Echocardiographic determination of aortic and pulmonary valve areas in subjects with normal hearts

Two-dimensional and Doppler echocardiography were performed in 70 subjects (aged 1 day to 16 years, body surface area from 0.08 to 2.1 m2) to determine aortic and pulmonary valve areas in normal children and adolescents. Valve areas were determined by the continuity equation using echo-determined ventricular outflow tract diameters and Doppler-determined flow velocities from the outflow tracts and corresponding great arteries. Left ventricular outflow tract diameter ranged from 0.3 to 2.2 cm and right ventricular outflow tract diameter from 0.4 to 2.8 cm. Outflow tract diameters were linearly related to the square root of body surface area. Flow velocity increased from a mean of 0.75 m/s in the left ventricular outflow tract to 1.12 m/s in the aorta and from 0.56 m/s in the right ventricular outflow tract to 0.89 m/s in the pulmonary artery. Flow velocities were unrelated to body size. Valve areas were linearly related to body surface area (r = 0.88 and 0.80 for the aortic and pulmonary valves, respectively). Mean aortic and pulmonary valve area indexes were 1.33 cm2/m2 and 1.70 cm2/m2, respectively. The data provide normal values for echocardiographically determined valve areas and validate the practice of indexing valve area for body surface area.     

Counselling anomie: clashing governmentalities of HIV criminalisation and prevention

HIV criminalisation is a term that describes the criminal prosecution of persons in instances of HIV transmission, exposure and so-called non-disclosure of their HIV serostatus. In the United States (US), there have been over 500 reported instances of HIV criminalisation. Over the past decade, several negative consequences of HIV criminalisation have been identified, including its capacity to increase stigma and social injustice. In addition, scholars have built an evidence base demonstrating that HIV criminalisation has the potential to undermine HIV prevention and that it is thus harmful to public health. This article contributes to that evidence base by (1) combining Foucaultian studies of ‘governmentality’ with the sociology of ‘anomie’ to theorise the larger implications of HIV criminalisation for the institution of public health, and (2) presenting interviews with public health service providers working in Tennessee, USA. This state is an important site for studying the public health implications of HIV criminalisation because, between 2008 and 2012, it was reported to have led all American jurisdictions in prosecutions of HIV-specific criminal offences. Concentrating on discussions of post-test counselling, this article argues that a major system-level effect of HIV criminalisation is the propagation of an anomic affective climate, which makes it difficult to establish norms of HIV prevention.     

The heart and gut relationship: a systematic review of the evaluation of the microbiome and trimethylamine-N-oxide (TMAO) in heart failure

Heart Failure Reviews - There is an expanding body of research on the bidirectional relationship of the human gut microbiome and cardiovascular disease, including heart failure (HF). Researchers...     

Yield of endomyocardial biopsy in patients with biventricular failure. Comparison of patients with normal vs reduced left ventricular ejection fraction

Twenty five patients with biventricular failure underwent endomyocardial biopsy procedures. Twelve of these 25 patients had normal left ventricular ejection fraction. Endomyocardial biopsy sampling was useful in eight of 12 patients (67 percent) with biventricular failure and normal left ventricular ejection fraction. Biopsy specimens in five of these 12 patients demonstrated endocardial or infiltrative heart disease and excluded these diseases in three other patients with constrictive pericarditis. This study suggests that the clinical presentation of biventricular failure, combined with the noninvasive determination of a normal left ventricular ejection fraction, is helpful in selecting patients for endomyocardial biopsy study. Patients with biventricular failure and normal left ventricular ejection fractions have a high probability of having pericardial or infiltrative heart disease, conditions that often can be differentiated only by analysis of myocardial tissue. Hemodynamic assessment of patients without infiltrative processes further allows one to eliminate those patients with a high likelihood of having constrictive pericardial disease.     

A randomised, open-label comparison of three highly active antiretroviral therapy regimens including two nucleoside analogues and indinavir for previously untreated HIV-1 infection: the OzCombo1 study

BACKGROUND: Highly active antiretroviral therapy (HAART) including two nucleoside analogues and a potent protease inhibitor is standard of care initial therapy for HIV-infected adults. The best-tolerated and most potent initial HAART regimen is unknown and was investigated in this study. METHODS: One hundred and nine HIV-infected adults with no prior antiretroviral therapy, and CD4 lymphocyte counts < 500 x 10(6) cells/l or plasma HIV RNA > 30,000 copies/ml were randomized to zidovudine-lamivudine-indinavir (ZDV-3TC-IDV), stavudine-lamivudine-indinavir (d4T-3TC-IDV) or stavudine-didanosine-indinavir (d4T-ddI-IDV) for 52 weeks. The primary endpoints were plasma HIV RNA and drug-related adverse events. Other assessments were overall safety, adherence and adverse events, CD4 lymphocyte counts, cutaneous delayed type hypersensitivity (DTH) responses and quality of life (Euroqol). RESULTS: Only 58% patients had HIV RNA < 50 copies/ml plasma at 12 months, with no significant difference between the three regimes (P = 0.34). Drug-related adverse events sufficiently severe to warrant drug discontinuation were less common (P = 0.06) in patients receiving d4T-3TC-IDV (18%) than in those receiving ZDV-3TC-IDV (34%) or d4T-ddI-IDV (41%). The percentages of patients who remained on their assigned therapy with plasma HIV RNA < 50 copies/ml at 52 weeks were 60% with d4T-3TC-IDV, 53% with ZDV-3TC-IDV and 35% with d4T-ddI-IDV. Virological failure at 52 weeks was more likely in those whose adherence was estimated to be < 100% in the first 4 weeks of therapy (P = 0.02), but not in those who developed grade 3 or 4 drug-related adverse events. At 52 weeks, the mean CD4 lymphocyte count increase was 200 x 10(6) cells/l with only 7% of patients having counts lower than at baseline; DTH responses improved but remained clinically impaired in most patients. Quality of life improved significantly in all groups. CONCLUSIONS: Initial HAART regimens including IDV failed to suppress plasma HIV RNA to < 50 copies/ml in > 40% patients after only 12 months of therapy although there was significant overall improvement immunologically and in quality of life. The type of dual nucleoside combination used was less important in predicting virological failure than was imperfect adherence early in therapy. Consideration should be given to modifying a HAART regimen relatively early in non-adherent patients.     

Chronic cough due to gastroesophageal reflux disease: failure to resolve despite total/near-total elimination of esophageal acid

BACKGROUND: While medical therapy may fail to improve cough due to gastroesophageal reflux disease (GERD), it is not known if inadequate esophageal acid suppression is responsible. METHODS: In a prospective, before-and-after interventional trial, we assessed the effects of antireflux surgery in eight patients whose chronic coughs were due to GERD resistant to intensive medical therapy. All patients met a profile predicting that cough was likely due to GERD and had an initial positive 24-h esophageal pH monitoring study, and then underwent serial 24-h esophageal pH monitoring on gradually intensified medical therapy until the percentage of time that esophageal pH was < 4 was zero and there were no acid reflux events > 4 min. The effects of medical and surgical therapy on cough were assessed clinically by a visual analog scale (VAS) and the Adverse Cough Outcome Survey (ACOS). RESULTS: Before surgery (median, 23.7 days), patients still complained of cough, VAS score was 73.1 +/- 6.1, and ACOS score was 15.0 +/- 1.1. After surgery (median, 41.2 days and 1 year), cough improved in all, VAS score decreased to 19.1 +/- 8.3 and 22.6 +/- 8.1 (p = 0.001), respectively, and ACOS score decreased to 2.0 +/- 1.3 and 3.6 +/- 2.3, respectively (p = 0.002). CONCLUSIONS: Antireflux surgery can improve chronic cough due to GERD resistant to intensive medical therapy. There is a clinical profile that can predict when GERD is the likely cause of cough. GERD cannot be excluded on clinical grounds as the potential cause of cough. The term acid reflux disease, when applied to chronic cough due to GERD, can be a misnomer.     

A score predicts failure of reperfusion after fibrinolytic therapy for acute myocardial infarction

Background A rapid, accurate, noninvasive means of predicting the likelihood of failure to achieve Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow within 90 minutes after the start of fibrinolysis with streptokinase could help to identify patients who might benefit from additional therapies that aim to preserve myocytes. Methods We measured ST recovery, which was assessed as the sum of ST deviation on a 12-lead electrocardiogram, and blood levels of the myocardial proteins, troponin T, creatine kinase myocardial band (CK-MB), and myoglobin before and 60 minutes after commencing streptokinase infused for 30 to 60 minutes in 107 patients, who presented within 12 hours of symptom onset and underwent angiography at 90 minutes. Results At 90 minutes, 56% of patients (95% CI 46-66) had TIMI-3 flow. The baseline levels of troponin T, CK-MB, and myoglobin were more commonly below the discrimination values in patients with TIMI-3 flow than in patients without TIMI-3 flow (all P < .005). On multivariate analysis, the factors associated with failure to achieve TIMI-3 flow were ST recovery of <70% (P = .009), a 60-minute/baseline troponin T ratio of ≤5 (P = .0004), a baseline CK-MB level of >4 μg/L (P = .039), or a baseline myoglobin level of >85 μg/L (P = .048). Age and a history of myocardial infarction were added into the multivariate model, and a risk score was developed to predict the likelihood of failure to achieve TIMI-3 flow. A score of ≤2 excluded failure to achieve TIMI-3 flow with 96% accuracy, and a score of ≥7 predicted failure to achieve TIMI-3 flow with 90% accuracy. Conclusion Failure to achieve TIMI-3 flow in the infarct-related artery within 90 minutes after the start of fibrinolysis can be accurately predicted at approximately 60 minutes by a score incorporating clinical variables, ST recovery, and the 60-minute/baseline ratios of troponin T, CK-MB, and/or myoglobin levels. This score may facilitate triage of patients at 60 minutes after fibrinolysis to additional reperfusion therapies. (Am Heart J 2003;145:508-14.)     

Histoplasmosis in renal allograft recipients. Two large urban outbreaks

During two large outbreaks, ten episodes of histoplasmosis were documented in eight renal allograft recipients. Another episode occurred before the outbreaks. Associated infections with cytomegalovirus occurred in five patients and may have further impaired cellular immunity. Prolonged fever was the predominant clinical finding; and dissemination was observed in seven of our nine patients, including three with meningitis. Special stains of tissues and the histoplasmal complement fixation test provided useful diagnostic information rapidly, while cultures were eventually positive in seven patients. Treatment with amphotericin B resulted in prompt clinical improvement in all patients, but relapse occurred in two patients one year following therapy.