Advances in pediatric cardiology and congenital heart diseases

This article reviews the most significant developments reported between July 2006 and July 2007 in the fields of pediatric cardiology and congenital heart disease, in diagnosis and treatment in particular. In the area of imaging techniques, the increasing clinical roles of magnetic resonance imaging, tissue Doppler imaging and three-dimensional echocardiography are highlighted, as is the application of these techniques to fetal cardiology and its repercussions. The incidence and treatment of arrhythmias in children are also discussed and, with regard to heart failure, there is an assessment of recent findings in epidemiology and diagnosis, new drugs, ventricular assist systems, and the current status of heart transplantation. In the area of interventional cardiology, present-day techniques for the closure of atrial and ventricular septal defects are reviewed and there is an assessment of early results with partially absorbable devices, percutaneous pulmonary valve implantation, and new types of stent (e.g., premounted, coated and absorbable stents). In cardiac surgery, the focus is on studies that evaluate outcome quality, the search for new biocompatible conduits, experience with new techniques for treating complex transpositions (e.g., the Nikaidoh procedure and its variants), the medium- and long-term results of treating aortic valvular disease with pulmonary autografts (i.e., the Ross and Ross-Konno procedures), and current findings on the treatment of pulmonary insufficiency after correction of either the tetralogy of Fallot or a dysfunctional Fontan circuit.     

Educational Impact on Apixaban Adherence in Atrial Fibrillation (the AEGEAN STUDY): A Randomized Clinical Trial

Adherence to non-vitamin-K oral anticoagulants (NOACs) may be lower than to vitamin K antagonists because NOACs do not require routine monitoring. We assessed the impact of an educational program on adherence and persistence with apixaban in patients with non-valvular atrial fibrillation (NVAF). Patients with NVAF eligible for NOACs with one or more stroke risk factor (prior stroke/transient ischemic attack, age ≥ 75 years, hypertension, diabetes, or symptomatic heart failure) were randomized (1:1) to standard of care (SOC) or SOC with additional educational (information booklet, reminder tools, virtual clinic access). The primary outcome was adherence to apixaban (2.5 or 5 mg twice daily) at 24 weeks. Patients receiving the educational program were re-randomized (1:1) to continue the program for 24 further weeks or to switch to secondary SOC. Implementation adherence and persistence were reassessed at 48 weeks. In total, 1162 patients were randomized (SOC, 583; educational program, 579). Mean implementation adherence ± standard deviation (SD) at 24 weeks was 91.6% ± 17.1 for SOC and 91.9% ± 16.1 for the educational program arm; results did not differ significantly between groups at any time-point. At 48 weeks, implementation adherence was 90.4% ± 18.0, 90.1% ± 18.6, and 89.3% ± 18.1 for continued educational program, SOC, and secondary SOC, respectively; and corresponding persistence was 86.1% (95% confidence interval [CI] 81.3–89.7), 85.2% (95% CI 81.5–88.2), and 87.8% (95% CI 83.4–91.1). Serious adverse events were similar across groups. High implementation adherence and persistence with apixaban were observed in patients with NVAF receiving apixaban. The educational program did not show additional benefits. This study is registered at ClinicalTrials.gov [NCT01884350].     

Use of proton pump inhibitors and risk of fragility hip fracture in a Mediterranean region

ObjectiveTo determine whether there is an increased risk of hip fracture associated with the use of proton pump inhibitors in a Mediterranean area after adjusting for other potential risk factors.MethodsRetrospective multicenter case–control study carried out in 6 primary health care centers in Catalonia, Spain. Cases were patients aged 50 years and over with a fragility hip fracture registered between January 2007 and December 2010, matched with 2 controls by sex and age. Data collected: use of proton pump inhibitors (type, dosage) in the 5 years previous to the hip fracture, socio-demographic data, body mass index, alcohol and tobacco consumption as well as health conditions and drugs associated with an increase risk of fragility hip fracture.Results358 cases were matched with 698 controls. The mean age was 82 years old in both groups. Women represented 77.1% in the case group and 76.9% in the control group. Crude association between proton pump inhibitors and hip fracture was 1.44 (95% CI, 1.09–1.89) and adjusted OR was 1.24 (95% CI, 0.93–1.65). No association was found with the continuous or discontinuous use of proton pump inhibitors, OR 1.17 (95% CI, 0.77–1.79), and OR of 1.16 (95% CI, 0.85–1.60) respectively. No association was found when restricting the analysis by sex, OR of 1.19 (95% CI, 0.27–5.14) or by age, younger or older than 80 years, OR of 0.72 (95% CI, 0.24–2.15).ConclusionThe use of proton pump inhibitors was not associated with an increased risk of hip fracture after adjusting for other risk factors in a Mediterranean area. This result suggests the existence of protective environmental factors linked to this southern area of Europe that eventually could compensate for the potential harm produced by proton pump inhibitors.     

Measuring functional status of chronic coronary patients: Reliability, validity and responsiveness to clinical change of the reduced version of the Duke Activity Status Index (DASI)

AIMS: Health-related quality of life assessment may be useful forunderstanding the variability in functioning of patients witha similar level of clinical impairment. We assessed the reliability,validity and responsiveness to clinical change of a reducedversion of the Duke Activity Status Index (DASI) in chroniccoronary patients. METHODS AND RESULTS: The reduced version of the DASI, a measure of self-reportedfunctional capacity, was administered twice to two groups ofpatients: 46 stable coronary heart disease outpatients weretested and re-tested 2 weeks after their initial visit; and44 patients undergoing elective angioplasty for angina pectoriswere evaluated the day before and one month after the procedure.The Canadian Cardiovascular Society (CCS) functional grade wasassessed in all patients, and a treadmill exercise test wasperformed sequentially (before and after the procedure) in angioplastypatients. Cronbach's alpha reliability coefficients for reducedDASI scores were high (between 0·81 and 0·89).Correlations of the reduced DASI scores with CCS grade and exercisetest duration were moderately high (r= – 0·51 andr=0·45, respectively). Improvement after angioplastyas assessed by the reduced DASI scores was important (effectsize=0·75, P<0·001). CONCLUSION: The reduced DASI is reliable, valid and responsive to clinicalchanges. Health-related quality of life measures may be usefulin monitoring coronary patients.     

Generalised erythematous skin eruptions induced by sorafenib: cutaneous toxicity and treatment outcome

A woman diagnosed of a renal cell carcinoma in 1989 had a metastatic kidney cancer localised in subcutaneous nodules, gut and lung in 2007. Sorafenib treatment was initiated a 400 mg orally twice a day. The patient developed generalised erythematous skin eruptions and two weeks later a widespread erythematous maculopapular eruption located exclusively on the legs and arms, along with an objective response. The most likely cause of the generalised erythematous skin eruptions was considered to be sorafenib because of the close temporal relationship between exposure to the drug and onset of symptoms. Furthermore, a relationship between sorafenib skin toxicity and treatment efficacy was observed. This therapeutic efficacy of EGFR inhibitors and cutaneous side effects should be better assessed in large cohorts or trials to determine whether the skin toxicity of patients can be linked to an objective antitumour response.     

The effect of music amplitude on the relaxation response

The purposes of this study were (a) to ascertain how 3 different volume levels of music affect the relaxation response both psychologically (preference scores and self-report) and physiologically (heart rate), (b) to determine the amplitude preference for relaxation among young adults, and (c) to compare differences in preference response between music and nonmusic majors and between the genders. One hundred forty-four college-age music and nonmusic majors were participants in this study. Subjects listened to 27 minutes of music while relaxing. The amplitude of the music was changed every 3 minutes in a randomized order so that each subject received loud (80-90 dB) medium (70-80 dB) or soft (60-70 dB) music 3 times each during the experimental period for a total of 9 amplitude changes. A sample of subjects wore a small heart rate monitor on their wrist and chest during the procedure. Simultaneously with the selected listening, they were encouraged to turn a dial on a Continuous Response Digital Interface (CRDI) indicating their amplitude preference for relaxation. Self-report information was gathered at the beginning and end of the experiment. Results of the CRDI analyses indicate that overall, subjects showed overwhelming preference for the soft music in comparison to medium or loud. Males, however, preferred the loud music more than females, and music majors preferred softer music over non-majors who preferred louder music. There were no differences attributed to amplitude level in the analysis of heart rate data. Analysis of the self report data yielded a wide variety of responses concerning their individual preferences, not always consistent with the empirical measures. Overall, there was an increase in relaxation reported over the duration of the experiment. Response differentiation to loudness levels indicates a long line of useful research not only on relaxation and stress reduction in health related fields, but also on the effects of background amplitude of music while studying, driving, and engaging in other cognitive and motor tasks.     

Spontaneous middle ear meningoencephalic herniation. 2 case reports

Two cases of idiopathic brain herniation into the middle ear without previous surgery are reported. Brain herniation is an unusual pathology, usually related to middle ear surgery. The idiopathic appearance of this disease is the secondly most frequent cause. Its origin is believed to be related to a congenital defect of tegmen timpani. Two elements, both rare, are emphazised: the spontaneous bilateral presentation in one of the cases, and the CSF leak as an initial symptom. We present a review of the literature, describing epidemiology results and the main accepted etiology theories. We discuss the diagnosis and treatment methods: magnetic resonance imaging and surgery.