[Very long term follow-up after radiofrequency ablation for atrial fibrillation: the Geneva experience]

Catheter ablation (CA) has emerged as an increasingly popular treatment option for selected patients with atrial fibrillation (AF) because drugs are frequently limited by side effects and poor effectiveness. However, very little data is available regarding outcomes of CA of AF beyond 5 years. Guidelines' recommendations are not clear regarding long-term oral anticoagulation (OAC) after 2 years. We assessed thromboembolic events (TE) and AF ablation outcomes at very long-term follow-up (> 5 years) after CA. During a mean follow-up of 9 years after CA, 68% patients were in stable sinus rhythm without anti-arrhythmic drugs and the TE event rate was 0.41 per 100 patients/year. Our data suggests that patients post ablation with a high risk for stroke (CHA2DS2-VASc ≥ 2) should however continue OAC treatment.

Discrepancy in fetal sex assignment between cell free fetal DNA and ultrasound

Noninvasive prenatal testing utilizing free fetal DNA is commonly used in pregnancy to screen for trisomy 13, 18, 21 and also fetal sex aneuploidy. We report on two cases of discrepancy between phenotypic and genotypic sex and potential medical implications. In our first case, a patient with known male gender via cell free fetal DNA (cffDNA) testing had an ultrasound at 18 weeks' gestation, which identified Dandy-Walker malformation and female-appearing ambiguous genitalia. As Dandy-Walker malformation could not be considered isolated in the presence of ambiguous genitalia, this finding allowed for more complete counseling of the parents as well as extensive genetic workup. Our second case involved a fetus with intrauterine growth restriction diagnosed by ultrasound and normal-appearing female genitalia. After birth, adrenal insufficiency was diagnosed and chromosome analysis identified normal male chromosomes. These two cases showed that fetal sex determination by cffDNA can be used as a tool for earlier identification of affected pregnancies, allowing for parental decision-making, genetic testing and earlier intervention.

Assisted reproductive technology in India: A 3 year retrospective data analysis

Assisted reproductive technology (ART) has grown by leaps and bounds in the last few years. India has one of the highest growths in the ART centers and the number of ART cycles performed every year. Very soon India will be the leader in the world of ART in terms of a number of cycles. With the advances of technology and availability of techniques even in tier II and tier III cities our country, the results still vary dramatically. There is no standardization of protocols and reporting is very inadequate. Furthermore, there are only ART guidelines and no law still exists. Our first and the biggest challenge is to document the tremendous work being done in India and on the basis of analysis of this work, a proper registry can be made and guidance given to all on standardization and improvement. This is the 8^th edition of National ART Registry of India being presented and analyzed.

Premature menopause - Meeting the needs

Premature menopause is characterized by amenorrhea, elevated gonadotropin levels and sex steroid deficiency occurring in women below 40 years of age. Heterogeneity of premature ovarian failure is reflected by various causes, both spontaneous and iatrogenic. X chromosomal abnormalities remain the main cause of primary ovarian insufficiency. Women with primary ovarian insufficiency present with amenorrhea, irregular cycles, signs of estrogen deficiency and infertility. They are at increased risk for non-communicable diseases such as, cardiovascular disease, Alzheimer's disease, and osteoporosis. Management includes use of menopausal hormone therapy till the age of natural menopause and customized as per the needs. In women having fertility issues, IVF with donor oocytes remains the treatment of choice with the best results. With advances in assisted reproductive technologies, cryopreservation of oocytes/embryos should be utilized, whenever impending primary ovarian insufficiency is anticipated either due to therapy or biological reasons.

Diagnosis of hyperinsulinaemia in a normoglycaemic healthy Indian Population--developing ethnic reference ranges

CONTEXT

Reference limits for diagnosing hyperinsulinaemia are currently derived from non-Indian cohorts and have not been validated in Indians even though it is acknowledged that different patterns of insulin secretion are seen across ethnicities.

AIMS

To develop ethnicity specific reference limits for insulin levels in a normoglycaemic healthy Indian cohort in order to derive a clinical cut off for hyperinsulinaemia as an effective screening tool for predicting future risk of metabolic and cardiovascular disease.

SETTINGS AND DESIGN

Prospective analysis of plasma insulin levels in healthy normoglycaemic volunteers availing diagnostic facilities at a central reference laboratory in Mumbai.

METHODS AND MATERIAL

122 normoglycaemic males between 19-73 years and 126 females between 19-55 years of age were selected based on a screening questionnaire as per the Clinical Laboratory and Standards Institute (CLSI) guidance document for deriving reference ranges. Fasting insulin levels were analysed using a Chemiluminescent Microparticle Immunoassay platform and derived results were analysed to determine reference limits for insulin.

STATISTICAL ANALYSIS USED

A non-parametric method of statistical analysis was used to determine the 2.5 and 97.5% limits with 90% confidence intervals.

RESULTS

Reference range for insulin in a normoglycemic Indian cohort was derived as 2.7-17 uIU/ml which established 17 uIU/ml as the clinical cut off for diagnosing hyperinsulinemia in healthy Indians.

CONCLUSIONS

Reference limits for insulin in normoglycemic Indians needs to be revised to 2.7-17 uIU/ ml. Clinical cut off for hyperinsulinemia needs to be lowered to 17 uIU/ml from currently used cut offs which range from 25-31 ulU/ml.

KEY MESSAGES

Reference limits currently used for diagnosing hyperinsulinemia in healthy normoglycemic adults need to be revised and made specific for different ethnicities. In Indians the upper limit of the normal reference range for insulin levels needs to be brought down to 17 uIU/ml from the existing 25-31 u IU/ml. This modified cut off would help clinicians identify apparently healthy individuals who may need to be screened for a future risk of metabolic and cardiovascular disorders.

Unilateral closed lip schizencephaly with septo-optic dysplasia

Schizencephaly is a rare malformation of the central nervous system. Both genetic and non-genetic etiologies like prenatal infections or ischemia have been postulated. Clinical manifestations most often include varying degrees of developmental delay, motor impairment and seizures. It can be associated with septo-optic dysplasia (SOD), optic nerve hypoplasia and absence of septum pellucidum, pachygyria, polymicrogyria, heterotopia and arachnoid cysts. We report a case of unilateral closed lip schizencephaly with SOD.

Metabolic gene profile in early human fetal heart development

The primitive cardiac tube starts beating 6-8 weeks post fertilization in the developing embryo. In order to describe normal cardiac development during late first and early second trimester in human fetuses this study used microarray and pathways analysis and created a corresponding 'normal' database. Fourteen fetal hearts from human fetuses between 10 and 18 weeks of gestational age (GA) were prospectively collected at the time of elective termination of pregnancy. RNA from recovered tissues was used for transcriptome analysis with Affymetrix 1.0 ST microarray chip. From the amassed data we investigated differences in cardiac development within the 10-18 GA period dividing the sample by GA in three groups: 10-12 (H1), 13-15 (H2) and 16-18 (H3) weeks. A fold change of 2 or above adjusted for a false discovery rate of 5% was used as initial cutoff to determine differential gene expression for individual genes. Test for enrichment to identify functional groups was carried out using the Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG). Array analysis correctly identified the cardiac specific genes, and transcripts reported to be differentially expressed were confirmed by qRT-PCR. Single transcript and Ontology analysis showed first trimester heart expression of myosin-related genes to be up-regulated >5-fold compared with second trimester heart. In contrast the second trimester hearts showed further gestation-related increases in many genes involved in energy production and cardiac remodeling. In conclusion, fetal heart development during the first trimester was dominated by heart-specific genes coding for myocardial development and differentiation. During the second trimester, transcripts related to energy generation and cardiomyocyte communication for contractile coordination/proliferation were more dominant. Transcripts related to fatty acid metabolism can be seen as early as 10 weeks and clearly increase as the heart matures. Retinol receptor and gamma-aminobutyric acid (GABA) receptor transcripts were detected, and have not been described previously in human fetal heart during this period. For the first time global gene expression of heart has been described in human samples to create a database of normal development to understand and compare with known abnormal fetal heart development.

[Should we perform a screening ECG among asymptomatic adults?]

The resting ECG is a safe, low cost and widely available in the clinical investigation of several cardiac symptoms. However, there is controversy regarding the use as a screening tool or routine cardiovascular (CV) risk assessment test among healthy asymptomatic adults. Two recent studies reported that ECG adds supplemental information in the estimation of coronary artery disease (CAD) risk in asymptomatic patients, especially in those with intermediate risk. However, we currently need more data on the impact of ECG on the prevention of clinical CV outcomes, especially in a randomized clinical trial, and on additional costs of testing and treatment. For the time being, routine ECG testing is not recommended for the prevention of CV events among healthy asymptomatic adults.

Differential changes in gene expression in human brain during late first trimester and early second trimester of pregnancy

OBJECTIVE

This study aimed to describe brain development during the first (B1) and second trimester (B3) in human fetuses.

DESIGN

Ten brains from 10 to 18 weeks of gestational age (GA) were collected, and the RNA was used for transcriptome analysis (Affymetrix 1.0 ST microarray chip). Differences in brain development within 10 to 18 GA were investigated by dividing the sample into 10 to 12 (B1), 13 to 15(B2) and 16 to 18(B3) weeks. A fold change of 2 or above, with a false discovery rate of 5%, was used as cut-off to determine differential gene expression for individual genes. Quantitative real-time PCR was used to confirm differences. Tests for enrichment procedures (using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes) were then used to identify functional groups of mRNA.

RESULTS

At 10 to 12 weeks, brains showed neuronal migration to be upregulated. From 10 to 18 weeks, brains showed genes coding for neuronal migration, differentiation and connectivity upregulated. ALDH1A1 and NPY genes, marker of spinal cord and striatum, were upregulated in B1 and B3 brains, respectively. Also, SLITRK6-HAS2 and CRYAB-PCDH18 genes for ear and eye sensory input were upregulated in B1.

CONCLUSIONS

For the first time, brain global gene expression was described in human samples. Period B1 was dominated by genes coding for neuronal migration, differentiation, programmed cell death and sensory organs. B3 was dominated by neuronal proliferation, branching and myelination. Creating such a database will allow comparison with abnormals in future studies.

Superior mesenteric artery syndrome: an uncommon cause of abdominal pain mimicking gastric outlet obstruction

Upper gastrointestinal symptoms like vomiting, abdominal pain, abdominal distention may be caused by many conditions like complicated peptic/duodenal ulcer, gastritis or hiatal hernia. However, these symptoms are uncommonly produced by superior mesenteric artery (SMA) syndrome. SMA syndrome is triggered when there is narrowing of the mesenteric angle and shortening of the aortomesenteric distance. We report a case of 42-year-old female who presented with features of gastric outlet obstruction which on further investigation was revealed as SMA syndrome. The aetiology, presentation, diagnosis and management of this unusual condition are discussed.