Parental Accompaniment in Operating Rooms Reduces Child Anxiety.

BACKGROUND: We believe that parental presence before the induction of anesthesia for surgery among children with a cleft palate/lip would be effective in mitigating their preoperative anxiety. OBJECTIVE: We assessed the states of patients with a cleft palate/lip when their parents accompanied them into operating rooms and clarified their and their parents' cognition using a questionnaire. METHODS: Data were collected via nursing observation when patients and their parents entered the operating room. Furthermore, an anonymous questionnaire was administered to patients and parents after the operation regarding their feelings about parental presence in the operating room. RESULTS: In total, nine patients cried when they entered the surgical room. Furthermore, six patients and three parents reported preoperative anxiety. In addition, eight patients agreed that they were satisfied with the presence of their parents before induction. CONCLUSION: Approximately half of the patients cried. However, the presence of parents before the induction of anesthesia was effective in reducing anxiety among most patients and their parents.

Aging exaggerates blood pressure response to ischemic rhythmic handgrip exercise in humans.

Ischemic skeletal muscle conditions are known to augment exercise-induced increases in blood pressure (BP). Aging is also a factor that enhances the pressor response to exercise. However, the effects of aging on the BP response to ischemic exercise remain unclear. We, therefore, tested the hypothesis that aging enhances the BP response to rhythmic handgrip (RHG) exercise during postexercise muscle ischemia (PEMI). We divided the normotensive participants without cardiovascular diseases into three age groups: young (n = 26; age, 18-28 years), middle-aged (n = 23; age, 35-59 years), and older adults (n = 23; age, 60-80 years). The participants performed RHG exercise with minimal effort for 1 min after rest with and without PEMI, which was induced by inflating a cuff on the upper arm just before the isometric handgrip exercise ended; the intensity was 30% of maximal voluntary contraction force. Under PEMI, the increase in diastolic BP (DBP) from rest to RHG exercise in the older adult group (Δ13 ± 2 mmHg) was significantly higher than that in the young (Δ5 ± 2 mmHg) and middle-aged groups (Δ6 ± 1 mmHg), despite there being no significant difference between the groups in the DBP response from rest to RHG exercise without PEMI. Importantly, based on multiple regression analysis, age remained a significant independent determinant of both the SBP and DBP responses to RHG exercise during PEMI (p < 0.01). These findings indicate that aging enhances the pressor response to ischemic rhythmic exercise.

Increased Pentraxin 3 Levels Correlate With IVIG Responsiveness and Coronary Artery Aneurysm Formation in Kawasaki Disease.

Kawasaki disease (KD) is a febrile disease of childhood characterized by systemic vasculitis that can lead to coronary artery lesions (CAL). This was a prospective cohort study to determine the levels of the pentraxin 3 (PTX3), soluble CD24-Subtype (Presepsin) and N-terminal pro-brain natriuretic peptide (NT-pro BNP) in consecutive KD patients. From January 2013 to March 2015, all patients with KD admitted to Aichi Medical University Hospital who provided consent had their plasma saved before IVIG administration. In total, 97 cases were registered. 22 cases of incomplete KD were excluded from the outcome analysis. The total 75 cases were used for statistical analyses. A PTX3 threshold of >7.92 ng/ml provided a specificity of 88.5 %, a sensitivity of 94.4 %, and a likelihood ratio as high as 15.92 for the diagnosis of KD compared with febrile non-KD controls. Although an echocardiographic diagnosis of CAL in the early course of the disease was confirmed in 24 cases, it was not in the remaining 51 cases. Neither NT-proBNP nor Presepsin had statistical significance for the prediction of the echocardiographic CAL diagnosis. Only PTX3 was significantly predictive of the echocardiographic CAL diagnosis (p=0.01). The PTX3 level was significantly higher in the intravenous immunoglobulin (IVIG) non-responders (45.9±7.45) than in the IVIG responders (17.0 ± 1.46 ng/ml) (p< 0.001). The PTX3 level also correlated with the number of IVIG treatment courses needed to resolve fever (R² =0.64). Persistent CAL (pCAL) formation was observed in three cases; one of aneurysm only and two aneurysms with dilatations. The patients with pCAL had significantly higher PTX3 levels (85 ± 8.4 ng/ml) than patients without pCAL (22 ± 2.2 ng/ml) (p< 0.0001). In terms of pCAL prediction, the area under the curve (AUC) of receiver operating characteristic ROC curve of PTX3 was 0.99, and it was significantly greater than that of Presepsin (0.67) or NT-proBNP (0.75). PTX3 is a soluble pattern recognition molecule that acts as a main component of the innate immune system. These data suggest that PTX3 can be utilized as a definitive biomarker for the prediction of IVIG resistance and subsequent CAL formation in patients with KD.

Contributions of residual hypoxemia to exercise hyperventilation in Fontan patients.

It is unsettled whether increased exercise ventilation in Fontan subjects is due to increased pulmonary dead space or augmented ventilatory drive. Twenty-six Fontan patients underwent symptom-limited treadmill cardiopulmonary exercise testing. Two groups of age- and sex- matched subjects served as controls: the biventricularly repaired (Bi, n = 18), and the "true" control (C, n = 29) groups. Peak oxygen uptake (V̇O2peak) was not different among groups (41.0 +/- 8.4 ml/min/kg, 43.5 +/- 6.6 ml/min/kg, and 45.9 +/- 11.6 ml/min/kg for Fontan, Bi, and C groups, respectively, p = 0.16). Fontan subjects, however, showed steeper alveolar ventilation/carbon-dioxide (V̇A/V̇CO2) regression slope (35.5 +/- 5.3, 28.7 +/- 3.8, and 29.5 +/- 3.0 l/ml, for Fontan, Bi, and C groups, respectively, p<0.0001), and lower end-expiratory carbon-dioxide fraction (FetCO2VAT) at ventilatory threshold (VAT) (4.4 +/- 0.5%, 5.5 +/- 0.5%, and 5.5 +/- 0.4%, for Fontan, Bi, and C groups, respectively, p<0.001). The dead-space ventilation fraction at VAT was similar among groups (0.33 +/- 0.06, 0.33 +/- 0.04, 0.35 +/- 0.05 for Fontan, Bi, and C groups, respectively, p = 0.54). In Fontan subjects, arterial oxygen saturation at rest (SaO2rest) was correlated with V̇A/V̇CO2 regression slope (r = -0.41, p = 0.04) and with FetCO2VAT (p = -0.53, p<0.01). We conclude that Fontan patients show exercise hyperventilation due to augmented central and/or peripheral ventilatory drive, which is further augmented by residual hypoxemia.

Insulin resistance is associated with an exaggerated blood pressure response to ischemic rhythmic handgrip exercise in nondiabetic older adults.

Patients with type 2 diabetes display an exaggerated pressor response to exercise. However, evidence supporting the association between the magnitude of the pressor response to exercise and insulin resistance-related factors including hemoglobin A1c (HbA1c) or homeostatic model assessment of insulin resistance (HOMA-IR) in nondiabetic subjects has remained sparse and inconclusive. Thus we investigated the relationship between cardiovascular responses to exercise and insulin resistance-related factors in nondiabetic healthy men (n = 23) and women (n = 22) above 60 yr old. We measured heart rate (HR) and blood pressure (BP) responses during: isometric handgrip (IHG) exercise of 30% maximal voluntary contraction, a period of skeletal muscle ischemia (SMI) induced by tourniqueting the arm after IHG, and rhythmic dynamic handgrip (DHG) exercise during SMI. Greater diastolic BP (DBP) responses to DHG with SMI was associated with male sex (r = 0.44, P = 0.02) and higher HbA1c (r = 0.33, P = 0.03), heart-ankle pulse wave velocity (haPWV) (r = 0.45, P < 0.01), and resting systolic BP (SBP) (r = 0.36, P = 0.02). HbA1c persisted as a significant determinant explaining the variance in the DBP response to DHG with SMI in multivariate models despite adjustment for sex, haPWV, and resting SBP. It was also determined that the DBP response to DHG with SMI in a group in which HOMA-IR was abnormal (Δ33 ± 3 mmHg) was significantly higher than that of groups in which HOMA-IR was at intermediate (Δ20 ± 4 mmHg) and normal (Δ23 ± 2 mmHg) levels. These data suggest that even in nondiabetic older adults, insulin resistance is related to an exaggerated pressor response to exercise especially when performed under ischemic conditions.NEW & NOTEWORTHY The diastolic blood pressure response to rhythmic dynamic handgrip exercise under ischemic conditions was demonstrated to be correlated with insulin resistance-related factors in nondiabetic older adults. This finding provides important insight to the prescription of exercise in this particular patient population as the blood pressure response to exercise, especially under ischemic conditions, could be exaggerated to nonsafe levels.

Effect of Using a Cardiac Catheterization Table-Stabilizing Stick on the Quality of Cardiopulmonary Resuscitation in the Cardiac Catheterization Laboratory: A Simulation-Based Study.

Rapid defibrillation and high-quality cardiopulmonary resuscitation (CPR) are necessary for patients with cardiopulmonary arrest, one of the most serious and frequently encountered complications in cardiac catheterization laboratories. However, when the catheterization table is withdrawn from its neutral position for fluoroscopy, it is unstable and unsuitable for resuscitation because of its cantilever structure. To stabilize the table in its withdrawn position, the use of a table-stabilizing stick might improve CPR quality. To investigate the effect of using a cardiac catheterization table-stabilizing stick on CPR quality, a CPR simulation mannequin was placed on a cardiac catheterization table that was withdrawn from the C-arm of the X-ray machine. CPR quality was assessed with or without the use of a table-stabilizing stick under the table. The CPR quality assessment (Q-CPR) scores were 79.6 ± 11.4% using the table-stabilizing stick and 47.7 ± 30.3% without the use of the stick device (p = 0.02). In this simulation-based study, the use of a table-stabilizing stick in a cardiac catheterization table withdrawn from the C-arm of the X-ray machine improved the quality of CPR.

Differences in autonomic neural activity during exercise between the second and third trimesters of pregnancy.

AIM: To test the hypothesis that autonomic neural activity in pregnant women during exercise varies according to gestational age. METHODS: This cross-sectional study involved 20 healthy women in their second (n = 13) or third (n = 7) trimester of pregnancy. Incremental cardiopulmonary exercise testing was performed with an electromagnetic cycle ergometer. Heart rate variability was analyzed by frequency analysis software. RESULTS: The low-frequency to high-frequency (LF/HF) ratio, an indicator of the sympathetic nervous system, was significantly higher in third trimester than in second trimester subjects (P < 0.05) at 1, 2, and 3 min of incremental exercise testing. In contrast, the HF/total power ratio, an indicator of rapidly acting parasympathetic activity, was significantly higher in second trimester than in third trimester subjects (P < 0.05) at 2 and 3 min. In addition, a negative correlation was found between gestational age and the 'accumulation half-time' of the LH/HF ratio, the time point at which the sum of the LF/HF ratio reached 50% of that accumulated in the total 6 min of exercise testing (r = -0.49, P = 0.028). CONCLUSIONS: The autonomic response to exercise in pregnant women differs between the second and third trimesters. These differences should be considered when prescribing exercise to pregnant women.

Acute Changes in Peripheral Vascular Tonus and Systemic Circulation during Static Stretching.

This study aimed to investigate the acute effect of static stretching (SS) on peripheral vascular tonus and to clarify the effect of SS on systemic circulation. Twenty healthy young male volunteers performed a 1-min SS motion of the right triceps surae muscle, repeated five times. The peripheral vascular tonus (|d/a| ratio) was obtained using second derivatives of the photoplethysmogram readings before, during, and after SS. Heart rate and blood pressure (BP) were also measured. The |d/a| ratio and BP were transiently, but significantly, elevated during SS and returned to baseline immediately after SS. Furthermore, we observed a significant correlation between the amount of change in the |d/a| ratio and the ankle range of motion during SS (r = 0.793 to 0.832, P = 0.01). These responses may be caused by mechanical stress during SS.

Successful arterial switch operation for transposition of the great arteries with intact ventricular septum and congenital diaphragmatic hernia: A case report.

We report performing a successful arterial switch operation on a full-term male infant with transposition of the great arteries and intact ventricular septum associated with a congenital diaphragmatic hernia. The patient developed severe persistent pulmonary hypertension after successful repair of a left congenital diaphragmatic hernia that restricted pulmonary blood flow into the hypoplastic left lung, and subsequent unilateral pulmonary congestion of the unaffected right lung occurred because of the hemodynamics generated by the transposition of the great arteries. Intravenous epoprostenol with nitric oxide inhalation and mechanical hypoventilation effectively controlled pulmonary vascular resistance before the arterial switch operation was performed. .

Assessment of late cardiotoxicity of pirarubicin (THP) in children with acute lymphoblastic leukemia.

BACKGROUND: Pirarubicin (tetrahydropyranyl-adriamycin: THP) is a derivative of doxorubicin with reportedly less cardiotoxicity in adults. However no studies of cardiotoxicity in children treated with THP have been reported. This study was performed to assess the THP-induced cardiotoxicity for children with acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS: This study comprised 61 asymptomatic patients aged from 7.6 to 25.7 years old. Median follow-up time after completion of anthracycline treatment was 8.1 years (range: 1.7-12.5). The cumulative dose of THP ranged from 120 to 740 mg/m(2) with a median of 180 mg/m(2) . Patients underwent electrocardiogram (ECG), echocardiography, the 6-min walk test (6MWT), and measurements of serum brain natriuretic peptide (BNP) before and after exercise. RESULTS: All subjects showed normal left ventricular function assessed by echocardiography. Ventricular premature contraction in Holter ECG and reduced exercise tolerance in the 6MWT were detected in 2/46 (3.3%) and 5/41(12.2%), respectively. Abnormal BNP levels were detected in 6/60 (10%) both before and after exercise. The cumulative dose of THP was significantly correlated with BNP levels after exercise (r = 0.27, P = 0.03), but not with any other cardiac measurements. Further analysis revealed that subjects with a high cumulative dose ≧300 mg/m(2) had significantly higher BNP levels after exercise compared with subjects with a low cumulative dose <300 mg/m(2) (P = 0.04). CONCLUSIONS: No significant cardiac dysfunction was detected in long-term survivors who received THP treatment. The use of post-exercise BNP level to indicate high cardiotoxicity risk should be verified by further study.

Role of insulin resistance in non-obese adolescents.

Insulin resistance in the obese is closely related with cardiovascular diseases and their risk factors not only in adults but also in children and adolescents. We aimed to elucidate whether insulin resistance in non-obese adolescents is related with these conditions. A total of 74 non-obese high-school students (38 boys and 36 girls) were recruited. Anthropometry, blood pressure, fasting serum chemistry and insulin activity were measured. Subjects with a homeostasis model assessment-insulin resistance (HOMA-IR) level greater than the 75th percentile (> 2.25 for boys and > 2.89 for girls) were defined as insulin resistant. Non-obese boys with impaired insulin sensitivity had higher systolic blood pressure, lower HDL-cholesterol concentration, and fewer hours of vigorous exercise during weekdays, while non-obese girls with impaired insulin sensitivity had higher systolic blood pressure than their peers with normal insulin sensitivity. By multiple stepwise regression analysis, systolic blood pressure (p < 0.001) and the hours of vigorous exercise during weekdays (p < 0.03) were independently associated with HOMA-IR in boys, while systolic blood pressure (p < 0.0001) and serum concentrations of HDL-cholesterol (p < 0.01) were found in girls. In nonobese adolescents, insulin sensitivity is related with cardiovascular risk factors.

Robustness of the oxygen uptake efficiency slope to exercise intensity in patients with coronary artery disease.

Oxygen uptake efficiency slope (OUES) and ventilatory efficiency (VE/VCO2 slope) are widely used as submaximal measurements of cardiopulmonary exercise testing as the evaluator or prognosticator of cardiac diseases. However, very few studies have compared the effects of submaximal exercise on these measurements. A total of 58 patients with coronary artery disease underwent maximal cardiopulmonary exercise testing on a treadmill. We compared the values obtained from the first 75% (VE/VCO2 slope75 and OUES75) and 90% (VE/VCO2 slope90 and OUES90) of the exercise period with the entire duration (VE/ VCO2 slope100 and OUES100). Although OUES100, OUES90 and OUES75 were virtually identical, submaximal calculations of VE/VCO2 slope underestimated the measurements. The Bland-Altman method revealed that submaximal measurements of OUES agreed very well with maximal OUES (limits of agreement -5.0% to +6.0% for OUES90, and -11.5% to +12.9% for OUES75). However, the submaximal calculations of VE/ VCO2 slope showed rather poor agreement with the maximal calculations (limit of agreement -11.8% to +3.1% for VE/VCO2 slope90, and -20.8% to +5.3%% for VE/VCO2 slope75). These results revealed that both the OUES and the VE/VCO2 slopes are not overly influenced by exercise.

Role of exercise in the prevention of obesity and hemodynamic abnormalities in adolescents.

BACKGROUND: Poor physical activity plays a key role in the development of obesity. Little is known, however, about how much or the level of intensity of exercise that is needed to prevent obesity and hemodynamic abnormalities in adolescents. METHODS AND RESULTS: Height, bodyweight, resting heart rate (HR), and systolic and diastolic blood pressure was measured in 17,523 male and 16,906 female high school students. Self-reported exercise intensity was related to percentage of overweight (POW), diastolic blood pressure, and resting HR in boys, and to bodyweight and resting HR in girls. Self-reported exercise amount was associated with POW, diastolic blood pressure, and resting HR in both boys and girls. Also, high intensity or adequate amount of exercise was associated with a lower prevalence of obesity and resting tachycardia in both sexes, and slightly associated with the prevalence of systolic high blood pressure in boys. CONCLUSION: Both intensity and amount of exercise are associated with the prevalence of obesity and hemodynamic abnormalities in adolescents.

Effect of immunoglobulin therapy on blood viscosity and potential concerns of thromboembolism, especially in patients with acute Kawasaki disease.

Kawasaki Disease (KD) is an acute febrile systemic vasculitis of unknown etiology that primarily affects children younger than five years of age. The most reliable treatment for acute-phase KD is the combination of aspirin and high dose (2g/kg) intravenous immunoglobulin (IVIG) therapy. However, IVIG therapy is occasionally associated with serious thromboembolism, probably because of a rapid increase in plasma IgG concentration. Therefore, patients with KD, who are associated with endothelial impairment, are not free from the risk of thromboembolism associated with IVIG therapy. High levels of IgG, immune complex formation, and increased platelet aggregation could increase blood viscosity after IVIG infusion. Increased serum viscosity reduces arterial and capillary blood flow, leading to thrombosis. We have previously reported that single high-dose IVIG therapy for acute KD raises plasma viscosity. Although there is scarce epidemiological information as to the prevalence of thromboembolism associated with IVIG therapy, the occurrence of these complications must be taken into consideration. This article also includes relevant patents on this topic.

Adolescent obesity adversely affects blood pressure and resting heart rate.

BACKGROUND: Obesity is associated with hypertension (HT) and high resting heart rate (HR), as well as metabolic disturbances. However, little is known about how strongly these hemodynamic abnormalities are associated with the degree of obesity in adolescents. METHODS AND RESULTS: Height, body weight, resting HR, and systolic and diastolic blood pressures were measured in 20,165 male and 19,683 female high-school students. Adiposity levels were classified into 6 groups by body mass index: group 1 (<20th percentile), group 2 (20th-39.9th percentile), group 3 (40th-59.9th percentile), group 4 (60th-79.9th percentile), group 5 (80th-98.9th percentile), and group 6 (> or =99th percentile). Systolic and diastolic hypertensions were defined as > or =140 mmHg and > or =85 mmHg, respectively. Resting tachycardia was defined as the corresponding 95th percentile or greater. Resting HR and systolic and diastolic blood pressures increased with adiposity level in both sexes (p<0.0001). Both systolic HT and diastolic HT were associated with high resting HR, and the clustering of these unfavorable conditions increased with the degree of obesity. CONCLUSION: Hemodynamic abnormalities, such as HT and a high resting HR, are closely associated with adolescent obesity and are probably explained by impaired autonomic nerve function.