Dilated cardiomyopathy secondary to vitamin D deficiency and hypocalcaemia in the Irish paediatric population: A case report.

We identified three infants with dilated cardiomyopathy (DCM) secondary to severe vitamin D deficieny and hypocalcaemia. All infants were exclusively breast fed, from dark skinned ethnic backgrounds, born and living in Ireland. None of these pregnant mothers or infants received the recommended vitamin D supplementation. Each infant presented in heart failure and required inotropic support as well as calcium and vitamin D replacement. Cardiac function subsequently improved. This highlights the public health issue that many high risk pregnant mothers and infants are not receiving the recommended vitamin D supplementation.

Ultrasonography to investigate the effect of supplementing whole milk with complex carbohydrates and specific amino acids on curd retention in the abomasum of dairy calves.

AIM: To determine whether the retention time of curd in the abomasum of calves was influenced by supplementing milk with a plant-derived carbohydrate and amino acid supplement, evaluated non-invasively using ultrasonography. METHODS: Female dairy calves aged between 2-6 days of age were sourced from a commercial farm in March 2013. All calves were fed whole milk until weaning (4 L per day); 21 calves were supplemented with a probiotic until 18 days of age, and thereafter with a plant-derived complex carbohydrate and amino acid supplement until weaning, and 22 calves were just fed whole milk. Treatment groups were balanced for age, weight and breed. At 9-14, 24-29 and 52-57 days of age, the abomasum of each calf was examined using ultrasonography immediately before and after feeding, 1 and 2 hours after feeding, and then at 30 minute intervals until curd was no longer visible in the abomasum. Abomasal volume and curd size were recorded to assess retention time of curd in the abomasum. RESULTS: At 9-14 days of age, mean retention time of curd in the abomasum was similar (4.6 hours) in both groups. At 24-29 days of age, when the supplemented calves had been receiving the supplement for approximately 10 days, mean curd retention time was longer by 1.4 (SE 0.28) hours in supplemented compared with unsupplemented calves (p<0.001). At 52-57 days of age, mean retention time was longer by 0.7 (SE 0.34) hours compared to unsupplemented calves (p=0.05). CONCLUSION: Using ultrasonography, changes in abomasal content could be followed non-invasively over time and it was demonstrated that the plant-derived complex carbohydrate supplement increased the curd retention time in the abomasum. We speculate that the increased retention time enables an increased availability of nutrients following a more complete digestion of milk, thereby improving animal performance.

Fasciola hepatica: a comparative survey of adult fluke resistance to triclabendazole, nitroxynil and closantel on selected upland and lowland sheep farms in Northern Ireland using faecal egg counting, coproantigen ELISA testing and fluke histology.

In order to investigate the incidence and distribution of adult fluke resistance to the fasciolicide tricalbendazole (TCBZ) amongst populations of Fasciola hepatica in sheep flocks in Northern Ireland (NI), individual rectal faeces samples were collected from 3 groups of 20 sheep, before (pre-dose), and 21 days after (post-dose) treatment of the animals with TCBZ, nitroxynil or closantel, on each of 13 well-managed sheep farms distributed across the province. The efficacy of each flukicide was determined for each farm, using faecal egg count reduction (FECRT) and F. hepatica coproantigen ELISA testing. In certain flocks, 2 sheep with high pre-dose faecal egg counts (FEC) were killed 3 days and 21 days respectively after TCBZ treatment, and the histology of the fluke reproductive organs was compared with that of flukes from untreated sheep, and from sheep treated with nitroxynil or closantel 2 days prior to death, using haematoxylin and eosin (H&E) staining and an in situ hybridisation method (TdT-mediated dUDP nick end labelling [TUNEL]) to demonstrate apoptosis. Results from FECRT revealed that in all flocks with a high fluke burden, TCBZ was ineffective in treating chronic fasciolosis, and this finding was generally supported by the results of the coproantigen reduction test (CRT). The histology of reproductive organs of flukes from TCBZ-treated sheep in these flocks was normal, when compared with untreated flukes, and this, together with the FECRT and CRT findings, indicated a likely diagnosis of TCBZ resistance in all the flocks with a high fluke burden. In contrast, nitroxynil and closantel were found to be fully effective against TCBZ-resistant flukes in each of the flocks bearing a high chronic fluke burden. All of the flocks with a high fluke burden and TCBZ resistance were managed on lowland in the South and East of NI. Upland flocks, in the North and West, had low fluke burdens, or were clear of infection; and FECs were too low to allow valid resistance testing. The study highlights the high level of penetration of TCBZ resistance throughout F. hepatica populations in areas of intensively managed sheep production with a high level of fluke challenge. Further, it emphasises the importance of pre-emptive chemotherapeutic action against chronic fasciolosis, using flukicides effective against the egg-producing adult flukes to minimise pasture contamination for the next season's lamb crop. This study also exemplifies the use of several complementary methods (FECRT; CRT; fluke histology; comparative anthelmintic efficacy testing) for confirmation of a diagnosis of fluke drug resistance.

Dietary antioxidant intake is associated with the prevalence but not incidence of age-related hearing loss.

OBJECTIVES: Diet is one of the few modifiable risk factors for age-related hearing loss. We aimed to examine the link between dietary and supplement intakes of antioxidants, and both the prevalence and 5-year incidence of measured hearing loss. DESIGN: Cross-sectional and 5-year longitudinal analyses. SETTING: Blue Mountains, Sydney, Australia. PARTICIPANTS: 2,956 Blue Mountains Hearing Study participants aged 50+ at baseline, examined during 1997-9 to 2002-4. MEASUREMENTS: Age-related hearing loss was measured and defined as the pure-tone average of frequencies 0.5, 1.0, 2.0 and 4.0 kHz >25 dB HL. Dietary data were collected in a semi-quantitative food frequency questionnaire, and intakes of α-carotene; ß-carotene; ß-cryptoxanthin; lutein and zeaxanthin; lycopene; vitamins A, C and E; iron and zinc were calculated. RESULTS: After adjusting for age, sex, smoking, education, occupational noise exposure, family history of hearing loss, history of diagnosed diabetes and stroke, each standard deviation (SD) increase in dietary vitamin E intake was associated with a 14% reduced likelihood of prevalent hearing loss, odds ratio, OR, 0.86 (95% confidence interval, CI, 0.78-0.98). Those in the highest quintile of dietary vitamin A intake had a 47% reduced risk of having moderate or greater hearing loss (>40 dB HL) compared to those in the lowest quintile of intake, multivariable-adjusted OR 0.53 (CI 0.30-0.92), P for trend = 0.04. However, dietary antioxidant intake was not associated with the 5-year incidence of hearing loss. CONCLUSIONS: Dietary vitamin A and vitamin E intake were significantly associated with the prevalence of hearing loss. However, dietary antioxidant intake did not increase the risk of incident hearing loss. Further large, prospective studies are warranted to assess these relationships in older adults.

Hypogonadism in men receiving methadone and buprenorphine maintenance treatment.

The aim of this study was to determine the prevalence and investigate the aetiology of hypogonadism in men on methadone or buprenorphine maintenance treatment (MMT, BMT). 103 men (mean age 37.6 +/- 7.9) on MMT (n = 84) or BMT (n = 19) were evaluated using hormone assays, body mass index (BMI), serological, biochemical, demographic and substance use measures. Overall 54% of men (methadone 65%; buprenorphine 28%) had total testosterone (TT) <12.0 nm; 34% (methadone 39%; buprenorphine 11%) had TT <8.0 nm. Both methadone- and buprenorphine-treated men had lower free testosterone, luteinising hormone and estradiol than age-matched reference groups. Methadone-treated men had lower TT than buprenorphine-treated men and reference groups. Prolactin did not differ between methadone, buprenorphine groups, and reference groups. Primary testicular failure was an uncommon cause of hypogonadism. Yearly percentage fall in TT by age across the patient group was 2.3%, more than twice that expected normally. There were no associations between TT and opioid dose, cannabis, alcohol and tobacco consumption, or chronic hepatitis C viraemia. On multiple regression higher TT was associated with higher alanine aminotransferase and lower TT with higher BMI. Men on MMT have high prevalence of hypogonadotrophic hypogonadism. The extent of hormonal changes associated with buprenorphine needs to be explored further in larger studies. Men receiving long term opioid replacement treatment, especially methadone treatment, should be screened for hypogonadism. Wide interindividual differences in methadone metabolism and tolerance may in a cross-sectional study obscure a methadone dose relationship to testosterone in individuals. Future studies of hypogonadism in opioid-treated men should examine the potential benefits of dose reduction, choice of opioid medication, weight loss, and androgen replacement.

Management of syncope in the Emergency Department: a single hospital observational case series based on the application of European Society of Cardiology Guidelines.

AIMS: The aim of this study was to evaluate the effect of introducing a European Society of Cardiology guideline-based Integrated Care Plan (ICP) for Syncope on hospital admissions and referral patterns to an outpatient Syncope Management Unit, of patients presenting to an Emergency Department (ED) with a syncopal episode and to determine the underlying causes of syncope. METHODS AND RESULTS: This study is a single-centre observational case series of consecutive adult patients presenting to the ED over a 5-month period. Two hundred and fourteen of 18 898 patients (1.1%) had a syncopal episode, 110 (51.4%) of whom were admitted. Forty-six (41.8%) admissions were indicated by the ICP. All potential cardiac syncope cases were admitted. There was a 500% increase in the overall number of referrals to the Syncope Management Unit with a small increase in the number of unnecessary referrals. CONCLUSION: The introduction of an ICP for syncope was not associated with any cases with potential adverse outcomes being lost to follow-up and resulted in increased referral rates to the syncope unit. However, hospitalization rates for syncope remain high, and a large number of patients requiring early outpatient assessment were not referred. There remains a need to develop further interventions to guide appropriate and safe syncope management in the ED.

Maternal folate status and neural tube defects in Ireland: the need for a national food fortification program.

To determine the present risk of a Neural Tube Defect [NTD] pregnancy in the caucasian primigravid population in Dublin by comparing the serum folate and red cell folate status of primigravid patients attending the first prenatal booking clinic with data from the late 80's. This Cross-sectional population study looking at blood folate status of over 400 sequential primigravid caucasian women with a singleton pregnancy, booking at less than or equal to 20 weeks gestation. All patients were attending a prenatal booking clinic at the Rotunda Hospital in Dublin during 2003-2004. Comparing serum and red cell folate values in 454 primigravid patients in 2003-4 to values to in a large case-control study based on over 56,000 women attending maternity hospitals in Dublin from 1986 to 1990. Just 13.9% of our patients took periconceptual folate, 33.5% of patients took folate in the first 20 weeks of pregnancy and 58.8% of mothers were taking no folate supplement. Overall, 30% of mothers had RCF levels below 400 ug/L--a level recommended as the minimum value required for protection. NTD risk occurred most frequently amongst patients with RCF levels between 300 and 400 ng/mL.

Intracerebroventricular melanin-concentrating hormone stimulates food intake in sheep.

Melanin-concentrating hormone (MCH) stimulates feeding when injected intracerebroventricularly (ICV) in rats. At present it is not clear whether the function of MCH is similar in ruminants, which are species with a continuous delivery of nutrients. Therefore the current investigation sought to determine the role of MCH in sheep. In the first experiment, six, castrate male sheep were satiated and received one of four treatments [saline, 0.1, or 1.0 nmol/kg MCH, and NPY (0.1 nmol/kg)] injected ICV over 30s, then infused ICV for 6 h ( approximately 500 microl/h). Food intake was measured for 2 h before and at 2, 4, 6, 8, 12 and 24 h. In this experiment, feed intake was increased (P

GH-releasing peptide-6 overcomes refractoriness of somatotropes to GHRH after feeding.

After a meal, somatotropes are temporarily refractory to growth hormone-releasing hormone (GHRH), the principal hormone that stimulates secretion of growth hormone (GH). Refractoriness is particularly evident when free access to feed is restricted to a 2-h period each day. GH-releasing peptide-6 (GHRP-6), a synthetic peptide, also stimulates secretion of GH from somatotropes. Because GHRH and GHRP-6 act via different receptors, we hypothesized that GHRP-6 would increase GHRH-induced secretion of GH after feeding. Initially, we determined that intravenous injection of GHRP-6 at 1, 3 and 10 microg/kg body weight (BW) stimulated secretion of GH in a dose-dependent manner. Next, we determined that GHRP-6- and GHRH-induced secretion of GH was lower 1 h after feeding (22.5 and 20 ng/ml respectively) than 1 h before feeding (53.5 and 64.5 ng/ml respectively; pooleds.e.m.=8.5). However, a combination of GHRP-6 at 3 microg/kg BW and GHRH at 0.2 microg/kg BW synergistically induced an equal and massive release of GH before and after feeding that was fivefold greater than GHRH-induced release of GH after feeding. Furthermore, the combination of GHRP-6 and GHRH synergistically increased release of GH from somatotropes cultured in vitro. However, it was not clear if GHRP-6 acted only on somatotropes or also acted at the hypothalamus. Therefore, we wanted to determine if GHRP-6 stimulated secretion of GHRH or inhibited secretion of somatostatin, or both. GHRP-6 stimulated secretion of GHRH from bovine hypothalamic slices, but did not alter secretion of somatostatin. We conclude that GHRP-6 acts at the hypothalamus to stimulate secretion of GHRH, and at somatotropes to restore and enhance the responsiveness of somatotropes to GHRH.

Somatostatin inhibits alpha-2-adrenergic-induced secretion of growth hormone-releasing hormone.

The purpose of this experiment was to determine the role of growth hormone-releasing hormone (GHRH) and somatostatin (SRIH) neurons in mediating alpha(2)-adrenergic receptor-induced stimulation of growth hormone (GH) secretion in cattle. Our first objective was to determine if stimulation of alpha(2)-adrenergic receptors increases activity of GHRH neurons in the arcuate nucleus (ARC) and/or decreases activity of SRIH neurons in periventricular (PeVN) and ARC nuclei. Clonidine (an alpha(2)-adrenergic agonist) or vehicle (saline) were injected i.v. into steers and dual-label immunohistochemistry was performed to quantify the number of GHRH and SRIH neurons expressing Fos and Fos-related antigens (Fos/FRA) as markers of neuronal activity. Clonidine increased concentrations of GH in serum and decreased activity of SRIH neurons in the PeVN, but not in the ARC. Clonidine did not alter activity of GHRH neurons in the ARC. Our second objective was to determine if clonidine decreases secretion of SRIH from perifused slices of hypothalami, which contain perikarya and terminals of GHRH and SRIH neurons, and from explants of hypophysial stalk alone, which contain only terminals of GHRH and SRIH neurons. Clonidine failed to alter release of GHRH or SRIH from hypothalamic slices, but stimulated release of GHRH from explants of hypophysial stalk. Blockade of SRIH receptors enabled clonidine to stimulate release of GHRH from slices of hypothalami, but also stimulated release of SRIH. These results suggest that alpha(2)-adrenergic-induced secretion of GH occurs via a dual mechanism involving inhibition of SRIH neurons in the PeVN and direct stimulation of GHRH release from axon terminals in the median eminence.

The increasing prevalence of childhood sickle-cell disease in Ireland.

BACKGROUND: Ireland has been relatively free of sickle-cell disease (SCD) and a care policy for the disease has not been established. AIM: To determine the prevalence of childhood SCD in Ireland and to predict requirements for a comprehensive care and assessment programme. METHODS: We retrospectively analysed the data of children with SCD presenting with sickle-cell crisis to one institution from January 1999 to April 2001. We also determined the nature and severity of the presenting haemoglobinopathy phenotype. RESULTS: Ninety-two patients with haemoglobinopathy have been registered with the Paediatric Haematology Service. The majority are from Nigeria with a smaller number from Angola and the Congo. Sixty have sickle-cell trait, 23 SCD, four haemoglobin SC disease and two haemoglobin E (HbE). There have been 32 sickle-cell crises. The majority were haemolytic or splenic sequestration events with a smaller number of aplastic and vaso-occlusive events and one osteomyelitis. CONCLUSION: The increasing number of children presenting with SCD as a result of the increasing refugee numbers requires a comprehensive care approach similar to that required for paediatric haemophilia to ensure optimum care.

Efficacy, safety and patient acceptance of sildenafil citrate as treatment for erectile dysfunction.

PURPOSE: We assessed the efficacy and safety of sildenafil citrate as treatment for erectile dysfunction. MATERIALS AND METHODS: A total of 433 completely evaluated men with chronic erectile dysfunction were treated with sildenafil citrate. Response was assessed prospectively by baseline and followup physician interviews, and by a patient self-administered 15-item questionnaire on the domains of patient treatment response and satisfaction, partner treatment satisfaction, comparative previous treatment satisfaction, adverse effects, and patient and partner quality of life. RESULTS: Of the 304 men (70.2%) who completed the questionnaire 278 received sildenafil, including 186 who previously had undergone treatment for erectile dysfunction, principally involving intracavernous injection therapy. A response was elicited by a median dose of 100 mg. in 188 patients (67.6%) who achieved erection suitable for sexual intercourse. Those with psychogenic erectile dysfunction responded significantly better than those with organic dysfunction (p <0.001). Erection suitable for intercourse was attained by 30.8% of patients with erectile dysfunction after radical prostatectomy and 80% with cavernous veno-occlusive dysfunction. Of previous intracavernous injection responders 29.9% were refractory to sildenafil, while 33. 3% of previous intracavernous injection nonresponders responded to sildenafil. The sildenafil response was considered inferior to the intracavernous injection response by 43.6% of the men who previously responded to intracavernous injection, of whom 51.5% continued to receive intracavernous injection as the only treatment (19.5%) or as an alternative to sildenafil (32%). Adverse effects in 53.6% of cases were assessed as mild in 56.4%, moderate in 38.3% and severe in 5.3%. Multiple adverse effects were reported by 62.4% of patients, while 17 (6.1%) discontinued sildenafil as a direct result of intolerable adverse effects. The most common adverse effects were facial flushing in 33.5% of cases, headaches in 23.4%, nasal congestion in 12.6%, dyspepsia in 10.1% and dizziness in 10.8%. Baseline patient and partner quality of life scores significantly improved after sildenafil treatment (p <0.001), while significantly improved quality of life was noticed by 51.5% and 43.1%, respectively. CONCLUSIONS: Sildenafil citrate is effective oral first line treatment for erectile dysfunction. Although more than 50% of men reported adverse effects, most were considered mild and rarely resulted in treatment cessation. There was a trend in those on intracavernous injection who responded to sildenafil to continue intracavernous injection as the only therapy or as an alternative to sildenafil. Also, we noted that some cases refractory to sildenafil responded to intracavernous injection. These findings imply that intracavernous injection remains an effective erectile dysfunction treatment option.

Psychosomatic concepts in the works of Shakespere.

Psychosomatic medical theory of the late European Renaissance is reflected in the works of Shakespere. The period's conceptions of cardiovascular involvement in emotion, experimental causation of psychosomatic disorders, and repression of emotion as pathogenic, are described with reference to quotations from the Shakesperian plays. It is concluded that the premodern holistic approach to organismic functioning lends itself well to interpreting psychophysiological phenomena, and that contemporaries could profit from a philosophical reorientation concerning mind-body relationships in the disease process.

Psychosomatic disease and the problem of causation.

Despite its impressive rate of growth in the past decades, an increasing amount if dissatisfaction with the area of psychosomatic medicine is reflected in recent literature. The discipline's failures relate to concepts of pathogenesis and therapeutic application of research findings. These failures are explained as a necessary consequence of the philosophical tenet of mind-body dualism which underlies medical theory. It is urged that advocates of psychosomatic medicine give the concept of "holism" meaning at the most fundamental level by establishing a rational basis for theory, or else forsake this line of research for others which yield causal relationships conductive to effective therapy.

The psychosomatic approach to heart disease. A study in premodern medicine.

Prior to the discovery of the circulation of the blood and the advent of modern mind-body dualism, heart disease was conceived as invariably psychosomatic. Familiar vestiges of premodern theory are found in such expressions as "bighearted," "warmhearted," "brokenhearted," and so on. The original medical meanings of such expressions are explained. The historical disappearance of the psychosomatic approach to cardiovascular disease is explained as a product of dualistic thinking and the mechanistic physiopathology it created. It is urged that contemporaries could profit from a return to a holistic view of the disease process.

The wind of the cannon ball: an informative anecdote from medical history.

When Cartesian dualism became a determining philosophical basis of medical theory, psychosomatic events became logical impossibilities. In the nineteenth century, physicians confronted with a class of such events - battle casualties without externally inflicted injuries - sought mechanistic interpretations in the 'wind' of the cannon ball. Those who rejected these ineffective hypotheses were forced to deny the existence of such casualties. Today we acknowledge the existence of psychosomatic events. The logical barrier to understanding them, however, remains at the basis of medical theory and must be eradicated.