Reduced left ventricular filling following blood volume extraction does not result in compensatory augmentation of cardiac mechanics

Abstract

An acute non-invasive reduction in preload has been shown to augment cardiac mechanics to maintain stroke volume and cardiac output. Such interventions induce concomitant changes in heart rate (HR), whereas blood volume extraction reduces preload without HR changes. Therefore, the purpose of this study was to determine whether a preload reduction in isolation resulted in augmented stroke volume achieved via enhanced cardiac mechanics. Nine healthy volunteers (4 female, age 29 ± 11 years) underwent echocardiography for the assessment of left ventricular (LV) volumes and mechanics in a supine position at baseline and end-extraction following the controlled removal of 25% of total blood volume (1062 ± 342 ml). Arterial blood pressure was monitored continuously by a pressure transducer attached to an indwelling radial artery catheter. HR and total peripheral resistance were unchanged from baseline to end extraction, but systolic blood pressure was reduced (148 to 127 mmHg). LV end diastolic volume (89 to 71 ml) and stroke volume (56 to 37 ml) were significantly reduced from baseline to end extraction; however, there was no change in LV twist, basal or apical rotation. In contrast, LV longitudinal strain (−20 to −17%) and basal circumferential strain (−22 to −19%) were significantly reduced from baseline to end extraction. In conclusion, a preload reduction during blood volume extraction does not result in compensatory changes in stroke volume or cardiac mechanics. Our data suggest that LV strain is dependent on LV filling and consequent geometry whereas LV twist could be mediated by heart rate.

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Mirror neurons and intention understanding: Dissociating the contribution of object type and intention to mirror responses using electromyography

Abstract

Since their discovery in the monkey and human brain, mirror neurons have been claimed to play a key role in understanding others' intentions. For example, "action-constrained" mirror neurons in inferior parietal lobule fire when the monkey observes a grasping movement that is followed by an eating action, but not when it is followed by a placing action. It is claimed these responses enable the monkey to predict the intentions of the actor. These findings have been replicated in human observers by recording electromyography responses of the mouth-opening mylohyoid muscle during action observation. Mylohyoid muscle activity was greater during the observation of actions performed with the intention to eat than of actions performed with the intention to place, again suggesting an ability to predict the actor's intentions. However, in previous studies, intention was confounded with object type (food for eating actions, nonfood for placing actions). We therefore used electromyography to measure mylohyoid activity in participants observing eating and placing actions. Unlike previous studies, we used a design in which each object (food, nonfood) could be both eaten and placed, and thus participants could not predict the actor's intention at the onset of the action. Greater mylohyoid activity was found for the observation of actions performed on food objects, irrespective of intention, indicating that the object type, not the actor's intention, drives the mirror response. This result suggests that observers' motor responses during action observation reflect the presence of a particular object, rather than the actor's underlying intentions.

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Aortic dysfunction in metabolic syndrome mediated by perivascular adipose tissue TNFα and NOX2 dependent pathway

Abstract

Aims

Perivascular adipose tissue (PVAT) is recognized for its vaso-active effects, however it's unclear how Metabolic Syndrome impact thoracic-aorta (t)PVAT and the subsequent effect on functional and structural aortic stiffness.

Methods & Results

Thoracic aorta and tPVAT were removed from 16–17 week old lean (LZR, n = 16) and obese Zucker (OZR, n = 16) rats. OZR presented with aortic endothelial dysfunction, assessed by wire-myography, and increased aortic stiffness, assessed by elastic modulus. OZR-tPVAT exudate further exacerbated the endothelial dysfunction reducing nitric oxide and endothelial dependent relaxation (P < 0.05). Additionally, OZR-tPVAT exudate had increased MMP9 activity (P < 0.05) and further increased elastic modulus of the aorta following 72-hours of coculture (P < 0.05). We found the observed aortic dysfunction caused by OZR-tPVAT was mediated through increased production and release of TNFα (P < 0.01), which was dependent on tPVAT NADPH-oxidase 2 (NOX2) activity. OZR-tPVAT ROS and subsequent aortic dysfunction was inhibited by TNFα neutralization and/or inhibition of NOX2. Additionally, we found OZR-tPVAT had reduced activity of the 20S proteasome's active sites (P < 0.05) and reduced superoxide dismutase activity (P < 0.01).

Conclusion

Metabolic syndrome causes tPVAT dysfunction through interplay between TNFα and NOX2 leading to tPVAT mediated aortic stiffness by activation of aortic ROS and increased MMP9 activity.

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Tuning CRISPR-Cas9 Gene Drives in Saccharomyces cerevisiae

Control of biological populations is an ongoing challenge in many fields including agriculture, biodiversity, ecological preservation, pest control, and the spread of disease. In some cases, such as insects that harbor human pathogens (e.g. malaria), elimination or reduction of a small number of species would have a dramatic impact across the globe. Given the recent discovery and development of the CRISPR/Cas9 gene editing technology, a unique arrangement of this system-a nuclease based "gene drive"-allows for the Super-Mendelian spread and forced propagation of a genetic element through a population. Recent studies have demonstrated the ability of a gene drive to rapidly spread within and nearly eliminate insect populations in a laboratory setting. While there are still ongoing technical challenges to design of a more optimal gene drive to be used in wild populations, there are still serious ecological and ethical concerns surrounding the nature of this powerful biological agent. Here, we use budding yeast as a safe and fully-contained model system to explore mechanisms that might allow for programmed regulation of gene drive activity. We describe four conserved features of all CRISPR-based drives and demonstrate the ability of each drive component-Cas9 protein level, sgRNA identity, Cas9 nucleocytoplasmic shuttling, and novel Cas9-Cas9 tandem fusions-to modulate drive activity within a population.

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Effects of yoga interventions practiced in heated and thermoneutral conditions on endothelium-dependent vasodilation: The Bikram yoga heart study

Abstract

We have previously documented improvements in endothelium-dependent vasodilation with a Bikram (hot) yoga intervention in middle-aged adults. Presently, the effect of environmental temperature in hot yoga on endothelial function is unknown.

Purpose

The purpose of this investigation was to determine the effects of Bikram yoga interventions performed in the heated and thermoneutral conditions on endothelium-dependent vasodilation.

Methods

Fifty-two sedentary but apparently healthy adults aged 40–60 years were randomly assigned to one of three groups: Bikram yoga practiced at 40.5°C (n = 19), Bikram yoga practiced at 23°C (n = 14), or sedentary time-control (n = 19). The yoga interventions consisted of 90-minute Bikram yoga classes 3 times a week for 12 weeks. Endothelium-dependent vasodilation was measured noninvasively using brachial artery flow-mediated dilation (FMD).

Results

Body fat percentage determined via dual energy x-ray absorptiometry was significantly lower in the hot yoga group after the intervention than in the thermoneutral yoga and control conditions. Brachial artery FMD increased (P < 0.05) in the thermoneutral yoga group and tended to increase in the hot yoga group (P = 0.056). No changes occurred in the control group. There were no significant differences in FMD change scores between groups.

Conclusions

Bikram yoga practiced in thermoneutral conditions improved endothelium-dependent vasodilation in healthy, middle-aged adults. These novels findings highlight the effectiveness of hatha yoga postures alone, in the absence of a heated practice environment, in improving vascular health and are of clinical significance given the increased propensity toward heat intolerance in aging adults.

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The effects of sediment transport on temporal variation in radiocesium concentrations in very shallow water off the southern coast of Fukushima, Japan

Publication date: April 2018
Source:Journal of Environmental Radioactivity, Volumes 184–185
Author(s): Akira Matsumoto, Hiroshi Myouse, Hisayuki Arakawa, Ken Higuchi, Naoto Hirakawa, Yoshiaki Morioka, Takuji Mizuno
We studied the very shallow coastal water off Iwaki City, Fukushima Prefecture, and investigated: (1) temporal variation in ¹³⁷Cs concentrations; (2) particle-size distribution of sediments; and (3) the effect on variation by waves, component-fractionated concentration of radiocesium and mineral composition at three sampling stations (Yotsukura, Ena rocky reef and Ena sandy station). There was a decline in ¹³⁷Cs concentrations in sediment samples at all sampling stations between 425 and 1173 days after the accident. All stations had fluctuations in ¹³⁷Cs concentrations between 425 and 800 days. At Ena sandy station and Ena rocky reef stations the declines in ¹³⁷Cs concentrations slowed from about 800 days after the accident. Fluctuations in particle median diameters were seen, as well as in ¹³⁷Cs concentrations. At Yotsukura, where the fluctuation in median diameter was small, a constant decrease in ¹³⁷Cs concentrations was observed. We considered that bioturbation may contribute the constant decrease. At Ena sandy station, where the fluctuation of the median diameter was large, the fluctuation in ¹³⁷Cs concentrations was also large. The movement of sediments was evaluated by the Shields parameter, and results indicated that at any station where the sediment was moved more frequently, the fluctuation in ¹³⁷Cs concentrations was also large. The highly contaminated small particles moved from our stations due to wave action between 425 and 800 days after the accident. The remaining relatively large particles might contribute to the slowing down in reduction of ¹³⁷Cs concentrations from 800 days after the accident. However, the ¹³⁷Cs concentrations in sediments in very shallow water off the southern coast of Fukushima may continue to decline over time.



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High-resolution 129I bomb peak profile in an ice core from SE-Dome site, Greenland

Publication date: April 2018
Source:Journal of Environmental Radioactivity, Volumes 184–185
Author(s): Angel T. Bautista, Yasuto Miyake, Hiroyuki Matsuzaki, Yoshinori Iizuka, Kazuho Horiuchi
¹²⁹I in natural archives, such as ice cores, can be used as a proxy for human nuclear activities, age marker, and environmental tracer. Currently, there is only one published record of ¹²⁹I in ice core (i.e., from Fiescherhorn Glacier, Swiss Alps) and its limited time resolution (1–2 years) prevents the full use of ¹²⁹I for the mentioned applications. Here we show ¹²⁹I concentrations in an ice core from SE-Dome, Greenland, covering years 1956–1976 at a time resolution of ∼6 months, the most detailed record to date. Results revealed ¹²⁹I bomb peaks in years 1959, 1962, and 1963, associated to tests performed by the former Soviet Union, one year prior, in its Novaya Zemlya test site. All ¹²⁹I bomb peaks were observed in winter (1958.9, 1962.1, and 1963.0), while tritium bomb peaks, another prominent radionuclide associated with nuclear bomb testing, were observed in spring or summer (1959.3, and 1963.6; Iizuka et al., 2017). These results indicate that ¹²⁹I bomb peaks can be used as annual and seasonal age markers for these years. Furthermore, we found that ¹²⁹I recorded nuclear fuel reprocessing signals and that these can be potentially used to correct timing of estimated ¹²⁹I releases during years 1964–1976. Comparisons with other published records of ¹²⁹I in natural archives showed that ¹²⁹I can be used as common age marker and tracer for different types of records. Most notably, the 1963 ¹²⁹I bomb peak can be used as common age marker for ice and coral cores, providing the means to reconcile age models and associated trends from the polar and tropical regions, respectively.

Graphical abstract

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Experience of on-site disposal of production uranium-graphite nuclear reactor

Publication date: April 2018
Source:Journal of Environmental Radioactivity, Volumes 184–185
Author(s): Alexander O. Pavliuk, Sergey G. Kotlyarevskiy, Evgeny V. Bespala, Elena V. Zakharova, Vyacheslav M. Ermolaev, Anna G. Volkova
The paper reported the experience gained in the course of decommissioning EI-2 Production Uranium-Graphite Nuclear Reactor. EI-2 was a production Uranium-Graphite Nuclear Reactor located on the Production and Demonstration Center for Uranium-Graphite Reactors JSC (PDC UGR JSC) site of Seversk City, Tomsk Region, Russia. EI-2 commenced its operation in 1958, and was shut down on December 28, 1990, having operated for the period of 33 years all together. The extra pure grade graphite for the moderator, water for the coolant, and uranium metal for the fuel were used in the reactor. During the operation nitrogen gas was passed through the graphite stack of the reactor. In the process of decommissioning the PDC UGR JSC site the cavities in the reactor space were filled with clay-based materials. A specific composite barrier material based on clays and minerals of Siberian Region was developed for the purpose. Numerical modeling demonstrated the developed clay composite would make efficient geological barriers preventing release of radionuclides into the environment.



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Comparisons between a new point kernel-based scheme and the infinite plane source assumption method for radiation calculation of deposited airborne radionuclides from nuclear power plants

Publication date: April 2018
Source:Journal of Environmental Radioactivity, Volumes 184–185
Author(s): Xiaole Zhang, George Efthimiou, Yan Wang, Meng Huang
Radiation from the deposited radionuclides is indispensable information for environmental impact assessment of nuclear power plants and emergency management during nuclear accidents. Ground shine estimation is related to multiple physical processes, including atmospheric dispersion, deposition, soil and air radiation shielding. It still remains unclear that whether the normally adopted "infinite plane" source assumption for the ground shine calculation is accurate enough, especially for the area with highly heterogeneous deposition distribution near the release point. In this study, a new ground shine calculation scheme, which accounts for both the spatial deposition distribution and the properties of air and soil layers, is developed based on point kernel method. Two sets of "detector-centered" grids are proposed and optimized for both the deposition and radiation calculations to better simulate the results measured by the detectors, which will be beneficial for the applications such as source term estimation. The evaluation against the available data of Monte Carlo methods in the literature indicates that the errors of the new scheme are within 5% for the key radionuclides in nuclear accidents. The comparisons between the new scheme and "infinite plane" assumption indicate that the assumption is tenable (relative errors within 20%) for the area located 1 km away from the release source. Within 1 km range, the assumption mainly causes errors for wet deposition and the errors are independent of rain intensities. The results suggest that the new scheme should be adopted if the detectors are within 1 km from the source under the stable atmosphere (classes E and F), or the detectors are within 500 m under slightly unstable (class C) or neutral (class D) atmosphere. Otherwise, the infinite plane assumption is reasonable since the relative errors induced by this assumption are within 20%. The results here are only based on theoretical investigations. They should be further thoroughly evaluated with real measurements in the future.

Graphical abstract

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Evaluation of abundance of artificial radionuclides in food products in South Korea and sources

Publication date: April 2018
Source:Journal of Environmental Radioactivity, Volumes 184–185
Author(s): S.H. Lee, J.S. Oh, K.B. Lee, J.M. Lee, S.H. Hwang, M.K. Lee, E.H. Kwon, C.S. Kim, I.H. Choi, I.Y. Yeo, J.Y. Yoon, J.M. Im
Food samples are collected nationwide from January 2016 to February 2017 and their contents of artificial radionuclides are measured to address the growing concerns regarding the radioactive contamination of food products in Korea. Specifically, 900 food samples are collected for this study and their contents of representative artificial radionuclides ¹³⁴Cs, ¹³⁷Cs, ^239,240Pu, and ⁹⁰Sr are analyzed. The analysis shows that the activity concentrations of ¹³⁷Cs in fish range from minimum detectable activity (MDA) to 340 mBq/kg of fresh weight. The concentration factor (CF) determined for ¹³⁷Cs as a measure of its bioavailability is calculated to be ca. 74 and found to be very similar to that (100) recommended by the International Atomic Energy Agency. With an MDA of <0.221 mBq/kg, the results reveal that ^239,240Pu values in fish are below the MDA. The activity concentrations of ¹³⁷Cs and ⁹⁰Sr are lower than the MDA in both shellfish and seaweed, while the activity concentrations of ^239,240Pu in shellfish range from 0.26 to 2.18 mBq/kg, and for seaweed samples range from 2.07 to 3.38 mBq/kg. The atom ratios of ²⁴⁰Pu/²³⁹Pu in shellfish caught at the Korean coast vary from 0.209 to 0.237, with a mean of 0.227. The higher ²⁴⁰Pu/²³⁹Pu atom ratio determined in shellfish is thought to be caused by the plutonium transported from the Pacific Proving Grounds rather than other sources such as the Fukushima nuclear power plant accident. The activity concentrations of ¹³⁷Cs in mushrooms are found to vary from 1.0 to 21.4 Bq/kg, with the highest concentrations observed in the Oak (shiitake) and Sarcodon asparatus. ¹³⁴Cs is detected in three mushroom specimens collected from Jeju Island and about 3–3.6% of ¹³⁷Cs present in the wild mushrooms native to the Jeju Island are introduced as a result of the Fukushima nuclear plant accident. The annual effective doses of ¹³⁷Cs received through consumption of mushrooms and fish are 2.0 × 10⁻⁴ mSv yr⁻¹ and 3.9 × 10⁻⁵ mSv yr⁻¹, and those values are negligible compared to the annual effective doses limit of 1 mSv yr⁻¹.



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Soil-to-plant transfer factors of natural radionuclides (226Ra and 40K) in selected Thai medicinal plants

Publication date: April 2018
Source:Journal of Environmental Radioactivity, Volumes 184–185
Author(s): Kiadtisak Saenboonruang, Endu Phonchanthuek, Kamonkhuan Prasandee
A soil-to-plant transfer factor (TF) is an important parameter that could be used to estimate radionuclides levels in medicinal plants. This work reports concentrations of natural radionuclides (²²⁶Ra and ⁴⁰K) and TFs in six Thai medicinal plants grown in central Thailand using an HPGe gamma ray spectrometer. Either root, leaf, or flower parts of each medicinal plant were selected for use in the investigation according to their practical uses in traditional medicine. The results showed that due to K being essential in plants, ⁴⁰K had higher arithmetic means of activity concentrations and geometric means of TFs (geometric standard deviations in parentheses) of 610 ± 260 Bq kg⁻¹ dry weight (DW) and 2.0 (1.4), respectively, than ²²⁶Ra, which had the activity concentrations and TFs of 4.8 ± 2.6 Bq kg⁻¹ DW and 0.17 (1.8), respectively. The results also showed that the leaves of medicinal plants had higher activity concentrations and TFs than root and flower parts, probably due to higher metabolic activities in leaves. Furthermore, there was good agreement between the results from the current work and other similar reports on medicinal plants. The information obtained from this work could strengthen knowledge of natural radionuclides in plants and particularly increase available TF data on Thai medicinal plants.



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Source identification of uranium-containing materials at mine legacy sites in Portugal

Publication date: March 2018
Source:Journal of Environmental Radioactivity, Volume 183
Author(s): A.C. Keatley, P.G. Martin, K.R. Hallam, O.D. Payton, R. Awbery, F. Carvalho, J.M. Oliveira, L. Silva, M. Malta, T.B. Scott
Whilst prior nuclear forensic studies have focused on identifying signatures to distinguish between different uranium deposit types, this paper focuses on providing a scientific basis for source identification of materials from different uranium mine sites within a single region, which can then be potentially used within nuclear forensics. A number of different tools, including gamma spectrometry, alpha spectrometry, mineralogy and major and minor elemental analysis, have been utilised to determine the provenance of uranium mineral samples collected at eight mine sites, located within three different uranium provinces, in Portugal. A radiation survey was initially conducted by foot and/or unmanned aerial vehicle at each site to assist sample collection. The results from each mine site were then compared to determine if individual mine sites could be distinguished based on characteristic elemental and isotopic signatures. Gamma and alpha spectrometry were used to differentiate between samples from different sites and also give an indication of past milling and mining activities. Ore samples from the different mine sites were found to be very similar in terms of gangue and uranium mineralogy. However, rarer minerals or specific impurity elements, such as calcium and copper, did permit some separation of the sites examined. In addition, classification rates using linear discriminant analysis were comparable to those in the literature.



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Refractory Pain Management in Amyloid-Associated Peripheral Neuropathy.

Objective: Systemic amyloidosis is a disease that often involves multiple organ systems, including the peripheral nervous system. Patients may present with severe, refractory neuropathic pain; however, the optimal treatment approach for pain for these patients remains unclear. Case Report: A man with severe, refractory neuropathic pain in his bilateral upper and lower extremities and the trunk secondary to amyloid neuropathy is presented. Multiple medication trials, including neuropathic and opioid agents, produced considerable adverse effects and minimal relief. Scrambler therapy, a novel electrical stimulation modality, was used and was associated with substantial short-term but nonsustained benefit. Spinal cord stimulation was considered, but given his diffuse symptoms, it was deemed a less-than-optimal approach. Ultimately, an intrathecal drug delivery system was placed with infusion of hydromorphone, resulting in substantial pain reduction in all involved areas and with an improved adverse effect profile. This intervention resulted in immense improvement in the patient's quality of life, despite progression of his systemic amyloidosis. Conclusions: Severe pain in the setting of amyloid neuropathy is often difficult to treat. To our knowledge, this represents the first report of Scrambler therapy or an implanted intrathecal drug delivery system used for a patient with refractory amyloidosis-related neuropathic pain, resulting in substantial analgesic benefit and improved quality of life. Copyright (C) 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Analgesia of Combined Femoral Triangle and Obturator Nerve Blockade Is Superior to Local Infiltration Analgesia After Total Knee Arthroplasty With High-Dose Intravenous Dexamethasone.

Background and Objectives: High-dose intravenous dexamethasone reduces the postoperative opioid requirement and is often included in the multimodal analgesia strategy after total knee arthroplasty (TKA). Combined obturator nerve and femoral triangle blockade (OFB) reduces the opioid consumption and pain after TKA better than local infiltration analgesia (LIA). The question is whether preoperative high-dose intravenous dexamethasone would cancel out the superior analgesic effect of OFB compared with LIA. The aim was to evaluate the analgesic effect of OFB versus LIA after TKA when all patients received high-dose intravenous dexamethasone. Methods: Eighty-two patients were randomly assigned either to OFB or LIA after primary unilateral TKA. All patients received 16 mg dexamethasone. Primary outcome was morphine consumption via patient-controlled analgesia during the first 20 postoperative hours. Secondary outcomes were pain, nausea, dizziness, and length of hospital stay. Results: Seventy-four patients were included in the analysis. Median total intravenous morphine consumption during the first 20 postoperative hours was 6 mg (interquartile range [IQR], 2-18 mg) in the OFB group and 20 mg (IQR, 12-28 mg) in the LIA group. The 14-mg difference (95% confidence interval, 6.4-18.0 mg) was significant (P

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Anatomical Variations of the Vertebral Artery in the Upper Cervical Spine: Clinical Relevance for Procedures Targeting the C1/C2 and C2/C3 Joints.

Background and Objectives: Accidental breach of the vertebral artery (VA) during the performance of cervical pain blocks can result in significant morbidity. Whereas anatomical variations have been described for the foraminal (V2) segment of the VA, those involving its V3 portion (between the C2 transverse process and dura) have not been investigated and may be of importance for procedures targeting the third occipital nerve or the lateral atlantoaxial joint. Methods: Five hundred computed tomography angiograms of the neck performed in patients older than 50 years for the management of cerebrovascular accident or cervical trauma (between January 2010 and May 2016) were retrospectively and independently reviewed by 2 neuroradiologists. Courses of the VA in relation to the lateral aspect of the C2/C3 joint and the posterior surface of the C1/C2 joint were examined. For the latter, any medial encroachment of the VA (or one of its branches) was noted. The presence of a VA loop between C1 and C2 and its distance from the upper border of the superior articular process (SAP) of C3 were also recorded. If the VA loop coursed posteriorly, its position in relation to 6 fields found on the lateral aspects of the articular pillars of C2 and C3 was tabulated. Results: At the C1/C2 level, the VA coursed medially over the lateral quarter of the dorsal joint surface in 1% of subjects (0.6% and 0.4% on the left and right sides, respectively; P = 0.998). A VA loop originating between C1 and C2 was found to travel posteroinferiorly over the anterolateral aspect of the inferior articular pillar of C2 in 55.5% of patients on the left and 41.9% on the right side (P

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Keeping Up With Heavy Call Volumes: Reliability in New World CAD

Brought to you by - Tyler Technologies Computer aided dispatch (CAD) administrators discuss how New World CAD handled heavy call volumes during large storms and catastrophic events.

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New World CAD Users Experience Tyler’s Text-to-911 Solution

New World computer aided dispatch (CAD) users participated in a focus group to use Tyler's Text-to-911 solution. In this video, they discuss their experience and the benefits of the technology.

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The Text-to-911 Experience

Dispatchers from the El Cajon Police Department in California preview Tyler's Text-to-911 solution and discuss their experience

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Streamlining Emergency Operations

A computer aided dispatch (CAD) administrator with the York County Department of Emergency Services in Pennsylvania discusses the benefits of implementing the New World CAD solution from Tyler Technologies.

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Keeping Up With Heavy Call Volumes: Reliability in New World CAD

Brought to you by - Tyler Technologies Computer aided dispatch (CAD) administrators discuss how New World CAD handled heavy call volumes during large storms and catastrophic events.

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New World CAD Users Experience Tyler’s Text-to-911 Solution

New World computer aided dispatch (CAD) users participated in a focus group to use Tyler's Text-to-911 solution. In this video, they discuss their experience and the benefits of the technology.

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The Text-to-911 Experience

Dispatchers from the El Cajon Police Department in California preview Tyler's Text-to-911 solution and discuss their experience

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Streamlining Emergency Operations

A computer aided dispatch (CAD) administrator with the York County Department of Emergency Services in Pennsylvania discusses the benefits of implementing the New World CAD solution from Tyler Technologies.

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Keeping Up With Heavy Call Volumes: Reliability in New World CAD

Brought to you by - Tyler Technologies Computer aided dispatch (CAD) administrators discuss how New World CAD handled heavy call volumes during large storms and catastrophic events.

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New World CAD Users Experience Tyler’s Text-to-911 Solution

New World computer aided dispatch (CAD) users participated in a focus group to use Tyler's Text-to-911 solution. In this video, they discuss their experience and the benefits of the technology.

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The Text-to-911 Experience

Dispatchers from the El Cajon Police Department in California preview Tyler's Text-to-911 solution and discuss their experience

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Streamlining Emergency Operations

A computer aided dispatch (CAD) administrator with the York County Department of Emergency Services in Pennsylvania discusses the benefits of implementing the New World CAD solution from Tyler Technologies.

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New Reference Values for Cardiopulmonary Exercise Testing in Children.

Introduction: Cardiopulmonary exercise testing (CPET) is an essential tool to assess cardiorespiratory fitness (CRF) in children. There is a paucity of adequate pediatric reference values that are independent of body size and pubertal stage. The purpose of this study is to provide Z score equations for several maximal and sub-maximal CRF parameters derived from a prospectively recruited sample of healthy children. Methods: In this cross-sectional multicenter study, we prospectively recruited 228 healthy children aged 12 to 17 years old in local schools. We performed a symptom-limited CPET progressive ramp protocol on an electronically-braked cycle ergometer. Eighteen CRF parameters were analysed. We tested several regression models to obtain prediction curves that minimized residual association with age, body size and pubertal stage. Both the predicted mean and the predicted standard deviation were modeled to account for heteroscedasticity. Results: We identified nonlinear association of CRF parameters with body size with significant heteroscedasticity. To normalize CRF parameters, the use of a single body size variable was not sufficient. We therefore used multivariable models with various combination of height, corrected body mass and age. Final prediction models yielded adjusted CRF parameters that were independent of age, sex, body mass, height, body mass index and Tanner stages. Conclusion: We present Z score equations for several CRF parameters derived from a healthy pediatric population. These reference values provide updated predicted means and range of normality that are independent of sex and body size. Further testing is needed to assess if these reference values increase sensitivity and specificity to identify abnormal cardiorespiratory response in children with chronic diseases. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. (C) 2018 American College of Sports Medicine

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Keeping Up With Heavy Call Volumes: Reliability in New World CAD

Tyler Technologies - Computer aided dispatch (CAD) administrators discuss how New World CAD handled heavy call volumes during large storms and catastrophic events.

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New World CAD Users Experience Tyler’s Text-to-911 Solution

New World computer aided dispatch (CAD) users participated in a focus group to use Tyler's Text-to-911 solution. In this video, they discuss their experience and the benefits of the technology.

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The Text-to-911 Experience

Dispatchers from the El Cajon Police Department in California preview Tyler's Text-to-911 solution and discuss their experience

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Streamlining Emergency Operations

A computer aided dispatch (CAD) administrator with the York County Department of Emergency Services in Pennsylvania discusses the benefits of implementing the New World CAD solution from Tyler Technologies.

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Role of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction?.

Purpose of review: Given the extremely expensive nature of critical care medicine, it seems logical that intensivists should play an active role in designing efficient systems of care. The true value of intensivists, however, is not well defined. Recent findings: Anesthesiologists have taken key roles in improving patient safety in the operating room. Anesthesia-related mortality rates have decreased from 20 deaths per 100 000 anesthetics in the early 1980s to less than one death per 100 000 currently. Anesthesiologist-intensivists remain rare (less than 5% of certified anesthesiologists), but increasingly play multiple roles within multidisciplinary teams. This review outlines the roles of intensivists in performance improvement, perioperative assessment; sedation services, extracorporeal and mechanical support, and code/rapid response teams. Critical-care physicians, by definition, work in collaborative multispecialty and multidisciplinary teams that make it difficult to isolate each team member's precise contribution to healthcare value. Summary: Anesthesiologist-intensivists working outside their usual environment provide leadership and clinical guidance towards improving patient outcomes. Copyright (C) 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Withdrawal of life-sustaining therapy.

Purpose of review: The aim of this review is to examine literature relating to the withdrawal of life-sustaining therapy (WLST). Recent findings: Discussions regarding end-of-life issues in adults and children are not occurring comprehensively. Discussions relating to the WLST in the pediatric population varies by institution and may vary by race, age, health insurance, diagnosis, and severity of illness. Completing advance directives prior to placement of life-sustaining treatments is not consistent practice. With the WLST, differences in perspectives exist between medical specialties, within one specialty at different levels of training, and in physicians' ethical and psychological responses to the WLST. The timing of WLST appears to be influenced by ICU strain and communication issues. Study outcomes differ regarding the functionally favorable survival of patients who have had WLST. Universal guidelines for the WLST may not address individual patient circumstances. Summary: Discussions of end-of-life issues early in the course of a patient's health care will contribute to the healthcare team's understanding and respect of the patient's wishes. This article addresses the withdrawal of left ventricular assist devices; attending physicians and physicians-in-training perspectives of WLST; do physicians distinguish between withholding and WLST; the timing of WLST; guidelines for the process of WLST; and pediatrics and end-of-life decisions. Copyright (C) 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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What has President Trump done for EMS?

President Donald J. Trump has been officially on the job for a year since his Jan. 20, 2017 inauguration. In that time, Trump has shown a clear affinity for public safety personnel, especially police officers. He has spoken to police officers about the MS-13 gang, posed for photos in a Pierce fire engine, invited members of the U.S. Coast Guard to a round of golf and visited paramedics at a Florida ...

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A computer simulation to investigate the association between gene-based gifting and pair-bonding in early hominins

Publication date: March 2018
Source:Journal of Human Evolution, Volume 116
Author(s): Ovi Chris Rouly
This article describes simulation research based on the Hamiltonian theory of gene-based altruism. It investigates the origin of semipermanent breeding bonds during hominin evolution. The research framework is based on a biologically detailed, ecologically situated, multi-agent microsimulation of emergent sociality. The research question tested is whether semipermanent breeding bonds (an emergent homoplastic social construct) might emerge among primate-like agents as the consequence of a mutation capable of supporting involuntary prosocial behavior. The research protocol compared several, single independent-variable longitudinal studies wherein hundreds of generations of autonomous, initially promiscuous, biologically detailed, hominin-like artificial life software agents were born, allowed to forage, reproduce, and die during experimental intervals lasting several simulated millennia. The temporal setting of the experiment was roughly contemporaneous with, or slightly after the time of, the Pan-Homo split. The simulation investigated what would happen if, within a population, a single gene for prosocial behavior (the independent variable in the experiment) was either switched on or switched-off. The null hypothesis predicted that, if the gene was switched off, then semipermanent breeding bonds (the dependent variable) would nonetheless emerge within the population. The results of the simulation rejected this null hypothesis, by showing that semipermanent breeding bonds would reliably emerge among the experimental populations but not among the control groups. Moreover, it was found that, across all experimental settings having constrained population numbers, the portion of each population having no prosocial trait would die out early, whereas the portion with the prosocial trait would survive. Large control populations had no discernible loss. The results of this research imply that, during the early stages of hominin evolution, there might have been a set of initially gene-based, altruistic excess forage-sharing social traits that contributed to the onset of morphological and additional complex social changes characteristic of this group. This work also demonstrates that modern computational technologies can extend our ability to test 'what if' hypotheses appropriate to the study of early hominin evolution.



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Reply to Crivelli et al.: The different faces of fear and threat. Evolutionary and cultural insights

Publication date: Available online 12 January 2018
Source:Journal of Human Evolution
Author(s): Mariska E. Kret, Larissa M. Straffon




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Lower limb articular scaling and body mass estimation in Pliocene and Pleistocene hominins

Publication date: Available online 10 January 2018
Source:Journal of Human Evolution
Author(s): Christopher B. Ruff, M. Loring Burgess, Nicole Squyres, Juho-Antti Junno, Erik Trinkaus
Previous attempts to estimate body mass in pre-Holocene hominins have relied on prediction equations derived from relatively limited extant samples. Here we derive new equations to predict body mass from femoral head breadth and proximal tibial plateau breadth based on a large and diverse sample of modern humans (avoiding the problems associated with using diaphyseal dimensions and/or cadaveric reference samples). In addition, an adjustment for the relatively small femoral heads of non-Homo taxa is developed based on observed differences in hip to knee joint scaling. Body mass is then estimated for 214 terminal Miocene through Pleistocene hominin specimens. Mean body masses for non-Homo taxa range between 39 and 49 kg (39–45 kg if sex-specific means are averaged), with no consistent temporal trend (6–1.85 Ma). Mean body mass increases in early Homo (2.04–1.77 Ma) to 55–59 kg, and then again dramatically in Homo erectus and later archaic middle Pleistocene Homo, to about 70 kg. The same average body mass is maintained in late Pleistocene archaic Homo and early anatomically modern humans through the early/middle Upper Paleolithic (0.024 Ma), only declining in the late Upper Paleolithic, with regional variation. Sexual dimorphism in body mass is greatest in Australopithecus afarensis (log[male/female] = 1.54), declines in Australopithecus africanus and Paranthropus robustus (log ratio 1.36), and then again in early Homo and middle and late Pleistocene archaic Homo (log ratio 1.20–1.27), although it remains somewhat elevated above that of living and middle/late Pleistocene anatomically modern humans (log ratio about 1.15).



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Hominin raw material procurement in the Oldowan-Acheulean transition at Olduvai Gorge

Publication date: Available online 10 January 2018
Source:Journal of Human Evolution
Author(s): Lindsay J. McHenry, Ignacio de la Torre
The lithic assemblages at the Oldowan-Acheulean transition in Bed II of Olduvai Gorge, Tanzania, represent a wide variety of raw materials reflecting both the diversity of volcanic, metamorphic, and sedimentary source materials available in the Olduvai basin and surroundings and the preferences of the tool-makers. A geochemical and petrographic systematic analysis of lava-derived archaeological stone tools, combined with textural and mineralogical characterization of quartzite, chert, and other metamorphic and sedimentary raw materials from two Middle and Upper Bed II sites, has enabled us to produce a comprehensive dataset and characterization of the rocks employed by Olduvai hominins, which is used here to establish a referential framework for future studies on Early Stone Age raw material provenancing. The use of rounded blanks for most lava-derived artifacts demonstrates that hominins were accessing lava in local stream channels. Most quartzite artifacts appear to derive from angular blocks, likely acquired at the source (predominantly Naibor Soit hill), though some do appear to be manufactured from stream-transported quartzite blanks. Raw material composition of the EF-HR assemblage indicates that Acheulean hominins selected high-quality lavas for the production of Large Cutting Tools. On the other hand, the HWK EE lithic assemblage suggests that raw material selectivity was not entirely based on rock texture, and other factors, such as blank shape and availability of natural angles suitable for flaking, played a major role in Oldowan reduction sequences.



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Wisconsin based electronics and technology firm wins major national contract to provide services and products across the United States

MILWAUKEE, Wis. — TKK Electronics, a Milwaukee, Wisconsin; based technology and electronics firm, has won a major national contract for providing information technology products and services across the United States with an emphasis on the public sector. The contract was awarded by Savvik which services a group of more than 7,000 members in the public and private sector such as fire departments ...

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Complex issues in new ultrasound-guided nerve blocks: how to name, where to inject, and how to publish

Abstract

The recent development of ultrasound-guide nerve block has led to innovation in anesthesia and pain clinics. However, it has also led to some complex issues, including (1) how to name a new technique, (2) the appropriateness of an intramuscular approach, and (3) how to publicize a new technique. This review addresses naming strategy, feasibility of intramuscular approach block, and methods of publication. First, researchers and authors should pay attention to appropriate nomenclature for the term 'approach', 'compartment block', and 'nerve block' for a new block. Second, it is lack of evidences to facilitate muscle injection, and adequate preparation and adherence to proper technique for intramuscular approach block should be considered; confirmation of abnormal signs at the injection area, use of a thin needle and the lowest concentration and volume of local anesthetic without supplementation with steroid or epinephrine, compressing hemostasis, and sufficient interval of the blocks. Third, adequate dissemination of information would also be necessary through publication in appropriate media. We hope this review boost reasonable development of nerve block.

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Epidemiology of Head Injuries Focusing on Concussions in Team Contact Sports: A Systematic Review

Abstract

Background

Although injuries to the head represent a small proportion of all sport injuries, they are of great concern due to their potential long-term consequences, which are even suspected in mild traumatic brain injuries.

Objective

The aim of this review was to compare the incidence of concussions and other head injuries in elite level football, rugby, ice hockey and American Football.

Methods

Four electronic databases (CINAHL, PsycINFO, Web of Science, PubMed) were searched. Prospective cohort studies on the incidence of concussion in elite athletes aged 17 years or older that were published in an English-language peer-reviewed journal since 2000 were included. Two authors independently evaluated study eligibility and quality. The extracted data on concussions were pooled in a meta-analysis using an inverse-variance fixed-effects model. The extracted data on head injuries were reported in a narrative and tabular summary.

Results

The search yielded 7673 results of which 70 articles were included in the qualitative and 47 in the quantitative analysis. In our meta-analysis, we found the highest concussion incidences in rugby match play (3.89 and 3.00 concussions per 1000 h and athletic exposures (AEs), respectively), and the lowest in men's football training (0.01 and 0.08 per 1000 h and AEs, respectively). Overall, concussions and all head injuries were rare in training when compared to match play. Female players had an increased concussion risk in football and ice hockey when compared to male players.

Conclusion

Future research should focus on concussion in women's contact sports, as there is little evidence available in this area. Methodological deficits are frequent in the current literature, especially regarding sample size and study power, and should be avoided.

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MedixSafe "firsts" make them first-rate choice for properly securing EMS pharmaceuticals

MEMPHIS, Tenn. — MedixSafe, known for providing the very best in narcotics security to first responders, EMS and pharmaceutical workers, has delivered an impressive list of "firsts" that have translated into unprecedented product offerings. Among them, MedixSafe was the first manufacturer to: Feature a fingerprint reader on its narcotics cabinets. Require triple authentication (PIN ...

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The Role of Mentors in Early Intervention Referrals: Overlooked Views of Pediatric Residency Training Directors

Abstract

Objectives There continues to be a pressing need to increase referrals to family-centered early intervention (EI) for more eligible infants and toddlers with inadequate consideration for the role of senior, mentoring professionals. Methods To address a dearth in our understanding, a subset of Pediatric Residency Training Directors shared views on EI, referral, and relevant training efforts. Results Participating directors primarily reported limited understanding of EI. Greater knowledge of family-focused EI correlated with its perceived helpfulness (r = .420; p = .021), which positively correlated with referring a child to EI. Despite 67% of the sample viewing pediatricians as 'most important' in screenings and EI referrals, residents were perceived as only somewhat aware of EI referral and services, and only somewhat aware of differences between clinic options and Part C EI. Although nearly all respondents noted minimal EI exposure during training, only 43% felt this amount was 'inadequate/insufficient'. The sample was fairly evenly divided in being 'extremely' or 'somewhat' interested in communicating with state EI leaders. Conclusions for Practice This preliminary analysis describes perceptions among senior medical professionals who may influence referrals via mentoring, training, and interdisciplinary collaboration. Findings inform next steps in terms of research, improving education for directors and residents, and collaborative information-sharing to bolster family-centered EI referrals to improve child and family outcomes.

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Getting published

Abstract

Publications remain an important part of the currency of academia, they are intimately related to your professional standing, advancement and funding.

This article is protected by copyright. All rights reserved

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Issue Information

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Arterial duct and pulmonary arteriovenous malformations: A shunt masking a shunt

Mario Giordano, Giuseppe Santoro, Maria Teresa Palladino, Maria Giovanna Russo

Annals of Pediatric Cardiology 2018 11(1):89-91

A 5-month-old infant, referred to our institution for percutaneous arterial duct (AD) embolization, showed multiple huge pulmonary arteriovenous malformations (PAVMs) associated with a small AD and several tiny systemic-to-pulmonary collaterals. This anatomic arrangement was a possible cause of lack of cyanosis and disproportionately higher hemodynamic relevance of the ductal shunt. The PAVMs became pathophysiologically evident immediately after the closure of AD and systemic to pulmonary artery collaterals and presented clinically with a life-threatening cyanosis. To improve the patient's clinical and hemodynamic condition, the PAVMs were closed in multiple sittings using a large number of Amplatzer Vascular Plugs (St. Jude Medical Inc., St. Paul, MN, USA). The hemodynamic burden of cardiac malformations resulting in left-to-right shunt may be magnified by the presence of PAVMs as a result of low pulmonary vascular resistance which in turn may completely mask the clinical impact of the latter. Transcatheter approach is life-saving in these complex arrangements.

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Extracorporeal membrane oxygenation in pediatric cardiac surgery: A retrospective review of trends and outcomes in Scotland

Maziar Khorsandi, Mark Davidson, Omar Bouamra, Andrew McLean, Kenneth MacArthur, Ida Torrance, Gillian Wylie, Ed Peng, Mark Danton

Annals of Pediatric Cardiology 2018 11(1):3-11

Introduction : Around 3.2%–8.4% of patients receive venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support after pediatric cardiac surgery. The desired outcome is "bridgetorecovery" in most cases. There is no universally agreed protocol, and given the associated costs and complications rates, the decisions as of when and when not to institute VA ECMO are largely empirical. Methods : A retrospective review of the ECMO database at the Scottish Pediatric Cardiac Services (SPCS) was undertaken. Inclusion criterion encompassed all children (<16 years of age) who were supported with VA ECMO following cardiac surgery between January 2011 and October 2016. The timing of ECMO support was divided into three distinct phases: "endofcase" or intheatre ECMO for patients unable to effectively wean from cardiopulmonary bypass (CPB), ECMO for cardiopulmonary resuscitation ("ECPR"), and Intensive Care Unit ECMO for "failing maximal medial therapy" following cardiac surgery. The patients were analyzed to identify survival rates, adverse prognostic indicators, and complication rates. Results : We identified 66 patients who met the inclusion criterion. 30day survival rate was 45% and survival rate to hospital discharge was 44% (the difference represents one patient). On followup (median: 960 days, range: 42–2010 days), all survivors to hospital discharge were alive at review date. "Endofcase" ECMO showed a trend toward better survival of the three subcategories ("end of case," ECPR, and ECMO for "failing maximal medical therapy" survival rates were 47%, 41%, and 37.5%, respectively, P = 0.807). The poorest survival rates were in the younger children (<6 months, P = 0.502), patients who had prolonged CPB (P = 0.314) and aortic crossclamp times (P = 0.146), and longer duration of ECMO (>10 days, P = 0.177). Conclusions : Allcomers VA ECMO following pediatric cardiac surgery had survival to discharge rate of 44%. Elective "endofcase" ECMO carries better survival rates and therefore ECMO instituted early maybe advantageous. Prolonged ECMO support has a direct correlation with mortality.

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Melody valve implantation through a recanalized occluded femoral vein

Neil D Patel, Jennifer A Su, Cheryl M Takao, Frank F Ing

Annals of Pediatric Cardiology 2018 11(1):111-113



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Comparison of skin dose measurement using nanoDot® dosimeter and machine readings of radiation dose during cardiac catheterization in children

Duraisamy Balaguru, Matthew Rodriguez, Stephanie Leon, Louis K Wagner, Charles W Beasley, Andrew Sultzer, Mohammed T Numan

Annals of Pediatric Cardiology 2018 11(1):12-16

Objectives : Direct measurement of skin dose of radiation for children using optically stimulated luminescence (OSL) technology using nanoDot® (Landauer, Glenwood, IL, USA). Background : Radiation dose is estimated as cumulative air kerma (AK) and dosearea product based on standards established for adult size patients. Body size of pediatric patients who undergo cardiac catheterization for congenital heart disease vary widely from newborn to adolescence. Direct, skindose measurement applying OSL technology may eliminate errors in the estimate. Materials and Methods : The nanoDot® (1 cm × 1 cm × flat plastic cassette) is applied to patient's skin using adhesive tape during cardiac catheterization and radiation skin doses were read within 24 hrs. nanoDot® values were compared to the currently available cumulative AK values estimated and displayed on fluoroscopy monitor. Results : A total of 12 children were studied, aged 4 months to 18 years (median 1.1 years) and weight range 5.3–86 kg (median 8.4 kg). nanoDot® readings ranged from 2.58 mGy to 424.8 mGy (median 84.1 mGy). Cumulative AK ranged from 16.2 mGy to 571.2 mGy (median 171.1 mGy). Linear correlation was noted between nanoDot® values and AK values (R2 = 0.88, R = 0.94). nanoDot® readings were approximately 65% of the estimated cumulative AK estimated using the International Electrotechnical Commission standards. Conclusions : Application of OSL technology using nanoDot® provides an alternative to directly measure fluoroscopic skin dose in children during cardiac catheterization. Our data show that the actual skin dose for children is approximately one-third lower than the AK estimated using international standards for adult size patients.

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Coronary sinus atrial septal defect without persistent left superior vena cava: Three-dimensional imaging of a rare defect

Sean Del-Rossi Quadros, Sreeja Pavithran, Ravi Agrawal, Kothandam Sivakumar

Annals of Pediatric Cardiology 2018 11(1):103-105

Coronary sinus defects refer to interatrial communications that lie out of the confines of the atrial septum and leads from left to right shunt through the ostium of the coronary sinus. When associated with persistent left superior vena cava (PLSVC), mild systemic desaturation may occur depending on the extent of unroofing of the coronary sinus. Isolated defects without PLSVC are rare. Three-dimensional echocardiographic and surgical images are presented.

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Normal reference ranges for cardiac valve cross-sectional areas in preterm infants

Lulu Abushaban, Mariappa Thinakar Vel, Jebaraj Rathinasamy, Prem N Sharma

Annals of Pediatric Cardiology 2018 11(1):17-27

Objective : To establish normal reference ranges for cardiac valve crosssectional areas (CSAs) in preterm infants and their correlation with gestational age, body weight, and chronological age. Materials and Methods : In a prospective study, 268 preterm babies fulfilling the criteria for inclusion were examined. Echocardiograms were performed to measure aortic, pulmonary, mitral, and tricuspid valve CSAs on 0–6 day (s) of life and at weekly intervals until they reached 36 weeks. Gestational age was divided into three groups, 24–27, 28–31, and 32–35 weeks, and body weight was divided into five groups, ≤999, 1000–1499, 1500–1999, 2000–2499, and ≥2500 g. Overall group differences were compared for each period of life: 0–6 days and 1–2, 3–4, and ≥5 weeks. Results : The mean gestational age was 29.8 (±2.38 standard deviation [SD]) weeks, ranging between 24 and 35 weeks, and the mean body weight was 1479 (±413 SD) g, ranging between 588 and 3380 g. All cardiac valve CSAs correlated well with body weight. A significant gradual increase was observed in all valve CSAs with body weight during each period of life. Overall, a progressive and significant increase in all valve CSAs was observed during the first 9 weeks of life. Conclusions : Cardiac valve CSAs were found to be significantly correlated with body weight. The study also provides reference data, which can be used as a normal reference tool for valve CSAs in preterm infants against gestational age, body weight, and chronological age.

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From the Editor's Desk: Congenital heart surgery in India – At the crossroads?

Krishna Subramony Iyer

Annals of Pediatric Cardiology 2018 11(1):1-2



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Evaluation of left ventricular function in obese children without hypertension by a tissue Doppler imaging study

Yazdan Ghandi, Mehrzad Sharifi, Danial Habibi, Fatemeh Dorreh, Mojtaba Hashemi

Annals of Pediatric Cardiology 2018 11(1):28-33

Background : The prevalence of obesity is increasing worldwide. Obese children without hypertension are becoming an important health challenge. Aims : Complications of obesity in adults are well established, but in obese children, cardiac dysfunction has not been reported clinically. Settings and Design : The present crosssectional study investigates subclinical systolic and diastolic dysfunction using echocardiographic modalities. Materials and Methods : Twentyfive youngsters with body mass index (BMI) >30 and 25 healthy children with BMI <25 were assigned into case and control group, respectively. In all participants, complete cardiovascular examination, electrocardiography, and echocardiography were fulfilled. Echocardiography surveys included standard, pulsed wave Doppler (PWD), and tissue Doppler imaging (TDI). Statistical Analysis Used : SPSS software, version 24. Results : The two groups were matched for age and sex. The resting heart rate and blood pressure were markedly higher in the obese group (P = 0.0001) though they were within the normal range in either category. Ejection fraction in the two groups was similar. Left ventricular (LV) mass (P = 0.0001), LV mass index (P = 0.029), left atrialtoaortic diameter ratio (P = 0.0001), and LV enddiastolic diameter (P = 0.008) were significantly greater in the case group, indicating cardiomegaly and subclinical systolic and diastolic dysfunction. Except for the aortic velocity, all PWD variables were considerably lower in the case group, suggesting subclinical diastolic dysfunction. All TDI parameters varied significantly between the two categories. There was a direct correlation between isovolumetric relaxation time and BMI. Conclusions : Obesity in children without hypertension is associated with subclinical systolic and diastolic cardiac dysfunction. We propose the evaluation of blood pressure as well as myocardial performance using PWD and TDI in all obese children without hypertension, regularly.

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Congenital aneurysm of both left ventricle and left atrium

Ryan F Halas, Christopher J Schmehil, Gary R Ten Eyck, James L Loker

Annals of Pediatric Cardiology 2018 11(1):97-99

This is a case of both congenital left ventricular (LV) free wall submitral aneurysm and left atrial appendage aneurysm with 6 years of clinical follow-up. Each lesion is a rare entity, and to the best of our knowledge, this is the first case in medical literature of both lesions occurring in the same patient, raising the likelihood of a common etiology. The workup was initiated in the third trimester of fetal life with irregular heart rate and abnormal fetal ultrasound and echocardiogram at that time. The patient required emergent atrial appendage plication due to blood clot formation and suffered from multiple other complications including ventricular ectopy and surgically induced pseudoaneurysm. Follow-up interval echocardiograms have revealed continued good LV function with persistent LV aneurysm. In review of the case, there were several potential in utero causes including maternal viral upper respiratory infection and bacteriuria with exposure to amoxicillin. These as well as other considerations are discussed along with a brief review of these rare lesions, usual presentation, and known associations.

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Clinical presentation, management, and postnatal outcomes of fetal tachyarrhythmias: A 10-year single-center experience

Balaganesh Karmegeraj, Sushmita Namdeo, Abish Sudhakar, Vivek Krishnan, Radhamany Kunjukutty, Balu Vaidyanathan

Annals of Pediatric Cardiology 2018 11(1):34-39

Background : Limited information is available regarding the prevalence and outcomes of fetal tachyarrhythmias from the developing countries. Aims : This study aims to report referral patterns, management protocols, and pregnancy outcomes of fetuses with tachyarrhythmias reporting to a single center in South India. Methods : All fetuses with documented sustained fetal tachyarrhythmia during the study period (2008–2017) were included. Arrhythmia characterization and hemodynamic evaluation were done using fetal echocardiography. Patients were grouped into supraventricular tachycardia (SVT) and atrial flutter (AF) groups. Patient characteristics, transplacental therapy (TPT), pregnancy, and postnatal outcomes were analyzed. Results : Total of 19 fetuses included; 11 had SVT and 8 AF. Mean gestational age at referral was higher for AF (32.5 ± 3.2 vs. 29.6 ± 3.3 weeks; P = 0.05). Hydrops fetalis was present 8 (42%) fetuses; 4 in each group. TPT was instituted in 18 fetuses; 12 (66.7%) received combination therapy; 4 (21%) received direct fetal therapy. Eighteen fetuses (91%) were born alive with one intrauterine death in a fetus with SVT and severe hydrops. Seven (87.5%) fetuses with hydrops survived. Twelve patients (66.7%) were delivered in sinus rhythm. Six babies (33.3%) had tachycardia at birth requiring anti-arrhythmic therapy. All patients survived the neonatal period. Duration of trans-placental therapy (3.8 + 3.3 vs. 7.3 + 3.4 weeks) was shorter in the AF group. Conclusions : Aggressive TPT using combination of drugs achieves excellent pregnancy and postnatal outcomes in fetuses with tachyarrhythmia. Early diagnosis and prompt referral before hemodynamic decompensation is critical for ensuring optimal outcomes.

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Cost-effectiveness analysis of devices for closure of patent ductus arteriosus

KM Krishnamoorthy, Arun Gopalakrishnan

Annals of Pediatric Cardiology 2018 11(1):109-109



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Exercise performance after univentricular palliation

Sachin Talwar, Manikala Vinod Kumar, Vishnubhatla Sreenivas, Vishwa Prakash Gupta, Shiv Kumary Choudhary, Balram Airan

Annals of Pediatric Cardiology 2018 11(1):40-47

Background : The optimal timing, need for primary/staged procedure in patients undergoing univentricular palliation, is debatable. Aims : We performed this study to assess the exercise performance of patients undergoing various forms of univentricular palliation. Setting and Design : This was a retrospective, prospective comparative study conducted at a multispecialty tertiary referral center. Patients and Methods : Between January 2012 and June 2015, 117 patients undergoing either bidirectional Glenn (BDG) (n = 43) or Fontan (total cavopulmonary connection [TCPC]) (n = 74) underwent exercise testing. Statistical Analysis : Comparisons between subgroups for continuous data were made with Student's ttest if normally distributed and Wilcoxon ranksum test otherwise. Tests between subgroups for qualitative data were made with Pearson's Chisquare test. Results : Patients who underwent BDG with open antegrade pulmonary blood flow (APBF) had higher saturations (oxygen saturation [SpO2]) compared to those without it (87.5 ± 5.0% vs. 81.1 ± 4.8%; P = 0.0001). However, we found no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC (n = 42) patients demonstrated better exercise capacity (15.0 ± 7.7 vs. 11.2 ± 6.2 min; P = 0.02) and increased SpO2 on exercise (87.0 ± 8.0% vs. 83.4 ± 7.6%; P ≤ 0.05) compared to lateral tunnel TCPC (n = 32). Fenestrated TCPC (n = 30) patients had higher exercise capacity reflected by higher metabolic equivalents (METs) consumption (6.4 ± 2.3 vs. 5.2 ± 2.0 METs, P = 0.02), fewer pleural effusions (7.0 ± 3.2 vs. 9.2 ± 6.2 days, P ≤ 0.05), and lower hospital stay (9.5 ± 4.0 vs. 12.7 ± 7.7 days, P = 0.04) compared to nonfenestrated TCPC (n = 44) patients. Conclusions : We observed no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC patients had better exercise capacity but longer postoperative hospital stay and pleural effusions than patients with lateral tunnel Fontan. Fenestrated TCPC patients seemed to fare better than nonfenestrated ones. Patients undergoing TCPC had better exercise capacity than patients undergoing BDG alone.

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Ominous comorbidities: Small ventricular septal defect and warm autoimmune hemolytic anemia

Elaheh Malakan Rad

Annals of Pediatric Cardiology 2018 11(1):114-116



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Impact of intensive care unit attending physician training background on outcomes in children undergoing heart operations

Priya Bhaskar, Mallikarjuna Rettiganti, Jeffrey M Gossett, Punkaj Gupta

Annals of Pediatric Cardiology 2018 11(1):48-55

Background : The existing training pathways to become a pediatric cardiac intensivist are very variable with physicians coming from varied training backgrounds of pediatric critical care, pediatric cardiology, neonatology, or pediatric anesthesia. Aim : To evaluate the impact of cardiac Intensive Care Unit (ICU) attending physician training background on outcomes in children undergoing heart operations. Setting and Design : Patients in the age group from 1 day to 18 years undergoing heart operation at a Pediatric Health Information System database participating hospital were included (2010–2015). Patients and Methods : Based on the training background of majority of attending physicians in an ICU, the participating ICUs were divided into three groups: critical care medicine (CCM), cardiology, and indeterminate. Statistical Analysis : Multivariable logistic regression models were fitted to evaluate the association of ICU physician training background with study outcomes. Results : A total of 54,935 patients from 42 ICUs were included. Of these, 31,815 patients (58%) were treated in the CCM group (26 ICUs), 19,340 patients (35%) were treated in the cardiology group (12 ICUs), and 3780 patients (7%) were treated in the indeterminate group (4 ICUs). In adjusted models, no specific group based on ICU attending physician training background was associated with lower mortality (CCM vs. cardiology, odds ratio: 0.75, 95% confidence interval: 0.48–1.18), or lower incidence of cardiac arrest, or prolonged hospital length of stay, or prolonged mechanical ventilation. Conclusions : This large observational study did not demonstrate any impact of ICU attending training background on outcomes in children undergoing heart operations.

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Transcatheter closure of postsurgical ruptured sinus of valsalva with amplatzer duct Occluder II AS™ device

Cristina Capogrosso, Giuseppe Santoro, Mario Giordano, Maria Giovanna Russo

Annals of Pediatric Cardiology 2018 11(1):86-88

Sinus of Valsalva (SV) rupture is a rare, cardiac complication after surgical repair of complex congenital heart disease. This paper reports a 4-year-old male child with double outlet right ventricle (RV) and pulmonary stenosis with superior-inferior arrangement of the ventricles, who was submitted to surgical repair using the "reparation a l'etage ventriculaire" procedure. A few months after an uneventful surgical repair, his clinical condition abruptly worsened because of the rupture of the right SV into the RV outflow tract resulting in large left-to-right shunt and RV functional impairment. To avoid surgical re-do, this late-onset complication was successfully treated by transcatheter implantation of an Amplatzer Duct Occluder Type II Additional Size™ (ADO-IIAS, St. Jude Medical Inc., St. Paul, Minnesota, USA) device.

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Prognostic value of troponin in infants with hypoplastic left heart syndrome between Stage I and II of palliation

Martin Christmann, Emanuela R Valsangiacomo Büchel, Hitendu Dave, Dietrich Klauwer, Anna Cavigelli-Brunner

Annals of Pediatric Cardiology 2018 11(1):56-59

Background : The period between stage I and II procedure for treatment of hypoplastic left heart syndrome (HLHS) bears high mortality and morbidity. Methods : We sought to analyze the prognostic value of Troponin T/I (Trop), a well-recognized marker for myocardial damage and heart failure, for predicting outcome in a retrospective analysis of 70 infants with HLHS at our institution between March 2001 and October 2014. Results : Stage I procedure consisted of Norwood I operation in 35 (50%) and Hybrid-approach in 22 (31%) patients. Palliative care was chosen for 13 (19%) patients. Trop values were collected from clinical charts and were analyzed in relation to the overall outcome. Trop was significantly higher after Norwood I operation in comparison to Hybrid-approach (median 7.1 g/l (0.7-20.9), vs 1.2 g/l (0.3-17.9), P < 0.001). Overall mortality of treated patients was 39% (22 patients). Survival was 54% (19 patients) after Norwood and 73% (16 patients) after Hybrid-approach. Independently from the procedure used, maximal Trop and initial lactate values were significantly higher in non-survivors than in survivors, with median Trop of 9 g/l (0.6-18.8) vs. 3.4 g/l (0.4-20.9), P 0.007, and median lactate of 3.7 mmol/L (1.6-25) vs. 2.9 mmol/L (0.3-14.6), p 0.03. Reinterventions were required in 17 (30%) patients, 4 (11%) after Norwood and 13 (59%) after Hybrid procedure. No correlation was found between the need for reintervention and Trop levels in the interstage period. Conclusions : Patients with HLHS have significantly higher Trop levels after Norwood procedure than after Hybrid-approach. Maximal Trop values were related to mortality, but did not correlate with the need for reinterventions.

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Discontinuity of the arch beyond the origin of the left subclavian artery in an adult: Interruption or coarctation?

Pradeep Vaideeswar, Supreet Marathe, Saranya Singaravel, Robert H Anderson

Annals of Pediatric Cardiology 2018 11(1):92-96

Congenital aortic anomalies are uncommon causes of secondary hypertension and are seldom suspected in the adult age group. We present a case of aortic interruption unexpectedly diagnosed on autopsy in a 38-year-old male who presented with cardiovascular collapse. Apart from interruption, a finding unique to our case was aneurysmal dilation of the proximal descending aorta just before the obstruction with thrombosis. We also attempt to review the literature for interrupted aortic arch in adults and clarify the nomenclature of interruption versus coarctation.

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Q fever endocarditis after right ventricle to pulmonary artery conduit insertion: Case series and review of the literature

Sundos A Alhadhoud, Mariappa Thinakar Vel, Mustafa Al Qbandi

Annals of Pediatric Cardiology 2018 11(1):60-63

Q fever (QF) is rarely reported in children. Awareness of the disease and newer diagnostic modalities have resulted in increasing recognition of unusual manifestations. We present three cases of QF endocarditis after right ventricle to pulmonary artery conduit insertion in children.

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Acquired ventricular septal defect due to infective endocarditis

Randi E Durden, Joseph W Turek, Benjamin E Reinking, Manish Bansal

Annals of Pediatric Cardiology 2018 11(1):100-102

Acquired intracardiac left-to-right shunts are rare occurrences. Chest trauma and myocardial infection are well-known causes of acquired ventricular septal defect (VSD). There have been several case reports describing left ventricle to right atrium shunt after infective endocarditis (IE). We present here a patient found to have an acquired VSD secondary to IE of the aortic and tricuspid valves in the setting of a known bicuspid aortic valve. This is the first case reported of acquired VSD in a pediatric patient in the setting of IE along with literature review of acquired left-to-right shunts.

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Hemodynamic rounds: Can we mimic a temporary pulmonary artery band in catheterization laboratory in corrected transposition of great arteries with severe tricuspid regurgitation?

Avinash Anantharaj, Kothandam Sivakumar

Annals of Pediatric Cardiology 2018 11(1):64-67

Right ventricular (RV) geometry is altered by septal shift after pulmonary artery banding. This may reduce tricuspid regurgitation (TR) and improve ventricular function in patients with corrected transposition of great arteries and systemic right ventricle. However, banding is risky in sick patients with severe RV failure. There are no predictive models in clinical practice to test this septal shift hypothesis before a risky surgery. A transcatheter model to mimic a pulmonary artery band is presented in corrected transposition of great arteries with failing right ventricle and severe TR.

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