Impact of gestational diabetes mellitus on maternal cardiac adaptation to pregnancy.

OBJECTIVE: To determine whether maternal cardiac adaptation at term differs between women with, and those without, gestational diabetes mellitus (GDM). METHODS: This was a prospective case-control study of pregnant women at term with or without GDM. For both cases and controls, only women without any comorbidity or form of pre-existing diabetes who had a singleton pregnancy without complication (such as pre-eclampsia or fetal growth restriction) were included. All women underwent conventional and speckle-tracking echocardiography to assess both the left- and right-heart geometry and function. RESULTS: A total of 40 women with GDM and 40 healthy controls were enrolled. Women with GDM, compared with controls, had a significantly higher heart rate (83 ± 10 vs 75 ± 9 beats per min; P < 0.001), left ventricular (LV) relative wall thickness (0.43 ± 0.07 vs 0.37 ± 0.08; P < 0.001), LV early diastolic transmitral valve velocity (E) (0.80 ± 0.15 vs 0.73 ± 0.12 m/s; P = 0.026) and LV late diastolic transmitral valve velocity (A) (0.65 ± 0.13 vs 0.57 ± 0.11 m/s; P = 0.006). In women with GDM compared with controls, speckle-tracking analysis revealed a significant reduction in LV global longitudinal strain (GLS) (-16.29 ± 2.26 vs -17.61 ± 1.89; P = 0.012), LV endocardial GLS (-18.50 ± 2.59 vs -19.84 ± 2.35; P = 0.031) and LV epicardial GLS (-14.40 ± 2.01 vs -15.73 ± 1.66; P = 0.005). Right ventricular (RV) analysis revealed a reduced pulmonary acceleration time (58 ± 10 vs 66 ± 11 ms; P = 0.001) and RV E/A ratio (1.13 ± 0.18 vs 1.29 ± 0.35; P = 0.017), as well as a higher RV myocardial systolic annular velocity (0.16 ± 0.04 vs 0.14 ± 0.02; P = 0.023) and peak late diastolic transtricuspid valve velocity (0.46 ± 0.1 m/s vs 0.39 ± 0.08 m/s; P = 0.001), in women with GDM compared to controls. CONCLUSIONS: Our findings show that even a short period of exposure to hyperglycemia, as occcurs in women with GDM, is associated with significant maternal functional cardiac impairment at term. Given these findings, further study of postnatal maternal cardiovascular recovery after GDM pregnancy is warranted. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Cardiac maladaptation in obese pregnant women at term.

OBJECTIVE: Obesity is an increasing problem worldwide, with well recognized detrimental effects on cardiovascular health; however, very little is known about the effect of obesity on cardiovascular adaptation to pregnancy. The aim of the present study was to compare biventricular cardiac function at term between obese pregnant women and pregnant women with normal body weight, utilizing conventional echocardiography and speckle-tracking assessment. METHODS: This was a prospective case-control study of 40 obese, but otherwise healthy, pregnant women with a body mass index (BMI) of ≥ 35 kg/m2 and 40 healthy pregnant women with a BMI of ≤ 30 kg/m2 . All women underwent a comprehensive echocardiographic examination and speckle-tracking assessment at term. RESULTS: Obese pregnant women, compared with controls, had significantly higher systolic blood pressure (117 vs 109 mmHg; P = 0.002), cardiac output (6.73 vs 4.90 L/min; P < 0.001), left ventricular (LV) mass index (74 vs 64 g/m2 ; P < 0.001) and relative wall thickness (0.43 vs 0.37; P < 0.001). Diastolic dysfunction was present in five (12.5%) controls and 16 (40%) obese women (P = 0.004). In obese women, compared with controls, LV global longitudinal strain (-15.59 vs -17.61%; P < 0.001), LV endocardial (-17.30 vs -19.84%; P < 0.001) and epicardial (-13.10 vs -15.73%; P < 0.001) global longitudinal strain as well as LV early diastolic strain rate (1.05 vs 1.24 /s; P = 0.006) were all significantly reduced. No differences were observed in the degree of LV twist and torsion between the two groups. CONCLUSIONS: Morbidly obese, but otherwise healthy, pregnant women at term had significant LV hypertrophy with evidence of diastolic dysfunction and impaired deformation indices compared with pregnant women of normal weight. These findings are likely to represent a maladaptive response of the heart to volume overload in obese pregnancy. The impact of theses changes on pregnancy outcome and long-term maternal outcome is unclear. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The value of cardiopulmonary exercise testing and stress echocardiography in the prediction of all-cause mortality in adults with end-stage renal disease.

We aimed to assess the prognostic utility of different parameters routinely assessed from cardiopulmonary exercise testing (CPET) and exercise echocardiography in adults with end-stage renal disease (ESRD). Forty-two ESRD (37 male) individuals (age: 58 ± 13 years, height: 169.30 ± 8.30 cm, weight: 81 ± 15 kg, body surface area: 1.92 ± 0.20 m2) underwent a maximal/symptom limited CPET, with a full cross-sectional echocardiogram performed at baseline and peak exercise. All participants were prospectively followed over a 10-year period, with all-cause mortality as the primary endpoint. After the follow-up period, a total of 19 participants (45%) died. Left atrial size (4.70 ± 0.70 vs. 3.65 ± 0.50 cm, P < 0.001) and anteroseptal wall thickness (1.28 ± 0.40 vs. 1.06 ± 0.02 cm, P = 0.002) were significantly greater in those that died, while peak heart rate was significantly lower (108 ± 12 vs. 128 ± 14 bpm, P < 0.001). The prevalence of myocardial ischaemia (13 vs. 8 participants, P = 0.03) was significantly greater, while peak VO2 (9.80 ± 2.10 vs. 15.90 ± 4.30 ml·kg-1·min-1, P < 0.001) was significantly lower in those that died. Following multivariate cox regression, myocardial ischaemia (Hazard Ratio 3.08; 95% Confidence Interval 1.09-8.70; P = 0.03) and peak VO2 (HR 0.73; 95% CI 0.64-0.84; P < 0.001) were significant independent predictors of 10-year all-cause mortality. This is the first study to establish peak VO2 as powerful marker of all-cause mortality when assessed with clinical, resting and stress echocardiography parameters in people with ESRD over a 10-year follow up period. This observation indicates that, in clinical practice, CPET and exercise echocardiography may serve as valuable tools for the risk stratification of individuals with ESRD.HighlightsWe aimed to assess the prognostic utility of cardiopulmonary exercise testing (CPET) and exercise echocardiography in end-stage renal disease (ESRD) with 10-year mortality.Peak aerobic capacity and the presence of ischaemic heart disease were independently associated with all-cause mortality.This observation indicates that, in clinical practice, CPET and exercise echocardiography may serve as valuable tools for the risk stratification of individuals with end-stage renal disease.

Left Ventricular Function and Cardiac Biomarker Release-The Influence of Exercise Intensity, Duration and Mode: A Systematic Review and Meta-Analysis.

OBJECTIVE: We performed a systematic review, meta-analysis and meta-regression of exercise studies that sought to determine the relationship between cardiac troponin (cTn) and left ventricular (LV) function. The second objective was to determine how study-level and exercise factors influenced the variation in the body of literature. DATA SOURCES: A systematic search of Pubmed Central, Science Direct, SPORTDISCUS and MEDLINE databases. ELIGIBILITY CRITERIA: Original research articles published between 1997 and 2018 involving > 30 mins of continuous exercise, measuring cardiac troponin event rates and either LV ejection fraction (LVEF) or the ratio of the peak early (E) to peak late (A) filling velocity (E/A ratio). DESIGN: Random-effects meta-analyses and meta-regressions with four a priori determined covariates (age, exercise heart rate [HR], duration, mass). REGISTRATION: The systematic search strategy was registered on the PROSPERO database (CRD42018102176). RESULTS: Pooled cTn event rates were evident in 45.6% of participants (95% confidence interval (CI) 33.6-58.2); however, the overall effect was non-significant (P > 0.05). There were significant (P < 0.05) reductions in E/A ratio of - 0.38 (SMD = - 1.2, 95% CI - 1.4 to - 1.0), and LVEF of - 2.02% (SMD = - 0.38, 95% CI - 0.7 to - 0.1) pre- to post-exercise. Increased exercise HR was a significant predictor of troponin release and E/A ratio. Participant age was negatively associated with cTn release. There was a significant negative association between E/A ratio with increased rates of cTn release (P < 0.05). CONCLUSIONS: High levels of statistical heterogeneity and methodological variability exist in the majority of EICF studies. Our findings show that exercise intensity and age are the most powerful determinants of cTn release. Diastolic function is influenced by exercise HR and cTn release, which implies that exercise bouts at high intensities are enough to elicit cTn release and reduce LV diastolic function. Future EICF studies should (1) utilise specific echocardiographic techniques such as myocardial speckle tracking, (2) ensure participants are euhydrated during post-exercise measurements, and (3) repeat measures in the hours following exercise to assess symptom progression or recovery. It is also recommended to further explore the relationship between aging, training history, and exercise intensity on cTn release and functional changes.

Cardiac maladaptation in term pregnancies with preeclampsia.

OBJECTIVES: To study biventricular cardiac changes with conventional echocardiography and new echocardiographic speckle tracking technologies such strain, twist and torsion in pregnant women with preeclampsia at term and normotensive control term pregnant women. STUDY DESIGN: For this prospective single centre case-control study, we consecutively recruited 30 women with preeclampsia at term as cases and 40 healthy control term pregnant women. All women underwent transthoracic echocardiographic examination at the time point of inclusion into the study. MAIN OUTCOME MEASURES: Signs of systolic and/or diastolic cardiac maladaptation to the increased volume load associated with pregnancy. RESULTS: Conventional echocardiography revealed mild left sided diastolic impairment in the form of significantly increased E/E' in preeclampsia (7.58 ±â€¯1.72 vs. 6.18 ±â€¯1.57, p = 0.001) compared to normotensive controls, but no evidence of systolic impairment. With speckle tracking analysis, significant decreases in left ventricular global (-13.32 ±â€¯2.37% vs. -17.61 ±â€¯1.89%, p < 0.001), endocardial (-15.64 ±â€¯2.79% vs. -19.84 ±â€¯2.35%, p < 0.001) and epicardial strain (-11.48 ±â€¯2.15% vs. -15.73 ±â€¯1.66%, p < 0.001) as well as left ventricular longitudinal strain rate (-0.84 ±â€¯0.14 s-1 vs. -0.98 ±â€¯0.12 s-1, p < 0.001) and left ventricular early diastolic strain rate (0.86 ±â€¯0.30 s-1 vs. 1.24 ±â€¯0.26 s-1, p < 0.001) could be observed in women with term preeclampsia. CONCLUSIONS: The findings of this study demonstrate that pregnant women with term preeclampsia with minimal functional changes on conventional echocardiography, demonstrated significant subclinical myocardial changes on speckle tracking analysis.

Congenital failure of automatic control of ventilation, gastrointestinal motility and heart rate.

A new congenital syndrome characterized by the simultaneous failure of control of ventilation (Ondine's curse) and intestinal motility (Hirschsprung's disease) is reported in three infants, all of whom died in the first few months of life; two were siblings. Detailed studies in one also revealed markedly decreased esophageal motility and abnormal control of heart rate. In one infant, minute ventilation was lower in quiet than in REM sleep and lower in both states of sleep than in wakefulness. Although the mean inspiratory flow was decreased in quiet sleep, the hypoventilation resulted primarily from a decrease in respiratory frequency. Intravenous doxapram increased ventilation but did not reverse respiratory failure. Aminophyllin, progesterone, physostigmine and chlorpromazine did not change ventilation significantly; imipramine resulted in a significant decrease. Both long and short-term variability of the heart rate were markedly decreased when compared with the normal infant. Although neuropathologic studies postmorten did not reveal an anatomic defect, we postulate that a developmental abnormality in serotonergic neurons is responsible for this new syndrome.

Language development in 2-year-old normal and risk infants.

A variety of language measures was obtained on two groups of 2-year-old infants matched for social class but differing in terms of birth conditions. One group, a high risk group, contained infants who suffered from RDS, birth asphyxia, hypercalcemia, and hyperglycemia while another group consisted of normal infants. The results of the language tests revealed that the high risk group showed poorer performance than the normal subjects. Other tests of perceptual-cognitive development revealed little difference between the groups. The data suggest that the assessment of early trauma needs to employ a variety of measures, especially those which are related to the unfolding skills appropriate for the particular age group studied. Pediatrics, 59:982-986, 1977, LANGUAGE DEVELOPMENT HIGH RISK, BIRTH ASPHYXIA, RESPIRATORY DISTRESS SYNDROME (RDS).

Natural history of neonatal colonization with group B streptococci.

Thirteen percent of the newborns in our study group were colonized with group B streptococci on day 3. This colonization rate appeared constant during the first two weeks of life and then decreased to 5%. Of the babies colonized on day 3, 59% and 91% were culture-negative on days 14 and 42, respectively. Sixty-five percent of the babies carrying group B streptococci on day 14 acquired this microorganism following discharge (day 3). Babies colonized with staphylococci or Escherichia coli were found to have decreased probability of colonization with group B streptococci.

PaO2 levels and retrolental fibroplasia: a report of the cooperative study.

The relation between PaO2 and retrolental fibroplasia (RLF) was studied prospectively in 719 premature infants born in or treated in the intensive care units of a group of university hospitals. Blood gas studies were performed on 589 of these infants, 66 of whom had a diagnosis of RLF; in 27 of these 66, some grade of mostly nonblinding cicatricial disease developed. The frequency of RLF was highest among infants of lowest birth weight. A multivariate statistical method was used to analyze simultaneously the effect of possible etiologic factors associated with RLF. The occurrence of RLF was found to be unrelated to PaO2, as determined by the limited information available from intermittent sampling. RLF is associated with concentration of oxygen administered in the lightest birth weight group, but the strongest association, aside from birth weight, was with time in oxygen. None of the other variables involving blood chemical values appeared to be associated with RLF. The severity of cicatricial RLF is clearly greater in infants weighing less than 1,200 g at birth. Conservative administration of oxygen may have been responsible for failure to demonstrate quantitative association between PaO2 levels and disease. Agreement between the observed and predicted numbers of infants with RLF demonstrate the strength of the multivariate technique employed in making the statistical analyses.

Hearing and neurodevelopmental outcome in survivors of persistent pulmonary hypertension of the newborn.

Thirty-four infants who had a diagnosis of severe persistent pulmonary hypertension of the newborn at birth (alveolar-arterial oxygen difference greater than 600) were treated without paralysis or hyperventilation to induce alkalosis. All survived. Twenty-seven of these 34 eligible infants (79%) underwent neurologic, intelligence, and audiologic testing between 10 months and 6 years of age. Children who were younger than 1 year of age at the initial hearing test were retested after they reached 2 years of age. The average IQ was within the normal range (mean = 96.23). None had sensorineural hearing loss. Severe neurologic abnormalities were seen in 4 children, 3 of whom had been severely asphyxiated at birth (determined by biochemical criteria). Mild neurologic abnormalities were observed in 5 children. Two infants had bronchopulmonary dysplasia because they required supplemental oxygen for 29 and 66 days, respectively, and had abnormal chest roentgenograms; 1 patient takes intermittent doses of albuterol (Ventolin) and neither currently requires supplemental oxygen. This study of 27 infants with severe persistent pulmonary hypertension of the newborn suggests that conservative management without induced alkalosis or respiratory paralysis is accompanied by no sensorineural hearing loss and a good neurologic outcome.

Mortality and morbidity in infants less than 1,001 grams birth weight.

A prospective study of 54 infants with birth weights of 1,000 gm or less was conducted over a period of two years. Of the 26 infants who survived, 24 weighed between 750 and 1,000 gm; two infants died after discharge and one was lost to follow-up, leaving 23 in whom serial observations were made over 18 months to 3 years of age. The incidence of neurologic deficit in these infants was 17% and of intellectual deficit, 13%. Of the four who were abnormal neurologically, two had spastic quadriparesis, one static encephalopathy, and one hydrocephalus secondary to intraventricular hemorrhage. The three with intellectual deficit had a developmental quotient less than 85. Of the perinatal factors examined, only birth asphyxia correlated significantly with both neonatal mortality and subsequent morbidity. Six (26%) of the surviving infants had mild, nonblinding retrolental fibroplasia; only one of them had a significant refractive error that required corrective lenses for vision. Sepsis was a significant contributor to neonatal mortality in ten of 28 infants who died, but was detected in only one survivor. Although the prognosis for the infant weighing 1,000 gm or less at delivery has improved significantly, there is promise for still further improvement by reducing perinatal asphyxia.

Effect of bacterial flora on staphylococcal colonisation of the newborn.

The umbilical and nasopharyngeal flora of newborn infants was examined on days 3, 14, and 42 of life. An analysis of the bacteriological findings suggests that colonisation by either Staphylococcus aureus or Staph. epidermidis prevents colonisation by the other staphylococcus. Similarly, colonisation by Gram-negative bacteria prevents colonisation by staphylococci. Further, this bacterial interference lasts for as long as 42 days, which suggests the possibility of artificially colonising newborns with nonpathogens to prevent subsequent colonisation and disease by virulent microorganisms.

Exploring attitudes of white dental students regarding willingness to treat people with HIV.

This descriptive field study examines the willingness of ninety white dental students to provide care to people with Human Immunodeficiency Virus disease (HIV disease). This study suggests that perceived clinical ability, attitudes toward gay men, and white racial attitudes account for white dental students' willingness to provide dental care to patients with HIV disease. Likewise, this study suggests that white dental students' perception of risk of occupational infection with HIV is uniquely predicted by the same variables. A hierarchical regression found that in white dental students, racial attitudes were significant predictors of willingness to treat persons with HIV disease beyond the significant contributions of perceived clinical competence and attitudes toward gay men. In terms of perceptions of occupational risk, results of the hierarchical regression were that both perceived clinical competence and attitudes toward gay men were significant predictors. Thus, the results of this study show that attitudes regarding cultural diversity can influence clinical intentions.

Perception of an aggressive interaction as a function of the perceiver's aggression.

This research examined whether persons high or low in naturally occurring aggression differ in attributions made to others engaged in an aggressive interaction. All participants were shown a videotaped aggressive exchange after which they completed a standard person-perception questionnaire and a self-report used to separate them into groups of persons high and low in aggression. The salience of the more aggressive stimulus person was manipulated as a means of relating results to existing findings and theory in person perception. Five of the seven dependent measures show effects of level of aggression consistent with prediction of more negative perceptions by persons high in aggression than by persons low in aggression. Level of aggression often interacts with salience and stimulus person, and some of these complex interactions are not easily interpretable. However, persons high in aggression than by persons low in aggression. Level of aggression often interacts with salience and stimulus person, and some of these complex interactions are not easily interpretable. However, persons high in aggression perceive greater injury, negative reactions, and domineering in such situations and make greater causal distinction among stimulus persons.