Transthoracic Doppler echocardiographic measurement of left atrial appendage blood flow velocity: comparison with transoesophageal measurement.

AIM: We validated transthoracic echocardiographic measurements of left atrial appendage flow velocity by comparing them with transoesophageal echocardiographic measurements. METHODS AND RESULTS: Eighty-four consecutive patients (mean age, 64.6 years) with various cardiac diseases, who underwent both transthoracic echocardiography and transoesophageal echocardiography were studied. Thirty-two patients were in sinus rhythm, and the remaining 52 patients were in atrial fibrillation. On transthoracic echocardiography, the transducer was placed somewhat superior and outside from the position viewing the conventional parasternal short-axis image of the aortic valve, so that the angle between left atrial appendage midline and Doppler beam could be narrowed. The left atrial appendage flow velocity pattern was recorded by pulsed Doppler mode with a sampling volume placed at the left atrial appendage orifice on both transthoracic echocardiography and transoesophageal echocardiography. In both approaches, the peak emptying velocity (LAA-E) and the peak filling velocity (LAA-F) of the left atrial appendage were measured. In sinus rhythm, the LAA-E was detectable in 25 of the 32 patients (78.1%) and the LAA-F in 20 of the 32 patients (62.5%). Both LAA-E and LAA-F were detectable in 46 of the 52 patients (88.5%) in atrial fibrillation. Good correlations of LAA-E and LAA-F were observed between transthoracic echocardiography and transoesophageal echocardiography measurements in sinus rhythm (r=0.94, r=0.95, respectively; both, P<0.0001) and in atrial fibrillation (r=0.89, r=0.95, respectively; both, P<0.0001). CONCLUSIONS: The left atrial appendage flow velocities could be sufficiently recorded and assessed by transthoracic echocardiography in 84 Japanese unselected consecutive patients with sinus rhythm or atrial fibrillation.     

Age-related changes in the electrophysiologic properties of the atrium in patients with no history of atrial fibrillation

Although atrial fibrillation is a common arrhythmia, especially in the elderly, little is known about age-related changes in the electrophysiologic properties of the atrium. The aim of this study was to analyze the effect of aging on atrial vulnerability to atrial fibrillation. An electrophysiologic study was performed in 45 patients with no history of atrial fibrillation, Wolff-Parkinson-White syndrome, structural heart disease, or conditions with potential effects on cardiac hemodynamic or electrophysiologic function (15 females; mean age, 52 +/- 18 years; range, 14 to 84 years). The following atrial excitability parameters were assessed: spontaneous or paced (A1) and extrastimulated (A2) atrial electrogram widths, percent maximum atrial fragmentation (A2/A1 x 100), effective refractory period, wavelength index (ERP/A2), and inducibility of atrial fibrillation. Atrial fibrillation was induced in 9 patients. Percent maximum atrial fragmentation was greater (176 +/- 36 vs 137 +/- 26%, P < 0.001) and wavelength index was shorter (2.4 +/- 0.4 vs 3.2 +/- 0.9, P < 0.01) in the patients with than without inducible atrial fibrillation. However, age was similar in patients with and without inducible atrial fibrillation (47 +/- 11 vs 53 +/- 19 years, P = 0.36). Percent maximum atrial fragmentation and effective refractory period directly correlated with age (r = 0.32, P < 0.05 and r = 0.45, P < 0.001, respectively). On the other hand, wavelength index (3.1 +/- 0.9) did not correlate with age (r = -0.05, P = 0.77). This study suggests that the mechanism triggering atrial fibrillation may be very well different between older and younger patients with atrial fibrillation, because younger patients have no marked substrate for atrial fibrillation.     

Echocardiography in chronic alcoholics following prolonged periods of abstinence

Left ventricular function was analyzed using standard echocardiographic techniques in 26 chronic asymptomatic alcoholics without clinical evidence of cardiovascular disease. All were studied following a long period of abstinence (mean 3.1 years; range 3 months to 17 years). Seven asymptomatic children (mean age 14.1 years; range 4 to 19 years) whose mothers had been actively drinking throughout their pregnancies were also studied. The calculated fractional shortening of the left ventricle (per cent ΔS), ejection fraction, mean velocity of circumferential fiber shortening (mean V_CF), excursions and maximal systolic velocites of the ventricular septum and left ventricular posterior wall, preejection period/left ventricular ejection time ratios, mitral valve EF slopes, and thicknesses of the left ventricular posterior wall and ventricular septum were obtained in all. Normal left ventricular function was found in all but one adult alcoholic. In this patient, the per cent ΔS, ejection fraction, and mean V_CF were reduced. One additional adult alcoholic had a minimally thickened ventricular septum. Our results differ from other studies which have shown significant left ventricular dysfunction in asymptomatic chronic alcoholics. A possible explanation is the much longer period of abstinence of our chronic alcoholics at the time of their examinations. It also appears that left ventricular function in children born of alcoholic mothers is not affected when assessed after the long interval following prolonged exposure to alcohol in utero.     

Advanced Liver Fibrosis Is Common in Patients With Type 2 Diabetes Followed in the Outpatient Setting: The Need for Systematic Screening

OBJECTIVEAssess the prevalence of nonalcoholic fatty liver disease (NAFLD) and of liver fibrosis associated with nonalcoholic steatohepatitis in unselected patients with type 2 diabetes mellitus (T2DM).RESEARCH DESIGN AND METHODSA total of 561 patients with T2DM (age: 60 ± 11 years; BMI: 33.4 ± 6.2 kg/m²; and HbA_1c: 7.5 ± 1.8%) attending primary care or endocrinology outpatient clinics and unaware of having NAFLD were recruited. At the visit, volunteers were invited to be screened by elastography for steatosis and fibrosis by controlled attenuation parameter (≥274 dB/m) and liver stiffness measurement (LSM; ≥7.0 kPa), respectively. Secondary causes of liver disease were ruled out. Diagnostic panels for prediction of advanced fibrosis, such as AST-to-platelet ratio index (APRI) and Fibrosis-4 (FIB-4) index, were also measured. A liver biopsy was performed if results were suggestive of fibrosis.RESULTSThe prevalence of steatosis was 70% and of fibrosis 21% (LSM ≥7.0 kPa). Moderate fibrosis (F2: LSM ≥8.2 kPa) was present in 6% and severe fibrosis or cirrhosis (F3–4: LSM ≥9.7 kPa) in 9%, similar to that estimated by FIB-4 and APRI panels. Noninvasive testing was consistent with liver biopsy results. Elevated AST or ALT ≥40 units/L was present in a minority of patients with steatosis (8% and 13%, respectively) or with liver fibrosis (18% and 28%, respectively). This suggests that AST/ALT alone are insufficient as initial screening. However, performance may be enhanced by imaging (e.g., transient elastography) and plasma diagnostic panels (e.g., FIB-4 and APRI).CONCLUSIONSModerate-to-advanced fibrosis (F2 or higher), an established risk factor for cirrhosis and overall mortality, affects at least one out of six (15%) patients with T2DM. These results support the American Diabetes Association guidelines to screen for clinically significant fibrosis in patients with T2DM with steatosis or elevated ALT.     

Harnessing innovative technologies to advance children's mental health: Behavioral parent training as an example

Disruptive behaviors of childhood are among the most common reasons for referral of children to mental health professionals. Behavioral parent training (BPT) is the most efficacious intervention for these problem behaviors, yet BPT is substantially underutilized beyond university research and clinic settings. With the aim of addressing this research-to-practice gap, this article highlights the considerable, but largely unrealized, potential for technology to overcome the two most pressing challenges hindering the diffusion of BPT: (1). The dearth of BPT training and supervision opportunities for therapists who work with families of children with disruptive behaviors; and (2). The failure to engage and retain families in BPT services when services are available. To this end, this review presents a theoretical framework to guide technological innovations in BPT and highlights examples of how technology is currently being harnessed to overcome these challenges. This review also discusses recommendations for using technology as a delivery vehicle to further advance the field of BPT and the potential implications of technological innovations in BPT for other areas of children's mental health are discussed.     

Neuroanatomical MRI study: reference values for the measurements of brainstem,cerebellar vermis,and peduncles

Objectives:To set age-specific normal reference values for brainstem, cerebellar vermis, and peduncles measurements and characterize values’ variations according to gender, age, and age by gender interaction.Methods:565 normal brain magnetic resonance examinations with normal anatomy and signal intensity of the supra- and infratentorial structures were categorized into six age groups (infant, child, adolescent, young adult, middle-age adult, and old aged adults). Patients with congenital malformations, gross pathology of the supra- or infratentorial brain, brain volume loss, developmental delay, metabolic disorders, and neuropsychological disorders (n = 2.839) were excluded. On midsagittal T₁ weighted and axial T₂ weighted images specific linear diameters and ratios of the brainstem, cerebellar vermis, and peduncles were attained. Two observers assessed a random sample of 100 subjects to evaluate the inter- and intraobserver reproducibility. Intraclass correlation coefficients, means ± standard deviation, one and two-way analysis of variance tests were used in the statistical analysis.Results:Good to excellent inter- and intraobserver measurements’ reproducibility were observed, except for the transverse diameter of the midbrain, the anteroposterior diameter of the medulla oblongata at the pontomedullary and cervicomedullary junctions, cerebellar vermis anteroposterior diameter, and thickness of the superior cerebellar peduncle. Age-specific mean values of the investigated measurements were established. A significant gender-related variation was recorded in the anteroposterior diameter of the basis pontis (p = 0.044), the anteroposterior diameter of the medulla oblongata at the cervicomedullary junction (p = 0.044), and cerebellar vermis height (p = 0.018). A significant age-related change was detected in all measurements except the tectal ratio. Age by gender interaction had a statistically significant effect on the tectal ratio, inferior, and middle cerebellar peduncles’ thickness (p = 0.001, 0.022, and 0.028, respectively).Conclusion:This study provides age-specific normal mean values for various linear dimensions and ratios of the posterior fossa structures with documentation of measurements’ variability according to gender, age, and their interaction.Advances in knowledge:It provides a valuable reference in the clinical practice for easier differentiation between physiological and pathological conditions of the posterior fossa structures especially various neurodegenerative diseases and congenital anomalies.     

Estimation of gender-specific connectional brain templates using joint multi-view cortical morphological network integration

Brain Imaging and Behavior - The estimation of a connectional brain template (CBT) integrating a population of brain networks while capturing shared and differential connectional patterns across...     

Potential Function of Granulysin,Other Related Effector Molecules and Lymphocyte Subsets in Patients with TB and HIV/TB Coinfection

Background: Host effector mechanism against Mycobacterium tuberculosis (Mtb) infection is dependent on innate immune response by macrophages and neutrophils and the alterations in balanced adaptive immunity. Coordinated release of cytolytic effector molecules from NK cells and effector T cells and the subsequent granule-associated killing of infected cells have been documented; however, their role in clinical tuberculosis (TB) is still controversy.Objective: To investigate whether circulating granulysin and other effector molecules are associated with the number of NK cells, iNKT cells, Vγ9⁺Vδ2⁺ T cells, CD4⁺ T cells and CD8⁺ T cells, and such association influences the clinical outcome of the disease in patients with pulmonary TB and HIV/TB coinfection.Methods: Circulating granulysin, perforin, granzyme-B and IFN-γ levels were determined by ELISA. The isoforms of granulysin were analyzed by Western blot analysis. The effector cells were analyzed by flow cytometry.Results: Circulating granulysin and perforin levels in TB patients were lower than healthy controls, whereas the granulysin levels in HIV/TB coinfection were much higher than in any other groups, TB and HIV with or without receiving HAART, which corresponded to the number of CD8⁺ T cells which kept high, but not with NK cells and other possible cellular sources of granulysin. In addition, the 17kDa, 15kDa and 9kDa isoforms of granulysin were recognized in plasma of HIV/TB coinfection. Increased granulysin and decreased IFN-γ levels in HIV/TB coinfection and TB after completion of anti-TB therapy were observed.Conclusion: The results suggested that the alteration of circulating granulysin has potential function in host immune response against TB and HIV/TB coinfection. This is the first demonstration so far of granulysin in HIV/TB coinfection.