Percutaneous transcatheter pulmonary valve replacement in children weighing less than 20 kg.

BACKGROUND: Since FDA approval of the Melody valve, transcatheter pulmonary valve replacement (TPVR) has been offered to an expanding population. Limited data exist regarding the safety and feasibility of TPVR in smaller patients. METHODS: All patients weighing <20 kg who underwent catheterization for percutaneous TPVR at four centers were reviewed. RESULTS: Of the 51 patients reviewed, 43 (84%) had successful valve implantation and 8 (16%) were found not to be candidates due to access veins too small (n = 3), coronary artery/aortic root compression (n = 3), and RVOT too large (n = 2). The 43 patients who underwent successful percutaneous TPVR had a median age and weight of 5.8 years (3.3-10) and 17.7 kg (13.5-19.8), and most had tetralogy of Fallot (TOF). TPVR was performed via femoral vein (FV) access in 24 patients and internal jugular vein (IJV) access in 19 patients. Median weight in patients with IJV implant was 1.1 kg lower than those who underwent transfemoral implant (17.0 vs. 18.1 kg, P = 0.05). There were four adverse events: one iliac vein injury, one contained MPA tear, and two patients with post-procedure femoral vein bleeding. All patients were alive at recent follow-up, a median of 2.0 years (0.1-6.0) after TPVR. There was excellent valve function with mean Doppler gradients of 3-20 mm Hg, and trivial or mild pulmonary regurgitation in all but one patient. There were no RVOT reinterventions and no cases of endocarditis. CONCLUSIONS: Percutaneous TPVR can be safely performed in patients <20 kg. The procedure frequently requires IJV access, and access site/bleeding complications may be more common in this cohort.

Incorporating wellness into employee benefit strategies--why it makes sense.

By putting together a comprehensive wellness strategy, employers are not only "doing the right thing" but also are able to see, believe and maintain the tangible return on investment (ROI) that wellness programs are capable of delivering. This article discusses employers' ROI from wellness initiatives, as well as innovations that support a culture of wellness and what enhanced opportunities for increasing employee wellness are available under health care reform. It also describes how wellness is a component of population health management, as well as a core component of the health care delivery system.

The Development of a Video-based Nutrition Education Curriculum for Patients Undergoing Radical Cystectomy.

BACKGROUND: The treatment for patients with muscle-invasive bladder cancer includes neoadjuvant chemotherapy followed by radical cystectomy. The American Urological Association guidelines stress the optimization of patient performance status in the perioperative setting. Therefore, implementation of nutrition education is critical for the multi-disciplinary care of this vulnerable patient population and wide distribution of information is critical. OBJECTIVE: The goal of our study was to create a nutrition-based video education series for patients undergoing chemotherapy and radical cystectomy for bladder cancer. METHODS: Scripts for the videos were developed through an iterative process by experts in nutrition, urology, and communication. Providers and patient advocates were recruited to perform semi-structured interviews and surveys for additional feedback. Performer facial emotion recognition (Noldus™) was used to assess displayed emotion by the presenters. Mangold VisionPlayer software was used for participant eye movement tracking of the video content. A knowledge survey was created, and Item Content Validity Index (I-CVI) was calculated with a nutrition expert advisory board. Participants were recruited for cognitive interviewing to understand the mental processes and interpretations while answering questions. RESULTS: The video series is available to the public on the Bladder Cancer Advocate Network (BCAN) website at the following URL: https://bcan.org/facing-bladder-cancer/nutrition-bladder-cancer/eating-healthy-bladder-cancer/. Cinematic filming methods, (smaller depth of field, lighting, and camera movement) enhanced message delivery along with music and text on screen to anchor important concepts. CONCLUSIONS: This study can be a framework for the development of a patient education video library accessible through electronic medical records, health care applications, and patient advocacy websites.

Echocardiographic Assessment of Melody Versus Sapien Valves Following Transcatheter Pulmonary Valve Replacement.

OBJECTIVES: The aim of this study was to compare the immediate and midterm echocardiographic performance of the Melody (Medtronic Inc) and Sapien (Edwards Lifesciences Inc) valves after transcatheter pulmonary valve replacement (TPVR) in native and conduit right ventricular outflow tracts (RVOTs). BACKGROUND: TPVR is now a common procedure, but limited data exist comparing postimplantation echocardiographic findings between Melody and Sapien valves. METHODS: This was a single-institution retrospective cohort study of all patients who underwent successful TPVR from 2011 to 2020. Patient demographics, procedural details, and immediate and midterm echocardiographic findings were collected and compared between valve types using the Wilcoxon rank sum, chi-square, or Fisher exact test as appropriate. Subgroups were analyzed individually and were adjusted for multiple comparisons using the Bonferroni method. RESULTS: A total of 328 patients underwent successful TPVR (Melody: n = 202, Sapien: n = 126). The groups had a similar baseline age, weight, and diagnosis. The most common indications for TPVR were pulmonary stenosis (32.2%) or mixed disease (46%) in the Melody group and pulmonary insufficiency in the Sapien group (52.4%) (P < 0.001). Sapien valves were more often placed in native RVOTs (43.7% vs 18.8%; P < 0.001). The discharge and follow-up mean and peak Doppler gradients were similar between the Melody and Sapien groups. Valves implanted in native RVOTs had significantly lower postimplantation gradients at each follow-up period. CONCLUSIONS: Echocardiographic performance after TPVR was generally acceptable and similar when comparing Melody and Sapien valves despite differences in the indication and anatomy in each group. The peak and mean gradients were lower in transcatheter valves implanted in native RVOTs compared with those implanted in conduits or bioprosthetic valves.

Mid- to late gestational morphine exposure does not alter the rewarding properties of morphine in adult male rats.

Prenatal exposure to drugs of abuse often leads to physiological and neurobiological abnormalities including decreased brain and body weight, cognitive deficits and behavioral alterations. A handful of studies showed increased vulnerability to drug abuse in prenatally drug-exposed offspring. Our work also demonstrated that prenatal exposure to analgesic doses of morphine during gestation days 11-18 increases mu-opioid receptor density in the nucleus accumbens and central amygdala of adult male rats. Both the nucleus accumbens and central amygdala play important roles in modulating drug-induced reward via the mesolimbic dopaminergic system. Therefore, two types of behavioral paradigms were used to test the hypothesis that the same prenatal morphine exposure would enhance the rewarding effects of morphine, making drug-exposed offspring more vulnerable to abuse this drug in adulthood. All experiments were performed with adult male offspring of saline-injected, morphine-injected or non-injected (control) dams. (1) The unbiased conditioned place preference (CPP) paradigm was used to investigate whether prenatal morphine exposure sensitizes adult male rats to non-contingent morphine reward. These adult animals were conditioned with 0.1, 0.3, 1, 3 or 5 mg/kg morphine. All control, prenatally saline- and morphine-exposed male rats preferred the morphine-paired compartment relative to the saline-paired compartment. However, the magnitude of morphine CPP in adult male rats was not dependent on the conditioning dose of morphine or prenatal morphine exposure. (2) Intravenous morphine self-administration was used to assess the behavioral response to contingent morphine reward. Each rat self-administered one of four doses of morphine (0.3, 1, 2 or 3 mg/kg/infusion). Morphine self-administration was not altered in prenatally morphine-exposed adult male offspring. Control males self-administered significantly less morphine at the lowest dose of morphine than both prenatally saline- and morphine-exposed males. Although our data show that prenatal exposure to an analgesic dose of morphine during the time of opioid receptor appearance does not enhance morphine CPP or self-administration, they do not exclude the possibility that this prenatal morphine exposure enhances the rewarding properties of other drugs of abuse.

What's in it for the companion animal? Pet attachment and college students' behaviors toward pets.

Research on the human-nonhuman animal bond has focused primarily on its advantages to the human. The purpose of this study is to investigate behaviors of caregivers (owners) of companion animals (pets) and to examine the relationship between such behaviors and scores on a pet attachment scale. Participants were 501 largely nontraditional (older, married, employed full-time) college students living with a pet dog or cat. The study categorized owner behaviors as essential, standard, enriched, or luxury care. Almost all participants reported engaging in essential care behaviors, with numbers declining from category to category. Pet attachment scores appeared related to standard and enriched care behaviors but not to essential care. Too few participants reported doing luxury care behaviors to link them to attachment. The results suggest that even pet owners reporting low attachment provide beneficial care and attention to their pets and that pet attachment may be of limited use when looking at the benefit of the human-animal bond to the companion animal.

Autoradiographic evidence that prenatal morphine exposure sex-dependently alters mu-opioid receptor densities in brain regions that are involved in the control of drug abuse and other motivated behaviors.

The present study examined the effects of prenatal morphine exposure on mu-opioid receptor density in young adult male and female rats to assess the long-term alterations in several brain areas including the nucleus accumbens (NAc), bed nucleus of stria terminalis (BNST), and the basolateral (BLA), lateral (LA), central (CeA), and posteromedial cortical (PMCoA) amygdaloid nuclei. These brain areas are involved in motivating and rewarding behaviors of opiates and other drugs of abuse. The reinforcing actions of opiates appear to be mu-opioid receptor dependent. The results demonstrate that in male rats, prenatal morphine exposure significantly increases the density of mu-opioid receptors in the NAc and PMCoA. In contrast, the same prenatal morphine exposure reduces the density of mu-opioid receptors in the BLA, while increasing it in the CeA and without effects in the LA or BNST. In female rats, prenatal morphine exposure has no effects on the density of mu-opioid receptors in the above six brain areas, but the density of these receptors is dependent on the presence or absence of ovarian hormones. Thus, the present study demonstrates that mid- to late gestational morphine exposure induces long-term, sex-specific alterations in the density of mu-opioid receptors in the NAc and amygdala. Moreover, this prenatal morphine exposure also eliminates sex differences in the density of mu-opioid receptors in the NAc, CeA, and PMCoA but not in the BLA, LA, and BNST.

Mu-opioid receptors in seizure-controlling brain structures are altered by prenatal morphine exposure and by male and female gonadal steroids in adult rats.

The present study used autoradiography to examine the effect of prenatal morphine exposure on mu-opioid receptor density in epileptic seizure-controlling brain structures including the substantia nigra pars compacta (SNC), substantia nigra pars reticulata (SNR), superior colliculus (SC), and subthalamic nucleus (STN) of adult male and female rats. The results demonstrate that prenatal morphine exposure increases the mu-opioid receptor density in the SNC and STN, but not in the SNR or in the SC of gonadally intact adult male rats. The density of mu-opioid receptors in the SNC and STN is, however, decreased following gonadectomy in morphine-exposed males, and testosterone treatment fails to restore this decrease to the level of gonadally intact males. Further, in the SC, the density of mu receptors was lower in both saline-exposed, gonadectomized (GNX) and GNX, TP-treated males and in morphine-exposed, GNX, TP-treated males relative to gonadally intact saline- and morphine-exposed males, respectively. In ovariectomized (OVX) female rats, the same prenatal morphine exposure increases the mu-opioid receptor density in the SNC and SNR, but decreases it in the STN. The density of mu-opioid receptors is also decreased in the SNC and SC of OVX estrogen-treated females and in the SNR and SC of OVX, progesterone-treated females. Thus, the present study demonstrates that mu-opioid receptors in seizure-controlling brain structures are sex-specifically altered by prenatal morphine exposure in adult progeny. Further, prenatal morphine exposure alters gonadal hormone effects on the density of mu receptors in adult, OVX females.

The relationship between adult health and childhood maltreatment, as moderated by anger and ethnic background.

Childhood maltreatment, anger, and racial/ethnic background were examined in relation to physical health, psychological well-being, and blood pressure outcomes. This study used data from a diverse sample of African American, Latino, and Caucasian participants (N=198). Results from a series of multiple regressions indicated anger and total childhood maltreatment were robust predictors of poorer health. Although correlational analyses found maltreatment from the mother and father were associated with poorer health outcomes, when considered as part of the regression models, only a relationship between maltreatment from the mother and physical health was found. Greater anger scores were linked with lower blood pressure, particularly systolic blood pressure. Generally, more psychological and physical symptom reporting was found with greater anger scores, and higher levels of total maltreatment also predicted physical symptoms. The pattern of interactions indicated anger was more detrimental for African American participant's (and marginally so for Latino participant's) physical health. Interestingly, interactions also indicated total childhood maltreatment was related to fewer symptoms for Latino participants. Although child maltreatment may be viewed as a moral and/or human rights issue, this study provides evidence that it can also be viewed as a public health issue. Our study demonstrated that known health risk factors such as anger and maltreatment may operate in a different pattern dependent on ethnic/cultural background. The findings suggest health and health disparities research would benefit from greater exploration of the differential impact of certain moderating variables based on racial/ethnic background.

Changing mechanisms of opiate tolerance and withdrawal during early development: animal models of the human experience.

Human infants may be exposed to opiates through placental transfer from an opiate-using mother or through the direct administration of such drugs to relieve pain (e.g., due to illness or neonatal surgery). Infants of many species show physical dependence and tolerance to opiates. The magnitude of tolerance and the nature of withdrawal differ from those of the adult. Moreover, the mechanisms that contribute to the chronic effects of opiates are not well understood in the infant but include biological processes that are both common to and distinct from those of the adult. We review the animal research literature on the effects of chronic and acute opiate exposure in infants and identify mechanisms of withdrawal and tolerance that are similar to and different from those understood in adults. These mechanisms include opioid pharmacology, underlying neural substrates, and the involvement of other neurotransmitter systems. It appears that brain circuitry and opioid receptor types are similar but that NMDA receptor function is immature in the infant. Intracellular signaling cascades may differ but data are complicated by differences between the effects of chronic versus acute morphine treatment. Given the limited treatment options for the dependent infant patient, further study of the biological functions that are altered by chronic opiate treatment is necessary to guide evidenced-based treatment modalities.

Food expenditures and food purchasing among low-income, urban, African-American youth.

BACKGROUND: Low-income, urban African-American youth are at higher risk for obesity and less likely to meet dietary recommendations than white, higher-income youth. Patterns of food purchasing among youth likely contribute to these disparities, but little published information is available. PURPOSE: To investigate food purchasing behaviors of low-income, urban African-American youth. METHODS: A total of 242 African-American youth, aged 10-14 years, were recruited from 14 recreation centers in low-income, predominantly African-American neighborhoods in Baltimore MD. Youth reported the amount of money typically spent on food, the source of this money, the place of purchase, and frequency of purchase for 29 foods and beverages. Data were collected in 2008-2009 and analyzed in 2009-2010. RESULTS: Youth reported spending an average of $3.96 on foods and beverages in a typical day. Corner stores were the most frequently visited food source (youth made purchases at these stores an average of 2.0 times per week). Chips, candy, and soda were the most commonly purchased items, with youth purchasing these an average of 2.5, 1.8, and 1.4 times per week, respectively. Older age was associated with more money spent on food in a typical day (p<0.01). CONCLUSIONS: Food purchasing among low-income, urban African-American youth is frequent and substantial. Interventions aimed at preventing and treating obesity in this population should focus on increasing access to healthy foods in their neighborhoods, especially in corner stores.