Trial protocol: a clustered, randomised, longitudinal, type 2 translational trial of alcohol consumption and alcohol-related harm among adolescents in Australia.

BACKGROUND: This cluster randomised control trial is designed to evaluate whether the Communities That Care intervention (CTC) is effective in reducing the proportion of secondary school age adolescents who use alcohol before the Australian legal purchasing age of 18 years. Secondary outcomes are other substance use and antisocial behaviours. Long term economic benefits of reduced alcohol use by adolescents for the community will also be assessed. METHODS: Fourteen communities and 14 other non-contiguous communities will be matched on socioeconomic status (SES), location, and size. One of each pair will be randomly allocated to the intervention in three Australian states (Victoria, Queensland and Western Australia). A longitudinal survey will recruit grade 8 and 10 students (M = 15 years old, N = 3500) in 2017 and conduct follow-up surveys in 2019 and 2021 (M = 19 years old). Municipal youth populations will also be monitored for trends in alcohol-harms using hospital and police administrative data. DISCUSSION: Community-led interventions that systematically and strategically implement evidence-based programs have been shown to be effective in producing population-level behaviour change, including reduced alcohol and drug use. We expect that the study will be associated with significant effects on alcohol use amongst adolescents because interventions adopted within communities will be based on evidence-based practices and target specific problems identified from surveys conducted within each community. TRIAL REGISTRATION: The trial was retrospectively registered in September, 2017 ( ACTRN12616001276448 ), as communities were selected prior to trial registration; however, participants were recruited after registration. Findings will be disseminated in peer-review journals and community fora.

The outcomes of health-promoting communities: being active eating well initiative-a community-based obesity prevention intervention in Victoria, Australia.

OBJECTIVE: The aim of this study is to evaluate the impact of the Health-Promoting Communities: Being Active Eating Well (HPC:BAEW, 2007-2010) initiative, which comprised community-based multi-component interventions adapted to community context in five separate communities. The intervention aimed to promote healthy eating, physical activity and stronger, healthier communities. METHODS: A mixed method and multilevel quasi-experimental evaluation of the HPC:BAEW initiative captured process, impact and outcome data. The evaluation involved both cross-sectional (children and adolescents) and longitudinal designs (adults) with data collected pre- and post-intervention in intervention (n=2408 children and adolescents from 18 schools, n=501 adults from 22 workplaces) and comparison groups (n=3163 children and adolescents from 33 schools, n=318 adults from seven workplaces). Anthropometry, obesity-related behavioural and environmental data, information regarding community context and implementation factors were collected. The primary outcomes were differences in anthropometry (weight, waist, body mass index (BMI) and standardised BMI (BMI z-score)) over time compared with comparison communities. Baseline data was collected 2008/2009 and post-intervention collected in 2010 with an average intervention time frame of approximately 12 months. RESULTS: The strategies most commonly implemented were related to social marketing, stakeholder engagement, network and partnership development, community-directed needs assessment and capacity building. Analysis of post-intervention data showed gains in community capacity, but few impacts on environments, policy or individual knowledge, skills, beliefs and perceptions. Relative to the comparison group, one community achieved a lower prevalence of overweight/obesity, lower weight, waist circumference and BMI (P<0.005). One community achieved a higher level of healthy eating policy implementation in schools; two communities achieved improved healthy eating-related behaviours (P<0.03); one community achieved lower sedentary behaviours; and one community achieved higher levels of physical activity in schools (P<0.05). All effect sizes were in the small-to-moderate range. CONCLUSIONS: This was a complex and ambitious initiative, which attempted to expand a previously successful community-based intervention in Victoria into five new contexts and communities. Overall, project success was quite inconsistent, and some significant differences were in the unanticipated direction. However, there are many important learnings that should inform future health-promotion activities. The heterogeneity of outcomes of HPC:BAEW communities reflects the reality of life whereby effectiveness of intervention strategies is dependent on individual and community factors. Future health promotion should consider a systems approach whereby existing systems are modified rather than relying heavily on the addition of new activities, with longer time frames for implementation.

Susceptibility loci for sporadic brain arteriovenous malformation; a replication study and meta-analysis.

BACKGROUND: Case-control studies have reported multiple genetic loci to be associated with sporadic brain arteriovenous malformations (AVMs) but most of these have not been replicated in independent populations. The aim of this study was to find additional evidence for these reported associations and perform a meta-analysis including all previously published results. METHODS: We included 167 Dutch patients and 1038 Dutch controls. Case genotyping was performed by KASPar assays. Controls had been previously genotyped with a genome wide single nucleotide polymorphisms (SNP) array. Differences in genotype frequencies between cases and controls were estimated by χ(2) testing in Plink V.1.07. Meta-analysis was performed in RevMan V.5.3. RESULTS: In our case-control study we found no significant association with brain AVM (BAVM) for previously discovered SNPs near ANGPTL4, IL-1ß, GPR124, VEGFA and MMP-3. The meta-analysis revealed a statistically significant association with BAVMs for the polymorphism rs11672433 near ANGPTL4 (OR 1.39; 95% CI 1.10 to 1.75, p value 0.005). CONCLUSIONS: The results of this study support a role for the previously identified SNP near ANGPTL4 in the pathogenesis of AVMs. Previously found associations with SNPs near IL-1ß, GPR124, VEGFA and MMP-3 genes could not be substantiated in our replication cohort or in the meta-analysis.

Evaluation of genetic risk loci for intracranial aneurysms in sporadic arteriovenous malformations of the brain.

BACKGROUND: In genome-wide association studies (GWAS) five putative risk loci are associated with intracranial aneurysm. As brain arteriovenous malformations (AVM) and intracranial aneurysms are both intracranial vascular diseases and AVMs often have associated aneurysms, we investigated whether these loci are also associated with sporadic brain AVM. METHODS: We included 506 patients (168 Dutch, 338 American) and 1548 controls, all Caucasians. Controls had been recruited as part of previous GWAS. Dutch patients were genotyped by KASPar assay and US patients by Affymetrix SNP 6.0 array. Associations in each cohort were tested by univariable logistic regression modelling, with subgroup analysis in 205 American cases with aneurysm data. Meta-analysis was performed by a Mantel-Haenszel fixed-effect method. RESULTS: In the Dutch cohort none of the single nucleotide polymorphisms (SNPs) were associated with AVMs. In the American cohort, genotyped SNPs near SOX-17 (OR 0.74; 95% CI 0.56-0.98), RBBP8 (OR 0.76; 95% CI 0.62-0.94) and an imputed SNP near CDKN2B-AS1 (OR 0.79; 95% CI 0.64-0.98) were significantly associated with AVM. The association with SNPs near SOX-17 and CDKN2B-AS1 but not RBBP8 were strongest in patients with AVM with associated aneurysms. In the meta-analysis we found no significant associations between allele frequencies and AVM occurrence, but rs9298506, near SOX-17 approached statistical significance (OR 0.77; 95% CI 0.57-1.03, p=0.08). CONCLUSIONS: Our meta-analysis of two Caucasian cohorts did not show an association between five aneurysm-associated loci and sporadic brain AVM. Possible involvement of SOX-17 and RBBP8, genes involved in cell cycle progression, deserves further investigation.

Multilevel analysis of the Be Active Eat Well intervention: environmental and behavioural influences on reductions in child obesity risk.

BACKGROUND: The Be Active Eat Well (BAEW) community-based child obesity prevention intervention was successful in modestly reducing unhealthy weight gain in primary school children using a multi-strategy and multi-setting approach. OBJECTIVE: To (1) examine the relationship between changes in obesity-related individual, household and school factors and changes in standardised child body mass index (zBMI), and (2) determine if the BAEW intervention moderated these effects. METHODS: The longitudinal relationships between changes in individual, household and school variables and changes in zBMI were explored using multilevel modelling, with measurement time (baseline and follow-up) at level 1, individual (behaviours, n = 1812) at level 2 and households (n = 1318) and schools (n = 18) as higher levels (environments). The effect of the intervention was tested while controlling for child age, gender and maternal education level. RESULTS: This study confirmed that the BAEW intervention lowered child zBMI compared with the comparison group (-0.085 units, P = 0.03). The variation between household environments was found to be a large contributor to the percentage of unexplained change in child zBMI (59%), compared with contributions from the individual (23%) and school levels (1%). Across both groups, screen time (P = 0.03), sweet drink consumption (P = 0.03) and lack of household rules for television (TV) viewing (P = 0.05) were associated with increased zBMI, whereas there was a non-significant association with the frequency the TV was on during evening meals (P = 0.07). The moderating effect of the intervention was only evident for the relationship between the frequency of TV on during meals and zBMI, however, this effect was modest (P = 0.04). CONCLUSIONS: The development of childhood obesity involves multi-factorial and multi-level influences, some of which are amenable to change. Obesity prevention strategies should not only target individual behaviours but also the household environment and family practices. Although zBMI changes were modest, these findings are encouraging as small reductions can have population level impacts on childhood obesity levels.

Obesity prevention in the family day care setting: impact of the Romp & Chomp intervention on opportunities for children's physical activity and healthy eating.

BACKGROUND: The Romp & Chomp intervention reduced the prevalence of overweight/obesity in pre-school children in Geelong, Victoria, Australia through an intervention promoting healthy eating and active play in early childhood settings. This study aims to determine if the intervention successfully created more health promoting family day care (FDC) environments. METHODS: The evaluation had a cross-sectional, quasi-experimental design with the intervention FDC service in Geelong and a comparison sample from 17 FDC services across Victoria. A 45-item questionnaire capturing nutrition- and physical activity-related aspects of the policy, socio-cultural and physical environments of the FDC service was completed by FDC care providers (in 2008) in the intervention (n= 28) and comparison (n= 223) samples. RESULTS: Select results showed intervention children spent less time in screen-based activities (P= 0.03), organized active play (P < 0.001) and free inside play (P= 0.03) than comparison children. There were more rules related to healthy eating (P < 0.001), more care provider practices that supported children's positive meal experiences (P < 0.001), fewer unhealthy food items allowed (P= 0.05), higher odds of staff being trained in nutrition (P= 0.04) and physical activity (P < 0.001), lower odds of having set minimum times for outside (P < 0.001) and organized (P= 0.01) active play, and of rewarding children with food (P < 0.001). CONCLUSIONS: Romp & Chomp improved the FDC service to one that discourages sedentary behaviours and promotes opportunities for children to eat nutritious foods. Ongoing investment to increase children's physical activity within the setting and improving the capacity and health literacy of care providers is required to extend and sustain the improvements.

Cholesterol efflux via ATP-binding cassette transporter A1 (ABCA1) and cholesterol uptake via the LDL receptor influences cholesterol-induced impairment of beta cell function in mice.

AIMS/HYPOTHESIS: Cellular cholesterol accumulation is an emerging mechanism for beta cell dysfunction in type 2 diabetes. Absence of the cholesterol transporter ATP-binding cassette transporter A1 (ABCA1) results in increased islet cholesterol and impaired insulin secretion, indicating that impaired cholesterol efflux leads to beta cell dysfunction. In this study, we aimed to determine the role of the LDL receptor (LDLr) in islet cholesterol uptake and to assess the contributions of cholesterol uptake compared with efflux to islet cholesterol levels. METHODS: Islet cholesterol and beta cell function were assessed in mice lacking LDLr (Ldlr(-/-)), or apolipoprotein E (Apoe(-/-)), as well as in mice with beta-cell-specific deficiency of Abca1 crossed to Ldlr(-/-) mice. RESULTS: Hypercholesterolaemia resulted in increased islet cholesterol levels and decreased beta cell function in Apoe(-/-) mice but not in Ldlr(-/-) mice, suggesting that the LDL receptor is required for cholesterol uptake leading to cholesterol-induced beta cell dysfunction. Interestingly, when wild-type islets with functional LDL receptors were transplanted into diabetic, hypercholesterolaemic mice, islet graft function was normal compared with Ldlr(-/-) islets, suggesting that compensatory mechanisms can maintain islet cholesterol homeostasis in a hypercholesterolaemic environment. Indeed, transplanted wild-type islets had increased Abca1 expression. However, lack of the Ldlr did not protect Abca1(-/-) mice from islet cholesterol accumulation, suggesting that cholesterol efflux is the critical regulator of cholesterol levels in islets. CONCLUSIONS/INTERPRETATION: Our data indicate that islet cholesterol levels and beta cell function are strongly influenced by LDLr-mediated uptake of cholesterol into beta cells. Cholesterol efflux mediated by ABCA1, however, can compensate in hypercholesterolaemia to regulate islet cholesterol levels in vivo.

Community variation in adolescent cannabis use in Australia and the Netherlands.

BACKGROUND: While controversial, cannabis use is common, and often begins in adolescence. In Australia and the Netherlands, cannabis use is understood and legislated within a harm-minimisation framework. In Australia it is illegal to purchase or consume cannabis. Cannabis use in the Netherlands is illegal, except in licensed coffee shops where the sale and consumption of small amounts (5 g) are permitted. METHODS: Secondary school aged children in Victoria, Australia and the Netherlands were surveyed using the same culturally adapted questionnaire, designed to measure community rates of substance use and risk factors. Youth cannabis use and predictors of use were compared between the two countries. RESULTS: Similar levels of cannabis use in the last month were reported in Australia and the Netherlands (4.5%), with slightly lower use amongst girls, compared to boys. Common predictors of use were found in both the Australian and Netherlands sample. CONCLUSIONS: The findings suggest that interventions that effectively target similar risk factors to reduce or prevent cannabis use may have applications cross-nationally.

Reducing unhealthy weight gain in children through community capacity-building: results of a quasi-experimental intervention program, Be Active Eat Well.

BACKGROUND: Be Active Eat Well (BAEW) was a multifaceted community capacity-building program promoting healthy eating and physical activity for children (aged 4-12 years) in the Australian town of Colac. OBJECTIVE: To evaluate the effects of BAEW on reducing children's unhealthy weight gain. METHODS: BAEW had a quasi-experimental, longitudinal design with anthropometric and demographic data collected on Colac children in four preschools and six primary schools at baseline (2003, n=1001, response rate: 58%) and follow-up (2006, n=839, follow-up rate: 84%). The comparison sample was a stratified random selection of preschools (n=4) and primary schools (n=12) from the rest of the Barwon South Western region of Victoria, with baseline assessment in 2003-2004 (n=1183, response rate: 44%) and follow-up in 2006 (n=979, follow-up rate: 83%). RESULTS: Colac children had significantly lower increases in body weight (mean: -0.92 kg, 95% CI: -1.74 to -0.11), waist (-3.14 cm, -5.07 to -1.22), waist/height (-0.02, -0.03 to -0.004), and body mass index z-score (-0.11, -0.21 to -0.01) than comparison children, adjusted for baseline variable, age, height, gender, duration between measurements and clustering by school. In Colac, the anthropometric changes were not related to four indicators of socioeconomic status (SES), whereas in the comparison group 19/20 such analyses showed significantly greater gains in anthropometry in children from lower SES families. Changes in underweight and attempted weight loss were no different between the groups. CONCLUSIONS: Building community capacity to promote healthy eating and physical activity appears to be a safe and effective way to reduce unhealthy weight gain in children without increasing health inequalities.

Diagnostic accuracy of the clapping test in Parkinsonian disorders.

BACKGROUND: To determine the diagnostic value of the clapping test, which has been proposed as a reliable measure to differentiate between progressive supranuclear palsy (where performance is impaired) and Parkinson's disease (where performance should be normal). METHODS: Our study group included a large cohort of consecutive outpatients including 44 patients with Parkinson's disease, 48 patients with various forms of atypical parkinsonism and 149 control subjects. All subjects performed the clapping test according to a standardized protocol. RESULTS: Clapping test performance was normal in all control subjects, and impaired in 63% of the patients with atypical parkinsonism. Unexpectedly, we also found an impaired clapping test in 29% of the patients with Parkinson's disease. CONCLUSION: Although the proportion with an abnormal clapping test was significantly higher in atypical parkinsonism, the clapping test did not discriminate well between Parkinson's disease and atypical parkinsonism.

Comparison of claw health and milk yield in dairy cows on elastic or concrete flooring.

This article reports on the effects of elastic (rubber) flooring compared with concrete flooring on claw health and milk yield in dairy cows. Milk yield and activity data of 53 complete lactations from 49 cows were recorded by an automatic milking system in the University of Munich Livestock Center dairy herd. Cows were kept in a loose housing system on concrete-slatted or rubber-matted slatted flooring. Claws were trimmed and measured linearly in combination with claw lesion diagnosis 3 times during one lactation period (including the transition phase). An automatic milking system recorded milk yield and activity. The net horn growth of the claws increased on elastic flooring. Therefore, correct and frequent claw trimming is at least as important for claw health in dairy herds kept on rubber flooring as for those on concrete-slatted flooring. Cows housed on rubber had an increased incidence of sole ulcers. Sole hemorrhages (except for hemorrhages associated with sole ulcers) occurred less frequently on rubber than on concrete. Results concerning digital dermatitis were difficult to assess, because manual manure scraping on rubber required sprinkling the flooring twice daily, which additionally moistened the digital skin of the cows. This might explain the greater incidence of digital dermatitis on elastic flooring. The incidence of clinically lame cows did not differ between flooring types. Cows showed greater activity on rubber, most likely caused by the more comfortable walking surface compared with the concrete-slatted flooring. The greater activity may indicate better overall health of high-yielding dairy cows on rubber flooring. Milk yield, however, did not differ between flooring types.

Benzalkonium tolerance genes and outcome in Listeria monocytogenes meningitis.

OBJECTIVES: Listeria monocytogenes is a food-borne pathogen that can cause meningitis. The listerial genotype ST6 has been linked to increasing rates of unfavourable outcome over time. We investigated listerial genetic variation and the relation with clinical outcome in meningitis. METHODS: We sequenced 96 isolates from adults with listerial meningitis included in two prospective nationwide cohort studies by whole genome sequencing, and evaluated associations between bacterial genetic variation and clinical outcome. We validated these results by screening listerial genotypes of 445 cerebrospinal fluid and blood isolates from patients over a 30-year period from the Dutch national surveillance cohort. RESULTS: We identified a bacteriophage, phiLMST6 co-occurring with a novel plasmid, pLMST6, in ST6 isolates to be associated with unfavourable outcome in patients (p 2.83e-05). The plasmid carries a benzalkonium chloride tolerance gene, emrC, conferring decreased susceptibility to disinfectants used in the food-processing industry. Isolates harbouring emrC were growth inhibited at higher levels of benzalkonium chloride (median 60 mg/L versus 15 mg/L; p <0.001), and had higher MICs for amoxicillin and gentamicin compared with isolates without emrC (both p <0.001). Transformation of pLMST6 into naive strains led to benzalkonium chloride tolerance and higher MICs for gentamicin. CONCLUSIONS: These results show that a novel plasmid, carrying the efflux transporter emrC, is associated with increased incidence of ST6 listerial meningitis in the Netherlands. Suggesting increased disease severity, our findings warrant consideration of disinfectants used in the food-processing industry that select for resistance mechanisms and may, inadvertently, lead to increased risk of poor disease outcome.

Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus.

Thrombi located in the left atrial appendage are frequently not detected with conventional two-dimensional echocardiography. The transesophageal echocardiographic approach readily visualizes left atrial morphology and may be used as an alternative. In 6 of 21 patients with mitral valve stenosis, a left atrial appendage thrombus was diagnosed by transesophageal two-dimensional echocardiography when transthoracic echocardiography had failed. The transesophageal echocardiographic findings were confirmed at surgery for mitral valve replacement in all cases.

Contribution of 'noncore' foods and beverages to the energy intake and weight status of Australian children.

OBJECTIVES: The Australian Guide to Healthy Eating is based on five core food groups and water. Foods or beverages that do not fit into these groups are considered extra or 'noncore'. We tested the hypotheses that noncore foods and beverages make a greater proportional contribution to mean daily energy intakes of: (1) children, compared with other age groups; and (2) overweight and obese children, compared with healthy weight children. DESIGN, SETTING AND SUBJECTS: We used data from 13 858 participants aged 2 to 80+ y who had 24-h dietary recall data collected in the 1995 cross-sectional Australian National Nutrition Survey. ANOVA was used to compare the percentage of energy provided by noncore foods and beverages by age and weight status. RESULTS: Children (5 to 12 y) and adolescents (13 to 18 y) obtained significantly more (P < 0.001) of their daily food energy from noncore foods (41.5 and 43.4%, respectively) than all other age groups. These age groups also obtained significantly more (P < 0.001) of their daily beverage energy from noncore beverages (30.7 and 36.9%, respectively). Results were not consistent with weight status, although very young (2-4 y) obese children obtained significantly more energy (P < 0.05) from noncore beverages than children in a healthy weight range. Younger children may also have consumed a greater quantity of foods and beverages. Under-reporting may have obscured similar results for older children. CONCLUSIONS: By definition, noncore foods and beverages are surplus to the requirements of a healthy diet. We found that Australian children consume these foods and beverages in excess.

Lunchbox contents of Australian school children: room for improvement.

OBJECTIVE: In light of the increasing prevalence of obesity in children and the potential of schools as a setting for intervention, we aimed to identify the main foods and beverages consumed at primary school and to determine differences in consumption patterns between children who used the school canteen and those who did not. DESIGN: Cross-sectional survey of school foods in 1681 5-12 y old children, 2003-2004. SETTING: Barwon South-Western region of Victoria, Australia. RESULTS: The school food provided an average (+/-s.e.m.) of 3087+/-26 kJ. Bread was the most frequently consumed food and contributed 20% of total energy at school, biscuits 13%, fruit 10%, muesli/fruit bars 8%, packaged snacks 7%, and fruit juice/cordial 6%. About 10% of children used the school canteen and these children obtained more total energy and more energy from cakes, fast foods and soft drink than noncanteen users (P<0.001). In all, 68% of children had fruit in their lunchboxes, however, over 90% of children had energy-dense, micronutrient-poor snacks ('junk food'). CONCLUSIONS: Fruit intake in primary schools seems reasonably high but could be targeted for further increase as part of promoting a healthy diet. Of concern, however, are the excessive amounts of energy-dense foods in school lunchboxes. These should be considered a priority for health promotion efforts along with reducing the consumption of sweetened drinks. These measures are urgently needed to improve the school-based diets of Australian children and attempt to curb the increasing prevalence of childhood obesity.

Evaluation of carcass composition of intact boars using linear measurements from performance testing, dissection, dual energy X-ray absorptiometry (DXA) and magnetic resonance imaging (MRI).

The objective of this study was to investigate non-invasive imaging methods to update the used regression equation for stationary tested boars. A total of 94 boars were examined. 20 boars were dissected to provide the reference LMP. Performance data (PD) from right carcasses were available from all groups. The left carcasses were studied by MRI & DXA. Based on the reference LMP and the MRI & DXA data, regression equations for LMP were developed. The estimates for LMP based on MRI & DXA data were used to calculate new regression equations for entire male carcass halves based on linear PD. Further 33 PD sets served as independent sample, which was included in a Monte Carlo simulation for imputing the missing reference LMPs (n=74) and discussing the accuracy of the results. The LMP regression equation based on the combined MRI & DXA data is as accurate as the former regression equation, but needs only three instead of seven variables.

Transesophageal two-dimensional echocardiography: comparison of ultrasonic and anatomic sections.

Conventional 2-dimensional echocardiography has become a well-established tool for evaluating cardiovascular diseases. Recent introduction of 2-dimensional transesophageal echocardiography has widened the ultrasonic examination possibilities of the heart and great arteries. The 6 standard transesophageal transducer positions that have proved representative and of diagnostic value are described. To facilitate structure identification and interpretation of anatomic relations, transesophageal recordings were compared with corresponding anatomic sections.

Controlled comparison of nefazodone and amitriptyline in major depressive inpatients.

Nefazodone, a phenylpiperazine antidepressant, exhibits novel dual activity on serotonin (5-HT) neurons; it binds to 5-HT2 receptors and inhibits 5-HT reuptake. Flexible doses of nefazodone (100-400 mg/day) and amitriptyline (50-200 mg/day) were compared in 106 major depressive inpatients in a 6-week double-blind study. Results showed significant superiority of amitriptyline over nefazodone on all rating instruments: Montgomery and Asberg depression rating scale (P < 0.0001), Hamilton depression scale (P < 0.0006), Clinical Global Impressions (P < 0.0001) and Patient Global Assessment (P < 0.01). A total of 65% of patients under amitriptyline and 56% of patients under nefazodone reported adverse events during the study, with significantly more dry mouth in the amitriptyline group (39% versus 11%, P = 0.001). Modal daily doses within the last treatment week reached 242 mg with nefazodone and 124 mg with amitriptyline. The lower efficacy of nefazodone, which contradicts comparative trials with imipramine in US patients, is discussed with regard to the dose of nefazodone, probably below the optimal therapeutic range for melancholic patients, and to the clinical differences between the patient samples.

The effect of alpha-adrenergic blockade on cardiac performance and tissue oxygen delivery during excision of pheochromocytoma.

To establish criteria for administration of the optimal dose of alpha-adrenergic receptor blocking drugs, we studied cardiac performance and tissue oxygen tension in three patients who underwent excision of pheochromocytoma. Subcutaneous oxygen tension was measured by the method of Niinikoski and Hunt. Cardiac function was assessed by thermodilution cardiac output, systemic and pulmonary arterial blood pressures, and continuous two-dimensional transesophageal echocardiography of a cross section of the left ventricle at the level of the papillary muscles. Despite large changes in cardiac output and systemic, pulmonary, and wedge pressures, intraoperative tissue oxygen tensions and ejection fractions remained normal (even at times of peak catecholamine excretion and very abnormal wedge pressures). Studies of healthy animals that received no alpha-adrenergic receptor blocking drugs showed major decrements of tissue oxygen in response to modest doses of epinephrine. We conclude that progressive administration of alpha-adrenergic receptor blocking drugs does not absolutely protect the patient from major changes in blood pressure during operation for pheochromocytoma, but that cardiac performance and oxygen supply to the tissues are unimpaired.

Beating heart operations including hybrid revascularization: initial experiences.

BACKGROUND: The outcome of patients (n = 45) with coronary one- to three-vessel disease undergoing beating heart operations using a recently developed stabilizing device was investigated. METHODS: Left internal mammary artery-to-left anterior descending coronary artery (LIMA-to-LAD) revascularization was carried out alone (n = 31) or as hybrid procedure in combination with a balloon angioplasty (n = 14). RESULTS: All 45 patients underwent a successful LIMA-to-LAD procedure without intraoperative complication during a 21 +/- 8-minute (range, 10 to 53 minutes) LAD occlusion time. In 14 hybrid procedures a total of 19 stenoses including 3 left main stenoses were treated successfully by percutaneous transluminal coronary angioplasty and stenting. The postoperative courses were uneventful with the exception of two surgical reexplorations necessitated by bleeding. No worsening of renal, neurologic, or respiratory functions occurred in any patient. In the group having a single LIMA-to-LAD procedure, early postoperative coronary angiograms (22 of 31) showed a patent LIMA graft and excellent anastomosis; this was also true in 4 patients 12 months after operation as shown in angiograms. All patients undergoing hybrid revascularization demonstrated a patent LIMA-to-LAD anastomosis; in 1 patient there was a dissection in the midlevel of the LIMA, which was stented successfully. The 6-month follow-up angiograms in 7 of 14 patients revealed open LIMA bypass grafts in all patients except 1, who was stented because of dissection. CONCLUSIONS: These data indicate that a beating heart operation including hybrid revascularization is safe and effective in selected patients with coronary one- to three-vessel disease including left main stenosis. This approach may be especially advantageous in comparison with conventional coronary artery bypass grafting in patients with severe concomitant disease.