Guidelines for the Evaluation of Heart Failure in the Fetus With or Without Hydrops

Fetal echocardiography has progressed to be able to diagnose many forms of congenital heart disease and to assess the prognosis of cardiac lesions based on their anatomy and presentation in utero. However, the presence of signs of fetal heart failure, such as hydrops or valvular regurgitation, makes the assessment of prognosis difficult. This article outlines a straightforward method for the rapid evaluation of the fetus who may have congestive heart failure. The differentiation of the prehydropic state from normal is illustrated.     

Advances in fetal cardiac intervention

Fetal cardiac intervention is in a rapid state of progress now. Attempts are being made to prevent fetal hydrops due to congenital heart defects, to recruit hypoplastic ventricles, to create a two-ventricle circulation after birth, and to remodel the fetal pulmonary vascular bed whose outlet is obstructed. Open heart surgery in the fetus has yet to be done successfully, but interventions for improved cardiac outcomes are now being tested. Their outcomes will depend, in large part, on their successful physiological effects. How to measure these and quantitate the effects of our interventions will require further advances in the understanding of these diseases-both their natural and unnatural courses. New ultrasound techniques and assessment tools to assess fetal cardiac wellness could enhance the limited progress in fetal intervention in the heart so far.     

Eating in larger groups increases food consumption

OBJECTIVE: To determine whether children's food consumption is increased by the size of the group of children in which they are eating. DESIGN: Crossover study. SETTING: University based preschool. PARTICIPANTS: 54 children, aged 2.5-6.5 years. INTERVENTIONS: Each child ate a standardised snack in a group of three children, and in a group of nine children. MAIN OUTCOME MEASURES: Amount each individual child consumed, in grams. RESULTS: Amount eaten and snack duration were correlated (r = 0.71). The association between group size and amount eaten differed in the short (<11.4 min) versus the long (> or =11.4 min) snacks (p = 0.02 for the interaction between group size and snack duration). During short snacks, there was no effect of group size on amount eaten (16.7 (SD 11) g eaten in small groups vs 15.1 (6.6) g eaten in large groups, p = 0.42). During long snacks, large group size increased the amount eaten (34.5 (16) vs 26.5 (13.8), p = 0.02). The group size effect was partially explained by a shorter latency to begin eating, a faster eating rate and reduced social interaction in larger groups. CONCLUSIONS: Children consumed 30% more food when eating in a group of nine children than when eating in a group of three children during longer snacks. Social facilitation of food consumption operates in preschool-aged children. The group size effect merits consideration in creating eating behaviour interventions.     

All currently used measurements of recirculation in blood access by chemical methods are flawed due to intradialytic disequilibrium or recirculation at low flow

Blood flows and recirculations with standard and reversed direction of lines were measured by chemical (urea and creatinine) and ultrasound dilution (saline) methods in 47 chronic hemodialysis patients. Thirty-seven patients had 47 dual-lumen, central vein (CV) catheters: 32 were PermCath (Quinton Instruments Company, Seattle, WA), 6 were Access Cath (MEDCOMP, Harleysville, PA), 3 were Soft Cell PC (Vas Cath, Mississauga, Ontario, Canada) and 6 were SNIJ (experimental catheters). Three of these last catheters had the tip staggered 7 mm, and three had flush tips; PermCath, Access Cath, and Soft Cell PC catheters have the tips staggered 23 to 25 mm. Forty-six catheters were implanted into the superior vena cava/right atrium, and one catheter was implanted through the left saphenous vein into the left iliac vein. The catheters were studied 1 to 31 months after implantation (median, 3.0 months). Ten patients with arteriovenous (AV) graft access were also studied. The stop-flow method was used in catheter dialysis, and the slow-flow method was used to calculate recirculations in AV access dialysis with samples for systemic blood concentrations taken from arterial line both before and after samples from the arterial and venous lines. At 500 mL/min pump speed, actual blood flow was 436+/-18 mL/min (mean+/-SD; range, 407 to 464 mL/min) with standard direction of catheter lines. At 500 mL/min pump speed, the arterial chamber pressure was -330+/-48 mm Hg (mean+/-SD; range, -380 to -225 mm Hg, and the venous chamber pressure was 259+/-48 mm Hg (mean+/-SD; range, 140 to 310 mm Hg). Arterial chamber pressure was less negative, and venous chamber pressure was less positive with SNIJ catheters, which had larger internal diameter (2.1 mm) compared with the other catheters (2.0 mm). Recirculation varied with the catheter design and the location of the catheter tip. In the catheters with tip staggered more than 20 mm and with standard line connection at pump speeds of 50 mL/min and 500 mL/min, recirculations were approximately 1 % and 5%, respectively, when measured by the chemical method. In the same catheters with reversed lines, the recirculations were approximately 5% and 27%, respectively. Inflow failure catheters with reversed lines had similar recirculation values to those of well-functioning catheters with reversed lines. In catheters with tips staggered 7 mm, and with standard connection of lines, recirculations were approximately 3% and 8%, respectively, at pump speeds of 50 and 500 mL/min. With reversed lines, at the same pump speeds, the values were 7% and 12%, respectively. In flush-tip catheters, the recirculation was higher at a 50 mL/min pump speed (approximately 17%) than at a pump speed of 500 mL/min (approximately 13%). The ultrasound dilution method usually gave lower values than the chemical methods, most likely because of overestimation of recirculation by chemical methods. At least triplicate measurements are needed because single measurements by the ultrasound dilution method are associated with substantial variation. We conclude that both currently used methods (stop flow and slow flow) of taking systemic samples for measurements of recirculation by chemical methods are flawed because of disequilibrium and recirculation at low flow.