The Relationship Between Early Term Birth and the Risk of Later Childhood Mental Disorders Within a Pregnancy Cohort.

This study examines whether gestational age, birth weight, and early term birth is associated with childhood mental disorders in 342 pregnant women recruited at less than 20 weeks gestation and were then followed up until 4 years postpartum, including 93 children born at early term. Women were assessed at recruitment using the Structured Clinical Interview for DSM. At 4 years of age their children were assessed using the Preschool Age Psychiatric Assessment (PAPA) and the Child Behavior Checklist (CBCL). This study found earlier birth predicted an increased risk for anxiety disorders and demonstrated a significant interaction between gestational age and lower birthweight. The risk for ADHD increased with lower gestational age independent of birthweight. In contrast, gestational age was not associated with Oppositional Defiant Disorder, Conduct Disorder, internalizing or externalizing symptoms. These findings highlight the important differences in the association of early term birth and vulnerability for specific mental disorders.

Retained Metabolic Flexibility of the Failing Human Heart.

BACKGROUND: The failing heart is traditionally described as metabolically inflexible and oxygen starved, causing energetic deficit and contractile dysfunction. Current metabolic modulator therapies aim to increase glucose oxidation to increase oxygen efficiency of adenosine triphosphate production, with mixed results. METHODS: To investigate metabolic flexibility and oxygen delivery in the failing heart, 20 patients with nonischemic heart failure with reduced ejection fraction (left ventricular ejection fraction 34.9±9.1) underwent separate infusions of insulin+glucose infusion (I+G) or Intralipid infusion. We used cardiovascular magnetic resonance to assess cardiac function and measured energetics using phosphorus-31 magnetic resonance spectroscopy. To investigate the effects of these infusions on cardiac substrate use, function, and myocardial oxygen uptake (MVo2), invasive arteriovenous sampling and pressure-volume loops were performed (n=9). RESULTS: At rest, we found that the heart had considerable metabolic flexibility. During I+G, cardiac glucose uptake and oxidation were predominant (70±14% total energy substrate for adenosine triphosphate production versus 17±16% for Intralipid; P=0.002); however, no change in cardiac function was seen relative to basal conditions. In contrast, during Intralipid infusion, cardiac long-chain fatty acid (LCFA) delivery, uptake, LCFA acylcarnitine production, and fatty acid oxidation were all increased (LCFA 73±17% of total substrate versus 19±26% total during I+G; P=0.009). Myocardial energetics were better with Intralipid compared with I+G (phosphocreatine/adenosine triphosphate 1.86±0.25 versus 2.01±0.33; P=0.02), and systolic and diastolic function were improved (LVEF 34.9±9.1 baseline, 33.7±8.2 I+G, 39.9±9.3 Intralipid; P<0.001). During increased cardiac workload, LCFA uptake and oxidation were again increased during both infusions. There was no evidence of systolic dysfunction or lactate efflux at 65% maximal heart rate, suggesting that a metabolic switch to fat did not cause clinically meaningful ischemic metabolism. CONCLUSIONS: Our findings show that even in nonischemic heart failure with reduced ejection fraction with severely impaired systolic function, significant cardiac metabolic flexibility is retained, including the ability to alter substrate use to match both arterial supply and changes in workload. Increasing LCFA uptake and oxidation is associated with improved myocardial energetics and contractility. Together, these findings challenge aspects of the rationale underlying existing metabolic therapies for heart failure and suggest that strategies promoting fatty acid oxidation may form the basis for future therapies.

Maternal attachment state of mind and perinatal emotional wellbeing: Findings from a pregnancy cohort study.

OBJECTIVES: Maternal attachment state of mind is an important potential predictor of risk and resilience to perinatal emotional wellbeing and early parenting. To explore maternal attachment in relation to perinatal depression and emotional wellbeing. METHODS: This study drew on data collected within an ongoing cohort from 170 women recruited in early pregnancy, including 67 who met criteria for Major Depression. Maternal attachment state of mind was assessed with the Adult Attachment Interview (AAI) in pregnancy. Additional measures included the Structured Clinical Interview for the DSM (SCID), at 12 months the Strange Situation Procedure (SSP), Child Trauma Questionnaire (CTQ), Parenting Stress Index, and antenatal maternal hair cortisol concentrations (HCC). LIMITATIONS: Sample size to be able to undertake all analyses using the 4 way classifications, cortisol measurement is limited to hair only and there is no prospectively collected measure of childhood trauma in mothers. CONCLUSIONS: This study found that maternal attachment, specifically the Non-Autonomous states of mind, adjusted for clinical depression, was associated with higher cortisol in pregnancy and higher depressive symptoms across pregnancy and the postpartum. Furthermore, separately those with depression and Non-Autonomous states of mind also had higher postpartum parenting stress. There was no significant intergenerational concordance between AAI and SSP attachment classifications. Our findings support future research exploring the role of maternal attachment state of mind in understanding perinatal depression and emotional wellbeing.

Prenatal predictors of childhood anxiety disorders: An exploratory study of the role of attachment organization.

Childhood anxiety disorders (CAD) are a common childhood mental disorder and understanding early developmental pathways is key to prevention and early intervention. What is not understood is whether early life stress predictors of CAD might be both mediated by infant cortisol reactivity and moderated by infant attachment status. To address this question, this exploratory study draws on 190 women recruited in early pregnancy and followed together with their children until 4 years of age. Early life stress is operationalized as maternal depression measured using the Structured Clinical Interview for the DSM, Childhood Trauma Questionnaire, Parenting Stress Index, and antenatal maternal hair cortisol concentrations. Infant cortisol reactivity was measured at 12 months together with the Strange Situation Procedure and CAD assessed at 4 years of age using the Preschool Age Psychiatric Assessment. There was no direct association between attachment classification and CAD. Furthermore, infant cortisol reactivity neither mediated nor attachment moderated the association of early life stress predictors and CAD. However, only for infants with organized attachment classifications, higher maternal antenatal depression, and hair cortisol were associated with a higher risk of CAD.

Rurality as a predictor of perinatal mental health and well-being in an Australian cohort.

OBJECTIVE: Perinatal emotional well-being is more than the presence or absence of depressive and anxiety disorders; it encompasses a wide range of factors that contribute to emotional well-being. This study compares perinatal well-being between women living in metropolitan and rural regions. DESIGN: Prospective, longitudinal cohort. PARTICIPANTS/SETTING: Eight hundred and six women from Victoria and Western Australia recruited before 20 weeks of pregnancy and followed up to 12 months postpartum. MAIN OUTCOME MEASURES: Rurality was assessed using the Modified Monash Model (MM Model) with 578 in metropolitan cities MM1, 185 in regional and large rural towns MM2-MM3 and 43 in rural to remote MM4-MM7. The Structured Clinical Interview for DSM-IV (SCID-IV) was administered at recruitment to assess depression, and symptoms of depression and anxiety were measured using the Edinburgh Post-natal Depression Scale and the State and Trait Anxiety Scale, respectively. Other measures included stressful events, diet, exercise, partner support, parenting and sleep. RESULTS: The prevalence of depressive disorders did not differ across rurality. There was also no difference in breastfeeding cessation, exercise, sleep or partner support. Women living in rural communities and who also had depression reported significantly higher parenting stress than metropolitan women and lower access to parenting activities. CONCLUSIONS: Our study suggests while many of the challenges of the perinatal period were shared between women in all areas, there were important differences in parenting stress and access to activities. Furthermore, these findings suggest that guidelines and interventions designed for perinatal mental health should consider rurality.

Functional and Metabolic Imaging in Heart Failure with Preserved Ejection Fraction: Promises, Challenges, and Clinical Utility.

Heart failure with preserved ejection fraction (HFpEF) is recognised as an increasingly prevalent, morbid and burdensome condition with a poor outlook. Recent advances in both the understanding of HFpEF and the technological ability to image cardiac function and metabolism in humans have simultaneously shone a light on the molecular basis of this complex condition of diastolic dysfunction, and the inflammatory and metabolic changes that are associated with it, typically in the context of a complex patient. This review both makes the case for an integrated assessment of the condition, and highlights that metabolic alteration may be a measurable outcome for novel targeted forms of medical therapy. It furthermore highlights how recent technological advancements and advanced medical imaging techniques have enabled the characterisation of the metabolism and function of HFpEF within patients, at rest and during exercise.

Parenting stress, maternal depression and child mental health in a Melbourne cohort before and during the COVID-19 pandemic.

AIM: This paper aims to examine the maternal and child mental health and parenting outcomes in the context of COVID-19 pandemic conditions using a sample from Melbourne, Australia - a city exposed to one of the longest lockdowns world-wide in response to the pandemic. METHODS: This study utilises observational data from a prospective, pregnancy cohort, Mercy Pregnancy Emotional Wellbeing Study and includes 468 women and their children followed up in Melbourne to 3-4 years postpartum pre-COVID pandemic and compared to those followed up during the COVID-19 pandemic. RESULTS: When compared to mothers followed up at 3-4 years postpartum pre-pandemic, those followed up during the COVID-19 pandemic showed higher depressive symptoms with a steep incline in their symptom trajectory (EMMdifference  = 1.72, Bonferroni-corrected P < 0.01, d = 0.35) and had a three times higher risk of scoring 13 or above on the EPDS (aRR = 3.22, Bonferroni-corrected P < 0.01). Although this increase was not associated with the variation in the duration of exposure to pandemic conditions, the steep increase in depressive symptoms was more pronounced in those with pre-existing depressive disorders. There was no difference in parenting stress or adjusted childhood mental health symptoms or disorder. CONCLUSIONS: Our findings highlight the vulnerability of those with pre-existing clinical mental health disorders and the need for adequate clinical care for this vulnerable group. Equally, our study indicates the possibility that  parenting and early childhood mental health outcomes, at least in the short term, may be resilient.

Neutrophils incite and macrophages avert electrical storm after myocardial infarction.

Sudden cardiac death, arising from abnormal electrical conduction, occurs frequently in patients with coronary heart disease. Myocardial ischemia simultaneously induces arrhythmia and massive myocardial leukocyte changes. In this study, we optimized a mouse model in which hypokalemia combined with myocardial infarction triggered spontaneous ventricular tachycardia in ambulatory mice, and we showed that major leukocyte subsets have opposing effects on cardiac conduction. Neutrophils increased ventricular tachycardia via lipocalin-2 in mice, whereas neutrophilia associated with ventricular tachycardia in patients. In contrast, macrophages protected against arrhythmia. Depleting recruited macrophages in Ccr2 -/- mice or all macrophage subsets with Csf1 receptor inhibition increased both ventricular tachycardia and fibrillation. Higher arrhythmia burden and mortality in Cd36 -/- and Mertk -/- mice, viewed together with reduced mitochondrial integrity and accelerated cardiomyocyte death in the absence of macrophages, indicated that receptor-mediated phagocytosis protects against lethal electrical storm. Thus, modulation of leukocyte function provides a potential therapeutic pathway for reducing the risk of sudden cardiac death.

Methamphetamine exposure during pregnancy: A meta-analysis of child developmental outcomes.

This paper examines developmental outcomes for children prenatally exposed to methamphetamine through maternal use. PSYCHINFO, Scopus, PubMed and ERIC databases were systematically searched for studies up to December 2020. The search identified 38 articles examining cognitive, language, motor and neuroanatomical outcomes in children from birth to 16 years. Study quality was appraised using the Newcastle Ottawa Quality Assessment Scale. Findings from neuroanatomical studies suggested that prenatal methamphetamine exposure may alter whole brain microstructure and reduce subcortical volumes across multiple brain regions. Meta-analysis of 14 studies using a random-effects model revealed associations between exposure and poorer intellectual functioning (Cohen's d = 0.89, 95 % CI: 0.47-1.30), problem solving skills (Cohen's d = 0.82, 95 % CI: 0.07 -1.56), short-term memory (Cohen's d = 0.91, 95 % CI: 0.38-1.43), and language development (Cohen's d = 0.74, 95 % CI: 0.30-1.18). These results emphasise the significant impact of intrauterine methamphetamine exposure across multiple areas of child development, noting that limited total sample size, heterogeneity between studies and control for confounds suggested further studies are required. There is a need for further intervention studies to identify effective prevention and harm minimisation approaches.

Exploring sex differences in fetal programming for childhood emotional disorders.

In examining maternal depression, placental 11ß-HSD2 mRNA expression and offspring cortisol regulation as a potential fetal programming pathway in relation to later child emotional disorders, it has become clear that sex differences may be important to consider. This study reports on data obtained from 209 participants in the Mercy Pregnancy and Emotional Wellbeing Study (MPEWS) recruited before 20 weeks of pregnancy. Maternal depressive disorders were diagnosed using the SCID-IV and maternal childhood trauma using the Childhood Trauma Questionnaire. Placental 11ß-HSD2 mRNA was measured using qRT-PCR. For assessment of stress-induced cortisol reactivity, salivary cortisol samples were taken at 12 months of age. At 4 years of age, measurement of Childhood Emotional Disorders (depression and anxiety) was based on maternal report using the Preschool Age Psychiatric Assessment (PAPA) and internalizing symptoms using the Child Behavior Checklist (CBCL). Maternal depression in pregnancy and postpartum, and infant cortisol reactivity, was associated with internalizing symptoms for females only. For female offspring only, increased 12-month cortisol reactivity was also associated with increased emotional disorders at 4 years of age; however, there was no association with placental 11ß-HSD2 mRNA expression. In females only, the combination of lower placental 11ß-HSD2 mRNA expression and higher cortisol reactivity at 12 months of age predicted increased internalising problems. These findings suggest there may be sex differences in prenatal predictors and pathways for early childhood depression and anxiety symptoms and disorder.

Trainee therapist personality and the rating of cognitive behavioural and dynamic interpersonal therapy processes.

Therapist factors are generally thought to be important predictors of the capacity to understand and respond to clinical material. The current study aims to identify which features of personality and clinical symptomatology predict a trainee therapist's rating of cognitive behavioural (CB) and psychodynamic interpersonal (PI) processes in video recordings of these therapies. Eighty psychology trainees completed the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and watched two video recordings of therapy sessions showing prototypical examples of CB and PI psychotherapy, rating the processes they could identify using the Comparative Psychotherapy Process Scale (CPPS). Trainees accurately differentiated CB from PI process while viewing the CB session but rated the CB video higher in PI processes than the PI video itself. Bayesian regression models showed that the most consistent MMPI-2-RF scale that predicted variance in ratings was hypomanic activation (RC9) predicting higher ratings of all psychotherapy processes in both conditions, while clinical scale factors such as Aggressiveness-Revised (AGGR-r) and personality scale factors of Psychoticism-Revised (PSYC-r) and Negative Emotionality/Neuroticism-Revised (NEGE-r) showed some notable but less consistent predictions. The variances in psychotherapy process ratings accounted for by MMPI-2-RF scales ranged from 15% to 51%. The study suggests that some clinical symptoms and personality factors do influence the rating of psychotherapy processes by psychology trainees, but further studies would be required to substantiate such findings. These findings have relevance to therapist training and selection for clinical training and therapist mental health.

Examining differences in placental efficiency following exposure to antidepressants and current depression: Findings from an Australian pregnancy cohort study.

INTRODUCTION: Placental dysfunction and inefficiency, is important in understanding fetal growth restriction and low birth weight. Two recent studies have examined the relationship between antidepressant use in pregnancy and placental weight ratios; one found lower placental weight ratio associated with antidepressant use and the other found a higher ratio. METHODS: This study examined 342 women recruited in early pregnancy, including 75 taking antidepressants, 29 with current depression and 238 controls. Antidepressant use was measured through self-report in early and late pregnancy, hospital records at delivery and drug concentrations in umbilical cord and maternal blood obtained at delivery. Maternal depression was measured using the Structured Clinical Interview for the DSM IV (SCID) at recruitment. Placentas were collected at delivery and weighed, and infant birth weight recorded. Placental efficiency was measured using standardised placental weight residuals and included as the outcome in general linear models (ANOVA/ANCOVA) to test hypotheses. RESULTS: While placental weight was higher for those on antidepressants compared to controls (z=.30 c.f. Z=-0.08, p=.012), there were no significant differences between the three groups after adjusting for maternal body mass index at recruitment. When comparing antidepressant groups separately there were small-to-moderate positive associations between (SSRI) concentrations and placental weight (rho's > 0.20, p's > 0.05), which did not reach significance. CONCLUSION: Antidepressant use in pregnancy was not associated with significant changes in placental efficiency after adjustment for confounding variables. Future research should expand on this to examine other aspects of placental function and include a wide range of potential confounding variables to draw clinically meaningful conclusions.

The perinatal origins of childhood anxiety disorders and the role of early-life maternal predictors.

BACKGROUND: The development of childhood anxiety disorders (CADs) is likely to depend on pathways that can be programmed by early-life risk factors. We test the hypothesis that early-life maternal factors can predict this programming effect on CAD. METHODS: Data were obtained from 198 women and children from the Mercy Pregnancy and Emotional Wellbeing Study (MPEWS), a cohort study with data collected across pregnancy, postpartum and until 4 years of age. Maternal antenatal depression was measured using the Structured Clinical Interview for DSM-IV (SCID-IV), together with antenatal hair cortisol concentrations, maternal childhood trauma and parenting stress at 6 months postpartum. CAD was assessed with the Preschool Age Psychiatric Assessment and the Child Behaviour Checklist. RESULTS: Antenatal depression, a history of maternal childhood trauma and lower gestational age at birth were each associated with anxiety disorders at 4 years of age in their children. A multivariate binary logistic model with these early predictors explained approximately 9% of variance in CAD outcome at 4 years of age; however, only maternal trauma and gestational age were significant predictors in the model. The effect of early parenting stress on CAD was found to vary by the concentration of maternal antenatal hair cortisol, whereby postpartum parenting stress was associated with CAD only when there were higher maternal antenatal cortisol levels. CONCLUSIONS: This study suggests the importance of maternal factors pre-conception, pregnancy and in the postnatal period, which predict CADs and this is consistent with a developmental programming hypothesis for CAD.

Adverse right ventricular remodelling, function, and stress responses in obesity: insights from cardiovascular magnetic resonance.

AIMS: We aimed to determine the effect of increasing body weight upon right ventricular (RV) volumes, energetics, systolic function, and stress responses using cardiovascular magnetic resonance (CMR). METHODS AND RESULTS: We first determined the effects of World Health Organization class III obesity [body mass index (BMI) > 40 kg/m2, n = 54] vs. healthy weight (BMI < 25 kg/m2, n = 49) upon RV volumes, energetics and systolic function using CMR. In less severe obesity (BMI 35 ± 5 kg/m2, n = 18) and healthy weight controls (BMI 21 ± 1 kg/m2, n = 9), we next performed CMR before and during dobutamine to evaluate RV stress response. A subgroup undergoing bariatric surgery (n = 37) were rescanned at median 1 year to determine the effects of weight loss. When compared with healthy weight, class III obesity was associated with adverse RV remodelling (17% RV end-diastolic volume increase, P < 0.0001), impaired cardiac energetics (19% phosphocreatine to adenosine triphosphate ratio reduction, P < 0.001), and reduction in RV ejection fraction (by 3%, P = 0.01), which was related to impaired energetics (R = 0.3, P = 0.04). Participants with less severe obesity had impaired RV diastolic filling at rest and blunted RV systolic and diastolic responses to dobutamine compared with healthy weight. Surgical weight loss (34 ± 15 kg weight loss) was associated with improvement in RV end-diastolic volume (by 8%, P = 0.006) and systolic function (by 2%, P = 0.03). CONCLUSION: Increasing body weight is associated with significant alterations in RV volumes, energetic, systolic function, and stress responses. Adverse RV modelling is mitigated with weight loss. Randomized trials are needed to determine whether intentional weight loss improves symptoms and outcomes in patients with obesity and heart failure.

A psychometric study of the Emotional Availability Scales: Construct validity and measurement invariance between depressed and nondepressed mother-infant dyads.

The Emotional Availability Scales (EAS) are the most widely reported observational assessment measure of parent-child relationships and has been of particular interest in understanding differences between samples of depressed and nondepressed mothers and their offspring. Despite its widespread use, psychometric validation of the factor structure in normative samples and the measurement of invariance within clinical samples has not been published. We evaluated the internal structure (dimensionality, reliability, convergent, and discriminant validity) of the EAS fourth edition using a nondepressed sample of 157 Australian women and their infants aged 6 months, including testing the measurement invariance of the EAS between the same nondepressed sample (n = 157), and a depressed group (n = 185) of mother-infant dyads, using MPlus. Participants were recruited from tertiary hospitals, and depression status was established using a diagnostic measure. Higher-order confirmatory factor analyses on the EAS' six dimensions supported a unidimensional factor solution in our data. Full measurement invariance was not demonstrated due to metric noninvariance of the maternal nonintrusiveness and child responsiveness dimensions. Full scalar invariance supported mean comparisons, and a medium effect of .78SD lower mean emotional availability for the depressed group was found; Cohen's d = .63, 95% CI [.41, .85]. While arguments exist for the clinical utility of differentiating between multiple dimensions of emotional availability, the current findings do not support a multidimensional factor structure or full multigroup measurement invariance of the EAS. Similar psychometric investigations of the EAS in clinical and nonclinical samples are needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Maternal trauma but not perinatal depression predicts infant-parent attachment.

Understanding if maternal depression is a predictor of infant-parent attachment classification is important to furthering knowledge about the early pathways and predictors of socio-emotional development. Yet few studies that have utilised the Strange Situation Procedure, the gold standard for measurement of infant-parent attachment, have examined antenatal depression as a predictor of attachment, and none has also included a measure of maternal trauma. This study uses data on 224 women recruited in early pregnancy and followed up until 12 months postpartum. Maternal depression was measured in pregnancy using the Structured Clinical Interview for the DSM and repeat Edinburgh Postnatal Depression Scale as well as Stressful Life Events scale across pregnancy and postpartum including items on domestic violence. A past history of trauma was measured using the Childhood Trauma Questionnaire. Attachment was measured using the Strange Situation Procedure (SSP) at 12 months postpartum. We found that maternal depression was not associated with insecure or disorganized attachment. However, a maternal history of childhood trauma and current domestic violence both predicted insecure-avoidant attachment at 12 months, whereas increased number of stressful life events prior to conception and in pregnancy was associated with insecure-resistant attachment. Neither trauma, past or current, nor depression predicted disorganized attachment. In the first study to have included measures of antenatal depression, maternal childhood trauma, and current stressful events as predictors of infant attachment measured using the SSP, we found maternal experiences of past and current trauma but not depression were significant predictors of infant-parent attachment security.

Major depression as a predictor of the intergenerational transmission of attachment security: Findings from a pregnancy cohort study.

OBJECTIVE: Understanding the relationship between attachment and mental health has an important role in informing management of perinatal mental disorders and for infant mental health. It has been suggested that experiences of attachment are transmitted from one generation to the next. Maternal sensitivity has been proposed as a mediator, although findings have not been as strong as hypothesised. A meta-analysis suggested that this intergenerational transmission of attachment may vary across populations with lower concordance between parent and infant attachment classifications in clinical compared to community samples. However, no previous study has examined major depression and adult attachment in pregnancy as predictors of infant-parent attachment classification at 12 months postpartum. METHODS: Data were obtained on 52 first-time mothers recruited in early pregnancy, which included 22 women who met diagnostic criteria for current major depression using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. The Adult Attachment Interview was also administered before 20 weeks of pregnancy. A history of early trauma was measured using the Childhood Trauma Questionnaire and maternal sensitivity was measured at 6 months postpartum using the observational measure of the Emotional Availability Scales. Infant-parent attachment was measured using the Strange Situation Procedure at 12 months. RESULTS: Overall, we found no significant association between the Adult Attachment Interview and the Strange Situation Procedure classifications. However, a combination of maternal non-autonomous attachment on the Adult Attachment Interview and major depression was a significant predictor of insecure attachment on the Strange Situation Procedure. We did not find that maternal sensitivity mediated parental and infant attachment security in this sample. CONCLUSION: While previous meta-analyses identified lower concordance in clinical samples, our findings suggest women with major depression and non-autonomous attachment have a greater concordance with insecure attachment on the Strange Situation Procedure. These findings can guide future research and suggest a focus on depression in pregnancy may be important for subsequent infant attachment.

Cardiovascular magnetic resonance facilitates entirely contrast-free transcatheter aortic valve implantation: case report.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is usually planned using contrast-enhanced computed tomography (CT) to determine the suitability of cardiovascular anatomy. Computed tomography for TAVI planning requires the administration of intravenous contrast, which may not be desirable in patients with severely reduced renal function. CASE SUMMARY: We present an unusual case of an 89-year-old patient with an urgent need for treatment of critical, symptomatic aortic stenosis who also had severe chronic kidney disease. We judged that this posed a relative contraindication to the use of intravenous contrast. We designed and implemented a novel, contrast-free cardiovascular magnetic resonance (CMR) protocol and used this to plan all aspects of the procedure. Transcatheter aortic valve implantation was conducted successfully with zero contrast medium administration leading to an excellent clinical result and recovery of renal function. CONCLUSION: Contrast-free CMR appears to be a viable alternative to CT for planning structural aortic valve intervention in the rare cases where intravenous contrast is relatively contraindicated.

Energetic Basis for Exercise-Induced Pulmonary Congestion in Heart Failure With Preserved Ejection Fraction.

BACKGROUND: Transient pulmonary congestion during exercise is emerging as an important determinant of reduced exercise capacity in heart failure with preserved ejection fraction (HFpEF). We sought to determine whether an abnormal cardiac energetic state underpins this process. METHODS: We recruited patients across the spectrum of diastolic dysfunction and HFpEF (controls, n=11; type 2 diabetes, n=9; HFpEF, n=14; and severe diastolic dysfunction attributable to cardiac amyloidosis, n=9). Cardiac energetics were measured using phosphorus spectroscopy to define the myocardial phosphocreatine to ATP ratio. Cardiac function was assessed by cardiovascular magnetic resonance cine imaging and echocardiography and lung water using magnetic resonance proton density mapping. Studies were performed at rest and during submaximal exercise using a magnetic resonance imaging ergometer. RESULTS: Paralleling the stepwise decline in diastolic function across the groups (E/e' ratio; P<0.001) was an increase in NT-proBNP (N-terminal pro-brain natriuretic peptide; P<0.001) and a reduction in phosphocreatine/ATP ratio (control, 2.15 [2.09, 2.29]; type 2 diabetes, 1.71 [1.61, 1.91]; HFpEF, 1.66 [1.44, 1.89]; cardiac amyloidosis, 1.30 [1.16, 1.53]; P<0.001). During 20-W exercise, lower left ventricular diastolic filling rates (r=0.58; P<0.001), lower left ventricular diastolic reserve (r=0.55; P<0.001), left atrial dilatation (r=-0.52; P<0.001), lower right ventricular contractile reserve (right ventricular ejection fraction change, r=0.57; P<0.001), and right atrial dilation (r=-0.71; P<0.001) were all linked to lower phosphocreatine/ATP ratio. Along with these changes, pulmonary proton density mapping revealed transient pulmonary congestion in patients with HFpEF (+4.4% [0.5, 6.4]; P=0.002) and cardiac amyloidosis (+6.4% [3.3, 10.0]; P=0.004), which was not seen in healthy controls (-0.1% [-1.9, 2.1]; P=0.89) or type 2 diabetes without HFpEF (+0.8% [-1.7, 1.9]; P=0.82). The development of exercise-induced pulmonary congestion was associated with lower phosphocreatine/ATP ratio (r=-0.43; P=0.004). CONCLUSIONS: A gradient of myocardial energetic deficit exists across the spectrum of HFpEF. Even at low workload, this energetic deficit is related to markedly abnormal exercise responses in all 4 cardiac chambers, which is associated with detectable pulmonary congestion. The findings support an energetic basis for transient pulmonary congestion in HFpEF.

"Bumps in the Road": A Pilot Study of a Therapeutic Technique for the Integration of Unresolved Family Loss and Trauma.

The ability to sustain a coherent narrative about experiences of trauma and loss is a prominent feature of secure-autonomous attachment states of mind as assessed in narrative tasks such as the Adult Attachment Interview. The current study examines the clinical application of the concepts of narrative coherence and discourse segregation within a therapeutic intervention for whole families. Bumps in the Road is a family drawing task, which aims to facilitate the co-construction of family narratives about adversities such as trauma, loss and hardship. The technique aims to increase the family's narrative coherence about such challenging events. The paper first presents a description of the task itself together with the discourse theories of defensive processing of adverse events. The study also presents pilot quantitative findings from 19 parents on the psychometric properties of a coding system of the families' discourses in undertaking the task and the therapist's techniques in administering the task. The predictive association of coding of the narratives were examined as predictors of change in internalising and externalising symptoms in the referred child, using the Child Behaviour Checklist. Findings showed that therapist competence in administration of the task did significantly predict the magnitude of treatment efficacy. The current study is the first presentation of this novel therapeutic task and sets a platform for further research on the use of narrative tasks and the formal coding of discourse in therapeutic work with children and families.