Search

AIMS: Although acute heart failure (AHF) with volume overload is treated with loop diuretics, their dosing and type of administration are mainly based upon expert opinion. A recent position paper from the Heart Failure Association (HFA) proposed a step-wise pharmacologic diuretic strategy to increase the diuretic response and to achieve rapid decongestion. However, no study has evaluated this protocol prospectively. METHODS AND RESULTS: The Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure (ENACT-HF) study is an international, multicentre, non-randomized, open-label, pragmatic study in AHF patients on chronic loop diuretic therapy, admitted to the hospital for intravenous loop diuretic therapy, aiming to enrol 500 patients. Inclusion criteria are as follows: at least one sign of volume overload (oedema, ascites, or pleural effusion), use=40mg of furosemide or equivalent for >1month, and a BNP>250ng/L or an N-terminal pro-B-type natriuretic peptide>1000pg/L. The study is designed in two sequential phases. During Phase 1, all centres will treat consecutive patients according to the local standard of care. In the Phase 2 of the study, all centres will implement a standardized diuretic protocol in the next cohort of consecutive patients. The protocol is based upon the recently published HFA algorithm on diuretic use and starts with intravenous administration of two times the oral home dose. It includes early assessment of diuretic response with a spot urinary sodium measurement after 2h and urine output after 6h. Diuretics will be tailored further based upon these measurements. The study is powered for its primary endpoint of natriuresis after 1day and will be able to detect a 15% difference with 80% power. Secondary endpoints are natriuresis and diuresis after 2days, change in congestion score, change in weight, in-hospital mortality, and length of hospitalization. CONCLUSIONS: The ENACT-HF study will investigate whether a step-wise diuretic approach, based upon early assessment of urinary sodium and urine output as proposed by the HFA, is feasible and able to improve decongestion in AHF with volume overload.

Summary Introduction Patients with severe GH deficiency (GHD) suffer with a reduced quality of life in addition to diverse changes in cardiac size and performance. So far, the cardiac reserve ability to maintain the circulation during peak exercise has not been measured. We tested the hypothesis that patients with severe GHD have reduced cardiac reserve function compared with healthy controls and that this could explain, in part, their reduced quality of life. Aims Eighteen patients with severe GHD and an assessment of GHD in adults (AGHDA) score ≥11 (mean 20·0, range 12–25) were studied and compared with 18 age-, sex- and body mass index-matched healthy controls. Peak cardiac power and cardiorespiratory fitness were investigated using noninvasive haemodynamic measurements during maximal cardiopulmonary exercise testing. Results Compared with matched controls, the cardiac power of GHD patients during exercise to volitional exhaustion was significantly reduced by 15% (mean ± SD 4·4 ± 1·0 W vs. 5·2 ± 1·0 W, P = 0·02). Patients with GHD also had lower cardiac chronotropic reserve (peak heart rate 154 ± 21/min vs. 174 ± 11/min, P = 0·001) and a lower cardiac pressure-generating capacity (systolic blood pressure 160 ± 25 mmHg vs. 200 ± 15 mmHg, P

Background: While information on how cardiac resynchronisation therapy (CRT) affects cardiac performance at rest is readily available, the mechanisms whereby CRT alters cardiac function during maximal exercise are unclear. Aims: We examined the medium-term effects of CRT on cardiac and physical functional reserve of patients with severe heart failure (CHF) and prolonged QRS duration. Methods: Seventeen consecutive patients with severe CHF (NYHA III–IV) and widened QRS underwent maximal cardiopulmonary exercise testing with non-invasive central haemodynamic measurements before and 6–8 weeks after CRT pacemaker implantation. Results After CRT there were significant increases in exercise cardiac output by 19.3% (P=0.0048) from 9.5±3.4 l min−1, peak mean arterial blood pressure by 14.1% (P=0.0001) from 91.3±13.6 mm Hg, and peak cardiac power output by 37.2% (P=0.0008) from 1.92±0.74 W. There were no significant changes in these variables at rest. Exercise duration (+42.3%, P=0.0002), NYHA functional class (P=0.0001) and SF-36 symptom score (P=0.0006) were also significantly improved. Powerful surrogate indicators of prognosis were also significantly improved with CRT: peak O2 consumption (+20.9%, P=0.0007), VE/VCO2 slope (−20.0%, P=0.005) and circulatory power (+42.0%, P=0.0012). Conclusion: In this cohort of patients, post-implant CRT significantly improved the flow-, pressure- and power-generating capacity of the failing hearts. This may be causally related to the improvements observed in exercise capacity, functional class and symptom scores.

Thirteen unusual shell and bone objects of contentious function are amongst the small finds from tomb I at Sharm. An inventory of the objects is provided after a discussion of the potential use of the objects is presented.

Four miscellaneous artefacts, which do not correspond to the other major small finds groups, are also included in the Sharm assemblage. Whilst the gastropod shell is positively identified as Tonna luteostoma, the materials and function of the remaining objects are conjectural.

The Wadi Suq period and Iron Age ceramics from Sharm are examined in terms of morphological, compositional and decorative features. The assemblage is typical of the second- and first-millennium BC ceramics of southeastern Arabia. The more unusual Iron Age ‘imitation soft stone’ ceramics are amply represented and the Sharm assemblage considerably expands upon this corpus of ceramics which has hitherto been less than abundant in the region. Comparisons with other second- and first-millennium sites suggest the tombs were largely occupied in the late Wadi Suq period, a pattern of occupation which again peaked in the Iron Age II period.

Eighty-seven beads of various materials are discussed according to the twelve typological groups into which they are divided. This typology is largely based on bead shapes, although manufacturing techniques and materials are also discussed. The beads are also compared to other assemblages in southeastern Arabia.

This is an interesting report of a supraventricular tachycardia in a paced patient with intermittent atrioventricular nodal block. Only electrophysiology testing revealed the correct diagnosis. Images explain how pacemaker timing cycles and refractory periods can confuse an otherwise straightforward diagnosis.

A group of thirteen fragmentary and complete shell and bone rings was excavated at Sharm, including one example likely to be a bracelet. The function of the objects as rings is undisputed. A number of the rings appear to be manufactured from Conus sp., whereas the remainder are apparently made from bone.

Eight discs, largely concavo-convex in shape and decorated with a symmetrical rosette pattern, were recovered from Tomb I during excavations. A similar undecorated concavo-convex disc was also found. The following paper presents the results of the typological examination of the objects, with the materials and manufacturing techniques published elsewhere in this volume. These discs are widely recognised in southeastern Arabia, with parallels suggesting a predominantly Iron Age date.

Two alabaster objects were recovered from the excavations at Sharm, both having unusual shapes. The function of each piece is unknown, although it is suggested that they may have been blanks or cores for the manufacture of other alabaster items.

S-305 is the worked remnant of one half of a spiny oyster which exhibits drill marks consistent with single and double dot-in-circle motifs. The object is briefly described with a view to determining its function. The manufacturing marks are analysed elsewhere in this volume by Katia Davis.

Melatonin is rhythmically synthesized in some vertebrate retinas and has been implicated in the regulation of key rhythmic events in the photoreceptor-pigment epithelial complex. In human retina, melatonin is present; however, no information exists on the cellular regulation of this hormone. We report here that the established human retinoblastoma cell line Y79 synthesizes and releases melatonin. Treatments that elevate cyclic AMP (cAMP) levels (forskolin, 8-Br-cAMP, and the phosphodiesterase inhibitor 3-isobutyl-1 -meth-ylxanthine) all stimulate melatonin release from static cultures of Y79 cells. Other 8-bromo nucleotide analogues (cyclic GMP, ATP, and AMP) are not effective. These results suggest that Y79 human retinoblastoma cells require a cAMP-dependent mechanism for melatonin biosynthesis similar to that described previously in other vertebrates. This is the first demonstration of melatonin release from a cultured human cell line. These results support the idea that human retinal cells share homologies with pineal cells, as suggested by the condition trilateral retinoblastoma.