Central and cardiovascular responses to emotional stimuli are normal in non-phobic subjects with Reflex Syncope.

OBJECTIVE: Reflex Syncope (RS) is a self-limited loss of consciousness due to systemic arterial hypotension resulting from widespread vasodilatation and/or bradycardia. Higher neural centres have been implicated in the pathophysiology of RS, particularly in blood/injury phobic patients. We investigated interictal central autonomic functions in non-phobic RS subjects compared to non-phobic controls evaluating their central and cardiovascular responses to emotional stimuli. METHODS: Cardiovascular responses to Valsalva Manoeuvre (VM), Deep Breathing (DB) and during presentation of 108 slides selected from the International Affective Picture System were assessed in 20 non-phobic RS subjects and 20 controls. Slide onset visual event-related potentials (ERPs) were also computed. RESULTS: No significant difference in cardiovascular responses and ERP amplitude were found in non-phobic RS subjects and controls at rest, in response to VM and DB or during picture presentation. CONCLUSIONS: Non-phobic patients with RS not only have a normal interictal autonomic control of the cardiovascular system but also a normal modulation and adaptation of central and cardiovascular response to emotional processing, in our experimental setting. SIGNIFICANCE: Non-phobic patients with RS present normal interictal central and cardiovascular responses. Autonomic dysfunction observed in phobic RS patients could be related to mechanisms underlying the phobia itself rather than the mechanisms causing RS.

The European Working Time Directive and training in cardiothoracic surgery in the United Kingdom.

The European Working Time Directive (EWTD) limited average working hours for junior doctors to 58 per week in 2004. The Cardiothoracic Specialty Advisory Board conducted postal and email surveys of cardiothoracic trainees' work patterns and attitudes in 2003 and 2005-6. The results reveal an increase in shift-based working from 15% to 58% of respondents. One hundred per cent of respondents felt that the EWTD had had a negative impact on training, and only 30% were satisfied with their training to date. Satisfied trainees were more likely to work in larger units as assessed by ITU beds (20.6 vs. 8.9, p < 0.001) and cardiac cases/year (1586.2 vs. 828.4, p < 0.001). They had performed more cardiac cases than their peers (72.7 vs. 26.7, p = 0.005). Fifty-two per cent thought that their quality of life improved after EWTD implementation. The EWTD is unpopular amongst cardiothoracic trainees, who perceive it as harming training. Overall trainee satisfaction is low. Larger units and increased personal operative experience are associated with trainee satisfaction. Training programmes must act vigorously to safeguard training quality before implementation of the 48-hour limit in 2009.

Alexithymia in female patients with eating disorders.

Previous studies indicate that patients with eating disorders have alexithymic characteristics, as revealed by the Toronto Alexithymia Scale (TAS). The aim of the present study was to investigate the role of negative affect (anxiety and depression) in the relationship between eating disorders and alexithymia. In addition, we have evaluated whether the relationship between negative affect and alexithymia varies according to the type of eating disorder (anorexia and bulimia). Eighteen female patients and 16 female patients who met the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) diagnostic criteria for restrictive anorexia nervosa and bulimia nervosa, respectively, and 18 healthy female controls matched by age and education were submitted to Beck Depression Inventory and Spielberger State-Trait Anxiety Inventory to assess depression and anxiety and the Toronto Alexithymia Scale (TAS-20) and the Bermond Vorst Alexithymia Questionnaire (BVAQ) to evaluate alexithymic characteristics. The findings indicated that, although anorexic and bulimic patients showed higher alexithymia scores compared to controls, this result could be mainly related to negative affect. In fact, taking negative affect into account, anorexic and bulimic patients did not show higher TAS-20 and BVAQ scores compared to controls. The only variable useful to discriminate among anorexics, bulimics and controls is the perceived inability to experience emotional feelings, which is higher in anorexic patients compared to the other two groups.

Clinical results of thoracoscopic Heller's myotomy in the treatment of achalasia.

OBJECTIVES: Ideal treatment for achalasia permanently eliminates the dysfunctional lower oesophageal sphincter, relieving dysphagia and regurgitation. The aim of this study was to review the results in a series of patients undergoing video-imaged thoracoscopic Heller's myotomy (THM). METHODS: Records of all patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire together with oesophageal manometry and/or 24 h pH monitoring when clinically indicated. RESULTS: Twenty-five consecutive patients (13 males, 12 females, mean age 40.3+/-19.9 years) suffering from grade 4 dysphagia underwent THM between 1993 and 2001. Preoperative mean lower oesophageal sphincter (LOS) pressure was 42.6+/-6.3 mmHg. Seven patients (28%) had undergone previous pneumatic dilatations. There were no hospital deaths and no oesophageal perforations. Length of hospital stay was 4.3+/-1.8 days. One patient died 3 years after surgery from unrelated causes. At follow-up of 5.4+/-2.1 years, freedom from any reintervention was 95.8% (23/24). Eleven patients (45.8%) were asymptomatic. In patients with residual or recurrent symptoms (n=13), their severity was significantly reduced from the preoperative period (dysphagia score 1.7+/-0.8 versus 4+/-0; P

Sequential VATS lung volume reduction surgery: prolongation of benefits derived after the initial operation.

OBJECTIVE: Sequential lung volume reduction (LVR) is thought to provide additional and prolonged benefit compared with unilateral LVR. We tested this hypothesis by reviewing physiological, subjective and survival outcome data on patients who underwent sequential or unilateral LVR. METHODS: LVR was performed as a unilateral video-assisted thoracoscopic surgery (VATS) procedure, with bilateral reduction being undertaken in a staged manner. Pulmonary function data were collected prospectively. A telephone survey of patients and general practitioners was used to determine quality of life and survival. RESULTS: Fifty patients underwent LVR. Twenty-one patients had staged reduction of the contra-lateral lung at a median interval of 9 months. Pre-operatively, patients undergoing sequential LVR were not significantly different from patients undergoing unilateral LVR: forced expiratory volume in 1 s (FEV1) 23% predicted vs. 27% predicted, KCO 40% vs. 45%, total lung capacity (TLC) 124% vs. 121%, residual volume (RV) 217% vs. 214%, health score 34.5 vs. 30.8. After single-side LVR, both groups demonstrated equivalent and significant improvement in spirometric and subjective health scores: FEV1 +15% predicted (P<0.01), TLC -5% (P=0.03), health score +80% (P<0.01). Patients undergoing sequential reduction demonstrated no further significant improvements using either an intragroup comparison with their pre-second operation values or an intergroup comparison with the unilateral LVR patients. However, sequential LVR appeared to prolong the benefits experienced after the initial surgery by 1 year. Overall, 12 patients (24%) died during follow-up with no survival difference between the two groups (P=0.65). CONCLUSION: Sequential LVR is a safe strategy. Undertaking LVR to the second side does not further improve spirometric or subjective performance but does prolong the benefits achieved with the initial reduction.

Surgically relevant structure on the ascending aorta.

We have examined the transverse vascularized ridge observed on the anterior surface of the intra-pericardial aorta during cardiac surgery. The ridge was a consistent feature of 20 consecutive cardiac patients and 11 cadavers no more than 2 days post-mortem. The aortic ridge was absent, however, in four of five embalmed cadavers additionally examined, probably due to the embalming process. Histological examination showed the ridge to be well vascularized, well innervated and composed of adipose tissue. This structure has surgical relevance as a possible source of post-operative hemorrhage, sometimes necessitating re-sternotomy.

Deficit in the discrimination of nonverbal emotions in children with obesity and their mothers.

OBJECTIVE: Referring to the alexithymia construct and Bruch's clinical observations, this study investigated the ability to decode nonverbal signs of emotion in obese boys and girls, and their mothers. METHOD: A group of 10 boys and 11 girls with obesity and their mothers, and a control group were tested. Both mothers and children were asked to recognize a set of 32 brief film sequences interpreted by four actors expressing four emotions (anger, sadness, fear, happiness) with two intensity levels. Each sequence was presented first without sound, second without video, and finally with video and sound. RESULTS: As expected, boys and girls suffering from obesity and their mothers showed a reduced ability to decode visual and verbal signs of emotion compared to the control group. DISCUSSION: This result may be interpreted in accordance with the alexithymia construct, and suggests the importance of developing therapeutic strategies to face alexithymic characteristics in obese children and their mothers.

Significant merits of a fibrin sealant in the presence of coagulopathy following paediatric cardiac surgery: randomised controlled trial.

OBJECTIVES: The efficacy of a fibrin sealant in paediatric cardiac surgery has been demonstrated. However, its effectiveness in the presence of significant untreated coagulopathy has not been addressed. This study was designed to investigate the role of the topical application of a fibrin sealant, Beriplast P (BP), in the presence of coagulopathy following paediatric cardiac surgery. METHODS: After confirming the presence of significant post-bypass coagulopathy, patients undergoing repair of congenital heart defects using cardiopulmonary bypass were randomised to the use of BP (group BP) or no intervention (group C). BP was applied over suture lines and microvascular bleeding sites. Criteria for transfusion of blood and blood products were standardised for both groups. Outcome variables were: (1) post-operative bleeding; (2) transfusion of blood and blood products; (3) theatre time to achieve haemostasis; (4) ventilation time, intensive therapy unit (ITU) and hospital stay. RESULTS: Fifty-two patients (n=26 in each group), aged 3 days to 17.4 years were recruited. There were no hospital deaths and no significant differences in demographic or intraoperative variables that might have affected the chosen endpoints. After protamine, all patients in both groups had significant coagulopathy (P< or = 0.05 versus baseline). There were fewer patients receiving transfusions of fresh frozen plasma (FPP) in the intervention group, when compared to the control group (P< or = 0.05). Patients receiving BP spent less time in theatre to achieve haemostasis (P< or = 0.05), had a lesser amount of bleeding intraoperatively (P< or = 0.01), at 4h (P< or = 0.05) and at 24h (P< or = 0.05), required a lower amount of transfusions of red cells (P< or = 0.01), FPP (P< or = 0.05) and platelets (P< or = 0.05). There were no differences in ventilation time, length of stay in ITU or in hospital. CONCLUSIONS: Even in the presence of significant coagulopathy, intraoperative use of fibrin sealant in paediatric cardiac surgery reduces the amount of bleeding and need for transfusions of blood and blood products. The theatre time necessary to achieve haemostasis is also significantly reduced. These findings have a potential to improve clinical outcomes and enhance cost benefits.

The role of fibrin sealants in hemostasis.

Hemostasis is a prerequisite for wound healing, and under normal physiologic conditions, it is achieved by means of the coagulation cascade. However, there are a number of surgical procedures where there may be considerable benefits to the patient, surgeon, or health-care costs if hemostasis can be achieved more efficiently. The rapid and effective control of bleeding during and after surgery reduces blood loss and can help reduce postoperative complications. These improved outcomes can reduce the need for transfusion, with the associated risk of viral transmission, and have a positive impact on operative and hospital stay times. Fibrin sealants are surgical hemostatic agents derived from human plasma that reproduce the final steps in the coagulation pathway and form a stable fibrin clot. Fibrin sealants are used in a broad range of surgical procedures to assist hemostasis, including cardiovascular, hepatic, and splenic surgery, gastrointestinal hemorrhage, skin grafting, and dental extractions in anticoagulated patients. Patients with coagulopathies are at high risk of prolonged or excessive bleeding during or after invasive surgery, and these patients may also benefit from the use of fibrin sealants. This article reviews the role of fibrin sealants in hemostasis, citing a number of key clinical studies that report a significant reduction in blood loss or chest drain output after surgery with fibrin sealant compared with controls.

Affective reactions to briefly presented pictures.

Affective reactions to briefly presented pictures were investigated to determine whether fleeting stimuli engage the motivational systems mediating emotional responses. Emotional and neutral pictures were presented for 500 ms; heart rate, skin conductance, corrugator EMG, and the evoked startle reflex were measured. The time course of reflex modulation was similar to that obtained with longer (6 s) presentations, suggesting that picture processing continues in the absence of a sensory stimulus. Affective reactions found with more sustained presentation were also obtained, with more corrugator EMG activity for unpleasant pictures, and greater skin conductance reactivity for emotional pictures. Heart rate modulation, however, appears to rely on the presence of a sensory stimulus. The data also suggest that brief presentations of unpleasant pictures may result in less defensive activation than sustained presentation.

Individualized heparin and protamine management in infants and children undergoing cardiac operations.

BACKGROUND: Measurements of activated coagulation time do not correlate with plasma concentration of heparin. This study investigated the effects of a patient-specific method to manage anticoagulation and its reversal in pediatric patients undergoing cardiopulmonary bypass. METHODS: Infants and children were randomly assigned to receive either a standard dose of heparin (300 IU/kg; group C, n = 13) or an individualized dose, calculated by an in vitro heparin dose-response test (group HC, n = 13). Protamine dose was based on a 1 mg/l mg ratio of total administered heparin for patients in group C and of the residual heparin concentration in group HC. RESULTS: Administered heparin was significantly higher and total protamine dose was significantly reduced in the HC group (both p < or = 0.001). There was less thrombin generation (p = 0.02) and fibrinolysis (p = 0.05) in group HC. Blood loss and requirement for transfusion of blood and fresh frozen plasma were also lower in group HC (all p < or =0.05). CONCLUSIONS: An individualized management of anticoagulation and its reversal results in less activation of the coagulation cascade, less fibrinolysis, and reduced blood loss and need for transfusions. Further studies are warranted to better define the clinical impact of these findings.

Emotion and motivation I: defensive and appetitive reactions in picture processing.

Emotional reactions are organized by underlying motivational states--defensive and appetitive--that have evolved to promote the survival of individuals and species. Affective responses were measured while participants viewed pictures with varied emotional and neutral content. Consistent with the motivational hypothesis, reports of the strongest emotional arousal, largest skin conductance responses, most pronounced cardiac deceleration, and greatest modulation of the startle reflex occurred when participants viewed pictures depicting threat, violent death, and erotica. Moreover, reflex modulation and conductance change varied with arousal, whereas facial patterns were content specific. The findings suggest that affective responses serve different functions-mobilization for action, attention, and social communication-and reflect the motivational system that is engaged, its intensity of activation, and the specific emotional context.

Emotion and motivation II: sex differences in picture processing.

Adhering to the view that emotional reactivity is organized in part by underlying motivational states--defensive and appetitive--we investigated sex differences in motivational activation. Men's and women's affective reactions were measured while participants viewed pictures with varied emotional and neutral content. As expected, highly arousing contents of threat, mutilation, and erotica prompted the largest affective reactions in both men and women. Nonetheless, women showed a broad disposition to respond with greater defensive reactivity to aversive pictures, regardless of specific content, whereas increased appetitive activation was apparent for men only when viewing erotica. Biological and sociocultural factors in shaping sex differences in emotional reactivity are considered as possible mediators of sex differences in emotional response.

Autonomic reactivity during viewing of an unpleasant film.

The effect of an aversive, high-arousing film on heart rate, respiratory sinus arrhythmia, and electrogastrographic activity (EGG) was investigated. Previous studies have indicated a larger heart-rate deceleration for visual stimuli depicting surgery or blood compared to neutral content, and this phenomenon is similar to the bradycardia observed in animals in response to fear. The heart-rate deceleration is clearly parasympathetically driven, and it is considered a general index of attention. An accurate index of cardiac vagal tone can be obtained by means of quantification of the amplitude of respiratory sinus arrhythmia. The relationship between cardiac vagal tone and EGG is complex, but animal research has shown that suppressing vagal activity dampens gastric motility. We have investigated whether a movie depicting surgery is associated with greater heart-rate deceleration, larger increase in respiratory sinus arrhythmia, and greater increase in EGG activity compared to a neutral movie. In addition, if both respiratory sinus arrhythmia and EGG are indices of vagal tone, a positive correlation between these physiological responses was expected. Analysis indicated an effect of the surgery movie on heart rate and respiratory sinus arrhythmia, but not on EGG activity. Moreover, the expected correlation was not found. Implications for future studies are discussed.

Management of anticoagulation and its reversal during paediatric cardiopulmonary bypass: a review of current UK practice.

Protocols for management of heparin and protamine administration in patients undergoing open-heart surgery have been developed from experience gained mainly in adult practice. However, it has been demonstrated that there are marked differences between paediatric and adult patients in their response to systemic anticoagulation and its reversal. The aim of this study was to obtain an overview of current practice of management of anticoagulation and its reversal from paediatric cardiac surgical units of Great Britain and Ireland. All centres performing paediatric cardiac surgery agreed to participate in the survey (n = 16). Telephone interviews were carried out with the chief or a senior perfusionist from all participating institutions, which were based on a structured questionnaire compiled specifically for the purpose. The answers were anonymised. At present, in the UK and Ireland, unfractionated heparin is the anticoagulant of choice in all units, with a slight prevalence of porcine mucosal (9/16, 56.5%) versus bovine lung preparation (7/16, 44.0%). The policy for administration of heparin to the patient is uniform, with a dose of 300 IU/kg. However, there is great variability in the amount of heparin added to the prime and to the volume infused during cardiopulmonary bypass (CPB). Monitoring of anticoagulation is achieved by activated coagulation time alone in all but one centre, with lower limits varying between 400 and 750 s. Use of aprotinin is widely accepted, but clinical indications are highly variable. No centre adopts heparin-bonded or heparin-coated circuitry for CPB. Calculation of initial and additional protamine doses followed a variety of criteria, resulting in a very wide distribution of doses. The data obtained highlighted the lack of uniformity among paediatric cardiac surgical units of Great Britain and Ireland with regard to most of the issues related to the management of anticoagulation and its reversal. The striking heterogeneity of our cross-sectional observations clearly underlines the need for prospective, multicentre studies on a national basis to relate different clinical practices to outcome measures.

Asymptomatic congenital oesophageal cyst infiltrating the lung: an unusual complication.

An asymptomatic 14-year-old boy presented with minor chest trauma. Chest X-ray showed opacity in the upper zone of the left lung. Further investigations with magnetic resonance imaging showed it to be a posterior mediastinal mass with a fistula to the lung, along with cystic changes in the left upper lobe of lung. Left upper lobectomy with excision of the mass was performed. Histological examination later showed an oesophageal duplication cyst with a fistula to the left upper lobe of the lung. We present this unusual complication of an oesophageal cyst infiltrating the lung in an asymptomatic child.

Late aortic homograft valve endocarditis caused by Cardiobacterium hominis: a case report and review of the literature.

An unusual case of Cardiobacterium hominis endocarditis involving an aortic homograft valve is presented. Although the patient was young (a 17 year old man) and showed few of the characteristic features of the disease, the report does illustrate a number of the problems associated with this illness and highlights the need for the careful assessment of apparent culture negative endocarditis. The organism itself is susceptible to most antibiotics but further treatment, including surgery, may be necessary. Patients must therefore be examined repeatedly and assessed for haemodynamic deterioration, valve destruction or embolic phenomena. Homograft valve replacement may offer some benefits in the setting of aortic valve endocarditis and is therefore an attractive option in this situation.

Persistent pulmonary hypertension of the newborn associated with pulmonary atresia and intact interventricular septum.

Neonates with pulmonary atresia and intact interventricular septum (PAIVS) do not have pulmonary vascular disease secondary to their heart abnormality. Persistent pulmonary hypertension of the newborn has not been described in association with this condition. The case is reported of a female neonate born with PAIVS, who preoperatively had no clinical evidence or any risk factors for persistent pulmonary hypertension of the newborn, but whose postoperative course was highly suggestive of persistent pulmonary hypertension; necropsy confirmed the features of pulmonary vascular disease.

One-stage repair of interrupted aortic arch, aortopulmonary window, and anomalous origin of right pulmonary artery with autologous tissues.

Interruption of the aortic arch, distal aortopulmonary septal defect, and aortic origin of the right pulmonary artery with intact interventricular septum were associated findings in a 4-month-old infant who underwent successful one-stage repair without the use of any synthetic material, thus allowing for a potential for growth of both the pulmonary artery and the aorta. The baby made an uneventful recovery and remains asymptomatic 36 months after repair.

Superiority of centrifugal pump over roller pump in paediatric cardiac surgery: prospective randomised trial.

OBJECTIVE: The merits of centrifugal pump in adult cardiopulmonary bypass are well established. This study compares the effects of the Medtronic Biomedicus centrifugal pump with conventionally used roller pump in routine cardiopulmonary bypass in infants and children. METHODS: Between June 1996 and March 1997, 42 children (aged 2 days-13 years) undergoing elective cardiac surgery were assigned to either centrifugal or roller pump bypass. The following variables were studied: haemolysis (haematocrit, free plasma haemoglobin, haptoglobins), platelet activity (platelet counts, Beta-thromboglobulin), leukocyte count, cytokine release (IL-2, IL-6, IL-8), complement activation (C3a and C5a), blood and blood product requirements, urine output on bypass, post-operative blood urea, duration of ventilation, intensive care and hospital stay. RESULTS: Age, weight, disease complexity, duration of bypass, and a number of other variables were comparable in the two groups. The centrifugal pump resulted in lower plasma free haemoglobin (mean +/- SD, 50 +/- 23 vs. 72 +/- 35 mg/dl, P < 0.01), higher platelet count (133.1 +/- 34.8 vs. 63.5 +/- 29.6 x 10(9)/l, P < 0.01), less platelet activation (beta-TG 1253 +/- 633 vs. 1657 +/- 677 ng/ml; P < 0.05), less cytokine release (IL-6 329 +/- 57 vs. 392 +/- 59 pg/ml; P < 0.05), and reduced levels of C3a (4822 +/- 274 vs. 5933 +/- 393 ng/ml, P < 0.01). Differences were detected in favour of the centrifugal pump in urine output on bypass (4.1 +/- 0.5 vs. 2.3 +/- 1.9 ml/kg per h, P < 0.01), post-operative maximal urea (6.5 +/- 3.1 vs. 10.2 +/- 6.7 mmol/l, P < 0.02), ventilation time (18.9 + 6.5 vs. 56.5 + 51.7 h, P < 0.01), duration of intensive care (1.4 +/- 0.79 vs. 3.33 +/- 2.8 days, P < 0.05) and hospital stay (5.7 +/- 1.4 vs. 15.75 +/- 23.9 days, P < 0.01), but not in blood and blood product requirements (RCC: 11.26 +/- 4.6 vs. 10.77 +/- 4.2 ml/kg per 24 h, P > 0.05). CONCLUSION: The centrifugal pump as compared to roller pump results in less blood trauma, reduced platelet activation and less pronounced inflammatory response. There is also an improved renal response during and after bypass. This is translated clinically into reduced requirement for ventilation, shorter intensive care and hospital stays. These results strongly favour the use of centrifugal pump in routine paediatric cardiac surgery.