Prevalence of SARS-CoV-2 in newborns born to SARS-CoV-2-positive mothers at 2 weeks of life

Introduction

Limited evidence exists on management recommendations for neonates born to SARS-CoV-2-positive mothers. This study looked at transmission risk of neonates presenting for primary care in a large regional health system within New York during the early months of the COVID-19 pandemic.

Methods

This was a prospective, observational study of newborns born to SARS-CoV-2-positive mothers presenting at any of the 19 Northwell Health-Cohen Children's Medical Center primary care practices who underwent another oropharyngeal/nasopharyngeal swab for detection of SARS-CoV-2 by day of life (DOL) 14.

Results

Among 293 newborns born to SARS-CoV-2-positive mothers who were negative at birth, 222 were retested at DOL 14, corresponding to times with different predominant strains. Of these, seven tested positive but had no symptoms.

Conclusion

The overall low transmission rates and absence of symptomatic infection support the safety of direct breastfeeding after hospital discharge with appropriate hand and breast hygiene.

Maternal immune activation and role of placenta in the prenatal programming of neurodevelopmental disorders

Maternal infection during pregnancy, leading to maternal immune activation (mIA) and cytokine release, increases the offspring risk of developing a variety of neurodevelopmental disorders (NDDs), including schizophrenia. Animal models have provided evidence to support these mechanistic links, with placental inflammatory responses and dysregulation of placental function implicated. This leads to changes in fetal brain cytokine balance and altered epigenetic regulation of key neurodevelopmental pathways. The prenatal timing of such mIA-evoked changes, and the accompanying fetal developmental responses to an altered in utero environment, will determine the scope of the impacts on neurodevelopmental processes. Such dysregulation can impart enduring neuropathological changes, which manifest subsequently in the postnatal period as altered neurodevelopmental behaviours in the offspring. Hence, elucidation of the functional changes that occur at the molecular level in the placenta is vital in improving our understanding of the mechanisms that underlie the pathogenesis of NDDs. This has notable relevance to the recent COVID-19 pandemic, where inflammatory responses in the placenta to SARS-CoV-2 infection during pregnancy and NDDs in early childhood have been reported. This review presents an integrated overview of these collective topics and describes the possible contribution of prenatal programming through placental effects as an underlying mechanism that links to NDD risk, underpinned by altered epigenetic regulation of neurodevelopmental pathways.

Oscillatory Deficits in the Sub-Chronic PCP Rat Model for Schizophrenia Are Reversed by mGlu5 Receptor-Positive Allosteric Modulators VU0409551 and VU0360172

The cognitive deficits of schizophrenia are linked to imbalanced excitatory and inhibitory signalling in the prefrontal cortex (PFC), disrupting gamma oscillations. We previously demonstrated that two mGlu5 receptor-positive allosteric modulators (PAMs), VU0409551 and VU0360172, restore cognitive deficits in the sub-chronic PCP (scPCP) rodent model for schizophrenia via distinct changes in PFC intracellular signalling molecules. Here, we have assessed ex vivo gamma oscillatory activity in PFC slices from scPCP rats and investigated the effects of VU0409551 and VU0360172 upon oscillatory power. mGlu5 receptor, protein kinase C (PKC), and phospholipase C (PLC) inhibition were also used to examine ‘modulation bias’ in PAM activity. The amplitude and area power of gamma oscillations were significantly diminished in the scPCP model. Slice incubation with either VU0409551 or VU0360172 rescued scPCP-induced oscillatory deficits in a concentration-dependent manner. MTEP blocked the PAM-induced restoration of oscillatory power, confirming the requirement of mGlu5 receptor modulation. Whilst PLC inhibition prevented the power increase mediated by both PAMs, PKC inhibition diminished the effects of VU0360172 but not VU0409551. This aligns with previous reports that VU0409551 exhibits preferential activation of the phosphatidylinositol-3-kinase (PI3K) signalling pathway over the PKC cascade. Restoration of the excitatory/inhibitory signalling balance and gamma oscillations may therefore underlie the mGluR5 PAM-mediated correction of scPCP-induced cognitive deficits.

Maternal Immune Activation Induces Adolescent Cognitive Deficits Preceded by Developmental Perturbations in Cortical Reelin Signalling

Exposure to maternal immune activation (MIA) in utero significantly elevates the risk of developing schizophrenia and other neurodevelopmental disorders. To understand the biological mechanisms underlying the link between MIA and increased risk, preclinical animal models have focussed on specific signalling pathways in the brain that mediate symptoms associated with neurodevelopmental disorders such as cognitive dysfunction. Reelin signalling in multiple brain regions is involved in neuronal migration, synaptic plasticity and long-term potentiation, and has been implicated in cognitive deficits. However, how regulation of Reelin expression is affected by MIA across cortical development and associated cognitive functions remains largely unclear. Using a MIA rat model, here we demonstrate cognitive deficits in adolescent object-location memory in MIA offspring and reductions in Reln expression prenatally and in the adult prefrontal cortex. Further, developmental disturbances in gene/protein expression and DNA methylation of downstream signalling components occurred subsequent to MIA-induced Reelin dysregulation and prior to cognitive deficits. We propose that MIA-induced dysregulation of Reelin signalling contributes to the emergence of prefrontal cortex-mediated cognitive deficits through altered NMDA receptor function, resulting in inefficient long-term potentiation. Our data suggest a developmental window during which attenuation of Reelin signalling may provide a possible therapeutic target.

The Falkland Islands marine ecosystem: A review of the seasonal dynamics and trophic interactions across the food web

The Falkland Islands marine environment host a mix of temperate and subantarctic species. This review synthesizes baseline information regarding ontogenetic migration patterns and trophic interactions in relation to oceanographic dynamics of the Falkland Shelf, which is useful to inform ecosystem modelling. Many species are strongly influenced by regional oceanographic dynamics that bring together different water masses, resulting in high primary production which supports high biomass in the rest of the food web. Further, many species, including those of commercial interest, show complex ontogenetic migrations that separate spawning, nursing, and feeding grounds spatially and temporally, producing food web connections across space and time. The oceanographic and biological dynamics may make the ecosystem vulnerable to climatic changes in temperature and shifts in the surrounding area. The Falkland marine ecosystem has been understudied and various functional groups, deep-sea habitats and inshore-offshore connections are poorly understood and should be priorities for further research.

Characterisation of C101248: A novel selective THIK-1 channel inhibitor for the modulation of microglial NLRP3-inflammasome

Neuroinflammation, specifically the NLRP3 inflammasome cascade, is a common underlying pathological feature of many neurodegenerative diseases. Evidence suggests that NLRP3 activation involves changes in intracellular K+. Nuclear Enriched Transcript Sort Sequencing (NETSseq), which allows for deep sequencing of purified cell types from human post-mortem brain tissue, demonstrated a highly specific expression of the tandem pore domain halothane-inhibited K+ channel 1 (THIK-1) in microglia compared to other glial and neuronal cell types in the human brain. NETSseq also showed a significant increase of THIK-1 in microglia isolated from cortical regions of brains with Alzheimer's disease (AD) relative to control donors. Herein, we report the discovery and pharmacological characterisation of C101248, the first selective small-molecule inhibitor of THIK-1. C101248 showed a concentration-dependent inhibition of both mouse and human THIK-1 (IC50: ∼50 nM) and was inactive against K2P family members TREK-1 and TWIK-2, and Kv2.1. Whole-cell patch-clamp recordings of microglia from mouse hippocampal slices showed that C101248 potently blocked both tonic and ATP-evoked THIK-1 K+ currents. Notably, C101248 had no effect on other constitutively active resting conductance in slices from THIK-1-depleted mice. In isolated microglia, C101248 prevented NLRP3-dependent release of IL-1β, an effect not seen in THIK-1-depleted microglia. In conclusion, we demonstrated that inhibiting THIK-1 (a microglia specific gene that is upregulated in brains from donors with AD) using a novel selective modulator attenuates the NLRP3-dependent release of IL-1β from microglia, which suggests that this channel may be a potential therapeutic target for the modulation of neuroinflammation in AD.

Development from a distance: Exploring an international non-profit's interactions with communities during the COVID-19 pandemic

A case study analysis of an international development non-profit identifies strategies and decision-making processes utilized to engage community members in person and virtually during the first year of the COVID-19 pandemic. The strategies employed led to a continuation of projects in the field, potentially excluding some stakeholder groups from decision-making processes at the community level. Staff members described how power dynamics and geographic distance affected internal decision-making for community involvement, highlighting the importance of adopting a critical self-reflection approach to facilitate communication among an intercultural team for more equitable community engagement.

Clustering of cognitive phenotypes identifies susceptible and resilient offspring in a rat model of maternal immune activation and early-life stress

Schizophrenia and other neurodevelopmental disorders often have very heterogeneous symptoms, especially regarding cognition: while some individuals may exhibit deficient cognition, others are relatively unaffected. Studies using developmental animal models often ignore phenotypic heterogeneity in favour of traditional treatment/control comparisons. This may result in resilient or unaffected individuals masking the effects of susceptible individuals if grouped together. Here, we used maternal immune activation and limited bedding and nesting, respectively, as a two-hit neurodevelopmental model for schizophrenia. Both factors reduced cognitive function in a novel object recognition (NOR) task. While we found treatment group effects on cognitive phenotypes, behavioural clustering identified three subpopulations exposed to either insult: those exhibiting ‘typical’ cognitive performance on the NOR, an intermediate phenotype, or a marked deficit. These clusters included offspring from each treatment group, although both intermediate and marked deficit clusters were composed primarily of offspring from treated groups. Clustering allowed stratification within treatment groups into ‘susceptible’ and ‘resilient’ individuals, while also identifying conserved phenotypes across treatment groups. Using unbiased cluster analyses in preclinical models can better characterize phenotypes and enables a better understanding of both face and construct validity of phenotypic heterogeneity. The use of unbiased clustering techniques may help identify potential markers associated with individual susceptibility and resilience in neurodevelopmental disorder models.

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Maternal immune activation and early life stress affect recognition memory.

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New groups were identified using unbiased clustering based on task performance.

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These clusters reflected high-, low-, and intermediary recognition memory.

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Treatment offspring were distributed across all three unbiased clusters.

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These findings suggest some offspring will be resilient to developmental insults.

The two pore potassium channel THIK-1 regulates NLRP3 inflammasome activation

The NLRP3 (NLR family, pyrin domain containing 3) inflammasome is a multi-protein complex responsible for the activation of caspase-1 and the subsequent cleavage and activation of the potent proinflammatory cytokines IL-1β and IL-18, and pyroptotic cell death. NLRP3 is implicated as a driver of inflammation in a range of disorders including neurodegenerative diseases, type 2 diabetes, and atherosclerosis. A commonly reported mechanism contributing to NLRP3 inflammasome activation is potassium ion (K⁺ ) efflux across the plasma membrane. Identification of K⁺ channels involved in NLRP3 activation remains incomplete. Here, we investigated the role of the K⁺ channel THIK-1 in NLRP3 activation. Both pharmacological inhibitors and cells from THIK-1 knockout (KO) mice were used to assess THIK-1 contribution to macrophage NLRP3 activation in vitro. Pharmacological inhibition of THIK-1 inhibited caspase-1 activation and IL-1β release from mouse bone-marrow-derived macrophages (BMDMs), mixed glia, and microglia in response to NLRP3 agonists. Similarly, BMDMs and microglia from THIK-1 KO mice had reduced NLRP3-dependent IL-1β release in response to P2X7 receptor activation with ATP. Overall, these data suggest that THIK-1 is a regulator of NLRP3 inflammasome activation in response to ATP and identify THIK-1 as a potential therapeutic target for inflammatory disease.

Investigating Markers of the NLRP3 Inflammasome Pathway in Alzheimer's Disease: A Human Post-Mortem Study

Neuroinflammatory mechanisms with glial cell activation have been implicated in the pathogenic process of Alzheimer’s disease (AD). Activation of the NLRP3 inflammasome is an essential component of the neuroinflammatory response. A role for NLRP3 activation in AD is supported by both in vitro and in vivo preclinical studies with little direct investigation of AD brain tissue. RNA expression of genes of three glial cell markers, HLA-DRA, AIF-1 and GFAP; the components of the NLRP3 inflammasome NLRP3, ASC, and caspase-1; and downstream pre-inflammatory cytokines IL-1 β and IL-18, were investigated in the temporal cortex of AD patients and age- and sex-matched controls. Protein expression of GFAP was also assessed. Increases in both mRNA and protein expression were observed for GFAP in AD. There were no significant changes in other NLRP3 activation markers between groups. Our results indicate the involvement of astrocyte activation in AD, particularly in more severe patients. We found no evidence for the specific involvement of the NLRP3 inflammasome.

WTO must ban harmful fisheries subsidies

[Figure: see text].

Fabrication of Amyloid-β-Secreting Alginate Microbeads for Use in Modelling Alzheimer's Disease

According to the amyloid cascade hypothesis, the earliest trigger in the development of Alzheimer's disease (AD) is the accumulation of toxic amyloid-β (Aβ) fragments, eventually leading to the classical features of the disease: amyloid plaques, neurofibrillary tangles and synaptic and neuronal loss. The lack of relevant non-transgenic preclinical models reflective of disease progression is one of the main factors hindering the discovery of effective drug treatments. To this end, we have developed a protocol for the fabrication of alginate microbeads containing amyloid-secreting cells useful for the study of the effects of chronic Aβ production. Chinese hamster ovary cells previously transfected with a human APP gene, secreting Aβ (i.e., 7PA2 cells), were used in this study. A three-dimensional (3D) in vitro model for the sustained release of Aβ was fabricated by encapsulation of 7PA2 cells in alginate. The process was optimized to target a bead diameter of 500-600 μm for further in vivo studies. Optimization of 7PA2 cell encapsulation in alginate was performed altering fabrication parameters, e.g., alginate concentration, gel flow rate, electrostatic potential, head vibration frequency, gelling solution. Levels of secreted Aβ were analyzed over time and compared between alginate beads and standard cell culture methods (up to 96 h). A concentration of 1.5 x 10⁶ 7PA2 cells/mL and an alginate concentration of 2% (w/v) buffered with HEPES and subsequent gelation in 0.5 M calcium chloride for 5 min were found to fabricate the most stable microbeads. Fabricated microbeads were 1) of uniform size, 2) with an average diameter of 550 μm, 3) containing about 100-150 cells per microbead and 4) able to secrete Aβ. In conclusion, our optimized method for the production of stable alginate microbeads containing amyloid-producing 7PA2 cells might enable the modeling of important aspects of AD both in vitro and in vivo.

A systematic review and meta-analysis of cognitive remediation in early schizophrenia

Neurocognitive impairment predicts disability in schizophrenia, making intervention theoretically attractive as a means to minimise chronic disability. Many trials confirm that cognitive remediation (CR) produces meaningful, durable improvements in cognition and functioning but fewer focus on the early stages. We systematically reviewed CR trials in early schizophrenia to determine its efficacy on global cognition, functioning and symptoms. Two reviewers independently searched electronic databases to identify randomised controlled trials investigating CR following a first episode of psychosis. Eleven trials with 615 participants were identified. Random effect models revealed a non-significant effect of CR on global cognition (effect size=0.13, 95% CI -0.04, 0.31; p0.14), p<0.05 in sensitivity analysis (effect size 0.19; CI 0.00, 0.38). One of seven neurocognitive domains showed a significant positive effect (verbal learning and memory) and five others showed borderline significant benefits. There was a significant effect on functioning (0.18; CI 0.01, 0.36; p<0.05) and symptoms (0.19; CI 0.02, 0.36; p<0.05). CR's effect on functioning and symptoms was larger in trials with adjunctive psychiatric rehabilitation and small group interventions. CR's effect sizes in early illness were smaller than those in chronic schizophrenia, perhaps because of participants' reduced scope for improvement, though trials' small number and size produces uncertain estimates of effect. However, significant benefits were seen in functioning and symptoms and moderator analyses indicate factors that may increase CR's effect. Findings here, theoretical considerations and trials in chronic schizophrenia suggest that targeting social cognition might also enhance its efficacy.

Schizophrenia-related endophenotypes in heterozygous neuregulin-1 'knockout' mice

Neuregulin-1 (NRG1) has been shown to play a role in glutamatergic neurotransmission and is a risk gene for schizophrenia, in which there is evidence for hypoglutamatergic function. Sensitivity to the behavioural effects of the psychotomimetic N-methyl-D-aspartate receptor antagonists MK-801 and phencyclidine (PCP) was examined in mutant mice with heterozygous deletion of NRG1. Social behaviour (sociability, social novelty preference and dyadic interaction), together with exploratory activity, was assessed following acute or subchronic administration of MK-801 (0.1 and 0.2 mg/kg) or PCP (5 mg/kg). In untreated NRG1 mutants, levels of glutamate, N-acetylaspartate and GABA were determined using high-performance liquid chromatography and regional brain volumes were assessed using magnetic resonance imaging at 7T. NRG1 mutants, particularly males, displayed decreased responsivity to the locomotor-activating effects of acute PCP. Subchronic MK-801 and PCP disrupted sociability and social novelty preference in mutants and wildtypes and reversed the increase in both exploratory activity and social dominance-related behaviours observed in vehicle-treated mutants. No phenotypic differences were demonstrated in N-acetylaspartate, glutamate or GABA levels. The total ventricular and olfactory bulb volume was decreased in mutants. These data indicate a subtle role for NRG1 in modulating several schizophrenia-relevant processes including the effects of psychotomimetic N-methyl-D-aspartate receptor antagonists.

Evidence for a selective prefrontal cortical gabab receptor-mediated inhibition of glutamate release in the ventral tegmental area: A dual probe microdialysis study in the awake rat

Glutamate-containing pyramidal neurons in the medial prefrontal cortex (mPfc) project to the ventral tegmental area (VTA) where they synapse on mesocorticolimbic dopamine containing cell bodies and GABA interneurons. In the present study we employed dual probe microdialysis in intact conscious rat brain to investigate the effects of intra-mPfc perfusion with a depolarising concentration of potassium chloride (KCl) (100 mM, 20 min) alone and in the presence of local GABA(A) and GABA(B) receptor blockade on VTA glutamate release. Intra-mPfc KCl transiently increased VTA glutamate release (+71.48+/-14.29%, 20 min). Intra-mPfc perfusion with a concentration of the GABA(A) receptor antagonist bicuculline (10 microM, 120 min) did not influence the intra-mPfc KCl-induced increase in VTA glutamate release (+102.35+/-33.61%, 20 min). In contrast, intra-mPfc perfusion with a concentration of the GABA(B) receptor antagonist CGP35348 (100 microM, 120 min) which when given alone did not influence basal glutamate levels in the VTA was associated with an enhanced KCl-induced stimulation of VTA glutamate release (+375.19+/-89.69%, 40 min). Furthermore, this enhancement was reversed in the presence of the selective GABA(B) receptor agonist baclofen (10 microM, 120 min). The present findings suggest a key role for the prefrontal cortex in the regulation of glutamate release in the VTA. Furthermore, we demonstrate a selective cortical GABA(B) receptor-mediated inhibition of glutamate transmission in the VTA. These findings may be important in the context of abnormalities in amino acid neurotransmission at the network level in schizophrenia.

Evidence for a differential medial prefrontal dopamine D1 and D2 receptor regulation of local and ventral tegmental glutamate and GABA release: a dual probe microdialysis study in the awake rat

The effects of perfusion with two selective dopamine receptor agonists SKF38393 and pergolide into the medial prefrontal cortex (mPfc) on local and ventral tegmental area (VTA) glutamate and gamma-aminobutyric acid (GABA) release were investigated using dual probe microdialysis in the awake rat. Intracortical SKF38393 (10, 100, 500 microM, 60 min) decreased glutamate and increased GABA release in the mPfc but had no effect on either amino acid neurotransmitter in the VTA. Intracortical perfusion with the selective GABA(A) receptor antagonist bicuculline (0.1 microM, 140 min) reversed the SKF38393 (100 microM, 60 min)-induced decrease in local glutamate release, while the selective GABA(B) receptor antagonist CGP35348 (100 microM, 140 min) was without effect. Intracortical pergolide (1 microM, 60 min) was associated with a prolonged reversible decrease in local and VTA glutamate release that was also associated with a decrease in VTA GABA release, which was reversed in the presence of intracortical raclopride (10 microM, 140 min). Taken together, the present findings indicate a differential regulation of glutamate and GABA release in the mPfc and VTA by dopamine D(1) and D(2) receptors in the mPfc whereby (a) activation of the dopamine D(1) receptor in the mPfc decreases local glutamate release possibly via a feed-forward activation of the local GABA interneurons; (b) activation of the dopamine D(2) receptor in the mPfc inhibits both local glutamate release and the excitatory glutamate drive on the VTA.

A dual probe characterization of dialysate amino acid levels in the medial prefrontal cortex and ventral tegmental area of the awake freely moving rat

Dual probe microdialysis was employed to characterize the origins of dialysate glutamate, aspartate and gamma-aminobutyric acid (GABA) in the medial prefrontal cortex (mPfc) and to investigate functional interactions between the mPfc and ventral tegmental area (VTA) in awake, freely moving rats. Perfusion with elevated potassium (K(+); KCl, 100 mM, 20 min), low Ca(2+) (0.1 mM, 60 min) or tetrodotoxin (TTX, 10 microM, 100 min) was performed in the mPfc and dialysate levels of glutamate, aspartate and GABA were measured locally and in the VTA. Elevated K(+) in the mPfc rapidly increased dialysate glutamate and aspartate locally (+90+/-10 and +41+/-9% from basal, respectively) and in the VTA (+71+/-14 and +42+/-14%, respectively). MPfc GABA was also rapidly increased (+241+/-62%) while VTA GABA was not affected. Perfusion with low Ca(2+) in the mPfc decreased local glutamate, aspartate and GABA (-26+/-8; -35+/-7 and -45+/-8%, respectively) and decreased only GABA (-40+/-5%) in the VTA. Intra-mPfc TTX increased glutamate and aspartate locally (+82+/-23 and +54+/-27%, respectively) and in the VTA (+84+/-18 and +38+/-17%, respectively). In contrast, intra-mPfc TTX decreased local GABA (-33+6%) while VTA GABA levels were not affected. Taken together, these data confirm the influence of the mPfc upon the ipsilateral VTA and provide evidence for two neuronal pools which contribute to basal extracellular mPfc and VTA glutamate, aspartate and GABA levels, the first pool derived from Na(+)- and Ca(2+)-dependent release and the second derived from voltage-dependent reuptake.

External fixation of distal radial fractures

From February 1995 until December 1997 we treated 48 patients aged between 26 and 79 years for distal radial fractures with external fixation. They were treated in an Arbeitsgemeinschaft fur Osteosynthestragen (A.O.) construct for periods of 5-10 weeks, the mean being 6 weeks. Forty patients were available for follow up. Our indications for this procedure were: severe comminuted displaced intra-articular fracture, severe shortening and inability to achieve fixation with other methods. The majority of patients had A.O. Classification type C fractures. Patients at follow up had objective clinical and radiological assessment as well as a subjective functional evaluation. Results were calculated using Stewart's modification of Gartland and Werley's assessment criteria. Functionally 90% achieved an excellent or good result. Radiographically 95% had an excellent or good result.

Pneumatocele complicated by fungal lung abscess in Job's syndrome. Successful lobectomy with the aid of videothoracoscopy

Hyperimmunoglobulin E (Job's) syndrome, is a complex immune disorder characterized by complications involving, pulmonary and cutaneous infections. An 11-year-old girl presented with a pneumatocele superinfected by aspergillosis and occupying almost the entire right lower lobe. Lobectomy was performed with the aid of videothoracoscopic instruments, and 9 months later the patient is doing well.

Sotalol infusion in the treatment of supraventricular tachyarrhythmias

Sotalol, a noncardioselective beta-adrenergic blocking agent without partial agonist activity, has class-3 antiarrhythmic effects. Twenty-nine patients with supraventricular tachyarrhythmias were treated on 31 occasions to determine the effective therapeutic dosage and optimal method of administration. Fifty percent of patients with paroxysmal supraventricular tachycardia, 33 percent of those with atrial flutter, and 20 percent with atrial fibrillation were restored to sinus rhythm by bolus administration; and when sotalol was given by continuous infusion, sinus rhythm was obtained in 100 percent, 86 percent, and 33 percent, respectively. Comparable dosages were given to both responders and nonresponders in the bolus-treated group and higher dosages to nonresponders than to responders in those treated by infusion. Furthermore, plasma levels in nonresponders tended to be higher than in responders. When responders alone were considered, the average dose required was 0.630 +/- 0.090 mg/kg of body weight (+/- SE), and the plasma level obtained was 0.526 +/- 0.088 microgram/ml. No relationship between plasma levels and therapeutic effectiveness was shown. No serious side effects were observed at the dosages used. These data suggest that while no concordance with plasma levels was observed, sotalol given by infusion is an effective therapy for atrial flutter and supra-ventricular tachycardia. It is less effective in atrial fibrillation, where less than half were responders, but a satisfactory reduction in ventricular rate response was obtained. A controlled trial to further substantiate these findings is indicated.