Clinical significance of inferolateral early repolarisation and late potentials in children with Brugada Syndrome.

INTRODUCTION: The clinical utility of inferolateral early repolarisation (ER) and late potentials (LP) in children with Brugada Syndrome (BrS) has not been previously evaluated. The aim of this study was to determine the prevalence of electrocardiographic (ECG) abnormalities in children with BrS, and to investigate their relationship with clinical outcomes. METHODS: 43 patients with BrS and 47 controls aged ≤18 undergoing systematic clinical and ECG evaluation, including signal-averaged ECG (SAECG) and pharmacological provocation testing, between 2003 and 2019 were included. RESULTS: Four patients with BrS (9%) presented with a spontaneous type 1 Brugada pattern; the remaining 39 (91%) were diagnosed following ajmaline provocation testing. Twelve BrS patients (28%) had late potentials (LP) on SAECG compared to 1 (2%) in controls (p = 0.001). LP were more common in 5 patients with a high-risk phenotype (60% vs 24%) but this was not statistically significant. Twelve patients with BrS (28%) had inferolateral early repolarisation (ER) and 2 (5%) had fractionated QRS (f-QRS), but there were no statistically-significant differences with controls in these parameters. A significant arrhythmia (non-sustained ventricular tachycardia or atrial fibrillation) was seen in 4 patients (9%). CONCLUSIONS: This study shows a high prevalence of SAECG abnormalities in children with BrS compared with controls, but this was not significantly associated with a high-risk phenotype.

Cardiac Manifestations of Myotonic Dystrophy in a Pediatric Cohort.

Myotonic dystrophy type 1 (DM1) is the most prevalent inherited neuromuscular dystrophy in adults. It is a multisystem disease with cardiac manifestations. Whilst these are well-defined in adults, there are scarce published data in the pediatric population. This study aimed to investigate the yield and progression of cardiac disease in pediatric DM1 patients, focusing on congenital DM1 (cDM1). Methods: A retrospective observational study of all pediatric DM1 patients referred to our center (December 2000-November 2020) was conducted. Patients were classified into DM1 forms according to age of symptom onset and disease severity. Patients underwent clinical and cardiac evaluation with 12-lead ECG, transthoracic echocardiography and 24-h ECG Holter monitoring. Results: 67 DM1 pediatric patients were included: 56 (83.6%) cDM1 and 11 (16.4%) non-cDM1. Median follow-up time of cDM1 patients was 8.0 [3.25-11.0] years. 49 (87.5%) cDM1 patients had baseline 12-lead ECG and 44 (78.6%) had a follow-up 12-lead-ECG, with a median follow-up time from diagnosis to baseline ECG of 2.8 [1.0-8.5] years and to follow-up ECG of 10.9 [5.7-14.2] years. Overall, 43 (87.8%) presented ECG abnormalities, most commonly in the form of asymptomatic conduction disease (n = 23, 46.9%), of which 21 (42.9%) had first degree atrioventricular block (1st AVB). There was an increase of prevalence from baseline to follow-up ECG in low QRS voltage (16.7%), poor R wave progression (13.9%), abnormal repolarisation (11.9%) and 1st AVB (7.6%). one patient (1.8%) underwent pacemaker implantation for syncope in the context of progressive conduction disease. No patients developed left ventricular systolic dysfunction. 4 (7.1%) cDM1 patients died during follow up, including three who died suddenly with no clear cause of death. Conclusions: This study is the first to analyse the prevalence and progression of ECG abnormalities in cDM1 pediatric patients. The high prevalence of abnormal findings, progressive changes and number of potentially associated events (1 pacemaker implantation and 3 unexplained sudden deaths) stresses the importance of systematic and continued cardiac evaluation of these patients.

The role of the electrocardiographic phenotype in risk stratification for sudden cardiac death in childhood hypertrophic cardiomyopathy.

AIMS: The 12-lead electrocardiogram (ECG) is routinely performed in children with hypertrophic cardiomyopathy (HCM). An ECG risk score has been suggested as a useful tool for risk stratification, but this has not been independently validated. This aim of this study was to describe the ECG phenotype of childhood HCM in a large, international, multi-centre cohort and investigate its role in risk prediction for arrhythmic events. METHODS AND RESULTS: Data from 356 childhood HCM patients with a mean age of 10.1 years (±4.5) were collected from a retrospective, multi-centre international cohort. Three hundred and forty-seven (97.5%) patients had ECG abnormalities at baseline, most commonly repolarization abnormalities (n = 277, 77.8%); left ventricular hypertrophy (n = 240, 67.7%); abnormal QRS axis (n = 126, 35.4%); or QT prolongation (n = 131, 36.8%). Over a median follow-up of 3.9 years (interquartile range 2.0-7.7), 25 (7%) had an arrhythmic event, with an overall annual event rate of 1.38 (95% CI 0.93-2.04). No ECG variables were associated with 5-year arrhythmic event on univariable or multivariable analysis. The ECG risk score threshold of >5 had modest discriminatory ability [C-index 0.60 (95% CI 0.484-0.715)], with corresponding negative and positive predictive values of 96.7% and 6.7. CONCLUSION: In a large, international, multi-centre cohort of childhood HCM, ECG abnormalities were common and varied. No ECG characteristic, either in isolation or combined in the previously described ECG risk score, was associated with 5-year sudden cardiac death risk. This suggests that the role of baseline ECG phenotype in improving risk stratification in childhood HCM is limited.

Fatty Acid Content of Retail Cow's Milk in the Northeastern United States-What's in It for the Consumer?

The fatty acid (FA) composition and content of whole milk (3.25% fat) from organic, omega-3 (n-3) FA fortified, and conventional retail brands available in the northeastern U.S. were assessed monthly via gas chromatography. Among the retail labels, organic milk stood out as it contained a distinct and more healthful FA profile, consistently comprising a higher content of unique bioactive FAs (short-chain FAs, odd- and branched-chain FAs, vaccenic acid, and conjugated linoleic acids) per serving, particularly during the warm season. The total content of saturated FAs did not differ by retail label. While organic and n-3 fortified milk contained a similar content of total n-3 FAs, the proportion of individual n-3 FAs differed significantly (organic milk: 18:3 n-3; n-3 fortified milk: 20:6 n-3) as a result of the production system and process, respectively. Overall, per serving, the FA profile of organic milk may provide added nutritional and health benefits.

Changes in tissue-Doppler echocardiographic assessment of left ventricular filling during NT-proBNP guided heart failure treatment titration: a pilot study.

BACKGROUND: Although brain natriuretic peptide (BNP) and E/Ea are closely related in heart failure (HF) patients and may be helpful to guide HF therapy, the response of E/Ea to changes in BNP over several weeks of intensive HF treatment optimisation is unknown. This study was designed to investigate this relationship. METHODS AND RESULTS: In 17 patients with decompensated HF, treatment was titrated to reduce the NT-proBNP level to <200pg/mL over 10 weeks. Paired NT-proBNP measurements and echocardiograms were performed at two weekly intervals during the study. Treatment titration was associated with a reduction in E/Ea (17.6+/-6.8S.D. to 13.7+/-5.0S.D., p=0.018) in keeping with the reduction in NT-proBNP (median 603 [S.E. 561] to 311 [S.E. 235], p=0.045). This relationship remained in those who responded to titration (reduction in NT-proBNP of >or=50%), and those who did not. The overall change in E/Ea was similar to the changes observed in NT-proBNP in each group however there appeared to be temporal differences in the changes in E/Ea and NT-proBNP. CONCLUSION: This pilot study demonstrates that the E/Ea decreases after NT-proBNP guided HF therapy. E/Ea may be a complementary target for HF therapy optimisation; this hypothesis should be further evaluated in larger scale randomised trials.

Caring for bereaved people 2: nursing management.

This two-part unit examines caring for bereaved people. Part 1 discussed the manifestations of grief and explored bereavement models. Part 2 examines nurses' role in helping bereaved relatives.

Caring for bereaved people 1: models of bereavement.

This is part 1 of a two-part unit on caring for bereaved relatives. It discusses manifestations of grief and explores three theoretical perspectives.

The effect of type 2 diabetes on diastolic function.

PURPOSE: This study aimed to determine whether sedentary overweight subjects with type 2 diabetes have impaired diastolic function compared with equally sedentary and overweight nondiabetic subjects. METHODS: Mitral valve pulsed Doppler echocardiography and tissue Doppler imaging (TDI) were used to assess left ventricular structure and diastolic function in 40- to 60-yr-old sedentary overweight subjects with type 2 diabetes (N = 13) and age- and body mass-matched sedentary nondiabetic subjects (N = 15). Pseudonormal filling was identified using preload reduction and TDI. RESULTS: Traditional Doppler mitral inflow parameters were not different between groups; however, early diastolic relaxation, as measured by peak early mitral annular velocity (E') and the ratio of E' and peak late mitral annular velocity (E'/A'), was reduced in type 2 diabetic subjects (P < 0.05). The ratio of peak early mitral inflow (E) to E' (E/E'), an estimate of left ventricular filling pressure, was also higher in the type 2 diabetes group (P < 0.05). The proportions of diastolic impairment (69 vs 40%) and pseudonormal filling (39 vs 20%) were not different between groups (P = 0.18). CONCLUSION: These findings suggest that type 2 diabetes has an effect on diastolic function that is independent of age and body composition.

Effects of carvedilol on left ventricular remodeling after acute myocardial infarction: the CAPRICORN Echo Substudy.

BACKGROUND: The CAPRICORN trial has shown that carvedilol improved outcome in patients with left ventricular dysfunction after acute myocardial infarction treated with ACE inhibitors. The aim of this substudy was to determine the effects of carvedilol on left ventricular remodeling in this patient group. METHODS AND RESULTS: Patients entering the CAPRICORN trial from 13 centers in New Zealand, Australia, and Spain were recruited for this echocardiographic substudy. In 127 patients, quantitative 2D echocardiography was performed according to a standard protocol before randomization and repeated after 1, 3, and 6 months of treatment with carvedilol or placebo. Left ventricular volumes, ejection fraction (Simpson's method), and wall motion score index were determined in a blinded analysis at the Core Echo Laboratory. At 6 months, left ventricular end systolic volume was 9.2 mL less in the carvedilol group than in the placebo group (P=0.023), and left ventricular ejection fraction was 3.9% higher (P=0.015). Left ventricular end diastolic volume and wall motion score index were not statistically different between the 2 groups at 6 months. CONCLUSIONS: In patients with left ventricular dysfunction after acute myocardial infarction treated with ACE inhibitors, carvedilol had a beneficial effect on ventricular remodeling, which may, in part, mediate the substantial clinical beneficial effects of carvedilol in this patient population.

Pseudonormal mitral filling pattern predicts hospital re-admission in patients with congestive heart failure.

OBJECTIVES: We sought to investigate whether pseudonormal (PN) filling was associated with death or hospital admission in patients with congestive heart failure (CHF). BACKGROUND: The high mortality rate associated with CHF is related to many clinical and echocardiographic variables. In particular, a short mitral deceleration time and restrictive diastolic filling predict death and/or hospital admission. We hypothesized that differentiating patients with nonrestrictive filling might identify an intermediate PN group that may be associated with intermediate risk. METHODS: A total of 115 patients admitted to the hospital for exacerbation of CHF symptoms underwent pre-discharge Doppler echocardiography to determine mitral inflow (before and after preload reduction) and pulmonary venous return. Patients were followed up for one year, and all-cause mortality and re-admission data were analyzed. RESULTS: The classification of filling patterns was: abnormal relaxation (AR) in 46 (40%) patients, pseudonormal (PN) filling in 42 (36.5%) patients and restrictive filling pattern (RFP) in 27 (23.4%) patients. When comparing the RFP group with the AR group, all-cause mortality was higher (38.4% vs. 17.4%, p = 0.033), hospital admission was higher (70.3% vs. 54.3%, p = 0.073), death/hospital admission was higher (77.8% vs. 56.5%, p = 0.02), CHF hospital admission was higher (40.7% vs. 15.2%, p = 0.01) and death/CHF hospital admission was higher (62.9% vs. 26.1%, p = 0.0005). Mortality in the PN group was not significantly different from that in the two other groups, but re-admissions were higher than the AR group (76.2% vs. 54.3%, p = 0.006), as was death/re-admission (78.6% vs. 56.5%, p = 0.004) and death/CHF re-admission (47.6% vs. 26.1%, p = 0.03). Re-admissions in the PN and RFP groups were comparable. CONCLUSIONS: In a general hospital population of older patients with CHF, PN filling was associated with hospital admission rates similar to those seen with restrictive filling. The combined end point of death/CHF hospital admission was similar for restrictive filling and AR. Measurement of these variables is easy to add to routine clinical echocardiography and may provide important prognostic information in a wide range of patients with CHF.

Association of fat-free mass and training status with left ventricular size and mass in endurance-trained athletes.

OBJECTIVES: We sought to study the relationship between left ventricular (LV) size and body composition in male endurance athletes and age-matched control subjects. BACKGROUND: Endurance training is associated with increases in both left ventricular mass (LVM) and left ventricular end-diastolic dimension (LVEDD) in athletes. In other populations, LVM is independently predicted by fat-free mass (FFM). We hypothesized that the increase in LV size and mass observed with training may be a normal response to increased FFM. METHODS: Twelve young and 18 older male endurance athletes and 10 young and 18 older untrained men underwent exercise testing, echocardiography, and dual-photon x-ray absorptiometry body composition analysis. Univariate correlates (Spearman) and multivariate determinants of LVM and LVEDD were sought from: height, height(1.4), height(2.7), height(3.0), body surface area (BSA), FFM, weight, and body mass index. Un-indexed and indexed LVM and LVEDD were then compared. RESULTS: Athletes were of a similar age, weight, and height, but had higher FFM and maximum oxygen uptake than untrained men. Both LVM and LVEDD were correlated with body size, including FFM, BSA, weight, and height (all p < 0.05). On multivariate analysis, FFM was the only independent predictor of both LVM (R(2) = 0.36, p < 0.001) and LVEDD (R(2) = 0.35, p < 0.001). Furthermore, LVM and LVEDD (un-indexed and indexed to BSA and height) were different between athletes and non-athletes, but not when indexed to height(2.7) or FFM. CONCLUSIONS: Both LVM and LVEDD are predicted by FFM in endurance athletes, and when indexed to FFM, no training-related differences were observed. Thus, the extent of LV remodeling (athletic heart) in trained individuals may reflect a normal physiologic response to increased FFM induced by training.

Plasma amino-terminal pro-brain natriuretic peptide and accuracy of heart-failure diagnosis in primary care: a randomized, controlled trial.

OBJECTIVES: The purpose of this study was to determine the effect of amino-terminal pro-brain natriuretic peptide (N-BNP) on the diagnostic accuracy of heart failure (HF) in primary care. BACKGROUND: The accurate diagnosis of patients with suspected HF presenting in primary care is difficult. Amino-terminal pro-brain natriuretic peptide is present in high levels in cardiac dysfunction and may improve the diagnostic accuracy of HF in primary care. METHODS: The Natriuretic Peptides in the Community Study was a prospective, randomized controlled trial of the effect of N-BNP on the accuracy of HF diagnosis. Patients presenting to their general practitioner (GP) with symptoms of dyspnea and/or peripheral edema were included. The GPs formulated an initial diagnosis based on clinical assessment. All patients underwent a full cardiologic assessment that included echocardiography and N-BNP. Each patient was randomized to the BNP group (GP received the N-BNP result) or the control group (GP did not receive the N-BNP result). Patients were then reviewed by their GP, and their diagnosis was reviewed. The primary end point was the accuracy of the GPs' diagnoses compared with the panel standard. RESULTS: A total of 305 patients were included; mean age was 72 years, 65% were female. Seventy-seven patients met the panel criteria for HF. The diagnostic accuracy improved 21% in the BNP group and 8% in the control group (p = 0.002). The main impact of N-BNP measurement on diagnostic accuracy was the GPs' correctly ruling out HF. The number needed to diagnose by N-BNP measurement was seven patients. CONCLUSION: This study demonstrates that N-BNP measurement significantly improves the diagnostic accuracy of HF by GPs over and above customary clinical review.

Role of echocardiography in the contemporary management of chronic heart failure.

Echocardiography is an excellent noninvasive tool for the assessment of ventricular size and both systolic and diastolic function, and it is routinely used in patients with heart failure. This review will discuss the role of echocardiography in heart failure diagnosis, prognostic assessment and in the management of heart failure patients.

Effect of tissue harmonic imaging and contrast upon between observer and test-retest reproducibility of left ventricular ejection fraction measurement in patients with heart failure.

AIMS: To investigate the effects of tissue harmonic imaging (THI) and contrast chamber opacification (LVO) upon measurement variability and reproducibility of echocardiographic left ventricular (LV) volume and ejection fraction (EF) measurements in patients with heart failure (HF). BACKGROUND: Echocardiography is often used in HF patients to determine LV volumes and EF. However, current echo methods are variable and may not be applicable for repeat testing in individual patients. THI and LVO have both been shown to improve endocardial visualisation, but it remains to be determined whether this results in better measurement reproducibility. METHODS: Thirty-one HF patients and 30 control subjects underwent echocardiography on two separate days. LV volumes were measured under four different imaging conditions: fundamental, THI, LVO and LVO with ECG-triggered Power Doppler. Chamber opacification, pulmonary transit time (PTT), endocardial enhancement, reproducibility and bias were assessed. RESULTS: Chamber opacification was inferior and the PTT longer in the HF patients. PTT was related to LV volumes, EF, jugular venous pressure and mitral filling pattern. THI improved endocardial visualisation, and although LVO improved endocardial visualisation in the controls, it offered no benefit over THI in the HF patients. LV volumes and EF were different for each method and THI was the least variable method for repeat measurements. CONCLUSIONS: THI improved endocardial visualisation and was the least variable of the techniques. LVO offered no further advantage in patients with HF and thus cannot be routinely advocated and since LV volumes and EF were different for each, these methods are neither comparable nor interchangeable for follow-up assessments.

Left ventricular diastolic filling and systolic function of young and older trained and untrained men.

Aging is associated with impaired early diastolic filling; however, the effect of endurance training on resting diastolic function in older subjects is unclear. Heart rate and ventricular loading conditions affect mitral inflow velocities measured by Doppler echocardiography; therefore, tissue Doppler imaging of mitral annular velocity, which is relatively preload independent, was combined with mitral inflow velocity and maximal oxygen consumption (V(o2 max)) in young (20-35 yr) and older (60-80 yr) trained and untrained men to determine whether endurance training is associated with an attenuation of age-associated changes in diastolic filling. As expected, V(o2 max) was higher in trained men (P < 0.01) and lower in older men (P < 0.01). Peak early mitral inflow velocity (E) and early-to-late mitral inflow velocity ratios were lower in older vs. young men (P < 0.01); however, there was no training effect (P > 0.05). Peak early mitral annular velocity (E') was higher and peak late mitral annular velocity (A') was lower in young vs. older men (P < 0.01). A significant interaction effect was found for A', E'/A', and peak systolic mitral annular velocity (S'). Training was associated with lower A' in young and higher A' in older men. S' was greater in trained vs. untrained older men (P < 0.05), but it was similar in trained and untrained young men. These findings suggest that early diastolic filling is not affected by training in older men, and the effect of training on A' and S' is different in young and older men.

The organisation of death and dying in today's society.

BACKGROUND: This literature review explores service provision for dying people in the wider context of changes in the modern hospice movement, recent government reforms and, in particular, the role of nursing in influencing and improving service delivery. These government reforms are reviewed in the context of the care of the dying. The article then examines the place of death in modern society, and health professionals' views. The concept of the 'good death' is also explored and the satisfaction of patients, carers and health professionals discussed in relation to terminal care in the community. CONCLUSION: Nursing makes a valuable contribution to the care of dying patients and nurses must take the opportunities presented to them by forthcoming healthcare changes to become proactive in representing those they care for.

The nature and severity of urinary incontinence in post-natal women.

This study investigated the frequency, nature and experience of urinary incontinence in post-natal women. Surveys were completed by 224 women, 50% of whom indicated that they had experienced accidental urine loss. The majority of women who had experienced any symptoms were moderately to greatly bothered by them. A variety of strategies were used to manage the problem; however, 42% of the women who experienced accidental urine loss had taken no action to ease the problem. Women received information about urinary incontinence and pelvic floor exercises from a variety of health care professionals, but this was not consistently provided. The implications of these findings are discussed.

Effects of carbonation on probiotic survivability, physicochemical, and sensory properties of milk-based symbiotic beverages.

Drinkable yogurt is a popular beverage in the United States and there may be a niche for carbonated drinkable yogurt in the functional foods market. Pomegranate (P) and vanilla (V) yogurt beverages were formulated, containing inulin as a prebiotic, along with probiotic bacteria Lactobacillus acidophilus and Bifidobacterium, to produce symbiotic products. These beverages were stabilized with high-methoxyl pectin and whey protein concentrate and compared to samples with approximately 2 volumes of added carbon dioxide (CO2 ). Samples were stored in sealed glass bottles at 4 °C for 9 wk for evaluation of physicochemical and functional properties. Trials were carried out in triplicate and 3 replicates from each trial were analyzed. Physicochemical attributes were analyzed using standard AOAC methods. Survivability of the probiotics and changes in pH and viscosity were measured weekly. Chemical composition of the carbonated beverages was: protein: 1.58 ± 0.05%, 1.59 ± 0.06%, fat: 1.24 ± 0.2%, 1.18 ± 0.11%, total solids: 14.78 ± 0.11%, 14.93 ± 0.05%, ash: 0.49 ± 0.02%, 0.46 ± 0.03%, and carbohydrate (by difference): 11.47 ± 0.12%, 11.69 ± 0.14% for P and V, respectively. Both L. acidophilus and Bifidobacterium were stable and remained above 10(6) CFU/g for both flavors of beverage both with and without carbonation. The new manufacturing technology for these prototypes may have potential for commercialization of carbonated symbiotic milk-based beverages.

A comparison of the effects of indexation on standard echocardiographic measurements of the left heart in a healthy multi-racial population.

Accurate reference ranges for measurements from echocardiography rely on an understanding of the distribution of each measurement in the diverse, multi-racial world population. The aim of this study was to determine the influence of gender, age and ethnicity on common echocardiographic measures of the left heart, and to evaluate the effect of different methods of indexation on measurements from healthy, non-Caucasian populations. Standard echocardiographic measurements of left heart size and left ventricular mass (LVM) were assessed in 341 healthy volunteers. Indexation was performed using height, body surface area, and fat free mass (FFM). Quantile regression was used to derive age-adjusted values at the 5th, 50th and 95th‰ of each measurement, by gender, within Caucasians. The effect of indexation method across ethnic groups could then be compared. Indexation of m-mode dimensions may overcompensate for body size, resulting in people of smaller build (women and those of South or East Asian descent) developing higher indexed values than those of larger build (men and people of Maori or Pacific descent). Indexation of 2D volumes by any method improves the integration of values across ethnic groups, with FFM yielding the greatest integration. LVM increases with age, suggesting that the static reference values currently recommended for this measurement may not be appropriate. There are important differences in the distribution of measurements of left heart size by gender, ethnicity and age.