Screening for Fontan-associated liver disease: are we doing enough?

Introduction

Fontan-associated Liver Disease (FALD) is an extracardiac complication with a substantial disease burden that can reduce quality of life, increase healthcare demand and result in premature mortality. Effective FALD screening is paramount in preventing late-stage complications.

Purpose

To assess the adherence of a tertiary adult congenital heart disease referral centre to FALD screening.

Methods

1. A total of 256 Fontan patients reviewed at our centre between 1st January 1977 and 31st December 2020 were identified from the congenital cardiac surgical database and the adult congenital heart disease clinical nurse specialist database.

2. The following patients were excluded: aged under 18 years on 31st December 2020 (103 cases), out of region or loss to follow-up (35 cases), death (30 cases), cardiac or liver transplantation (4 cases) and Fontan takedown (3 cases.) The mean endpoint (death, transplant or Fontan takedown) was 30 years.

3. The final study population included 81 patients.

4. Data was collected by review of clinic letters, blood test and imaging results from electronic records between 1st January 2018 and 31st December 2020.

5. The data were analysed to determine whether the screening recommendations from “Fontan-Associated Liver Disease: Proceedings from the American College of Cardiology Stakeholders Meeting, October 1 to 2, 2015, Washington DC” (ACC Stakeholders Meeting) were performed.

Results

The ACC Stakeholders Meeting recommended history taking and physical examination at least once a year with Fontan blood tests (full blood count, urea and electrolytes, liver function tests, alpha-fetoprotein and international normalized ratio) and imaging (abdominal ultrasound, computerised tomography or magnetic resonance imaging) at least once every three years.

Of the 81 patients (47 male, mean age 27±8.3 years), the mean age of Fontan completion was 6.6±5.3 years. The mean follow-up period since Fontan completion was 20±8.1 years. History taking and physical examination were documented in 84% (68/81) and 79% (64/81) of patients respectively. 60% (59/81) had a full set of Fontan blood tests taken which increased to 73% (49/81) if alpha-fetoprotein was excluded while imaging was performed in 80% (65/81) of cases.

Overall, 46% (37/81) cases had abnormal Fontan blood test or imaging. Hepatology referral was made in only 21% (17/81) of cases and MELD-XI score was not documented.

Conclusions

FALD screening tests were frequently underperformed compared to international guidance. Adherence may be improved by 1) promoting a Fontan blood test bundle; 2) implementing a standardised letter template which includes an investigation date list; 3) advocating MELD-XI score; and 4) exploring a joint cardiac and hepatology Fontan clinic.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Transition for patients with congenital heart disease in the UK: need for a universal model with adequate training and support

Background

Adolescence is a vulnerable period for patients with congenital heart disease (CHD). Transition is a process that guides these patients through adolescence and ensures a smooth transfer to adult services, in order improve adherence to medical care and reduce loss to follow-up. While the importance of a formal Transition process is widely recognised and a requirement for specialist services in the UK, the optimal structure and delivery of Transition remains a matter of debate.

Aims

To examine the different models of Transition currently in place in specialist CHD centres around the UK.

Methods

A survey of Adult CHD centres in the UK was performed. A focus was placed on the structure of the Transition service, relevant training and areas of perceived improvement.

Results

There were 10 responses to our survey covering 10 specialist CHD centres. All respondents were consultant adult CHD specialists, looking after patients from the age of 16 [14–17] years. All centres have a specialised Transition service, which runs from the age 13 [11–15] to 18 [16–25] years (duration of transition 5 [2–13] years). The majority of centres (80%) report providing transition care “well before” transfer to adult care, whereas 20% provide transition care at or immediately before transfer (i.e. first adult CHD appointment). Transition is delivered by physicians and clinical specialist nurses in approximately equal numbers in 9 (90%) centres and exclusively by clinical nurse specialists in 1 (10%) centre. A median of 2 [1–5] visits are planned for each patient, with 7 (70%) centres seeing patients at least twice during transition. The majority, but not all centres (70%) provide a health passport during transition. A significant number of centres felt they werer not receiving sufficient support in the following domains: financial (50%), training (30%), clinical space (30%), referrals from paediatrics (50%). All respondents felt that their Transition service had room for improvement. Other areas of improvement highlighted included reduction in loss to follow-up, difficulties in providing a Transition service to patients followed in peripheral hospitals, the need for more support from paediatric services in referring all appropriate patients, and dedicated administrative support. The vast majority of respondents (9, 90%) felt equipped with the appropriate skills to care for transition patients. However, few (2, 20%) had completed formal training in more than one area related to adolescent health and transition.

Conclusions

While all CHD centres have a Transition service, Transition models and delivery differs significantly. There is urgent need for research in this area to develop a unified model, greater financial support and relevant training to optimise care.

Figure 1. Participating UK centres

Funding Acknowledgement

Type of funding source: None

Multicentre study on pulmonary arterial hypertension therapies in fontan patients: underutilised or of limited use?

Introduction

The Fontan circulation is successful in abolishing cyanosis and chronic volume overload in congenital heart disease (CHD) patients with single ventricle physiology. “Fontan failure” is a major cause of poor quality of life and mortality in these patients. Recently, pulmonary arterial hypertension (PAH) therapies have been used in Fontan patients with variable success, even though patients included in these studies are generally at the best end of the spectrum.

Aim

To assess contemporary patterns of PAH therapy in Fontan patients in large specialist CHD centres.

Methods

We identified all adult patients with a Fontan-type circulation under active follow-up in 8 specialist CHD centres between 2009 and 2019. Patients on PAH therapies were matched by age and gender to untreated patients (1:1 or 1:2). Baseline data were collated immediately prior to initiation of therapy (treated group) or from a synchronous routine clinical assessment (untreated group).

Results

During the study period, 70 Fontan patients were started on PAH therapy (6.5% of those under follow-up). The majority 63 (90.0%) were started on monotherapy with a phosphodiesterase-5 (PDE5) inhibitor, 6 (8.6%) patients were started on an endothelin receptor antagonist (ERA) and 1 (1.4%) received early sequential therapy with a PDE5 inhibitor and ERA. Prostacyclin analogues were not used, and no patients received triple therapy. Overall, 51 (72.9%) patients started therapy electively (49% in outpatient clinic, 51% as day case admission), while 18 (25.7%) were treated following urgent hospital admission with fluid overload +/− acute kidney injury. The remainder (2,2.9%) started therapy following cardiac surgery. Adverse events during treatment were rare. Patients starting PAH therapy were matched to 112 untreated patients (table 1). Patients were well matched between groups for age (p=0.52) and sex (p=0.27). Treated patients were more likely to be significantly impaired than matched patients (56.7% vs. 8.6% in NYHA class III/IV, p<0.0001) and were more likely to have ascites (16.2% vs. 0.9%, p=0.0002). Treated patients were also more likely to have a lower albumin level (43 [14–56] vs. 45 [29–54], p=0.01) or to be on a loop diuretic e.g. furosemide (p<0.0001), at a higher daily dose (p<0.0001) than matched patients. Only a quarter of patients on therapies had no high-risk features (24.2%), 80% of whom were from a single centre.

Conclusion

A small minority of Fontan patients followed in specialist centres receive PAH therapies. PAH therapy was reserved in most centres for patients with more advanced disease, targeting predominantly those with a “failing Fontan” in an individualised approach, in line with the recent adult CHD American Heart Association (AHA) guidelines. Further studied are needed to establish the role of PAH therapies in Fontan patients, provided that adult patients with advanced disease who are at increased risk of adverse outcome are included.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Dr Constantine received an educational grant from Actelion Pharmaceuticals, a Janssen company of Johnson & Johnson, which helped to pay for travel for data collection.

MRI in adult patients with aortic coarctation: diagnosis and follow-up

Aortic coarctation is a disease that usually presents in infancy; however, a proportion of patients present for the first time in adulthood. These lesions generally require repair with either surgery or interventional techniques. The success of these techniques means that increasing numbers of patients are presenting for follow-up imaging in adulthood, whether their coarctation was initially repaired in infancy or as adults. Thus, the adult presenting to the radiologist for assessment of possible coarctation or follow-up of coarctation repair is not an uncommon scenario. In this review, we present details of the MRI protocols and MRI findings in these patients so that a confident and accurate assessment can be made.

Evidence supporting nutritional interventions for persons in early stage Alzheimer's disease (AD)

The purpose of this paper is to grade research evidence supporting nutritional interventions for persons with early stage dementias and to report the recommendations of a consensus panel. Thirty four studies were reviewed in the areas of dietary restriction, antioxidants, and Mediterranean diet with strong support from epidemiological studies found in all three areas. The body of evidence to support nutritional interventions in the prevention and treatment of AD is growing and has potential as a treatment modality following translational studies.

Easy rider wheelchair biking. A nursing-recreation therapy clinical trial for the treatment of depression

Depression is a common condition among long-term care residents with limited treatment options available. There are few nonpharmacological interventions available to this population. This study examined the use of a prescribed, therapeutic recreation-nursing intervention, wheelchair biking, for treatment of symptoms of depression in older adults in a long-term care setting. A classical experimental design was used and was guided by the Roy Adaptation Model. Forty residents were pretested for depression and randomly assigned to two groups. A 2-week trial of biking therapy was provided to the treatment group. All participants were posttested. Findings indicated there was a statistically significant improvement in depression scores for the treatment group and no significant change for the control group. This study contributes to the body of knowledge of nursing regarding options for the treatment of depression in older adults, and is an encouraging indicator that psychosocial interventions may be effective in reducing depression.

Replicative senescence as a barrier to human cancer

There is evidence that one critically short telomere may be recognized as DNA damage and, as a consequence, induce a p53/p21WAF- and p16INK4A-dependent G1 cell cycle checkpoint to cause senescence. Additionally, senescence via a p53- and p16(INK4A)-dependent mechanism can be induced by the over- or under-stimulation of certain signalling pathways that are involved in cancer. Central to this alternative senescence mechanism is the p14ARF protein, which connects oncogene activation, but not DNA damage, to p53 activation and senescence. We find that immortal keratinocytes almost invariably have dysfunctional p53 and p16 and have high levels of telomerase, but very often express a wild-type p14(ARF). Furthermore, when normal keratinocytes senesce they show a striking elevation of p16 protein, but not of p14(ARF) or its downstream targets p53 and p21(WAF). These results suggest that p16, rather than p14(ARF), is the more important gene in human keratinocyte senescence, but do not exclude a co-operative role for p14(ARF), perhaps in the induction of senescence by activated oncogenes in neoplasia. Regardless of mechanism, these results suggest that replicative senescence acts as a barrier to human cancer development.

Valsartan and hydrochlorothiazide in patients with essential hypertension. A multiple dose, double-blind, placebo controlled trial comparing combination therapy with monotherapy

OBJECTIVE

This study compares the antihypertensive efficacy and tolerability of valsartan, a novel angiotensin II antagonist, given with hydrochlorothiazide (HCTZ) vs placebo or vs valsartan or HCTZ alone.

DESIGN

871 adult out-patients with essential hypertension participated in this double-blind study. Patients were randomised in equal number to receive either combination therapy of valsartan (80 mg or 160 mg) and HCTZ (12.5 mg or 25 mg), or valsartan (80 mg or 160 mg) or HCTZ (12.5 mg or 25 mg) alone, or placebo. Patients were treated once daily for 8 weeks and assessed at 2, 4 and 8 weeks after randomisation.

MAIN OUTCOME MEASURES

The primary efficacy variable was change from baseline in mean sitting diastolic blood pressure (MSDBP) at end-point. The secondary variable was change in mean sitting systolic blood pressure (MSSBP) from baseline to end-point.

RESULTS

All active treatments produced a statistically significant difference in MSDBP (P < 0.001) from baseline to end-point compared with placebo. Similar results were obtained for MSSBP. All combination regimens produced a statistically significantly greater reduction in MSDPB and MSSBP than the corresponding monotherapies. Dizziness and headache were the most common treatment-related adverse experiences reported. Hypokalaemia, associated with the use of thiazide diuretics, was more commonly reported in the higher dose HCTZ 25 mg groups.

CONCLUSIONS

Valsartan 80 mg and 160 mg act additively with HCTZ 12.5 mg or 25 mg to lower MSDBP and MSSBP in patients with essential hypertension. The addition of HCTZ to valsartan 80 mg or 160 mg was well tolerated.

Valsartan, a new angiotensin II antagonist: antihypertensive effects over 24 hours

This study was done to assess the antihypertensive efficacy of once-daily valsartan 20 mg, 80 mg, 160 mg, and 320 mg over 24 hours using ambulatory blood pressure monitoring (ABPM). A total of 217 adult outpatients with uncomplicated essential hypertension (office mean sitting diastolic blood pressure [DBP] of > or = 95 to < or = 115 mm Hg) participated in this multicenter, double-masked, placebo-controlled study. Patients were randomized to receive valsartan 20 mg, 80 mg, 160 mg, 320 mg, or placebo for 8 weeks. Twenty-four-hour ABPM was done at baseline and after 8 weeks of treatment. All valsartan doses produced significant decreases in average ambulatory systolic blood pressure (SBP) and DBP over 24 hours compared with placebo. A trend to greater reductions compared with placebo was observed for doses of valsartan 80 mg and greater (80 mg, -6.61 mm Hg DBP, -11.04 mm Hg SBP; 160 mg, -5.51 mm Hg DBP, -10.61 mm Hg SBP; 320 mg, -8.44 mm Hg DBP, -14.34 mm Hg SBP) compared with valsartan 20 mg (-3.52 mm Hg DBP, -5.92 mm Hg SBP). Valsartan produced consistent reductions compared with placebo during both day (> 6 AM to < or = 10 PM) and night (> 10 PM to < or = 6 AM). However, in all groups, the circadian pattern of blood pressure over 24 hours was preserved and was similar to that observed at baseline (but shifted into the normotensive range in a parallel fashion). The data show that single daily doses of valsartan 80 mg and greater provide effective control of both DBP and SBP over a 24-hour period without loss of diurnal variation.

The efficacy and safety of valsartan compared with placebo in the treatment of patients with essential hypertension

A multicenter, randomized, placebo-controlled, double-masked, parallel-group study was performed to compare the efficacy and safety of valsartan 20, 80, 160, and 320 mg with placebo in the treatment of patients with essential hypertension. A total of 736 adults with uncomplicated essential hypertension stages 1 to 3 were randomized to receive placebo or valsartan 20, 80, 160, or 320 mg daily for 8 weeks. Assessments were made at baseline, after 4 and 8 weeks of treatment, and 2 to 3 days after stopping treatment. The primary efficacy variable was change from baseline in mean sitting diastolic blood pressure (MSDBP). Other variables included change from baseline in mean sitting systolic blood pressure (MSSBP) and responder rates (ie, MSDBP < 90 mm Hg or decrease of > or = 10 mm Hg from baseline). All doses of valsartan produced statistically significant reductions in both MSDBP and MSSBP at end point compared with placebo. A dose-response effect was seen, although the incremental reduction in blood pressure with doses of valsartan > 80 mg was relatively small. Statistically significant differences in responder rates at end point were seen for doses of valsartan of 80 mg and above compared with placebo, whereas the responder rates for valsartan 20 mg was not significantly different from that for placebo. Safety and tolerability variables included data on adverse experiences, rebound hypertension, and clinical laboratory evaluations. Tolerability was good, with headache being the most common complaint and occurring most frequently in placebo patients. The incidence of dizziness was similar among the placebo (5.4%) and valsartan 20-mg to 160-mg groups (2.1% to 3.4%); there was an increase in the incidence of dizziness in the 320-mg group (9.3%). No cases of symptomatic orthostatic hypotension occurred. Analysis of rebound showed that 11.6% of patients receiving placebo and 16.6% receiving valsartan had an increase in MSDBP to baseline levels or above 2 to 3 days after stopping treatment. No clinically significant adverse experiences were noted after stopping treatment. There were no clinically or statistically significant changes in laboratory values during treatment. Thus valsartan proved to be both effective and safe in reducing blood pressure in adults with essential hypertension. The optimal dose range is 80 to 160 mg, given once daily.

Clonal diversity of Streptococcus mitis biovar 1 isolates from the oral cavity of human neonates

The clonal diversity of 101 isolates of the pioneer bacterium Streptococcus mitis biovar 1 obtained from the oral cavities of 40 human neonates 1 to 3 days, 2 weeks, and 1 month postpartum was examined by using rRNA gene restriction patterns. There was a high degree of genetic diversity, with the 101 isolates comprising 93 unique PvuII ribotypes. There were eight identical pairs of ribotype patterns, and seven of the eight pairs were obtained from individual neonates. Only one identical pair comprised isolates obtained from different neonates. In all but two cases, isolates with matching ribotypes were obtained at one visit. Two pairs of isolates with matching ribotype patterns were obtained from neonates on successive visits. The ribotype patterns of the isolates were examined by cluster analysis. The isolates forming each cluster were very similar, yet each cluster was well separated from its neighbors. When several isolates were obtained from individual neonates at a particular visit, in some instances they were contained in a single cluster, whereas in other cases each isolate was contained in a separate cluster. Isolates obtained from individual neonates on successive visits tended to be contained in different clusters. This high degree of diversity, which has been observed in other mucosal commensal bacteria, may serve as a mechanism for avoiding immune elimination of these bacteria.

Pioneer oral streptococci produce immunoglobulin A1 protease

As part of a longitudinal study of the relationship between bacterial colonization and the secretory immune response, 367 isolates of pioneer viridans streptococci collected from 40 breast- and bottle-fed neonates within the first month postpartum were tested for the production of immunoglobulin A1 (IgA1) protease and glycosidases. Fifty percent of the streptococci isolated produced IgA1 protease, including all isolates of Streptococcus oralis and S. sanguis, 60.7% of S. mitis biovar 1 isolates, and some isolates that could not be identified. Three cleavage patterns of alpha 1 heavy chains were observed. Six isolates of S. mitis biovar 1 that did not produce IgA1 protease attacked the alpha 1 chain. Incubation of IgA1 protease-negative S. mitis biovar 1 isolates with IgA1, either prior to or together with S. sanguis, rendered the IgA1 paraprotein resistant to cleavage by the IgA1 protease of S. sanguis. The ability of some pioneer streptococci in the human oral cavity to produce IgA1 protease and of others to modify the susceptibility of IgA1 to cleavage by IgA1 protease perhaps enhances their ability to survive in this habitat.

A phase I trial of CGS 16949A. A new aromatase inhibitor

CGS 16949A is a new, nonsteroidal competitive inhibitor of the aromatase enzyme. In this Phase I trial, 16 heavily pretreated postmenopausal patients with metastatic breast cancer were treated with escalating doses of CGS 16949A from 0.6 to 16 mg total daily oral dose. No hematologic, biochemical, or significant clinical toxicity was encountered. Endocrinologic and pharmacologic data were available from 12 of these patients. Maximum inhibition of estrogen biosynthesis was observed at a dose of 2 mg CGS 16949A daily. At this dose, the inhibition of estrogen biosynthesis was equivalent to 1000 mg aminoglutethimide (AG). The fall in plasma and urinary estrogens without a concomitant drop in androgens confirmed the specific blockade of aromatase activity. At doses of 4 to 16 mg daily, CGS 16949A appeared to inhibit the C21-hydroxylase enzyme as well. The t1/2 of CGS 16949A in the circulation was 10.5 hours. Of 16 evaluable patients there were two partial responses and seven patients with stable disease.