larger doses were required by the high-iPTH groups. Highest serum calcium levels averaged 9.82 +/- 0.14 and 9.67 +/- 0.11 mg/dL during oral and intravenous 1alphaD(2) treatment, respectively (P: = not significant [NS]). Prevalences of serum calcium levels greater than 11.2 mg/dL during oral and intravenous treatment were 3.62% and 0.86% of calcium measurements, respectively (P: < 0.001). Highest serum phosphorus levels during oral and intravenous treatment averaged 5.82 +/- 0.21 and 5.60 +/- 0.21 mg/dL, respectively (P: = NS). The percentage of increments in serum phosphorus levels during oral treatment exceeded that during intravenous treatment during 5 of 12 treatment weeks. Thus, intermittent oral and intravenous therapy with 1alphaD(2) reduced iPTH levels effectively and similarly, hypercalcemia was less frequent, and serum phosphorus levels increased less during intravenous than oral 1alphaD(2) therapy, suggesting that intravenous 1alphaD(2) therapy may be advantageous in patients prone to hypercalcemia or hyperphosphatemia.

[Vitamin C in treatment of certain cardiovascular diseases]

The human organism is incapable of producing vitamin C by biosynthesis. We are therefore totally dependent on the presence of this vitamin in our diet. Vitamin C is capable of essentially influencing the course of many metabolic processes, and it is therefore used in the treatment and prophylaxis of many diseases, including those that are a consequence of the activity of the so-called reactive forms of oxygen. The presence of vitamin C in the anti-oxidant protective system is believed to be very important, since it can react with the free radicals of oxygen and other oxidants, and "sweep" them away. Therefore, attention is more and more frequently focused on the possibility of using vitamin C in the treatment of those circulatory diseases that are believed to be associated with the action of free radicals. Routine administration of vitamin C should be therefore recommended in the treatment of patients with coronary arterial disease, treatment of patients after cardiac infarction or cerebral stroke, or in the treatment of arterial hypertension.

Abnormal right coronary artery flow and multiple right ventricular myocardial infarctions associated with severe right ventricular systolic hypertension

The impact of left ventricular hypertension on coronary flow patterns in adult patients has been well described. In contrast, few reports exist regarding the association of right coronary flow abnormalities with right ventricular hypertension. The observation of myocardial infarcts, right ventricular hypertension, and abnormal coronary flow pattern-as well as its normalization with relief of right ventricular hypertension-lends support to a causal relation between ventricular hypertension and coronary flow abnormalities.

Intraoperative myocardial ischemia recognized by transesophageal echocardiography monitoring in the pediatric population: a report of 3 cases

We used continuous intraoperative transesophageal echocardiography (TEE) monitoring to detect intraoperative myocardial ischemia in children after they had been weaned from cardiopulmonary bypass for cardiac surgery. Three pediatric patients are described here to illustrate the usefulness of such TEE monitoring in surgical procedures involving coronary arteries. The indications for intraoperative TEE monitoring and a simplified scheme for immediate qualitative interpretation are discussed.

Left ventricular volume after correction of isolated aortic coarctation in neonates

To determine the capacity of the left ventricle to expand after biventricular repair of left ventricular (LV) outflow tract obstruction, we studied pre- and postoperative echocardiographic variables from 14 infants (< 2 months old) who underwent successful repair of isolated aortic coarctation. We show that in this lesion, LV volume is a dynamic entity, and that the left ventricle achieves a larger cavity size once surgery relieves compression and normalizes loading conditions.

Transesophageal imaging of the mid to distal left pulmonary artery in congenital heart disease

We assessed how well transesophageal echocardiography (TEE) images the left pulmonary artery (LPA) in congenital heart disease (CHD). Seventy-nine consecutive patients with CHD were studied. Ideal imaging displayed the mid to distal LPA from the takeoff of the upper lobe artery through the second bifurcation. Imaging quality was graded from 1 (excellent) to 5 (not visualized). Imaging quality was excellent in 8 (10%) patients, good in 25 (32%), fair in 23 (29%), and poor in 12 (15%); the LPA was not visualized in 11 (14%) patients. Imaging grade averaged 2.9 +/- 1.2 (SD) and correlated poorly with weight (r = 0.24) but was better in patients without prior operation (grade 2.8 vs 3.3, P <.05). In 2 patients, TEE showed residual stenosis. Thus informative LPA imaging by TEE can be achieved in many patients with CHD and has the potential to change intraoperative or postoperative treatment.

Pediatric echocardiography: applications and limitations

Echocardiography is an extraordinarily useful imaging technique in fetuses, infants, children, and adolescents. Recent technologic innovations have expanded its versatility in the pediatric population. However, limited societal resources, limitations inherent to ultrasound imaging, and numerous imaging options even within the field of pediatric echocardiography necessitate the discriminate and thoughtful use of echocardiography in children. The clinical assessment remains a critical prelude to echocardiographic examination of the pediatric cardiovascular system.

Acute peripheral inflammation induces moderate glial activation and spinal IL-1beta expression that correlates with pain behavior in the rat

Our laboratory has previously shown that glial activation and increased proinflammatory cytokine expression are observed in the rat spinal cord following peripheral nerve injuries that result in neuropathic pain behaviors. In the present study, we sought to determine whether acute peripheral inflammation induces changes in central glial and cytokine (Interleukin-1beta) expression similar to those seen following peripheral spinal nerve transection. Two models of peripheral inflammation were used in this study: formalin (5% solution) or zymosan (25 mg/ml) injected subcutaneously into the plantar portion of the left hind paw of male Holtzman-strain Sprague-Dawley rats. The rats were euthanized at 1 h, 6 h, and 1, 3, 7 days post-injection (n=4 or 5/group/time point). As expected, the animals treated with formalin showed a spontaneous pain response and mechanical allodynia that persisted for approximately 60 min following injection. The animals treated with zymosan exhibited mild spontaneous pain responses during the first hour and mechanical allodynia at 6 h and 1 day following injection. Immunohistochemistry for glial activation and cytokine expression was performed on L4-L5 spinal levels in all rats. Spinal sections from both formalin and zymosan treated animals exhibited microglial and astrocytic activation and increased Interleukin-1beta immunoreactivity at 1 and 6 h, respectively. Spinal glial activation and upregulation of Interleukin-1beta appear to parallel the development and maintenance of zymosan and formalin-induced mechanical allodynia. These findings support a unifying theory that glial activation and cytokine expression have a similar, if not related, role in producing hyperalgesia following either peripheral inflammation or peripheral nerve injury.

[Vitamin C in medicine: "normal concentration" in serum]

Vitamin C functions in a human organism have been discussed. Connection with many diseases and its systemic deficiency has been emphasized. A review of current application of this vitamin in medicine has been made. Problems accompanying the use of reference sources of vitamin C "normal concentrations" in blood plasma have been characterised. 10 ranges of concentrations given by medical handbooks and textbooks have been compared in detail with 15 parallel ranges taken from scientific papers, paying attention to their significant discrepancies. Basing on source values, performing basic statistical calculations, a reliable mean range of vitamin C "normal concentrations" in blood plasma has been obtained: 36.1-79.4 mumol/l.

The phenotype of SLE associated with complete deficiency of complement isotype C4A

Complete deficiency of the complement C4A isotype is a known genetic risk factor for systemic lupus erythematosus (SLE). The disease phenotype of C4A-deficient patients has never been defined. Among 200 patients with SLE from five centers, 18 (9%) with C4A deficiency were identified. These individuals were compared to those who were C4A replete with regard to a series of clinical and serologic features. The only significant differences between the two groups were in the presence of renal disease (C4A deficient, 11%; C4A replete, 46%; P < 0.006) and a decrease in the serum concentrations of C3 (C4A deficient, 11%; C4A replete, 35%; P < 0.04). There was also a trend for the C4A-deficient individuals to have milder disease. In light of the tendency for C4A-deficient individuals to have lower serum concentrations of C4, it is important that such patients not be subjected to overly aggressive efforts to "normalize" their C4 levels.

Unusual case of prominent Chiari network trapped in the left atrium

We describe a case of an unusually prominent Chiari network in a premature neonate who was evaluated with echocardiography. The network, which is an embryologic remnant, was extensive, mobile, and moved in and out of the right ventricle. Later, tissue strands passed the foramen ovale and ultimately became trapped in the left atrium. The differential diagnosis included thrombus, tumor, vegetation, and ruptured chordae.

Loss of protein kinase C inhibition in the beta-T594M variant of the amiloride-sensitive Na+ channel

We previously reported the presence of a novel variant (beta-T594M) of the amiloride-sensitive Na+ channel (ASSC) in which the threonine residue at position 594 in the beta-subunit has been replaced by a methionine residue. Electrophysiological studies of the ASSC on Epstein-Barr virus (EBV)-transformed lymphocytes carrying this variant showed that the 8-(4-chlorophenylthio) adenosine 3':5'-cyclic monophosphate (8cpt-cAMP)-induced responses were enhanced when compared to wild-type EBV-transformed lymphocytes. Furthermore, in wild-type EBV-transformed cells, the 8cpt-cAMP-induced response was totally blocked by the phorbol ester, phorbol 12-myristate 13-acetate (PMA). This inhibitory effect of PMA was blocked by a protein kinase C inhibitor, chelerythrine. We now have identified individuals who are homozygous for this variant, and showed that PMA had no effect on the 8cpt-cAMP-induced responses in the EBV-transformed lymphocytes from such individuals. Cells heterozygous for this variant showed mixed responses to PMA, with the majority of cells partially inhibited by PMA. Our results demonstrate that an alteration in a single amino acid residue in the beta-subunit of the ASSC can lead to a total loss of inhibition to PMA, and establish the beta-subunit as having an important role in conferring a regulatory effect on the ASSC of lymphocytes.

Electrocardiographic measures and heart rate variability in patients with familial dysautonomia

Cardiovascular abnormalities are prominent in the genetic disorder, familial dysautonomia (FD). To determine if autonomic dysfunction involves cardiac, as well as peripheral vascular integrity, noninvasive tests were performed in 10 FD patients and 8 healthy control subjects while supine and at 90 degrees tilt. Simultaneous blood pressure (BP) and heart rate (HR) and QTc were obtained, while performing signal-averaged electrocardiography (SAECG) and heart rate variability (HRV). FD subjects were tested on 2 separate days, before and 1 h after oral fludrocortisone or midodrine; controls were tested once without medication. With tilt, all FD subjects decreased mean BP > or = 24 mm Hg by 5 min. On SAECG, 70% of supine FD subjects had a prolonged tQRS; only 2 FD subjects shortened tQRS with tilt. The QTc interval was prolonged (> 440 ms) in 2 supine FD subjects; with tilt, the QTc prolonged in a third. Frequency domain analysis of HRV revealed that mid (MF) and high frequency band areas were significantly decreased when supine, but not when upright. On time domain analysis, the pNN50 was significantly decreased in FD subjects (8.9 +/- 1.7 vs. 17.7 +/- 3.6%, p < 0.01). Fludrocortisone lowered supine BP and HR and increased supine MF area. Midodrine raised supine and erect BP, lowered erect HR, and shortened erect QTc. Although all FD subjects have abnormal orthostatic BP and HR responses, cardiac tone, as assessed by electrocardiographic and HRV responses, varies. Prolongation of the tQRS appears to be a sensitive but not specific indicator of autonomic dysfunction. QTc prolongation may indicate more extensive sympathetic dysfunction. HRV data suggest some FD patients have abnormalities in parasympathetic, as well as sympathetic, cardiac tone.

The influence of alkoxymethyl purine and pyrimidine acyclonucleosides on growth inhibition of Kirkman-Robbins hepatoma and possible mechanism of their cytostatic activity

Newly synthesized allyloxymethyl purine and pyrimidine acyclonucleosides [Fig. 1, comp. 1-6] were tested in Syrian hamster, six days after heterotransplantations of Kirkman-Robbins hepatoma and compared with Th5, Th5P and PMT [Fig. 1, comp. 7-9]. 48 hours after intraperitoneal (i.p.) administration of AMT and Th5 in a dose of 80 mg per kg body weight, these compounds reduced tumor weight by 42%, while AMU (in the same dose) by 30%. The inhibition of tumor weight is accompanied by a decrease in dThd and dGuo kinase activities in tumor cytosol by AMU (36% and 33%, respectively) by AMT (59% and 53%, respectively) and by Th5 (58% and 55%, respectively). AMU, AMT and Th5 are phosphorylated in vivo by kinases present in cytosol of growing hepatoma to mono, di and triphosphates, but allyloxymethyl residue of AMU and AMT is first hydrated to hydroxypropoxymethyl residue, having CH2OH group. The lack of phosphorylation of PMT in vivo (having saturated propoxymethyl residue) and phosphorylation of Th5P (when used as a substrate for dNMP kinase) only to Th5 diphosphate suggested that AMU, AMT and Th5 triphosphates are responsible for the inhibition of dTMP and dGMP synthesis.

Renal blood flow velocity in neonates with and without umbilical artery catheters

We performed an observational prospective cohort study on the applicability of two-dimensional echocardiography with pulsed Doppler technique as a noninvasive modality to serially evaluate renal blood velocities in premature neonates with and without umbilical artery catheters. We also sought to determine the incidence of umbilical artery catheter-related thrombus formation in our neonatal intensive-care unit. We established normative values for renal artery blood flow velocities in premature neonates and postulate that this echo-Doppler technique is valid and can be used to evaluate renal developmental physiology in the neonatal population. In addition, we observed that even in the absence of clinical sequelae due to thrombus formation, the presence of a thrombus in the aorta caused abnormalities in renal hemodynamics.

Sinus venosus atrial septal defect associated with vein of Galen malformations: report of two cases

Two unique cases are presented of infants with signs of vein of Galen malformations, whose unsuspected associated sinus venosus atrial septal defects were detected during routine echocardiography. A conservative approach to cardiac treatment is advocated.

Abnormalities of the corrected QT interval in familial dysautonomia: an indicator of autonomic dysfunction

We report abnormalities in corrected QT intervals with changes in position and after exercise in patients with familial dysautonomia and confirm the previously reported finding of abnormal heart rate and blood pressure responses. Prolonged corrected QT intervals (> 440 msec) with lack of appropriate shortening with exercise is a noninvasive means of demonstrating an aberration in autonomic regulation of cardiac conduction.

Transient third-degree atrioventricular block in a 4-year-old child with familial dysautonomia

The case of a transient third degree atrioventricular block in a 4-year-old patient with familial dysautonomia is reported. A review of the literature follows with analysis of the significance of arrhythmias in the natural history of the patient with familial dysautonomia.

Biotransformation, by Enterobacter agglomerans, of pyrimidine acyclonucleosides to acyclonucleotides

The ability of Enterobacter agglomerans to transform naturally occurring nucleosides into nucleotides has been utilized to transform newly synthesized pyrimidine acyclonucleosides into the corresponding acyclonucleotides. Unselected bacteria were used as the source of nucleoside phosphotransferase, the phosphate group donor being 4-nitrophenyl phosphate in the presence of Zn2+ ions. Optimal reaction conditions are outlined.

Juvenile autoimmune thyroiditis and mitral valve prolapse

An increased incidence of mitral valve prolapse (MVP) has been reported in adult patients with autoimmune thyroid disease. The aim of this study was to assess the incidence of MVP in children and adolescents with juvenile autoimmune thyroiditis (JAT). Cardiac echo studies using M-mode, 2D, and Doppler examinations were performed on 23 patients (21 females, 2 males). The patients were studied at a median age of 12 years (range 5-20 years). Only one patient was found to have evidence suggestive of MVP, an incidence (4.3%) similar to that seen in the normal pediatric population. We, therefore, conclude that the incidence of MVP in children and adolescence with JAT is not increased.

Anomalous origin of the left coronary artery. Use of thallium perfusion scans in the evaluation of successful revascularization

Thallium imaging was performed on a 2-month-old infant with a left coronary artery originating from the pulmonary artery. Imaging was performed before and after corrective surgery, which involved creating a new left coronary osteum from the ascending aorta. The radionuclide study documented successful revascularization postoperatively.

Repair of posterior left ventricular aneurysm in a six-year-old boy

Left ventricular aneurysms and diverticula are rarely encountered in the pediatric age group. This paper reports a case of congestive heart failure and mitral regurgitation in a 6-year-old boy with a large posterolateral left ventricular aneurysm. Complete repair was successfully performed by excision of the aneurysm and Dacron patch reconstruction of the left ventricular free wall. The patch extended onto the posterior annulus of the mitral valve, thus restoring the mitral valve to normal geometry and correcting the mitral insufficiency. The surgical literature on congenital cardiac diverticula and acquired aneurysms in children is reviewed and summarized.

Congenital fistulous tract between aorta and right atrium presenting as heart failure in a newborn

A newborn with a fistulous communication between the right coronary sinus and right atrium had congestive heart failure on the first day of life. Medical management was unsuccessful and operative repair was performed using bypass surgery at 5 days of age. Echocardiographic evaluation preoperatively diagnosed the defect correctly and postoperatively confirmed a complete repair. Since aneurysms and/or fistulae can occur in other sinuses after an initial repair of the presenting lesion, the infant will continue to be followed with periodic echocardiographic and clinical evaluations.