Library

Notes: Objective To determine whether knowledge of the result of Doppler velocimetry of the umbilical artery is beneficial to the management of a high risk pregnancy.Design Randomised controlled trial. The trial was of the management type, designed to assess benefit accruing from additional information supplied by Doppler velocimetry.Setting Tygerberg Hospital, Cape Town, South Africa. The hospital serves a population from the lower socio-economic groups.Subject Women with pregnancies 28 or more weeks gestation with hypertensive diseases and/or suspected small for gestational age fetuses were referred for Doppler velocimetry. From this population, three subsets were formed: 1. those with fetuses with absent end-diastolic velocities (20 fetuses); 2. those with hypertension but with fetuses with end-diastolic velocities (89 fetuses); and 3. those with fetuses suspected of being small for gestational age but with end-diastolic velocities (104 fetuses).Interventions Doppler velocimetry on all subjects. The study group consisted of 10 cases with absent end-diastolic velocities, 47 cases with hypertensive diseases with end-diastolic velocities and 51 cases with suspected small for gestational age fetuses but with end-diastolic velocities in which the result was revealed to the clinician. The control group consisted of 10, 42 and 53 cases, respectively, in which the Doppler results were not revealed. All other routine investigations (sonar and antenatal fetal heart rate monitoring) were available to the clinicians. Standard management protocols were followed in all groups.Main outcome measures Perinatal mortality and morbidity, antenatal hospitalisation, maternal intervention, admission to the neonatal intensive care unit and hospitalisation until discharge from the neonatal wards.Results In the study and control groups the gestational age at entry to the study, maternal age, parity and various complications were not significantly different. In the subset with absent end-diastolic velocities, there was one neonatal death in the study group, but in the control group there were six deaths, five intrauterine and one perinatally related infant death (P= 0.029). Because of this significant finding, the study was stopped. There were no differences in outcome in the subset where there was hypertensive disease with end-diastolic velocities between the study and control groups. In the subset in which small for gestational age fetuses were suspected, but in which end-diastolic velocities were present, the women in the study group had significantly fewer days in hospital before delivery (P 〈 0.001) and tended to have fewer maternal interventions (study group = 27%, control group = 43%; P= 0.07; odds ratio (OR) 0.49, 95% confidence limits (CL) 0.2 and 1.25) and caesarean sections (study group =13%, control group = 27%; P= 0.08; OR 0.43, 95% CL 0.14 and 1.32). The infants of the study group in this subset also spent significantly less time in the neonatal wards (P= 0.029).Conclusions Within the confines of this study, knowledge of the Doppler velocimetry result was beneficial in the subsets with absent end-diastolic velocities and in which intrauterine growth retardation was suspected. In the subset in which women had hypertension but whose fetuses had end-diastolic velocities, there was no beneficial or adverse effect.

Notes: Normally, ventricular APD exceeds the VERP. However, under specific circumstances this relation may change and can become inverse. This phenomenon of postrepolarization refractoriness may be caused by a decrease in excitability. The threshold current (TC) for pacing has never been quantified as a possible explanation for these observations. Using a MAP pacing catheter in the right ventricular apex, the rate dependent behavior of TC, VERP, and APD before and after procainamide (dose 20 mg/kg in 10 min + 5 mg/min infusion) was determined in 17 dogs with chronic complete AV block. Initially, TC was determined with 0.1 mA accuracy. Using a pacing current of at least twice TC, VERP and APD showed a similar, rate dependent shortening for PCLs 800, 575, and 350 ms. Procainamide treatment led to an equal, rate independent VERP and APD increase: no post repolarization refractoriness. Subsequently, accuracy for TC determination was increased to 0.01 mA. Comparing PCLs 800 and 250 ms, TC doubled from 0.05 ± 0.01 to 0.10 ± 0.09 mA during control and almost tripled from 0.06 ± 0.02 to 0.17 ± 0.10 mA (P 〈 0.05) after procainamide. Using a fixed pacing current of exactly twice TC found at 800 ms PCL during control, VERP exceeded APD after procainamide treatment at 300 and 250 ms PCL: postrepolarization refractoriness. Increasing the pacing current to twice the rate dependent TC, the relation between VERP and APD normalized: no postrepolarization refractoriness. We conclude that after procainamide, rate dependent TC increase is of major importance for the phenomenon of postrepolarization refractoriness.

Notes: Sudden death can be the first manifestation of the Wolff-Parkinson-White (WPW) syndrome. The underlying mechanism being atrial fibrillation with a very high ventricular rate, because of a short anterograde refractory period of the accessory atrioventricular pathway (AP), deteriorating into ventricular fibrillation. Information on the anterograde refractory period of the AP is therefore important to recognize asymptomatic people with the WPW ECG at risk for dying suddenly. Several noninvasive tests are available to identify the low risk patient. Decision making when to interrupt the AP in asymptomatic WPW patients not at low risk requires an invasive study to document the electrophysiological properties of the AP and to determine its exact location.

Notes: Aim: The aim of this article is to examine whether cardiac resynchronization therapy (CRT) induces improvements in the neurohumoral system. Methods and Results: Thirteen patients with HF (left ventricular (LV) ejection fraction 〈35%) were included. Before and after 6 months of CRT, myocardial 123I-metaiodobenzylguanidine (123I-MIBG) uptake indices, used as an index of neural norepinephrine reuptake and retention, and brain natriuretic peptide (BNP) levels, used as an index of LV end-diastolic pressure, NYHA classification and echocardiographic indices were assessed. Six months of CRT resulted in significant improvement in (1) NYHA classification and reduction in QRS width (P 〈 0.001), (2) decrease of LV end-diastolic diameter (P = 0.005), LV end-systolic diameter (P = 0.005), septal to lateral delay (P = 0.01) and mitral regurgitation (MR, P = 0.04), (3) delayed 123I-MIBG heart/mediastinum ratios improved (P = 0.03) and 123I-MIBG washout decreased (P = 0.001), and (4) BNP levels decreased (P = 0.001). Conclusions: Parallel to significant functional improvement and echocardiographic reverse remodeling and resynchronization, our data indicate that CRT induces favorable changes in the neurohumoral system.

Notes: In a case-control study of cognitive performance, tests of intelligence, reading, spelling, and pragmatic language were administered to the parents and siblings of 90 community-ascertained probands with autism (AU group) and to the parents and siblings of 40 similarly ascertained probands with trisomy 21 Down syndrome (DS group). The two samples were comparable for age and parents' education; both groups were well-educated and had above-average intelligence. AU parents scored slightly but significantly lower on the WAIS-R Full Scale and Performance IQ, on two subtests (Picture Arrangement and Picture Completion), and on the Word Attack Test (reading nonsense words) from the Woodcock-Johnson battery. There were no differences between AU and DS siblings. As in earlier studies, AU parents, more often than DS parents, reported a history of early language-related cognitive difficulties; we were not able to replicate this in siblings. AU parents who reported such difficulties scored significantly lower on Verbal IQ, spelling, and the nonsense reading test. AU parents without a history of early language-related cognitive difficulties often had a Verbal IQ that exceeded Performance IQ by more than one standard deviation. AU siblings with early language-related difficulties had similar findings: lower Verbal IQ, poorer spelling, and poorer reading scores, compared to AU siblings without such a history. Parents with a positive history also scored worse on a measure of pragmatic language, the Pragmatic Rating Scale, but not on measures of social-related components of the broader autism phenotype. We propose that cognitive differences in a subset of autism family members are manifestations of the language-related component of the broader autism phenotype, and separate from the social-related component. This is consistent with the hypothesis that there are several genes that may interact to cause autism which segregate independently and have distinguishable manifestations in family members. The hypothesis would be further supported by finding different patterns of genetic loci linked to autism in families where one or both parents has language difficulties.

Notes: Reliable quantification of cytokine mRNA expression is an important technique for analyzing immune responses. Up until now, little to no information has been available as to whether different mRNA quantification techniques lead to similar results. Recently, real time quantitative reverse transcriptase (RT)-PCR using SYBR® Green I as a double stranded DNA specific dye has been introduced. This novel method enables simple and rapid measurement of PCR product accumulation during the log-linear reaction phase and obviates the need for expensive hybridization probes. Here, we analyzed murine gamma interferon (IFN)-γ mRNA expression in splenocytes by this technique in comparison to semiquantitative noncompetitive RT–PCR, Northern blot analysis, and ELISA after stimulation of the cells with interleukin (IL)-12, IL-18 and a combination of both cytokines. The results clearly show that all of the techniques detect differences in the IFN-γ gene expression induced by these distinctive stimuli qualitatively exactly in the same order. However, real-time kinetic RT–PCR offers several advantages, notably its high sensitivity that allows the detection of basal IFN-γ mRNA expression in unstimulated samples. In addition it provides the lowest interassay variability of all techniques investigated. Finally, the gene expression measured by this method eliminates any post-PCR manipulations because the PCR product identification can be easily performed by melting curve analysis.