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Objective: To determine whether pharmacological stress leads to prolonged but reversible left ventricular dysfunction in patients with coronary artery disease, similar to that seen after exercise.Design: A randomised crossover study of recovery time of systolic and diastolic left ventricular function after exercise and dobutamine induced ischaemia.Subjects: 10 patients with stable angina, angiographically proven coronary artery disease, and normal left ventricular function.Interventions: Treadmill exercise and dobutamine stress were performed on different days. Quantitative assessment of systolic and diastolic left ventricular function was performed using transthoracic echocardiography at baseline and at regular intervals after each test.Results: Both forms of stress led to prolonged but reversible systolic and diastolic dysfunction. There was no difference in the maximum double product (p = 0.53) or ST depression (p = 0.63) with either form of stress. After exercise, ejection fraction was reduced at 15 and 30 minutes compared with baseline (mean (SEM), -5.6 (1.5)%, p < 0.05; and -6.1 (2.2)%, p < 0. 01), and at 30 and 45 minutes after dobutamine (-10.8 (1.8)% and -5. 5 (1.8)%, both p < 0.01). Regional analysis showed a reduction in the worst affected segment 15 and 30 minutes after exercise (-27.9 (7.2)% and -28.6 (5.7)%, both p < 0.01), and at 30 minutes after dobutamine (-32 (5.3)%, p < 0.01). The isovolumic relaxation period was prolonged 45 minutes after each form of stress (p < 0.05).Conclusions: In patients with coronary artery disease, dobutamine induced ischaemia results in prolonged reversible left ventricular dysfunction, presumed to be myocardial stunning, similar to that seen after exercise. Dobutamine induced ischaemia could therefore be used to study the pathophysiology of this phenomenon further in patients with coronary artery disease. [ABSTRACT FROM AUTHOR]

Aim: To review the efficacy and tolerability of pegylated interferon-a and ribavirin for treatment of chronic hepatitis C (CHC) in children in the UK. Methods: Retrospective review of children treated for CHC in 3 UK paediatric specialist liver centres between 2005 and 2010. Data on viral response to treatment, demographic and clinical details were collected. Treatment outcome was assessed by the absence of detectable viral RNA in blood 24 weeks after treatment --sustained viral response (SVR). Results: 75 children were included; 34 genotype 1; 39 genotypes 2 and 3; 2 genotype 4. Overall SVR was achieved in 54/71 (76%); 65% genotype 1; 89% genotypes 2 and 3; 100% genotype 4. Early response at 12 weeks was achieved in 53 and sustained in 47 (89%). Data on rapid response after 4 weeks of treatment were available in 25; 17/25 (68%) responded and 16 of these (94%) achieved SVR. IL28 T/T genotype was associated with higher SVR. There were no significant changes in weight and height z scores from baseline compared with 24 weeks post-treatment followup. No child discontinued treatment due to side effects, although 43 required dose modification. Treatment affected quality of life (QoL) in the initial 12 weeks of treatment, which improved by the end of treatment. Conclusions: Children respond well to therapy for CHC. Treatment was tolerated with minimal impact on QoL and no significant effect on growth. Knowledge of viral and IL28 genotypes and early viral response is useful to plan treatment in children and provide appropriate counselling. [ABSTRACT FROM AUTHOR]

Objectives: To compare the relationship between dobutamine myocardial blood flow (MBF), rate-pressure product (RPP) and stenosis severity in patients with coronary artery disease (CAD). Methods: 27 patients with single-vessel CAD were allocated to three groups based on stenosis severity: group 1, 50-69% (n = 9); group 2, 70-89% (n = 9); and group 3, ≥90% (n = 9). Nine normal volunteers served as controls. Resting and dobutamine MBF were measured by positron emission tomography in the territory subtended by the stenosis (Isc) and remote myocardium (Rem). Mean left ventricular MBF was used for controls. Results: In group 1, mean dobutamine MBF-Isc (2.48 (SD 0.48 ml/min/g)) and dobutamine MBF-Rem (2.70 (0.50) ml/min/g, NS) were comparable. In groups 2 and 3, dobutamine MBF-Isc (1.91 (0.44) and 1.22 (0.21)ml/min/g) was significantly lower than dobutamine MBF-Rem (2.27 (0.28) and 1.98 (0.25) ml/min/g, p < 0.02 and p < 0.005, respectively). An inverse relation between dobutamine MBF and stenosis severity existed both in Isc (r = 0.79, p < 0.001) and in Rem territories (r = 0.71, p < 0.001). For any given RPP, dobutamine MBF was greater in controls than in Rein (p < 0.05), which in turn was greater than in Isc (p < 0.05). Conclusion: Dobutamine MBF inversely correlated with stenosis severity and achieved significant flow heterogeneity for coronary stenoses > 70%. Dobutamine MBF and RPP were dissociated in both Isc and Rem segments in patients compared with controls. [ABSTRACT FROM AUTHOR]

Acute idiopathic pancreatitis is a term used when no underlying cause has been identified on routine investigation. However, more specialised investigations may identify aetiological factors, biliary sludge and sphincter of Oddi dysfunction for example, in 38-72% of patients with recurrent episodes. Treatment of these abnormalities may prevent further episodes of pancreatitis. The aim of this study was to follow up and determine the outcome in patients with a first episode of idiopathic pancreatitis, and thus determine the need for further investigation and treatment in this group of patients. Thirty one patients with a single episode of idiopathic pancreatitis were studied who had no specialised investigations or specific treatment. During a median follow up of 36 months only one patient has had recurrent pancreatitis. Two patients experienced a single episode of unexplained abdominal pain; serum amylase, liver biochemistry, and abdominal ultrasound were all normal and the pain resolved within 48 hours. In conclusion, in the medium term, the prognosis is good after a first episode of idiopathic pancreatitis and specialised investigation is unnecessary. [ABSTRACT FROM PUBLISHER]

A letter to the editor is presented in response to an article about the role of Mohs excision in periocular basal cell carcinoma, published in a 2006 issue of the "Journal of Ophthalmology."

Reports on access to full texts of articles about cardiology in the web site, www.heartjnl.com. Findings of trial on stent or open heart surgery; Adverse lipid profile from active rheumatoid arthritis; Method to handle non-cardiac chest pain.

Organ-specific antibodies were looked for in 26 patients with lichen sclerosus. Ten of the 25 female patients (40%) had organ-specific antibodies to thyroid cytoplasm and 11 (44%) had organ-specific antibodies to gastric parietal cells. Both values were significantly greater than those obtained in age-matched controls. None of the sera from patients with lichen sclerosus contained antibodies to steroid-producing tissues. No organ-specific antibodies were found in the one male patient. The findings suggest that lichen sclerosus may be related to an autoimmune process. [ABSTRACT FROM PUBLISHER]

Anti-complementary activity was detected in the sera of 23 (59%) out of 39 patients with Hashimoto thyroiditis; in 10 (29%) out of 34 patients with primary hypothyroidism; in six (17%) out of 36 patients with thyrotoxicosis; and in only six (8%) out of 78 control subjects. Fractionation of Hashimoto sera by Sephadex G-200 chromatography showed that the anti-complementary activity was founding fractions of larger molecular size than monomeric IgG, being localized predominantly in the ascending limb of the second elution peak, suggesting that it was in the form of small immune complexes. [ABSTRACT FROM PUBLISHER]

Hepatitis B (HBV) and C (HCV) -specific CD8+ T-cells are characterised by expression of the NK receptor CD161. CD8+ T cells with high levels of CD161 (CD161++) make up a mean of 12% of CD8+ T-cells in healthy controls and have distinct properties; they express the gut and liver homing chemokine receptors CCR6 and CXCR6, cytokines IL-17, IFN-y and IL-22 and have narrow TCR Vb usage (predominantly Vb 7.2 and 13), linking them to the mucosal-associated invariant T-cells of the gut. In healthy controls ∼40% of this CD161++ subset does not express the co-receptor CD8 alpha-beta (CD8ab), but the co-repressor CD8 alpha-alpha (CD8aa), yet share key functional and phenotypic features of the subset. Aim We aimed to the study the distribution and phenotype of CD8ab and CD8aa subsets in chronic hepatitis C (cHCV) and hepatitis B (cHBV). Method Flurochrome-labelled antibodies were used for multi-colour FACS analysis of lymphocytes in whole blood from 24 cHCV, 6 e-antigen (Ag) +ve HBV and 14 eAg−ve HBV patients and 19 healthy controls (HC). Liver infiltrating lymphocytes (LILs) (obtained from explant material; 4 HCV patients with paired PBMCs, eight alcoholic liver disease and 1 PBC) were included in the study. FACS data were analysed using FloJo software (Tree Star, Inc) and statistics were performed using PRISM (Graftpad software, Inc). Results CD8aa cells are exclusive to the CD161++ subset in HCs, cHCV and cHBV. In cHCV and eAg−ve cHBV there is a significant reduction in the proportion of cells in the CD161++CD8+ subset compared to HCs (p≤0.05). Within the CD161++CD8+ subset there is a further reduction in the fraction of CD8aa cells in cHCV patients (18.5% vs 34.13%, p=0.0086) compared to HCs. No difference is observed in cHBV. CD8ab and CD8aa CD161+ populations are found within human LILs in HCV, ALD and PBC. The CD161+CD8aa cell subset constitute a mean of 9.9% of the total CD8+ LILs. Relative enrichment of CD161+CD8aa cells is seen in the liver of patients with cHCV compared to peripheral blood (p=0.0079). In eAg−ve cHBV a distinct CD8a+blow population can be identified within the CD161+ and CD161− subsets. These populations are not seen in HCs, eAg+ve HBV and HCV (p<0.05). Conclusion CD161++ CD8+ T-cells are lost from the peripheral blood in cHCV and eAg−ve HBV. Maintenance of this subset in eAg+ve HBV may reflect immuno-tolerance to virus at this stage of infection. In chronic HCV there is a relative enrichment of the CD161+CD8+ subset in LILs, indicating recruitment to and retention in the liver. The role of these cells in health, immunity and disease outcome in viral hepatitis requires further study. The emergence of a CD161+/CD161-CD8a+blow subset in eAg−ve HBV may reflect activation or exhaustion of these cells; their phenotype and function requires investigation. [ABSTRACT FROM PUBLISHER]

The article presents a case of a 75-year-old man with progressive dyspnea. He has a 24-year history of severe deforming rheumatoid arthritis for which he had required a number of disease modifying therapies. The patient has no clinical signs of cardiac tamponade on presentation. Histology revealed fibrinous pericardium and chronic inflammatory infiltrates.

Introduction: Severe aortic stenosis is a major cause of morbidity and mortality. The existing treatment pathway for transcatheter aortic valve implantation (TAVI) traditionally relies on tertiary Heart Valve Centre workup. However, this has been associated with delays to treatment, in breach of British Cardiovascular Intervention Society targets. A novel pathway with emphasis on comprehensive patient workup at a local centre, alongside close collaboration with a Heart Valve Centre, may help reduce the time to TAVI., Methods: The centre performing local workup implemented a novel TAVI referral pathway. Data were collected retrospectively for all outpatients referred for consideration of TAVI to a Heart Valve Centre from November 2020 to November 2021. The main outcome of time to TAVI was calculated as the time from Heart Valve Centre referral to TAVI, or alternative intervention, expressed in days. For the centre performing local workup, referral was defined as the date of multidisciplinary team discussion. For this centre, a total pathway time from echocardiographic diagnosis to TAVI was also evaluated. A secondary outcome of the proportion of referrals proceeding to TAVI at the Heart Valve Centre was analysed., Results: Mean±SD time from referral to TAVI was significantly lower at the centre performing local workup, when compared with centres with traditional referral pathways (32.4±64 to 126±257 days, p<0.00001). The total pathway time from echocardiographic diagnosis to TAVI for the centre performing local workup was 89.9±67.6 days, which was also significantly shorter than referral to TAVI time from all other centres (p<0.003). Centres without local workup had a significantly lower percentage of patients accepted for TAVI (49.5% vs 97.8%, p<0.00001)., Discussion: A novel TAVI pathway with emphasis on local workup within a non-surgical centre significantly reduced both the time to TAVI and rejection rates from a Heart Valve Centre. If adopted across the other centres, this approach may help improve access to TAVI., Competing Interests: Competing interests: HR received an educational grant from Edwards Lifesciences and VP is a proctor for Medtronic Plc., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine the effect of continuous wound infusion of local anaesthetic drug (bupivacaine) on total amount of systemic opioid use in the first 72 hours in newborn infants undergoing laparotomy., Design: A two-arm parallel, open-label randomised controlled trial., Setting: A quaternary newborn intensive care unit., Patients: Infants > 37 weeks of gestation undergoing laparotomy for congenital or acquired abdominal conditions., Interventions: Continuous wound infusion of local anaesthetic (bupivacaine) for the first 72 hours along with systemic opioid analgesia (catheter group) or only systemic opioid analgesia (opioid group)., Main Outcome: Total amount of systemic opioid used within the first 72 hours post laparotomy., Results: The study was underpowered as only 30 of the expected sample size of 70 infants were enrolled. 16 were randomised to catheter group and 14 to opioid group. The two groups were similar at baseline. There was no significant difference between the groups for the primary outcome of median total systemic opioid use in the first 72 hours post laparotomy (catheter 431.5 µg/kg vs opioid 771 µg/kg, difference -339.5 µg/kg, 90% CI high 109, p value 0.28). There was no significant difference between the groups for any of the secondary outcomes including pain scores, duration of mechanical ventilation, time to reach full feeds and duration of hospital stay. There were no adverse events noted., Conclusion: Continuous wound infusion of local anaesthetic along with systemic opioid analgesia is feasible. The lack of a difference in total systemic opioid use in the first 72 hours cannot be reliably interpreted as the study was underpowered., Trial Registration Number: ACTRN12610000633088., Competing Interests: Competing interests: No, there are no competing interests., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)