Opening Pandora's box: parental anxiety and the assessment of childhood murmurs

BACKGROUND

Most family physicians and pediatricians recognize the induction of parental anxiety when a newly diagnosed childhood murmur is discussed with a child's parent.

OBJECTIVES

To assess parental anxiety before and after consultation with a pediatric cardiologist for assessment of a childhood murmur. The study investigated the relationship between anxiety and parental understanding of murmurs, and assessed the possible role of the primary physician's initial diagnosis of the child's murmur on the anxiety level of parents.

SUBJECTS AND METHODS

One hundred ninety-five consecutive parents who presented with their child to the Alberta Children's Hospital Cardiology Clinic, Calgary, Alberta, were recruited. The children were referred for an initial consultation with a pediatric cardiologist for assessment of a heart murmur noted previously by the referring physicians. Before consultation, the patients were divided into three murmur groups for diagnosis: innocent, pathological and unknown. Anxiety questionnaires, as well as questionnaires assessing basic parent understanding of childhood murmurs, were administered to one of the parents pre- and postconsultation.

RESULTS

The initial diagnosis given to the caregiver by the primary care physician as the reason for referral did not seem to affect the level of parental anxiety within groups. As expected, postconsultation anxiety levels were significantly higher in parents whose children received a pathological diagnosis from the pediatric cardiologist. A significant drop in parental anxiety post-consultation was seen in all parent groups, including parents of a child diagnosed with a significant cardiac problem or pathology requiring further investigation and/or cardiac follow-up. There was a consistent correlation between higher scores on parental understanding and lower levels of parental anxiety.

CONCLUSION

The present study confirms that the finding of a childhood murmur by the family doctor or pediatrician induces significant parental anxiety, even when the presumptive diagnosis is that of an 'innocent' murmur. Pediatric cardiology consultation decreases parental anxiety, even in parents whose child has been given a diagnosis of pathology. The correlation between poor understanding of murmurs and high parental anxiety suggests that further study is required on the role of the referring physician in augmenting parental understanding of the term 'heart murmur' and the referral process.

A three-step strategy for targeting drug carriers to human ovarian carcinoma cells in vitro

To improve tumor-to-tissue ratios of anticancer agents in radioimmunotherapy, a three-step targeting approach was used to deliver biotinylated liposomes to human ovarian cancer cells (NIH:OVCAR-3, SK-OV-3) in vitro. Targeting was based upon the use of two antibodies specific for the CA-125 antigen that is highly expressed on NIH:OVCAR-3 cells but not expressed on SK-OV-3 cells. Briefly, the approach consists of prelabeling target cells with biotinylated anti-CA-125 antibody and FITC-labeled streptavidin (SAv) prior to administration of biotinylated liposomes containing a marker dye for visualization by confocal laser scanning microscopy (CLSM). In addition, the two anti-CA-125 antibodies (B27.1 and B43.13) were labeled with FITC and incubated with ovarian cancer cells at 37 degrees C from 30 min to 24 h to study binding and uptake kinetics. Shedding kinetics of bound antibody from tumor cells was performed using radiolabeled B27.1. Results demonstrated that both B27.1 and B43.13 specifically bound to the cell surface of OVCAR-3 cells but not to SK-OV-3 cells. Biotinylation, FITC-labeling and radiolabeling of the antibodies did not compromise immunoreactivity. Less than 6% of the bound B27.1 was shed from tumor cells by 4 h following incubation, and the antibody-antigen complex resided predominantly on the cell surface by 4 h at 37 degrees C with slow internalization by 12-24 h. Biotinylated, conventional liposomes were specifically and effectively delivered to OVCAR-3 cells prelabeled with biotinylated B27.1 and SAv. The slow internalization and shedding properties of these antibodies are useful for multistep pretargeting methods. Thus, a modified targeting strategy, utilizing a bispecific antibody and liposomes, may be feasible for radioimmunoliposomal therapy of ovarian cancer.

Antibiotic therapy in coronary heart disease--where do we currently stand?

A casual association between Chlamydia pneumoniae infection and atherosclerosis remains unresolved but plausible. Evidence comes from sero-epidemiological data, pathological specimen examinations, animal models and in vitro experiments. A number of prospective antibiotic intervention trials targeted against C. pneumoniae infection in patients with coronary heart disease are now underway. We remain wary that C. pneumoniae infection can persist in cell lines (associated with atherosclerosis) despite antibiotic therapy and also that reactivation of infection can occur. Issues such as delineating the patient group that could be targeted for treatment, choice of optimal antibiotic regimens, duration of therapy and effective methods of monitoring treatment response remain controversial and, as yet, unresolved. The relevance of persistence of C. pneumoniae infection and potential antimicrobial resistance will require equal consideration.

Atypical manifestation of dural arteriovenous fistula

A case of secondary dural arteriovenous fistula presenting as infantile stroke, in a fifteen month old boy, is reported. The initial impression on CT scan in this case was misleading, due to the atypical appearance of the pathological periventricular blood vessels, interpreted as periventricular calcification.

Hyperglycemia increases endothelial superoxide that impairs smooth muscle cell Na+-K+-ATPase activity

Nitric oxide (NO) plays an important role in the control of numerous vascular functions including basal Na+-K+-ATPase activity in arterial tissue. Hyperglycemia inhibits Na+-K+-ATPase activity in rabbit aorta, in part, through diminished bioactivity of NO. The precise mechanism(s) for such observations, however, are not yet clear. The purpose of this study was to examine the role of superoxide in modulating NO-mediated control of Na+-K+-ATPase in response to hyperglycemia. Rabbit aorta incubated with hyperglycemic glucose concentrations (44 mM) demonstrated a 50% reduction in Na+-K+-ATPase activity that was abrogated by superoxide dismutase. Hyperglycemia also produced a 50% increase in steady-state vascular superoxide measured by lucigenin-enhanced chemiluminescence that was closely associated with reduced Na+-K+-ATPase activity. Specifically, the hyperglycemia-induced increase in vascular superoxide was endothelium dependent, inhibited by L-arginine, and stimulated by N(omega)-nitro-L-arginine. Aldose reductase inhibition with zopolrestat also inhibited the hyperglycemia-induced increase in vascular superoxide. In each manipulation of vascular superoxide, a reciprocal change in Na+-K+-ATPase activity was observed. Finally, a commercially available preparation of Na+-K+-ATPase was inhibited by pyrogallol, a superoxide generator. These data suggest that hyperglycemia induces an increase in endothelial superoxide that inhibits the stimulatory effect of NO on vascular Na+-K+-ATPase activity.

Generalized lymphadenopathy caused by Trichosporon asahii in a patient with Job's syndrome

Of the six species of Trichosporon known to cause human infections, T. asahii is the main agent of invasive trichosporonosis. We describe an unusual case of generalized lymphadenopathy due to T, asahii in a 10-year-old boy with Job's syndrome (markedly elevated IgE with eosinophilia). The diagnosis was based on the presence of blastic conidia and hyphal elements breaking into arthroconidia in biopsied tissue of the cervical lymph node and isolation of the causal agent T, asahii in pure culture. The patient responded initially to amphotericin B therapy, but the infection recurred within 4 weeks and did not respond to therapy of liposomal amphotericin B and 5-fluorocytosine for 10 days. The patient left the hospital against medical advice.

Hepatitis C virus related cryoglobulinemic glomerulonephritis

A 46 years male presented with skin rash and acute nephritic syndrome. He had history of jaundice four months back. Rheumatoid factor and cryoglobulins were present in the serum. Although anti-HCV antibodies were negative, HCV RNA was detected by polymerase chain reaction. Kidney biopsy showed membranoproliferative glomerulonephritis and thrombi in the lumen of the glomerular capillary loops. His renal functions improved with steroids.

Emergence of rotavirus G4P8 strain among children suffering from watery diarrhea in Calcutta, India

Rotavirus RNAs from the fecal samples were hybridized with cDNAs specific for G1 and G2 genotypes. 59 out of 138 samples (42.7%) did not hybridize with either probe. The cDNAs coding for VP7 and VP4 from one such sample, SC134, were synthesized by combined reverse transcriptase/polymerase chain reaction (PCR) using specific oligonucleotide primers and were used as probes to screen those local isolates which did not hybridize with either G1 or G2. 26/59 (44%) of fecal RNA hybridized with these cDNAs indicating a possible emergence of this strain in this part of India. The VP7 and VP4 genotype specificity of SC134 was found to be G4P8 by multiplex PCR. The VP7 gene of SC134 was cloned and characterized in detail by restriction enzyme digestion and DNA sequence analysis. Comparison of nucleotide and predicted amino acid sequence of the VP7 gene of SC134 with other serotypes revealed that the VP7 gene of SC134 was closely related to G4. However, amio acids within the VP7 sequence differed in seven positions with that of both the subtype 'A' and 'B' of the G4 serotype. To establish the relation of this emerging strain with the other reported G4 strains, a phylogenetic tree was constructed and SC134 was found to be more closely related to the ST3 strain isolated in England and included in the tetravalent vaccine formulation along with two Japanese strains, although all four were distinct and did not form any cluster as was evident by the horizontal distance separating them. The VP7 gene sequence of SC134 was submitted to EMBL and was assigned the accession number AJ278217.

Transport of Bose-Einstein condensates with optical tweezers

We have transported gaseous Bose-Einstein condensates over distances up to 44 cm. This was accomplished by trapping the condensate in the focus of an infrared laser and translating the location of the laser focus with controlled acceleration. Condensates of order 10(6) atoms were moved into an auxiliary chamber and loaded into a magnetic trap formed by a Z-shaped wire. This transport technique avoids the optical and mechanical access constraints of conventional condensate experiments and creates many new scientific opportunities.

Chlamydia pneumoniae and atherosclerosis -- what we know and what we don't

The clinical manifestations of atherosclerosis include coronary artery disease (CAD), stroke, abdominal aortic aneurysm and peripheral vascular disease. World-wide, CAD and stroke are the leading causes of death and disability. The recognition of atherosclerosis as an inflammatory disease in its genesis, progression and ultimate clinical manifestations has created an interesting area of vascular research. Apart from those well-known traditional risk factors for atherosclerosis, novel and potentially treatable atherosclerotic risk factors such as homocysteine (an amino acid derived from the metabolism of dietary methionine that induces vascular endothelial dysfunction) and infections have emerged. In fact, the century-old 'infectious' hypothesis of atherosclerosis has implicated a number of micro-organisms that may act as contributing inflammatory stimuli. Although cytomegalovirus, Helicobacter pylori and Chlamydia pneumoniae are the three micro-organisms most extensively studied, this review will focus on C. pneumoniae. Collaborative efforts from many disciplines have resulted in the accumulation of evidence from seroepidemiological, pathological, animal model, immunological and antibiotic intervention studies, linking C. pneumoniae with atherosclerosis. Seroepidemiological observations provide circumstantial evidence, which is weak in most prospective studies. Pathological studies have demonstrated the preferential existence of C. pneumoniae in atherosclerotic plaque tissues, while animal model experiments have shown the induction of atherosclerosis by C. pneumoniae. Finally, immunological processes whereby C. pneumoniae could participate in key atherogenic and atherothrombotic events have also been identified. Although benefits of the secondary prevention of atherosclerosis have been demonstrated in some antibiotic intervention studies, a number of negative studies have also emerged. The results of the ongoing large prospective human antibiotic intervention trials may help to finally establish if there is a causal link between C. pneumoniae infection and atherosclerosis.

Plasmodium falciparum: in vitro interactions of artemisinin with amodiaquine, pyronaridine, and chloroquine

In the scenario of drug-resistant Plasmodium falciparum malaria combination therapy represents an effective approach. Artemisinin and its derivatives are of special interest because they represent the most effective group of compounds against multidrug-resistant malaria with a rapid onset of action and a short half-life. Interactions of artemisinin with amodiaquine, pyronaridine, and chloroquine were therefore investigated against three strains of P. falciparum using a 48-h in vitro culture assay. Two of the strains were chloroquine sensitive and one was partially chloroquine resistant. Observed effective concentrations (O) of the combined compounds at different concentration ratios were calculated for different degrees of inhibition (EC50, EC90, EC99) and compared to expected calculated effective concentrations (E) using a probit method. Synergism with mean O/E EC90 values of 0.25 and 0.8 were found with the combination of artemisinin and the two Mannich bases, amodiaquine and pyronaridine, respectively, whereas chloroquine showed addition with a mean value of 1.2. Although both amodiaquine and chloroquine are 4-aminoquinolines, their interaction with artemisinin appears to be different. The combination of artemisinin with amodiaquine represents an important option for the treatment of falciparum malaria.

A fatal case of systemic brucellosis

A 65 years man presented with fever, drenching sweats, progressive dyspnoea, backache and weight loss. On examination, he had wide pulse pressure, clubbing, retinal hemorrhages, aortic and mitral regurgitation, hepatosplenomegaly, lower spinal tenderness and bilateral basal crepitations. Transthoracic 2D-echocardiography showed a large vegetation on the aortic valve. Antibody titers for brucella were positive. X-ray spine was suggestive of brucella spondylitis. Early surgical intervention was planned and the patient was given combination antibiotic therapy. The course was complicated by renal failure and the patient succumbed while being taken up for surgery.

A predictable outcome of a preventable disease

Infective endocarditis is a systemic illness that can present with a variety of non-specific clinical symptoms. Patients with certain underlying heart valve abnormalities are at increased risk for development of infective endocarditis while undergoing minor procedures, particularly those associated with bacteremia by pathogens that typically cause infective endocarditis. We present a case of infective endocarditis that developed after a dental procedure in a patient with a previously undetected congential bicuspid aortic valve.

Sutureless vascular anastomosis: the VCS clip

Non-penetrating, arcuate-legged clips facilitate vascular reconstructions and significantly reduce the incidence of anastomotic neointimal hyperplasia. Though originally developed as a microvascular-approximating instrument, by far the largest application has been for hemodialysis vascular access. Long-term studies comparing suture to clip for access creation have demonstrated the clear technical and biological superiority of the clip for this procedure. This "sutureless" vascular anastomotic technique is more demanding than conventional suturing, requiring precise vessel preparation and supervised training.

Evaluation of cysticercus fasciolaris antigen for the immunodiagnosis of neurocysticercosis

Cysticercus cellulosae antigen has been frequently used to detect antibodies for immunodiagnosis of neurocysticercosis. We have, for the first time, used membrane extract of cysticercus fasciolaris, the larval stage of Taenia taeniaeformis, in ELISA, with successful results. IgM and IgG antibodies against cysticercus were measured in serum from cases of neurocysticercosis (217), normal and diseased controls (89). 203 sera from cases of neurocysticercosis were positive for either or both IgG and IgM antibodies while 157/217 cases showed IgM and 158/217 showed IgG antibodies. Ten controls showed false postivity in IgG ELISA. Eight of these cases also had IgM antibodies. The test had an overall sensitivity of 93.54% and a specificity of 84.2% with a positive predictive value of 93.54% and a negative predictive value of 84.2%. Cysticercus fasciolaris can be conveniently produced in the experimental laboratory host, Rattus rattus, and would be of practical value in the immunodiagnosis of cysticercosis in humans.

A comparison in monkeys of (99m)Tc labeled to a peptide by 4 methods

Although a number of different strategies for labeling peptides with (99m)Tc have been developed, only a few studies have compared the in vivo properties of (99m)Tc when attached to different chelators. Furthermore, these comparisons are usually in mice, whereas results obtained in nonhuman primates may be expected to be more relevant to the clinical situation.

METHODS

We evaluated the influence of 4 common chelators on the biodistribution in monkeys of (99m)Tc-labeled HNE-2, a 6.7-kDa peptide being investigated as an inflammation/infection imaging agent. The peptide was conjugated with the N-hydroxysuccinimide ester of mercaptoacetyltriglycine (MAG3), mercaptoacetyltriserine (MAS3), hydrazinonicotinamide (HYNIC), and the cyclic anhydride of diethylenetriaminepentaacetic acid (DTPA). After radiolabeling, each peptide was administered intravenously to rhesus monkeys with a Staphylococcus aureus-induced focal inflammation/infection.

RESULTS

Quantification of radioactivity accumulation by regions of interest over 3 h after administration in monkeys showed important differences among labeling methods: For example, at 3 h, kidney accumulation varied in percentage injected dose per organ (%ID per organ) from 31 %ID per organ (HYNIC) to 18 %ID per organ (MAG3), whereas liver varied from 7.8 %ID per organ (MAG3) to 2.8 %ID per organ (MAS3). Radioactivity accumulation in the lesion was independent of labeling method. These organ accumulations were compared with that obtained earlier in mice by sacrifice and dissection also at 3 h and at the same administered dosage. In the rodent, kidney levels varied from 45 %ID per organ (HYNIC) to 12 %ID per organ (MAS3) and liver levels varied from 6.5 %ID per organ (DTPA) to 2.0 %ID per organ (MAS3).

CONCLUSION

In agreement with previous work from this laboratory and elsewhere, the method of radiolabeling had an important effect on the biodistribution of (99m)Tc. Furthermore, although biodistribution results in mice should be used with caution to predict biodistributions in primates, in major organs, these results in mice and monkeys were similar.